DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 24th day of October, 2024
Present : Sri. Vinay Menon V., President
: Sri. Krishnankutty N.K., Member Date of Filing: 23/06/2023
CC/162/2023
Madhavikutty K.P.,
W/o. P.N. Gangadharan,
Pathiyarathodi House,
VI/482 Keralassery (PO),
Palakkad – 678 641 - Complainant
(By Adv. V.C. Janardhanan)
Vs
- The Authorised Signatory,
M/s. Star Health & Allied Insurance Co.Ltd.,
Corporate Office - #1,
New Tank Street, Valluvarkottam High Road,
Nungampakkam,
Chennai – 600 034.
- The Branch Manager,
M/s. Star Health & Allied Insurance Co. Ltd.,
Branch Office, Fine Centre, 4th Floor,
T.B. Road, Palakkad – 678 014 - Opposite parties
(By Adv. M/s. Ratnavally P. & Kiran G. Raj A.)
O R D E R
By Sri. Vinay Menon V., President
- Complaint pleadings shorn to bare necessities is that from 2020 onwards till 2022 -23, the complainant was a beneficiary under the health insurance coverage provided by the OP insurance company. The complainant was suffering from diabetes mellites and its complications which was disclosed at the time of executing the first proposal form. She was not suffering from any other disease. But the OPs, subsequent to the complainant’s hospitalization in Valluvanadu Hospital and Lakshmi Hospital for treatment and subsequent surgery for umbilical hernia, repudiated her claims stating that the complainant was suffering from seizure and coronary artery disease. Aggrieved thereby this complaint is filed.
- OPs filed version stating that the complainant was having coverage under Arogya Sanjeevani Policy from 31/10/2020 onwards. During 2022, the complainant had submitted 3 claims from October to December. The OPs received request for cashless hospitalization from Valluvanad Hospital Complex Ltd. on 16/10/2022 wherein it was stated that the complainant had suffered seizure disorder and intra cranial space occupying lesion (ICSOL). It was also seen that the complainant had a history of seizure. Hence a query was issued seeking details regarding the exact duration of seizure, consultation taken and medications. Since the hospital had not forwarded the details, OP denied pre-authorization request for cashless treatment and informed the complainant. As the discharge summary showed that the complainant was diagnosed with seizure disorder, coronary artery disease, hyper tension / dyslipidemia, hypo-thyroidism and umbilical hernia, the OPs issued a query seeking directions as to the first consultation details of CAD / seizure / umbilical hernia. To the said query, son of the complainant issued an e-mail stating that the complainant is not suffering from seizure, CAD or umbilical hernia. Hence the said claim was denied. Thereafter, at the request of complainant, the claim was re-opened. On a perusal of the documents, it became clear that the complainant was suffering from seizure disorder prior to issuance of policy. Furthermore, the complainant has also failed to produce the documents sought for by the OP for considering the claim. Hence the claims were denied for misrepresentation and non-disclosure of material facts and directed the complainant to apply for reimbursement with necessary documents as sought for.
- The following issues were framed for consideration:
- Whether there was any non-disclosure of material facts by the complainant?
- Whether non-disclosure was intentional?
- Whether the repudiation of claim is as per the terms and conditions of the policy?
- Whether there is any deficiency in service or unfair trade practice on the part of OPs?
- Whether the complainant is entitled to any of the reliefs sought for?
- Any other reliefs?
4. (i) Documentary evidence of complainant comprised of proof affidavit and Exhibits
A1 to A14.
(ii) Complainant was examined as PW1.
(iii) Exts.B1 to B15 were marked through confrontation of PW1.
(ii) OPs filed joint proof affidavit.
Issue No.1
5. It is the case of the complainant that the claim raised by her for undergoing treatment in Valluvanad Hospital and surgery in Lakshmi Hospital were denied on the ground that she was having pre-existing disease that were not disclosed. The complainant had raised 3 claims i.e. (1)CIR/2023/181214/0942785 (2) CIR/2023/181214/1099426 & (3) CIR/2023/181214/1258638. Exts.B5, B9 & B15(a) are the letters indicating repudiation of the aforesaid claims. It is to be noted that all these documents are denial of pre-authorization requests for cashless treatment and not repudiation of the claim per se. All these documents direct the complainant to seek reimbursement of expenses incurred relating to the treatment of the diseases that were diagnosed.
