NEERJA SHAH - Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

(UNDER RULE NO: 16 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH

In the matter of: MR. KIRAN N v/s STAR HEALTH & ALLIED INSURANCE CO. LTD

Complaint No: BNG-H-044-1920-0459

Award No: IO(BNG)/A/HI/0282/2019-20 .

The Complaint emanated from the repudiation of hospitalisation claim by Respondent

Insurer (RI) under Star Comprehensive Insurance policy under policy no.

P/141100/01/2020/004971 from 05.09.2019 till 04.09.2020.

Complainant was admitted to Aster CMI Hospital from 07.10.2019 to 10.10.2019 for diagnosis of CAG – Double vessel disease and underwent PTCA and stenting.

He applied for reimbursement claim to RI, which was repudiated by RI vide letter dt 10.10.2019 for further evaluation of claim documents. He submitted reimbursement claim, which was repudiated vide letter dt 15.11.2019 under condition 1 of the policy terms and conditions stating that there was chronic, longstanding heart disease, which is non-payable for first 48 months from date of inception of first policy. The policy was modified by passing the endorsement for inclusion of above disease as PED.

He approached to Grievance cell of RI, stating that he did not any PED but his plea was not considered favourably and thus, she approached this forum for resolution of his grievance.

The complaint is yet to be posted for posted for personal hearing.

This forum sent an e-mail to RI on 25.02.2020 explaining brief facts of the case to RI. RI

vide mail dt 28.02.2020 agreed to settle the claim for Rs 2,00,094/- as per terms and

conditions of the policy.

The complainant vide his mail dated 29.02.2020 agreed to the amount offered by RI.

RI is directed to settle the amount as agreed and cancel the erroneous endorsement of PED

under the policy.

Since the complaint was resolved on compromise basis wherein both have agreed for the

same and hence, the Complaint is treated as Closed and Disposed off accordingly.

Compliance of Award:

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

a. The Complainant shall submit all requirements/Documents required for settlement of

award within 15 days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall

comply with the award within thirty days of the receipt of the award and intimate

compliance of the same to the Ombudsman.

Dated at Bengaluru on the 02nd day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA



OMBUDSMAN –NEERJA SHAH

In the matter of: MR. RAJESH P V/s RELIGARE HEALTH INSURANCE COMPANY LIMITED


Award No.: IO/(BNG)/A/HI/0283/2019-20

1 Name & Address of the Complainant Mr. Rajesh P

c/o Shalini Rajesh

No.14, 4th Main, Rammohanpuram,

Off Devaiah Park,

Bangalore – 560021

Ph.9880198648/9341492380

2 Policy /Cert. No.

Type of Policy

Duration of Policy/ Policy Period

12280852

CARE Individual Health Insurance

24.03.2018 to 23.03.2020

3 Name of the Insured/ Proposer

Name of the policyholder

Mrs.Shalini Rajesh

Mr.Rajesh P

4 Name of the Respondent Insurer RELIGARE HEALTH INSURANCE COMPANY LIMITED

5 Date of repudiation/rejection 07.11.2019

6 Reason for repudiation Ailment falls under waiting period of 2 years-

D.O.A 04.11.2019

7 Date of receipt of Annexure VI-A 30.12.2019

8 Nature of complaint Rejection of claim

9 Amount of claim ₹.1,44,620/-

10 Date of Partial Settlement NA

11 Amount of relief sought ₹.1,44,620/-

12 Complaint registered under Rule no: 13 (1) (b) of Insurance Ombudsman Rules, 2017

13 Date of hearing/place 26.02.2020 / Bengaluru

14 Representation at the hearing

a) For the Complainant Self

b) For the Insurer Mr.Pratyush Prakash, Manager- Legal

15 Complaint how disposed Disallowed

16 Date of Award/Order 02.03.2020

17. Brief Facts of the Case:

The complaint emanated from the rejection of the claim on the grounds of that claim falls under waiting

period of Twenty four months.

18. Cause of Complaint:

a. Complainant’s arguments:

The complainant obtained the cited policy covering himself and his wife for a sum insured of Rs.

5,00,000/-.The complainant’s wife (Insured Person) was admitted to M S Ramaiah Memorial Hospital from

04.11.2019 to 07.11.2019 for ERCP (Endoscopic Retrograde CholangioPancreatography), Common Bile duct

Clearance and Common Bile Duct Stent Replacement. He applied for cashless on 04.11.2019 which was

rejected on 07.11.2019 by RI stating “2 YEARS WAITING PERIOD : TREATMENT OF KIDNEY STONE/URETERIC

STONE/LITHOTRIPSY/GALL BLADDER STONE”. He tried to convince RI that the procedure done is ERCP+CBD

clearance+ CBD stent replacement. Submitted letter dt. 08.11.2019 from the Hospital stating that above

mentioned procedure is not for Gall Bladder/GB Stone. Complainant was forced to pay the bill.

Subsequently submitted for claim reimbursement of 1,44,620/- on 20.11.2019. R.I rejected the claim on

the same grounds vide their letter dt.03.12.2019. He feels RI tried to downgrade his claim by stating that

“Any stone in any part of the body is under 2 years waiting period”. The Complainant contended with GRO

that there was variation in the diagnosis in the claim registration and rejection and the treatment taken

was for ERCP+CBD clearance+ CBD stent replacement. Despite representing his claim was not settled.

Hence he approached Forum requested to get justice to him.

b.Respondent Insurer’s Arguments:

The Respondent Insurer in their Self Contained Note (SCN) dated 03.01.2020 received on 05.02.2020

submitting that at the very outset as the complaint is not maintainable under the provision of Rule 14 (3)of

Insurance Ombudsman Rules 2017 as the complainant has not made any such representation to R.I.

They admitted the coverage of insurance for the first time inception from 24.01.2018 to 23.03.2020,

preferring claim for IP and their rejection. IP was admitted with chief complaint of Jaundice, Puke etc. and

was diagnosed with Chronic Portal vein thrombosis and choledocholithaisis. Cashless claim was denied vide

letter dt.04.11.2019 as per terms and condition under clause 4.1(II) as the same was within the ambit of

waiting period clause and is covered after 24 months coverage from the inception of first policy period.

Pre-authorisation request from IP was diagnosed and underwent procedure choledocholithsis which is

covered only after 24 months from the inception of policy. The claim was submitted for reimbursement for

the hospitalization period from 04.11.2019 to 07.11.2019 diagnosed as Chronic Portal vein thrombosis and

choledocholithsis. The same was denied vide letter dt.03.12.2019 as per policy terms and conditions clause

4.1(ii). R.I. provided medical expert opinion to upheld that their rejection is in order. They submitted that

the Hon’ble Supreme Court of India in the matter of Export Credit Guarantee Corp of India Ltd. Vs Ms.Gard

Sons International held that “the insured cannot claim anything more than what is covered by the

insurance policy.”…the terms of the contract have to be construed strictly, without altering the nature of the

contract as the same may affect the interests of the parties adversely.” The contract must be read as a

whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of

contra proferentem does not apply in case of commercial contract, for the reason that a clause in a

commercial contract is bilateral and has mutually been agreed upon. (Vide: Ms.Oriental Insurance Co.Ltd.

Vs. Mr.Sony Cheriyan AIR1999 SC 3252 : Ms Polymat India P.Ltd., Vs National Insurance Co.Ltd., AIR 2005

SC 286: M/S Sumitomo Heavy Industries Ltd., V Oil & Natural Gas Company, AIR2010 SC 3400: and

Rashtriya Ispat Nigam Ltd. Vs Ms. Dewan ChandRam Saran AIR 2012 SC 2829).

Under the above circumstances requested the forum to dismiss the complaint.

19. Reason for Registration of complaint:-

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017, and so it was

registered.

20. The following documents were placed for perusal.

a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions):

Forum observes from the record that complainant vide mail dt. 04.12.2019 represented to the RI,

and they have rejected his representation vide their letter dt.05.12.2019. Hence the complaint is

maintainable under 14 (3) (a) (iii) of the said Rules and R.I‟s argument on this ground is set aside.

The dispute is whether the IP was diagnosed for a condition that has specified waiting period of 24 months in the policy if so, whether the said waiting period has not been completed. This Forum has perused the documentary evidence available on record and the submissions made

by both the parties during the personal hearing. The complainant and RI reiterated their contentions

earlier made. The complainant submitted that he has produced certificate dt. 08.11.2019 from the

Doctor where there is no mention about „Stones‟.

R.I strongly contended that there is no medical records to shown that stones will form in Bile Duct.

Stones are formed in Gall Bladder only which travel to the common bile duct and get lodged there.

The CBD procedure for Choledocholithsis done for the IP is clearance of stone from the Bile Duct

which has struck while passing through and chronic portal vein thrombosis/portal cavernoma are

related to cause effect of Choledocholithsis. Forum carefully scrutinized all the relevant documents and found the following:

1. I.P was admitted diagnosed with Chronic Portal vein thrombosis with Portal Cavernoma Choledocholithaisis, Fatty Liver-Grade- I , Iron Deficiency.

2. Procedure shows: USG (22/10/2019) PC with PVT ,Grade I Hepatic Fatty Infiltration Cholecystolthiasis,

3. Course of Admission shows: relevant investigation with USG and MRI ABD+MRCP was found to have Chronic PVT with collaterals with Choledocholithiasis causing obstructive biliopathy and asymptomatic Cholelithiasis. A diagnostic EUS was done on 06.11.2019 and ERCP+CBD clearance+CBD Stenting was carried out .

4. Doctor’s certificate dt. 08.11.2019 clearly says I.P’ diagnosed with Acute Choledocholithiasis which is stone in common Bile Duct. Treatments given during her admission are ERCP+CBD+CBD plastic stent placement.

5. From the Public domain, for the question ‘What is Choledocholithiasis?’ it is noted that – ‘also called bile duct stones or gallstones in the bile duct . Gallstones usually form in

gallbladder…These stones usually remain in the gallbladder or pass through the common bile duct unobstructed.’ For the question Who is at risk? – it is noted that ‘people with a history of gallstones or gallbladder disease are at risk for bile duct stones’. Cholecystolthiasis as noted in the procedure of hospital denotes ‘the occurrence of gallstones within the gallbladder’. Cholecystectomy is the most commonly performed to treat the gallstones. If Gallstone are in the gallbladder are called Cholelithiasis. For Gallstones in the bile duct are Choledocholithiasis.

6. Upper GI Endoscopy dt.06.11.2019 reveals:’Cholangiogram revealed dilated CBD upto 10mm with filing defects and mild IHBR dilation. GB opacified- showed calculi’.

The Insured person in the present case underwent treatment for Choledocholithiasis, i.e CBD with CBD stent which is gallstone clearance from the bile duct. The gallstone invariably forms in the gall bladder. In this case, it has travelled to the biliary duct where the surgery was performed nonetheless the Proximate cause of Choledocholithiasis is due to gallstone in gallbladder. The inception of policy period is from 24.03.2018 to 23.03.2020 and the hospitalization of IP is dated 04.11.2019. Clause 4 of the policy deals with Exclusions.

Clause 4.1 covers Waiting Period: It states:- “Specific waiting period: Any claim for or arising out of any of

the following illness or surgical Procedure shall not be admissible during 24(Twenty Four) months of

coverage of the insured person by the company from the first policy period start Date:

11. Kidney stone/Ureteric Stone/Lithotripsy/Gall Bladder Stone”.

Considering the above, Forum does not find any flaw with the decision of the Respondent Insurer in rejecting the claim

Hence the complaint is Disallowed.

A W A R D

Taking into account of the facts and circumstances of the case, the documents the oral submissions

made by both the parties, the rejection of the claim by the Respondent Insurer is found to be in order

and in consonance with the terms and conditions of the policy.

Hence the complaint is Disallowed.

Dated at Bangalore on the 2nd day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MR. RAMJI SRINIVASARAGHAVAN v/s MAX BUPA HEALTH INSURANCE COMPANY LTD


Award No: IO(BNG)/A/HI/0285/2019-20 .

The Complaint emanated from rejection of hospitalisation claim followed by cancellation of

insurance policy by Respondent Insurer (RI) for non disclosure of past medical history.

Complainant submitted he was covered with ICICI Lombard General Insurance Company Ltd since 2010 and then took Familyfirst Silver policy vide policy no 30683883201902 with RI in 2018.

Complainant was admitted at Coimbatore Kidney Centre and Speciality Hospital from 06.08.2019 to 08.08.2019 for removal of kidney stones. He submitted a reimbursement claim to RI for ₹.54,068/-.

On scrutiny of medical documents RI rejected the claim for non-disclosure of past medical history of lithotripsy in 2012, 2014 and fistulectomy 10-15 years ago and cancelled the policy.

Complainant once again approached GRO of RI for settlement of his claim. However the same was not considered favourably. Aggrieved he approached this forum for resolution of his grievance. The complaint was posted for personal hearing on 11.03.2020.

After registering the complaint with this office, RI vide mail dt 04.03.2020 has agreed to

settle the claim for ₹.53,873/- and reinstate the policy coverage subject to payment of

renewal premium if any, under the policy. Complainant vide mail dt 05.03.2020 has given consent for the settlement of claim as well

reinstatement of policy coverage. Since the complaint is resolved on compromise basis, the Complaint is treated as Closed

and Disposed off accordingly.









Dated at Bengaluru on the 5th day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)


In the matter of MR.PRASAD ADIGA Vs RELIGARE HEALTHINSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. PRASAD ADIGA

No.25,Chirayu Sadana,L.D.Block,

Ganganagar 4thMain,

Bangalore-560032

Ph. 9845146494

Email [email protected]

2 Policy Number

Type of Policy


Policy No.16111426

CARE Individual

29.10.2019 To 28.10.2020



Mr. Suryanarayana Adiga

Mr. Prasad Adiga

4 Name of the Respondent Insurer RELIGARE HEALTH INSURANCE COMPANY LIMITED

5 Date of repudiation 13.11.2019

6 Reason for repudiation Rejection of claim for PED exclusion under 4 year

waiting period/Non-disclosure


8 Nature of complaint Repudiation of claim

9 Amount of claim ₹.70,100/-

10 Date of Partial Settlement Not Applicable

11 Amount of relief sought ₹.70,100/-

12 Complaint registered under Rule no: 13 (1) (b) & (g) of Insurance Ombudsman Rules,

2017

13 Date of hearing/place 26.02.2020/ Bengaluru



b) For the Respondent Insurer Mr.Pratyush Orakash, Manager Legal

15 Complaint how disposed Partially allowed



The complaint emanated from the rejection of the claim of his father on the grounds of pre-existing

diseases which falls under four years waiting period, and non issuance of policy as per the proposal while

porting the policy.


a) Complainant’s arguments:

Complainant submitted that he has been customer for 9 years with Max Bupa without any claim and the

policy was due for renewal on 26.10.2019. The representative of Religare Health Insurance Company (RI)

approached over phone for porting the policy by continuing all existing benefits available under Max Bupa

health policy.

He decided to port the policy since R.I’s email confirmed the coverage as:’No waiting period, coverage of all

diseases, certain waivers of exclusion and more additional benefits’. He was informed over phone that

there is no co-payment and everything will be covered as mandatory waiting period is already covered. He

was satisfied with the offer made by R.I and remitted the premium on 25.10.2019.

His grievances are:

a) Non receipt of policy on timely manner: Until followed up multiple times, RI did not send policy copy. Soft copy was sent on 01.11.2019 without exclusions or waiting period.

b) Policy was issued w.e.f.29.10.2019 instead of 27.10.2019 as continuity of Max Bupa policy leaving 3 days gap.

c) I.P underwent operation for Hernia on 13.11.2019 , cashless claim was rejected on the ground of PED & 4 years waiting period. He did not get any support from the customer care for his query.

d) He visited R.I’s office on 16.11.2019 to understand the reason of rejection of claim but they did not have much information. He was surprised to know incorrect email ID was associated with his policy. In view of which he was not getting his policy soft copy and rejection communication.

e) He submitted for reimbursement of claim to R.I Gurgoan Office which was received by them. Since then R.I’s representative is missing and no longer receiving calls/responding. Till the date of complaint he did not receive any response. Post visit to R.I’s office at Bangalore, he has sent another email along with supporting documents then followed up is done on Nov 21 & 27, 2019. No appropriate reply from the R.I received except automated mail reply.

f) He got reply from R.I on 28.11.2019 stating that the policy is processed based to details received during proposer stage and they are unable to trace any misrepresentation facts made by them during policy inception. They indicated that he was given 15 days free look period to apprise concerns/discrepancy regarding terms& conditions which is baseless. He replied to R.I with proof from his end. It is clear case of mis-selling,misleading/misrepresentation. Hence he approached Forum to get relief.

b) Respondent Insurer’s Arguments:

R.I submitted SCN dt. 24th December 2019 received by the forum on 27th January 2020,

submitting that at the very outset as the complaint is not maintainable under the provision of Rule 14 sub-

rule 3 of Insurance Ombudsman Rules 2017 as the complainant had not made any such representation to

R.I.

They admitted the coverage of insurance for complainant’s father and mother for the period from

29.10.2019 to 28.10.2020, preferring claim for his father (insured person- IP) and their rejection. The

policy was ported from Max Bhupa Health Insurance Company. During the currency of policy IP was

hospitalized on 13.11.2019 at Chitanya Medical Centre with the complaint of swelling in Inguinal region and

was suggested surgical treatment of inguinal/hernia repair Mesh. Cashless was denied on the same day i.e.

on 13.11.2019 as per policy condition clause 4.1(iii) as the same will be within the ambit of waiting period

clause and is covered only after 48 month of coverage of IP by the company from the first policy period

start date 29.10.2019 till 48 months.

The relevant clause is reproduced.

Clause 4 of the policy deals with Exclusions

Clause 4.1 covers Waiting Period

Clause 4.1(iii) covers specific Waiting period

‘Pre-existing Disease: Claim will not be admissible for any Medical Expense incurred fo hospitalization in

respect of diagnosis/treatment of any Pre-existing disease until 48 months of continuous coverage has

elapsed, since the inception of the first policy with the company’.

Upon careful scrutiny of medical documents , it is observed that as per Abdonomino-pelvi Sonography

Report dt. 15.10.2019 of V-care diagnostic centre IP was diagnosed with left sided inguinal hernia, which is

well before the policy period with RI and the proposer is aware of the same. Admission for hernia repair

was made on13.11.2019. It is clear that IP was having pre-existing disease(Left side Hernia) before taking

policy and not disclosed the same to RI in the proposal form.

They submitted that the Hon’ble Supreme Court of India in the matter of Export Credit Guarantee Corp of

India Ltd. Vs Ms.Gard Sons International held that “the insured cannot claim anything more than what is

covered by the insurance policy.”…the terms of the contract have to be construed strictly, without altering

the nature of the contract as the same may affect the interests of the parties adversely.” The contract must

be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that

the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in

a commercial contract is bilateral and has mutually been agreed upon. (Vide: Ms.Oriental Insurance Co.Ltd.

Vs. Mr.Sony Cheriyan AIR1999 SC 3252 : Ms Polymat India P.Ltd., Vs National Insurance Co.Ltd., AIR 2005

SC 286: M/S Sumitomo Heavy Industries Ltd., V Oil & Natural Gas Company, AIR2010 SC 3400: and

Rashtriya Ispat Nigam Ltd. Vs Ms. Dewan ChandRam Saran AIR 2012 SC 2829).

Under the above circumstances they requested the forum to dismiss the complaint.


The complaint was registered as it falls within the scope of the Insurance Ombudsman Rules, 2017.



21. Result of personal hearing with both the parties (Observations & Conclusions): Forum observed from the record that complainant vide mail dt. 25.11.2019 represented and R.I has

responded vide their mail dt.17.12.2019. Hence the complaint is maintainable under 14 (3) of the

said Rules and R.I‟s argument on this ground is set aside.

The dispute is as to whether 1. there is Mis-representation , Mis-selling on the part of R.I 2. IP was diagnosed from the condition that has waiting period of 48 months, if so whether

the said waiting period has not been completed. 3. Non- disclosure of PED of IP at the time of making insurance contract with R.I.

This Forum has perused the documentary evidence available on record and the submissions made

by both the parties during the personal hearing. The complainant and RI reiterated their contentions

earlier made. The complainant submitted that he has not submitted any proposal form nor he signed

any form, there is delay in resolution for claim reimbursement from R.I.

R.I produced following copy of documents in their support:-

1. email dt.26.10.2019 with mail ID ,‟[email protected]‟ where in it is mentioned as

„enclosing portability letter for shifting from max to religare with all continuity. Mail ID belongs to

the complainant

2. policy copy of Max Bhupa valid from 29.10.2018 to 28.10.2019 which is said to be submitted

by the complainant during porting policy.

3. Application for porting dt.26.10.2019 where in policy expiry date is mentioned as 28.10.2019 to

prove there is neither mis-representation nor mis- selling as complainant produced another (fake)

policy copy which is valid up to 28.10.2019. R.I. ported and issued policy w.e.f 29.10.2019 to

28.10.2020.

4 copy of online proposal form No. 1120009784366 dt.26.10.2019 in the proposer name Mr.

Prasad . Policy start date is mentioned as 29.10.2019.

Representative of RI strongly contended that initially IP applied preauthorization for cash less on

13.11.2019 for Inguinal Hernia repair with Mesh. After going through the nature of illness and since

the policy was effective from 00.00 hrs 29.10.2018 cashless was denied immediately on 13.11.2019

itself mentioning 4 years waiting period. From the medical document dt.15.10.2019 of V-CARE

Diagnostic Centre it was found that IP had undergone Abdomino-Pelvi Sonography which reveal

he had Left Sided Inguinal Hernia. Complainant did not disclose the same in the online proposal at

the time of porting the policy which is clear case of non-disclosure /misrepresentation. During

processing reimbursement claim, R.I gets sufficient opportunity to go through all the documents

and deny the claim by giving relevant reason and would have taken appropriate decisions. In this

case Complainant‟s reimbursement has not been received by the concerned department. From the

Complainant‟s mail correspondence it is noted that copies of claim documents are sent to the mail

ID „[email protected]‟ which is not official mail ID of R.I. Contact details for Claims Servicing

is clearly elicited in the policy as „[email protected]‟.

The representative of R.I argued that though Complainant is having insurance policies with earlier

insurer, it is his duty to disclose pre-existing diseases while making proposal with new insurer as it

enables them to take right decisions. He has violated the principle of Utmost Good Faith hence not

entitled for claim.

Forum has carefully scrutinized all the relevant documents and observes that:

1. IP had earlier taken policy from Max Bupa valid from 27.10.2010 covering self and spouse

for sum insured of Rs.3,00,000/- each and continuously renewed . The complainant

Mr.Prasad, son of the I.P has taken up for porting the policy as a proposer covering both his

parents and submitted online application dt.26.10.2019 with R.I. Under the column

„Application Payment Receipt‟ in the online application, which is submitted by RI, Receipt

date is shown as 26.10.2019 and Deposit Date shown as 27.10.2019. This reveals that the

RI erred in effecting the policy period w.e.f 27.10.2019 as the „Date of First Enrolment‟ is

clearly mentioned in their policy as‟ 27 Oct 2010 under the Portability Details of the

Insured.

2. As per IRDAI guidelines under Schedule-I of “Portability of Health Insurance Policies

offered by General Insurers and Health Insurers” Rule No. 1 lays down that „A policy holder

desirous of porting his/her policy to another insurance company shall apply to such

Insurance company to port the entire policy along with all the members of the family, if

any,..‟. Rule No. 3 lays down that „ Portability shall be opted by the policy holder only..‟. It

is noted in the present case the complainant Mr.Prasad is the proposer who has initiated for

porting the policy whereas he was not a policy holder with Max Bupa . The policy holder

was Mr. Ba Suryanarayana Adiga,the I.P in the present case. R.I has thus clearly erred in

porting process.

3. In the online proposal, the complainant who is the proposer with RI has mentioned as „NO‟

form for the specific question „Does Any insured has PED?‟ for both the insured persons.

For the question „Have any of the above mentioned person(s) to be insured been

diagnosed/hospitalized for any illness/injury during the last 48 months?‟ he has answered

„NO‟ for both the insured persons.

4. During the hearing, on inquiry by showing the medical report of V-Care Diagnostic Centre

dt.15.10.2019 pertaining to the IP wherein impression is mentioned as „Left Sided Inguinal

Hernia‟, complainant admitted the report and said that the Diagnostic Centre is at their

hometown „Kundapura‟.

5. Hospital Discharge summary of IP for the period from12.11.2019 to 15.11.2019 Pre-Op

Diagnosis shows „LEFT INGUINAL HERNIA‟ and treated with „LEFT INGUINAL

HERNIOPLASTY‟.

Clause 19(4) of IRDA (Protection of Policy Holder’s Interest) Regulation, 2017 enumerating the “General

Principal” are reproduced as follows:

“The policy holder shall furnish all the information that is sought from him by the insurer, either directly or

through the distribution channels which the insurer consider as having a bearing on the risk to enable the

insurer to assess properly the risk covered under a proposal for insurance”

Clause 7.1 of the policy Terms and condition deals with Disclosure to Information Norm which is

reproduced as follows:

“if any untrue or incorrect statement are made or there has been a misrepresentation,

misdescription, or non-disclosure of any material particulars or any material information having

been withheld or if the claim is fraudulently made or any fraudulent means or devices are used by

the policy the holder or the insured person or any one acting on his/her behalf, the company shall

have no liability to make payment or any claims and the premium paid be forfeited ab initio to the

company”

Under DEFINITIONS of terms and conditions of policy, Pre-Existing Diseases are defined as: -

„any condition, ailment or injury or related condition(s) for which Insured Person had signs or

symptoms, and/or were diagnosed, and/or received medical advice/treatment within 48 months

prior to the first policy issued by the insurer „.

At the time of porting the complainant/proposer is required to give complete details as sought by the

insurer in his fresh proposal form along with portability form Schedule 1 of IRDAI Health

Regulation 2016 as amended. Forum noted that the complainant/proposer has not mentioned the

fact of diagnoses of Left Sided Inguinal Hernia of I.P in the proposal form of R.I. This is in

violation of his duty to disclose as defined in Definition 4.8 of Protection of Policy Holders Interest

Regulations 2017.

As porting with the new insurer is involved, fresh application is required to be submitted with all

questions rightly answered to scrutinize and assess risk for their acceptance. Though IP has policy

with Baxbhupa w.e.f. 27.10.2010 and continuously renewed, the complainant erred by non-

disclosure of PED of IP which is material fact at the time of making proposal with new insurer.

In view of the above clear provisions Forum concludes that this is a case of non-disclosure of material facts/pre-existing diseases/ailments at the time of proposal.

The Hon‟ble Supreme court of India has said in the case of CIVIL APPEAL NO. 2059 OF 2015’ If the

insurer has not taken delay in intimation as a specific ground in letter of repudiation, they cannot do

so at the stage of hearing of the consumer complaint before NCDRC‟. In the present complaint,

undoubtedly it is the responsibility of the proposer to furnish all the material facts i.e. relevant

health condition of insured person/s in the proposal form while entering into the contract. He has

violated the basic principles of Utmost Good Faith governing Insurance policies, by not disclosing

the material fact of PED of IP which is well within the knowledge of the complainant before

entering into the contract with the new insurer. This has proved costly to the Complainant.

This Forum relies on the Hon’ble Supreme Court of India’s decision in the case of Satwant

Kaur Sandhu v/s. The New India Assurance Company Limited IV (2009) CPJ 8 (S.C),

dt.10.07.2009 wherein the hon’ble court held: “The upshot of the entire discussion is that in a

Contract of Insurance, any fact which would influence the mind of a prudent insurer in deciding

whether to accept or not to accept the risk is a "material fact". If the proposer has knowledge of

such fact, he is obliged to disclose it particularly while answering questions in the proposal form. “there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance”. Each representation or statement may be material to the risk. The insurance company may still offer insurance protection on altered terms. “

Considering the above, Forum come to the conclusion that;

1. He is not eligible for claim relief.

2. R.I is directed to rectify the policy period w.e.f 27.10.2019 in order to give the continuity of

policy period after confirming Sec.64VB of Insurance Act.

Hence the complaint is Partially allowed.

A W A R D

Taking into account of the facts and circumstances of the case and the submissions made by both

the parties and documents submitted during the course of the Personal Hearing, RI is directed to

to rectify the policy period w.e.f 27.10.2019 in order to get the continuity of policy after

confirming Sec.64VB of Insurance Act. However complainant is not eligible for claim relief.

The Complaint is Partially allowed.

Dated at Bangalore on the 5th day March of, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)


In the matter of MR. R G SRINIVAS Vs STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Sri R G Srinivas

No.34, 14th Cross, 2nd Block,

V P Layout, Begur,

Bengaluru-560068

Ph.9448808643

Email: [email protected]

2 Policy Number

Type of Policy


P/141123/01/2020/004481

Family Health Optima Insurance Plan

10.08.2019 to 09.08.2020



Mrs.Durga Devi. S (Wife)

Mr.R.G.Srinivas

4 Name of the Respondent Insurer Star Health and Allied Insurance Company Limited


6 Reason for repudiation Rejection of claim for PED


8 Nature of complaint Repudiation of claim

9 Amount of claim Rs.38000/-


11 Amount of relief sought Rs.38000/-


13 Date of hearing/place 26.02.2020/ Bengaluru



b) For the Respondent Insurer Dr.Umadevi, Sr.Manager

15 Complaint how disposed Allowed



The complaint emanated from the rejection of the claim and cancellation of policy for on the grounds of

non-disclosure of pre-existing disease.



Complainant states that he is an honest policy holder since 2006. He has never claimed in last 13 years. Due

to false promise from Agent he migrated from Medi Assist India Pvt. Ltd. to Star Health and Allied Insurance

Limited on 10.08.2019. His wife was admitted to St.Johs Medical College Hospital from 12.08.2019 to

15.08.2019. He has spent the amount of Rs.38000/- which has been rejected by RI vide their letter dated

18.10.2019 and cancelled my policy w.e.f 30.11.2019. He has sent various representations to RI and the

same was not considered. Hence he approached this forum and requested forum to get justice.


The Respondent Insurer (R.I) in their Self Contained Note (SCN) dated 17.02.2020 received on 26.02.2020

admitting the policy coverage and their claim rejection. Complainant raised pre-authorization request to

avail cashless facility on 12.08.2019 for the treatment of Seronegative Arthiritis/Iron deficiency

anemia/Vitamin D deficiency and the same was denied. Subsequently he submitted the claim for

reimbursement of Rs.37,290/-. The claim was repudiated and policy was cancelled under non-disclosure of

material fact.

