IN THE CONSUMER DISPUTES REDRESSAL  COMMISSION, KOLLAM

Dated this the   29^th   Day of  September 2022

    Present: -   Sri. E.M.Muhammed Ibrahim, B.A, LL.M. President

           Smt.S.Sandhya Rani, Bsc, L.L.B,Member

                       Sri.Stanly Harold, B.A.LLB, Member

                                                    CC.174/2015

John Mathai                                                          :         Complainant

Vallivilla Veedu

Thrippilazhikom P.O

Kollam-691509.

[By Adv.V.Hariprasad]

V/s

1. Branch Manager                                      :         Opposite parties

        United India Insurance Company Ltd.

       Navaneetha Building, Mukkada,

       Kundara-691 501

       Kollam District.

      [By Adv.S.Subhash Chandra babu]

2. Branch Manager

         MD India Healthcare Services(TPA)

        Pvt Ltd., Regional Office at

       EI-63/521

       Opposite Karuna Printers

       Kasom Lane, Near St.Augustine School

       Kaloor-682017, Eranakulam,

3. Branch Manager

        E-MeditekTPA) Service Limited

       Branch Office at SNDP Auditorium

       Mamangalam, Pin 682025

       Eranakulam District.

      Also at Door No.35/292,1^st Floor

      Challirickal Building, Pottakuzhi Road,

      Mamangalam, Palarivattom

       Cochin-682025.

FINAL  ORDER

E.M.MUHAMMED IBRAHIM , B.A, LL.M, President

   This is a case based on a complaint filed u/s 12 of the Consumer Protection Act.

   The averments in the complaint in short are as follows:-

   The complainant is an insured under the Individual Health Insurance Policy bearing Policy No.100702/48/12/97/00000897 with insured sum of Rs.1,00,000/- as well as the Super Top Up Medicare Policy bearing Policy No.100702/48/12/36/00000898 with insured sum  of Rs.3,00,000/- since 2009 provided by the 1^st opposite party insurance company.  The top up policy  was taken in addition to the Individual Health Policy as the sum insured under the health policy was insufficient and the top up policy provided for coverage of an additional amount of Rs.3,00,000/- at a comparatively lesser premium amount.  The complainant is still under the coverage of the said policies which has been renewed periodically till date.  The premium paid by the complainant for the above two policies for the period 2013-2014 was Rs.11,520/- and Rs.3258/-  respectively.  Since the complainant was already suffering from Diabetes Mellitus(which is under control) he was very much attracted by the offers in the policy and he opted for the said policy by paying the huge premium amount.  The fact of his Diabetic condition was also declared and disclosed to the insurer while making the proposal.  The said policy was regularly renewed since 2009 through the Kundara branch of the 1^st opposite party and is still under coverage.  The 2^nd opposite party who is TPA(3^rd party administrator) was servicing the above two policies.

          There was no claim whatsoever under the policies for the period from 2009-2010,2010-2011.  But after renewal of premium for the Super Top Up Medicare Policy for the year 2013-2014, the complainant received a copy of the policy wherein it was stated against the policy number column in the 2^nd page, that the year of the previous policy as 2011 instead of 2009.  Immediately the complainant wrote the fact to the 1^st opposite party vide letter dated 20.03.2013 requesting to correct the mistaken entry in the policy.  On getting the above letter the 1^st opposite party issued an endorsement Schedule noting the correct policy inception date with Endorsement wording as under.

NOTWITHSTANDING ANYTHING STATED HEREIN TO THE CONTRARY. IT IS HEREBY DECLATED AND AGREED THAT THE FIRST INCEPTION DATE SHALL READ AS 31.03.2009 AND NOT AS STATED THEREIN. ALL OTHER TERMS AND CONDITIONS REMAIN UNALTERED. 

          During the year 2013-14 the complainant was admitted for treatment at the Travancore Medical College Hospital, Mylapore, Kollam for  the period from 13004.2013 to 18.04.2013 and he had to spend Rs.35,768/- for his medical bill for which he lodged claim under the original policy.  However the 2^nd opposite party allowed only Rs.19,125/- after wrongly deducting an amount of Rs.16,643/- from the amount claimed.  But an amount of Rs.2974/- was also reimbursed pursuant to the explanation given to the letter dated 10.05.2016 of the 2^nd opposite party.

