IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 30th day of August, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 135/2021 (Filed on 02-08-2021)
Petitioners : (1) Rovin Scaria Stanley,
S/o. Stanley Scaria,
A-8 Golden Enclave,
Kanjikuzhy, Kottayam.
Pin – 686 004.
(2) Ashwani Parakkal,
W/o. Rovin Scaria Stanley,
A-8 Golden Enclave,
Kanjikuzhy, Kottayam.
Pin – 686 004.
(Adv. Binoy Abraham)
Vs.
Opposite party : The New India Assurance Co. Ltd.
Kottayam City Branch,
3rd Floor, P John Zacharia Buildings,
Central Junction, Kottayam
Pin 686 001.
Rep. by its Branch Manager.
(Adv. P.G. Girija)
O R D E R
Smt. Bindhu R. Member
The 1st complainant is a policy holder of a mediclaim policy known as ‘New India Floater mediclaim policy’ issued by the opposite party on 25.2.20 for the period from 6.3.20 to 5.3.21 bearing policy no. 76010134192800000239. Floater sum insured as per the said policy was 8,00,000/- plus cumulative bonus amounting to Rs.2,00,000/-. The 2nd complainant, who is the wife of the 1st complainant also was covered by the aforesaid policy. The date of inception of the policy is 29.2.12 in the name of the 1st complainant and after his marriage the name of his wife, the 2nd complainant also was incorporated from 6.3.2019.The 2nd complainant was having her own individual mediclaim policy covering an amount of Rs.5,00,000/- with Star Health and Allied Insurance Company ltd. from 25.3.2013 onwards without any break. The last policy taken by the 2nd complainant with the said star health and allied insurance ltd, was for the period from 25.3.18 to 24.3.19 . Hence the 2nd complainant is also having mediclaim coverage without any break from 25.3.2013 onwards. Both the complainants are totally covered from 6-3-2020 to 5-3-2021. The said policy was a cashless policy. In December 2020 the 2nd complainant began to feel some sort of discomfort during breathing and on detailed medical check up Severe mitral Regurgitation was diagnosed and a heart surgery was advised by the doctors and she was admitted at SRM Institute for Medical Science, Vadapalani, Chennai on 7.1.2021. She underwent a major heart surgery on 8.1.2021 for repairing her mitral valve using 34mm Medtronic CG future mitral ring P2 resection and sliding plasty.’After the surgery the 2nd complainant continued her post-operative treatment at the hospital about two weeks and she was discharged on 21.1.21. A total amount of Rs.6,84,541/- was incurred to the complainants for the said surgery and incidental treatment expenses at the hospital. As the policy taken by the complainants was a cashless policy, they informed the hospital authorities about the policy and the hospital authorities informed the opposite party about the existence of the cashless policy of the complainants and requested the payment but the opposite party denied the cashless facility to the 2nd complainant. The sudden denial of the policy by the opposite party caused much hardships to the complainants. It was very difficult for the 1st complainant to arrange money as they were in Chennai. Somehow the 1st complainant managed to arrange the money. The only reason stated by the opposite party to decline the cashless benefit is that “suspecting” that it was a pre-existing disease, that too without medical evidence. It was a clear denial of service ought to have been given by the opposite party to the complainants. Thereafter the opposite party advised the complainants to make their claim after discharge from the hospital for reimbursement of the amount paid towards treatment expenses. Accordingly the complainants submitted the claim of Rs.6,84,541/- to the opposite party but to the utter dismay of the complainants that too was rejected on 19.3.21 for the reason that “ No claim will be payable under this policy for the treatment of any pre- existing condition disease, until 48 months of continuous coverage of such insured person have elapsed.”
The 2nd complainant had no pre-existing disease. The surgery was done for a decease which was diagnosed just few days before the surgery. The opposite party has purposefully denied the insurance coverage accrued under the policy taken by the complainants without any valid and cogent reason but according to their whims and fancies. The complainants are entitled for the reimbursement of the entire bill amount of Rs.6,84,541/- towards treatment expenses. The act of the opposite party to deny the cashless facility as well as the reimbursement of the amount is a clear case of deficiency in service and hence the opposite party is liable to reimburse the insurance amount and to compensate the complainant for their mental agony and hardships.
