By Sri. Ananthakrishnan. P. S, President:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
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2. The Complainant’s case in brief is as follows:- The complainant is the holder of mediclaim policies issued by second opposite party. The policies are having continuity from 19.08.2014 to 28.07.2018. As per the policies, the complainant, his spouse and two children were covered. Meanwhile, the complainant’s wife Mrs. Jeena Biju was sick due to fibroid uterus, cervical elongation and cystocele. So, she was under the treatment at Vinayaka hospital Sulthan Bathery and DM WIMS, Wayanad. She was admitted in DM WIMS hospital for 7 days from 27.05.2017 to 02.06.2017. She had undergone surgery from DM WIMS hospital. Thus the complainant has spent an amount of Rs.56,882/- for the treatment. Thereafter, the complainant made a claim for reimbursement of hospital expenses from the opposite parties. But the second opposite party rejected the claim with a vague and unjustifiable reasons vide their letter dated 10.08.2017. It is against law and principles of natural justice. The complainant had paid all the hospital bills. Therefore, as per the conditions of the policy, the complainant is entitled to get the reimbursement of the hospital expenses. Therefore the rejection of his claim by second opposite party is deficiency in their service. There is unfair trade practice also. Therefore complainant filed this complaint to get Rs.56,882/- with interest at the rate of 6% p.a from the date of discharge and Rs.25,000/- towards compensation and Rs.1,000/- as cost.
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3. Opposite parties filed version and additional version contending as follows: They denied that there is deficiency in service on the part of opposite parties. The complainant filed this complaint without any bonafides. They admitted that they have issued a Universal health insurance policy in favour of complainant on 19.08.2015 and that the wife of complainant was admitted in DM WIMS hospital on 20.05.2017 for the treatment of fibroid uterus with cervical elongation. As per the discharge summary dated 23.05.2017 issued from DM WIMS hospital, the patient presented with mass per vagina since 5-6 years. So, the ailment of the wife of the complainant “fibroid uterus with cervical elongation” was a pre-existing disease which is thus not covered as per the terms and conditions of the policy. Here the policy of the complainant commenced on 19.08.2015 and the wife of the complainant was admitted in hospital on 20.05.2017 within 2 years of inception of policy. Since the claim submitted by complainant was not admissible as per the condition, these opposite parties rejected the claim and it was intimated to the complainant on 10.08.2017. The complainant had taken universal health insurance policy with a sum insured of Rs.30,000/- for his family with total expenses incurred for any one illness limited to Rs.15,000/-. While, the same policy was in force from 19.08.2014 to 18.08.2015, the complainant took a New India Floater Mediclaim Policy No.76060434152800000011 on 29.07.2015 for a sum insured of Rs.2 lakhs
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without furnishing existing policy details and suppressing the fact regarding the pre-existing disease. The complainant has taken this policy anticipating an expensive treatment of his wife for an ailment of fibroid uterus with cervical elongation. The complainant didn’t disclose the pre-existing disease of his wife in the proposal form submitted on 29.07.2015. Therefore the complainant is not entitled to get Rs.56,882/- with interest, compensation and cost as requested. Hence, this complaint is to be dismissed with cost of the opposite parties.
4. On the above contentions, the points raised for consideration are:-
1. Whether there is any deficiency in service on the part of opposite
parties.
3. Reliefs and Cost.
5. The evidence in this case consists of oral testimonies of PW1, OPW1 Ext.A1 series to A3, Ext.B1 to B3 and Ext.X1 series. Heard both sides.
6. Points No.1 :- It is an admitted fact that the complainant is a policy holder of mediclaim policy under the opposite parties and during the existence of this policy his wife was admitted and treated for fibroid uterus with cervical elongation. The grievance of the complainant is that even though, he entitled to get hospital
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expenses and he presented a claim before the second opposite party, the second opposite party rejected his claim without a valid reason. The opposite parties challenged the claim of the complainant on the ground that the wife of the complainant was treated for a pre-existing disease which is not covered by policy and he has also taken a new policy suppressing the earlier policy and pre-existing disease. Therefore, they contented that the rejection of the claim is within their power.