On receipt of the hearing notice from the Forum R.I reviewed the claim and considered for the settlement

of claim for Rs.26,721/- as per terms and conditions of policy and restore the policy with continuity

coverage and benefits. They requested to absolve from the complaint made.






The issues which require consideration is whether the action of the R I to repudiate the claim and cancel

the policy on the grounds of non disclosure of pre existing disease in the proposal form is in order.

During the personal hearing, both the parties reiterated their earlier submissions. Complainant submitted

that R.I is prepared to settle the claim for that he has sent consent letter dt. 25.02.2020 along with ID Proof

and Bank details on 25.02.2020. He submitted copy of his letter and requested for continuity of policy

without break in policy period. He argued that all medical investigation reports are submitted while

submitting reimbursement through the agent of R.I even he has not kept copies of the same. R.I submitted

the calculation of admissible claim amount of Rs.30, 371/- and agreed to settle the same within three days

from the date of hearing i.e. 26.02.2020. As complainant did not submit some of medical investigation

report like Aerobic Culture and Sensitivity dt. 13.08.2019 ANA IF By Method dt. 12.08.2019, HB, TC, DC,

platelet count dt. 15.08.2019, GRBS,Auto Plot Perimetry both Eye, IOP dt.15.08.2019 are disallowed.

However, the same will be verified from their records if available. If not, Representative of RI agreed to

consider the same provided the reports are submitted by the complainant along with the request letter for

reimbursement.

Forum carefully observed the submissions made by both the parties. R.I’s mail dt. 25.02.2020 along with the calculation of admissible claim amount confirms their decision for settlement of Rs. 30,371/- and restoration with continuity coverage and benefits of policy. Accordingly R.I was directed to settle the agreed amount of Rs.30,371/- within three days from the date of hearing , as the same was agreed by both the parties and confirm the forum along with details of payment made. Forum noted till the date of this order R.I did not settle the claim. R.I informed on 06.03.2020 that complainant has written on 26.02.2020 stating he wants to discontinue the policy. No such records have been received and the complainant had requested during the hearing for the continuity of his policy. Considering the above, Forum directs R.I to settle the claim of Rs. 30,371/- within three days as agreed during the hearing and reinstate the policy with continuity of all benefits. Complaint is Allowed.

A W A R D

Taking into account of the facts and circumstances of the case & the documents, R.I is directed

to settle the claim as above along with interest @ 6.25% + 2% to the date of payment of claim,

as per regulation 16 (1) (ii) of Protection of Policy Holders’ Interests Regulations, 2017 issued

vide notification dated 22.06.2017 and reinstate the policy with continuity of all benefits.

Hence, the Complaint is Allowed

22. Compliance of Award:

The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules,

2017:

a. According to Rule 17(6) of the Insurance Ombudsman Rule, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to Ombudsman.

Dated at Bangalore on the 6thday of March, 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16 of THE INSURANCE OMBUDSMAN RULES, 2017)


In the matter of: MRS. RANJINI C v/s STAR HEALTH & ALLIED INSURANCE CO. LTD


Award No: IO(BNG)/A/HI/0290/2019-20

.

The Complaint emanated from the repudiation of hospitalisation claim by Respondent

Insurer (RI) under Mediclassic Individual policy under policy no. P/141116/01/2020/002717

from 05.09.2019 to 04.09.2020.

Complainant‟s mother, Mrs. Usha G., was admitted to Ganga Hospitals from 23.10.2019 to

05.11.2019 for diagnosis of bilateral osteoarthritis of knee with varus deformity.

She applied for reimbursement claim to RI, which was repudiated by RI vide letter dt.

03.12.2019 under exclusion no. 1 of the policy pertaining to pre-existing disease. The policy

was modified by passing the endorsement on 03.12.2019 for inclusion of disease of

musculoskeletal system and its complications as PED.

She approached Grievance cell of the RI, stating that her mother did not have any PED but

her plea was not considered favourably. Therefore, she approached this forum for

resolution of her grievance. The complaint is posted for personal hearing on 20.03.2020.

RI vide mail dt 10.03.2020 has settled the claim for Rs. 3,02,291/- as per terms and


The complainant vide her e-mail dated 10.03.2020 agreed to the amount offered by RI.

RI is directed to settle the amount as agreed and cancel the erroneous endorsement of PED

under the policy.

Since the complaint was resolved on compromise basis wherein both have agreed for the

same and hence, the Complaint is treated as Closed and Disposed off accordingly.










(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MR. SOMASHEKARA M. V/s TATA AIG GENERAL INSURANCE COMPANY LIMITED



1. The Complainant’s son, Mr. R S Sandeep, was insured under Individual Medi Prime Policy No.

0235611590 for a Sum Insured of Rs. 3,00,000/- and cumulative bonus of Rs. 60,000/- from

13.07.2019 to 12.07.2020.

2. The Insured Person was admitted to M/s Ramaiah Medical Hospital, Bengaluru on 27.08.2019

for fever and abdominal pain.

3. He applied for the reimbursement of the claim but the same was rejected by the Respondent

Insurer (RI) on the ground of non-disclosure stating that obesity was not disclosed in the

proposal form.

4. He applied to Grievance cell of RI for reconsideration of the claim; however his claim was not

settled. Hence the Complainant approached the Forum for settlement of his claim.

5. The complaint was taken up for further process and the same was posted for personal hearing

on 11.03.2020.

6. Meanwhile, the Respondent Insurer vide their Self contained note dated 10.02.2020 submitted

that they have reviewed the claim and agreed for settlement for ₹. 42,494/- without any

deduction.

7. The Complainant confirmed the receipt of the claim amount vide his email dated 10.03.2020

and requested for closure of the complaint.

8. As the Complaint was resolved on Compromise with the intervention of the Ombudsman, the

complaint is Closed and disposed off accordingly. Consequently the personal hearing scheduled

for 11.03.2020 stands cancelled.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –NEERJA SHAH In the matter of:Smt. Shilpa prabhu B V/s THE UNITED INDIA INSURANCE COMPANY LIMITED

Complaint No: BNG-H-051-1920-397 Award No.: IO/(BNG)/A/HI/0292/2019-20

The complaint emanated from delay in crediting the approved claim amount for reimbursement lodged

with the Respondent Insurer (RI) under policy No.5001002818P109892643 covered for the period

01.10.2018 to 30.09.2019.

The complainant was hospitalized for Endometrial Hyperplasia and undergone Hysteroscopy on 29.06.2019

opted for cashless. She was advised by R.I to apply for reimbursement of claim. She submitted claim papers

to TPA of R.I on 10.07.2019. They took up the claim after a delay of 3 months. When the claim was

approved she noticed from the message that RI has initiated payment process by wrongly mentioned her

bank account number though she has provided cancelled cheque leaf for their reference. Immediately she

took up the matter with R.I to rectify the account number. Inspite of representation to GRO she did not get

her claim settlement. Hence she approached Forum to get relief.

The complaint was posted for personal hearing on 11.03.2020. After receipt of hearing notice, RI submitted

by mail on 23.01.2020 that her complaint was resolved, an amount of Rs.45002/- vide their UTR No

CITIN20010618009 dt. 21.01.2020 is credited to complainant’s bank account and requested to close the

case. Forum forwarded the communication to the complainant for her consent to close the complaint if

she is satisfied with the settlement of claim amount. Complainant replied vide mail dt. 31.01.2020

disagreeing to close the complainant as RI delayed the settlement requested for interest and suitable

compensation for undergoing mental agony.

During the hearing complainant reiterated their contentions earlier made. R.I submitted that they resolved

her complaint and credited the amount on 21.01.2020.

Forum observed and noted that though R.I settled the amount before hearing date there in inordinate

delay. R.I could have paid the interest suo moto without waiting for specific demand from the claimant as

per Provisions made in IRDAI (Protection of Policyholders’ Interest) Regulations, 2017 under Regulation

No.16- Claim procedure in respect of a Health Insurance Policy. Taking into account of the facts and

circumstances of the case & the documents, R.I is directed to settle interest @ 6.25% + 2% to the date of

payment of claim, as per regulation 16 (1) (ii) of Protection of Policy Holders’ Interests Regulations, 2017

issued vide notification dated 22.06.2017. However, her claim for compensation for undergoing mental

agony is not considered as the same is out of purview of Insurance Ombudsman Rule 2017.

Hence, the complaint is Allowed.

The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules,

2017:

a. According to Rule 17(6) of the Insurance Ombudsman Rule, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to Ombudsman.

Dated at Bengaluru on the 11th day of March 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA



In the matter of: Shri NAYAK VITHALDAS V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No: IO/BNG/A/HI/0293/2019-20

1 Name & Address of the Complainant Mr. Nayak Vithaldas Venkatesh

1038, Saptagiri, 1st Main, 1st Phase

Manasagar, Nagarbhavi

BENGALURU – 560 096

Mobile No. 9731110030

E-mail id: [email protected]

2 Policy No.

Policy period

Type of Policy

0105002019484100000206583

01.03.2019 to 29.02.2020

Indian Bank Arogya Raksha Health Insurance Policy



Mrs Sheetal Nayak

Wife

4 Name of the Respondent Insurer United India Insurance Company Limited

5 Date of Repudiation NA

6 Reason for repudiation/rejection NA

7 Date of receipt of Annexure VI A 21.01.2020

8 Nature of complaint Pre and post hospitalisation expenses plus Interest on

delay in settlement of claim

9 Amount of claim Rs.5,223/-

10 Date of Partial Settlement 26.09.2019

11 Amount of relief sought Rs.5,223/-

12 Complaint registered under Rule no 13 (1) (b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Ms H A Pannaga, Dy Mgr



17. Brief Facts of the Case

The complaint emanated over short settlement of hospitalisation claim plus non-payment of interest on

delay in settlement of claim by RI. His approach to the Grievance Redressal Officer of Respondent Insurer

(RI) as well as IRDAI did not yield any positive result and hence, the Complainant approached this Forum for

reimbursement of same.

18. Cause of complaint:

a. Complainant’s argument:

Complainant submitted that he alongwith his wife (Insured Person), hereafter referred to as IP, was

covered under Indian Bank Arogya Raksha Health Policy. His wife was diagnosed with fibroid uterus and

hospitalised in Padamshree Nursing & Maternity Home where she underwent hysterectomy. He submitted

reimbursement claim for Rs. 67,878/- vide claim no CHE-0719-FL-0006167 to RI. Claim was settled for

Rs. 50,000/- vide NEFT No UIIC_19036558556 dt 24.09.2019 as per terms and conditions of the policy. He

submitted that RI has erred in restricting the claim to limits specified in the policy and he is eligible for pre

and post hospitalisation expenses as well. He also submitted that even though claim was approved on

24.07.2019 he received amount on 26.09.2019 after an inordinate and intentional delay of 45 days. He

approached RI to compensate him for delay in settlement of claim as well payment of pre and post

hospitalisation expenses. However his representation was not considered favourably and therefore, he has

approached this forum for payment of interest on delayed claim settlement as well as pre and post

hospitalisation expenses.

b. Insurer’s argument:

The Respondent Insurer in their Self Contained Note (SCN) dated 30.01.2020 submitted that IP was covered

under Indian Bank Arogya Raksha policy for Sum Assured of Rs. 4,50,000/- from 01.03.2019 to 29.02.2020.

RI submitted that IP had submitted claim for diagnosis of Fibroid Uterus on 15.07.2019. The claim was

settled in beneficiary account on 26.09.2019 for Rs. 50,000/- as per terms and conditions of Arogya Raksha

policy. Since the maximum eligibility for Hysterectomy under the policy was Rs. 50,000/-, IP is not eligible

for any further payment towards pre and post hospitalisation. Furthermore RI informed that there was no

inordinate delay in settlement of claim which warrants award of interest.

19. Reason for Registration of complaint:

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so, it was

registered.

20. The following documents were placed for perusal:

a. Complaint along with enclosures, b. SCN of the Respondent Insurer along with enclosures and c. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.

21. Result of the personal hearing with both the parties(Observations & Conclusions):

The dispute is with regard to eligibility of pre and post hospitalisation expenses under the policy where maximum eligibility for a specified surgical procedure or treatment is specified in the policy. Another dispute is whether there was inordinate delay in claim settlement by RI.

This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing.

Clause 1.2.1 of policy terms and conditions clearly mentions that the hospitalisation benefit in

respect of Hysterectomy will be restricted to 20% of Sum Insured under the policy subject to

maximum of ₹. 50,000/-. The Sum Insured under the policy is ₹. 4,50,000/- while total expenses incurred were ₹. 67,878/-. In view of above the forum finds that hospitalisation claim has been settled as per terms and conditions of the policy. As regards pre and post hospitalisation expenses the relevant policy provisions 2.14, 2.32 and 2.33 are produced below:

2.14 HOSPITALIZATION:

Hospitalization means admission in a Hospital/Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours

2.32 PRE – HOSPITALISATION MEDICAL EXPENSES:

Medical expenses incurred immediately 30 days before the insured person is hospitalized will be considered as part of a claim(Italics provided) as mentioned under Item 1.2 above provided that;

i. such medical expenses are incurred for the same condition for which the insured person’s hospitalization was required and ii. the inpatient hospitalization claim for such hospitalization is admissible by the insurance company.

2.33 POST HOSPITALISATION MEDICAL EXPENSES: Relevant medical expenses incurred immediately 60 days after the Insured person is discharged from the hospital provided that;

a. Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required; and b. The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company.

Thus it is clear from above that pre-hospitalisation expenses form part of claim for Hysterectomy. It is also clear from 2.33 above that expenses post hysterectomy incurred immediately after 60 days from date of surgery are allowable. Hence he is eligible for claiming expenses against post hospitalisation expenses subject to 10% of the SI as per policy condition 1.3.

As per Regulation 16(1)(ii) of IRDAI Protection of Policyholder’s Interest Regulations 2017, in case of delay in payment of claim, the insurer shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of the claim @ rate 2% above the bank rate.

Since all medical documents were submitted on 15.07.2019 and claim was settled on 26.09.2019, there was delay in settlement of claim, the complainant is eligible for interest on delayed settlement of claim of hysterectomy from date of receipt of last medical document to date of payment of claim. He is also eligible for interest on delayed settlement of post hospitalisation expenses from date of receipt of last medical document till payment of claim.. The Complaint is

allowed.

A W A R D

Taking into account of the facts and circumstances of the case and the submissions made by both the

parties and documents submitted during the course of the Personal Hearing, the forum directs RI to

settle post hospitalisation expenses of ₹. 2,288/- and also pay interest for main hospitalisation to

complainant for delay in settlement of claim from the date of receipt of last necessary documents to

the date of payment of claim @2% above bank rate at start of financial year in which claim was made,

as per regulation 16 (1) (ii) of Protection of Policy holders’ Interests Regulations, 2017 issued by IRDAI

vide notification dated 22.06.2017.

The Complaint is ALLOWED.










(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MRS. KOOSHMA S V/s UNITED INDIA INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mrs. Kooshma S

No. 169, 7th Cross, 11th Main Road,

Hanumanthnagar,


Mobile # 9538746643

E-mail: [email protected]

2 Policy No.

Type of Policy

Duration of Policy/Policy Period

0727002818P116692934

Individual Health Insurance Policy – Platinum

Not Available


Name of the Insured Person

Mrs. Kooshma S

Self


5 Date of Repudiation Not available

6 Reason for repudiation Treatment done on OPD basis are not payable

even if converted as an in-patient for more than

24 hours


8 Nature of complaint Rejection of medi-claim

9 Amount of claim Rs. 65,051/-


11 Amount of relief sought Rs. 65,051/-




a) For the Complainant Mr. J Sreyams Prasad , Father

b) For the Respondent Insurer 1. Ms. Pannaga H A, Dy. Manager

2. Ms. Kusuma K, Asst. Manager




The complaint emanated from the rejection of the claim for administration of rituximab injection which

does not warrant hospitalization. Despite taking up with the Grievance cell of Respondent Insurer (RI), her

claim was not settled. Hence the Complainant approached this Forum for settlement of the claim.



The Complainant was covered under the above mentioned policy since 30.03.2011 for sum insured of ₹.

10,00,000/-. The Complainant was admitted to Vikram Hospital, Bengaluru on 13.08.2019 for relapsing

remitting multiple sclerosis and discharged on 14.08.2019. She was treated with inj. Methylprednisolone

and inj. Rituximab. At the time of admission in the hospital, cashless pre-authorization was rejected. Later

she submitted all the documents to the TPA/RI. However her claim was repudiated under clause 2.1 for

administration of rituximab injection which does not warrant hospitalization. She represented to the

Grievance cell of the RI, however her complaint is not considered favourably.

b. Respondent Insurer’s argument:

The Respondent Insurer has not submitted their Self Contained Note (SCN).




a. Complaint along with enclosures, b. Consent of the Complainant in Annexure VI-A

21. Result of the personal hearing with both the parties (Observations & Conclusions):

The issue which requires consideration is whether administration of rituximab injection warrants

hospitalization or not.

During the personal hearing, the Complainant’s father reiterated earlier submissions and submitted

certificate from the treating doctor and extract of the protocol for use of Rituximab in neurological diseases

in support of their contention.

The representative of RI submitted that complainant is a known case of multiple sclerosis had undergone

administration of rituximab administration which does not warrant hospitalization and hence the claim was

rejected as per clause 2.1 of the policy, Procedures/treatments usually done on outpatient basis are not

payable even if converted as an in-patient in the hospital for more than 24 hours or carried out in day care.

Forum notes from the Discharge summary of the hospital that complainant with relapsing remitting

multiple sclerosis, presented with gait imbalance and visual blurring. She was admitted for injection

Rituximab 1mg with 1mg of methylprednisolone after taking due consent with standard pre-medications

with steroid, paracetetamol and antihistamine.

It is noted from the Rituximab infusion instruction dated 13.08.2019 of Vikram hospital that she was

administered inj. Solumedrol/Methylpredlinisolone 1000 mg IV in 100ml saline over one hour. Tab Dolo 650

mg 1 tab stat and Tab Cetrizine 10mg 1 tab stat. Later inj. Rituximab 500 mg in 500ml normal saline over

continuous period of 7 hours. Then 2nd dose in the same way. Inj. Effcorlin 100mg IV Q4H and normal saline

100 ml over one hour with 2 AMPS optineuron after completion of infusion.

From the certificate dated 31.12.2019 given by the treating doctor, it is noted that Rituximab is a

monoclonal antibody which is known to cause profound and life threatening immunological reactions

during infusion. Therefore, the infusion has to be administered very slowly with continuous monitoring

during and after infusion in the ICU. The safety requirements for infusion necessitate hospital admission

with strict monitoring. Typically, the infusion is started at a slow rate and then based on the adverse effects

and tolerability, the speed of infusion is gradually increased. Usually a 1 mg infusion exceeds more than a

day.

The RI has repudiated the claim under condition 2.1 of the policy stating that Procedures/treatments

usually done on outpatient basis are not payable even if converted as an in-patient in the hospital for more

than 24 hours or carried out in day care. It is clear from the certificate from the treating doctor as well as

hospital records that the procedure carried out on the IP was not usual in nature. Hence repudiation

quoting condition no. 2.1 is not found acceptable.

From the above all, the Forum concludes that hospitalization was necessary for continuous monitoring

during and after infusion in the ICU and hence the decision of RI in repudiating the claim is not in order. The

complaint is therefore allowed with interest.

AWARD

Taking into account of the facts and circumstances of the case and upon scrutiny of the documents

submissions made by both the parties, the Respondent Insurer is advised to settle the claim as per

terms and conditions of the policy along with interest @ 8.25% (Bank rate of 6.25% + 2%) from the

date of filing of the last relevant document by the Insured till the date of payment of the claim as per

Regulation 16.1.(ii) of IRDAI (Protection of Policyholders’ Interests) Regulations, 2017.

The Complaint is Allowed.




a. The Complainant shall submit all requirements/Documents required for settlement of award within 15

days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall comply with the

award within thirty days of the receipt of the award and intimate compliance of the same to the

Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MRS. KOOSHMA S V/s UNITED INDIA INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mrs. Kooshma S

No. 169, 7th Cross, 11th Main Road,

Hanumanthnagar,


Mobile # 9538746643

E-mail: [email protected]

2 Policy No.

Type of Policy

Duration of Policy/Policy Period

0727002818P116692934

Individual Health Insurance Policy – Platinum

Not Available


Name of the Insured Person

Mrs. Kooshma S

Self


5 Date of Repudiation Not available

6 Reason for repudiation Treatment done on OPD basis are not payable

even if converted as an in-patient for more than

24 hours


8 Nature of complaint Rejection of medi-claim

9 Amount of claim Rs. 65,051/-


11 Amount of relief sought Rs. 65,051/-




a) For the Complainant Mr. J Sreyams Prasad , Father

b) For the Respondent Insurer 1. Ms. Pannaga H A, Dy. Manager

2. Ms. Kusuma K, Asst. Manager




The complaint emanated from the rejection of the claim for administration of rituximab injection which

does not warrant hospitalization. Despite taking up with the Grievance cell of Respondent Insurer (RI), her

claim was not settled. Hence the Complainant approached this Forum for settlement of the claim.



The Complainant was covered under the above mentioned policy since 30.03.2011 for sum insured of

Rs. 10,00,000/-. The Complainant was admitted to Vikram Hospital, Bengaluru on 13.08.2019 for relapsing

remitting multiple sclerosis and discharged on 14.08.2019. She was treated with inj. Methylprednisolone

and inj. Rituximab. At the time of admission in the hospital, cashless pre-authorization was rejected. Later

she submitted all the documents to the TPA/RI. However her claim was repudiated under clause 2.1 for

administration of rituximab injection which does not warrant hospitalization. She represented to the

Grievance cell of the RI, however her complaint is not considered favourably.

b. Respondent Insurer’s argument:

The Respondent Insurer has not submitted their Self Contained Note (SCN).




a. Complaint along with enclosures,

b. Consent of the Complainant in Annexure VI-A

21. Result of the personal hearing with both the parties (Observations & Conclusions):

The issue which requires consideration is whether administration of rituximab injection warrants

hospitalization or not.

During the personal hearing, the Complainant’s father reiterated earlier submissions and submitted

certificate from the treating doctor and extract of the protocol for use of Rituximab in neurological diseases

in support of their contention.

The representative of RI submitted that complainant is a known case of multiple sclerosis had undergone

administration of rituximab administration which does not warrant hospitalization and hence the claim was

rejected as per clause 2.1 of the policy, Procedures/treatments usually done on outpatient basis are not

payable even if converted as an in-patient in the hospital for more than 24 hours or carried out in day care.

Forum notes from the Discharge summary of the hospital that complainant with relapsing remitting

multiple sclerosis, presented with gait imbalance and visual blurring. She was admitted for injection

Rituximab 1mg with 1mg of methylprednisolone after taking due consent with standard pre-medications

with steroid, paracetetamol and antihistamine.

It is noted from the Rituximab infusion instruction dated 13.08.2019 of Vikram hospital that she was

administered inj. Solumedrol/Methylpredlinisolone 1000 mg IV in 100ml saline over one hour. Tab Dolo 650

mg 1 tab stat and Tab Cetrizine 10mg 1 tab stat. Later inj. Rituximab 500 mg in 500ml normal saline over

continuous period of 7 hours. Then 2nd dose in the same way. Inj. Effcorlin 100mg IV Q4H and normal saline

100 ml over one hour with 2 AMPS optineuron after completion of infusion.

From the certificate dated 31.12.2019 given by the treating doctor, it is noted that Rituximab is a

monoclonal antibody which is known to cause profound and life threatening immunological reactions

during infusion. Therefore, the infusion has to be administered very slowly with continuous monitoring

during and after infusion in the ICU. The safety requirements for infusion necessitate hospital admission

with strict monitoring. Typically, the infusion is started at a slow rate and then based on the adverse effects

and tolerability, the speed of infusion is gradually increased. Usually a 1 mg infusion exceeds more than a

day.

The RI has repudiated the claim under condition 2.1 of the policy stating that Procedures/treatments

usually done on outpatient basis are not payable even if converted as an in-patient in the hospital for more

than 24 hours or carried out in day care. It is clear from the certificate from the treating doctor as well as

hospital records that the procedure carried out on the IP was not usual in nature. Hence repudiation

quoting condition no. 2.1 is not found acceptable.

From the above all, the Forum concludes that hospitalization was necessary for continuous monitoring

during and after infusion in the ICU and hence the decision of RI in repudiating the claim is not in order. The

complaint is therefore allowed with interest.

AWARD

Taking into account of the facts and circumstances of the case and upon scrutiny of the documents

submissions made by both the parties, the Respondent Insurer is advised to settle the claim as per

terms and conditions of the policy along with interest @ 8.25% (Bank rate of 6.25% + 2%) from the

date of filing of the last relevant document by the Insured till the date of payment of the claim as per

Regulation 16.1.(ii) of IRDAI (Protection of Policyholders’ Interests) Regulations, 2017.

The Complaint is Allowed.








Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MR. SAJJAN JHUNJHUNWALA V/s UNITED INDIA INSURANCE COMPANY LIMITED



9. The Complainant along with his wife was insured under Family Medicare Insurance Policy No.

0304002816P107039244 for a Sum Insured of ₹. 3,00,000/- for the period from 25.08.2016 to

24.08.2017.

10. The Insured Person, Mr. Sajjan Jhunjhunwala was admitted to Manipal Hospitals, Bangalore for

ailment Acute Ischaemic CVA – Right Cerebellar Infarct along with Biabetes Mellitus,

hypertension and old CVA.

11. He was managed conservately during hospitalization and the total hospitalization bill was ₹.

1,30,321/- out of which ₹. 5,000/- was paid in advance by the complainant.

12. The complainant submitted his claim for reimbursement to the TPA on 08.08.2017. The TPA

asked the complainant to submit original money receipt of ₹. 1,25,321/- which was paid to

Hospital at the time of final discharge.

13. The complainant had submitted the original money receipt vide his letter dated 05.07.2018.

However, the TPA maintained that the money receipt was a duplicate one and closed the claim

for non-submission of original documents.

14. Complainant approached Grievance cell of RI on 19.09.2019 for reopening the claim; however

his claim was not settled. Hence the Complainant approached the Forum for settlement of his

claim.

15. The complaint was taken up for further process and the same was posted for personal hearing

on 20.03.2020.

16. Meanwhile, the Respondent Insurer vide their SCN (Self Contained Note) dated 24.02.2020

submitted that Money receipt for ₹. 1,25,321/- submitted by the complainant was genuine and

original and hence they instructed the TPA to re-process the claim and settle the claim as per

terms and condition of the policy.

17. The Complainant accepted for the said claim settlement vide his email dated 13.03.2020.

18. As the Complaint was resolved on Compromise with the intervention of the Ombudsman, the

complaint is Closed and disposed off accordingly. Consequently the personal hearing

scheduled for 20.03.2020 stands cancelled.

19. Since the complainant submitted all the required documents on 05.07.2018, the Respondent

Insurer is advised to settle the claim as per terms and conditions of the policy along with

interest (Bank rate + 2%) from the date of filing of the last relevant document by the Insured

till the date of payment of the claim as per Regulation 16.1.(ii) of IRDAI (Protection of

Policyholders‟ Interests) Regulations, 2017.

20. The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17 (6)

of the Insurance Ombudsman Rules, 2017, whereunder the Respondent Insurer shall comply

with the Award within 30 days of the receipt of the Award and shall intimate compliance of the

same to the Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN




OMBUDSMAN – Mrs NEERJA SHAH

In the matter of MR. SATISH BADIGER V/s STAR UNION DAI-ICHI LIFE INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. Satish Badiger

Hemareddy Mallama Temple,

Vivek Nagar East,

HUDCO Colony, Vijayapura,

Karnataka – 586 109

Mob. No. 9900764570

2 Policy No.

Type of Policy


00957566

SUD Life Aarogyam

23.06.2016 to 23.03.2026



Mr. Satish Badiger

Self

4 Name of the Respondent Insurer Star Union Dai-ichi Life Insurance Company Limited


6 Reason for repudiation Misrepresentation/non disclosure of material facts


8 Nature of complaint Repudiation of claim & cancellation of policy.

9 Amount of claim Not mentioned


11 Amount of relief sought Rs. 5,00,000/-





b) For the Respondent Insurer Mr. Gowri S, Zonal Lead Customer Manager

15 Complaint how disposed Disallowed



It is a case of repudiation of mediclaim for hospitalization on the ground that the insured had not disclosed

about acute pancreatitis with pseudocyst at the time of re-instatement of the policy. The Complainant took

up the matter with the Grievance Cell of the Respondent Insurer (RI) and the same was not considered

favorably.



Complainant submitted that he was insured with RI since 2015 and was paying regular premium towards

renewal of the same. He was admitted to Fortis Hospitals, Bangalore on 17.09.2018 for Pancreatic

Pseudocyst and discharged on 20.09.2018. He submitted all claims papers to the RI however the

reimbursement has been rejected and policy was also cancelled. The approach to Grievance also did not

yield any result and hence, the Complainant had approached this Forum.


The RI has submitted their Self Contained Note dated 04.03.2020 admitting insurance, reporting of claim

and their rejection. It is submitted that complainant submitted duly filled proposal form no. 12431370 on

22.03.2016 and based on the submission, policy was issued from 23.03.2016 for 10 years with premium

paying terms of 10 years for sum insured of Rs.5,00,000/-. As per terms and condition, complainant has to

pay the annual renewal premium on 22.03.2017 but owing to non-receipt of the premium, the policy

moved to “Lapsed status”. It is submitted that in order to revive the policy, the complainant has submitted

duly signed declaration of good health (DGH) form dated 30.09.2018 to the RI. It is submitted that as on

30.09.2018, he is in good health and has never been diagnosed with any disease of pancreas. Based on his

good health declaration, RI revived his policy. On 16.09.2019, RI received a claim intimation form from the

complainant for his admission to Fortis Hospital, Bangalore on 17.08.2019. He was diagnosed with acute

pancreatitis with pseudocyst and discharged on 20.09.2019. It is submitted that since he had not disclosed

of the said pancreatic disorder in the DGH form, RI rejected the claim and cancelled his policy and refunded

the premium. Hence, RI has requested to absolve them from the complaint made.


The complaint falls within the scope of the Insurance Ombudsman Rules, 2017


a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A


It is noted that the present dispute is for rejection of claim for non-disclosure of pancreatic disorder

in Good Health Declaration Form and cancellation of policy.

During the course of personal hearing, the complainant reiterated his earlier submission and

submitted that he has not signed any document or good health declaration form.

The RI reiterated their contentions stated in SCN and submitted that their decision was based on the

medical records and the terms and conditions of policy. RI submitted that they have duly refunded

the premium amount of Rs. 43,655/- to the complainant vide NEFT-N323190985604932 on

15.11.2019 and cancelled the policy.

