DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 8th day of September, 2023
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member Date of Filing: 08/07/2022
CC/118/2022
V.Murukan,
S/o.Velan P, (Late),
15/682, “Aardhra”,
Attingal Road, Thiruvalathur (PO),
Kodumbu, Palakkad – 678 551 - Complainant
(By Adv. M/s Praseetha K., & Faiq Syed)
Vs
United India Insurance Company Ltd.,
Rep. by its Manager,
2nd Floor, Delma Centre,
Near Post Office Junction,
Nemmara, Palakkad – 678 508 - Opposite party
(O.P. by Adv. T. Giri)
O R D E R
By Sri. Vinay Menon V., President
- Complaint pleadings depict that the complainant was a beneficiary of a health insurance policy issued by the O.P. During the subsistence of the policy, complainant was admitted for treatment. Complaint is filed pursuant to repudiation of claim for the hospital expenses by the O.P.
- Opposite parties admitted issuance of the policy, its subsistence and validity. But they defended rejection as being a pre-existing disease as contemplated under the terms and conditions of the policy, indemnification for which will be possible only after a stipulated period of time. They also stated that the claim was barred based on the first thirty days bar. They sought for dismissal of the complaint.
- Based on the pleadings and counter pleadings, the following issues were framed:
- Whether the complainant was suffering from pre-existing disease (hypertension) at the time of inception of the policy?
At the time of framing of issues, this Commission had missed to frame one issue regarding the first thirty days clause as contemplated under Clause 5.30 on the terms and conditions in the policy. Hence this question is being framed as Additional Issue 1A
1A. Whether the date of admission of the complaint falls under the first thirty days waiting period as contemplated under the terms and conditions of the policy?
- Whether there was any suppression of material facts from the part of the complainant?
- Whether the repudiation of the claim by the O.P. was as per the policy Terms and Conditions?
- Whether there is any deficiency in service on the part of the O.P.?
- Whether the complainant is entitled to any of the reliefs claimed?
- Reliefs and costs, if any?
4. (i) Complainant filed proof affidavit and marked Ext. A1 to Ext. A16.
(ii) O.P. filed proof affidavit and marked Exts. B1 and B2.
Issue Nos. 1 & 1A
5. Both these issues can be considered together.
Complainant’s case is that he was admitted during the subsistence of the policy. O.P.s repudiated the claim stating that condition was a preexisting condition as contemplated under the terms and conditions of the policy document.
On 22/12/2021, the complainant met a doctor for consultation regarding hypertension. Ext. A4 is the referral letter issued by the said consulting doctor, one Dr. S.K. Lakshminarayanan. Consultant doctor had referred the complainant for further management and complainant was admitted for treatment on 28/12/2021 and discharged on 04/01/2022. He was admitted for treatment of Systemic Hypertension and CVA – Acute Pontine Infarction. These facts are not in dispute.
6. None of the parties had submitted letter of repudiation. Hence cause of repudiation has to be assimilated from the pleadings in the version.
Line 1 onwards of paragraph 4 shows the cause of repudiation: “Since the petitioner has taken policy only on 5.11.2021 and admission at hospital on 28.12.2021 and diagnosed cerebrovascular acute pontine infarct and hypertension ………………………………………..So the company is not liable to reimburse the amount.”
Hence repudiation was based on the ground that the condition suffered by the complainant was a pre-existing disease as contemplated under Clause 4.0 and the exclusion based on first thirty days under Clause 5.3.
7. Ext.A2 is the policy schedule issued to the complainant. Clause 4.0 is as below:
“4.0. PRE-EXISTING DISEASE means any condition, ailment, injury disease:
i. That is / are diagnosed by a physician within 48months prior to the effective date of the policy issued by the insurer or its reinstatement or
ii. For which medical advise or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement”.
8. Clause 5.3 is reproduced as herein below:
“5.3. First Thirty Days Waiting Period
i. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
ii…………………………………………
iii. ………………………………………….”
9. In order to ascertain whether 22/12/2021, i.e. the date on which the complainant was diagnosed with blood pressure falls within the exceptions stated above we have to go through the relevant dates.
