Individual Mediclaim Policy Case No. BNG-G-003-1516-0409 Mr. Ravikumar PV/s Apollo Munich ...

337 Pages·2017·2.5 MB·English

Individual Mediclaim Policy

Case No. BNG-G-003-1516-0409

Mr. Ravikumar P V/s Apollo Munich Health Insurance Company Limited

Date of Award – 5th January, 2016

The Complainant held an Individual Mediclaim Insurance Policy. During the currency of the
Policy, the complainant was hospitalized in an Ayurvedic Hospital for complaints of pain in
the lower back region radiating to the right leg and was diagnosed as suffering from
Grudrasi (Ayurveda). Claim for hospitalization expenses was denied.

The Insurer repudiated the claim stating that the X-rays submitted were normal and did not
indicate any fracture/infection and the treatment provided for spinal subluxation was merely
for muscle strain/muscle stimulation which falls under (d) (xii) exclusion of the policy.

Based on the facts and circumstances of the case, documents made available by and
submissions made by both the parties, it was concluded that the repudiation of the claim by
the Insurer was justified and required no interference at the hands of this Forum.

Hence, the case was Dismissed.
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Diabetes Safe Insurance Policy

Case No. BNG-G-044-1516-0511

Dr. (Mrs.) Hema Sridhar V/s Star Health And Allied Insurance Company Limited

Date of Award – 19th January, 2016

The Complainant was a Diabetes Safe Insurance Policy holder uninterruptedly for 8 years.
She was administered 12 injections as a part of treatment of Myeloma.

The Insurer repudiated the claim stating that the treatment was taken at home (Domiciliary
treatment) and does not fall under in-patient treatment and day care procedures.

Taking into account the facts & circumstances of the case and the submissions made by
both the parties during the course of personal hearing, it was concluded that the decision of
the Insurer in repudiating the claim was in order and does not require any interference.

Hence, the Complaint is Dismissed.
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Individual Mediclaim Insurance Policy

Case No. BNG-G-037-1516-0512

Ms. Vijayalakhsmi Kishore V/s Religere Health Insurance Company Limited

Date of Award – 19th January, 2016

During the 1styear of the Policy, the Complainant was hospitalized and was diagnosed as
suffering from LeucocytoclasticVascuiltis.

But, the Insurer repudiated the claim stating that the line of treatment was not in consistent
with the diagnosis and unrelated investigations and consultations were carried out. Insurer
reported to the Indian Medical Council about this irregularity.

Since the matter was pending before the Medical Council of India, which is Apex Body as far
as medical profession is concerned, this compliant does not fall within the scope of the
functioning of the Insurance Ombudsman.

Hence, the Complaint is Disposed of.

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Medi-Classic Insurance Policy (Individual)

Case No. BNG-G-044-1516-0593

Mr. Basavaraju v/s Star Health & Allied Insurance Company Limited

Date of Award – 16th February, 2016

The Complainant took a Mediclassic Insurance Policy (Individual) covering himself for the
period from 05.03.2015 to 04.03.2016. During the currency of the policy, the insured was
hospitalized for left ICA thrombosis. He pleaded that during 2014, he consulted for
neurological problems and some tablets were prescribed but the treating doctor did not
disclose the disease and he was not aware of any pre-existence medical condition.

Insurers submitted earlier treatment papers which confirms that the patient had suffered
from Thrombos formation and ecosporin tablets were used for avoiding clotting of blood.
They went to add that thrombosis leads to weakness of limbs and the current hospitalization
of a repeat of the hospitalization which he had prior to taking the said policy. Further, the
insured failed to disclose the earlier hospitalization at the time of taking the policy which
amounts to non-disclosure of material fact and the claim merits repudiation.

It has been concluded that the decision of the Insurer in repudiating the claim is in order
and as per terms and conditions of the Policy and does not require any interference at
the hands of this Forum.

Hence, the Complaint is Dismissed.
Senior Citizens Red Carpet Insurance Policy

Case No. BNG-G-044-1516-0582

Mr. J Sathyanarayan v/s Star Health & Allied Insurance Company Limited

Date of Award – 16th February, 2016

The Complainant took a Senior Citizens Red Carpet Insurance Policy covering his father.
During the currency of the 7th year of Insurance, the Insured Person (aged 72 years) was
hospitalized for the complaints of abdominal bloating, early satiety and decreased appetite
and was a known case of DM & HTN and on medication and was diagnosed with Intestinal
Sysmotility, Parkinson plus syndrome, Diabetes Mellitus and Hypertension.