It is noted that policy was issued from 23.03.2016 for 10 years with premium paying terms of 10

years. Owing to non-receipt of the premium from the complainant, the policy moved to “Lapsed

status” on 22.03.2017. In order to revive the policy, the complainant has submitted duly signed

declaration of good health (DGH) form dated 30.09.2018 to the RI. The relevant extract of the DGH

is reproduced as below:

4. (c) Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the

following condition?

Disease of liver or pancreas.

To the particular question asked, the complainant ticked “NO” in the DGH form.

It is noted from the Discharge summary of Fortis Hospital dated 20.09.2018 that the complainant

was diagnosed with pancreatic pseudocyst and EUS guided cysto gastrostomy was done.

This Forum relies on the Hon’ble Supreme Court of India’s decision in the case of Satwant Kaur Sandhu v/s. The New India Assurance Company Limited IV (2009) CPJ 8 (S.C), wherein the hon’ble court held : “The upshot of the entire discussion is that in a Contract of Insurance, any fact which

would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk

is a "material fact". If the proposer has knowledge of such fact, he is obliged to disclose it

particularly while answering questions in the proposal form. Needless to emphasise that any

inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption

that any information sought for in the proposal form is material for the purpose of entering into a

Contract of Insurance”. Since the treatment at Fortis Hospital dated 20.09.2018 was done before the date of submission of

declaration of good health form on 30.09.2018 there is a clear non-disclosure of material facts. The

RI has rightly cancelled the policy and refunded the premium amount to the complainant. The

Complaint is Disallowed..

A W A R D Taking into account of the facts and circumstances of the case and the submissions made by both

the parties and documents submitted during the course of the Personal Hearing, the decision of

the Respondent Insurer in repudiating the claims are in consonance with the terms and conditions

of the policy and does not warrant any interference at the hands of the Ombudsman.

Hence, the Complaint is Disallowed.

Dated at Bangalore on the 20th day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MR. SHAILANDER SINGH V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED


Award No.: IO(BNG)/A/HI/0303/2019-20

1 Name & Address of the Complainant Mr. Shailander Singh

Q. No. 18, Doctors Staff Quarters, BRIMS Campus,

BRIMS Medical College,

Bidar, Gulbarga - 585401

Mobile No.: 9886978875

Email ID: [email protected]

2 Policy Number

Type of Policy


P/100001/01/2020/018068

Senior Citizans Red Carpet Insurance Policy

30.07.2019 to 29.07.2020



Mr. Bhagath Singh

Self

4 Name of the Respondent Insurer Star Health and Allied Insurance Company Limited


6 Reason for repudiation Non disclosure of Pre existing Diseases


8 Nature of complaint Rejection of hospitalisation claim and cancellation

of claim

9 Amount of claim Rs. 2,93,148/-


11 Amount of relief sought Rs. 2,93,148/-




a) For the Complainant Absent

b) For the Respondent Insurer 1. Mr. M G Mahadevan, Sr. Consultant

2. Ms. Umadevi M B, Sr. Manager




The complaint emanated from the rejection of claims on the ground that the Liver cirrhosis existed prior to

inception of the policy. The Complainant represented to Grievance Redressal Officer (GRO) of the

Respondent Insurer for reconsideration of his claim. However the claim was not settled. Aggrieved with the

decision of RI, he approached this forum for settlement of the claim.



The Complainant submitted that his father was insured with RI for sum insured of Rs. 3,00,000/- since

30.07.2019. He was admitted to Vivekanand Hospital, Latur on 26.10.2019 for hypertension, diabetes

mellitus and septic shock and discharged on 04.11.2019. He applied for cashles pre authorization but the

same was rejected stating insured person IP is a known case of liver cirrhosis for the past 3 years. The

complainant applied for reconsideration of his claim. However his claim was not settled. Hence the

complainant approached this Forum for settlement of his claim and revival of the policy.


The Respondent Insurer in their Self Contained Note dated 10.02.2020 whilst admitting the insurance

coverage submitted that complainant reported the claim in the 3rd month of the policy. It was submitted

that the complainant was a known case of liver cirrhosis for the past 3 years which was prior to the

inception of the policy and was not disclosed at the time of taking the policy which amounted to non-

disclosure of material facts. Hence, they rejected the claim as per condition no. 6 of the policy and as

condition no. 12, cancelled the policy. The Respondent Insurer requested the Forum to dismiss the

complaint.


The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so it was

registered.


a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A


The issue which require consideration is whether the complainant was suffering from Liver

cirrhosis prior to the commencement of the policy.

During the personal hearing, complainant expressed his inability to attend the personal hearing however

the representatives of RI were present.

The complainant in his complaint to this forum submitted that he had disclosed about Hypertension in the

proposal form as he was aware of it. Since, he was not having Liver cirrhosis at the time of inception of the

policy; he had not disclosed the same. It is noted that RI vide their SCN confirmed that the complainant

disclosed Hypertension in the proposal form and the same is incorporated in the policy as Pre-existing

disease.

Representatives of RI stated their decision of repudiating the claim relied on the Discharge summary of the

treating hospital that stated the complainant was a known case of liver cirrhosis for the past 3 years.

It is noted from the abdominal and pelvic sonography dated 29.10.2019 that Liver is normal and there is no

mention of any scar tissue which is characteristic of liver cirrhosis.

The indoor case paper of Vivekanand Hospital, Latur (MH) that stated “? Liver Cirrhosis for 3 years – details

not known”. Forum finds that there is no documentary evidence other than the comment in the indoor

case paper that the complainant was a known case of Liver cirrhosis. This comment is not supported by the

discharge summary. Furthermore, Forum does not find any reason why the IP would not disclose about

Liver cirrhosis since he had disclosed about Hypertension in the proposal form.

Forum relies on the Supreme Court Judgment in the case of Satwant Kaur Sandhu vs. The New India

Assurance Co. Ltd., wherein it is stated that disclosure of material facts extends only to facts which are

known to the applicant and not to what he ought to have known. The obligation to disclose necessarily

depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no

moment.

Considering the above, the decision of the RI is not in accordance with the terms and conditions of the

policy. Hence, the Complaint is hereby allowed with interest.

A W A R D

Taking into account the facts & circumstances of the case and the personal submissions made by

both the parties and the information/documents placed on record, the respondent insurer is

advised to settle the claim as per terms and conditions of the policy along with interest @ 8.25%

(Bank rate of 6.25% + 2%) from the date of filing of the last relevant document by the Insured till

the date of payment of the claim as per Regulation 16.1.(ii) of IRDAI (Protection of Policyholders’

Interests) Regulations, 2017.

RI is directed to revive the policy with all existing benefits subject to premium receipt.

Hence, the Complaint is Allowed.

22) Compliance of Award:







Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G.

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mr.Arvind S.Chouhan ……………..…..………………………………Complainant

V/s

Manipal Cigna Health insurance Company Ltd………………....…….Respondent

COMPLAINT NO: BHP-H-053-1920-0218 ORDER NO: IO/BHP/A/HI/ 0094/2019-2020

Mr. Arvind Singh Chouhan (Complainant) has filed a complaint against Manipal Cigna

Health Insurance Co. Ltd (Respondent) alleging rejection of claim.

Brief facts of the Case -The Complainant has stated that he and his wife were covered under

above mentioned Health Insurance Policy. His wife was diagnosed with Gall Stone and was

recommended for surgery, which was later done at Indira Memorial Hospital (Rajendra Nagar,

Indore MP) on 04.09.2019. All the claim documents, bills were sent to the Insurance

Company, for reimbursement. The Insurance company rejected the claim on ground of Patient

History of COPD (Chronic Obstructive Pulmonary Disease) claiming that it was not disclosed

at the time of policy inception. Although he has submitted a Certificate from doctor (who did

the surgery) that COPD does not have any direct relation with the Gall Stone and Patient is

not on any Medication of COPD. Here it is important to highlight that during policy inception,

the respondent company never asked for any Pre Medical Checkups and also during Two

1. Name & Address of the

Complainant

Mr.Arvind Singh Chouhan

C/o Mr. J.P.Shukla, Flat No. 305, Amrut

Ganga Apartment, Biju Nagar, Jharsuguda,

Sambalpur (Orissa)

2. Policy No:

Type of Policy

Duration of policy/Policy period

PROHLR155009824

ManipalCigna ProHealth Protect Insurance

24.06.2019 to 23.06.2020

3. Name of the insured


Mr. Arvind Singh Chouhan

SAME

4. Name of the insurer Manipal Cigna Health Insurance Co. Ltd.

5. Date of Repudiation/ Rejection 16.10.2019

6. Reason for Repudiation/ Rejection As per clause VIII.1 (Non disclosure of pre-

existing disease)

7. Date of receipt of the Complaint 31.12.2019

8. Nature of complaint Rejection of claim

9. Amount of Claim Rs.44,008/-

10. Date of Partial Settlement --

11. Amount of relief sought Rs.44,008/-

12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017

13. Date of hearing/place On 12.03.2020 at Bhopal

14. Representation at the hearing

For the Complainant Mr Ashish Chouhan, Brother

For the insurer Mr Manish, Rai, BM

15. Complaint how disposed Dismissed

16. Date of Award/Order 12.03.2020

consecutive Policy renewals. Also wife of complainant is not suffering any problem of COPD

and is not taking any medicines for it and the same was certified by the doctor also.

Complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that the complainant and his wife were covered

under above mentioned policy effective from 05.05.2016 having term of two years and was

subsequently renewed twice. The Complainant filed a claim for his wife registered under

claim no.20527074 on 19.09.2019 for reimbursement of hospitalization expenses for Calculus

of gall bladder with acute cholecystitis without obstruction at Indira Memorial Hospital,

Indore from 04.09.2019 to 06.09.2019. On scrutiny of mediclaim documents submitted by the

complainant, it was observed from the Discharge Summary that she has history of chronic

obstructive pulmonary disease (COPD) since 7-8 years. The complainant nor his wife

disclosed regarding (COPD) which is material at the time of issuance of the policy. Hence the

claim of the complainant was rejected under Clause VIII-1 stating as “patient had history

COPD since 7-8 years which is material to policy decision and was not disclosed in proposal

form at the time of policy inception.

The complainant has filed complaint letter, Annex. VI A and correspondence with respondent,

while respondent have filed SCN with enclosures

I have heard both parties at length and perused paper filed on behalf of the complainant as

well as the Insurance Company.

A claim under above policy was lodged by the complainant for the treatment of his wife /

insured taken at Indira Memorial Hospital, Indore from 04.09.2019 to 06.09.2019 which was

repudiated under clause VIII-1 by the respondent stating that insured had history k/c/o COPD

since 7-8 years which was not disclosed in the proposal form at the time of inception of policy

which was material to the policy decision. Discharge Summary of Indira Memorial Hospital

has been filed by the respondent which shows that the insured was admitted on 04.09.2019,

discharged on 06.09.2019 and was diagnosed with Cholelithiasis. In Discharge Summary in

the column of present complaints, it is mentioned that insured had a history of COPD since 7-

8 years. Discharge Summary clearly reveals that insured had a history of COPD since 7-8

years. The representative of the respondent has argued that material fact of having ailment

COPD was not disclosed at the time of inception of the policy which was material for the

policy decision. Respondent has filed copy of proposal form wherein complainant had not

mentioned insured‟s previous ailment of COPD and hence suppressed material fact and not

disclosed. Clause VIII.1 of the policy states that the policy shall be null and void and no

benefit shall be payable in the event of non-disclosure of any material particulars, untrue or

incorrect statements, misrepresentation, mis-description in the proposal form, personal

statement, declaration, claim form declaration, medical history on the claim form and

connected documents, or any material information having been withheld by insured or any

one acting on insured‟s behalf, under this policy. As the complainant / insured had not

disclosed previous ailment of COPD in the proposal form, hence respondent has rightly

repudiated the claim as per clause VIII.1 of the policy terms and conditions. In the result,

complaint is liable to be dismissed.

The complaint filed by Mr Arvind S Chouhan stands dismissed herewith.

Let copies of the order be given to both the parties.

Dated : Mar 12, 2020 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman



Mr. Anil Sharma ……..……………..…..………………………………Complainant

V/s

IFFCO TOKIO General Insurance Co. Ltd. ......………...…………...Respondent


Mr. Anil Sharma, (Complainant) has filed a complaint against IFFCO TOKIO General

Insurance Co. Ltd (Respondent) with respect to two claims alleging repudiation.


Complainant

Mr. Anil Sharma

116, Kanyakubj Nagar,

Aerodrome Road, Indore

2. Policy No:

Type of Policy


H0111219

Family Health Protector Policy

22.06.2019 – 21.06.2020



Mr. Anil Sharma

Mr. Anil Sharma

4. Name of the insurer IFFCO TOKIO General Insurance Co. Ltd.

5. Date of Repudiation/ Rejection 20.12.2019 & 07.01.2020

6. Reason for Repudiation/ Rejection Non disclosure of HTN and Diabetes


8. Nature of complaint Repudiation of Mediclaim

9. Amount of Claim Rs.3,50,000/-

10. Date of Partial Settlement ---

11. Amount of relief sought ---


13. Date of hearing/place 12.03.2020 at Bhopal


For the Complainant Mr Anil Sharma

For the insurer Dr Aditya Gulati, Asstt Manager



Brief facts of the Case -The Complainant has stated that he had opted for a health insurance

policy from Oriental Insurance Co. Ltd. in the year 2013 and later ported to IFFCO TOKIO in

the year 2016. Since inception the said policy is being regularly renewed. Due to

hospitalization (CHL Hospital and Medanta Hospitals, Indore) on 26.10.2019 & 02.11.2019,

claims were lodged with IFFKO TOKIO and the same were repudiated in view of having

known case of Hypertension and Diabetes since 4 years. As per treating Doctor‟s certificate

“Diabetes and Hypertension were since 2017. As per hospitals‟ records random plasma

glucose report dated 26.10.2019 blood sugar level was 127.22 and hypertension was 120/70.

These indexes are normal as per medical standards. Complainant has approached this forum

for redressal of his grievance.

The respondent in their SCN have stated that the complainant was covered with them

under above policy for the period 22.06.2019 to 21.06.2020 and insured had ported this policy

with effect from 22.06.2016, prior to that insured had policy with Oriental Insurance

Company Ltd. Complainant was admitted to CHL Hospital, Indore on 26.10.2019 under Cl

No.2019102600945 with complaints of acute onset of chest pain, diagnosed with CAD, Acute

anterior wall MI. On scrutiny of documents, it has been observed that the patient is known

case of hypertension and diabetes since 4 years. While filling the proposal form, insured had

not disclosed the fact that he has been suffering from HTN and Diabetes, hence this claim was

denied under policy terms and conditions of disclosure to information norms. Again the

patient was admitted in Medanta Hospital, Indore under claim no.2019110500319 with

diagnosis T2DM, HTN, Coronary Artery Disease and underwent Angiography with

Angioplasty and this claim was also denied under terms and condition of disclosure to

information norms. As the insured was suffering from diabetes & HTN prior to taking policy

with IFFKO TOKIO and did not disclose the material facts at time of filling the proposal form,

which is a breach of contract under utmost good faith. Hence the aforesaid claims have been

denied on grounds of Condition no.16, disclosure to information norms. It is further stated

that insured represented that the history was wrongly mentioned as 4 years instead it was from

2017, for which the Company would like to mention that it is a matter of practice that medical

complaints are recorded/ maintained on real time basis, based on confirmation/ history

provided by patient to treating Dr./ Hospital and changing / modifying the history post denial

of claim is an afterthought.


while respondent have filed SCN with enclosure.



Two claims No.2019102600945 and No.2019110500319 were lodged by the complainant for

the treatment taken from 26.10.2019 to 29.10.2019 at CHL Hospital, Indore and from

02.11.2019 to 08.11.2019 at Medanta Super Specialty Hospital, Indore which were repudiated

by the respondent on the ground of condition No.16 (49) of the policy stating that

complainant / insured was suffering from Diabetes Mellitus Type 2 and HTN since 4 years

and before inception of the policy i.e. 22.06.2016. Respondent has filed Initial Assessment

form of CHL Hospital, Indore with respect to history of present illness in which it is

mentioned by the Doctor that history has been given by the wife of the complainant and

insured was a k/c/o Type 2 DM and HTN. In the column of past history it is also mentioned

that insured was a k/c/o of Type 2 DM and HTN since 3-4 years. In Discharge summary of

Medanta Hospital, Indore also in the column of history and previous complaints, Type 2 DM

and HTN on regular medication has been mentioned. It is clear from LAMA Summary of

CHL Hospital, Indore that insured was diagnosed with CAD, Acute Anterior wall MI, LVEF

45% and was treated for the same and as per discharge summary of Medanta Hospital, Indore

insured was diagnosed with CAD, Type 2 DM, HTN and had undergone Angioplasty. Hence

medical records of CHL Hospital, Indore shows that insured was a k/c/o of Type 2 DM and

HTN since 3-4 years. During hearing, complainant has argued that he is not suffering from

HTN and DM and in Initial Assessment of the Hospital insured had not informed the Doctor

that he is suffering from DM and HTN since 3-4 years. The representative of the respondent

opposed the above argument and argued that Initial Assessment form clearly reveals that the

history of the patient was given by wife of the insured patient, hence argument that insured

was not suffering from DM and HTN since 3-4 years, is not acceptable. In Initial Assessment

form of CHL Hospital, Indore Doctor has mentioned that the history has been given by wife

of the insured patient. Besides, this complainant has not filed any such medical evidence that

he was not suffering from DM and HTN since 3-4 years. A certificate of Doctor of CHL

Hospital dated 28.10.2019 has been filed by the complainant in which doctor has mentioned

that as per history given by patient and attendants‟, insured is having DM and HTN since

2017. While issuing this certificate Doctor had not mentioned that on what basis he is

certifying that insured is having DM and HTN since 2017 whereas Initial Assessment form

has been filled up by the Doctor and signed by the wife of the insured. In the column of

history also complainant‟s wife had signed. In the presence of Initial Assessment form and in

absence of any base for issuing certificate on 28.10.2019, certificate issued by the Doctor on

28.10.2019 has no relevance. If as per certificate, insured was having DM and HTN since

2017 why Doctor of the above hospital had not mentioned the fact in Initial Assessment form.

Hence argument of the complainant is not at all acceptable. Complainant has not filed any

evidence showing that insured was suffering from DM and HTN since 3 years. Policy

incepted on 22.06.2016 hence DM and HTN were pre-existing prior to the inception of the

policy. As per respondent, complainant / insured had not declared his DM and HTN in the

proposal form. Copy of proposal form dated 21.06.2016 has been filed by the respondent in

which insured had denied of having any high or low blood pressure and Diabetes. Hence

complainant had not disclosed his pre-existing DM and HTN at the time of filling the

proposal form dated 21.06.2016. Condition No.16 (condition No.49 of old policy) of the

policy states that the policy shall be void and all premiums paid hereon shall be forfeited in

the event of non-disclosure of any material fact, misrepresentation and mis-description. As

complainant has suppressed and not disclosed material facts as to health, hence as per above

condition respondent has rightly repudiated the claims. In the result, complaint is liable to be

dismissed.

The complaint filed by Mr Anil Sharma stands dismissed herewith.






Mr. Saksham Singh Rajput ….……………..…..……………………………..…Complainant

V/s

Star Health & Allied Insurance Co. Ltd.…. .....…………….…...…………...Respondent

COMPLAINT NO: BHP-H-044- 1920-0246 ORDER NO: IO/BHP/A/HI/ 0096/2019-2020


Complainant

Mr. Saksham Singh Rajput

B-401 MIG- 11, Sarwadharam Colony,

Kolar Road, Bhopal

2. Policy No:

Type of Policy


P/161130/01/2019/039686

Family Health Optima Insurance Plan

19.01.2019 to 18.01.2020



Mr. Saksham Singh Rajput

Mr. Kamlesh Rajput

4. Name of the insurer Star Health & Allied Insurance Co. Ltd


6. Reason for Repudiation/ Rejection Multiple Discrepancies in material facts


8. Nature of complaint Repudiation of mediclaim





Mr.Saksham Singh Rajput (Complainant) has filed a complaint against Star Health & Allied

Insurance Co. Ltd (Respondent) alleging rejection of his mediclaim.

Brief facts of the Case -The Complainant has stated that he got unwell and was admitted in

Ganga Super Specialty Hospital, Bhopal from 18.11.2019 to 25.11.2019. He was suffering

from Typhoid and later on his health recovered. He submitted the application and papers but

his claim was repudiated stating that the claim is not true which can be ascertained from the

hospital authorities. Complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that the insured took Family Health Optima

Insurance Plan Online for the period 19.01.2018 to 18.01.2019 and the same was renewed for

the period 19.01.2019 to 18.01.2020 for sum insured of Rs.5,00,000/-. The insured reported

the claim during the 2nd

year of the policy. The insured was admitted on 18.11.2019 and got

discharged on 25.11.2019 from Ganga Multispecialty Hospital, Bhopal, Mandideep. As per

the Discharge summary, the diagnosis was Acute Diarrheal Disease with Enteric Fever. The

claim was intimated to Company on 27.11.2019, i.e after 2 days from the date of discharge

and the insured submitted the claim documents for reimbursement on 06.12.2019 for

Rs.94,797/-. On scrutiny of the claim records, it was observed that the insured resides at Kolar

Road, Bhopal whereas he was hospitalized at Ganga Hospital, Mandideep.There are number

of Network hospitals available in Kolar Road area including Bansal Hospital, Galaxy Hospital,

J K Hospital, V Care Hospital etc. and instead of taking cashless treatment at these nearby

Network hospitals, the insured preferred a non – network hospital having poor infrastructure

which is more than 20 kms away from his residence. In order to verify the genuineness of the

admission, the claim was entrusted for verification and following were the findings of the

claim verification : i) Patient was diagnosed with Acute Diarrheal Disease, but no stool

examination was done by the hospital, without investigating, performing the diagnose,

hospital has prepared the records and the pathology reports are not signed by the pathologist.

ii) During verification the hospital authorities couldn‟t show ICP, Bill Book, Cashbook,

Ledger, Daily collection register, Visiting Dr. register, Payment record to visiting Dr.s and

previous OPD/ IPD record of the patient, details of mode of payment & qualification

certificate of the Treating/ Visiting doctors. iii)On verification of IPD register, IPD no. 1045



For the Complainant Mr Saksham Singh Rajput

For the insurer Mr Ravi Tiwari, AGM Claims



of patient Saksham Singh found tampered from actual IPD No. 0045. Previous pages of this

IPD register shows IPD no. 00042, 00143, 00144 where in figure 043 and 044 were tampered

as 143 & 144. iv) The receipts no.3913 & 3920 were issued without dates and receipt no.

3945 was issued on 29.11.2019 to other patients. After issuing above receipt on 29.11.2019,

the receipt number 3961, 3963, 3966 & 3970 were issued to the patient Sakhsham Singh on

22nd

, 23rd

, 24th

and 25th

November 2019 which is not possible as per date wise sequence, it

shows that all receipts were issued for claim purpose. v) As per the submitted final bill,

patient is charged for deluxe ward without room/ bed number for Rs.3,000/- per day but as the

room tariff details of the hospital an amount of Rs. 3000/- was not mentioned in the room

tariff for any applicable bed category. From the above findings it is noted that there is

discrepancy in the claim documents and the claim is not payable as per policy condition No.2

and 6. Hence the claim was repudiated and the same was communicated to the insured vide

letter dated 04.01.2020.





A claim for Rs.94,797/-was filed by the policyholder Mr Kamlesh Rajput for the treatment of

insured / complainant taken at Ganga Super Multi Specialty Hospital, Mandideep, Bhopal

from 18.11.2019 to 25.11.2019 which was repudiated by respondent under policy condition

No.2 and 6 stating multiple discrepancies were observed and material facts were

misrepresented.

First ground for repudiation has been taken as that the claim was intimated to the company on

27.11.2019 at 08.02 PM i.e. after two days from the date of discharge from the hospital which

was necessary to be given within 24 hours from the date / time of occurrence of the event as

per policy condition No.5.2. The representative of the respondent has filed intimation details

showing date and time of intimation as 27.11.2019 at 08.02 PM and argued that as the

complainant had given delayed intimation and no intimation was given during hospitalisation

period from 18.11.2019 to 25.11.2019, hence the respondent company was deprived of

verifying the hospitalisation. During hearing, complainant has accepted that it is mistake on

his part to have intimated the respondent on 27.11.2019 after discharge from hospital on

25.11.2019. Policy condition No.5.2 states that upon hospitalisation, notice with full

particulars shall be sent to the company within 24 hours from the time/date of occurrence of

the event. In this case, complainant had not intimated his hospitalisation within 24 hours of

admission but intimated on 27.11.2019 after discharge from hospital. Admission intimation

was necessary to be given in time to verify the hospitalisation of the patient for which

respondent company was deprived as intimation was given by complainant after two days of

discharge from hospital. Hence this ground for repudiation is justified and is as per policy

condition.

Other ground for repudiation of claim is taken as that on verification of IPD register, actual

IPD No.1045 of insured patient found tampered from IPD No.0045 and previous pages of IPD

Register shows IPD No.00042, 00143, 00144 wherein in figure 043 and 044 were tampered as

143 and 144. Respondent has filed 3 photocopies of Registration Patients admitted to Nursing

home. On perusal of first page of this register, it is observed that reference number of 3

patients are entered in the page and all the three numbers have been tampered / altered as

1045, 1046 and 1047 while previously these were written as 0045, 0046 and 0047. On perusal

of other two pages, it is observed that reference number of patients numbering 043 and 044

were tampered / overwritten as 143 and 144. Over writing in IPD Number creates doubts as

regard to the genuineness of the patient IPD number. During investigation, investigator of the

respondent found that receipt No. 3913 and 3920 were issued by the Hospital without date

and receipt No.3945 was issued on 29.11.2019 to other patient. The representative of the

respondent has argued that receipt No.3961, 3963, 3966 and 3970 were issued to the insured

patient on 22nd

, 23rd

, 24th

and 25.11.2019 which is not possible as per date wise sequence

because receipt No.3945 was issued on 29.11.2019. He further argued that this shows that all

the receipts were issued for claim purpose only. Photocopy of receipt No.3945 shows issuing

date as 29.11.2019 while receipt No.3961, 3963, 3966 and 3970 were issued to the insured

patient on 22nd

, 23rd

, 24th

and 25.11.2019. This discrepancy also creates suspicion over

genuineness of the receipts The representative of the respondent has argued that at the time of

verification hospital authorities could not show ICP, bill book, cash book, ledger, daily

collection register, visiting doctors register, payment record to visitor doctor and previous

OPD record of patient and only IPD register and cash receipt book were shown. Investigator

report is also on record in which also it is mentioned by the investigator that hospital could

hardly show OPD /IPD register and cash receipt book but could not show ICP, bill book, cash

book, ledger, daily collection register, visiting doctors register. He further argued that

verification of documents and registers is the right of the respondent which was deprived.

The representative of the respondent has argued that in the case of acute diarrhea stool

examination is necessary which was not done and all pathology reports do not bear the

manual signature of the Doctor but e-signed as all the signatures are of same size and pattern.

No stool examination report is on record and pathology report of serum electrolyte is neither

manually signed nor e-signed. Cash receipts of Ganga Medical stores has been filed which are

not signed by the medical store.

The representative of the respondent has argued that the insured patient is a resident of Kolar

Road, Bhopal and the treating hospital (non-network hospital) is more than 20 kms away from

his residence while network hospitals were existing in the vicinity of his residence which

creates a doubt over hospitalisation. During hearing, complainant has accepted that treating

hospital is certainly more than 20 kms away from his residence and argued that on the date of

admission he had gone to his relatives place where he fell sick. Complainant could not

produce any evidence showing that on the date of admission he was at his relatives place at

Mandideep.

Condition No.5.6 of the policy states that the company shall not be liable to make any

payment under the policy in respect of any claim if such claim is in any manner supported by

any fraudulent means or device or misrepresentation. Discrepancies narrated above shows that

the facts of the case have been misrepresented by the complainant leading to suspicion over

genuineness of claim.

In view of above facts and circumstances, respondent has rightly repudiated the claim and

acted in accordance with the terms and conditions of the policy. In the result, complaint is

liable to be dismissed.

The complaint filed by Mr Saksham Singh Rajput stands dismissed herewith.






Mr. Rajesh Kumar Jain ……….………………..…..………………………………Complainant

V/s

Religare Health Insurance Co. Ltd………….……………….………...…………...Respondent

COMPLAINT NO: BHP-H-037- 1920-0222 ORDER NO: IO/BHP/A/HI/0098 /2019-2020


Complainant

Mr. Rajesh Kumar Jain

Baretha Road Near Bharat Mata Convent

School Ganjbasoda, Vidisha

2. Policy No:

Type of Policy


14202480

Care Floater Policy

21.05.2019- 20.05.2020



Mr. Rajesh Kumar Jain

Miss. Livie Jain

4. Name of the insurer Religare Health Insurance Co. Ltd.

Mr.Rajesh Kumar Jain (Complainant) has filed a complaint against Religare Health Insurance

Company (Respondent) alleging rejection of the mediclaim.

Brief facts of the Case -The Complainant has stated that on 15.06.2019 his daughter Livie

Jain fell down while playing. As she had difficulty in walking, a Doctor was consulted.

Though medicine was prescribed but as there was no relief, hence Dr. Manish Shroff of

Indore was consulted. X ray and MRI were done and the Doctor advised for surgery and on

22.06.2019 the complainant informed the Insurance Company. All the documents related to

the claim were submitted at the Bhopal Branch, thereafter on 17.07.2019 the Company

informed through email that the claim has been denied. He further states that he had submitted

the claim as it was an accident case but the Company rejected the claim citing the condition of

waiting period. He has stated that the loss suffered is based on the accident occurred. As per

the policy it should not be treated on any of the waiting period condition of the policy, which

is mentioned on page no.11.30 clause 4.1(i) The Doctor has also mentioned it as an unnatural

incident. Complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that the complainant filed a reimbursement

claim for an amount of Rs.1,07,933/- for the hospitalization of the insured from 22.06.2019

till 24.06.2019 at Global SNG hospital, Indore, with complaint of pain and swelling of left

region. The insured had history of fall 6 days ago while playing and was diagnosed with ACL

injury left knee. The complainant underwent Arthroscopic left knee + ACL Reconstruction

under sub- arachnoid block (SAB) on 22.06.2019. On the basis of the documents received

along with the claim form, it came to the forefront of the respondent that insured underwent

surgery i.e Arthroscopic left knee + ACL Reconstruction under sub-arachnoid block (SAB).

