Date of filing: 30.07.2022
Date of Disposal: 02.06.2023
BEFORE THE III ADDITIONAL BANGALORE URBAN
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU – 560 027.
DATED THIS THE 02ND DAY OF JUNE, 2023
CONSUMER COMPLAINT NO.154/2022
PRESENT:
-
SRI.RAJU K.S,
SMT.REKHA SAYANNAVAR,:MEMBER
Satish Chandra Goel,
S/o. late Prem Chand Goel,
Aged About 77 Years,
C/o. San Soaps and Detergents,
Godavari Estate,
Near Budigere Cross,
Off: Old Madras Road,
(Rep by Sri. B.V.Prashanth, Advocate)
- V/s -
1) Star Health & Allied insurance
Company Limited, No.255,
-
Ganganagar, Bangalore-560032,
Represented by its Manager.
(Rep. by Sri.Janardhan Reddy, Advocate)
2) Head Office situated at:-
Star Health & Allied Insurance
Company Limited, Sri Balaji
Complex, 15, Whites Road,
Represented by its Manager.
(Rep. by Sri.Janardhan Reddy, Advocate)
//JUDGEMENT//
BY SRI. SHIVARAMA K, PRESIDENT
01. The complainant has filed this complaint on 10.02.2020 under section 35 of the Consumer Protection Act, 2019 seeking for a direction to opposite parties to pay a sum of Rs.1,55,659/- towards medical expenses and such other relief as this Commission deems fit in the circumstances of the case.
02. It is not in dispute that, the complainant has availed Senior Citizens Red Carpet Health Insurance Policy for the period between 18.07.2021 to 17.07.2022 through its branch office, Bangalore, covering the risk of the complainant and the sum insured was of Rs.10,00,000/-.
03. Further it is not in dispute that, the inception of the policy was on 18.07.2017 and it was renewed year after year continuously. Further it is not in dispute that, the complainant was admitted as an inpatient at Manipal Hospital on 16.12.2021 and discharged on 18.12.2021 for diagnosis Syncope under evaluation that means, one episode of loss of consciousness associated with slurring of speech lasting about 5 minutes. Further the complainant incurred total expenses at hospital to the tune of Rs.1,55,659/-. Further it is not in dispute that, the complainant applied for reimbursement of the said expenses and the opposite party had rejected the claim on 19.12.2021. Further it is not in dispute that, the opposite parties had repudiated the claim on the ground that, the complainant had suppressed the pre-existing disease of Syncope.
04. It is the further case of the complainant that, Syncope is not a disease but a symptom and a manifestation of an underlying cause/disease. Further on 21.12.2021 a Doctor had given an opinion that, Syncope is not a disease, but it is a symptom and a manifestation of an underlying cause/disease. Further the complainant got issued a legal notice through his advocate dated: 31.05.2022 calling upon the opposite parties to reimburse the hospital expenses and the said notice was duly served on the opposite parties. Since the opposite parties did not reimburse the claim the present complaint came to be filed.
05. It is the further case of the opposite parties that, the policy is a contractual in nature and the claims arising therein subject to the terms and conditions of the policy. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Further on perusal of the documents submitted by the insured, it was observed that, the insured patient has been suffering from Syncope disease/condition since 2013 which was prior to inception of the first policy. Hence it was a pre-existing disease. Further as per the IRDA guidelines if the non-disclosed disease is other than the disease from the list of permanent exclusions, then the insurer can incorporate additional waiting period of not exceeding 12 months for the said undisclosed disease or condition from the date the disease was found out and it is now incorporated in the above policy that All Neurological diseases and its complications as pre-existing disease/condition by passing endorsement. Subsequently the insured has approached the Ombudsman and on 22.04.2022 the Ombudsman had confirmed the rejection passed by the opposite parties. Hence it is sought to dismiss the complaint.
06. To prove the case complainant/PW.1 has filed affidavit in the form of his evidence in chief and got marked EX.P.1 to EX.P.10 documents. The Working Assistant Manager of opposite party No.1 (RW-1) has filed affidavit in the form of his evidence in chief and got marked EX.R.1 to EX.R.12 documents.
