Date of filing of the case- 07.07.2017
Date of order - 11.05.2018.
ORDER.
Sri A.K.Purohit, President.
The complainant has preferred this case alleging deficiency in health insurance service. The case of the complainant is that, the complainant had taken health insurance policy (Hospitalization benefit policy) under Health Insurance Plain from the O.P since 2012 and the policy is renewed in each and every year on payment of premium upto fourth year and the premium amount is Rs 15,790/-. The fourth year policy is valid from 5.12.2016 to 4.12.2017 which covers the complainant and his family members and the coverage is upto 6,75,000/-. During subsistence of the said policy the complainant on dated 1.5.2017 suddenly suffered chest pain and he was immediately shifted to Apollo Hospital Bhuaneswar, where he was treated in the ICU from 2.5.2017 to l4.5.2017 and another one day in bed No.431 for observation. The complainant alleges that although he is entitled to cashless benefit as per the policy condition, the same was denied by the O.Ps for which the complainant paid Rs 3,35,399/- to the Hospital and without any valid reasons the O.Ps have repudiated the claim of the complainant. Hence the complaint.
2. The O.Ps have contested the case by filing their written version jointly. In their version the O.Ps have denied all the allegations of the complainant and submitted that, on verification of the claim the O.P found that, the complainant was treated as out patient in Narayan Hrudalay Hospital where he under went Angio on 2005 and subsequent investigation was performed in the year 2013, which the complainant has not disclosed in his proposal form and hence the claim was repudiated for non discloser of previous disease as per condition No.9 of the policy. Hence there is no deficiency in service on the part of the O.Ps.
3. Heard both the parties, perused the documentary evidence available on record. In support of his case the complainant has filed insurance papers, payment receipt of hospital bill along with detailed cost and repudiation letter. On the other hand the O.Ps have filed medical report of previous treatment of the complainant and conditions of policy.
4. It is an admitted fact that, the complainant ;had taken the health insurance policy from the O.P for himself and for his family under family Health Optima Insurance plan since 2012 and the same was renewed each and every year upto 4 times on payment of premium. It is also not disputed by the O.Ps that, during subsistence of the said policy the complainant was treated at Appolo Hospital, Bhuaneswar and was admitt6ed in the ICU. Perused the repudiation letter and denial of cashless treatment. The claim of the complainant was repudiated on the ground of suppression of material facts i.e non disclosure of pre-existing disease.
5. After going through the material available on record, it is seen from the out patient medical report issued by the Narayan Health dated 17.06,2015 that the said institute found minor CAD without chest pain in the year 2005 and some investigation were done on dt.5.3.2013. This report filed by the O.P does not have any seal and signature of the authority of the Narayan Health . Assuming it to be true, then the ailment was in the year 2005 and the complainant had taken the policy in the year 2012 i.e after seven years of the said report. The report discloses that the complainant was having the symptom of acidity and debility which are minor disease and the same must have cured by the time of taking the policy in the year 2012. The report does not disclose any disease in the year 2013 and it show that some investigations are done on dt.5.3.2013. Further it is seen from the admitted facts that, the policy was renewed on each and every year upto 4 time since 2012 but the O.Ps have not taken any step for an inquiry relating to pre-existing disease and for the first time after demand of cashless treatment they have come of with this plea. Therefore in the absence of believable evidence the stand of the O.Ps can not be accepted. Hence the repudiation of the claim of the complainant is without any reasonable grounds.
6. Health Insurance policy is meant to overcome the financial burden in making payment to the hospital. Denial of the same during the validity of the policy by the O.Ps amounts to deficiency in service on the part of the O.Ps.
7. The deposit receipt of the Appolo Hospital vide receipt No. 3888938 dt.6.5.2017 shows that the complainant had paid to the hospital an amount of Rs 3,35,399/- for his treatment. The O.Ps are duty bound to indemnify the said amount to the complainant.
Hence ordered.
The O.Ps are directed to pay Rs 3,35,399/- (Rupees Three Lakhs thirty five thousand seven hundred ninety nine) only with an interest @ 9% P.A from the date of repudiation i.e from 15.5.2017 till payment along with Rs 10,000/- (Rupees Ten Thousand) towards litigation expenses to the complainant within one month from the date of receipt of this order failing which the entire amount shall carry an interest @ 12% P.A from 15.5.2017 till payment.
Order pronounced in open forum this the 11th day of May 2018.
Sd/- Sd/-
(S.Rath) (A.K.Purohit)
MEMBER. PRESIDENT.
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