As per the reimbursement claim form the insured was primarily diagnosed with left knee ACL


6. Reason for Repudiation/ Rejection Orthroscopic knee surgery covered after 24

months of continuous policy coverage as per

clause 4.1(ii)


8. Nature of complaint Rejection of mediclaim







For the Complainant Mr Rajesh Kumar Jain

For the insurer Mr Sachin Kumar Verma, Manager Legal



injury. It was also mentioned that the insured underwent Arthroscopy ACL Reconstruction.

As per MRI of Vishesh Hospital Diagnostic dated 22.06.2019 for left knee joint, the anterior

cruciate ligament shows diffusely altered signal/edema with a small partial thickness tear at

the tibia insertion. It was also mentioned that Grade I-II intra meniscal changes involving the

body and posterior horn of the medial meniscus. As per the operation record dated

22.06.2019 of Global SNG Hospital, Indore, the insured was diagnosed with ACL injury (left )

knee and underwent surgery i.e Arthroscopy of Left Knee +ACL Reconstruction under SAB.

It is submitted by the respondent that the claim related to the Arthroscopic Knee Surgery are

covered only after 24 months of continuous policy coverage. The claim of the insured falls

under the category of treatment related to Arthroscopic Knee Surgery and it was filed within

24 months of policy inception i.e 21.05.2019. Thus the claim of the insured was rejected

under clause No.4.1(ii) in accordance with the policy terms and conditions.





A claim for Rs.1,07,933/- under above policy was filed by the complainant for the treatment

of insured taken from 22.06.2019 to 24.06.2019 at Global SNG Hospital Indore which was

repudiated by the respondent under clause 4.1(ii) of the policy stating that Arthroscopic knee

surgery are covered only after 24 months of continuous coverage. The representative of the

respondent has argued that the insured underwent surgery of Arthroscopic left knee + ACL

Reconstruction under SAB arachnoid (SAB) which is not payable upto 24 months of

continuous coverage. Discharge Summary of Global SNG Hospital, Indore reveals that

insured was admitted from 22.06.2019 to 24.06.2019 and was diagnosed with ACL injury

(left) knee and operation for Arthroscopic left knee and ACL reconstruction was done on

22.06.2019. Clause 4.1(ii) of policy states that any claim for or arising out of any of the

following illness or surgical procedures shall not be admissible during the first 24 consecutive

months of coverage of the insured person by the Company from the first policy period start

date for any treatment related to Arthritis (if non-infective) osteoarthritis, osteoporosis, gout,

rheumatism, spinal disorders (unless caused by accident), joint replacement surgery (unless

caused by accident), Arthrosopic knee surgeries/ ACL reconstruction / meniscal and ligament

repair. As the insured had undergone operation of Arthroscopic left knee surgery and ACL

reconstruction and the claim is in the first year of the policy, hence as per above clause the

claim is not payable upto 24 months of continuous coverage. During hearing, complainant has

argued that claim is based on accidental fall and hence is covered under the policy. The

representative of the respondent has opposed the argument and argued that as per clause 4.1(ii)

Arthroscopic knee surgeries / ACL reconstruction is having 2 years waiting period hence not

payable. In clause 4.1(ii) of policy it is only mentioned that claim of Arthroscopic knee

surgeries / ACL reconstruction / meniscal and ligament repair shall not be admissible during

the first 24 months of coverage and no exception to this is provided by mentioning unless

caused by accident. Hence the argument of the complainant is not at all acceptable. In view of

above discussion respondent has rightly repudiated the claim and acted in accordance with the

terms and conditions of the policy. In the result, complaint is liable to be dismissed.

The complaint filed by Mr Rajesh Kumar Jain stands dismissed herewith.






Mrs. Mamta Bhargava ………………………..………………………………Complainant

V/s

HDFC ERGO General Insurance Co. Ltd. ......………….…...…………...Respondent



Complainant

Mrs. Mamta Bhargava

E-5/112, Arera Colony

Bhopal

2. Policy No:

Type of Policy


2825100270271200000

Health Suraksha Policy Silver Plan

22.01.2018 to 21.01.2020



Mrs. Mamta Bhargava

Mrs. Mamta Bhargava

4. Name of the insurer HDFC – ERGO General Insurance Co. Ltd.


6. Reason for Repudiation/ Rejection The diagnosed disease falls under the 2 year

waiting period clause of the policy


8. Nature of complaint With respect to denial of mediclaim

9. Amount of Claim --






For the Complainant Dr Mukesh Bhargava

For the insurer Mr Anand Shrivastava, Legal Manager

Mrs.Mamta Bhargava (Complainant) has filed a complaint against HDFC- ERGO Insurance

Company Ltd.(Respondent) alleging rejection of Mediclaim.

Brief facts of the Case -The Complainant has stated that she was hospitalized on 21.11.2019

in emergency in a state of shock because of sudden massive lower GI Bleeding and was

managed conservatively with IV fluids, Voluvain, antibiotic, blood transfusion and other

supportive treatment only and not surgically with endoscopy. Investigations like CT Angio of

abdomen was absolutely normal and Upper & Lower GI Endoscopy were normal. It is also

stated that no surgical management was done with endoscopy and hence the reason mentioned

in the mail regarding rejecting the claim on the basis of managed surgically with endoscopy is

absolutely baseless and incorrect. As the investigations were normal she was further referred

for Meckels‟ Diverticulum Scan on 23.11.2019. In this study, the consultant radiologist

mentioned that the scan revealed abnormal focal area of tracer uptake seen – left hypogastric

region and reported impression as Scintigraphic evidence of Ectopic gastric mucosa/ Meckel‟s

Diverticulum. As the Meckel‟s Diverticulum study was non-conclusive as neither the clinical

presentation nor the region that is left Hypogastric region mentioned in the scan were unusual

the learned treating doctor at Parul Hospital discharged the patient from Parul Hospital on

24.11.2019 with the provisional diagnosis of Lower GI bleed with shock ? Meckel‟s

Diverticulum Bleeding and further referred the patient for capsule endoscopy from Parul

Hospital on 24.11.2019 itself to confirm / rule out the diagnosis of Ectopic gastric mucosa /

Meckel‟s Diverticulum which was reported in Meckel‟s Diverticulum scan. The patient had

undergone capsule endoscopy at Gastro care hospital on 24.11.2019 which revealed that the

Entire small bowel is normal and No erosions /ulcer/ Arteriovenous malformation/ Meckel‟s

Diverticulum seen and thus the Consultant Gastroenterologists reported the study a Normal

Study. The above narration events will make the facts of the case absolutely clear and would

be able to understand that the patient was admitted because of sudden onset of bleeding per

rectum with shock. The patient was managed only conservatively for bleeding and shock.

Possibility of Meckel‟s Diverticulum which was raised by the Radiologist on Meckels‟

Diverticulum study on 23.11.2019 was absolutely ruled out by a normal study report of

capsule endoscopy done on 24.11.2019 and checked and reported by consultant

gastroenterologist on 25.11.2019. There was no surgical management with endoscopy as is

being postulated in the email of the Company, a fact which is reflected very clearly in the

records submitted by the hospital to the Company and hence section 9.a.ii a of policy, a

waiting period of 2 years is applicable for the said ailment Meckels‟ Diverticulum bleeding



(Internal Congenital disease) is not at all applicable as neither there is any evidence of

Meckels‟ Diverticulum in Capsule endoscopy nor any surgical management with endoscopy

was done in this case. In this case the patient presented with sudden lower G I bleeding with

shock and was managed conservatively only at Parul Hospital. In complaint, complainant has

requested to look into the claim and register her complaint by giving due consideration to all

the facts regarding illness and treatment highlighted by her.

The respondent in their SCN have stated that claim was intimated for reimbursement of

hospital expenses by the insured. As per details provided for the claim, insured was admitted

in Parul Hospital, Bhopal on 21.11.2019. She was admitted in a state of shock due to massive

bleeding per rectum which started all of sudden before 1 hour of admission. She was

discharged on 24.11.2019. As per discharge card and certificate of Parul Hospital submitted

by the insured, she was diagnosed with lower GI bleed and shock and Meckel‟s Diverticulum

bleeding, (internal congenital disease). As per policy terms and conditions, section 9 a(ii), a

waiting period of 2 years is applicable for the said aliment of Meckel‟s Diverticulum bleeding

(internal Congenital Disease). Thus considering this condition claim was repudiated. The

Company decided the claim on the basis of Discharge Card and Certificate of Parul Hospital.

However insured was advised for a capsule endoscopy test which was conclusive test for

Meckel‟s Diverticulum. The result of this test was dated 24.11.2019 and insured was found

not suffering from this ailment. The condition of lower GI shock with bleeding was managed.

However the same was not mentioned in the Discharge card or certificate issued by Parul

Hospital. The claim was then subsequently reviewed and on the basis of the test result of

capsule endoscopy dated 24.11.2019 Company decided to honour the claim of insured and the

whole claim amount of Rs.1,03,750/- without any deductions was transferred to the Bank

account of the insured on 02.03.2020.





A claim for Rs.1,03,750/- under above policy was filed by the complainant for her treatment

taken at Parul Hospital, Bhopal from 21.11.2019 to 24.11.2019 which was initially rejected by

the respondent under policy condition No.9a(ii). As per SCN, respondent had settled the

claim for Rs.1,03,750/- and transferred the amount vide UTR No.003020158249 to the Bank

account of the complainant. During hearing, complainant also acknowledged receipt of

Rs.1,03,750/- in her bank account. Hence claim has been settled and paid. During hearing,

representative of the complainant has requested to penalize the respondent and requested that

some compensation must be allowed to her. In complaint and in Annexure VI-A, complainant

has only requested for review of her claim and not prayed for anything else. Besides this,

above requests raised during hearing is also out of the scope of this forum. In the result,

complaint is liable to be dismissed.

The complaint filed by Mrs Mamta Bhargava stands dismissed herewith.






Mr. Manish Vijay Raj …..……….………………..…..………………………Complainant

V/s

The Oriental Insurance Co. Ltd…...…….....…………….……...…………...Respondent

COMPLAINT NO: BHP-H-050- 1920-0227 ORDER NO: IO/BHP/A/HI/0099 /2019-2020

Mr.Manish Vijay Raj (Complainant) has filed a complaint against The Oriental Insurance

Company Ltd. (Respondent) alleging unjustified deduction from claimed amount.


Complainant

Mr. Manish Vijay Raj

Sneh Ganga, D-71

Patel Nagar, Raisen Road, Bhopal

2. Policy No:

Type of Policy


152109/48/2019/1046

Happy Family Floater -2015

14.12.2018 to 13.12.2019



Mrs. Snehlata Jain

Mr. Manish Vijay Raj

4. Name of the insurer The Oriental Insurance Co. Ltd

5. Date of Repudiation/ Rejection ----

6. Reason for Repudiation/ Rejection ----


8. Nature of complaint Unjustified deduction from claim amount.

9. Amount of Claim Rs. 9,000/-

10. Date of Partial Settlement 20.09.2019

11. Amount of relief sought Rs. 9,000/- + Expenses for taking up this issue




For the Complainant Mr Manish Vijay Raj

For the insurer Mr D N Dharade, Branch Manager



Brief facts of the Case -The Complainant has stated that in September, 2019 he had

submitted a medical claim for reimbursement of Rs.35,570/- towards the expenses incurred

for the cataract surgery of left eye of his mother vide claim no. HH372001062. TPA has

settled it for Rs.26,045/- only. Rs.9,000/- was deducted with the reason – “Customary and

reasonable charges (Toric Lens)”. The reason for deduction in the cost of toric lens is

unjustified because earlier in July 2019 the full amount was reimbursed for the same against

claim no.HH 372000708 towards the cataract surgery of right eye of his mother. He had

communicated with the concerned person by mails and on phone at Heritage Health, Indore

Branch only to hear a negative response in this regard. Subsequently, on 10.12.2019 a notice

was given to The Oriental Insurance Co. Ltd., CBO -5, Bhopal and a copy of the of the same

given to its TPA- Heritage Health Insurance TPA (P) Ltd, Indore but did not get any response.

Complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that complainant‟s mother/insured

underwent a surgery of her right eye correction of eye sight in the month of July 2019. She

was again admitted for left eye correction of eye sight in the month of September 2019

(02.09.2019). The insured has objected for the deduction of Rs.9,000/- towards customary

and reasonable charges. As per medical opinion Toric IOL is used in cases to reduce or

eliminate corneal Astigmatism and to improve distant vision. Hence the Company had paid

for conventional cataract surgery and extra cost for Toric is not payable which is used for

correction of vision. The TPA Heritage Health Pvt. Ltd. due to oversight had processed the

claim of right eye in the month of July and wrongly paid by not deducting Rs.9,000/- the cost

of Toric lens which is used to treatment for Astigmatism i.e distorted, blurry, fuzzy vision

with irregular cur of lens which comes under correction of eye sight and as per policy terms

and conditions under clause 4.6 & 3.41 it is not admissible. Therefore Rs.9,000/ was wrongly

paid in the month of July 2019 which is under process for recovery from the TPA (TPA letter

is attached) and the para 4.6 & 3.41 of policy conditions is attached). The Company has stated

that in view of the above they confirm that the insured‟s claim was processed as per the policy

conditions.

The complainant has filed complaint letter, Annex. VI A and correspondence with respondent




A claim for Rs.35,570/- under above policy was filed by the complainant for the

reimbursement of expenses incurred in the treatment of his mother / insured for the cataract

surgery of left eye with Toric IOL in the month of September 2019. Claim was settled for

Rs.26,045/- under customary and reasonable charges and an amount of Rs.9,000/- was not

paid as Toric IOL lens is used for eye correction which is not payable under clause 4.6 of

policy. As per clause 4.6 of policy, surgery for correction of eye sight is excluded. Cataract

surgery was performed with Toric IOL. As per medical references special intra ocular lenses

(called Toric IOL) have been developed to more predictably correct astigmatism and Toric

IOL is used to eliminate corneal astimagatism i.e. vision problem. During hearing

complainant has argued that previously respondent had already paid Toric lens amount but in

case of left eye operation they are not paying which is not justified. The representative of the

respondent has informed that by mistake it was paid by the TPA and recovery proceedings

with TPA are pending and will be recovered. Under the circumstance, the payment made by

respondent is as per terms and conditions of the policy and needs no interference by this

forum. In the result, complaint is liable to be dismissed.

The complaint filed by Mr Manish Vijay Raj stands dismissed herewith.






Mr Rakesh Sharma ..………….…………………..…..………………….. Complainant

V/S

Star Health & Allied Insurance Co.Ltd………………………….…...…Respondent

COMPLAINT NO: BHP-H-044-1920-0255 ORDER NO: IO/BHP/A/HI/0100/2019-2020


Complainant

Mr Rakesh Sharma

126, Sagar Avanue, Bypass Road

Bhopal – M.P- 462023

2. Policy No:

Type of Policy


P/201113/01/2019/005110

Family Health Optima Insurance Plan-2017

07.12.2018 to 06.12.2019



Mrs Sudesh Sharma

Mr Rakesh Sharma

4. Name of the insurer Star Health & Allied Insurance Co. Ltd


6. Reason for Repudiation/ Rejection Hospitalization not warranted for treatment


8. Nature of complaint Repudiation of claim


10. Date of Partial Settlement --


Mr Rakesh Sharma (Complainant) has filed a complaint against Star Health & Allied

Insurance Co. Ltd (Respondent) alleging rejection of claim.

Brief facts of the Case -The complainant has stated that he had filed the claim to respondent

on 27.09.2019 which was repudiated on 03.10.2019 saying it is out door patient case. He has

submitted the Doctors certificate again on 21.10.2019 which respondent has rejected. The

complainant has further sent the mail on 08.01.2020 to Grievance Cell of the respondent but

no reply is received so far. The respondent has settled the claim for same ailment on

30.07.2019 earlier. Hence the complainant has approached this forum for redressal of his

grievance.

The respondent in their SCN have stated that insured patient was hospitalized on

29.07.2019 and discharged on 30.07.2019 for the treatment of Giddiness and submitted the

claim for Rs.13,374/- which was rejected on 03.10.2019. Subsequently on receipt of notice

from Ombudsman the claim was once again reviewed by respondent considering the claim for

settlement for an amount of Rs.13,274/- as per terms and conditions of the policy. The insured

has agreed for the same as full and final settlement and furnished the consent letter for

acceptance of amount and withdrawal of the complaint. The DD will be issued shortly. The

respondent has agreed to settle the claim for Rs. 13,274/- in full as per policy conditions.


while respondent have filed SCN with enclosures.

During hearing complainant remained absent. I have heard the representative of the

respondent company at length and perused paper filed on behalf of the complainant as well as

the Insurance Company.

A claim for Rs.13,374/- under above policy was filed by the complainant for the

reimbursement of expenses incurred in the treatment of his wife / insured taken at Devmata

Hospital, Bhopal from 29.07.2019 to 30.07.2019 which was repudiated by the respondent

stating the insured could have been treated as an outpatient and hospitalisation was not

warranted for treatment of the diagnosed ailment. As per SCN after rejection of claim, they

had reviewed the claim and have considered settlement for an amount of Rs.13,274/- as per

terms and conditions of the policy. They further stated that the insured had also agreed for an


13. Date of hearing/place On 17.03.2020 at Bhopal


For the Complainant Absent

For the insurer Mr Ravi Tiwari, AGM Claims

15. Complaint how disposed Allowed


amount of Rs.13,274/- as full and final settlement of the claim and furnished the consent letter

for acceptance of the amount and withdrawal of complaint. They further stated that DD of the

settled amount will be issued shortly to the complainant. The respondent had settled the claim

for Rs.13,274/- for which complainant is also agreed and furnished consent letter stating that

he readily agree for settlement and gives consent for an amount of Rs.13,274/- as full and

final settlement of the claim. The respondent is ready to pay the settled amount within 15 days

to the complainant. Hence, complaint is liable to be allowed with the directions to the

respondent for making payment within 15 days.

The complaint filed by Mr Rakesh Sharma is allowed and respondent is directed to make

payment of Rs.13,274/- to the complainant within 15 days from the date of receipt of this

order.




PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Munish Aggarwal V/S Star Health and Allied Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-H-044-1920-0377

1. Name & Address of the Complainant Mr. Munish Aggarwal

# 84-AL, Model Town, Yamunanagar, Haryana-

135001

Mobile No.- 8816000475

2. Policy No:

Type of Policy


P/211120/01/2019/002310

Star Comprehensive Insurance Policy

27-07-2018 to 26-07-2019



Mr. Munish Aggarwal

Mr. Munish Aggarwal

4. Name of the insurer Star Health and Allied Insurance Co. Ltd.

5. Date of Repudiation 13-03-2019

6. Reason for repudiation Rehabilitation therapy and stem cell therapy

not payable

7. Date of receipt of the Complaint 19-09-2019


9. Amount of Claim Rs 5,00,000/-

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Rs 5,00,00/- + harassment/ Agony as

Ombudsman deems fit.

12. Complaint registered under

Rule no: Insurance Ombudsman Rules,

2017

Rule 13-1(b) – any partial or total repudiation

of claims by an insurer

13. Date of hearing/place 04-02-2020/ Chandigarh


For the Complainant Mr. Munish Aggarwal, Complainant

For the insurer Ms. Mamta Gupta, Senior Manager

15 Complaint how disposed Dismissed


17) Brief Facts of the Case:

On 19-09-2019, Mr. Munish Aggarwal had filed a complaint of insurance company that he is having

insurance policy since 25-07-2013 for him and his family. In September 2017, his wife experienced

symptoms of spinocerebellar Ataxia and had undergone stem cell transplant in October 2018 for the same

as it is claimed to be the only available treatment for the same. Claim was intimated to the insurance

company for reimbursement but company repudiated the claim saying it is a rest cure and is excluded so

not payable. Representation was made to the grievance team of the insurance company that it is not a rest

cure and proper transplant of stem cell performed under the effect of anesthesia. He also gave a letter

from the hospital confirming the same. They stated that stem cell transplant is itself and excluded expense

and they offered a partial settlement 50% as a onetime exception. He asked the company to point out

where in the terms and condition it is written that stem cell transplant is excluded they sent a document

where they highlighted and exclusion that state “other excluded expenses” as detailed in the website

www.starhealth.in. He totally disagree to the partial settlement they then totally repudiated his claim by

saying that stem cell transplant isn't payable as it is in experimental stage and is excluded. He requested

this forum for payment of claim on account of his wife treatment.

On 27-09-2019, the complaint was forwarded to Star Health and Allied Insurance Co. Ltd. Regional Office,

Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 13-12-2019.

The Insured took Star Comprehensive Policy through Branch Office – Chandigarh covering Mr. Munish

Aggarwal (Self), Mrs. Sheetal Aggarwal Mr. Yogesh Aggarwal, & Miss. Pragya Aggarwal (Dependent

children) for the floater Sum Insured of Rs. 5, 00,000/- vide policy no. P/211120/01/2019/002310 from

27/07/2018 to 26/07/2019 for SI Rs. 25,00,000. The Insured has reported the claim in the 6th year of the

Medical Insurance Policy. As per Claim form, the insured has claimed an amount of Rs. 4,72,170/- during re-

imbursement of medical expenses. The Insured person, Mr. Munish Aggarwal aged 40 years, was admitted

on 28/10/2018 in Neurogen Brain And Spine Institute - Navi Mumbai and discharged on 03/11/2018. As per

Discharge Summary, the insured was diagnosed with Spinocerebellar Ataxia. The Insured has submitted the

last necessary documents along with the claim form on 05/12/2018. The Insured has submitted claim for

reimbursement of medical expenses. On scrutiny of the investigation reports and hospital records including

Discharge Card, it is observed that the insured patient was admitted for Rehabilitation. Since, the

Rehabilitation is not payable as per Exclusion No.9 is not payable as per the policy. As per Exclusion No. 9 of

the policy, “The Company shall not be liable to make any payments under this policy in respect of any

expenses what so ever incurred by the insured person in connection with or in respect of: Convalescence,

general debility, Run-down condition or rest cure, nutritional deficiency states, psychiatric, Psychosomatic

disorders, Congenital external disease or defects or anomalies ( except to the extent provided under

Section 2 for New Born ) sterility, venereal disease, intentional self injury and use of intoxicating

drugs/alcohol”. Hence, the claim was repudiated and the same was communicated to the Insured.

Moreover, as per other Excluded items (item No.77) of the policy, the stem cell therapy is not payable. The

claim was repudiated and the same was communicated to the insured vide letter dated 13/03/2019.

The complainant was sent Annexure VI-A for compliance, which reached this office on 14-10-2019.

18) Cause of Complaint:

a) Complainant’s argument: Complainant stated that he is very well covered as per terms and

conditions of the policy. Complainant was represented by his son during personal hearing.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN and requested for dismissal

of complaint.

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017.

20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties(Observations & Conclusion)

I have gone through the various documents available in file including the copy of complaint filed by

complainant, copy of policy schedule, copy of SCN and submission made by both the parties during

personal hearing. On perusal of various documents referred to above in the preceding para it is observed

that complainant’s wife, a resident of Yamunanagar duly covered under the said policy had undertaken

treatment for Spinocerebellar Ataxia by hospitalization at Neurogen Brain And Spine Institute - Navi

Mumbai on 28/10/2018 for the procedure and undergone stem cell transplant in October 2018 for the

same as it is claimed to be the only available treatment for the same and got discharged on 03-11-2018. It

was a case of planned elective treatment according to complainant since he had to travel all the way to

Navi Mumbai for the same. Insurance company on another hand besides reiterating the contents of SCN

added that the treatment taken by patient for Spinocerebellar Ataxia at Neurogen Brain And Spine Institute

- Navi Mumbai by stem cell therapy was unproven/ experimental treatment and same falls under excluded

items. Further, insurance company relied on Exclusion No. 9 of the policy which reads that “The Company

shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred

by the insured person in connection with or in respect of: Convalescence, general debility, Run-down

condition or rest cure, nutritional deficiency states, psychiatric, Psychosomatic disorders, Congenital

external disease or defects or anomalies ( except to the extent provided under Section 2 for New Born )

sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol”. After careful

consideration of submissions made by both complainant and insurance company and also as per terms and

conditions of policy it is seen that the excluded items at serial no 77 specifically exclude stem cell therapy

which is experimental/ unproven treatment/ therapies. It is a fact that treatment by stem cell therapy due

to latest advancement in medical field is a proven therapy/ treatment in respect of certain diseases but so

far as Spinocerebellar Ataxia is concerned the same is at experimental stage and is not an established

procedure till date. As per establishment procedure in India standard treatment guidelines by Government

of India neuroregenerative therapy is rehabilitative therapy and is still undergoing clinical trials registered.

The procedure also does not form part of the Standard treatment Guidelines published by the Government

of India for the treatment of Spinocerebellar Ataxia. Hence, it is substantiated beyond reasonable doubt

that it does not form part of the established medical practice of India. It is also established that the said

treatment procedure is unproven/ experimental. Keeping in view the above discussions the claim for

treatment taken by complainant is held to be non admissible on merits and no relief is granted. Hence, the

case is dismissed.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties during the course of personal hearing, the case is dismissed.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 04th

March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Puneet Aggarwal V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Puneet Aggarwal

S/o Late Sh. Anil Kumar, C/o Devki Nandan and

Sons, Rampur Bushahr, Shimla, Himachal

Pradesh-0

Mobile No.- 9818000309

2. Policy No:

Type of Policy


P/211116/01/2018/000237

Health Policy

19-06-2018 To 18-06-2019



Mr. Anil Kumar Singla

Mr. Anil Kumar Singla



6. Reason for repudiation PED


8. Nature of complaint Repudiation of Claim



11. Amount of relief sought Rs 18,45,823/-



2017





For the Complainant Mr. Puneet Aggarwal, Complainant


15 Complaint how disposed Award



On 14-06-2019, Mr. Puneet Aggarwal had filed a complaint of insurance company that they have declined

claim amount of Rs 18,45,823/- because they claim that his father was suffering from the disease from

January 2017 which is prior to the date of policy taken by him and same was not disclosed in the policy.

Complainant clarified that his father was very health conscious person. He was not ill from January 2017,

the reason given by insurance company is wrong and on false grounds. It is just a typing mistake in LAMA

discharge summary of Fortis hospital, any other document does not support this. He requested for

payment of his claim.




The Complainant took Senior Citizens Red Carpet Health Insurance Policy through Branch Office-Shimla

covering Self for the Sum insured of Rs.10,00,000/- vide policy no. P/211116/01/2018/000237 for the

period from 12/06/2017 to 11/06/2018 for the first time. The Complainant reported the claim in the 1st

year of the Medical Insurance Policy from inception. As per claim form, the Complainant claimed an

amount of Rs. 18,45,823/- during re-imbursement of medical expenses. The Complainant submitted the

last necessary claim documents along with the claim form on 18/10/2018.The Complainant patient was

diagnosed to have Pemphigus Vulgaris prior to the commencement of the medical insurance policy which

was evidenced through the Discharge Summary of Fortis Hospital for the admission dated 17/06/2018.

Whereas, the same was omitted to be disclosed in the proposal form at the time of taking the policy. It is

clearly asked in the proposal form that the proposer should fill in the respective column for each of the

person proposed to be covered under column – Health History – (3) (l) – Have you ever suffered or

suffering from any of the following – Any other problem (please specify) – “No” The Complainant answered

– “No” for the above specific question relating the medical history in the proposal form which is clearly a

Non–disclosure of material fact making the Contract of Insurance voidable as confirmed by the Supreme

Court in Satwant Kaur Sandhu v. New India Assurance Co. Ltd. (2009) 8 SCC 316 (citation). At the time of

inception of the policy which is from 12/06/2017 to 11/06/2018, the Complainant has not disclosed the

above mentioned medical history/health details of the Complainant person in the proposal form which

amounts to misrepresentation/non-disclosure of material facts. As per the contract of Insurance, it is the

duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the

material facts and decide whether to accept the proposal or not, as the insurance contract is based on

utmost good faith. As per Condition No.9 of the policy, “if there is any misrepresentation/non-disclosure of

material facts whether by the Complainant person or any other person acting on his behalf, the Company is

not liable to make any payment in respect of any claim”. From the above finding, it was confirmed that the

Complainant was diagnosed to have Pemphigus Vulgaris prior to commencement of the medical insurance

policy. Although the present admission of the Complainant patient is for treatment of Multiple GI Ulcers,

the Complainant have not disclosed about Pemphigus Vulgaris in the proposal at the time of talking the

policy which amounts to non-disclosure of material facts. Hence, the claim was repudiated and

communicated to the Complainant vide letter dated 21/11/2018.



a) Complainant’s argument:

Complainant stated that his father was healthy person and all of a sudden symptom for disease was visible in January 2018. His father never had this problem before. Further, Fortis doctor have wrongly mentioned the disease as pre-existing. He requested for payment of his claim.

b) Insurers’ argument:

Insurance Company reiterated the stand taken in SCN and requested for dismissal of complaint.

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules, 2017. 20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties (Observations & Conclusion)

I have gone through the various documents available in file including the copy of complaint, copy of SCN,

copy of discharge summary of hospital and also considered the submissions made by both representative

of complainant and representative of insurance company. It is evident from documents that complainant

was admitted at Ganga Ram Hospital, Delhi from 20.06.2018 and passed away on 10.07.2018 during course

of treatment. He was diagnosed with Multiple Gastrointestinal Ulcers (Crohn’s), Pulmonary Tuberculosis,

Pancytopenia (Secondary Hemophagocytic Lymphohistocytos, Sepsis, Septic Shock, Multi Organ

Dysfunction and Acute Kidney Injury. The claim for treatment taken by complainant was denied on grounds

of Pemphigus Vulgaris which was evidenced through the Discharge Summary of Fortis Hospital for the

admission dated 17/06/2018. As per SCN the claim has been denied because this fact was not disclosed by

policyholder in their proposal form. The complainant patient was hospitalized and was being treated for

multiple GI ulcers and other problems. However it is also clear from the Lama discharge summary of Fortis

hospital dated 18.06.2018 that the patient was apparently well about 5-6 months back. Even the earlier

record of Ganga Ram hospital where patient was admitted from 22.05.2018 to 31.05.2018 it is seen that

the patient has no known co-morbidity. As such the denial of claim by insurance company is unwarranted

and without any basis. The insurance company is directed to settle the claim as per terms and conditions of

the policy within 30 days after receipt the copy of award.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the

parties during the course of personal hearing, insurance company is directed to settle the claim as

per terms and conditions of the policy within 30 days after receipt the copy of award.