7. Complainant has given evidence as PW1. The Divisional Manager of the opposite parties has given evidence as OPW1. It is evident that the wife of the complainant Mrs. Jeena Biju was admitted in DM WIMS hospital Wayanad on 27.05.2017 and was discharged on 02.06.2017 during the existence of a valid policy. Ext.A1 series are the policy certificates. It is evident that she had undergone a surgery for fibroid uterus with cervical elongation. Ext.X1 series contain the claim form, treatment records and medical bills. The same documents are also mistakenly marked as Ext.A2 series through complainant. (So, hereafter, we have to refer the said documents as Ext.X1 series). Ext.A3 is the letter from the second opposite party by which they repudiated the claim of the complainant.
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8. As already stated, the specific stand taken by the opposite parties is that the complainant is not entitled to get anything because he suppressed the pre-existing disease of his wife and purposefully, he took New India Floater Mediclaim policy for a higher amount anticipating the huge expenses of the treatment of his wife while another policy for a lesser amount was in force. OPW1 deposed the reasons for rejection of the claim of the complainant. Ext.B1 is the proposal form. Ext.B2 is the schedule with conditions of New India Floater mediclaim policy. Ext.B3 is the schedule with conditions of Universal Health insurance policy. Normally, insurance companies never entertain any claim, for the treatment of a pre existing disease. The exclusion clause of every policy may contain this condition. Clause 4.1 of Ext.B2 and B3 contains such a clause. As per the said clauses, claim for treatment expenses of any pre-existing condition/disease is excluded, until 48 months of continuous coverage of such insured person have elapsed, from the date of inception of first policy. Therefore, the complainant is not entitled to get the claim, if his wife was treated for a pre-existing disease as stated in the condition. So, we have to find out, whether the wife of the complainant was treated for a pre-existing disease as contended by the opposite parties. Ext.X1(b) is the discharge summary by which it can be seen that the wife of the complainant was admitted on
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27.05.2017 before the DM WIMS hospital. The complainant presented a claim for getting the expenses towards the hospitalization of his wife during this period. Ext.X1(b) would go to show that the wife of the complainant was suffering from fibroid uterus with cervical elongation. It is evident from Ext.X1(ad) that the wife of the complainant was admitted in same hospital on 20.05.2017 and discharged on 23.05.2017. Ext.X1(ad) is the Discharge summary of the said period. Ext.X1(b) does not contain that the wife of the complainant had a previous history of any ailment. But, Ext.X1(ad) contains that the wife of the complainant was suffering from mass per vagina since 5-6 years. The opposite parties rejected the claim of complainant stating that the complainant suppressed this previous disease. According to them, the treatment of the wife of the complainant was in continuation of this previous disease. Here, there is no materials to prove that the opposite parties rejected the claim of the complainant after getting medical opinion. Mass per vagina as per medical dictionary means there is large and firm mass in vagina. Fibroid are abnormal growth that develop mainly in or on a womens womb. Cervical elongation denotes an elevated cervics. Cervics is the lower narrower part of uterus. So, presence of mass in vagina is not a reason to develop fibroid in or on uterus with cervical elongation. It is seen from medical records that the wife of the complainant was treated from 27.05.2017 for fibroid uterus with cervical elongation which is
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evidently not due to mass per vagina. Though OPW1 has given reasons for rejection of claim of the complainant, opposite parties have not examined any experts to prove that the mass per vagina is a pre-existing disease connected with fibroid uterus with cervical elongation. Without getting any expert opinion, they simply rejected the claim of complaint stating that his wife was suffering from a previous disease and they suppressed this to get illegal benefit. If that be so, we are of view that the opposite parties rejected the claim of the complainant without a valid reason with regard to the pre existing disease.
