DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 27th day of January, 2022
Filed on: 09/02/2017
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member
Smt. Sreevidhia T.N. Member
C.C. NO. 70/2017
COMPLAINANT
1. K.P. Paul, S/o. Pappu, Kannampuzha House, Angamaly South, Ernakulam, 683572
2. Annie Paul, W/o. K.P. Paul, Kannampuzha House, Angamaly South, Ernakulam, 683572
(Rep. by Adv. C.A. Joy, Thankam Building, Mathew Pylee Road, Ernakulam North 682018
Vs
OPPOSITE PARTY:
1. M/s. Max Bupa Health Insurance Company Ltd., B-1/1-2, Mohan Co-operative Industrial Estate, Mathura Road, New Delhi 110044. Rep. by its CMD
2. The Manager-Operations, M/s. Max Bupa Health Insurance Company Ltd., 7th Floor, Puthuran Plaza, KPCC Junction, MG Road, Ernakulam 682011.
(Rep. by Adv. Saji Isaac K.J., 311, HB Flats, Panampilly Nagar, Kochi 682036)
FINAL ORDER
Sreevidhia T.N., Member
1. A brief statement of facts of this complaint is as stated below:
The complainants are husband and wife. The complainants are the holders of Mediclaim Policy under the opposite party from 2011 onwards. Prior to these Mediclaim Policies the complainants are maintaining Medical Insurance Policy with the National Insurance Company Ltd. from 2005 onwards. The complainants allege that the opposite party canvassed the complainants to become their customer and accordingly joined in the Medical Insurance Scheme of the opposite party. The last renewed insurance policy of the complainants was for the period from 11/11/2015 to 10/11/2016. The plan of the policy is Family First Silver Policy- 4 lakhs + 5 lakhs. The sum assured is Rs.13,00,000/- and the gross premium paid was Rs.29,910/- within the sum insured there was a floater insurance cover upto the amount specified in the schedule of insurance certificate. The individual sum insured was Rs.4,00,000/- and the floater sum insured is Rs.5,00,000/-. On 08/01/2016, the 1st complainant was admitted in Aster Medicity Hospital, Cheranelloor, Ernakulam due to continuous fever and urinary tract infection. The complainant submitted a claim for cashless treatment through the hospital authorities. In spite of the discharge of the 1st complainant on 16/01/2016 he was again admitted in the hospital on 17/01/2016 and undergone inpatient treatment till 20/01/2016. The 1st complainant was again admitted in the hospital from 02/02/2016 to 05/02/2016. The hospital authorities informed the complainant that pre-authorization request given by the hospital authorities for cashless treatment has been denied by the 1st opposite party. Consequently the opposite party cancelled the policy and issued a communication to the complainant stating that there has been a non-disclosure of pre-existing illness medical conditions at the time of applying for Health Insurance Policy. The 1 st complainant underwent Renal Transplantation on 02/07/2016 at Little Flower Hospital, Angamaly. For the above treatment the 1 st complainant was admitted in the hospital on 30/06/2016 and discharged on 08/07/2016. Thereafter on 15/07/2016 the 1st complainant was again admitted for stent removal and discharged on 16/07/2016. The complainants alleges that as per Para 2.9 of the terms and conditions of the policy, the organ donor is also eligible for the medical expenses. The 1st complainant was underwent renal transplantation on 02/07/2016. The total expenses incurred for the organ donor was Rs.1,80,982/- . 2nd complainant was also undergone a treatment at Little Flower Hospital, Angamaly for a period from 10/03/2016 to 12/03/2016. An amount of Rs.24,071/- was incurred for the treatment of 2nd complainant in the Little Flower Hospital. The total medical expenses incurred by the complainants during the validity of the policy is Rs.7,21,528/-.a request for cashless treatment was given through the hospital authorities. The pre-authorization request given by the hospital authorities for cashless treatment was denied by the 1st opposite party stating that “the claim submitted along with the pre-authorization suggest that that the patient has adverse medical condition due to which it is not possible to ascertain the liability at this juncture (due to non-disclosure of material facts)”. The opposite party had cancelled the policy of the complainant as per Clause 3 of the policy terms and conditions. The complainant raised objection against the cancellation of the policy and a letter was sent to the opposite party against the cancellation of the policy. No reply was given by the opposite party. A legal notice was also sent to the opposite party. The opposite party has not cared to give any reply denying the facts stated in the notice. The complainant states that they have suffered huge mental agony, pain and other difficulties in order to meet the hospital expenses in spite of a valid insurance policy with the benefit of cashless treatment. The complainants filed this complaint for an amount of Rs.7,21,528/- towards medical claim and Rs.1,00,000/- as compensation for the deficiency in service and for the mental agony sustained by the complainant.