March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Vikram Gupta V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vikram Gupta

House No.- 610, Gali No.-6, Karan Vihar, Karnal,

Haryana- 132001

Mobile No.- 9215040708

2. Policy No:

Type of Policy


P/211114/01/2019/002220

Family Health Policy

25-06-2018 to 24-06-2019



Mrs. Sakshi Gupta

Mrs. Sakshi Gupta



6. Reason for repudiation Waiting period of disease


8. Nature of complaint Non-payment of claim

9. Amount of Claim Not mentioned in Form VI A


11. Amount of relief sought Not mentioned in Form VIA



2017





For the Complainant Mr. Vikram Gupta, Complainant





On 22-06-2019, Mr. Vikram Gupta had filed a complaint of insurance company that their agent visited his house and they completed all the formalities regarding the information which was required for insurance. It was also told to the insurance company that his wife has undergone two cesarean operations due to birth of his kids as normal delivery was not possible. Unfortunately on 08-03-19, his wife suffered with vomiting problem and was admitted to Gyan Bhushan nursing Home, kunjpura road, Karnal. After undergoing so many tests, it was informed that there is a blockage in intestine and surgery is needed. Complainant shifted his wife to Medanta the Medicity due to better facilities. Cashless was rejected by insurance company and he was told to come for reimbursement. Finally, his wife discharge from hospital and when he came back to home unfortunately his wife again suffered with vomiting problem on 26-03-2019. As her situation was critical complainant decided to admit in local hospital in karnal named Aparna Hospital, karnal , Madhuban and inform the company about the admission. Doctor informed that she will be in good health and will get discharge in 3 days. He applied for reimbursement of his claim and received claim amount against Gyan Bhushan nursing Home bill of Karnal but he was surprised to see rejection letter for Medanta Hospital as well as Aparna hospital bill with the reason mentioned that complainant's wife was admitted for the complication of previous LSCS surgery. As per waiting period clause, the company is not liable to make any payment in respect of expenses for treatment of pre existing disease condition until 48 months of continuous coverage has elapsed. Complainant stated that insurance company is relating the birth cesarean operation with intestine problem unnecessarily just to avoid payment. He requested for payment of his claim. On 17-07-2019, the complaint was forwarded to Star Health and Allied Insurance Co. Ltd. Regional Office,



In the SCN (Self Contained Note) insurance company stated that this Complaint has been filed since

complainant is aggrieved by the total repudiation of claim. The complainant took Family Health Optima

Insurance Plan covering Mrs. Sakshi Gupta (Self), Ms. Harshita & Master Sidhik for the floater Sum Insured

of Rs. 5,00,000/- vide policy no. P/211114/01/2019/002220 for the period from 25/06/2018 to 24/06/2019

for the first time. The Insured reported the claim during the 1st year of the Medical Insurance Policy. As per

Claim form, the insured claimed an amount of Rs. 36,341/- during re-imbursement of medical expenses.

The Insured was admitted on 14/03/2019 in Medanta the Medicity (Unit of Global Health Pvt. Ltd.) –

Sukhrali (CT) and discharged on 17/03/2019. As per Discharge Summary, the insured was diagnosed with

Sub acute intestinal obstruction (adhesive). Subsequently, the Insured submitted claim documents for re-

imbursement of medical expenses. On scrutiny of the claim documents, it is observed from their internal

verification report that the patient has a history of LSCS in the year 2017. As per Discharge Summary from

the treating hospital, the insured was diagnosed with Sub acute intestinal obstruction (adhesive). From the

above finding, it is noted that the insured has history of LSCS in the year 2017 which is prior to the

commencement of the first medical insurance policy. The present admission and treatment of the insured

patient is for the complication of previous LSCS surgery which is not payable as per waiting period 3(iii) of

the policy. Hence, the claim was repudiated and communicated to the insured vide letter dated

24/05/2019. They requested for dismissal of complaint.



a) Complainant’s argument: Complainant stated that the company has rejected his claim on flimsy grounds and he requested for payment of his claim.

b) Insurers’ argument: The insurance company stated during the course of personal hearing that they have rightly repudiated the claim as per the policy term and conditions.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules, 2017. 20) The following documents were placed for perusal.


21) Result of Personal hearing with both parties(Observations & Conclusion):

On perusal of various documents available in the file including the copy of complaint dated 26.06.2019,

company reply dated 24.05.2019 about the rejection of the health claim in respect of the treatment taken

by Mrs. Sakshi Gupta complainant’s wife treatment record of Arpana Hospital, Karnal & Medanta Hospital ,

Gurgaon and also after consideration of submissions made by both parties during the course of personal

hearing, it is seen that complainant’s wife Mrs. Sakshi Gupta was treated for Sub Acute Intestinal

Obstruction (SAIO) and remained hospitalized at Medanta the Medicity (Unit of Global Health Pvt. Ltd.) –

Sukhrali (CT) from 14/03/2019 and got discharged on 17/03/2019, Arpana Hospital, Karnal, from

27.03.2019 to 31.03.2019. The claim for reimbursement of the expenses incurred on the treatment filed for

Rs. 36,341/- under the policy no. P/211114/01/2019/002220 was rejected by insurance company under 3(iii)

of policy terms and conditions which provides specific four years waiting period in respect of certain

illnesses and the policy start date in the instant case was 25.06.2018, the claim has been rejected. As per

the insurance company the patient has history of LSCS in the year 2017 which is prior to the

commencement of the first medical insurance policy. The present admission and treatment of the insured

patient is for the complication of previous LSCS surgery which is not payable as per waiting period 3(iii) of

the policy. In the instant case patient presented with symptoms of abdominal pain, distension, vomiting for

last one week and according to company the patient i.e. Mrs. Sakshi Gupta was treated at Medanta the

Medicity (Unit of Global Health Pvt. Ltd.) during the above period for complications of Sub Acute Intestinal

Obstruction (SAIO) and hence covered under four years waiting period in terms and conditions of policy. On

going through the various documents available in the file, it is evident that the patient has been treated for

SAIO at above hospital. The insurance company in the instant case has made an attempt to correlate the

present episode of sub acute intestinal obstruction (SAIO) for which patient has taken treatment and filed

reimbursement claim with the LSCS section which the patient had undergone in the year 2017. It is beyond

comprehension that the claim for treatment of SAIO has been repudiated on the above ground which

clearly indicates the unreasonableness on the part of insurance company in settlement of health claim. The

decision of insurance company is as such is not based on any logical conclusion. It is highly improper on the

part of insurance company to reject the claim on arbitrary basis by stretching the policy wordings to their

advantage. Hence the insurance company is directed to settle the claim as per terms and conditions of the

policy within 30 days after receipt of award copy.

AWARD


parties during the course of personal hearing, the insurance company is directed to settle the

claim as per terms and conditions of the policy within 30 days after receipt of award copy.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH



Case of Mr. Chanchal Jain V/S Bajaj Allianz General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-005-1920-0248

1. Name & Address of the Complainant Mr. Chanchal Jain

House No.- 1266/1, Krishna Nagar, Ghumar

Mandi, Ludhiana, Punjab- 141001

Mobile No.- 9814925221

2. Policy No:

Type of Policy


OG-18-1203-8421-00000281

Health Policy

18-07-2017 to 18-07-2020



Mr. Chanchal Jain

Mr. Chanchal Jain

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd.


6. Reason for repudiation No active line of treatment



9. Amount of Claim Rs 45861/-


11. Amount of relief sought Rs 45681/-



2017



13. Date of hearing/place 07-01-2020 / Chandigarh


For the Complainant 07-01-2020,

Vide Email 31-12-2019 requested for another

date

28-01-2020

Vide Email 17-01-2020 requested for another

date

04-02-2020

Mr. Chanchal Jain

For the insurer 07-01-2020

Dr. Ravindra Shingate

Mr. Saurav Khullar

28-01-2020

04-02-2020

Mr. Saurav Khullar




On 29-07-2019, Mr. Chanchal Jain had filed a complaint of insurance company with regard to non-payment

of his claim. He informed that he ported to Bajaj Allianz General Insurance Co. Ltd from Reliance General

Insurance Co. Ltd after three years of continuous renewal and better service promise by agent. He was

admitted in DMC Ludhiana on 31-08-2018 to 01-09-2018 due to severe pain in his lower limbs. But when he

submitted claim document to insurance company same was repudiated on the ground that there was no

need of hospitalization. He stated that he do not know how they decided it. He was suffering from this

problem for past 15 to 20 days before hospitalization and was taking treatment from Dr Sandeep Puri but

due to severe pain on 31-08-2018 that was unbearable and his family took him to DMC emergency in

morning time. All tests were done by doctor where his ESR, creatinine and BP was on higher side. Due to

heavy Rush in emergency, doctor has advised him to shift in room which was accepted by him since he has

no choice before treating doctor. Next day, Dr.Sandeep Puri has visited and checked all his investigation

report and said to take some medicine which will make him alright. So accordingly he was discharged. So

where is his fault after discharge as he had been admitted as well as discharged by the treating doctor.

After two-three months, he is now okay. He requested to do justice in matter.

On 09-08-2019, the complaint was forwarded to Bajaj Allianz General Insurance Co. Ltd. Regional Office,


was made available to this office on 03.01.2020.

In the SCN insurance company stated that complainant had taken Star Package Insurance Policy vide Policy

number- OG-18-1203-8421-00000281 which was valid from 18-07-2017 to 18-07-2020, subject to terms,

conditions and limitations thereof. On receiving claim intimation of the complainant on 31-08-2018, this

answering insurance company has registered claim of the complainant vide claim registration no. OC-19-

1002-8421-00006487. After scrutiny of the documents, it was observed that complainant was hospitalized

for the symptom of Hypertension and joint pain under evaluation and is claiming for expenses incurred of

INR 45861/- and claim of the complainant was repudiated vide letter dated 11-01-2019 by this answering

insurance company as there was no such treatment being administered (active line of treatment) or any

such investigative procedure being performed which requires hospitalization means given oral line of

treatment can be administer on OPD also evaluation can be done on OPD basis. Exclusion condition no. 11

of section 2 clause B general exclusions II of terms and conditions of the insurance policy reads as under:

Section 2: B- Exclusions Specific to section 2:

II-General Exclusions- 11- Medical expenses to any hospitalization primarily or specifically for diagnostic,

X-ray or laboratory examinations and investigations.

Accordingly, claim of the complainant was repudiated as per policy terms and conditions.



a) Complainants argument: Complainant requested that his claim has been repudiated on flimsy

ground and he was admitted in the hospital as per advice of doctor only. He requested for payment of

his claim.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN and stated that their decision

is as per policy terms and conditions.






On going through the complaint and other documents in file, and submission made by both the party

during personal hearing, it is seem that complainant has filed complaint because of denial of claim by

insurance company on the ground of active treatment. Insurance company on other hand stated that there

was no active treatment during stay in hospitalization. It observed from the discharge summary that

complainant was admitted in Dayanand Medical College and Hospital, Ludhiana on 31-08-2018 to 01-09-

2018 with a diagnosis of Hypertension and joint pain under evaluation. On going through discharge

summary of Dayanand Medical College and Hospital, it is observed that patient had chief complaint of pain

in Left Upper limb for last twenty days and was admitted primarily for evaluation. Further, his USG

abdomen showed renal parenchymal change Grade- I. He was managed with tablets and capsules like

Omnacortal, Tazlou, Duvanta, Duoforte and Oud 20 mg and there was no active treatment gives to the

patient during said hospitalization. Hence, the decision of the insurance company is in order and no

interference is required in their decision. Keeping in view the above facts, the said complaint is hereby

dismissed and no relief is granted.

AWARD


parties during the course of personal hearing, the said complaint is hereby dismissed on merits.



March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Raj Deo Pandey V/S Religare Health Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-037-1920-0207

1. Name & Address of the Complainant Mr. Raj Deo Pandey

C-2/851, 2nd Floor, Palam Vihar, Gurugram,

Haryana- 122017

Mobile No.- 9717598165

2. Policy No:

Type of Policy


13140607

Care

09-10-2018 To 08-10-2019



Mr. Dharm Deo Pandey

Mr. Dharm Deo Pandey


5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Cancellation of Mediclaim Policy

9. Amount of Claim N.A

10. Date of Partial Settlement N.A

11. Amount of relief sought Reinstatement of cancelled policy/refund



2017

13(1)i



For the Complainant Sh. Raj Deo Panday

For the insurer Dr. Nisha Sharma, Manager


16 Date of Award/Order 06/03/2020


On 02-07-2019, Mr. Raj Deo Pandey , brother of the insured had filed a complaint against the

cancellation of Mediclaim policy and submitted that he took the Mediclaim Insurance policy

no13140607 effective from 09/10/2018 to 08/10/2019 from Religare Health Insurance Co. Ltd for

his brother Sh. Dharam Deo Panday and paid premium of Rs.46000/- .In the meantime ,the insured

got admitted in Hospital at Ahmedabad on 08/11/2018 after failure of left knee function, disabling

an inch movement of his left leg and doctor advised immediate replacement of the Knee Joint. The

hospital sent a letter to insurance company as insurance office persons of Thane had told him that

after one month of the policy any sort of surgery could be done but the claim request was denied

saying it was a non disclosure case as slight BP and Arthritis was not disclosed. The complainant on

3rd December, 2018 sent a detailed letter about mis selling of policy and enquiring about

surrender and refund of premium but the company did not reply even after three reminders. The

complainant again on15th Feb, 2019 wrote to insurer for change of address and email but was not

done. On 4th March 2019, the complainant received a mail from insurer attached with a notice

which was replied by him through mail on 23/03/2019 and also submitted hard copies on

26/03/2019 and again requested to reinstate the policy on the factual ground of reply.

On 18-07-2019, the complaint was forwarded to Religare Health Insurance Co. Ltd. Regional Office,

Gurugram, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 05-08-2019.As per the SCN, the insurance

company issued policy no 13140607 to Mr. Dharam Deo Pandey,his spouse with effect from

09/10/2018 to 08/10/2019 for sum insured of Rs.3,00,000/-to each insured subject to policy terms

and conditions. During the continuation of the policy, the complainant approached the company

with a cashless request for hospitalization request at Shalby Multi Specialty Hospital, Ahmadabad

from 19/11/2018 to 25/11/2018 with complaint of pain in both knee joints. On receipt of the

documents, the company came to the conclusion that insured has a history of Osteoarthritis and

hypertension before the date of policy inception and the same was not disclosed at the time of

proposal. Hence the company denied the cashless claim vide denial letter dated 08/03/2019 as per

clause7.1 i.e Non disclosure as per policy terms and conditions. As per cashless form dated

17/11/2018, as filled by the insured, the insured had specified that he is having a history of

Osteoarthritis since 6 months which is before the date of policy inception. The insured had the

opportunity to disclose the pre existing condition/ailment of Osteoarthritis and hypertension prior

to the policy inception at the time of filing up of the proposal form, but no such disclosure were

made in the proposal form for the reason best known to the insured. As a result of Non Disclosure

of Pre existing disease, the company canceled the policy of insured vide policy cancellation letter

dated 28/12/2018 The termination of policy was done in accordance with the policy terms and

conditions as per clause 7.13(a) read with clause 7.1

“7.13- Cancellation / Termination (a)-The Company may at any time, cancel this policy on the

ground as specified in clause 7.1 by giving 15 days notice in writing by registered post

acknowledgment due/recorded delivery to the policy holders at his last known address”



a) Complainant’s argument: The insurance company should refund the premium as policy has been

cancelled.

b) Insurers’ argument: The refusal of the cashless claim and policy termination is as per terms and conditions of the policy.



21) Result of Personal hearing with both parties (Observations & Conclusion):

On perusal of the various documents placed on record including the copy of complaint, SCN of the insurer,

terms and conditions of policy and submissions made by both the parties during personal hearing, it has

been observed that complainant purchased mediclaim policy for his brother Sh. Dharam Deo Pandey

effective from 09/10/2018 to 08/10/2019. In the meantime the insured got admitted in the hospital in

Ahmadabad on 08/11/2018 within a month of taking policy after failure of left knee function and advised

immediate knee replacement due to severe osteoarthritis both knee joint. The insurance company denied

the cashless claim as per clause 7.1 i.e. non disclosures as per policy terms and conditions because in the

cashless form filled by the insured it was specified that he is having a history of Osteoarthritis since 6

months which is before the date of policy inception. As a result of non disclosure of pre-existing disease,

the company cancelled the policy of insured vide letter dated 28/12/2018.The complainant did not file the

reimbursement claim but sought refund of premium on account of cancellation of policy. As the

termination of the policy has been done by the insurer in accordance with the policy terms and conditions

as per clause 7.13(a) read with clause 7.1 i.e non disclosure, the complainant’s request for refund of

premium is not admissible and cannot be entertained as refund is being sought after the denial of claim on

the ground of non disclosure, in consequence of which policy was cancelled by insurer as per terms and

conditions. Hence complaint is dismissed being devoid of merits.

AWARD


parties during the course of personal hearing, no relief is granted to the complainant.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Rajeev Somany V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajeev Somany

House No.- 1280, Sector- 6, Bahadurgarh,

Haryana- 124507

Mobile No.- 9416057382

2. Policy No:

Type of Policy


261200/48/2018/2799

Mediclaim Policy

30-03-2018 to 29-03-2019



Sh. Rajeev Somani

Mrs. Beena Somany

4. Name of the insurer The Oriental Insurance Co. Ltd.

5. Date of Repudiation 31/05/2019

6. Reason for repudiation Non submission of required documents


8. Nature of complaint Denial of cashless facility and Non payment of

claim.

9. Amount of Claim Not mentioned


11. Amount of relief sought Due Claim + interest



2017

Rule 13 (1)(b) – any partial or total repudiation

of claim by an insurer

13. Date of hearing/place 10.02.2020/ Chandigarh


For the Complainant Sh. Rajeev Somany

For the insurer Ms. Indu Khurana, Dy. Manager



17) Brief Facts of the Case: On 08-07-2019, Mr. Rajeev Somany had filed a complaint that he is the holder of the mediclaim policy

No 261200/48/2018/2799 issued by the Oriental Insurance Company Limited Rohtak through oriental

bank of commerce. Due to non uploading of vital data (64VB) online by the Rohtak Branch of Oriental

Insurance and callous & rude approach of Raksha TPA, the complainant had to bear torture and

harassment because not only his cashless claim was denied but even after submitting all the necessary

documents with Raksha TPA, the claim is yet to be settled. The complainant’s wife remained

hospitalized in Maharaja Agrasen Hospital from 15/12/2018 to 20/12/2018 and diagnosed with suffering

from Sub Acute Obstruction with Gibbon’s Hernia (Paraumbilical Hernia).

On 25-07-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office, New

Delhi, for Para-wise comments and submission of a self-contained note about facts of the case, which

was not received.


18 Cause of Complaint:

a) Complainant’s argument: The deductions made from the claim amount are not justified and are payable.

b) Insurers’ argument: The claim has been settled and paid as per policy terms and conditions.

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules,

2017. 20) The following documents were placed for perusal.



On perusal of various documents placed on record including the copy of the complaint and submission

made by both the parties during personal hearing, it has been observed that the complaint was lodged

against the oriental insurance company limited for non settlement of hospitalization claim of

complainant’s wife due to the ailment of sub acute intestinal obstruction with hernia. On receipt of

complaint from this office, the insurer approved and paid the claim for Rs.36358/- after deducting

Rs.18413/-from the claimed bill amount of Rs.54771/- but the claimant is still not satisfied with the

settlement and deductions from the claimed amount .During the personal hearing, insurer submitted

the details of paid amount and deductions made from the claimed bill. It has been found that

deductions made by insurer towards hospital services for dietary charges, TPA processing charges &

hospital discount are as per policy terms and conditions, hence not payable. But there is no

justification for deduction of medication charges amounting to Rs.10195/- on the ground that no

break up available of the medicines. The insurance company has failed to place on record the SCN in

support of their defense or any other document to prove that they had called for the breakup of billed

amount of Rs.10195/- towards medication. As the expenses incurred towards the medication charges

are payable as per terms and condition of the policy, Hence the insurance company is directed to pay

to the complainant a sum of Rs.10195/- deducted from the claim amount within 30 days from the

receipt of the copy of award.

AWARD


parties during the course of personal hearing, Rs 10195/- is hereby awarded to be paid by the

Insurer to the Insured, towards full and final settlement of the claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Rajinder Kumar V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajinder Kumar

S/o Sh. Shadilal, House No.- BX/195,

Kishanpura, Jalandhar, Punjab-0

Mobile No.- 9964018751

2. Policy No:

Type of Policy


10989330

Care

02-02-2019 To 01-02-2020



Mr. Rajinder Kumar

Mr. Rajinder Kumar


5. Date of Repudiation

6. Reason for repudiation Pre Existing Disease


8. Nature of complaint Non Payment of Hospitalization claim

9. Amount of Claim Rs.67353/-


11. Amount of relief sought Rs.67353/-



2017





For the Complainant Mr. Rajinder Kumar





On 05-07-2019, Mr. Rajinder Kumar had filed a complaint against the Religare Health Insurance Co. Ltd. for

Non Payment of mediclaim and submitted that he purchased mediclaim Policy no 10989330 dated

01/02/2017 for his family and paid Rs42205/- as premium .The insurance advisor had told that treatment

on cashless basis can be taken from the approved hospital. The complainant was admitted in CMC hospital

Ludhiana on 25/10/2018 for treatment and the hospital bill amounting to Rs.62353/- was sent to the

Gurgaon office of Religare Health Insurance Co. Ltd but the company refused to make payment on the

ground of pre existing disease . The complainant further stated that why the company did not conduct the

medical tests prior to policy to ascertain about any pre existing disease. The policy documents issued by the

company are in the English language and the complainant can read little bit in Hindi language only and

hardly signs in Hindi. He further requested for payment of the medical bill of hospital.


Gurugram, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 08-11-2019.As per the SCN, the insurance company issued policy

no10989330 to Mr.Rajinder Kumar ,his spouse and son with effect from 01/02/2017 to 31/01/2019 for

sum insured of Rs.5,00,000/-to each insured subject to policy terms and conditions. The policy was further

renewed from 02/02/2019 to 01/02/2020. During the continuation of the policy, the complainant

approached the company with a cashless request for hospitalization request at Christian Medical College

and Hospital, Ludhiana from 25/10/2018 to 30/10/2018 with complaint of severe pain in right hip region .

The insured was given the final diagnosis of Muscle Edema involving the right lliacus and gluteal region. On

receipt of the cashless form, they triggered a claim investigation for appropriate analysis of the claim and

issued a deficiency letter dated 25/10/2018 and reminder to seek complete indoor case papers with

admission notes, history sheet,doctor’s notes ,nursing notes ,vital charts pre- hospitalization OPD

treatment record and treating doctor’s certificate for etiology of present ailment. On perusal of the

documents received, the company came to the fact that illness of the insured is a spinal disorder. Hence

claim was denied vide cashless denial letter dated 30/10/2018 as per terms and conditions under clause

4.1(ii)(1) as the same was within the ambit of waiting period clause and was covered only after 24 months

of coverage of the insured person by the company from the first policy period start date. Post denial of

cashless claim, the insured approached the Company with reimbursement request and on receipt of

documents company came to the conclusion that insured was in a state of morbid obesity which was not

disclosed at the time of proposal. Hence the company denied the claim vide denial letter dated 28th

May,2019 as per clause 7.1 i.e Non Disclosure of obesity as per policy terms and conditions.

That during and after the above hospitalization the complainant again approached the company with a

reimbursement request for his hospitalization at CMC Ludhiana from 31/10/2018 to 03/11/2018 with

complain of pain in the right thigh region. The complainant was given final diagnosis of Psoas abscess and

type 2 Diabetes Mellitus. The claim was denied on the ground of non disclosure of morbid obesity vide

claim denial letter 27/05/2019 in accordance with clause 7.1 of the policy terms and conditions.

The complainant had the opportunity to disclose the pre-existing condition/ ailment of Morbid Obesity

prior to policy inception at the time of filing up of the proposal form, but the complainant had intentionally

hidden his true height and weight from the company and by not disclosing the correct health status

blatantly violated the principal of good faith. Since the complainant hospitalization is related to spinal

disorder and the same is covered only after 24 months from the date of policy inception and also the

insured is suffering Morbid Obesity prior to policy inception and the same was not disclosed to company.

Hence, the claim of complainant was denied as per clause 4.1(ii)(1) and clause 7.1 of the terms and




a) Complainant’s argument: There is no justification of denial of claim on the ground of pre existing disease.

b) Insurers’ argument: The claims are not payable as per clause 4.1(ii)(1) and 7.1 of the policy terms and conditions

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman

Rules, 2017.

20) The following documents were placed for perusal. a) Complaint to the Company b) Copy of Policy Document c) Annexure VI-A d) Reply of the Insurance Company


On perusal of various documents available in file including the copy of complaint, copy of discharge

summary, copy of SCN filed by insurance company and also considering the submissions made by both

complainant and insurance company, it is seen that hospitalization claim for admission of complainant at

CMC Ludhiana from 25/10/2018 to 30/10/2018 for treatment of Muscle Edema cashless claim was denied

by the insurer under clause 4.1(ii)(1) of the policy conditions. On receiptof documents company came to

the conclusion that insured was in a state of morbid obesity which was not disclosed at the time of

proposal. Hence the company denied the claim as per clause 7.1 i.e Non Disclosure of obesity as per policy

terms and conditions and his second claim for hospitalization at SPS Hospital from 31/10/2018 to

03/11/2018 for the final diagnosis of Psoas abscess and type 2 diabetes was also denied in accordance with

clause 7.1 of the policy. The complainant during the personal hearing stated that all the policy documents

are in English and he only can read little bit Hindi and pleaded for payment of claim. On the contrary,

insurer submitted that claim for the hospitalizations are not payable on the ground of non disclosure of

morbid obesity as per clause 7.1 of the policy terms and conditions. The complainant was under obligation

to disclose all the material facts at the time of taking the policy which he did not as per the record placed

on record by the insurance company. As such the denial of claims by the insurance company is as per terms

and conditions of the policy and does not warrant any interference. The complaint is dismissed being

devoid of merits.

ORDER





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Piyush Mittal V/S The United India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-051-1920-0198

1. Name & Address of the Complainant Mr. Piyush Mittal

S/o Sh. Jai Parkash Mittal, R/o Kasera Nagar,

Old Fazilka Road, Abohar, Punjab-0

Mobile No.- 9814001645

2. Policy No:

Type of Policy


0701002816P104240918 (Group)&

2001012816P109616182 (Individual)

18.10.16 to 17.10.17



Mr. Jai Parkash Mittal

4. Name of the insurer The United India Insurance Co. Ltd.

5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Less payment of claim

9. Amount of Claim Rs. 360483/-

10. Date of Partial Settlement Rs. 05.06.17

11. Amount of relief sought Rs. 243693/-



2017



13. Date of hearing/place 17-01-2020 / 28.01.20/13.02.20/Chandigarh


For the Complainant 17.01.2020-A(req. for next date)

28.01.2020-A

13.02.2020-Mr. Piyush Mittal,Complainant

For the insurer 17.01.2020-Ms.Mamta & Ms.Shweta

28.01.2020-Ms.Mamta Bansal, Dy.Manager

13.02.2020-Ms.Mamta Bansal, Dy.Manager




On 26-06-2019, Mr. Piyush Mittal had filed a complaint vide which he informed that his employer Media IQ

Digital India Pvt. Ltd. had mediclaim policy for him and his family through United India Ins. Co. vide pol.no.

0701002816P104240918 for the period 20.06.16 to 19.06.17. Mr.Jai Parkash Mittal was admitted in Fortis

Hospitals Ltd. Gurgaon on 27.05.2017 for surgery of Acute Perforated appendicitis and was discharged on

05.06.2017. He had also purchased another policy from United India Ins. Co.Ltd. for an amount of Rs.

1,50,000/- vide pol.no. 2001012816P109616182. Total bill of hospital was Rs.360483/- out of which Raksha

TPA passed an amount of Rs. 116790/-. As complainant was covered under two policies, he applied to

United Insurance Co. Ltd. for reimbursement of remaining claim of Rs. 243693/- on 16.06.17. After

completion of all formalities, he was intimated vide email dt. 15.11.17 that his claim was rejected on flimsy

grounds that as per GIPSA, cost for the procedure is Rs. 70000/-. As per complainant, first, Fortis Hospital,

Gurgaon is not in PPN list, secondly the limit of Rs. 70,000/- is fixed for cashless facility and thirdly there is

no provision in the insurance policy that only amount fixed by GIPSA with PPN Network hospital is payable.

He requested for release of his balance amount of Rs. 243693/-.

On 18-07-2019, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,



As per SCN received from insurance company, Mr.Piyush Mittal is cover under tailor made Group Health

pol.no. 0701002816P10424091 issued to M/s Media IQ Digital India Pvt. Ltd. for the period 20.06.16 to

19.06.17. He claimed hospitalization expenses for his father Mr.Jai Prakash Mittal under Individual health

policy no. 2001012816P109616182 through Raksha TPA for Rs. 3,60483/- and company had already

settled/paid the claim amount of Rs. 1,16,760/-. Subsequently insured had again claimed compensation

under Tailor made health policy. As per CMO letter of M/s FHPL the claim amount of Rs. 1,16,760/- had

already been paid, which is reasonable and customary. Hence the remaining amount of Rs. 2,43,693/- is not

payable. Their Bengaluru RO Doctor/official are also opined the same that the claim paid by Raksha TPA is

in order and remaining amount is not payable.



a) Complainants argument : Company has made undue deductions from his claim in the name of

reasonable and customary charges although he has paid more and requested for payment of

balance claim amount.

b) Insurers’ argument: Insurance Company stated that they have logically deducted as per the terms

and conditions of the policy.