9. According to the opposite parties, during the existence of a policy, the complainant took another policy suppressing the previous one anticipating the treatment of his wife. But it is to be noted that the complainant took the second policy in the year 2015. But his wife was treated in the year 2017. So, it cannot be said that he took second policy anticipating a treatment of his wife in the year 2017. The opposite parties have also argued that the complainant suppressed the prior policy and pre-existing disease in the proposal form. Ext.X1(a) is the proposal form. Complainant has not mentioned the earlier policy in Ext.X1(a). As already stated, since it is evident that his wife had no previous disease, he need not mention the presence of mass per vagina in the proposal form. So, here no materials to prove
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that the complainant or his wife had knowledge about this so called previous disease. More over, we don’t understand why the opposite parties rejected the claim of the complainant stating that he suppressed all these things. Clause 5.1 of Ext.B3 provided that the policy is issued on the basis of the truth and accuracy of the statement in the proposal and if there is any misrepresentation or non-disclosure, the insurance company is entitled to treat the policy as void ab-initio. As we already stated, here there is no suppression with regard to previous disease. It is true that the complainant has not mentioned about the previous policy in the proposal form when he took the second policy.
10. The previous policy was Universal Health Insurance policy and new policy is New India Floater Insurance policy. It is evident that the complainant has taken Universal Health Insurance policy for a lesser claim than that of the claim entitled as per New India Floater Insurance policy. More over it is evident that he has not taken the second policy anticipating the disputed treatment of the wife of the complainant. So, we don’t understand what is the harm in taking a second policy for a higher amount. Opposite parties have no case that a party is not entitled to join a second policy if there is an existing policy. Therefore the evidence put forth in this case established that there is deficiency in service from the part of opposite
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parties. So, the complainant is entitled to get the claim amount with cost and compensation.
11. The complainant wants to get Rs.56,882/- as the expenses incurred by him in the hospital. Ext.X1 series contained the medical bills by which it can be seen that he spent Rs.56,882/- during the hospitalization. So, no doubt he is entitled to get back this amount. Complainant claimed Rs.25,000/- as compensation. It is exorbitant amount. Rs.10,000/- is reasonable. So, no doubt, he is entitled to get Rs.10,000/- as compensation and Rs.2,000/- as cost.
12. Points No.2 :- Since the Point No.1 is found in favour of complainant, he is entitled to get relief and cost as stated above.
In the result, the complaint is allowed and the Opposite parties are directed to pay Rs.56,882/- (Rupees Fifty Six Thousand Eight Hundred and Eighty Two Only) to the complainant with an interest at the rate of 6% per annum from the date of discharge from the hospital ie. From 02.06.2017. They are also directed to pay Rs.10,000/- (Rupees Ten Thousand Only) as compensation and Rs.2,000/- (Rupees Two Thousand Only) as cost to the complainant. The opposite parties are directed to pay this amount within 30 days from the date of receipt of this Order.
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Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 23rd day of October 2020.
Date of Filing: 09.11.2017.
PRESIDENT :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the complainant:-
PW1. Biju. A. V. Driver.
Witness for the Opposite Parties:-
OPW1. K. Somanathan Nair. Divisional Manager.
Exhibits for the complainant:
A1(a). Universal Health Insurance Policy Schedule. Dt:18.08.2014.
A1(b). Universal Health Insurance Policy Schedule. Dt:18.08.2015.
A1(c ). New India Floater Mediclaim Schedule.
A1(d). New India Floater Mediclaim Schedule. Dt:27.07.2016.
A1(e ). New India Floater Mediclaim Schedule. Dt:26.07.2016.
A3. Letter. Dt:10.08.2017.
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X1(a). Claim Form for Health Insurance Policies of the New India
Assurance Company Limited.
X1(b). Discharge Summary.
X1(c ). Test Report. Dt:27.05.2017.
X1(d). In-patient Final Bill. Dt:02.06.2017.
X1(e ). IP Final Bill Invoice. Dt:02.06.2017.
X1(f). IP Final Bill Invoice. Dt:02.06.2017.
