Order No. 9 dt. 31/01/2017
The case of the complainant in brief is that the complainant had availed of mediclaim insurance policy of o.ps. under the Floatal Scheme in the year 2014. The said mediclaim scheme was in the joint name of the complainant and his wife. At the time of issuing of the said policy o.p. no.1 had taken the premium in full for the year 2014 and the policy was valid till April of the succeeding year. The complainant was admitted to We Care Nursing Home in the month of Feb 2015 due to respiratory trouble and he was released on 11.3.15. After the recovery from illness the complainant made claim towards the expenses borne by him to the tune of Rs.1,42,000/- for medical reimbursement. The o.ps. after receiving the application for the reimbursement of the claim refused on the ground that the complainant had pre existing disease in the name of SOB / Wheeze for the last 35 years. The complainant thereafter issued a lawyer’s notice and since no reply was given and no action was taken on the part of o.p. no.1 the complainant had to file this case praying for total reimbursement of the medical bills with interest and compensation of Rs.30,000/- and litigation cost of Rs.20,000/-.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that from the record it transpires that the insured took mediclaim policy being no.311700/48/2015/147 and the said policy was valid from 7.4.11 to 6.4.15 for sum assured of Rs.1 lakh. The complainant was admitted in the We Care Nursing Home on 26.2.15 and he was discharged on 11.3.15 due to his illness of Pneumonia Organism Unspecified, other Septicemia. The o.ps. made enquiry after receiving the documents filed by the complainant and it came to the knowledge of o.ps. that as per investigation report showing patient suffering SOB / Wheeze since 35 years as per the treatment sheet dt.28.2.15. Based on the investigation report and on recommendation of TPA o.p. no.1 repudiated the claim vide letter dt.22.7.15. The o.ps. relied on the exclusion clause as mentioned in the policy 4.1 wherein it was stated that in case of any ailment, disease, injuries, health condition which are pre existing, in case of any insured person of the family when the cover incepts for the first time are excluded for such insured person upto three years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered provided the renewals have been continuous and without any break in period. Since here in this case the complainant had the pre existing disease, the claim of the complainant for reimbursement of medical bills was repudiated. In view of the said fact o.ps. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the mediclaim policy at the relevant point of time.
- Whether the complainant was admitted in the said nursing home and underwent treatment.
- Whether the complainant had the pre existing disease.
- Whether there was any justifiable cause for repudiation of the claim of the complainant.
- Whether there was any deficiency in service on the part of o.ps.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant had the mediclaim policy along with his wife and the complainant suddenly became ill and was admitted to the We Care Nursing Home in the month of Feb 1015 due to respiratory trouble and he had been there for several days and he was discharged on 11.3.15. During the stay of the complainant in the said nursing home he had to borne the medical expenses to the tune of Rs.1,42,000/- and the complainant after recovery demanded the said amount but the claim of the complainant was repudiated.
Ld. lawyer for the complainant emphasized that the first year policy can be denied only on the ground of pre existing disease and the said pre existing disease has to be established through proper medical test by the insurance company and o.ps. must prove the said fact that the complainant had the pre existing disease. Since o.ps. failed to prove the pre existing disease as alleged and as such the plea of the first year policy for repudiation of claim does not stand valid and acceptable in the present case. the exclusion clause as mentioned in 4.1 it states that any ailment, disease, injuries, health condition which are pre existing (treated untreated, declared undeclared in the proposal form) in case of the insured person of the family when the cover incepts for the first time are executed for such insured person upto three years of this policy being in force continuously. From the statement of the exclusion clause the said clause has been framed in order to cover of the latches and/or deficiency on the part of the insurance company and to repudiate the claim of the insured of this vague clause. It is the duty of the insurance company to execute pre medical test of the insured in order to ascertain the existence of any pre existing disease or not. A patient is not always in knowledge of the pre existing disease till treated by a doctor [2005(1) CPC 482 Punjab]. The medical certificate relied upon by the insurance company was not produced by an affidavit and in a judgment reported in 2009 (3) CPR 123 Punjab wherein it was held that the medical certificate is without any affidavit from the concerned doctor, the said certificate cannot be considered. In view of the facts and circumstances as stated above the ld. lawyer for the complainant prayed for allowing the prayer of the complainant with the compensation and other reliefs.
Ld. lawyer for o.ps. argued that it is not any dispute that the policy was not valid at the relevant point of time and it is also an admitted fact that the complainant was submitted to the nursing home but from the medical report collected by TPA it appears that the complainant had the history of suffering from SOB / Wheeze for the last 35 years and as per exclusion clause of the policy 4.1 the complainant since had the pre existing disease and suppressed the said fact and the policy was for the first time therefore the complainant will not be entitled to get the medical reimbursement as claimed by him. On the basis of the said fact o.ps. rightly repudiated the claim of the complainant.
Considering the submissions of the respective parties it is admitted fact that the complainant had the valid policy at the relevant point of time. From the materials on record it is also found that the complainant became ill and he was admitted to We Care Nursing Home wherein he was treated there and after recovery he claimed the medical reimbursement of the bills to the tune of Rs.1,42,000/-. Ld. lawyer for the complainant emphasized that if the insurance company would have examined the complainant by a doctor it could have been ascertained whether the complainant had the illness prior to getting admission in the said nursing home. Since the insurance company did not make any arrangement for examination of the complainant by a doctor, therefore the plea of o.ps. that there was suppression of pre existing disease and on the basis of the clause 4.1 of the policy the claim of the complainant cannot be repudiated. In support of the said contention ld. lawyer for o.ps. relied on some decisions.
We have gone through those decisions as well as the documents and evidence produced by the respective parties. From the materials on record it is crystal clear that the complainant had the illness for which he was admitted to the nursing home. So far as the repudiation of the claim of the complainant is concerned ld. lawyer for the complainant emphasized that it was the bounded duty of o.ps. to examine the insured at the time of acceptance of the insurance policy. Ld. lawyer for o.ps. emphasized that the complainant did not disclose his illness in the column therefore how the o.ps. will come to know that there was any disease. Ld. lawyer for o.ps. in support of the said contention relied on the documents wherein it was mentioned that the complainant was suffering from Episodic SOB / Wheeze for the last 35 years and the said fact was disclosed from the medical treatment sheet dt.28.2.15 and those documents were provided by the complainant himself. Apart from the said fact the complainant had other illness, those facts were also suppressed at the time of obtaining the policy.
In this respect we can rely on a decision as reported in 2016 (4) CPR 471 (NC) wherein it was held by Hon’ble National Commission that any fact which goes to root of contract of insurance and as a bearing on risk involved would be material. Had assured disclosed that he was suffering from those diseases the Oriental Insurance Co. would have asked for special medical reports which would have been placed before a medical referee and based upon report of medical referee, decision would have been taken whether to accept proposal or not. False or inaccurate statement by assured was on material aspect which influenced decision of insurer on whether to accept proposal or not and therefore Hon’ble Commission held that the insurer was justified in repudiating the claim on account of false statement made by the assured in the proposal form. Here in this case since the complainant suppressed the material fact regarding his pre existing disease, therefore o.ps. did not make any arrangement for medical test of the complainant before acceptance of the policy, accordingly we hold that the repudiation made by o.p. insurance company was justified and the complainant could not establish the fact that he had no such ailment prior to the filling up of the proposal form and the said ailment occurred after the acceptance of the policy. No such evidence was brought by the complainant at the time of hearing of the case, accordingly the repudiation made by o.ps. was justified and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.529/2015 is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