Insurer repudiated the claim stating that the patient had history of tremors and was
diagnosed with Parkinson‟s disease since 20 years and the same was not disclosed while
taking the first policy which amounts to non-disclosure of material information.

The complainant emphatically denied about suffering from the disease of Parkinson since 20
years since his father was a teacher by profession which required writing on the black board
which was done without any problem and they could become aware of the existence of the
Parkinson‟s disease during the current hospitalization only. Further, the patient was very
keen on his good health, he used to undergo various medical tests and the same presented
to the Forum.

The Forum directed the Insurance Company to settle the claim as per the terms and
conditions of the Policy.
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Heartbeat Gold 05 lacs Insurance Certificate

Case No. BNG-G-031-1516-0542

Mr. Kiran G V/s Max Bupa Health Insurance Company Limited

Date of Award – 16th February, 2016

During the currency of the current policy, the Complainant had a fall from the stairs
sustained injury to right shoulder dislocation reduced outside – III episode. He had similar
episodes one year ago and reduction was done and was treated with sling for 3 weeks. This
policy being first year of insurance.

The claim was denied by the Insurer stating that the complainant had history of Right
Shoulder Injury 6 years back and he had the similar episode one year back and was treated
with sling for 3 weeks. However, while taking the insurance, the complainant did not
disclose previous health history which amounts to non-disclosure of material
information/facts and the repudiation of claim was justified.

During the course of the Hearing, the Complainant informed that he had also filed a case in
Consumer Redressal Forum for the compensation of the same claim.
It is concluded by the Forum that the complaint is beyond the scope of the functioning of
the Insurance Ombudsman under Rule 13(3)(c) of the RPG Rules, 1998, wherein it is stated
that “the complaint should not be on same subject matter, for which any proceedings before
any Court or Consumer Forum or Arbitration is pending or were so earlier”, and does not
warrant any interference by this Forum.

Hence, the Complaint is Dismissed.
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ICICI Lombard Complete Health Insurance

Case No. BNG-G-020-1516-0581

Mr. Ravi Shankar S. Poll v/s ICICI Lombard General Insurance Company Limited

Date of Award – 16th February, 2016

The Complainant took the Policy 7 years ago through tele-sale and had been renewing
without any break. During the currency of the present policy, the insured was hospitalized
and was diagnosed with Right Upper ureteric Calculi and Cystoscopy + Right URS +
Lithoclast + Righjt DJ Stenting was performed on him. He was suffering from HTN since 20
years but the same was not disclosed as he was advised by the sales tem not to disclose, if
proper medication was taken and the same was under control. Treating Doctor certified
that the HTN had no relevance to the present complaint. He preferred a claim for
Rs. 1,61,694/-

The Insurer repudiated the claim on the ground of non-disclosure of material fact at the
time of taking the first policy and the same was substantiated by playing pre-acceptance
IVRS call through a pre-corded CD disc.

Through conciliation and mediation, the Insurers agreed to settle the claim for Rs. 74,695/-
in full and final settlement of the claim and the Insured agreed for the same.

Accordingly, the case was disposed of.
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Senior Citizens Red Carpet Health Insurance Policy

Case No. BNG-G-044-1516-0639

Mrs. S G Saraladevi v/s Star Health & Allied Insurance Company Limited

Date of Award – 10th March, 2016

The Complainant along with her spousewas covered in the policy taken by her spouse.
Policies were taken continuously since 2013. The Complainantsuffered pain in abdomen
since 2 days prior to admission and progressed gradually. It was a sudden onset. She was
admitted into an emergency ward and was discharged after 4 hours, carrying out the
necessary investigations.
Insurer repudiated claim stating that the claim was not admissible unless the treatment was
taken as an inpatient for more than 24 hours whereas in the instant case, the treatment
was only for 4 hours and the same was also on outpatient basis.

The Complainant pleaded that recently the Sum Insured was enhanced and relevant
premium was paid and sought for refunding of the same. Insurer agreed to refund, upon
receipt of request for the same.

However, during the hearing, the Insurer agreed to pay Rs. 1,000/- towards consultation
charges, as the same were payable since the same were incurred in a Net Work Hospital.