Upon notice the opposite party appeared and filed version contending that the complainants policy starts from 6-3-20 to 5-3-21 vide policy no. 76010134192800000239. The date of inception of the said policy with regard to the second complainant is 6-3-2019. As far as the second complainant is concerned, there was no porting of any other policy to the opposite party. The complainant has to prove the treatment undergone by the second complainant and the medical expenses involved. It is admitted that the complainants have submitted a claim of Rs.6,84,541/-and the opposite party rejected the same.
The reason of rejection is as per Exclusion no 4.1 of the policy terms and
conditions, “No claim will be payable under this policy for the treatment of any pre-existing condition / Disease until 48 months of continuous coverage of such insured person have elapsed”. The commencement date of the policy with respect to the 2nd complainant is 6.3.2019,the surgery was on 7.1.21.So the claim arose before 48 months of continuous coverage of the policy since the 2nd complainant had pre-existing decease. As per the treating doctor, the cause of the heart ailment of the 2nd complainant was degenerative and the ailment existed prior to the commencement of the policy. So the repudiation of the claim is fair and proper and there is no deficiency of service on the part of the opposite party.
The complainant has filed proof affidavit along with documents which were marked as Exhibit A1 to A6.The opposite party filed proof affidavit and exhibit
B1.
On perusal of the pleadings and evidence on record, we would frame the
following issues.:
- Whether the repudiation of the claim by the opposite party amounts to
deficiency of service?
2. If so what are the reliefs the complainant is entitled for?
Points 1 and 2
1. The case of the complainant is that the name of his wife also was incorporated in the policy no 7601034182800000249from 6-3-19 to 5-3-20 whereas the wife of the complainant had a mediclaim policy of star health from 25-3-2013. On 7-1-21 the complainant’s wife underwent a surgery, but in spite of the fact that the policy was a cashless one, they repudiated the same. Later though he had submitted a claim to the opposite parties, it was also repudiated on the ground of pre existing decease. This is alleged as deficiency in service whereas the opposite party contended that the 2nd complainant had the policy only from 6-3-19 and so as the decease was a pre-existing one, as per their terms and conditions, they were unable to award the claim.
2. Now, we gave a thoughtful consideration over the pleadings and evidence. The complainants have produced Ext.A1, the policy schedule of policy no 7601034192800000239from 6.3.20 to 5.3.21, the previous policy date is shown as 6.3.19 to 5.3.20 and the policy no is 761034182800000249 in which the 1st complainant claims that the name of the 2nd complainant also is included. It is correct that the 2nd complainant is also an insured in the said policy. But though the 2nd complainant was insured under the Star Health allied insurance limited from 25-3-13 onwards, it was a different policy. The complainant has no averment that the said policy was ported to the opposite party company. So the
averment regarding the date of enrolment of the 2nd complainant is not correct as the date of enrolment of the 2nd complainant with the opposite party is 6.3.2019 As per B1.
3. The policy taken by the 1st complainant from the opposite party has insured the 2nd complainant also from 6.3.19. The contention of the opposite party is that as the inception of the 2nd complainant’s policy was only 6.3.19 and the surgery date was on 8.1.21 which was within 48 months from the inception of the policy, it was repudiated. The opposite party did not pay the bill of the hospital to provide the cashless facility or did not approve the claim submitted by the 1st complainant subsequently for the reason that “No claim will be payable under this policy for the treatment of any pre-existing condition disease until 48 months of continuous
coverage of such insured person have elapsed.”
4. We have verified the B1 document which is the policy document of the 1st complainant with the opposite party in which the 2 nd complainant also is made an insured. The 1st clause of B1 is that “If during the Period of Insurance, You or any insured Person incurs Hospitalization Expenses which are Reasonable and Cutomary and Medically Necessary for treatment of any Illness or injury sustained in Accident, We will reimburse such expense incurred by You, in the manner stated herein” So the policy will cover “treatment for any illness” during the period of insurance.
Cl.2.21 defines: illness means sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment”
5. The opposite party repudiated the claim under clause 4.1.which reads as Pre existing diseases
a. Expenses related to the treatment of pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured Increase.
d. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.