          There after the complainant was admitted in the Christian Medical College, Vellore, Tamil Nadu for his brachial treatment from 10.06.2013 to 24.06.2013 and the complainant submitted a mediclaim form duly filled up on 13.07.2013 with all supporting documents and bills in original under their covering letter dated 13.07.2013 to the 2^nd opposite party TPA for getting medical reimbursement or Rs.1,09,080/- along with all original documents.  However the 1^st opposite party repudiated the claim of the complainant under the individual health policy on 23.08.2013 on the ground that it was not coming under the purview of  Health Insurance Policy Condition under clause No.4.1 as the complainant was a diabetic patient and that the said disease is the complication of the pre-existing disease and therefore the claim is not payable. 

          According to the complainant the present disease is not any complication of the pre-existing disease as wrongly alleged by the opposite parties.  Being aggrieved by the above said wrongful repudiation the complainant made a representation to the 1^st opposite party vide letter 26.08.2013 informing them that the complainant was under coverage of  the policy since 31.03.2009 and the repudiation of the claim under clause 4.1 is illegal and also requesting the 1^st opposite party to re-open and reviews the wrongful repudiation and reimburses his valid claim.  The complainant has also send supporting documents received from the treated hospital by stating that illness of  Bibrachial Amyotrophy is unrelated to his diabetes and is of recent onset.  Though several letters and remainders issued by the  complainant to the opposite party No.1 to 3 there was no response from any of the opposite parties and hence the complainant totally issued a registered letter with acknowledgement to the Regional Office of the 1^st opposite party at Eranakulam for which the complainant received reply letter from the 2^nd opposite party through 1^st opposite party intimating the complainant that the opposite party is unable to re-open the claim already repudiated under clause 4.1 of the policy term.  They also enclosed a re-repudiation statement of the 3^rd opposite party dated 27.05.2014 along with the said letter, which was received for the first time by the complainant .

          Complainant had spent a total amount of Rs.2,67,865/- in connection with his medical treatment at Christian Medical College, Vellore and he claimed the above amount with discharge summary and all original supporting documents to the 3^rd opposite party under the top up policy.  The complainant has also issued letter dated 30.08.2013 to the 3^rd opposite party by registered post with acknowledgment due with seven bills in original vouchers, discharge statement, doctor’s prescription etc.  The complainant was advised by the staff of the 3^rd opposite party to first approach and submit his mediclaim under the individual health policy to the 2^nd opposite party and after getting the said amounts reimbursed to approach the  3^rd opposite party for the balance amounts.  Since there was no reply or settlement of the claim the complainant had visited the said opposite party office at Mamagalam, Eranakulam, when they assured the complainant that the claim will be settled at the earliest.  The opposite party have neither paid the said amounts nor replied to the claim under the top up policy till date which is serious deficiency in service and amounts to unfair trade practice.  The complainant thereafter received a letter dated 17.09.2014 for the 1^st opposite party reiterating and finally repudiating his genuine claim under the individual health policy on false premises, from which the complainant understands that the opposite parties have no intention whatsoever to pay the genuine claims of the complainant. The complainant further submits that the hospitalization is not for a pre existing disease and has no connection with diabetes at all as evident from the certificate issued by the doctors.  The claim is raised for the period from 10.06.2013 to 25.06.2013 and in any event after 48 months of continuous coverage of the policies.  Moreover, the earlier claim of the complainant was settled by the opposite parties under the same insurance policies and hence the present repudiation, on whatsoever ground is illegal.  At the time of submitting the proposal for mediclaim it was specifically represented to the 1^st complainant that the pre-existing disease whatsoever may it be shall also be covered under the policy of insurance subject to the lapse of 48 months period from the first policy inception date.  The complainant was under continuous policy coverage from the year 2009.  The claim is raised in 2013.  Therefore the repudiation under clause 4.1 is illegal.  The insurance company and the underwriters/TPA have rejected the genuine claim of the complainant on false premises.  The rejection of the claim has been done arbitrarily and without any justification and is therefore illegal.  There is deficiency in service and unfair trade practice on the part of all the opposite parties.