Sl. No. | Date | Description | Source | Remark |
1 | 05/11/2021 | Inception of policy | Ext.A2 | Effective date of policy |
2 | 5/12/2021 | 30 days after inception | Clause 5.3 of Ext.A2 | |
3 | 22/12/2021 | First detection of disease | Ext.A4 | 17 days after first 30 days |
4 | 28/12/2021 | Admission for treatment | Ext.A1 | |
5 | 5/11/2017 | 48 months prior to the date of inception | Clause 4 of Ext.A2 | First diagnosis is on 22/12/21 |
10. It can be seen that in order to have the date fall within the definition of preexisting disease the symptom should have occurred on some dates between 5/11/2017 to 5/11/2021. Thus we can see that the symptom was diagnosed after the period referred in clause 4, ie. 48 months prior to the effective date of the policy.
We therefore hold that the condition suffered by the complainant is not a pre-existing disease.
11. The next question is whether the symptom is covered under the first 30 days clause. Date of inception is 5/11/2021. 30 days period will fall within 5/12/2021. As already stated, first detection was made on 22/12/2021, 17 days after the first 30 days. Thus the case of the complainant falls beyond the ambit of clause 5.3 also.
12. Therefore we hold both Issues 1 and 1A in favour of the complainant and against the O.P.
Issue No. 2
13. Since the opposite party is not having a plea that the complainant had suppressed material facts, and the pre-existing disease contemplated hereunder is merely one under the terms and conditions of the policy, we need not look into this issue.
Issue Nos.3 & 4
14. In view of the findings in issue No.1, we hold that repudiation of complainant’s claim is not in accordance with the terms and conditions of the policy.
15. Resultantly, there is deficiency in service on the part of OP.
Issue No. 5
16. Reliefs sought for by the complainant is that a direction be issued to the OPs to indemnify Rs.65,000/- which includes the cost of this complaint. We are not inclined to accept this prayer since the amount that would be indemnifiable would contain exclusions which are part of the terms and conditions. It is for the insurance company to come to a conclusion as to the amount payable based on the terms and conditions of the policy.
Issue No.6
17. Resultant to the findings above we allow the complaint on the following terms:
1) Repudiation of the claim is not in accordance with the terms and conditions of the policy documents.
2) Repudiation of the claim of the complainant tantamount to deficiency in service.
3) The complainant shall submit a claim before the opposite party within 30 days of receipt of a copy of this order, which shall be considered in accordance with the terms and conditions of the policy document by the opposite party within 15 days thereof.
4) The sum so arrived as admissible and payable shall carry interest @10% from 8/3/2022 (date of Ext.A3) till date of payment.
5) The complainant is entitled to a compensation of Rs.20,000/-.
6) The complainant is entitled to a cost of Rs.10,000/-.
7) The above order shall be complied within a maximum of 30 days from the date of submission of a claim by the complainant failing which the opposite party shall pay a solatium of Rs.500/- per month or part thereof from the date of this order till date of settlement of the amounts payable as per this order.
Pronounced in open court on this the 8th day of September, 2023.
Sd/-
Vinay Menon V
President Sd/-
Smt. Vidya A.
Member
APPENDIX
Exhibits marked on the side of the complainant :
Ext.A1 – Original discharge summary dated 4/1/2022
Ext.A2 – Original policy document
Ext.A3 – Printout of communication dated 8/3/2022
Ext.A4 - Original certificate dated 14/4/2022
Ext.A5 - Original cash bill dated 28/12/21
Ext.A6 - Original pharmacy bill bearing No.2122/110546 dated 28.12.21
Ext.A7 - Original pharmacy bill bearing No.2122/079216 dated 4/1/2022
Ext.A8 - Original bill no. 2122/010891 dated 4/1/2022
Ext.A9 - Original bill bearing No.57957 dated 8/1/2022
Ext.A10 - Original bill bearing No.59300 dated 14/1/2022
Ext.A11 - Original bill bearing No.2122/083466 dated 18/1/22
Ext.A12 – Original bill bearing No.2122/081658 dated 18/1/22
Ext.A13 - Original pharmacy bill bearing No.2122/086237 dated 27.1.22
Ext.A14 - Original bill bearing No.12948 dated 18/2/2022
Ext.A15 - Original Invoice bearing No.3784 dated 29/4/2022
Ext.A16 – Original consolidated list of medicines purchased through determined bills.
Exhibits marked on the side of the opposite party:
Ext.B1 – Distorted copy of policy schedule.
Ext.B2 – Original proposal form
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