Whereas the clause 4.2 specific waiting period
subclause (i) 90 days waiting period:
- Diabetes Millitus
- Hypertension
- Cardiac Conditions
6. So it is clear from B1 conditions itself that the waiting period of cardiac conditions is only 90 days. In the case of the 2nd complainant she was not ill at the time of enrolment in the policy as perA2 series which are the policy schedule of Star health insurance. In A2 series no previous disease is recorded from 2013
to 2018. The disputed policy date is 6.3.19. In A1 document which is the policy document of the opposite party also the pre-existing disease column is filled as nil. We find that it is the duty of the opposite party to verify and confirm whether the insured is having any disease at the time of inception of the policy. Here in the policy certificate itself it is shown that no pre-existing disease at the time of the inception of policy. The clause C2.35 – Pre-Existing Disease (PED) means any condition, ailment, injury or illness
- That is / are diagnosed by a physician within 48 months prior to the effective date of the policy issued by Us and its reinstatement or
- For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the Policy or its reinstatement stipulates that pre-existing disease if any to be diagnosed or treatment advised within 48 months prior to the inception of policy. Here there is no evidence that the complainant had undergone any treatment prior to the policy inception.
Moreover, the opposite party has not established that the 2nd complainant insured was having any pre-existing decease at the time of inception of the policy and hence the contention that repudiation on pre-existing disease is not sustainable.
7. On a perusal of Exhibit A3, the discharge summary issued by SRM Institutes for Medical science, Vadapalani where the 2nd complainant was treated and underwent surgery, we find that it is noted that past medical history as ‘nil significant’ and past surgical history also is noted as ‘Nil significant’. If any disease existed previously it would have been noted in the discharge summary
and the 2nd complainant would have been treated also. But no such evidence is on record to prove that the 2nd complainant was undergoing any treatment or she had knowledge of having some decease but did not disclosed to the opposite party wilfully.
9. Though the insurance companies stipulate that pre-existing conditions are excluded from the policy coverage, the term itself has been interpreted widely by the honourable apex courts.
10. In A1, the policy schedule the column regarding the personal details of the insured persons, in the column for pre existing disease it is written as ‘N’for both the insured. So also in A2 series documents which are the policy schedules of the other policy of the 2nd complainant, pre existing diseases if any is shown as ‘NIL’.
Thus in the light of above discussion of evidence on record and judicial precedents, we find that there is deficiency of service on the part of the opposite party in denying the cashless facility to the complainant and repudiating the claim submitted by the complainant on the ground of preexisting disease as the opposite party has failed to prove their contention of pre-existing disease with coherent evidence.
11. As per Exhibit A1 and admittedly, the complainant has paid 11,343/- as annual premium for the two insureds. The sum insured of the policy is Rs.8,00,000/- and the cumulative bonus is Rs.2,00,000/-. Exhibit A4 shows that the complainant had paid Rs.6, 84,541/- as the net bill amount incurred in the hospital which is unchallenged. The complainant in the belief that the opposite
party would indemnify him for the hospital expenses as cashless was put in fretfulness with the ailing wife in the hospital that too outside Kerala due to the act of the opposite party. The mental agony of the complainants should be compensated in terms of money.
12. Hence considering all the pleadings and evidence and in the light of above discussion, we allow the complaint in following terms:
- The opposite party is directed to give Rs.6,84,541/- with interest @9% p.a.
from the date of admission in the hospital ie.21.1.21
- The opposite party is further directed to pay Rs.50,000/-to the complainant
as compensation for mental agony.
3. The opposite party is directed to pay Rs.5000/- towards cost.
Pronounced in the Open Commission on this the 30th day of August, 2022
Smt. Bindhu R. Member Sd/-
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant.
A1 – Copy of insurance policy in the name of 1st complainant
A2 – Copy of Mediclassic insurance policy No. P/181217/01/2018/007860
A2 series – Copy of family health optima insurance policy – schedule (5 nos)
A3 – Copy of discharge summary from SIMS SRM Institute for Medical Science
A4 –Copy of bill dtd.21-01-21 issued by SIMS Institute for Medical Science
A5- Copy of letter dtd.08-01-2021 by Medi Assist Insurance TPA Pvt. Ltd to the Administrator, SRM Institute for Medical Science
A6 –Copy of letter dtd.19-03-21 by opposite party to 1st complainant
Exhibits marked from the side of opposite party
B1 – Copy of policy with terms and conditions
By Order
Assistant Registrar