          In response to the notice 1^st opposite party entered appearance, opposite party No.1&2 remained absent after receiving notice.  Hence they were set exparte.  The contention of the 1^st opposite party  in the written version in short  are as follows.  The complaint is not maintainable either in law or on facts.  The complainant is not a consumer under the Consumer Protection and filed the present complaint without any bonafides.  However the 1^st opposite party would admit that the complainant joined in the individual health insurance policy 2010 scheme with 1^st opposite party and issued policy No. 100702/48/12/97/00000897 for an insured sum of Rs.1,00,000/- and also taken a Super Top Up Medicare Policy bearing Policy No.100702/48/12/36/00000898 with insured sum of Rs.3,00,000/-.  Both the policies are begins to run from 31.03.2013 to 30.03.2014 has coverage up to 30.03.2014 in continuation of his previous policy 2011.  The date of first proposal and declaration for the previous policy by the complaint was on 21.03.2012 and the date of inception is 31.03.2012  which is clearly mentioned in the super top up Medicare policy bearing No.100702/48/12/36/000000898.  The said policies are not the continuations of the policy said to have been issued from 2009 onwards as claimed in the complaint.  As per policy schedule diabetes is an excluded disease from getting medi claim under the policy and the claim documents preferred by the complaint, the opposite parties notices that the complainant has been hospitalized for the treatment of Bibrachial Amytrophy, immune mediated on immunomodulation. 

The complainant was a patient of diabetes for the last 25 years.  The treatment availed between 10.06.2013 to 24.06.2013 was in connection with the complication of  the pre-existing diabetes disease.  Since the complainant joined in the said insurance scheme only on 31.03.2012 the averments that he did not claimed any amount  till 2012 are irrelevant.  The 1^st opposite party has no knowledge about the correction on the policy regarding the inception of the policy date, the first date on which the policy begins to run or its endorsement in the schedule  of policy as described in capital letters in paragraph No.5.  The 1^st opposite party can act only on policy documents and its conditions including the exclusions also.  As per the terms and conditions the claim is not payable under clause  4.1 of the policy conditions.  The 1^st opposite party would further admit that the 2^nd opposite party(TPA) settled the claim application in connection with the medical bills produced by the complainant for the diagnosis and treatment in Travancore Medical College Hospital, Kollam for a sum of Rs.19125/- and the averments that the claim was settled for Rs.16643/- is incorrect.  The admitted hospital bills at the time were only to the tune of that amount and as such the claim settled.

 As stated in paragraph No.5 the complainant was a patient of diabetes for the last 25 years and the treatment period was 10.06.2013 to 24.06.2013 in connection and exclusions the claim is not payable under clause 4.1 of the policy and as such the opposite parties repudiated the claim of Rs.109080/-.  The repudiation of the claim for Rs.109080/- as the treatment expense in Christian Medical College, Vellore was not wrongful as stated in the  paragraph because the complainant was not under the policy coverage since 31.03.2019.  As per the policy condition clause 4.1. pre-existing disease is covered only after 48 months of continues coverage of the policy from the date of inception.  But the policy was in the second year from the date of inception and as such though the claimant requested to reopen and review the repudiation it was not possible.  The averment that Bibrachial Amyotrophiy is un related to diabetes and is on recent onset, is not correct. On the basis of the opinion of the doctors in the company’s panel it is a complication of prolonged diabetes. 

The 1^st opposite party would admit  that the complainant had sent letter dated 08.04.2014 to the grievance cell of the 1^st opposite party at Eranakulam and the 1^st opposite party sent reply to the complainant on 27.05.2014 stating the reasons for the repudiation, with pre repudiation statement of the 3^rd opposite party.  But the averment that the complainant did not receive the pre repudiation statement on earlier occasions is not correct.  The hospital bills for the period of treatment from 10.06.2013 to 25.06.2013 are only Rs.109080/-.  The averment that the complainant had spent a total amount of Rs.267865/- is falsehood.  If the complainant spent more amount than the amount under the discharge bills, for meeting any other expenses, as per the policy conditions the expenses exceeding the hospital bills need not be counted for settlement in case the complainant is eligible to get the treatment expense.  Here the complainant is not eligible to get the treatment expenses from the opposite party on the ground of policy violations.