X1(g). IP Final Bill Invoice. Dt:02.06.2017.
X1(h). Prescription. Dt:30.05.2017.
X1(i). Material Bill Credit. Dt:30.05.2017.
X1(j). Prescription. Dt:29.05.2017.
X1(k). Pharmacy Credit Bill. Dt:30.05.2017.
X1(l). Material Bill Credit. Dt:29.05.2017.
X1(m). Pharmacy Credit Bill. Dt:29.05.2017.
X1(n). OP Bill Cash. Dt:27.05.2017.
X1(o). Patient Deposit Receipt. Dt:27.05.2017.
X1(p). Patient Deposit Receipt. Dt:28.05.2017.
X1(q). Patient Deposit Receipt. Dt:31.05.2017.
C1(r ). Pharmacy Cash Bill. Dt:08.06.2017.
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X1(s). Pharmacy Credit Bill. Dt:02.06.2017.
X1(t ). Prescription. Dt:31.05.2017.
X1(u). Material Bill Credit. Dt:28.05.2017.
X1(v). Material Bill Credit. Dt:28.05.2017.
X1(w). Prescription. Dt:30.05.2017.
X1(x). Prescription. Dt:01.06.2017.
X1(y). Pharmacy Credit Bill. Dt:30.05.2017.
X1(z). Pharmacy Credit Bill. Dt:01.06.2017.
X1(aa). Pharmacy Credit Bill. Dt:31.05.2017.
X1(ab). Prescription. Dt:28.05.2017.
X1(ac). Pharmacy Credit Bill. Dt:28.05.2017.
X1(ad). Discharge Summary.
X1(ae). Result Report.
X1(af). Result Report.
X1(ag). Result Report.
X1(ah). Result Report.
X1(ai). Result Report.
X1(aj). Result Report.
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X1(ak). Result Report.
X1(al). In-patient Final Bill. Dt:23.05.2017.
X1(am). IP Final Bill Invoice. Dt:23.05.2017.
X1(an). Result Report.
X1(ao). Material Bill. Dt:23.05.2017.
X1(ap). Pharmacy Cash Bill. Dt:23.05.2017.
X1(aq). Pharmacy Credit Bill. Dt:23.05.2017.
X1(ar). Realtime Covex Sector Ultra Sound Study of the
Abdomen and Pelvis. Dt:19.05.2017.
X1(as). Test Report. Dt:18.05.2017.
X1(at). Claim Form Part-B. Dt:19.05.2017.
X1(au). Discharge Summary.
X1(av). Final Bill. Dt:19.05.2017.
X1(aw). Pharmacy Bill. Dt:19.05.2017.
X1(ax). Pharmacy Bill. Dt:18.05.2017.
X1(ay). Test Report. Dt:18.05.2017.
X1(az). Pharmacy Bill. Dt:18.05.2017.
X1(ba). Pharmacy Bill. Dt:18.05.2017.
X1(bb). Pharmacy Bill. Dt:18.05.2017.
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X1(bc). Pharmacy Bill. Dt:19.05.2017.
X1(bd). Test Report. Dt:19.05.2017.
X1(be). Test Report. Dt:19.05.2017.
X1(bf). Pharmacy Bill. Dt:18.05.2017.
X1(bg). Bill. Dt:18.05.2017.
X1(bh). Test Report. Dt:19.05.2017.
X1(bi). Bill. Dt:19.05.2017.
X1(bj). Test Report. Dt:19.05.2017.
X1(bk). Service Bill. Dt:19.05.2017.
X1(bl). Test Report. Dt:18.05.2017.
Exhibits for the opposite parties:-
B1. Copy of Proposal Form for New India Floater
Mediclaim Policy.
B2. Copy of Universal Health Insurance Policy
Schedule. Dt:18.08.2014.
B3. Copy of New India Floater Mediclaim
Schedule. Dt:26.07.2016.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
SENIOR SUPERINTENDENT,
CDRC, WAYANAD.