The Complaint is accordingly disposed of.
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Individual Care Health Insurance Policy

Case No. BNG-G-037-1516-0735
Mr. Paras Chand Jain v/s Religare Health Insurance Company Limited

Date of Award – 22nd March, 2016

The Complainant obtained a Policy in the year 2014 and renewed the same in the year
2015. During the currency of the 2nd year, the wife of the Complainant underwent a
comprehensive health checkup and as part, TMT Report was positive which necessitated
angiography test. The Discharge Summary stated that TMT positive for IndusibleIschemia
CAG done on 23.12.2015 – CAD Triple Vessel, S/P PTCA + Stent to LAD to RCA normal LV
systolic function was carried out. The Claim was rejected by the Insurer stating “non-
disclosure of pre-existing disease ie., Angina Pectoris in 2013, which was present at the
time of taking the policy. The Complainant submitted his justification that she was not
suffering from any disease prior to present hospitalization. A Notarized Affidavit was also
submitted to that effect. Further the gap between the ECG taken in India and in Singapore
was hardly one month
Insurer submitted that the patient had undergone Heart Treatment in Tan Tock Seng
Hospital, Singapore and was diagnosed with Angina Pectoris, Left-sided Chest – pain
radiating to Left arm and generalized weakness and was prescribed medication for the chest
discomfort. This aspect of hospitalization at Singapore and the relevant treatment taken and
also the illness of Angio Petcoris which she suffered and the continuous medication she had
been taking for the said illness, was not disclosed in the Proposal form at the time of
inception of the first policy, which amounts to non-disclosure of material information and
claim merits repudiation as per the term and conditions of the Policy.
This Forum concluded that the decision of the Insurer in repudiating the claim was in order
and in consonance with the terms and conditions of the policy and does not require any
interference at the hands of the Ombudsman.
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ICICI Lombard Complete Health Insurance

Case No. BNG-G-020-1516-0707

Mr. Elangovan T S v/s ICICI Lombard General Insurance Company Limited

Date of Award – 22nd March, 2016

The Insured along with spouse was covered since 2007 continuously. During the currency
of the current policy, the insured was hospitalized for complaints of retrosternal chest pain
since 5 days with peak pain on the previous day and was referred by another hospital giving
him initial treatment. He was a known case of IHD-S/P PTCA with stent to LAD (2006), HTN
&n DM on treatment. He diagnosed as suffering from IHD – Acute AWMI, CAG – Single
Vessel Disease (28.10.2015) with patent LAD Stent, Successful Primary PTCA with stent to
LAD (Promus Element) with IABP support done on 28.10.2015, S/P PTCA with stent to LAD
(2006). Reduced LV Function, LVEF – 30%, Diabetes Mellitus, Hypertension, ?Cardioembolic
Stroke – Recovered (VBI – AICA Territory). Cashless request and subsequent claim for
reimbursement of expenses were denied by the Insurers on the ground of non-disclosure of
the pre-existing diseases/illness.

Insurers pleaded that the Insured had a history of DM and HTN since 6 years and PTCA
Percutaneous Transluminal Coronary Angioplasty was done in 2006,Single Vessel Disease
(28.10.2015) with patent LAD Stent and was on continuous medication. However, the
Insured did not disclose these pre-existing ailments in the proposal form, at the time of
taking the first policy. They also played the audio of IVRS tele-recording carried out prior to
the policy commencement and the tele-call confirms that he declared that he was healthy
and did not disclose the above aspects ofpre-existing illness/medical condition. They drew
reference of a case decided in National Consumer Commission Redressal (LIC of India and
another v/s Smt. VimlaVerma) wherein it was held that the Insurance Contract are based on
the principle of “Ubberima Fides” (Utmost Good Faith) and suppression of material
information by the insure would amount to breach of contract which would justify
repudiation of the claim by the Insurance Company. They also confirmed the refund of the
premium of the current policy.

The Forum concluded that the Insurer‟s decision of repudiating the under the Policy is in
consonance with the terms and conditions of the Policy and does not warrant any any
interference at the hands of the Ombudsman.
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ICICI Lombard Complete Health Insurance

Case No. BNG-G-020-1516-0717

Mr. BrahmanandK v/s ICICI Lombard General Insurance Company Limited

Date of Award – 22nd March, 2016

The Complainant was holding the above policy covering himself and his spouse since 2012
continuously without any break of insurance. During the currency of the present policy, the
spouse of the Insured was admitted into Hospital and was dignosed for Bilateral
Degenerative Osteoarthritis of Knee and underwent Bilateral Total Knee Replacement
Surgery-Stryker Scorpio CR was done under epidural/spine anesthesia. The claim was
rejected by the Insurer stating that the patient was suffering from HTN prior to
commencement of the fir policy and the same was not disclosed in the proposal form.