6. It goes without saying that the complainant had declared that she was suffering from diabetes and its complications. Thereafter, on admission in Valluvanad Hospital, the treating doctor, Dr. Praveen had stated that the complainant was suffering from seizure as presenting complaint. Diagnosis was seizure disorder and intra cranial space occupying lesion(ICSOL). Ext.B6 is the discharge summary issued by Valluvanad Hospital pertaining to the period under which claim bearing No.942785 was filed. The discharge summary shows the clinical history to be of altered sensorium and abnormal movements. Diagnosis pertains to seizure disorder, CAD, hypertension and dyslipidemia, hypothyroidism and umbilical hernia. Ext.B7 cross consultation record dated 16/10/2022 shows that the complainant was a known case of all these conditions and were not newly diagnosed conditions. Therefore, as per Ext.B3, the OP sought for exact duration of seizure, all consultation taken till date and for details of current medication. Since the same was not provided, the OP refused to provide approval for cashless treatment and directed the complainant to submit documents for reimbursement of expenses. In this connection deposition of PW1 in page 6, lines 5 to 16 is as follows:
“Valluvanad Hospital ല് ചികിത്സിച്ച് കൊണ്ടിരിക്കുമ്പോഴുള്ള cross consultation record ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്. (Marked as Ext.B7). hospitalizationന് ശേഷം claim submit ചെയ്തപ്പോള് OP അയച്ച letter – Requirement of Additional document and information dated 16/11/22 ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത് (marked as Ext.B8). Discharge summaryല് പറഞ്ഞ രോഗങ്ങളെ കുറിച്ചുള്ള ആവശ്യപ്പെട്ട രേഖകള് ഹാജരാക്കാത്ത്ത്കൊണ്ട് കമ്പനി നിങ്ങളുടെ claim 8/12/22ന് നിരസിച്ചു എന്ന് പറഞ്ഞാല് ശരിയാണ്”.
Complainant herself has admitted that she has failed to submit the documents sought for by the O.P. company.
7. Ext.B11 is the request for cashless hospitalization issued for treatment in Lakshmi Hospital. Date of admission is 18/11/2022. In 3rd page of Ext.B11, in the details of patient admitted, it is seen that the complainant was suffering from ailments of thyroid for 10 years and hyper tension for 2 years. It is also stated that she was suffering from heart disease for one month. Deposition of the complainant with regard to her admission in Lakshmi Hospital is as follows:
Lines 7 to 17 in page 7 and lines 1 to 17 in page 8: “18/11/22 ലാണ് ഞാന് ലക്ഷ്മി hospital ല് അഡ്മിറ്റ് ആകുന്നത്. അന്ന് cashless facility ക്ക് വേണ്ടി Lakshmi hospital ല് നിന്നും കമ്പനിക്ക് അയച്ച request letter ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്. (Marked as Ext.B11) അതില് detail of patient admitted എന്നതില് 10 വര്ഷമായി Thyroid ഉണ്ടെന്നും രണ്ടു വര്ഷമായി hyper tension ഉണ്ടെന്നും രേഖപ്പെടുത്തിയിട്ടുണ്ടെന്നു പറഞ്ഞാല് ശരിയാണ്. ആയത് ഒന്നും തന്നെ declarationല് പറഞ്ഞതായി കാണുന്നില്ല എന്ന പറഞ്ഞാല് എനിക്കറിയില്ല. മകനാണ് ചേര്ത്തിട്ടുള്ളത്.
(Continues in page 8) 18/11/22ന് എതിര്കക്ഷികള് Lakshmi Hospital ലേക്ക് അയച്ച letter ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്. Query on authorization of cashless treatment dated 18/11/22 is marked as Ext.B12. അതിന്റെ documents ഒന്നും ഹാജരാക്കത്തത് കൊണ്ട് അവിടെ നിന്നും cashless treatment കിട്ടിയില്ല എന്ന് പറഞ്ഞാല് ശരിയാണ്. 23/12/22ന് ഞാന് Lakshmi hospital ല് admit ആയി. അന്ന് cashless facility വേണ്ടി Lakshmi hospital ല് നിന്നു കമ്പനിക്ക് അയച്ച letter (dated 23/12/22) ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്. Marked as Ext.B13. അന്നും ഹെര്ണിയയുടെ treatment ന് വേണ്ടിയാണ് admit ആയത്. അതില് Details of patient admitted എന്ന കോളത്തില് heart disease since 2 years എന്ന് കാണിച്ചിരിക്കുന്നു എന്ന് പറഞ്ഞാല് എഴുതിയിട്ടുണ്ട്. അങ്ങനെ ഒരു അസുഖം എനിക്കില്ല. Thyroid since 20 years എന്നും എഴുതിയിട്ടുണ്ടെന്ന് പറഞ്ഞാല് ശരിയാണ്.”
8. Thereafter she was admitted again on 23/12/2022 in Lakshmi Hospital. Request for cashless hospitalization issued is marked as Ext.B13. In the part dealing with details of patient, it can be seen that the complainant was suffering from heart disease for 10 years. It is also stated that she was on treatment for ailments related to thyroid for 20 years. All the aforesaid claims were denied. The OP directed the complainant to seek reimbursement after production of the documents sought for careful consideration of the condition suffered by the complainant.
Page 9. lines 3 to 7 of the deposition: “Lakshmi hospitalലേക്ക് company അയച്ച query letter dated 23/12/22 ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്. (Marked as Ext.B14) ആയതൊന്നും തന്നെ ഹാജരാക്കാത്തതുകൊണ്ട് കമ്പനി അത് നിരസിച്ചുകൊണ്ട് Lakshmi hospitalനെ അറിയിച്ച letter dated 26/12/22 ആണ് ഇപ്പോള് എന്നെ കാണിച്ചത്.”