 According to the 1^st opposite party they have no knowledge about the conversations between the staff of the 3^rd opposite party and the complainant regarding the alleged assurance that the claim will be settled.  The earlier settlement was effected on the diagnosis “parsonage turner syndrome” which is occurred not as the complications of diabetes.  On the other hand the claim of treatment expense for the period from 10.06.2013 to 25.06.2013 is for the treatment of Bibrachial Amyotrophy which is a complication of diabetes mellitus, a pre-existing disease has no policy coverage because the policy has not covered 48 months from 31.03.2012 the date on which the policy begins to run.  The averment in paragraph 11 specifically reiterates that pre-existing deceases are covered under the policy subject to the lapse of 48 months period from the first policy inception date.  As the complainant was under policy coverage from 31.03.2012 only and as such 48 months have not covered when the claim is raised in the year 2013.  Therefore the repudiation is under clause 4.1 of the policy condition is legal and genuine.  It is not an arbitrary action of the opposite parties against the complainant.  Hence there is no deficiency in service on the part of the opposite parties as alleged.  The 1^st opposite party is specifically pin pointing that there is no willful latch or negligence or deficiency in service or dereliction of duty or any unfair trade practice in dealing the claim petition preferred by the complainant in this matter.  The 1^st opposite party would further content that  the complainant has no cause of action and the complainant is not entitled to get any relief  claimed in the complaint.  The opposite party further prays to dismiss the complaint with its costs.

In view of the above pleadings the points that arise for consideration are:-

1. Whether the complainant is entitled to get claim of Rs.109080/- under the Individual Health Insurance Policy along with interest  as claimed?
2. Whether the complainant is entitled to get her claim of Rs.2,67,865/- under Super Top Up Medicare Policy?
3. Whether  the complainant is entitled to get compensation as claimed?
4. Reliefs and costs.

Evidence on the side of the complainant consists of the oral evidence of PW1&Ext.P1 to P19 documents.Evidence on the side of the 1^st opposite party consists of the oral evidence of DW1 and Ext.D1&D2 documents.Both sides have filed notes ofargument.Heard both sides.

Point No.1 to3

For avoiding repetition of discussion of materials these 3 points are considered together.  Following are the admitted facts in this case.  The complainant had taken the Individual Health Insurance Policy from the 1^st opposite party for an insured sum of Rs.1,00,000/-  and also taken up  a Super Top Up Policy with insured sum of Rs.3,00,000/-.  The complainant himself and his wife were covered under the Individual Health Insurance Policy.  According to the complainant he had taken the above policies during the year 2009 provided by the 1^st opposite party and he has been renewing the policy continuously and even now  himself and his wife are under the coverage of said policies.  The complainant has been examined as PW1.  According to PW1  he was very much attracted by various benefits introduced in the policy by the insurer as it has provided coverage to the insured even for the pre-existing diseases subject to terms.   Since the complainant has already suffering Diabetes Mellitus(which is under control) he was very much attracted by the offers in the policy and he opted for the said policy by paying the huge premium amount.  The fact of his Diabetic condition was also declared and disclosed to the insurer while making the proposal.  The said policy was regularly renewed since 2009 through the Kundara branch of the 1^st opposite party and is still under coverage.  Though there was no claim whatsoever under the policy for the period 2009 till 2012 after making the renewal of the premium for the Super Top Up Medi Care policy for the year 2014.  PW1 has further sworn that he has received a copy of the policy which was noticed that as against policy number column at the 2^nd page the insurer had wrongly mentioned the year of previous policy for the year 2011.  Hence he contacted the 1^st opposite party by sending Ext.P3 letter dated 20.03.2013 by pointing out the mistaken entry in the policy to him and also by noticing the previous year as 2009.  Accordingly the 1^st opposite party has issued Ext.P4 endorsement schedule noting the correct inception date of policy No.100702/48/12/97/00000897 non traditional individual health insurance policy schedule in the name of the complainant.  It is also stated in Ext.P4 endorsement that it has been corrected at the request of the  insured and correct inception date is 31.03.2009 and not as stated in the original individual health insurance policy .  It is true that in Ext.P3 letter the complainant has quoted the number of the Individual Health Insurance Policy and also the Super Top Up Medi Care policy both covering 31.03.2013 to 30.03.2014. 

