SMT. RAVI SUSHA: PRESIDENT
Complaint has been filed U/s 35 of Consumer Protection Act 2019 seeking to get an order @ directing the opposite party to pay an amount of Rs.53,148/- being the hospitalization charge, Rs.50,000/- towards compensation for the mental agony and pain caused to the complainant together with cost of the proceedings alleging deficiency in service on the part of opposite parties.
Brief facts of the case are that the complainant took health insurance policy on 23/01/2020 by remitting a total premium amount of Rs.7,307/- including GST with a validity period of one year ends on 22/01/2021. He was admitted in Aster Mims hospital Chala, Kannur on 07/01/2021 due to chronic sinusitis and discharged on 09/01/2021. He had applied for cashless treatment at the hospital as inpatient, the same has been denied. The reason for the denial is that the specific one year waiting period is not satisfied. The complainant after discharging from hospital, submitted an application with supporting documents on 28/01/2021 for an aggregate amount of Rs.53,148/- before the stipulated time of one month and the same has been repudiated. Aggrieved by this, the complainant further submitted an appeal within the stipulated time through email to healthserve@universalsompo.com and grievance @universalsompo.com the same have been rejpudiated stating 1 year waiting period is mandatory. The petitioner then submited an appeal to the Honorable Insurance Ombudsman, Southern region, Ernakulum on 17/03/2021 and the same has been dismissed. Complainant submits that he is fully eligible for the claim because he has applied for claim within the stipulated period fixed by the company. The petitioner has suffered a lot mental agonies and pains due to non receipt of cashless claim, arranging money for discharge, repudiation of reimbursement claim, filing appeals to insurance grievance cell of Universal Sompo and insurance Ombudsman and so on, apart from the physical-mental pains suffered in connection with ENT surgery for which the petitioner claims Rs.50,000/- compensation from the company. Hence filed this complaint.
After receiving notice, OP entered appearance and filed version admitting that the complainant has availed health insurance policy from this OP with a validity period of one year. OP also admits that ‘he has applied for cashless treatment at the hospital as inpatient and the same has been denied. Obviously the reason for the denial is that the specific one year warranty period was not satisfied. Since the claim was contrary to the conditions of the policy OP has rejected the claim petition of the complainant. The complainant is entitled to the insured sum from the OPs as the claim is at par with the terms and conditions elaborated in the policy document. Further submitted that in the discharge summary it is clearly mentioned the ‘diagnosis’ was nasal polyposis with chronic sinusitis and the procedure done on the complainant Bilateral functional endoscopic sinus surgery with septoplasty under general anesthesia. The OP submits that after going through all the documents it is clear that the treatment taken by the complainant is excluded during the first year of the policy. Thus in view of the policy and its exclusions the claim of the complainant is not payable. As such the claim of complainant was rightly repudiated by this OP. Hence prayed for the dismissal of the complaint.
Complainant has filed chief-affidavit and documents. He was examined as Pw1 and the documents were marked as Ext.A1 to A5. After that complainant has argued the matter.
The admitted facts in this case are the complainant had taken a health Insurance policy on 23/01/2020 with a validity period of one year end on 22/01/2021. Further he was admitted in Aster Mims Hospital Chala, Kannur on 07/01/2021 due to sinusitis and discharged on 09/01/2021. It is also admitted that he had applied for cashless treatment at the hospital as inpatient and the same was denied. Further after discharging from hospital, the complainant submitted claim application to OP on 28/01/2021 for getting the treatment expense of Rs. 53,148/-. The same has been repudiated by the OP through Ext.A4 letter dated 16/02/2021 with a reason that as per the policy condition exclusions: “This policy does not cover expenses arising from waiting periods- We are not liable for any treatment which begins during waiting periods except if you suffer an accident. Specific waiting periods – The illness and treatments listed below will be covered subjected to waing period of 1 year as long as in the second policy year has been insured under this policy continuously and without any break. Treatments- Benign ear , nose and throat (ENT) disorder and surgeries (including but not limited to adenoidectomy. However, a waiting period of 1 year will not apply if you were insured continuously and without interruption for at least 1 year under any our or other Indian insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital. Complainant alleged that a person takes a health Insurance policy for a period of 1 year with a view to overcome the unforeseen situations in his life during that period for time. So one year waiting period cannot be considered as justifiable since the insured has the option to select new insurers available in the country. Hence he is entitled to get the policy benefit.
On the other hand OP contended that as per the 12 months exclusion guideline (ii) the reason for the denial is that the specific one year warranty period was not satisfied. Further since the claim was contrary to the conditions of the policy OP has rejected the clam petition of the complainant.
Since the policy commenced on 23/01/2020, the period up to 24/01/2021 is the waiting/exclusion period. According to the OP since the disease sinusitis was diagnosed to the complainant and underwent surgery on 08/01/2021, clam of the complainant clearly falls within the waiting period and the OP is not liable to pay insurance amount to the complainant. Ext.A3 clearly shows that the complainant was diagnosed to have bilateral nasal polyposis with chronic sinusitis. He underwent bilateral functional endoscopic sinus surgery with septoplasty under general anesthesia on 08/01/2021. Therefore, admittedly the contracting of the disease was clearly within the waiting period.
Complainant argued that as per exclusion para 3 of the policy condition, “However, a wating period of 1 year will not apply if you were insured continuously and without interruption for at least 1 year under any our or other Indian insurer’s individual health insurance policy for the reimbursement of medical costs for impatient treatment in a hospital”. Complainant submits that since he has renewed the policy continuously, I am fully eligible for the reimbursement of the expenses for the medical treatment. Complainant submits that the Insurer had collected Rs.14,614/- being the Premium for 2 years, even before completing 1 year of policy. Further stated that even after collecting the premia for 2 years, that too within 1 year, the insurer cannot repudiate his claim on the ground of waiting period.
But here Ext.A1 shows that the Insurance company had collected only Rs.6,192.40/- as premium for 1 year ie from 23/01/2020 to 22/1/2021. Complainant has not substantiate his said contention by producing the premium receipt of OP collecting premium of Rs.14,641,/- or policy certificate for the 2nd year without substantiating the said version, we cannot direct the OP insurer let policy benefit to the complainant for his treatment expense.
From the settled law, the Insurance company can repudiate the claim of the insured in case where there is a breach of the policy conditions. On the bare reading of the exclusion clause in the Insurance contract, there is waiting period of 1 year from the inception of policy for the disease happened to the complainant. It is well settled that insurance contract is like any other contract as per its own terms and conditions. The insured cannot claim anything more than what is covered by the insurance policy.
In view of the above discussion, we are of the opinion that the repudiation made by the Insurance company is justifiable and there is no deficiency in service on the part of opposite party.
In the result complaint fails and hence it is dismissed. No order as to cost.
Exts.
A1-Insurance policy issued OP No.1(marked with object policy not completed)
A2-Cashless denied letter photocopy
A3-Medical certificate issued ENT surgeon
A4-Copy of claim repudiation letter
A5-Dismisssal letter by ombudsman
Pw1-Complainant
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
