Order no. 10
The case of the complainant in brief is that the complainant maintained a mediclaim with o.p. insurance company in the year 2004. During the subsistence of the policy the complainant became ill and in or about Jan. 2018 the complainant was detected of having GA Kappa Myeloma i.e. a form of cancer and was admitted to Apollo Gleneagles hospital for transplantation of stem cells for treatment of multiple myeloma on 2.8.18 and he was discharged on 20.8.18. After recovery the complainant on Sept. 2018 lodged his claim with o.ps. along with supporting documents for a sum of Rs.5,09,790/- towards hospitalization expenses for treatment of the aforesaid disease. The o.p. no.2 rejected the claim of the complainant vide letter dt.20.9.19 on the ground that the claim of the complainant is inadmissible under exclusion clause 4.17 of the policy set out hereunder ‘genetic disorder and stem cell implantation surgery’. The complainant by a letter dt.27.1.19 raised an objection regarding the illegal rejection of the claim of the complainant and it was categorically stated that the claim was rejected without having any cogent reason whatsoever since in the original policy at least till the year Feb. 2012 the same was not incorporated in the policy itself. The o.p. by a letter dt.4.2.19 contended that the terms and conditions have not been changed during the course of the current policy period. In other words, o.ps. denied that there has been change of the policy terms during the renewal of the policy. The claim of the complainant was rejected illegally on the basis of the clause 4.17 and without the knowledge of the complainant inserted the said clause in the policy and thereby, the excluding of stem cell implantation surgery was subsequently surreptitiously inserted in the policy for the period 19.2.12 to 18.2.13 without any notice or consent of the policy. On the basis of the said fact the complainant filed this case praying for direction upon the o.ps. to pay the claim amount of Rs.5,09,789/- as well as compensation and litigation cost.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant enjoyed the health insurance policy being policy nol0306002817P116379668 and the policy was valid from 19.2.18 to 18.2.19. The complainant lodged a claim in connection with the treatment for ischemic heart disease and was treated at Lilabati hospital at Mumbai for Rs.5,80,215/- with the insurance company for reimbursement. It was categorically stated by o.ps. that the complainant was suffering from myeloid leukemia and during admission stem cell implantation was done and as per clause 4.17 which provides stem cell implantation surgery is not admissible for payment as per the said policy. In view of the said fact insurance company vide letter dt.20.9.18 repudiated the claim of the complainant as per the policy document as laid down in the said policy being condition no.4.17. The o.ps. rejected the claim of the complainant as per the advice and observation of TPA which was communicated to the insurance company vide letter dt.11.19.18. The o.ps. after getting the claim made by the complainant duly informed the said fact to the complainant. In support of the said contention o.ps. also mentioned several judgments in the w/v on the ground that if any suppression of material fact happens and as per the terms and conditions of the policy the disease suffered by the complainant was not covered within the policy document and the said disease is excluded from the policy terms and conditions which has been duly communicated to the complainant and the said fact of incorporation in the policy document had taken place in the year 2012 i.e. the complainant had full knowledge regarding the exclusion clause as mentioned in 4.17 of the policy document. On the basis 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 policy with o.ps.?
- Whether during subsistence of the policy the complainant became ill and he was treated for the disease?
- 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 maintained a mediclaim with o.p. insurance company in the year 2004. During the subsistence of the policy the complainant became ill and in or about Jan. 2018 the complainant was detected of having GA Kappa Myeloma i.e. a form of cancer and was admitted to Apollo Gleneagles hospital for transplantation of stem cells for treatment of multiple myeloma on 2.8.18 and he was discharged on 20.8.18. After recovery the complainant on Sept. 2018 lodged his claim with o.ps. along with supporting documents for a sum of Rs.5,09,790/- towards hospitalization expenses for treatment of the aforesaid disease. The o.p. no.2 rejected the claim of the complainant vide letter dt.20.9.19 on the ground that the claim of the complainant is inadmissible under exclusion clause 4.17 of the policy set out hereunder ‘genetic disorder and stem cell implantation surgery’. The complainant by a letter dt.27.1.19 raised an objection regarding the illegal rejection of the claim of the complainant and it was categorically stated that the claim was rejected without having any cogent reason whatsoever since in the original policy at least till the year Feb. 2012 the same was not incorporated in the policy itself. The o.p. by a letter dt.4.2.19 contended that the terms and conditions have not been changed during the course of the current policy period. In other words, o.ps. denied that there has been change of the policy terms during the renewal of the policy. The claim of the complainant was rejected illegally on the basis of the clause 4.17 and without the knowledge of the complainant inserted the said clause in the policy and thereby, the excluding of stem cell implantation surgery was subsequently surreptitiously inserted in the policy for the period 19.2.12 to 18.2.13 without any notice or consent of the policy. On the basis of the said fact the complainant filed this case praying for direction upon the o.ps. to pay the claim amount of Rs.5,09,789/- as well as compensation and litigation cost.