Complainant has no case that pursuant to such request from O.P., she or her son had submitted documents.
9. It is true that there are discrepancies in the period of illnesses as shown by the treating doctor. When the O.P. has proved by their documents, which they have availed from the hospital that treated the complainant, burden of proof shifted to the complainant to disprove the case of the O.P. But the complainant states that she is not aware why the doctor has stated likewise in the medical records.
Page 10 lines 2 to 5 of deposition: “വള്ളുവനാട് hospitalല് ചികിത്സിച്ച doctor പല വിധത്തിലുള്ള രോഗങ്ങള് ഉണ്ടെന്നു കളവായി രേഖപ്പെടുത്തിയതാണോ എന്ന് എനിക്കറിയില്ല.”
10. Nothing prevented the complainant from producing the documents sought for by the insurer and filing a claim for reimbursement. Having failed to do so, we are of the opinion that balance of probability, based on the evidence adduced tilts in favour of the O.P. We hold that there is non-disclosure of material facts.
Issue No.2
11. As already stated supra, the complainant was a known case of various ailments that went undeclared in the proposal forms. Ext. B7 shows that the complainant was a known case of hyper tension, dyslipidemia, thyroid ailments and coronary artery disease. Thus, we can see that these ailments are not diagnosed on the first admission during October 2022 in Valluvanad Hospital. The treating doctor has stated that the heart disease and ailments of thyroid are of years of duration. No action whatsoever is taken by the complainant against the doctor who issued the certificates stating the pre-existing diseases suffered by the complainant. The complainant could very well have examined the said doctor as a witness, had the statement of the doctor been false or a mistaken statement. Non-examination of a material witness goes against the complainant.
12. We hold that the complainant was aware of the existence of the said diseases at the time of preparation of proposal forms.
Issue No.3
13. It can be seen that, from a perusal of documents, it is only the cashless treatment that was denied and not the claim itself. The complainant has not applied for reimbursement of the medical bills. From a discussion of the facts and appreciation of evidence adduced, we hold that the cashless treatment was denied on the basis of terms and conditions of the policy.
Issue Nos.4 to 6
14. Based on the discussions and findings above, we hold that there is no deficiency in service on the part of OPs.
15. Complaint is not entitled to any of the reliefs sought for.
16. Accordingly, complaint stands dismissed.
Pronounced in open court on this the 24th day of October, 2024.
Sd/-
Vinay Menon V
President Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - Original certificate of insurance bearing No. P/181214/01/2021/008269
Ext.A2 – Copy of certificate of insurance bearing No. P/181214/01/2023/010013
Ext.A3 - Copy of Ext.A1.
Ext.A4 - Copy of discharge summary dated 19/10/2022 together with hospital reports.
Ext.A5 (a) to (j) - Original set of bills from Valluvanad Hospital
Ext.A6 - Copy of discharge summary together with other reports
Ext.A7 (a) to (i) - Original set of bills from Lakshmi Hospital
Ext.A8 - Copy of discharge bill issued from Lakshmi Hospital.
Ext.A9 - Copy of 1st reminder dated 1/12/2022
Ext.A10 – Copy of discharge bill issued from Valluvanad Hospital
Ext.A11 - Copy of denial of pre-authorisation request for cashless treatment dated
26/12/2022 directing submission of documents seeking reimbursement.
Ext.A12 – Copy of communication dated 22/12/2022 intimating non disclosure of PED
Ext.A13 – Copy of repudiation of claim dated 8/12/2022
Ext.A14 – Copy of receipt dated 24/1/2023 showing acknowledgment of documents.
Exhibits marked on the side of the opposite party:
Ext.B1 – Copy of certificate of insurance bearing No.P/181214/01/2022/008788
Ext.B2 - Copy of request for cashless hospitalization.
Ext.B3 – Copy of query on authorisation for cashless treatment dated 18/10/2022
Ext.B4 – Copy of denial of pre-authorisation request for cashless treatment dated 20/10/2022
addressed to hospital
Ext.B5 – Copy of denial of pre-authorisation request for cashless treatment dated 20/10/2022
addressed to Mr.Jithin
Ext.B6 – Copy of discharge summary
Ext.B7 – Print out of cross consultation record
Ext.B8 – Copy of communication seeking additional documents / information
Ext.B9 – Copy of repudiation of claim dated 8/12/2022
Ext.B10 – Copy of repudiation of claim dated 21/12/2022
Ext.B11 – Copy of request for cashless hospitalisation for health insurance.
Ext.B12 – Copy of query on authorisation for cashless treatment dated 18/11/2022
Ext.B13 – Copy of request for cashless hospitalisations for health insurance.
Ext.B14 – Copy of query on authorisation for cashless treatment dated 23/12/2022
Ext.B15(a) – Copy of denial of pre-authorisation request for cashless treatment dated
26/12/2022 directing submission of documents seeking reimbursement.
Ext.B15(b) – Copy of denial of pre-authorisation request for cashless treatment dated
26/12/2022 showing the documents required to consider the claim.
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant:
PW1 – Madhavikutty, Complainant
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
