By. Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the complaint:- The Complainant had availed a Group Insurance Mediclaim policy from SYND, Arogya (Group Health Insurance Scheme) from Vidal Health TPA Pvt Ltd, 1400B, Mareena building MG Road, Ernakulam for the period of 04.09.2019 to 03.09.2020 under the aegis of the United India Insurance Company Ltd. On termination of the policy, the Complainant ported to Opposite Party, who assured all continued benefits at the time of commencement of policy. The Complainant duly paid Rs. 14,195/- as premium. The Opposite Party assured that the Mediclaim Insurance Policy is issued with portability benefits from Mediclaim Policy of United Insurance Company Ltd. The Complainant’s wife was admitted in Iqraa Hospital, Calicut in the advance stage of pregnancy for delivery and post natal care whereupon the Complainant had to bear an expenditure of Rs.40,000/- under the faith of getting complete hospital expenses be paid by the insurance company as per the clause provided in United India Insurance Company’s Maternity Expense Benefit extension scheme which was out rightly disowned and rejected the claim by the Opposite Party when approached by the Complainant. The Complainant reiterates that he had got his wife admitted in the hospital for delivery and post natal care on the assurance given in the policy documents of United India Insurance Company which the Opposite Party also promised to provide all continued services as contained therein. The Complainant when approached for clearing of hospital expenses to the Opposite Party, they categorically denied the claim and refused to make any payment towards this. According to the Complainant, the act of Opposite Party is deficiency in service. Hence, this Complaint.
3. After the admission of the complaint, the Commission issued summons to the opposite party, who appeared and filed version wherein they admitted that the Complainant has ported his old mediclaim insurance policy to the Opposite Party Company and the sum assured for each member of the family is 2 lakhs each. But they denied that the Opposite Party assured that all the benefits of old policy will be continued for the duration of 04.09.2020 to 03.09.2021. The Complainant stated in the Complaint that the mediclaim insurance policy of United India Insurance Company Ltd. and continuity is extended from 04.09.2015. According to the Opposite Party, the portability of benefits are applicable to the terms and conditions of the policy. It is the choice of the insured to decide what all benefits are to be included under the policy. The insured has not opted for the benefits under the maternity expense benefit extension scheme and not paid premium towards the same. The term portability does not mean same coverage of the previous insurance policy. It is known to the Opposite Party that the Complainant’s wife was admitted in IQQRA Hospital and Research Center Malaparamba in connection with pregnancy. But she is not entitled for the amounts spent in connection with the same. It is pertinent to note that according to the Complainant, he is entitled for the hospital expenses as per the clause provided in United India Insurance Company’s maternity expenses benefit extension scheme. Further, the Complainant is not having a claim that he is entitled for the above said expense as per the policy conditions of the Opposite Party’s Insurance policy. The Opposite Party repudiated the claim only on the ground that there is no policy coverage to provide maternity hospitalization expenses. As per the policy terms and conditions, treatment arising from or traceable to pregnancy and child birth including caesarean section, or any treatment related to pre and post natal care and complications arising out of pregnancy and child birth are specifically excluded. Hence, the Opposite Party prayed to dismiss the Complaint.
4. On perusal of complaint and documents, Commission raised the following points for consideration:-
- Whether there is any deficiency of service from the part of Opposite Party?
- Whether the Complainant is entitled to get any relieves as prayed for?
5. Point No. 1 and 2 :- For the sake of convenience and brevity both the points are considered together.
6. The Complainant had adduced oral evidence. He was examined as PW1 and the documents produced were marked as Ext. A1 to A6. The Opposite Party submitted that they have no oral evidence, produced one document which was marked as Ext. B1 & B1 (a).
7. The case of the Complainant is that he was availed a Group Insurance Medi Claim Policy from United India Insurance Company for the duration of 04. 09.2019 to 03.09.2020 and thereafter, the Complainant ported his health cover with Opposite Party i.e., Bajaj General Insurance Company for the duration of 04.09.2020 to 03.09.2021 and paid Rs.14,195/-. During the subsistence of said policy on 31.01.2021, the wife of the Complainant was admitted in the hospital for delivery and incurred a sum of Rs.40,150/-Then the Complainant claimed for reimbursement of the amount from Opposite Party, but the Opposite Party refused to pay the amount stating that the treatment undergone by the Complainant’s wife was not covered by the policy terms and conditions. The Opposite Party has pointed out condition No. 5 of the exclusion clause mentioned in the terms and conditions of the policy which is marked as Ext. B1. The relevant portion of the exclusion clause is marked as Ext. B1(a), no benefits are available hereunder and no payments will be made for any claim under this policy on account of hospitalization or surgery directly or indirectly caused by based on, arising out of or however attributable to any of the following. Any diagnosis or treatment arising from or traceable to pregnancy and child birth including caesarean section or any treatment related to pre and post natal care and complications arising out of pregnancy and child birth. The Complainant has not produced any documentary evidence to show that this treatment arising from or traceable to pregnancy come under the policy. Ext A4 is the discharge summary filed by the Complainant, as per this document the wife of the Complainant was admitted in hospital for safe confinement and was discharged on 04.02.2021. Evidently, as contended by the Opposite Party the case of the Complainant falls under the exclusion clause. The said treatment undergone by the Complainant falls under the exclusion clause of the policy terms and conditions under Ext. B1, which cannot be entertained by the Opposite Party and the Opposite Party repudiated the claim. Such repudiation of the claim by Opposite Party is justified. The Opposite Party has rightly rejected the claim. Moreover, as per Ext B1 portability means transfer by an individual health insurance policy holder (including family cover) of the credit gained for pre-existing conditions and time bound exclusions if he/she chooses to switch from one insurer to another. As per clause 5 of the guidelines issued by IRDA, it is the policy holder who to fill the portability form along with proposal form. Here, the Complainant has not produced portability form. The terms and conditions are part of the insurance policy and the Complainant was expected to know it or he could have exercised the option to cancel the policy during the free look period as provided by the insurance company to the customers. Hence, there is no deficiency in service on the part of Opposite Party. So, Complaint is liable to be dismissed.
In the result, the Complaint is dismissed without costs.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 27th day of October 2023.
Date of Filing:-29.07.2021.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Vipin. O. S. Civil Engineer.
Witness for the Opposite Party:-
Nil.
Exhibits for the Complainant:-
A1. SYND Arogya (Group Health Insurance Scheme) for the period of
04.09.2019 to 03.09.2020.
A2. Mediclaim Insurance Policy Schedule.
A3. Copy of Denial of Cashless Facility. Dt:01.02.2021.
A4. Discharge Summary.
A5. Cash Bill.
A6. Summary of cash receipts for directly purchased medicine from
Iqra Hospital Pharmacy.
Exhibits for the Opposite Party:-
B1. Mediclaim Insurance Policy, Policy wordings.
B1(a). Condition No.5 shown in exclusions portion.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