Initially hearing was fixed on 17.01.2020 and then on 28.01.2020, which was attended by insurance

company only. Due to marriage of Mr.Piyush Mittal complainant, on his request, one more opportunity

was given and final hearing was scheduled on 13.02.2020. As per documents submitted and

submissions made in personal hearing it is observed that Mr.Jai Parkash Mittal, father of Mr. Piyush

Mittal is covered under two different policies of United India Insurance Co.Ltd. One is individual health

policy and other is Group health policy in the name of M/s Media IQ Digital India Pvt. Ltd. In claim for

Rs. 3,60,483/- regarding hospitalization expenses of Mr.Jai Prakash Mittal, who remain hospitalized in

Fortis Memorial Research Hospital, Gurgaon from 27.05.2017 to 05.06.2017, under Individual health

policy no. 2001012816P109616182 through Raksha TPA, company had settled / paid the claim amount

of Rs. 1,16,760/-. Subsequently insured had again claimed compensation under Tailor made group

health policy. But his claim is rejected by company with plea that patient underwent lap appendectomy

for acute perforated appendicitis. As per GIPSA, the cost of said procedure is Rs. 70,000/-. As per

company, since the surgery and post operative period was complicated the amount for the surgery and

its complication can be extended to Rs. 116790/-, as per reasonable and customary clause, which is

already been settled by Raksha TPA. As per Family Health Plan Insurance TPA Ltd., since there is no

balance amount to be settled from them, claim is rejected. Insuracne Company concur the opinion of

FHPL TPA. As such, there is no dispute regarding coverage of insured under two policies and

admissibility of claim regarding hospitalization and treatment taken by insured. Company deducted the

amount on the basis of reasonable and customary charges clause only. Moreover, as per investigation

of Probus Associates and Consultants Pvt. Ltd., carried out on behalf of FHPL(TPA), insured had paid Rs.

243693 to the hospital against hospital bill of Rs. 360483/- as cashless was approved for Rs. 1,16,790/-

(under individual policy). As per hospital records, patient was operated for appendicitis and was shifted

to room however he had developed respiratory distress for which he was shifted to ICU and once

patient was stable he was shifted back to room. As per investigator, the duration of stay is justified on

medical grounds.

It is seen that insurance company has wrongly made deduction in claim of complainant in the name of

reasonable and customary charges. So called reasonable and customary rates have not been specified

for various ailment/ diseases in the policy for different locations. There is no restriction in policy to take

treatment in PPN hospitals only. There is no provision in the insurance policy that only amount fixed by

GIPSA with PPN Network hospital is payable. Insurance company has arbitrarily made deductions in the

name of reasonable and customary charges, although rates of two hospital may vary with

infrastructure, locations and status of treating doctors etc. Moreover, Insurance company never

provided any proof of charges prevailing in that geographical area in such type of treatment to justify

their stand. As such, in lieu of above and further when investigator has confirmed the amount actually

incurred by complainant and duration of stay is also justified on medical grounds, insurance company is

directed to pay balance admissible claim amount to complainant as per terms and conditions of policy

within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, the balance admissible claim amount as per terms

and condition of policy is hereby awarded to be paid by the Insurer to the Insured, towards full

and final settlement of the claim.


Dated at Chandigarh on 9th day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Ashok Kumar Sharma V/S The United India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-051-1920-0355

1. Name & Address of the Complainant Mr. Ashok Kumar Sharma Flat No.- 603, Tower No.- 18, Motia Royal City, Zirakpur, Punjab- 140603 Mobile No.- 7889027092

2. Policy No: Type of Policy Duration of policy/Policy period

1202002817P115041010 Mediclaim Policy 16-01-2018 to 15-01-2019

3. Name of the insured Name of the policyholder

Mr. Ashok Kumar Sharma





8. Nature of complaint Less claim paid



11. Amount of relief sought Rs. 72515/- + Rs.10000/- disc.+Rs. 1 lac for mental agony

12. Complaint registered under Rule no: Insurance Ombudsman Rules, 2017

Rule 13 (1)(b) – any partial or total repudiation of claim by an insurer



For the Complainant Mr.Ashok Kumar Sharma

For the insurer Ms. Mamta Bansal




On 12-09-2019, Mr. Ashok Kumar Sharma had filed a complaint vide which he informed that he is

covered under SBI‟s scheme to provide health insurance coverage to its pensioners through United

India Insurance Co. Ltd. Due to canal decompression surgery at L3-4 & L4-5, he had to hospitalize

from 10.09.18 to 13.09.18 in Trinity Hospital and Medical Research Institute, Zirakpur. Bill of

total expenses incurred on hospitalization was Rs. 235201/- and same was paid by complainant. He

negotiated with hospital authorities, who agreed to provide a discount to the tune of Rs. 10,000/-

which was to be applied separately on different items of hospital expenses. He submitted medical

claim bill of Rs. 235201/- on 28.09.18. But to his surprise, insurance company passed the bill only

for Rs.162689/-, thereby unduly deducting a hefty amount of Rs. 72515/-. On perusal of settlement

voucher dt. 26.10.18, it is observed company omitted to take into account the discount of Rs.

10,000/-. Further, expenses reported under RMO and Nursing charges separately were clubbed with

room rent to accelerate the room rent while at the same time discount offered on room rent, nursing

and RMO had been clubbed only in procedure charges. Complainant submitted the revised bill of

hospital as required, after taking into account proportionate item wise discount and showing clear

final item wise charges issued by Trinity Hospital and submitted through e-mail dt. 12.11.18. But

TPA vide mail dt. 04.01.19 informed that insurance company had refused to reconsiders the case as

the representation was received after settlement of claim, although as per company any

disagreement about the settlement shall be intimated to the United India within 10 days. As per

complainant, hospital is not charging differential rates for the expenses incurred on treatment while

hospitalized on the basis of room or ward, for which they issued a certificate also. Further the

hospital charged only Rs. 1500/- per day after adjusting discount against his entitlement of Rs.

3000/- per day as room rent as per policy. Further claim settlement voucher clearly shows that room

rent as per bill amount is Rs. 3000/- having no deduction. He requested for payment of balance

amount of Rs.72515/- and harassment charges of Rs. 1,00,000/-.




As per SCN submitted by insurance company, Mr. Ashok Kumar Sharma was hospitalized with diagnosis of

intervertebral disc stenosis of neural canal, in Trinity Hospital and Medical Research Institute from

10.09.2018 to 13.09.2018. Claim has been settled for Rs. 162689/- on 19.10.2018 after deduction of Rs.

72512/-, primarily deducted as per entitled room rent category. As per SCN, out of total claim amount of

Rs. 235201/-, claim had been settled for Rs. 162689/- on 19.10.2018 as per reasonable and customary

charges.



a) Complainant’s argument: Complainant requested for balance payment which has been arbitrarily deducted by company in spite of submission of item wise discount given by hospital.

b) Insurers’ argument: Insurance Company stated that they have logically deducted claim amount as per the terms and conditions of the policy.


Rules, 2017.





On perusal of various documents available in the file and submissions made in personal hearing, it

is seen that there is no dispute regarding admissibility of claim under policy terms and conditions.

Insurance company has already paid Rs. 162689/- to the complainant against submitted mediclaim

bill of Rs. 235201/-. As per claim settlement voucher & SCN, out of total deductions of Rs. 72512/-

made by company, Rs. 71579/- has been deducted as per higher entitled room rent category. Rs.

933/- is deducted under medication charges for non payable items, which is in order. It is seen that

company approved full room rent of Rs.3000/- per day, as billed without any deduction. Company

could not provide any logic behind making deductions in other heads in lieu of higher room rent

then entitled, when they are reimbursing full room rent. Moreover it is observed that company in

writing confirmed that Mr. Ashok Kumar Sharma who has opted for Sum insured of Rs. 4,00,000/-

was entitled for room rent of Rs. 3000/- for tier 3 cities. As such he hospitalized in a room, which

was as per his entitled room rent category. Further, hospital has given additional discount of Rs.

10,000/- to the complainant. As per modified hospital bill submitted by complainant later on with

break up of discount, final amount charged for room charges is Rs.4500/-, i.e. @ 1500/- per day.

Company has also taken different line of defense in SCN that Rs. 72512/- is deducted as per

reasonable and customary charges, but the same is nowhere mentioned in claim settlement voucher.

Moreover, company has neither provided any proof of rates of relevant geographical area nor the

same is mentioned in policy issued to complainant.

Hence, company has arbitrarily made deductions of Rs.71579/-, which is not justified. On the other

hand, company has reimbursed room rent @ 3000/- although as per hospital‟s revised bill,

complainant has paid @ 1500/- per day. Considering all facts of the case, besides already paid claim

amount, insurance company is directed to pay Rs 65000/- more to the insured subject to terms and

condition of policy within 30 days after receipt of award copy.

AWARD


parties during the course of personal hearing, the balance amount of Rs. 65000/- subject to terms

and condition of policy is hereby awarded to be paid by the Insurer to the Insured, towards full

and final settlement of the claim.



day of March 2020

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Eishan Aryan V/S ICICI Lombard General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-020-1920-0365

1. Name & Address of the Complainant Mr. Eishan Aryan Critical Care Department-ICU Firs Floor, Artemis Hospital & Institutes, Gurugram, Haryana- 122022 Mobile No.- 9915325200


41281/P-iH/143862858/00/000 Ih_2Adults_1Child_1Year 05-02-2018 to 04-02-2019


Mr. Eishan Aryan/Ms. Anuja Sharma Mr. Eishan Aryan/Ms. Anuja Sharma

4. Name of the insurer ICICI Lombard General Insurance Co. Ltd.

5. Date of Repudiation 05.02.2019

6. Reason for repudiation Non disclosure of PED



9. Amount of Claim Rs. 71859/-(as per bills)

10. Date of Partial Settlement NA

11. Amount of relief sought Claim amount and reinstatement of policy





For the Complainant Dr. Eishan Aryan, Complainant

For the insurer Mr. Parveen Singh, Regional Head




On 16-09-2019, Mr. Eishan Aryan had filed a complaint vide which he informed that his wife Mrs.

Anuja Sharma underwent Hysteroscopy at La Femme Fortis, Greater Kailash, New Delhi in the

month of December 2018, provisionally diagnosed as DUB(irregular periods) for which his claim

was rejected on the ground of non disclosure and his policy is also terminated. Prior to this, he had

policy of Apollo Munich for two years and ported to ICICI Lombard. He underlined that his claim

is right and company‟s decision of claim rejection and termination of his policy is unethical. As per

complainant, the clause of PED does not suits in case of his wife as they ported policy in February

2018 and as per first consolation – provisionally diagnosed complain as Menorrhagia on 25.08.18.

Moreover, irregular periods are not a disease but a symptom. He requested company many times to

review his case, as he and his family are without any policy. Complainant requested for solution of

his case.

On 26-09-2019, the complaint was forwarded to ICICI Lombard General Insurance Co. Ltd. Regional Office,

Mohali, for Para-wise comments and submission of a self-contained note about facts of the case, which was

made available to this office on 06.02.20. The complainant was sent Annexure VI-A for compliance, which

reached this office on 14-10-2019.

As per SCN submitted by insurance company, Mr.Eishan Aryan, had ported the said policy from

Apollo Munich Health Insurance Co. to ICICI Lombard General Ins. Co. Ltd. after submitted duly

signed and filled proposal form to them. Complainant had nowhere disclosed that his wife had

complaints of irregular period prior to inception of policy inspite of having specific column in

proposal form regarding same. On receipt of signed and filled proposal form, the company had

issued health insurance policy no. 4128-i/P-Ih/143862858/00/000 to the complainant for the period

05.02.18 to 04.02.19. Later on, company had received the cashless authorization request wherein it

was mentioned that the complainant‟s wife was admitted in Fortis La Femme Hospital on

Dec.10,2018 and provisionally diagnosed with Dysfunctional Uterine Bleeding (DUB) and duration

of the present ailment being specified as 360 days. Alongwith cashless request company received

the case history from the hospital wherein it was clearly mentioned the complainant‟s wife was

suffering from Menorrhagia since January 2018, i.e. prior to issuance of the policy. Hence the

cashless authorization claim was not approved by the company on Dec. 10,2018. After receipt of

reimbursement claim, the company investigated the said claim. Company‟s investigator met the

complainant‟s wife wherein she gave the statement to the company‟s investigator in which she

clearly mentioned that she has the history of menstrual bleeding problem since Dec. 2017, i.e. prior

to issuance of the said policy. Therefore, after verification of medical documents and the statement

of the Complainant‟s wife, the company had rejected the claim reimbursement vide letter dt.

05.02.2019.



Complainant stated that their genuine claim is being repudiated on flimsy ground of PED.


Insurance Company reiterated the stand taken in SCN and requested for dismissal of

complaint since their repudiation is justified as per term and conditions of policy.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman

Rules, 2017.





Mr. Eishan Aryan had ported his mediclaim policy which covers him and family from Apollo

Munich Health Insurance Co. to ICICI Lombard General Ins. Co. from 05.02.2018. Hospitalization

claim of his wife Mrs. Anuja Sharma, who remain hospitalized from 10.12.2018 to 11.12.18 with

diagnosis Dysfunctional uterine bleeding has been not paid by insurance company. As per

repudiation letter dt. 05.02.19, patient is k/c/o DUB prior to inception of policy and the same is not

disclosed at the time of policy inception, which is against part III of schedule, clause 1 of policy T

& C related with duly of disclosers. On perusal of various documents available in the file including

the copy of complaint, SCN submitted by the insurance company, discharge summary, repudiation

letter of the insurance company, and submissions made in personal hearing, it is seen that as per

hospitalization papers, patient Mrs. Anuja Sharma has Menorrhagia since Jan. 2018. She herself

admitted in questionnarire of patient submitted to insurance company that she has problem of heavy

bleeding since Dec. 2017. Contrary to this confirmation, in the duly filled and signed proposal form

submitted by complainant at the time of porting the policy, in column no. 10, in question of

menstrual bleeding abnormal, answer is given as NO, which confirms the stand of non disclosure

taken by company. Keeping in view the above facts, the decisions of insurance company being in

order does not call for any interference. The said complaint is hereby dismissed and no relief is

granted.

AWARD




Dated at Chandigarh on 2nd day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Kulwant Singh V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Kulwant Singh House No.- 231-E, B.R.S. Nagar, Ludhiana, Punjab-0 Mobile No.- 9814450188


1202002818P114211757 Health Policy 16-01-2019 to 15-01-2020


SBI pensioners Group Mediclaim Policy Mr.Kulwant Singh/Ms.Gurmeet Arora



6. Reason for repudiation Physchatric treatment covered in domiciliary limit, which has not been opted.


8. Nature of complaint Not payment of claim



11. Amount of relief sought Rs. 64960/-+10,000 for harassment





For the Complainant Mr. Kulwant Singh

For the insurer Ms. Mamta Bansal



17) Brief Facts of the Case: On 31-08-2019, Mr. Kulwant Singh had filed a complaint regarding repudiation

of claim on the ground that ‘Phychatric disorder is payable in domiciliary option only. Patient Ms.Gurmeet

Arora hospitalized in DMCH, Ludhiana from 13.03.2019 to 22.03.2019. As per IRDA guidelines encl.no.3,

psychiatric disorder cannot be excluded by the insurer for reimbursement. As per complainant, insurance

company has manipulated to pay the claim in domiciliary case only, while his case was related to

hospitalization of the patient. Further, insurer registered the claim after 2 months from the date of

intimation. As per complainant’s opinion domiciliary treatment is taken at OPD or day care and patient can

remain at home. In his case hospitalization was necessary. He requested for payment of claim of Rs.

64960/-.


Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case, which


As per SCN received from insurance company, the patient Gurmeet Arora was admitted in DMC Hospital,

Ludhiana, as a case of suspiciousness irritability with stiffness in body, Tremors of hands, difficulty in

walking. Patient was diagnosed as a case of Schizophrenia Paranoid type EPS (recovered) with

Hypertensions, Diabetes Mellitus Type 2. Schizophrenia is Psychiatric ailment, which is not payable as per

policy terms and conditions. Also the patient not opted for domiciliary treatment, therefore the claim for

ailment not payable as it is excluded from hospitalization benefit and domiciliary benefit not opted by

insured. Hence the claims stand repudiated.



a) Complainants argument :

Company repudiated genuine claim of his wife on the basis of psychiatric disorder which is

payable as per IRDA guidelines also.


Claim is repudiated as per terms and conditions of the policy.





On perusal of various documents, and submissions made during personal hearing, it has been observed

that Mrs. Gurmeet Arora remains admitted in Dayanand Medical College & Hospital, Ludhiana from

13.03.19 to 22.03.2019 with diagnosis of Schizophrena – Paranoid type with EPS (recovered) with

Hypertension with Diabetes Milletis Type II. Patient admitted in psychiatry ward and managed accordingly.

As per insurance company, the claim is non payable as psychiatric treatment payable in domiciliary limit

and patient has not opted for domiciliary limit. Complainant although admitted that he has not opted for

domiciliary limit as premium was too high but emphasized that claim is otherwise payable, documents of

which were returned back by company with allegation that case is withdrawn by him. In defense, company

submitted e-mail dt. 15.06.19 from complainant and broker to company vide which it was requested to

return the original documents if claim is non payable. As per exclusion clause 4.9 of the tailor made group

health policy a/c State Bank of India, company shall not be liable in respect of expenses on treatment

relating to all psychiatric and psychomatic disorders. This clause was further modified for relevant policy no.

1202002818P114211757 which states that ‘Only Psychiatric disorder including Schinzophrenia and

Psychotherapy as per domiciliary hospitalization within the limit of 10% of the sum insured are payable’.

Complainant repeatedly took plea that as per IRDA guidelines letter dt. 27.08.2018 Psychiatric diseases

were deleted from the list of optional covers, resulting of which every insurance company had to include

this disease for insurance cover. On reading in totality the original IRDA circular dt. 29.07.2016 and

modified guidelines dt. 27.08.2018, it is observed that nowhere it suggests that coverage of psychiatric

disorder is a binding for insurance company.

Keeping in view the facts, the decisions of insurance company is in order and does not call for any

interference. The said complaint is hereby dismissed and no relief is granted.

AWARD




Dated at Chandigarh on 2nd

day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Satwinder Singh Grover V/S Star Health and Allied Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-044-1920-0155

1. Name & Address of the Complainant Mr. Satwinder Singh Grover

House No.- 1659-60, Sector-12, Hudda, Panipat,

Haryana- 132103

Mobile No.- 9416176159

2. Policy No:

Type of Policy


P/211124/01/2018/001070

Family Health Optima Insurance policy

06/07/2017 to 05/07/2018



Mr. Satwinder Singh Grover

Mr. Satwinder Singh Grover


5. Date of Repudiation 21-07-2018 and 31-08-2018

6. Reason for repudiation Alcohol Intake


8. Nature of complaint Repudiation of two Claim

9. Amount of Claim Rs 66978/- + Rs 80000 ( Approx)


11. Amount of relief sought Not mentioned in Form VI A



2017





For the Complainant Mr. Satwinder Singh Grover, Complainant





On 12-06-2019, Mr. Satwinder Singh Grover had filed a complaint that he had ported his health insurance

policy after four year continuous coverage from ICICI Lombard General Insurance Company Limited to Star

Health and Allied Insurance Company Limited after assurance of better coverage and payment of claim for

all disease. He has already had one renewal of his policy from Star Health and Allied Insurance Company

Limited. After 10 months of his porting, he noticed blood in his stool and due to infection in stomach he

was admitted in Ahuja Hospital Panipat. As per Dr. Jagjit Ahuja, his treating doctor his liver ailment is not

due to alcohol consumption or any pre-existing disease. He remained admitted in hospital for three days

and insurance company paid the claim for the same. He was referred Fortis Hospital New Delhi for better

management and he remained admitted there for five days. He incurred an expense of Rs 70000/- for this

hospitalization. His cashless was denied and he was asked to come up for reimbursement of his claim.

Insurance Company denied his claim on the basis that ailment is due to alcohol consumption and same is

not payable as per terms and condition of the policy. He stated that his problem is NASH (Non-alcoholic

Steatohepatitis), which is not related to alcohol at all. Further, in April 2019 again he was feeling weakness

and he went to Ahuja Hospital who found that there is less oxygen in body. He immediately referred him to

Fortis hospital Delhi and he was taken in ambulance to Fortis Hospital. He was admitted for five days and

he incurred an expense of Rs 80,000/-. Again his claim has been denied by the insurance company on same

ground. He requested the forum for payment of his claim.




In the SCN, insurance Company stated that the Complainant took Family Health Optima Insurance policy

covering Mr. Satvinder Singh Grover (Self), Mrs. Hema Grover (Spouse), Darmanpreet Grover (Dependent

child) for the Sum insured of Rs. 5,00,000 /- vide policy no. P/211124/01/2018/001070 from 06/07/2017 to

05/07/2018. The Complainant patient, Mr. Satvinder Singh Grover had insurance cover earlier for the Sum

Complainant of Rs. 3, 00,000/- with ICICI and switched over to our company under Portability and the

details are given below;

Policy No 4128i/HP/81199581/00/000 from 06/07/2013 TO 05/07/2014

Policy No 4128i/HPR/81199581/01/000 from 06/07/2014 TO 05/07/2015



The Complainant, Mr. Satvinder Singh Grover, aged 42 years/Male, reported the claim in the 5th year of the

policy and 2nd year of the Medical Insurance Policy with Star Health and Allied Insurance Co. Ltd. As per

Claim form, the treating Complainant claimed an amount of Rs. 66,978/-. The Complainant was admitted

on 07/06/2018 in Fortis Hospitals Limited - NEW DELHI and discharged on 11/06/2018. As per Discharge

summary, the Complainant was diagnosed with :-

GI BLEED - ESOPHAGEAL VARICES

CLD/PIIT (NASH RELATED)

CHILD-A, MELD-13, CTP- 6

The Complainant raised a pre-authorization request to avail cashless facility. On perusal of the claim

documents, it is noted that the patient is known case of CLD and further evaluation is required to ascertain

the exact onset of the ailment. Hence the request for pre authorization for cashless treatment was denied

and the same was communicated vide letter dated 08/06/2018. Subsequently, the Complainant submitted

a claim for reimbursement of medical expenses. On perusal of the claim documents it is observed that,

during field visit, the Complainant stated that he was occasional drinker for the last 2-4 years and the last

alcohol intake was around 12-15 days back. From the these facts, it is observed that the Complainant

patient was admitted for treatment of GI BLEED - ESOPHAGEAL VARICES which is due to the complication of

intake of alcohol. Hence, the claim for reimbursement of medical expenses was repudiated and the same

was communicated to the treating hospital and the Complainant vide letter dated 31/08/2018. As per the

Exclusion No. 4(8) of the policy which states as: “The Company shall not be liable to make any payments

under this policy in respect of expenses what so ever incurred by the Complainant person in connection

with or in respect of use of intoxicating substances, substance abuse, drugs / alcohol, smoking and tobacco

chewing”.


18) Cause of Complaint: a) Complainants argument: Complainant stated that despite completing all formalities insurance

company is not paying claim. He requested for payment of his pending claim bill. b) Insurers’ argument: Insurance Company stated that they have rightly repudiated the claim as per

terms and condition of the policy. Insurer reiterated the stand taken in SCN and requested for dismissal of complaint.





After hearing both the parties and examining the documents available in the complainant file, it has been

observed that there was no disagreement between both the parties on issue of hospitalization and nature

of disease. Insurance company stated that the cause of NASH related CLD was mainly due to alcohol

consumption and accordingly the claims were repudiated. It is seen that complainant had already

completed four year continuous coverage at ICICI before porting. He had no claim experience as company is

silent on the same. Further, NASH is Non-alcoholic Steatohepatitis which doesn’t relate to alcohol. He fell ill

after ten months from porting which clearly indicate that insurance company arbitrarily denied his justified

claim. At the time of personal hearing on first date i.e. 04-02-2020, insurance company stated that they are

ready to pay claim for hospitalization but it was brought out by company that they have not received the

documents pertaining to Fortis Hospitalization from 07-06-2018 to 11-06-2018. On the other hand,

complainant stated that he has already sent claim related documents to insurance company through their

agent. But it was seen from papers that complainant had not sent few documents. It was also brought out

by complainant that he has misplaced some documents and has not claimed from any other insurer. He can

provide the photocopy of the same after obtaining from Hospital. Insurance company stated that they are

ready to pay claim if these compliance are done and proper affidavit is given for above facts. Complainant

agreed for the same. Since insurance company is ready to pay admissible claim amount subject to terms

and condition of policy. As such complainant is also directed to give affidavit stating the reason for

duplicate documents and submit the same to insurance company. Hence, insurance company is directed to

settle the claim on receipt of affidavit subject to terms and condition of policy within 30 days after the

receipt of copy of award.

AWARD


parties during the course of personal hearing, settle the claim on receipt of affidavit as per

wording above subject to terms and condition of policy is hereby awarded to be paid by the




March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mrs. Bimal Garg V/S The National Insurance Co. Ltd.


1. Name & Address of the Complainant Mrs. Bimal Garg

W/o Sh. Janak Kumar Garg,

House No.- 696-A, Gali Old Wadi Hospital,

Amrik Singh Road, Bathinda,

Punjab- 151001

Mobile No.- 9530677055

2. Policy No:

Type of Policy


406003501810000001

Mediclaim Policy

01-04-2018 To 31-03-2019



Mr. Janak Kumar Garg, Mrs. Bimal Garg

4. Name of the insurer The National Insurance Co. Ltd.


6. Reason for repudiation Non submission of documents


8. Nature of complaint Non payment of claim



11. Amount of relief sought Rs. 91,998/-



2017



13. Date of hearing/place 13-02-2020 / 26.02.2020, Chandigarh


For the Complainant 13.02.2020-Absent

26.02.2020-Ms. Romy Bansal, Daughter

For the insurer 13.02.2020-Mr. Rajinder Kumar, A.M.

26.02.2020- Mr. Rajinder Kumar, A.M.


16 Date of Award/Order 13.03.2020.


On 20-08-2019, Mrs. Bimal Garg had filed a complaint vide which she informed that she is 67 years old and

previously having policies from United India Insurance Co. Bathinda from 02.07.2007 to 01.07.2015

regularly. Later on she purchased Health policy from National Insurance Co. Ltd. for F.Y. 2015-16, 2016-17

(Gurgaon), 2017-18 & 2018-19 (from Ludhiana), 2019-20 (from Raman Mandi, Bathinda). Her son in law

working in Mckinsey Knowledge centre (P.) Ltd. Gurgaon took group policy of company covering entire

family including father/month in law. It was told that no medical check up or other formalities are required.

On 18.12.18, she feel some pain and uneasiness and was admitted in Bathinda in the hospital of Dr. Sharad

Gupta who referred him to Hero DMC Ludhiana on 19.12.18. She remains admitted in Hero DMC from

19.12.18 to 27.12.2018. At the time of discharge few reports, lab reports, X ray film, ECG report, CD

alongwith payment receipts, discharge summary etc. were given to her, which had already been submitted

to Vipul TPA, Chandigarh on various dates. Complainant provided details of letter with enclosures sent to

Vipul TPA Med. Corp. Insurance Pvt. Ltd. On 18.06.19, she received a letter from company which reads as,

‘ This is with reference to your claim, this is to inform you that competent authority has closed your claim

file as ‘No Claim’ on the basis of non-submission of document even after three reminders by Vipul TPA’. As

per complainant each and every quary of TPA has been replied. She referred NCDRC case in which while

dismissing the revision plea said the onus to prove pre-existing disease lays on the insurance company. She

requested for payment of her claim.

On 11-09-2019, the complaint was forwarded to The National Insurance Co. Ltd. Regional Office,


was made available to this office on 14.02.2020. The complainant was sent Annexure VI-A for compliance,

which reached this office on 18-09-2019.

As per SCN submitted by insurance company, insured has lodged reimbursement claim for an amount of Rs.

68170/- who has undergone CAG on 19.12.18 when he was diagnosed as a cash of ‘Triple vessel disease’ for

which he has taken a conservative treatment from 19.12.18 to 27.12.18 at Dayanand Medical College,

Ludhiana. As per the claim papers received by company from the hospital, the patient has a history of

Diabetes Mellitus (DM) from the last 18 years and history of Hypertension (HTN) from the last 8 years. Her

policy coverage is from 01.04.2015. As both HTN and DM are a pre existing prior to her coverage under the

first policy serviced by Medi Assist TPA (P) Ltd. and since DM & HTN, both are major risk factors for

insured’s disease, i.e. CAD as defined in policy clause 4.1 above, the claim would not be admissible as the

insured has not completed 48 months of insurance coverage with National Insurance Co. Ltd. as per policy

records. Company has sought underwriter’s confirmation on insured’s coverage before 2015. As per

company, on receipt of underwriter’s confirmation on insured’s coverage before 2015, they will be in a

position to process the claim and convey their opinion on admissibility/ non admissibility of claim as per

policy terms and conditions.


a) Complainants argument : Complainant stated that she had completed all claim related formalities and

documents were sent to the company but company has not paid her claim.

b) Insurers’ argument: As per company, on receipt of underwriter’s confirmation on insured’s coverage

before 2015, they will be in a position to process the claim and take decision in the matter.





On going through the various documents available in file including the copy of complaint, SCN of company

and submissions made by both complainant and insurance company during the personal hearing, it is

observed that claim of Rs.68170/- of Complainant Mrs. Bimal Garg related to his hospitalization in DMC

Hospital, Ludhiana from 19.12.18 to 27.12.18, has not been paid by insurance company. As per insurance

company, the patient has a history of Diabetes Mellitus (DM) from the last 18 years and history of

hypertension (HTN) from the last 8 years. As per policy clause 4.1, pre-existing diseases are not covered

until 48 months of continuous coverage. As per SCN of company, both HTN and DM are pre existing and

both are major risk factors for insured’s disease, i.e. CAD, hence claim would not be admissible as insured

has not completed 48 months of insurance coverage with National Insurance Co. Ltd. As such, company has

raised two issues, one is of pre-existing disease and other is of 48 months of continuous coverage.

Regarding continuous coverage, insurance company informed that they have sought underwriter’s

confirmation on insured’s coverage before 2015 for taking final decision in the matter. During personal

hearing, complainant’s representative submitted copies of her previous insurance coverages, which show

her covered under individual policy of United India insurance Co.Ltd. from 02.07.12 to 01.07.13, 02.07.13 to

01.07.14 and from 02.07.14 to 01.07.15. As such she has continuously covered under individual policy of

United India, prior to shifting to National Insurance Co.Ltd. in the year 2015. Further company has not

provided any proof of treatment taken by complainant of pre-existing disease, if any. Moreover,

hypertension is a lifestyle problem and can be controlled by medicines.

Keeping in view the facts of the case, insurance company is directed to pay the admissible claim to the

insured as per terms and condition of policy within 30 days from the receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claim, as per terms and condition of

policy is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement

of the claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Chandandeep Singh V/S Religare Health Insurance Co. Ltd.


1. On 14-08-2019, Mr. Chandandeep Singh had filed a complaint against the Religare Health

Insurance Company Limited for rejection of his medicalim under policy no13645307. The

required documents were submitted to the insurance company but the insurance

company did not settle the claim.

2. This office pursued the case with the insurance company to re-examine the complaint

and they agreed to reconsider the claim.

3. Mr. Chandandeep Singh confirmed through mail dated 18-02-2020 that his complaint

has been resolved by insurance company and hence there is no need to further pursue

the matter.