07. Counsels for both the parties have filed their respective written arguments.
08. The points that would arise for consideration are as under:-
(1) Whether there is deficiency of service on the part of the opposite parties?
(2) Whether the complainant is entitle for the
relief sought ?
(3) What order ?
09. Our findings on the aforesaid points are as follows:-
POINT NO.1:- In negative
POINT NO.2:- In negative
POINT NO.3:- As per the final order
for the following:
REASONS
10. POINT NO.1:- PW.1 and RW.1 have reiterated the fact stated in their pleadings, in the affidavits filed in the form of their evidence in chief.
11. It is the contention of the learned counsel for the opposite parties that, since the complainant had supressed the fact of pre-existing disease and had obtained the policy thereby as per the terms and conditions of the policy the complainant is not entitled for reimbursement. EX.R.11 is the order of rejection of authorization for cashless treatment dated: 19.12.2021. In which it is stated that, on scrutiny of the documents produced by the insured for the approval of cashless treatment for the diagnosed disease of Syncope under evaluation it was found that, the complainant has been suffering from the above disease prior to inception of the first policy, hence it was a pre-existing disease. Thereby as per exclusion clause-1 of the policy the claim is not admissible until the expiry of 12 months from the date of admission 06.12.2021 after first October 2020. EX.P.5 and EX.R.11 are one and the same.
12. EX.R.4 is the terms and conditions of the policy. In clause-3 Exclusions in 1A it is stated that, “expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 12 months of continuous coverage after the date of inception of the first policy with insurer”. It reflects in EX.P.1 copy of the policy that, the date of inception of the first policy was 18.07.2017. EX.R.7 is the final bill dated: 18.12.2021 contemplates that, the complainant was admitted to the hospital on 16.12.2021 and discharged on 18.12.2021. The repudiation was as per EX.P.5 dated: 19.12.2021. Since the claim was after the expiry of 12 months of continuous coverage after the date of inception of the first policy with insurer, we feel this contention would not come in the way of the insurer to reimburse the claim.
13. It is the further contention of the learned counsel for the opposite party that, the undisclosed disease or condition was found on 19.12.2021 and now it has been incorporated in the policy issued to the insured as pre-existing disease/condition by passing endorsement. Further as per IRDA guidelines if the non-disclosed disease is other than the disease from the list of permanent exclusions, then the insurer can incorporate additional waiting period of non-exceeding 412 months for the said undisclosed disease or condition from the date the disease was find out.
14. EX.R.12 is the copy of the guidelines in Chapter VI said to have been issued by IRDA. In which it is stated that, “insurers are allowed to incorporate waiting periods for any specific disease condition however for a maximum of 4 years”. Further Chapter-VI Clause-2(b) of the guidelines vide EX.R.12, “if the non-disclosed condition is other than from the list of permanent exclusions, then the insurer can incorporate additional waiting period of not exceeding 4 years for the said undisclosed disease or condition from the date the non-disclosed condition was detected and continue with the policy subject to obtaining the prior consent of the policy holder or the insured person”. It is the contention of the learned counsel for the complainant that, the complainant was suffering from Syncope under evaluation. It is the further contention of the learned counsel for the opposite party that, when the claim was made by the complainant for reimbursement of medical expenses in the year 2021 on perusal of the documents vide eX.R.10 issued by the Doctor of Manipal Hospital opposite party came to know that, the complainant was admitted the hospital under the complaint of Syncope in the year 2013. The complainant did not oppose the EX.R.10. It is clearly stated in EX.R.10 letter said to have been issued by the Manipal Hospital that, the complainant was admitted to Manipal Hospital in the year 2013 for the complaint of Syncope. Further as per Clause-3(1)(d) of Exclusion vide EX.R.4 Conditions of the Policy, it reflects that, “coverage under the policy after the expiry of 12 months for any pre-existing disease is subject to same being declared at the time of application and accepted of insurer”. EX.R.3 is the proposal form dated: 17.07.2017. On perusal of EX.R.3 it appears that noting is incorporated the guidelines related to exclusions as per IRDA that, the insurer can incorporate additional waiting period of not exceeding 4 years for the undisclosed disease or condition from the date of non-disclosed condition was detected and the policy could be continued subject to obtaining the prior consent of the policy holder of the insured person. Therefore we feel since after detect of the disease on 19.12.2021 the incorporation in the policy issued to the insured, with regard to the pre-existing disease by passing an endorsement that, 4 years waiting period shall be completed has more force since the said condition has not at all been incorporated in the proposal form. Hence we feel there is no merit in the contention of the learned counsel for the opposite party with regard to the reimbursement of claiming complainant has to wait for a period of 4 years from the date of pre-existing disease been found.