The specific contention of the 1^st opposite party is that only the Individual health Insurance Policy has been taken from the year 2009 and Ext.P4 endorsement is relating to that policy and that Super Top Up Medi Care policy was taken for the 1^st time on 31.03.2013 and prior to  that policy the complainant was not having any such policy and therefore the complainant is not entitled to get the coverage under Ext.P2 Top Up policy.  The learned counsel for the opposite party would argue  that the complainant has not produced any documentary evidence to show that the inception date of Super Top Up Policy was  2009 and it was renewed without any break till 2013 and that endorsement in Ext.P4 is relating to Individual health Insurance Policy alone.  The learned counsel for the opposite party has further pointed out that in Ext.P6 to P10 claim payment statement policy the policy number shown in that of the Individual Health Insurance Policy and the number of the top up policy is not shown in.  We find much force in the above argument  especially when the complainant has failed to produce any documentary evidence to substantiate that he has taken Top Up policy during the year 2009 and he has been renewing the same till 2013.

As the opposite party has clearly denied the inception date of the top up policy the complainant ought  to have produced any material to indicate that the inception date of the top up policy is 2009 and he has continuously renewing the policy till 2013.  The learned counsel for the complainant has argued that the endorsement made in Ext.P4 schedule relates to both individual health insurance policy and Super Top Up policy and hence it is clear that the inception date of both policies are 2009.  In view of the materials available on record we find no force in the above argument.  On perusal of Ext.D2/P2 document it is clear that it the Super Top Up Medi Care policy No.00000898 for Rs.3,00,000/-.  Though it was issued on 31.03.2013 against the 1^st column  it is stated that the previous policy 2011.  If the Super Top Up Policy for the year 2011 was the previous policy it will end during the year 2012.  But Ext.D2/P2 policy starts from 31.03.2013.  It is to be pointed out that Ext.P1&P2 are separate policies endorsement made in Ext.P4 stating the policy number of Ext.P1 policy alone is not sufficient hold that the endorsement relates to Ext.P2 Super Top Up Policy also.  The complainant ought to have produced the back policy of Ext.P2 Super Top Up Policy to prove the inception date of P2 is 2009 and not 2011 or 2012 as contented by the 1^st opposite party.  Even if it is considered that 2011 is the inception date as shown in Ext.P2it is not sufficient to hold that there was continuous coverage of policy for 48 months from the date of inception.    In the circumstances the complainant is not entitled to get coverage for pre existing disease since he was not having super Top Up policy coverage for the last 48 months(4 years) from the date of inception of Ext.P2 policy.  Though specific opportunity was granted to produce any documentary evidence to show that Ext.P2 policy was in force from 2009 till 2012-13 the complainant has not produced any such document.  In the circumstances we find no merit in the claim of the complainant that the inception date of Ext.P2 policy was 2009.  It is also further to be pointed out that though the complainant would claim that he has met an expense of Rs.2,67,865/- at the hospital he has not seen produced any documentary evidence to show that he sent  the above documents to the opposite parties.

On evaluating the entire materials available on record we come to the conclusion that the complainant is entitled to get the balance amount covered under Ext.P1 policy as admitted by the 1^st opposite party and that he is not entitled to get the entire amount claimed under A &B relief in the complaint.  As the opposite parties have acted in accordance with the conditions of the policy we disagree with the allegations of the complainant that the opposite party has committed any deficiency in service as alleged in the complaint.  The points answered accordingly. 