4. In view of the above, no further action is required to be taken by this office and the

complaint is disposed off accordingly.

Dated : 05.03.2020 (Dr. D.K. VERMA)

PLACE: CHANDIGARH INSURANCE OMBUDSMAN




Case of Mr. Sanjeet Katoch V/S Religare Health Insurance Co. Ltd.


1. On 11-09-2019, Mr. Sanjeet Katoch had filed a complaint against the Religare Health

Insurance Company Limited for non settlement of his medicalim under policy no. 13034896

2. The required documents were submitted to the insurance company but the insurance company did not settle the claim.

3. This office pursued the case with the insurance company to re-examine the complaint and

they agreed to reconsider the claim.

4. Mr. Sanjeet Katoch confirmed through mail dated 13 -02-2020 that his complaint has been

resolved by insurance company and hence there is no need to further pursue the matter.

5. In view of the above, no further action is required to be taken by this office and the complaint

is disposed off accordingly.






Case of Mr. Gurdeep Singh V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Gurdeep Singh

House No.- 70, FF Phase- 6, Mohali, Punjab-0

Mobile No.- 9855511454

2. Policy No:

Type of Policy


13794779

Care

26-02-2019 To 25-02-2020



Mr. Boharh Singh

Mr. Boharh Singh



6. Reason for repudiation Deficiency not replied


8. Nature of complaint Non Payment of hospitalization claim

9. Amount of Claim Rs.2,40,063/- (Two claims)


11. Amount of relief sought Rs.2,40,063/- + interest.



2017





For the Complainant Gurdeep Singh


15 Complaint how disposed Agreement


17) Brief Facts of the Case: On 07-08-2019, Mr. Gurdeep Singh had filed a complaint against the Religare

Health Insurance Co. for denial of his medicalim and submitted that his father who is covered under

mediclaim policy of Religare Health Insurance company suddenly felt uneasiness and got medicine from

the village compounder and felt good .Thereafter 3 to 4 days he again felt uneasiness and went to Dr.

Sukhwinder in Mukatsar who referred them them to Bathinda Pragma Hospital for treatment ,where

doctors advised for angioplasty due to blockage of vein. The insurer rejected the cashless claim of the

complainant’s father and advised them to seek reimbursement. The complainant submitted all the

documents to the insurance company but the claim was denied due to the reason that the

complainant’s father had B.P problem. According to complainant his father did not have any B.P

problem or hypertension and never took any treatment related to this and has now sought the

intervention of this office for the payment of his two claims of hospitalization on 11/05/2019 and

20/05/2019.


Gurugram, for Para-wise comments and submission of a self-contained note about facts of the case,

which was not received till hearing date.


18) The complainant agreed to accept the offer of the insurance company during personal hearing that

they are ready to pay a claim amount of Rs.1,80,388/-and Rs.60,741/- under policy number 13794779

without interest and without deduction of any charges.

19) Accordingly an agreement was signed between the insurance company and the complainant on

05/03/2020.

20) The complaint is closed with a condition that the company shall comply with the agreement and shall

send a compliance report to this office within 30 days of receipt of this order for information and

record


day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Rinku Kumar V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rinku Kumar

House No.- 338, Sarafa Bazar Wali Gali,

Aggarwal Chowknissing, Karnal,

Haryana- 132024

Mobile No.- 8930317777

2. Policy No:

Type of Policy


11903458

Care

03-01-2018 To 02-01-2019



Mr. Rinku Kumar

Mr. Rinku Kumar



6. Reason for repudiation Not payable as per clause 4.2.6 being

permanent exclusion.


8. Nature of complaint Non Payment of mediclaim






2017





For the Complainant Mr. Rinku Kumar

For the insurer Dr. Nisha Sharma




On 02-07-2019, Mr. Rinku Kumar had filed a complaint against Religare Health Insurance Co. Ltd. stating

that he is covered under the mediclaim policy no 11903458 effective from

03-01-2018 to 02-01-2019 but his claim for hospitalization from 17/10/2018 to 22/10/2018 due to Dengue

treatment has been denied because he took treatment from B.A.M.S Doctor whereas there is no such

condition mentioned in the policy before sale or after. The complainant has sought intervention for





As per the SCN, during the currency of the policy, the complainant applied for reimbursement request for

hospitalization at Kapoor Health Care Centre, Karnal from 17th Oct, 2018 till 22nd Oct, 2018 with chief

complaint of dengue. On consideration of the documents submitted by the insured the insurer observed

that as per discharge summary dated 22nd October 2018 the treatment was performed under the

supervision of Dr. Sanjay Kapoor (B.A.M.S) specialized in Ayurvedic Medicines and as per discharge

summary the insured was advised to take allopathic medicines. In the light of these facts, it is clear that

allopathic treatment was provided by the doctor specialized in Ayurveda and practicing outside the

discipline for which he is licensed. Accordingly company repudiated claim of the insured vide letter dated

28/11/2018 in accordance to clause 4.2.6 i.e. Permanent exclusion information as per policy terms and

conditions. The company reiterated that during the course of investigation carried out by them, it was

observed that allopathic treatment was provided by the ayurvedic doctor and accordingly the said claim is

rejected as per policy terms and conditions.



a) Complainant’s argument: Complainant stated that the claim has been rejected by insurance company on flimsy grounds and he requested for payment of his claim.

b) Insurers’ argument: Insurance Company stated that the claim has been repudiated as per policy

terms and conditions.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules, 2017.





On perusal of various documents available in file including the copy of complaint filed by complainant,

copy of discharge summary, copy of no claim letter dated 28.11.2018 of insurance company, copy of

SCN filed by insurance company and after considering the submissions made by both complainant and

insurance company during personal hearing, it is seen that the complainant’s claim for treatment taken

by him at Kapoor Health Care Centre, Karnal from 17.10.2018 to 22.10.2018 for fever and diagnosed to

be a case of dengue fever has been denied by insurance company vide repudiation letter dated

28.11.2018. The complainant is duly covered under the said policy for sum insured of Rs. 3,10,000/-. He

was treated with allopathic medicines by a doctor at such facility who was a practicing B.A.M.S doctor

and the management was done by use of allopathic medicines like tab ciplox, tab monte & other

allopathic medicines and no ayurvedic medicines were prescribed which a B.A.M.S doctor is authorized

to practice. As such the repudiation of claim by insurance company on the basis that allopathic

medicines were prescribed by an Ayurvedic doctor and treatment from medical practitioner practicing

outside his discipline being permanently excluded under the policy terms and conditions (4.2.6) which

clearly mentioned that “ treatment taken from anyone who is not a medical practitioner or from a

medical practitioner who is practicing outside the discipline for which he is licensed or any kind of self-

medication.” being in order, the complaint is dismissed.

AWARD


parties during the course of personal hearing, the case is dismissed.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Sukhmeet Pal Singh V/S Religare Health Insurance Co. Ltd.


1. On 03.09.2019, Mr. Sukhmeet Pal Singh had filed a complaint in this office against

Religare Health Insurance Co. Ltd for rejection of Mediclaim of his wife. The required

documents were submitted to the insurance company but the insurance company

rejected the claim under insurance policy no. 10198635

2. This office pursued the case with the insurance company to re-examine the complaint and they

agreed to reconsider the claim.

3. Mr. Sukhmeet Pal Singh confirmed through mail dated 14-03-2020 that his complaint has been

resolved by insurance company.

4. In view of the above, no further action is required to be taken by this office and the complaint is

disposed off accordingly

Dated: 16.03.2020 (Dr. D.K. VERMA) PLACE: CHANDIGARH INSURANCE OMBUDSMAN




Case of Mr. Dharminder Verma V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Dharminder Verma

House No.- 3657/2, Julanigarh,

Near Khumhar Mohalla, Ambala,

Haryana-134003

Mobile No.- 9216466849

2. Policy No:

Type of Policy


11953947

Care

17/01/2018 to 16/01/2019



Bhavik Sugandh

Sh. Dharminder Verma



6. Reason for repudiation Not Payable under clause 4.2 (23) of policy due

to drug abuse.


8. Nature of complaint Non Payment of accidental hospitalization

claim.



11. Amount of relief sought Claim Amount



2017





For the Complainant Mr. Dharminder Verma

For the insurer Dr. Nisha Sharma Manager




On 26-09-2019, Mr. Dharminder Verma had filed a complaint against the Religare Health Insurance

Company Ltd for denial of hospitalization claim due to accident of his son who was covered under policy no

11953948 effective from 19/01/2018 to 18/01/2019, expired on 23/12/2018 .The complainant stated that

he had submitted all the claim papers on 09/01/2019 to the insurer after denial of cashless facility. The

company asked the complainant for some additional documents to process the claim and all queries like

F.I.R copy, Postmortem report were submitted but the insurer rejected the claim due to Drug /Substance

abuse. The complainant further stated that his son had not taken any type of drug. Postmortem report and

Doctor’s report clearly mentioned that he did not use any type of drug etc but the insurer rejected the

claim.



was made available to this office on 25/02/2020.

As per the SCN, the insurer issued policy bearing no 11953947 to complainant providing insuring

the complainant along with his spouse, son (deceased insured)and daughter providing insurance

coverage with effect from 17/01/2018to 16/01/2019 for a sum insured of Rs.5,00,000/- subject to

policy terms and conditions. During the currency of the policy, the complainant approached the

insurer with cashless facility request for emergency hospitalization of the insured namely Bhavik

Sugandh at Fortis Hospital Ludhiana for 5-7 days on 17/12/2018 for injury due to road traffic

accident. The insured was provisionally diagnosed with Head injury with facial injury (SDH with

diffused Edema).The insured was admitted for decompressed craniotomy + SDH removal and

plastic surgery. On receipt of cashless facility request, the insurer sent query letter dated

17/12/2018 to complainant with a request to provide 1st consultation paper immediately after

accident, copy of MLC/FIR, investigation report along with the treating doctor’s certificate for

alcohol/any other drug abuse. That on perusal of the documents received in the query reply, it

came to forefront of the insurers that the insured was found Positive for Opiate a day prior to

accident.

As per the urine for Opiates of Sh. Krishna diagnostic dated 16/12/2018, the insured was found

positive for opiates.

As per the letter of treating doctor of Fortis Hospital, Ludhiana, the insured was a drug abuser and

was now on rehabilitation and his treatment was going and the patient is under continuous

monitoring and is being treated on regular intervals for opiate abuse.

On the basis of documents received from query reply, the insurer observed that the opiate effect

stay for 48 hours in the body. The insurer further submitted that substance abuse comes under the

permanent exclusion as per policy terms and conditions. The cashless request was denied under

permanent exclusion of substance abuse of drugs and the same was intimated to complainant vide

cashless denial letter dated 18/12/2018.The claim was rejected under clause 4.2 clause 23 of policy

terms and conditions. That post denial of cashless facility claim, the complainant filed

Reimbursement claim of Rs.5,72,053/- for the hospitalization of the deceased at Fortis Hospital

from 17/12/2018 till 23/12/2018 with the alleged history of Road Traffic Accident. The deceased

injured was diagnosed with RTA with severe head injury with shock ( Neurogenic, Septic), Massive

SAH with diffuse cerebral edema with acute SDH and midline shift, Polytrauma with RT

Pneumothorax with ICD insitu, AKI with severe respiratory failure, Multiple facial fractures. The

insured died on 23/12/2018.The insurer observed that the deceased insured was a drug addict and

was under treatment for the same. The claim was rejected under permanent exclusion of drug

abuse as per clause 4.2 clause 23 of policy terms and conditions.


18) Cause of Complaint: a) Complainant’s argument: The Company rejected the claim of my son due to drug /substance abuse

whereas he did not use any type of drug. b) Insurer’s argument: The claim was rejected under clause 4.2 clause 23 of policy terms and

conditions.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules, 2017. 20) The following documents were placed for perusal.



I have gone through the various documents available in file including the copy of complaint, copy of

SCN submitted by insurance company and submissions made by both complainant and insurance

company during the personal hearing. It is seen from documents that the claim was filed by

complainant with the insurer for treatment taken by his son for hospitalization at Fortis hospital,

Ludhiana from 17.12.2018 to 23.12.2018 following road side accident. The claim was denied by

insurance company vide letter dated 09.03.2019 due to the fact that the patient was a case of drug

abuse/ intoxicants that resulted in the road side accident which ultimately led to his death. The

repudiation of the claim has been done by the insurer on the grounds mentioned in the SCN and

investigation report of Shri Krishna Diagnostic, wherein the urine for opiates has been found to be

positive. As per letter of treating doctor of Fortis Hospital, Ludhiana the insured was a drug abuser and

was now on rehabilitation and his treatment was going. He also stated that the patient has multiple

thrombosed veins on hands and arms clinically HCV positive status so enquired about intravenous drug

abuser and his parents told that he used to be an intravenous drug abuser, now on rehabilitation and

treatment is going on. It has been observed that proximate cause which led to the hospitalization,

treatment and unfortunate death of complainant’s son was road side accident. The treatment given to

him during the hospitalization was for the accidental injuries and reimbursement of expenses for such

treatments are admissible as per terms and conditions of the policy. The insurance company has not

placed any cogent evidence to establish that the complainant’s son was under the influence of drugs, at

the time of accident, which caused his accident. On the contrary the complainant placed on record the

drug abused report for which the sample taken by Fortis Hospital on the same day of accident i.e

17/12/2018 under the treating Dr. Vishnu Gupta and this report shows ‘ Not Detected’ Opiates. The

complaint’s motor own damage claim of car driven by his son at the time of accident has been paid by

the concerned insurer .Had the complainant’s son under the influence of drugs at the time of accident,

the insurer would not have paid motor claim. The denial of claim by the insurer under permanent

exclusion of drug abuse as per clause 4.2 clause 23 of policy terms and conditions is on flimsy ground

and unjustified. As such, insurance company is directed to pay the admissible claim amount as per

terms and conditions of the policy within 30 days from the date of receipt of copy of the award.

AWARD


parties during the course of personal hearing, admissible claim amount is hereby awarded to be

paid by the Insurer to the Insured, towards full and final settlement of the claim.


Dated at Chandigarh 09th

day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Arun Gupta V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Arun Gupta

S/o Sh. Neeraj Gupta, House No.- 34, Gupta

Niwas, Chaudhary Colony,

W. No.- 9, Bassi Pathana, Sirhind Fatehgarh

Sahib, Punjab- 140412

Mobile No.- 9041514099

2. Policy No:

Type of Policy


12857636

Care

14/08/2018 to 13/08/2019



Arun Gupta



6. Reason for repudiation Not payable as clause 7.1 of policy condition.

i.e. non disclosure


8. Nature of complaint Refusal of claim due to non disclosure



11. Amount of relief sought Rs. 1,15,000/- + post hospitalization expenses +

reinstating of policy



2017





For the Complainant Mr. Arun Gupta





On 08-08-2019, Mr. Arun Gupta had filed a complaint against Religare health insurance Company for denial

of his mediclaim and stated that the cashless claim filed on 21/02/2019 was rejected on 23/07/2019 on

account of ‘Essential (primary) Hypertension as a pre existing disease mentioned under provisional

diagnosis whereas he had no such history. The complainant observed swelling in both his legs in October

2018 for which he consulted Hepatologist who recommended for visit to PGIMER where he was diagnosed

with Budd-Chiari Syndrome but its root cause could not be diagnosed .Thereafter the complainant started

OPD consultations at Institute of Liver and Biliary sciences and underwent hepatic vein angioplasty on

22/02/2019. Prior to this the complainant had mild jaundice for which he took the treatment for about a

week from local physician and didn’t have to any medicines post its treatment. The reimbursement claim

filed with the insurer was rejected vide letter dated 15/05/2019 on account of non disclosure of liver

disease and past treatment of Hepatitis A at the time of policy issuance. As per complainant, the current

situation is that insurers after receiving the renewal premium of the policy have neither reinstated the

policy nor refunded the amount and desires to be medically insured in continuation to previous year’s

policy along with the claim settlement of the claim.



was made available to this office on 25/02/2020. As per SCN, Policy bearing no 12857636 was issued to the

complainant effective from 14/08/2018 to 13/08/2019 for sum insured of Rs.5,00,000/- was issued to the

complainant. During the continuation of the policy, the complainant approached to avail cashless facility

request for hospitalization of complainant at Institute of liver & Biliary Sciences, New Delhi on 21/02/2019

for 2-3 days with complaints of Ascites & Pedal edema. The complainant was diagnosed with Portal

Hypertension- Non Bleeder, grade 1 esophageal varices. The insurer sent a query letter dated 21/02/2019

and 22/02/2019 to get information with respect to exact duration and past history of present ailment. On

receipt of the query reply, it came to forefront that complainant had a past history of treatment of

Jaundice.

As per outpatient consultation record dated 30/12/2018 of the institute of liver and biliary

sciences, the complainant had a history of jaundice in May 2018 i.e. prior to the policy inception.

As per the inpatient history sheet dated 21/02/2019 of the institute of liver and biliary sciences, as

per treating doctor the complainant’s history of present illness the index presentation of May,2018

i.e. when the complainant developed jaundice associated with problem ( Fever and vomiting )

which was later diagnosed as chronic liver disease.

As per the duly signed statement of the complainant had history of Jaundice in May 2018.

In the light of above observation, the insurer observed that the complainant had a history of Jaundice

treatment in May, 2018 i.e. prior to the policy inception and the same was not informed to insurer at the

time of policy inception. So the insurer rejected the claim of complainant for non disclosure of material

information i.e. past history of jaundice and intimated to complainant vide letter dated 23/02/2019. The

contract of insurance is contract of Uberrimae Fides, and by not declaring correct and accurate information

at the time of proposing for the referred policy, the complainant is guilty of breach of principal of utmost

good faith. That as per clause 7.1 of policy terms and conditions the complainant was under obligation to

disclose all material facts at the time of taking the policy. In the light of above stated facts, the claim of the

complainant was denied in accordance with terms and conditions of the policy.



a) Complainant’s argument: Complainant stated that the claim has been rejected by insurance

company and he requested for payment of his claim.

b) Insurers’ argument: Insurance Company stated that the claim has been repudiated due to the non-

disclosure of material facts at the time of taking the policy.




I have gone through the various documents available in file including the copy of complaint filed by

complainant, copy of treatment record of complainant, copy of SCN filed by Insurance Company and

also consideration of submissions made by both complainant and insurance company during personal

hearing. According to complainant the claim duly covered under the policy period from 14.08.2018 to

13.08.2019 for sum assured of Rs. 5 lack for his hospitalization at Institute of Liver and Biliary sciences

from 21.02.2019 to 23.02.2019 has been denied by insurance company on the grounds of non-

disclosure/ misrepresentation of facts relating to his past illness treatment. The policy also stands

cancelled by insurance company due to the above reason. On perusal of discharge summary of ILBS

hospital the complainant presented with the symptoms of pedal edema, abdominal distension and was

found to be a case of chronic liver disease and diagnosed to be a case of portal hypertension, Ascites

and pleural effusion all due to his being a case of chronic liver disease and was treated by procedure

Balloon angiography. According to insurance company the complainant had a history of jaundice in

May, 2018 before taking the present policy. As per the OPD slip of Kuldeep hospital, Bassi Pathanan

where the complainant had gone in May, 2018 produced by insurance company and various lab

investigations undertaken by complainant his liver function also were outside normal range on

11.05.2018. Even the OPD papers of ILBS of 31.12.2018 refer to the history of jaundice in May, 2018.

The above documents confirm the fact that complainant was a case of chronic liver disease starting

with infective hepatitis and had not disclosed the same at the time of taking policy. As such the decision

of insurance company in repudiating the claim due to non-disclosure of material fact is in order. The

complaint is dismissed on merits and doesn’t call for any interference.

AWARD





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Bikramjeet Singh V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Bikramjeet Singh

S/o Sh. Gurbhajan Singh, Village- Luhand, P.O.-

Nanhera, Rajpura, Patiala,

Punjab- 140417

Mobile No.- 7009628782

2. Policy No:

Type of Policy


13216334

Care

26-10-2018 to 25-10-2019



Mr. Bikramjeet Singh

Mr. Bikramjeet Singh



6. Reason for repudiation Not admissible as per clause 4.1 (ii) 2 years

waiting period.


8. Nature of complaint Rejection of mediclaim



11. Amount of relief sought N.A



2017



13. Date of hearing/place 10.02.2020/ Chandigarh


For the Complainant Sh. Bikramjeet Singh

For the insurer Dr. Nisha Sharma, Manager Claims




On 01-08-2019, Mr. Bikramjeet Singh had filed a complaint regarding the denial of mediclaim by

Religare Health Insurance Company under policy no 13216334.The claimant met with road accident

on 17/11/2018 and was admitted and operated on 27/11/2018 for ligament change in C Lal

Hospital Ambala Cantt .The insurance company denied the claim for the reason that the treatment

is not included in the policy terms and conditions.


Gurugram, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 20-09-2019.As per SCN submitted by the insurance

company, The complainant purchased a Health Insurance Policy bearing Number 13216334 from

them where in the insurance coverage was provided to complainant along with his spouse and two

children for Sum Insured of Rs. 5,00,000/- w.e.f 26-10-2018 till 25-10-2019 subject to policy terms

and conditions. That during the currency of the policy period, the complainant approached them

with reimbursement claim w.r.t hospitalization at C.LL Hospital on 27-11-2018 wherein underwent

treatment for ACL tear (Left Knee). As per the discharge summary issued by concerned hospital

authorities dated 29.11.2018 the complainant underwent treatment for ACL Tear (Left Knee).As per

policy any claim pertaining to ACL Reconstruction/ Ligament repair shall not be admissible during

first 24 consecutive months of the insured person by the company from the first policy start date.

The treatment undergone by the complainant falls under Two Years waiting period, accordingly the

company repudiated the claim filed by complainant vide letter dated 19.09.2019 on the basis of

clause 4.1.(ii)(1) of the policy terms and conditions. The relevant clause is mentioned below:

4. Exclusions

4.1 Waiting Periods

(ii) Specific waiting period : Any claim for or arising out of any of the following illness or surgical

procedures shall not be admissible during the first 24 consecutive months of coverage of the

insured person by the company from the first policy period start date:

Any treatment related to Arthritis (if non infective), Osteoarthritis and Osteoporosis, Gout,

Rheumatism, Spinal Disorders (unless caused by accident), Joint Replacement surgeries

(unless caused by accident), Arthroscopic, Knee Surgeries/ACL Reconstruction/ Meniscal and

Ligament Repair.



a) Complainant’s argument: The hospitalization was due to road accident & ligament was changed.

b) Insurers’ argument: As per policy any claim pertaining to ACL Reconstruction/ Ligament repair shall

not be admissible during first 24 consecutive months of the insured person by the company from

the first policy start date.






I have gone through the documents available in the file including the copy of the complaint, SCN of

the insurer and hospitalization record of the complainant whose claim for the hospitalization at

C.L.L hospital on 27/11/2018 where he underwent for treatment of ACL tear has been denied by

the insurance company under clause 4.1.(ii)(1) of the policy terms and conditions. The complainant

stated that his hospitalization and treatment was due to road accident so the claim should be

paid.The issue here to be decided is as to whether the denial of claim for ACL tear treatment is in

order or not. As per the discharge summary issued by the concerned hospital authorities dated

29/11/2018, the complainant underwent treatment for ACL tear (left knee).As per the policy terms

and conditions ,any claim for or arising out of any treatment of the insured person related to ACL

reconstruction / ligament repair shall not be admissible by the company during first 24 consecutive

months. As such, the repudiation of the claim by the insurance company is in order as per terms

and conditions of the policy and this office finds no reason for intervention in the same. The

complaint is dismissed being devoid of merits.

AWARD





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Luxmi Nand V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Luxmi Nand

House No.- 33-34, Chowk Bazar, Subathu,

Solan, Himachal Pradesh-0

Mobile No.- 9418089628

2. Policy No:

Type of Policy


263103/48/2009/567

Individual Mediclaim Policy

14-07-2008 to 13-07-2009



Mr. Luxmi Nand





8. Nature of complaint Refund of excess premium under various

policies

9. Amount of Claim Rs.644/- plus interest


11. Amount of relief sought Rs.644/- plus interest



2017

Rule 13 (1)(c) – any dispute with regard to

premium paid or payable in terms of policy

13. Date of hearing/place 10-02-2020,26/02/2020

05/03/2020/Chandigarh


For the Complainant Absent on 10/02/2020 &26/02/2020

Sh. Luxmi Nand on 10/03/2020

For the insurer Sh. Rajeev Dewan B.M




On 02-08-2019, Mr. Luxmi Nand had filed a complaint that he is purchasing insurance policies like Personal Accident, Mediclaim, Fire Insurance, BHB Insurance and Motor Insurance from the oriental insurance Company Limited through its branch at Solan since 1990.It was a practice to issue only cover notes which were instantly delivered by the Development Officer who collected cheques toward premium amount. Policy bonds were never issued by the office. The complainant collected corresponding policy bonds from the insurance company under the RTI Act and also collected information relating to rates of premium, early entry discount etc. There was a large difference between the premium shown on the policy bond and the premium paid by complainant. The complainant sent a registered letter dated 12.03.2018 and sought refund of excess premium from the insurance company. The complaint was acknowledged by the regional office of the Insurance company vide their letter dated 10.04.2018. The concerned branch of insurance company vide letter dated 28.08.2018 informed the complainant that no excess premium have been charged under the policies and therefore no refund of excess premium arise. The company has not responded to his complaint dated 20/04/2019.

On 21-08-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,

Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 26/02/2020.

As per the SCN, the matter has been verified and observed that it pertains to year 2006-07, 2007-

08, 2008-09 could not be verified due to non availability. The policy is also governed by free look

period of 15 days as per condition no 6 of mediclaim policy which entitles the insured to review the

terms and conditions and reject which he did not exercise and thus the matter is time barred .So it

is not possible to comment as to whether the insured is entitled to the desired amount at this stage

after about12to14 years. Insurers have generated one policy from their system of the year 2009

showing premium of Rs.1421/-on the face of the policy and premium receipt of same amount has

been issued to the insured. So request the authorities to close the matter. The internal guidelines

from their head office also advise them to maintain the record up to three years for such matters.

Thus no difference of amount between the amount received and policy issued.



a) Complainant’s argument: The insurance company has charged the excess premium for the policies

and he is entitled for refund.

b) Insurer’s argument: As per company’s guidelines, they are to maintain record up to three years for

such matters. It is not possible for them to comment as to whether the insured is entitled to the

desired amount at this stage after about 12-14 years.

19) Reason for Registration of Complaint:-within the scope of the Insurance Ombudsman Rules, 2017.




On perusal of the copy of the complaint, SCN submitted by the insurer, and submission made by

both the parties during personal hearings, it has been observed that the complainant has sought

refund of excess premium charged against various policies issued to him from 2004-2005 to 2014.

The insurance company submitted that as per guidelines of their head office, they are to maintain

under writing record only up to 3 years for such matters. It is not possible for them to comment as

to whether the insured is entitled to the desired amount at this stage after about 12 to14 years .On

the other hand, the complainant has not provided any basis for refund calculations and supporting

documents to establish his case of excess charging. Moreover no representation or complaint was

made to the insurer during the currency of the policies with regard to the excess charging of

premium. Therefore the complaint filed after the abnormal delay for refund of excess premium

without supporting documents cannot be evaluated and entertained for the reasons explained

above. As such, the complaint is dismissed being devoid of merits and no relief is granted.

ORDER





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Arvind Kumar V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Arvind Kumar

House No.- 297, Chowk Bazar, Subathu, Solan,

Himachal Pradesh- 0

Mobile No.- 9418089628

2. Policy No:

Type of Policy


263103/48/2014/296 and various policies

Individual Mediclaim Policy

14-07-2013 To 13-07-2014



Mr. Arvind Kumar





8. Nature of complaint Refund of excess premium under various

policies






2017

Rule 13 (1)(c) – any dispute with regard to

premium paid or payable in terms of policy

13. Date of hearing/place 10-02-2020,26/02/2020

05/03/2020/Chandigarh


For the Complainant Absent on 10/02/2020

Sh. Arvind Kumar on 26/02/2020 & 05/03/2020

For the insurer Sh. Rajeev Dewan B.M




On 02-08-2019, Mr. Arvind Kumar had filed a complaint that he is purchasing insurance policies like

Personal Accident, Mediclaim, Fire Insurance, BHB Insurance and Motor Insurance from the oriental

insurance Company Limited through its branch at Solan since 1990.It was a practice to issue only cover

notes which were instantly delivered by the Development Officer who collected cheques toward

premium amount. Policy bonds were never issued by the office. The complainant collected

corresponding policy bonds from the insurance company under the RTI Act and also collected

information relating to rates of premium, early entry discount etc. There was a large difference

between the premium shown on the policy bond and the premium paid by complainant. The

complainant sent a registered letter dated 12.03.2018 and sought refund of excess premium from the

insurance company. The complaint was acknowledged by the regional office of the Insurance company

vide their letter dated 10.04.2018. The concerned branch of insurance company vide letter dated

28.08.2018 informed the complainant that no excess premium have been charged under the policies

and therefore no refund of excess premium arise. The company has not responded to his complaint

dated 20/04/2019.


Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,

which was made available to this office on 26/02/2020.

As per the SCN, the matter has been verified and observed that it pertains to year 2004 -2005 to 2014.

Record from 2004 to 2007 could not be verified due to non availability. The policy from 2008-2009 to

2014 has been generated from the computer inlias system along with receipts. The policy is also

governed by free look period of 15 days as per condition no 6 of medi claim policy which entitled the

insured to review the terms and conditions and reject which he did not exercise and thus the matter is

time barred .So it is not possible to comment as to whether the insured is entitled to the desired

amount at this stage after about 12 to 14 years so request the authorities to close the matter. Our

internal guidelines from the head office also advise to maintain the record up to three years for such

matters. However difference of Rs21/-has been noted between the amount charged from the insured

and policies issued against it.



a) Complainant’s argument: The insurance company has charged the excess premium for the

policies and he is entitled for refund.

b) Insurer’s argument: As per company’s guidelines, they are to maintain record up to three years

for such matters. It is not possible for them to comment as to whether the insured is entitled to

the desired amount at this stage after about 12-14 years.

19)Reason for Registration of Complaint: -within the scope of the Insurance Ombudsman Rules, 2017.

20) The following documents were placed for perusal. a) Complaint to the Company b) Copy of Policy Document c) Annexure VI-A d) Reply of the Insurance Company


On perusal of the copy of the complaint, SCN submitted by the insurer, and submission made by both

the parties during personal hearings, it has been observed that the complainant has sought refund of

excess premium charged against various policies issued to him from 2004-2005 to 2014. The

insurance company submitted that as per guidelines of their head office, they are to maintain under

writing record only up to 3 years for such matters. It is not possible for them to comment as to

whether the insured is entitled to the desired amount at this stage after about 12 to14 years but

admitted that a difference of Rs21/-has been noted by the insurer between the amount charged from

the insured and policies issued against it.