Ld. lawyer for the o.ps. argued that the complainant enjoyed the health insurance policy being policy nol0306002817P116379668 and the policy was valid from 19.2.18 to 18.2.19. The complainant lodged a claim in connection with the treatment for ischemic heart disease and was treated at Lilabati hospital at Mumbai for Rs.5,80,215/- with the insurance company for reimbursement. It was categorically stated by o.ps. that the complainant was suffering from myeloid leukemia and during admission stem cell implantation was done and as per clause 4.17 which provides stem cell implantation surgery is not admissible for payment as per the said policy. In view of the said fact insurance company vide letter dt.20.9.18 repudiated the claim of the complainant as per the policy document as laid down in the said policy being condition no.4.17. The o.ps. rejected the claim of the complainant as per the advice and observation of TPA which was communicated to the insurance company vide letter dt.11.19.18. The o.ps. after getting the claim made by the complainant duly informed the said fact to the complainant. In support of the said contention o.ps. also mentioned several judgments in the w/v on the ground that if any suppression of material fact happens and as per the terms and conditions of the policy the disease suffered by the complainant was not covered within the policy document and the said disease is excluded from the policy terms and conditions which has been duly communicated to the complainant and the said fact of incorporation in the policy document had taken place in the year 2012 i.e. the complainant had full knowledge regarding the exclusion clause as mentioned in 4.17 of the policy document. On the basis of the said fact o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant enjoyed the policy issued by o.ps. since the year 2004. The complainant had all along paid the premium and the policy continued. It appears from the materials on record that in the year 2018 the complainant became ill and he was treated at Apollo Gleneagles Hospital. The complainant in order to substantiate his claim filed some documents including the treatment papers. On the basis of the said fact it has been urged by the complainant that the claim of the complainant was denied by o.ps. without any cogent reason whatsoever. It has also been argued by ld. lawyer for the complainant that as per the judgment pronounced by Hon’ble Delhi High Court RFA 610 / 2016 wherein it was held that whether the exclusion clause 4.17 relied upon by the defendant for rejecting the claim of the plaintiff applies. In the body of the said judgment it was stated that as per clause 4.17 genetic disorders and stem cell implantation surgery is applicable in the case of the plaintiff in this case. After thorough discussion Hon’ble Judge of Hon’ble High Court was pleased to affirm the judgment passed by trial court. Ld. lawyer for the complainant has also relied on another judgment as disposed of by Hon’ble Supreme Court being Civil Appeal No.2296 of 2000 wherein it was held by Hon’ble Supreme Court a renewal of an insurance policy means repetition of original policy. When renewed the policy is extended and the renewed policy in the identical terms from a different date of days expiration comes into force. It was also observed that on renewal a new contract comes into being, but the said contract is on the same terms and conditions as that of the original policy. On the basis of the said judgment it was emphasized by ld. lawyer for the complainant that the refusal of the claim of the complainant by the insurance company is deficiency in service and the complainant will be entitled to get the amount as claimed by him.
It appears from the materials on record and also ld. lawyer for the insurance company pointed out that the complainant claimed the amount from the insurance company for his treatment of ischemic heart disease and he underwent treatment at Lilabati Hospital and claiming an amount of Rs.5,80,215/- for reimbursement. But on query it was found that the complainant was suffering from myeloid leukemia and during treatment stem cell implantation was done. Insurance company has also provided the advice made by TPA i.e. Vipul Medcorp Insurance Co. Pvt. Ltd. wherein it was clearly opined that patient was suffering from myeloid leukemia. During admission stem cell implantation was done. This claim is not admissible as per clause 4.17 (stem cell implantation surgery) of Gold Policy. On perusal of the discharge certificate it appears that the patient was treated at Apollo Hospital and in the policy document it was incorporated the said clause long before the renewal of the policy by the complainant and the complainant was fully aware of the exclusion clause as incorporated in the policy document. The complainant by suppressing the said fact and for claiming amount wrongly disclosed that he was suffering from heart ailment and he underwent treatment at Lilabati Hospital. Since in the policy document it was categorically stated that the clause 4.17 was incorporated excluding such treatment received by the complainant and the complainant was fully aware, therefore it cannot be said that there was any suppression of material fact and in the policy document it was surreptitiously incorporated. In view of the facts and circumstances as stated above though the judgment cited by ld. lawyer for the complainant has got the different facts and circumstances with this case, therefore, we are not inclined to rely on the decisions as cited by ld. lawyer for the complainant. Having regard to the facts and circumstances of the case we hold that insurance company rightly rejected the claim of the complainant and there is no deficiency in service or unfair trade practice on the part of o.ps. and as such, 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. 140/2019 is dismissed on contest without cost against the o.ps.