Insurer contended that the Insured Person had history of both the knee problem (Arthritis)
and was on continuous medication and also had history of HTN and was on mediation,
before the commencement of the first policy and the same were not disclosed during the
proposal period. This non-disclosure of material information renders the contract void.
They drew reference of a case decided in National Consumer Commission Redressal (LIC of
India and another v/s Smt. VimlaVerma) wherein it was held that the Insurance Contract
are based on the principle of “Ubberima Fides” (Utmost Good Faith) and suppression of
material information by the insure would amount to breach of contract which would justify
repudiation of the claim by the Insurance Company.

The Forum concluded that even though the pre-existing disease of Hypertension does not
have direct bearing on the current surgery, the decision of the Insurers to repudiate the
claim is in order and justified, as 48 months have not elapsed since policy inception and the
Discharge Summary states that “the patient suffered from significant antalgic gait due to
severe osteoarthritis of both knees which had been significantly symptomatic for the past
few years, was severely affecting her activities of daily living, sleep and walk for even a
short distance….”
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PNB-Oriental Royal Mediclaim Policy

Case No. BNG-G-050-1516-0644

Mr. Satish Kumar K P v/s Oriental Insurance Company Limited

Date of Award – 22nd February, 2016

The Complainant was holding the said policy covering himself, spouse and dependent
daughter. While he was renewing the Policy through online (using credit card), though his
account was debited for the premium amount, he received an error message stating that
the Policy could not be issued and was advised to visit local office and get the policy
renewed and accordingly he got the policy renewed offline. Inspite of taking up his matter
with the Insurance Company for refund of the premium paid for the on-line failed
transaction, he could not get the same refunded and hence he approached this Forum.

Insurer submitted in their Self Contained Note that the premium was refunded but the same
was after a lapse of 87 days.

The Insured informed that he was unable to attend the Hearing. Insurer contended that
there was no facility in their software module to incorporate any charges/interest on
account of delay in refund of online premium.

The Forum directed the Insurance Company to pay interest @ 6% for the delay of
87 days in refunding the premium.

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Individual Health Insurance Policy

Case No. BNG-G-051-1516-0635

Mr. Gopalakrishnan R v/s United India Insurance Company Limited

Date of Award – 10th March, 2016

The Complainant had obtained the Policy covering himself and his spouse and the policy
being first year of insurance. During the currency of the policy, the Complainant had
undergone OsteoArtjritis treatment of both of his knees. The X-ray taken during the
treatment revealed that patient had arthritic changes in both knees and while Right Knee
had Grade II changes and Left Knee with Grade III changes. He was advised treatment
using Sequential Programmed Magnetic Field (SPMF Therapy) for 21 days consecutively.
During the treatment, the affected joints were exposed to radiofrequency beams for 1 hour
followed by physiotherapy for an hour and observation for one hour and thus total stay was
for 3 hours for every visit. On the first day of the treatment, the patient was admitted for 8
hours for blood investigation, treatment, rehab exercises, pain management and
observation.

The Insurer repudiated the claim stating that –

Exclusion Clause 4.19 and as per Exclusion Clause No. 3.14.
Minimum of 24 hours hospitalization is not fulfilled, as per Exclusion Clause No. 3.15
Unproven/experimental treatment as per Exclusion No. 3.39

During the personal hearing, the Insurer‟s representatives submitted that treatment of
SPMF Therapy is similar to RFQMR, besides the grounds made for the repudiation of the
claim. The Doctor of TPA submitted that the treatments viz., RFQMRand SPMF are similar
but not the same and submitted the same in the form of an affidavit.

The Complainant submitted that SPMF Therapy is a modern non-surgical treatment to help
regenerate worn out cartilage cell on the weight bearing knee joints. He quoted a judgment
of National Consumer Disputes Redressal Commission wherein all the aspects of the present
case were similar. While directing the Insurer to honour the claim, the Commission
observed that the particular treatment viz., SPMF Therapy is not specifically excluded from
the scope of the policy and further excluding the age related diseases in a policy issued to a
senior citizen, amounts to unfair trade practice.

Forum observed that the Affidavit is submitted by a doctor on the rolls of TPA would be
either directly or indirectly influenced by the decision of repudiation of claim done by his
employer and SPMF therapy is not specifically excluded in the policy, a cue from the
decision of NCDRC.