15. It is the further contention of the learned counsel for the opposite party that, since the complainant had supressed the material fact, he is not entitled for reimbursement. In the proposal form vide EX.R.3 it is stated with regard to the previous illness that, the complainant had diabetes. It is the contention of the learned counsel for the complainant that, the disease Syncope under Evaluation is the result of BP variation. Hence the complainant has disclosed the pre-existing disease. Since in Ex.R.10 issued by the Doctor at Manipal Hospital it is specifically stated that, the complainant was admitted for the treatment of Syncope, it cannot be said that, the complainant had no knowledge that, he had Syncope under Evaluation disease/condition. In EX.R.4 conditions of the policy in clause 9 with regard to Fraud it is stated that, “if any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited”. Further clause 9 provides that, the company shall not repudiate the claim and/or forfeit the policy benefits on the ground of Fraud, if the insured person/beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to supress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer”. Since the suppression of pre-existing disease was found by opposite party in the year 2021, it cannot be said that, at the time of submitting the proposal form for the policy, the insurer had the knowledge about the pre-existing disease. Hence it appears to us that, the complainant has supressed the pre-existing disease. Hence the opposite party is correct in repudiating the claim and no deficiency of service can be attributed against the opposite party. Accordingly we answer this point in negative.
16. POINT NO.2:- In view of the finding given on point No.1 this point is answered in negative.
17. POINT NO.3:- In view of the discussion made above, we proceed to pass the following:-
ORDER
The complaint is dismissed. No order as to costs.
Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.
Applications pending, if any, stands disposed-off in terms of the aforesaid judgment.
(Dictated to the Stenographer, typed by him, the transcript corrected, revised and then pronounced in the open Commission on 02nd Day of JUNE 2023)
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
MEMBER MEMBER PRESIDENT
//ANNEXURE//
Witness examined for the complainant side:
Sri. Satish Chandra Goel, the complainant (PW-1) has filed affidavit in the form of his evidence in chief.
Documents got marked for complainant side:
- Copy of the insurance policy dt.18.07.2017 to 18.07.2022 – EX.P.1.
- Copy of discharge summary – EX.P.2.
- Copy of hospital bill – EX.P.3.
- Copy of the letter of request dt.16.12.2021 – eX.P.4
- Copy of the rejection for cash less statement – EX.P.5.
- Copy of email correspondence – EX.P.6.
- Copy of opinion given by doctor through email – Ex.P.7.
- Copy of the insurance ombudsman letter – EXP.8.
- Copy of the award given by insurance ombudsman in award No.30/2022-23 – Ex.P.9.
- Office copy of the legal notice dt.31.05.2022 with 2 RPAD receipt and Acknowledgment – Ex.P.10.
Witness examined for the opposite party side:
Smt. Prema, Assistant Legal Manager, in opposite party (RW-1) has filed affidavit in the form of her evidence in chief.
Documents got marked for the Opposite Party side:
1. Letter of authorization – EX.R.1.
2. Copy of policy schedule – EX.R.2.
3. Copy of Proposal form – EX.R.3.
4. Copy of policy terms and conditions – EX.R.4.
5. Copy of query on authorization for cash less treatment dt.18.12.2021 – EX.R.5.
6. Copy of denial for pre-authorization dt.18.12.2021 – EX.R.6.
7. Copy of final bill dt.18.12.2021 – EX.R.7.
8. Copy of discharge summary – EX.R.8.
9. Copy of progress sheet of Manipal Hospital – EX.R.9.
10. Copy of letter given by doctor who had treated in the year 2013 – EX.R.10.
11. Copy of rejection letter dt.19.122021 for cash less treatment – EX.R.11.
12. Copy of IRDA guidelines – EX.R.12.
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
MEMBER MEMBER PRESIDENT