In the result the complaint stands allowed in part:-

1.          Directing the opposite parties to pay the balance amount covered under Ext.P1/D1 Individual Health Insurance Policy after deducting Rs.19,225/- on production of proper bill and other documents if not already submitted to the opposite parties within 45 days from the date of this order.
2.        As no deficiency in service or any unfair trade practice is established on the part of the opposite parties the complainant is not entitled to get any other reliefs claimed in the complaint including costs of the proceedings from opposite parties No.1&2.

If the opposite parties failed to comply with the above direction No.1 the complainant is at liberty to execute the order under Section 71&72 of the Consumer Protection Act.

Dictated to the Confidential Assistant  Smt. Deepa.S transcribed and typed by her corrected by me and pronounced in the  Open Commission this the   29^th  day of  September  2022.

E.M.Muhammed Ibrahim:Sd/-

S.Sandhya Rani:Sd/-

Stanly Harold:Sd/-

Forwarded/by Order

Senior Superintendent

INDEX  

Witnesses Examined for the Complainant:-

PW1  :         John Mathai

Documents marked for the  complainant

Ext P1:        True copy of the individual health insurance policy-2010 schedule dated 15.03.2013 issued by the United India Insurance Company Ltd.

Ext P2:        True copy of the Super Top Up Medicare Policy dated 15.03.2013 issued by the United India Insurance Company Ltd.

Ext.P3:        True copy of the letter dated 20.03.2013 issued by the complainant to the 1^st opposite party.

Ext.P4 :       True copy of endorsement schedule issued by the 1^st opposite party.

Ext.P5         :True copy of letter dated 10.05.2013 issued by the 2^nd opposite party to the complainant requesting to provide detailed Break-Up charges of Rs.2974/-.

Ext.P6         : True copy of Claim Payment Statement dated 16.05.2013 issued by the 2^nd opposite party to the complainant.

Ext.P7         :True copy of the Claim Acknowledgment Sheet dated 13.07.2013 issued by the 2^nd opposite party to the complainant.

Ext.P8         :True copy of the Reimbursement certificate dated 25.06.2013 issued from the Christian Medical College, Vellore.

Ext.P9         : True copy of Repudiation letter dated 23.08.2013 issued by the 1^st opposite party to the complainant.

Ext.P10       :True copy of the letter dated 26.08.2013 issued by the complainant to the 1^st opposite party.

Ext.P11       :True copy of the letter dated 30.08.2013 issued to the 3^rd opposite party TPA by Regd. Post with acknowledgment due along with acknowledgment card and postal receipt with enclosure.

Ext.P12       :True copy of the certificate dated 03.09.2013 issued from the Department of  Neurological Sciences, Christian Medical College,Vellore to the complainant.

Ext.P13       :True copy of the letter dated 05.11.2013 issued by the complainant to the 1^st opposite party with copy to TPA by Regd. Post with Acknowledgment due.

Ext.P14       : True copy of the letter dated 05.11.2013 issued by the complainant to the 3^rd opposite party with copy to TPA by Regd. Post with Acknowledgment due.

Ext.P15       :True copy of the letter dated 29.01.2014 issued by the complainant to the 1^st opposite party.

Ext.P16       :True copy of the letter dated 08.04.2014 issued by the complainant to the 2^nd opposite party by Reg. post with Acknowledgment  due.

Ext.P17       :True copy of the letter dated 27.05.2015 issued by the 2^nd opposite party to the complainant enclosing Pre Repudiation Statement dated 27.05.2014 of the 3^rd opposite party.

Ext.P18       : True copy of the letter dated 17.09.2014 issued by the 1^st opposite party to the complainant.

Ext.P19       :True copy of  identity card issued by the opposite parties to the complainant.

Witnesses Examined for the opposite party:-

DW1           :   Bindhu

Documents marked for the opposite party:-

Ext.D1        :         Copy  of the Individual Health Insurance Policy-2010 Schedule dated 15.03.2013 issued by the United India Insurance Company Ltd.

Ext.D2        :         Copy  of the Super Top Up Medicare Policy dated 15.03.2013 issued by the United India Insurance Company Ltd.