Accordingly, the complaint is Disposed of.
Family Floater Policy

Case No. BNG-G-050-1516-0395

Mr. Jeetendra Kumar B V/s The Oriental Insurance Company Limited

Date of Award – 5th January, 2016

The Complainant obtained a Happy Family Floater Policy covering his family members till
29.03.2015 since 2010 onwards, without any break of insurance.

One of the Insured Persons was hospitalized and was diagnosed to be suffering from
Chronic Liver Disease (Compensated), S/P Traumatic Paraplegia, Fracture shaft of Femur
(Lower 1/3), Chronic Constipation, Hemorrhoids, Diabetes Mellitus Type-2, and suspected
AIN-NSAID related.

The claim of the Complainant was repudiated by the Insurer stating that the hospitalization
expenses incurred were primarily for evaluation/diagnostic purposes with no active line of
treatment, by invoking the exclusion of 4.11. The insurer relied on an independent medical
opinion obtained by them which confirmed that the hospitalization was for constipation and
the treatment/investigations carried out were of general in nature, in respect of her
associated co-evaluation/diagnostic purposes not followed by any active line of treatment.

Based on the facts and circumstances of the case, documents made available by and
submissions made by both the parties, it was concluded that the repudiation of the claim by
the Insurer was justified and required no interference at the hands of this Forum.

Hence, the case was Dismissed.
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Optima Restore Floater (2 year)

Case No. BNG-G-003-1516-0430

Mr. Mehul Shah V/s Apollo Munich Health Insurance Company Limited

Date of Award – 22ndJanuary, 2016

The Insured Person was hospitalized and was diagnosed with Pelvic Abscess. The Discharge
Summary stated that the patient had h/o Lap Cystectomy done 7 years back and h/o
Endometriotic Right Ovarian Cyst. During hospitalization, doctors performed laparoscopic
drainage of? Pelvic Abscess? Ovarian Abcess.

Insurer contended the patient was diagnosed to have a benign cyst and had undergone
pelvic region abscess drainage on account of the infected cyst. The nursing records also
confirmed the presence of an ovarian cyst and the pathological report findings declared the
cyst to be benign. They further contended that the specific waiting period for the coverage
of cyst was 2 years and in the instant case, it happened before the completion of 2 years
and hence the claim was not admissible as per the terms, conditions and exclusions of the
policy.
Based on the facts and circumstances of the case, documents submitted by both the parties
and the submissions made during the Personal Hearing, it can be concluded that the
Insured underwent treatment for benign cyst and pelvic ovarian abscess. As it was not
possible to segregate the expenses, it was prudent to allow payment of the claim to
the extent of 50% of the total claim, towards full and final settlement of the claim as
per terms and conditions of the policy.
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Happy Family Floater Policy

Case No. BNG-G-050-1516-0580

Mr. Shivlal G V/s Oriental Insurance Company Limited

Date of Award – 26th February, 2016

The Complainant obtained above Insurance Policy covering himself, spouse and two
dependent children. During the second year of the Policy, the complainant‟s wife was
hospitalized for Right Upper Uretic Calculus and she underwent Right Uretholithotomy + DJ
stenting.

Insurer repudiated the claim on the ground that Calculus Disorder is covered after two
continuous policy renewals (4.3 & 4.1 of the Policy) whereas in the instant case, the claim
occurred during the currency of the second year policy and hence the claim was
inadmissible.

The decision of the insurer was in order and did not require any intervention at the hands of
this Forum.
Hence, the Complaint isDismissed.
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Family Health Optima Insurance Plan

Case No. BNG-G-044-1516-0562

Mr. Ananth Kumar Diwakar v/s Star Health & Allied Insurance Company Limited

Date of Award – 16th February, 2016

The Complainant took the above policy (first policy) covering himself and his spouse for the
period from 09.12.2014 to 08.12.2015. During the currency of the Policy, his spouse was
admitted into Hospital in Mangalore and was diagnosed as suffering from Laprotomy (LP)
Cystectomy and the same was removed through a surgery. The Complainant and his spouse
were earlier covered under ManipalArogya Suraksha Schme since 01.09.2013 and hence the
period of coverage under the said scheme should also be considered for application of any
waiting period in the policy.

Insurer repudiated the claim stating that the current policy was the first insurance policy
obtained from them and hence it would satisfy the waiting period applicable for the said
disease/illness. The earlier coverage was under a scheme for development for Konkan‟s
Community and the same was not considered as coverage provided by an Insurer,