2. Notice.
Notice was issued to the opposite parties from this Commission and the notice sent to opposite parties seen served and nobody appeared for 1st opposite party. 1st opposite party called absent and set ex-parte (complainant has produced the track record of 1st opposite party). Upon notice, 2nd opposite party appeared and seeks time for vakalath and version. The Commission directed 2nd opposite party to file version within 15 days. No version was filed by the 2nd opposite party within the statutory period and the case was posted for evidence on 27/07/2017. On 14/09/2017 2nd opposite party filed I.A. 467/2017 for accepting the version. I.A. 647/2017 was allowed on cost.
3. Version of 2nd opposite party
The above complaint is not maintainable either in law or on facts. The complainant was having kidney disease from 2002 onwards. Renal biopsy was done for the complainant in 2002 and the complainant was having nephropathy since 2002. The complainant was also having hypertension for 17 years. Complainant is not entitled to the benefits of the said policies as the complainant had not ported the policy with National Insurance Co. Ltd. to this opposite party. According to the conditions of the policy “If you wish to exercise the Portability Benefit, we should have received your application and the completed Portability Form with complete documentation at least 45 days before the expiry of your present period of insurance”. The complainant had taken a policy with the opposite party for the first time on 11/11/2011. The individual sum insured for the policy of the complainant is only Rs.4,00,000/-. According to the conditions of the policy, “If a claim is in any way found to be fraudulent or if any false statement or declaration is made or used in support of such a claim, or if any fraudulent means or devices are used by the insured person any false or incorrect disclosure to information norms or anyone acting on behalf of the insured person to obtain any benefit under this policy, then this policy shall be void.” Had the complainant disclosed the fact that he was having membranous nephropathy, the opposite parties would have assessed the risk accordingly. The allegation of the complainant that pre-existing diseases are covered subject to waiting period can be applied only when the complainant disclosed the disease as a pre-existing disease. The policy of the complainant was cancelled according to the conditions of the policy. The opposite parties are not liable to pay any of the expenses incurred by the complainant as stated in complaint as the policy had become void due to non-disclosure and suppression of material facts and subsequently the policy was cancelled. There has been no deficiency in service on the part of the opposite parties.
4. Evidence
The evidence consists of the proof affidavit filed by the complainant and the documentary evidence filed by the complainant which is marked as Exbt. A1 to A14.
On 23/02/2018, opposite party filed I.A.89/18 to direct the production of documents from 3rd party. Since the petition was filed belatedly, I.A. 89/2019 was dismissed by the Commission on 23/02/2018. Opposite party challenged this order dated 23/02/2018 before the Hon’ble State Commission as R.P. 14/18 and RP 14/18 allowed by the Hon’ble State Commission and consequently summons was issued to the Administrator, Aster Medicity to produce the hospital records of the complainant. Hospital records of the complainant produced and marked as Exbt. ‘X1’.
Later the complainant filed I.A. 250/2021 to re-open the evidence of the complainant which was allowed on 17/03/2022. Complainant filed additional proof affidavit and additional seven documents. Exbt. A15 to 21 marked from the side of the complainant (Exbt. A20 and A21 marked subject to objection from opposite party’s counsel) and the complainant is cross-examined by opposite party’s counsel on the basis of additional proof affidavit filed by the complainant. Evidence of the complainant closed.
Opposite party filed two documents which are marked as Exbt. B1 and B2.
Heard both sides.
We have gone through the complaint, version and documents of both sides.
5. Points for consideration in this case are
1. Whether any deficiency in service or unfair trade practice is proved from the side of the opposite party towards the complainant?
2. If so, reliefs and costs?
For the sake of convenience, we consider issue No. (1) and (2) together.
The case of the complainant is that he had a mediclaim policy from the opposite parties from 2011 onwards. Prior to that policy he had a mediclaim policy from the National Insurance Company from 2005 onwards. The plan of the policy is Family First Silver- 4lakhs +5 lakhs. The sum assured is Rs.13,00,000/-. Gross premium paid is Rs.29,910/-. Within the sum insured there is an individual cover for each insured person which shall be upto the amount specified in the schedule of Insurance Certificate for that insured person within the sum insured. There is a floater insurance cover upto the amount specified in the schedule of Insurance Certificate. As per A1 policy the individual sum insured is Rs.4,00,000/- and the floater sum insured is Rs.5,00,000/-.
The 1st complainant was admitted in Aster Medicity, Ernakulam from 18/01/2018 to 16/01/2016 due to continuous fever and urinary tract infection. 1st complainant was again admitted at the Hospital on 17/01/2016 and discharged on 20/01/2016. Again on 02/02/2016, the 1st complainant was admitted in the Hospital and was discharged on 05/02/2016. The pre-authorization request given by the Hospital authorities for cashless treatment was denied by the opposite parties.
While so, the complainant had received a communication from the opposite parties on 22/02/2016 stating that the policy of the complainant stands cancelled by invoking Clause 3 of the terms and conditions of the policy. The last renewal of the policy of the complainant was for the period from 11/11/2015 to 16/11/206. The sum insured of the policy was Rs.13,00,000/-.
The opposite parties illegally and without any basis cancelled the mediclaim policy of the complainant. The policy was continued from 2005 onwards from National Insurance Company and from 2011 onwards from the opposite parties. Hence the complainant is entitled to the policy benefits as per the policy. The stand taken by the opposite parties are not sustainable. The stand taken by the opposite parties are that the complainant had taken the mediclaim policy which was obtained without disclosing the pre-existing ailment. According to the opposite parties the complainant had Renal disease and Systemic Hypertension for the last years and was under the treatment for the same and the same was not disclosed anywhere. Hence the complainant was not entitled for the claim benefits as per policy conditions.
From the available documents and evidence it can be seen that the complainant had a mediclaim policy from the opposite parties from 2011 onwards. Moreover there was no dispute with regard to the fact that from the year 2005 onwards the complainant had taken Mediclaim policy from the National Insurance Company. Hence it is assumed that the complainant had a mediclaim policy from the National Insurance Company from 2005 onwards.
From the medical reports produced from Aster Medicity Hospital, Ernakulam it can be seen that the complainant was treated in the above hospital in the year 2016 (from 08/01/2016 to 16/01/2016 – Exbt. A2 and A3). Moreover there was no evidence to show that the ailment of the complainant was prior to the inception of the mediclaim policy.
The stand taken by the opposite parties are not sustainable because there was no evidence adduced by the opposite party that the complainant had the history of the alleged ailment prior to 2005. So we are of the opinion that the case of the complainant is found in favour of the complainant and the complainant is eligible to get compensation and cost of proceedings from the opposite parties. Hence Point No. (1) and (2) are found in favour of the complainant.
In the result, the complaint is allowed as follows:
1. We direct the opposite parties to pay Rs.7,21,528/- (Rupees seven lakh twenty one thousand five hundred twenty eight only) to the complainant as per Exbt. B1 Policy.
2. We direct the opposite parties to pay Rs.10,000/- (Rupees ten thousand only) as compensation to the complainant.
3. An amount of Rs.5,000/- (Rupees five thousand only) is to be paid to the complainant by the opposite parties as cost of proceedings.
The opposite parties shall be jointly and severally liable for the above-mentioned directions which shall be complied with by the Opposite Parties within 30 days from the date of the receipt of a copy of this order. If the above order is no complied within one month the amount will carry interest at the rate of 5% per annum from the date of order till realisation.
Pronounced in the Open Commission this 27th day of January, 2023.
Sd/-
Sreevidhia.T.N, Member
Sd/-
D.B.Binu, President
Sd/- V.Ramachandran, Member
Forwarded/by Order
Assistant Registrar
APPENDIX
COMPLAINANT’S EVIDENCE
Exbt. A1: Copy of Policy terms and conditions
Exbt. A2: Copy of discharge summary
Exbt. A3: Copy of discharge summary
Exbt. A4: Copy of Denial of authorization
Exbt. A5: Copy of letter received from opposite party
Exbt. A6: Copy of discharge summary
Exbt. A7: Copy of discharge summary
Exbt. A8: Copy of discharge summary
Exbt. A9: Copy of discharge summary
Exbt. A10: Copy of Case Summary & Discharge Record
Exbt. A11: Copy of letter sent to the opposite party
Exbt. A12: Copy of lawyer notice
Exbt. A13: Track Consignment
Exbt. A14 Series: Copies of Policy Certificate (7 in No.s)
Exbt. A15: Patient Bill (summary)
Exbt. A16: Patient Bill (summary)
Exbt. A17: Patient Bill (summary)
Exbt. A18: Patient Bill (summary)
Exbt. A19: Patient Bill (summary)
Exbt. A20: Patient Bill (summary)
Exbt. A21: Medical Bills
OPPOSITE PARTY’S EVIDENCE
Exbt. B1: Heartbeat Health Insurance Policy Proposal Form
Exbt. B2: Copy of Policy Terms and Conditions
DEPOSITION
Pw1: K.P. Paul (Complainant)
X1: Medical records
Despatch date:
By hand: By post
kp/
CC No. 70/2017
Order Date: 27/01/2023