On the other hand, the complainant has not provided any basis for refund calculation and supporting

documents to establish his case of excess charging .Moreover no representation or complaint was

made to the insurer during the currency of the policies with regard to the excess charging of premium.

Therefore the complaint filed after the abnormal delay for refund of excess premium without

supporting documents cannot be evaluated and entertained for the reasons explained above. As such,

the complaint is dismissed being devoid of merits and no relief is granted.

ORDER


the parties during the course of personal hearing, no relief is granted to the complainant.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)


Case of Mr. Surendra Kumar Sareen V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Surendra Kumar Sareen

Omaxe Heights, Messeturn Tower, Flat No.-

801, Sector- 86, Faridabad, Haryana-0

Mobile No.- 9650392600

2. Policy No:

Type of Policy


252100/48/2019/3076

Mediclaim Policy

23-10-2018 To 22-10-2019



Mr. Surendra Kumar Sareen



6. Reason for repudiation Not payable as per terms and conditions of the

policy- calculus disease


8. Nature of complaint Non Payment of claim






2017





For the Complainant Sh. Surinder Kumar Sareen

For the insurer Sh. P.K.Kalra Dy. Manager



17) Brief Facts of the Case: On 06-09-2019, Mr. Surendra Kumar Sareen had filed a complaint against the

oriental insurance company Ltd for denial of mediclaim. The complainant submitted that he had filed

reimbursement claim with TPA M/S Raksha Health Insurance Ltd Faridabad on 24/04/2019 for

reimbursement of medical expenses incurred by him at Apollo Hospital Delhi but the said claim was

declined /rejected by the TPA stating that Genetic Disorders are not covered under the policy. The

decision of the TPA is arbitrary and without going into the facts of the case. The complainant further stated

that he was suffering from high fever due to Kidney Cyst infection and was under treatment by Dr. Sanjeev

Jasuja, a Nephrologist at Indraprastha Apollo Hospitals from 19/03/2019. Since the infection was not

coming under control with the oral medication, he was admitted to Apollo Hospital on the advice of

treating doctor on 06/04/2019 and was discharged from the hospital on 20/04/2019 after the infection

came under control i.e TLC at 11.12 and creatinine at2.6. The reimbursement claim for Rs.268823/- was

submitted to TPA as the claimant had not opted for cashless. The officials at TPA did not go through the

facts of the case and declined the claim based on the additional commentary mentioned in the discharge

summary. The complainant further submitted that he was suffering from high fever due to Cyst infection

and was given treatment at the hospital only for this purpose. It is true that complainant have a history of

ADPKD as mentioned in the discharge summary but there was no treatment given at hospital for ADPKD.

This fact has also been stated in the certificate issued by the treating doctor DR. Sanjeev Jasuja on

15/05/2019 which was issued on the advice of TPA officials in order to reexamine and facilitate the

reimbursement claim. However after getting the treating doctor certificate that complainant got treatment

only for cyst infection and no treatment was given at hospital for ADPKD, the TPA did not pay an heed to

this and declined the claim on the pretext that genetic disorders are not covered under the policy and

further submitted that it is not a case of genetic disorder as no treatment was given to him at hospital for

his genetic disease i.e. ADPKD.


Delhi, for Para-wise comments and submission of a self-contained note about facts of the case, which was

made available to this office on 26-12-2019.As per SCN ,the insurer had issued policy No

252100/48/2019/3076 for the period 23/10/2018 to 22/10/2019 to Surinder kumar Sareen covering his

wife Kiran Sareen for Sum Insured of Rs.10,00,000/-and Rs.24018/- was collected as premium inclusive of

tax. Sh. Surinder Kumar Sareen was admitted in Indraprastha Apollo Hospital, Sarita Vihar New Delhi on

06/04/2019 to 20/04/2019 with temperature and chill. His case was diagnosed as ADPKD with renal

impairment as per attached discharge summary. As per policy terms and conditions Renal is excluded under

the terms& conditions of the policy, Exclusion No 4.15 of OBC-Oriental Medical Policy-item (xix) CALCULUS

DISEASES.

The complainant was sent Annexure VI-A for compliance, which reached this office on 26-09-2019. 18) Cause of Complaint:

a) Complainant’s argument: The claim is admissible as he was given treatment for fever due to cyst

and not for ADPKD.

b) Insurers’ argument: As per discharge summary, the complainant is a known case of ADPKD so the

claim is not payable as per terms and conditions of the policy.

19) Reason for Registration of Complaint: within the scope of the Insurance Ombudsman Rules, 2017.




On perusal of the various documents placed on record including the copy of complaint, SCN of the insurer,

discharge summary, and submissions made by both the parties during personal hearing, it is observed that

complainant was admitted in the Indraprastha Apollo Hospital ,New Delhi on 06/04/2019 to 20/04/2019

with temperature and chill . His case was diagnosed as ADPKD with renal impairment. The insurance

company denied the hospitalization claim stating that genetic disorders are not covered and renal disease

is excluded under terms and conditions of the policy exclusion no 4.15 of OBC-Oriental Mediclaim Policy

item XIX calculus diseases. The basic issue here to be decided is whether the denial of claim on the ground

of genetic disorder is as per terms and conditions of the policy or not. The complainant submitted that he

was suffering from high fever due to cyst infection and was given treatment at the hospital only for this

purpose and not for ADPKD. But as per the discharge summary, he was diagnosed as a case of ADPKD with

renal impairment. It is a fact that Autosomal dominant polycystic kidney disease (ADPKD) is a genetic

disorder characterized by the growth of numerous cysts in the kidneys. The most striking feature of ADPKD

is the occurrence of numerous renal and hepatic cysts. The complainant was hospitalized with high fever

due to kidney cyst which in turn was most probably caused due to ADPKD and was given treatment for the

same.

Therefore, the denial of claim by the insurer is in order treatment as related disorders due to genetic

disease are not covered as per policy terms and conditions. The complaint is dismissed being devoid of

merits.

ORDER




Dated at Chandigarh on 23rd day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Hawa Singh V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Hawa Singh

House No.- 1000, Saini Vihar, Ph- III, Baltana,

Zirakpur, Mohali, Punjab-0

Mobile No.- 9317584003

2. Policy No:

Type of Policy


12313976

Care

30-03-2018 to 29-03-2019



Mr. Hawa Singh

Mr. Hawa Singh



6. Reason for repudiation Claim not payable due to permanent exclusion

under 4.2 (23) of policy condition


8. Nature of complaint Non Payment of claim

9. Amount of Claim Rs. 24132/- (As per SCN)





2017





For the Complainant Mr. Hawa Singh





On 19-07-2019, Mr. Hawa Singh had filed a complaint against the Religare insurance company for rejection

of his mediclaim and submitted that he is insured under mediclaim policy no 12313976 of the Religare

Insurance Company but his admissible claim has been rejected by insurer and sought intervention of this

office for the payment of the claim.



was made available to this office on 06-11-2019. As per the SCN, the insurer issued policy plan care bearing

no 12313976 to complainant providing insurance coverage with effect from 30/03/2018to 29/03/2019 for a

Sum Insured of Rs.5,00,000/- subject to policy terms and conditions. During the currency of the policy, the

complainant approached the insurer with cashless facility request for the planned hospitalization of insured

at Sukhdata Multi –specialty hospital Hisar on 25/03/2019 for 4-5 days with complaint of cough, shortness

of breath since 10-15 days. The complainant was provisionally diagnosed with Acute Exacerbation of COPD.

On receipt of the cashless request, the insurer sent its query letter dated 25/03/2019 to the complainant to

get information with respect to the etiology of COPD and documents related to personal habit of smoking,

quantity and duration by treating doctor for proper assessment for proper assessment of the claim. That

due to non receipt of necessary documents, the insurer were unable to rule out the pre existing nature of

complainant’s COPD and cashless claim was rejected due to non compliance of deficiency and complainant

was informed to file reimbursement claim with all the necessary documents. The complainant filed

reimbursement claim of Rs.24132/- for the hospitalization from 25/03/2019 to 29/03/2019. The

complainant was diagnosed with COAD with AE, CAD with AWMI (LEF30%), old treated KOCH>2003,

Diabetes Mellitus Type 2(Recent). The insurer sent a query letter dated 19/04/2019 to get information with

respect to exact duration and past history of the present ailment with 1st consultation paper and all past

treatment records of Chronic Obstructive Pulmonary Disease. On receipt of the query reply, it came to

forefront that complainant was an ex smoker.

As per the letter of treating doctor dated 26/03/2019 of Sukhda Hospital, the complainant was an

ex smoker and quit smoking in 2001. Also as per letter of the treating doctor dated 26/03/2019, the

treating doctor duly states that the complainant’s x-ray shows significant right upper zone fibrotic

lesion and his ex-smoker status would have contributed to the etiology of COPD. The treating

doctor is duly corroborating the fact that the present ailment of COPD of the complainant is duly

attributed to the history of smoking and that smoking is an etiology of the present ailment of the

complainant

The insurer also took expert opinion from Pulmonologist to confirm whether there is relationship

between the past history of smoking of complainant is related with Acute Exacerbation and as per

Dr. Rushika Shah DNB “ I opine that yes, patient’s COPD and current hospitalization is related to his

past history of smoking.

In the light of above noted observations, the insurers observed that complainant’s current ailment was related to his past history of smoking and claim was rejected under permanent exclusion on condition caused by suicide or substance abuse/intoxication and the same was intimated to the complainant vide letter dated 17/05/2019.


18) Cause of Complaint: a) Complainant’s argument:

Complainant stated that the admissible claim has been rejected by insurer and he requested for settlement of his claim.


Insurance Company stated that the claim has been rejected as per condition no. 4.1 (23) of policy. 19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules, 2017.





On perusal of various documents available in file including the copy of complaint filed by complainant, copy of discharge summary of Sukhda Hospital Hisar, copy of policy, copy of SCN and after considering of submissions of both complainant and insurance company, it is seen that the complainant duly covered under the policy remained hospitalization at Sukhda hospital Hisar from 25.03.2019 to 29.03.2019 for presenting symptoms of cough for last 15 days, shortness of breath and he was diagnosed as a case of COAD with AE. He was a treated case of pulmonary Koch in 2003. As per letter of treating doctor the complainant was a chronic smoker and quit smoking in 2001 and the present ailment could be attributed to history of smoking. Cashless facility in the case was denied due to non-submissions of required documents. Claim was denied by insurance company vide letter dated 17.05.2019 by taking a recourse to policy condition no. 4.1 (23) which refers to permanent exclusion in respect of condition caused by suicide or substance abuse/ intoxication. Since as per the certificate of treating doctor COPD for which the patient had taken treatment at Sukhda Hospital is attributed to the history of smoking, complainant being a chronic smoker in past. The claim filed by complainant has been denied by insurance company. The complaint is accordingly dismissed being devoid of merits.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the




day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Krishan Kumar Sachdeva V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Krishan Kumar Sachdeva

House No.- 2502, G- block, Saink Colony,

Sector- 49, Faridabad, Haryana-0

Mobile No.- 9953580465

2. Policy No:

Type of Policy


272401/48/2019/984

Happy Family Floater

12-02-2019 To 11-02-2020



Mr. Krishan Kumar Sachdeva



6. Reason for repudiation Misc items not payable


8. Nature of complaint Non Payment Of Claim

9. Amount of Claim Rs26000/-

10. Date of Partial Settlement




2017






For the insurer Sh. P.K. Kalra Dy. Manager




On 20-08-2019, Mr. Krishan Kumar Sachdeva had filed a complaint against the oriental insurance company

for Non Payment of mediclaim of re cataract. The complainant submitted that Health Insurance TPA of

India Ltd (Oriental Insurance Company Ltd) has rejected his medi claim of Rs.26000/- which was paid in

cash to Hospital Asian Institute of Medical Sciences. They have sent the letter on mail on 26/06/2019 and

this amount has been shown as Doctor’s fee (sub category). The complainant further sent a letter on

23/07/2019 to the TPA regarding the above matter and requested them many times telephonically but did

not get the reply regarding the rejected amount of Rs.26000/-.The complainant further stated that he had

deposited this amount in cash to hospital and his claim is genuine and sought the direction from this office

to the insurer for payment of claim.

On 18-09-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office, New Delhi,

for Para-wise comments and submission of a self-contained note about facts of the case, which was made

available to this office on 28/02/2020.

As per the SCN, the complaint is on account of deductions in cashless pre post claim no 191400000850 of

sh. Krishan Kumar Sachdeva. Both the claims have been revisited and insurer’s observations are as:

(1) Pre Post Claim:

Claimed amount : Rs.30256/-

Settled amount : Rs.3838/-

Deducted amount: Rs.26427/- (Rs. 26000/-has been deducted against Misc. Consumables charges

as company has already paid cataract charges in cashless main claim as per agreed GIPSA PPB PKG

rates. + Rs.427/- has been deducted as 10% co payment as per policy terms and conditions.

The patient was admitted in a PPN Network Hospital (Asian Institute of Medical Sciences,

Faridabad.) and insurer has negotiated GIPSA Rates with these hospitals. According to company,

the cashless main claim has already been settled for Rs.26000/-(Rs.24000/-minus Rs.2400/-as 10%

co-payment) as per agreed GIPSA PPN PKG and the final bill received by the hospital was for the

same amount. But it seems that the hospital has charged Rs.26000/-as Misc. Consumable charges

over and above the GIPSA PPN Package and charges were paid by the patient.

The insurer further stated that they had also received GIPSA Network Declaration Form, signed by

the insured/insured’s attendant wherein he had given the undertaking that he will pay in the case

of availing better facility. Thus the amount of Rs.26000/-on account of Misc. Consumable

Charges is not admissible.

(2) Pre-Post Claim: Claimed amount Rs.840/-, Settled amount Rs.756/-, Deducted amount Rs. 84/- as 10% co-payment as per policy terms and conditions.



a) Complainant’s argument: The complainant is seeking the reimbursement of deducted amount of

Rs26000/- paid by him to the hospital which is in addition to the package amount paid by the

insurer.

b) Insurers’ argument: The claim has been settled as per GIPSA PPN package as per declaration signed

by the insured / representative at the time of admission.





21) Result of Personal hearing with both parties (Observations & Conclusion): On perusal of various documents placed on record including the copy of complaint, SCN of the insurer, mail

of the complainant dated 28/02/2020 and submission made by the insurer during personal hearing, it is

observed that insurance company has already paid the hospitalization cashless claim for treatment of

cataract to the hospital as per GIPSA agreement with the hospital on the basis of GIPSA Network

declaration form signed by the insured/ insured’s attendant. In the said declaration form the insured

agreed to pay in case of availing better facility and not to claim from the insurer. Since it was a cashless

planned surgery and the complainant was informed about the cost of treatment, later on he cannot take a

plea that a particular amount has been deducted from his additional claimed amount. Since complainant’s

hospitalization claim has already been settled by the insurer under the cashless arrangement with claim

amount of Rs.3838/- for Pre- Post hospitalization as per terms and conditions of the policy, no further

intervention is required in the decision of the insurer. As such complaint is dismissed being devoid of

merits.

ORDER





D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Narendra Kumar Verma V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Narendra Kumar Verma

S/o Late Sh. Navnidh Singh Verma,

House No.- 1690, Sector- 8, Faridabad,

Haryana-0

Mobile No.- 9811686828

2. Policy No:

Type of Policy


272400/48/2018/12200

PNB Oriental Royal Mediclaim

27/12/2017 to 26/12/2018



Narinder Kumar Verma



6. Reason for repudiation Not payable under clause 4.2(xvii)


8. Nature of complaint Non Payment of Mediclaim

9. Amount of Claim Rs. 1,55,414/-


11. Amount of relief sought Rs.1,55,414/- along with interest @24%



2017





For the Complainant Sh. Narendra Kumar Verma





On 23-09-2019, Mr. Narendra Kumar Verma had filed a complaint against the insurance company for denial

of Mediclaim The complainant who is covered under Mediclaim policy no 272400/48/2018/12200, due to

chest pain on 28/11/2018 went to Mani clinic Faridabad and after first aid was referred to Metro Heart

institute where he underwent coronary angiography which revealed significant single vessel disease and his

PTCA with drug coated stunting to LAD was done. The reimbursement claim for Rs.154414/- for

hospitalization of the complainant from 28.11.2018 to 01.12.2018 was denied by the insurer under clause

4.2 (xvii) which states “During the period of insurance cover, the expenses on the treatment of

Hypertension for specified period of two years are not payable if contacted and /manifested during the

currency of the policy vide letter dated nil received by the complainant on or about 18.03.2019. On

25/03/2019, a request for reconsideration of claim along with relevant certificate issued by the Metro

Hospital was submitted to the insurer but the claim was repudiated through mail dated 25/03/2019 and

rejection letter received by complainant on 15.05.2019.Despite going through all the documents on record,

the facts and circumstances of the case, the grievance committee of the insurance company again

repudiated vide mail 07/06/2019.Moreover the complainant on 04/09/2019 again consulted the medical

officer of the said hospital and disclosed about repudiation of claim for treatment of angioplasty / heart

surgery in spite of submission of certificate issued by the hospital that patient was treated for Acute MI and

angioplasty. On request of complainant and after considering the claim history the concerned medical

officer on 09/09/2019 has issued the correct and revised discharge summary sheet wherein the mistake

K/C/O HTN was removed from the said discharge summary. According to complainant now it is crystal clear

that his case is not a case of hypertension and he is eligible for reimbursement of the expenses for

treatment of his angioplasty and requested this office for direction to insurance company for payment of

claim along with interest @ 24% per annum since 24/12/2018.



made available to this office on 27/02/2020. As per SCN, the complainant submitted a claim for

hospitalization for treatment of CAD with hypertension as per copy of discharge summary and OPD card

issued by the hospital. From the policy document it is observed that insured was covered vide policy no

272400/48/2018/12200 and same was first year of policy. As per copy of OPD card the insured was

suffering with unstable angina with history of HTN. As per copy of discharge summary the diagnosis

recorded were CAD-AWM, Coronary artery disease, Hypertension and PTCA with drug coated with Stenting

to LAD. LV dysfunction (LVEF=40%) APICAL LV CLOT

The claim was denied by TPA vide letter dated 23/04/2019 accordingly vide insurer letter dated 02/05/2019

under clause no.4.2(XVII)- During the period of insurance cover the expenses of treatment of hypertension

for specified period of two years are not payable. Since as per the policy expenses related to hypertension

and its related complications are not admissible during first two years from the date of inception, the claim

deserved repudiation.



a) Complainant’s argument: Denial of angioplasty claim is not justified as he got treatment for

coronary heart disease and not for hypertension.

b) Insurers’ argument: Expenses related to hypertension and its related complications are not

admissible for two years as per clause 4.2(XVII) of the policy.


20) The following documents were placed for perusal




On perusal of various documents placed on record including the copy of complaint, SCN of

the insurer, discharge summary and submission made by both the parties during personal

hearing, it is observed that complaint is against the insurer for denial of reimbursement claim

for treatment of CAD with hypertension at Metro Heart Institute. The insurer denied the claim

under clause 4.2(XVII) which states that during the period of insurance cover, the expenses of

treatment of hypertension for specified period of two years are not payable. The issue here to

be decided is whether the denial of claim for the treatment of CAD under clause 4.2(XVII) is

justified or not. According to insurer the complainant was hospitalized for treatment of CAD

with hypertension as per the discharge summary. Further as per copy of OPD card, the insured

was suffering with unstable angina with history of HTN. As per policy terms and conditions

expenses related to hypertension and its related complications are not admissible during first

two years from the date of inception, so the claim was repudiated. On the contrary, the

complainant submitted that denial of claim, for treatment of CAD through angiography and

stunting is not justified, as he got treatment for coronary heart disease and not for hypertension.

As per copy of discharge summary, the diagnosis recorded were CAD-AWM, coronary artery disease,

Hypertension and PTCA with drug coated with Stenting to LAD. The hospitalization and treatment of

complaint was mainly for coronary disease and not for hypertension. There is no cogent independent

evidence on the record to establish that complaint had prior history of hypertension. The clause under

which the claim has been repudiated is related with the treatment of hypertension whereas the

complainant’s claim is for reimbursement of expenses incurred for treatment of heart ailment. The decision

of insurer to repudiate claim is not justifiable and sustainable as per terms and conditions of the policy. As

such, the insurance company is directed to pay the admissible claim amount as per terms and conditions of

the policy within 30 days after receipt of the copy of award.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of personal hearing, admissible claim amount is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Naresh Ahuja V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Naresh Ahuja

43-FF, Isher Singh Nagar, Flats, Pakhowal Road,

Ludhiana, Punjab- 141001

Mobile No.- 9888667901

2. Policy No:

Type of Policy


233902/48/2020/489

Mediclaim Policy

02-05-2019 To 01-05-2020



Mr. Naresh Ahuja



6. Reason for repudiation Claim not payable as per clause 4.19


8. Nature of complaint Non Payment of mediclaim



11. Amount of relief sought Rs. 1,32,000/-



2017





For the Complainant Sh. Naresh Ahuja

For the insurer Sh. P.K Kalra Dy. Manager




On 10-10-2019, Mr. Naresh Ahuja had filed a complaint against the oriental insurance company limited for

denial of his medical reimbursement claim. As per his complaint, he is aged about 72 years and holder of

Mediclaim policy for the last five years. About three years back, the complainant developed Osteoarthritis

for which ED knee surgery was recommended. The complainant went to Dr. S.S Sibia M.B.B.S.,MD who is

having his medical centre equipped with various latest machines, who first gave him medicines and

injections and later on admitted him in the hospital and was given Cytotron which was part of treatment

and effective method of treatment of Osteoarthritis of knee joints. There was least pain, faster recovery,

minimum post treatment requirements with overall low cost as compared to knee replacement. After

submission of all the documents required for the reimbursement of the claim, the insurance company on

19/06/2019 replied that under 4.19 clause of their prospectus the claim is not tenable. The complainant

further submitted that the prospectus given to him on the start of his policy did not mention about this

clause. Now the insurer is showing him new prospectus about which they never informed earlier and he felt

disappointed due to disown the policy shared with him because presented new policy was never given or

signed by complainant and the claim for Rs. 1.32 has been refused on the basis of new policy. The

complainant further requested that very similar cases have already been awarded by Lok Adalat, his case is

similar so it should be considered.



was made available to this office on 27/02/2020. As per SCN, The complainant availed PNB-Oriental royal

mediclaim policy from 02/05/2018 to 01/05/2019 for a sum insured of Rs.3,00,000/-. Policy inception date

is 02/05/2014 and it is a continuous renewal with the insurer since 02/05/2014 with a sum insured of Rs. 3

lacs. The insured was admitted at Sibia Medical Centre, Ludhiana from 07/04/2019 to 09/04/2019 due to

pain in knee. The insured submitted claim documents to the TPA after getting TPA letter dt. 28/05/2019.

After going through the file it is observed that the patient is K/Y/O Osteoarthritis Knees\Bilateral. As per the

documents the insured undergone Cytotron /RFQMR (Rotational Field Quantum Magnetic Resonance)

therapy from 04/04/2019 to 08/05/2019 for cartilage regeneration/repair. RFQMR therapy falls under

permanent exclusion clause 4.19 as per policy terms and conditions. Therefore the claim recommended for

repudiation by the TPA under exclusion clause 4.19 i.e “Treatment for age related Macular Degeneration

(ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter

Pulsation(ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.”The insured was

informed about repudiation of claim vide B.O letter dt. 19/06/2019.As per insurer, the claim has been

rightly repudiated since RFQMR is excluded vide exclusion clause 4.19 of policy.



a) Complainant’s argument: Denial of Mediclaim by the insurance company under clause 4.19 of the

policy is not justified as the condition was not mentioned in the prospectus when the policy was first

purchased by him in the year 2014.Cytotron therapy taken by him for treatment of Osteoarthritis of

knee joints is cost effective as compared to knee replacement.

b) Insurers’ argument: Claim not admissible as the complainant’s treatment / therapy such as

Rotational Field Quantum Magnetic Resonance (RFQMR)falls under permanent exclusion clause 4.19

of policy.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017. 20) The following documents were placed for perusal.



21) Result of Personal hearing with both parties (Observations & Conclusion): On perusal of the various documents placed on record including the copy of complaint, SCN of the insurer

and submissions made by both the parties during personal hearing, it is observed that complaint is about

the denial of claim by the insurer under clause 4.19 of the policy. The issue to be decided here is whether

the denial of claim by the insurer is in order or not. As per claim documents, the complainant had

undergone Cytotron / RFQMR therapy from 04/04/2019 to 08/05/2019 for cartilage regeneration/repair

and remained admitted at Sibia Medical Centre. He is a known case of Osteoarthritis/Bilateral. According to

insurer, claim is not admissible as the complainant’s treatment / therapy such as Rotational Field Quantum

Magnetic Resonance (RFQMR) falls under permanent exclusion clause 4.19 of policy. On the contrary, the

complainant submitted that denial of mediclaim by the insurance company under clause 4.19 of the policy

is not justified as the condition was not mentioned in the prospectus when the policy was first purchased

by him in the year 2014.Cytotron therapy taken by him for treatment of Osteoarthritis of knee joints is cost

effective as compared to knee replacement.

The complainant is a regular Mediclaim Policy holder of the insurance company since 2014, underwent non

established procedure of Cytotron therapy for the treatment of his knees problem rather than regular knee

replacement treatment which is otherwise covered under the policy. The therapy through which the

insured chose to get his knees treated, does not fall under the established medical procedures being

unproven procedure or treatment and is also not tenable as per clause 4.13 of copy of prospectus placed

on record by the complainant. Since the insurance policy contracts are subject to terms and conditions ,the

claim of complainant is not admissible as his treatment / therapy such as Rotational Field Quantum

Magnetic Resonance (RFQMR) falls under permanent exclusion clause 4.19 of policy against which the

claim has been lodged. Hence the decision of denial of claim by the insurer is as per policy terms and

conditions and does not warrant any interference. Therefore the complaint is dismissed being devoid of

merits.

ORDER





D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Maninderpal Sharma V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Maninderpal Sharma

S/o Sh. Nasib Chand Sharma, Gulmohar Nagar,

Near Sai Market, Khanna,

Punjab- 141401

Mobile No.- 9417602508

2. Policy No:

Type of Policy


233605/48/2019/530

Happy Family Floater Policy

02-08-2018 to 01-08-2019



Mr. Maninderpal Sharma



6. Reason for repudiation Not payable as per clause 3.11 of policy


8. Nature of complaint

9. Amount of Claim Rs.35227/-(Two Claims)





2017





For the Complainant Sh. Maninderpal Sharma

For the insurer Sh. P.K.Kalra Dy. Manager




On 19-09-2019, Mr. Maninderpal had filed a complaint against the oriental insurance company Ltd for

nonpayment of medicalim. The complainant stated that he is holding mediclaim policy no.

233605/48/2019/530 from the oriental insurance company limited from Khanna Branch and being in force

over nine years. The complainant was admitted in Sankara Eye Hospital on 30/03/2019 and as per the

doctor recommendation, injection Lucentis was administered and was discharged on 31/03/2019 Again on

dated 07/06/2019 was admitted in the same hospital, injection avastin was administered and discharged

on 08/06/20219 due to diabetic retinopathy. Claims for reimbursement of expenses were lodged with

oriental insurance company’s TPA Vipul Medical Corp. TPA. Pvt. Ltd. and were rejected under clause 3.11.

but it is no where mentioned that the injection is not payable under day care or 24 hours hospitalization or

any other period. The complainant further stated that he had already filed a complaint with office vide ref.

no CHD-G-050-1718-0425 with the same type of case history and was awarded in the favour of complainant

in past on 23/01/2019 vide award reference no IO/CHD/A/GI/0318/2018-2019. Even after the above

settled case through insurance ombudsman in complainant’s favour, again same type of claim has been

rejected.



was made available to this office on 03/03/2020

As per SCN, the complainant is insured under happy family floater policy no 233605/48/2019/530 for the

period from 02/08/2018 to 01/08/2019 for Sum insured of Rs.3,00,000/- covering the risk of insured and

his family members. The complainant was treated with Intravitreal Inj. Lucentis/ avastin is given as

intravitreal injection and is an OPD treatment though the injection was given in the operation theater.

Neither the injection requires in-patient hospitalization. Policy clause 3.11 excludes OPD treatments. The

clause is reproduced hereunder:

Day care treatment: refers to medical treatment, and /or surgical procedure which is:

a) Undertaken under general or local anesthesia in a hospital/day care centre in less than 24 hours

because of technological advancement, and

b) Which would have otherwise required a hospitalization of more than 24 hours.

As per documents submitted to TPA this is a case of Cystoid Macular Edema and intravitreal

injection Lucentis is given, which is an OPD treatment and the same is excluded from the scope of

the policy. As per the claim form (part B Hospital) completed/signed by the hospital that ailment is

not covered under the policy. Keeping in view the facts the claim was filed as NO-Claim.



a) Complainant’s argument: In spite of settlement of claim of similar nature, as per order of Insurance

Ombudsman in previous complainant, again similar type of claim has been rejected.

b) Insurer’s argument: The complainant was treated with Intravitreal Inj. Lucentis/ avastin which is

given as intravitreal injection and is an OPD treatment hence not payable as per terms and


19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017.





On perusal of various documents placed on file including the copy of complaint, SCN of insurer and

submission made by both the parties during personal hearing, it is observed that complaint is against the

insurer for denial of claims for eye treatment at Sankara Eye Hospital. The claims were denied by the

insurer on the ground that complainant was treated with Intravitreal Inj. Lucentis/ avastin which is given as

intravitreal injection and is an OPD treatment, hence not payable as per terms and conditions of the policy

under clause 3.11 On the contrary, complainant submitted that In spite of settlement of claim of similar

nature, as per order of Insurance Ombudsman in previous complainant, again similar type of claims have

been rejected. under clause 3.11, but it is nowhere mentioned that the injection is not payable under day

care or 24 hours hospitalization or any other period.

In the instant case complainant was admitted in eye hospital on 30/03/2019 and as per doctor’s

recommendations injection Lucentis was administered and was discharged on 31/03/2019.The complainant

was again admitted in the same hospital on 07/06/2019 and was administered injection avastin and

discharged on 08/06/2019 due to diabetic retinopathy. The said injection is administered in an operation

theater under strict sterile conditions and requires post procedure observations of the patient since the

same is not free from complications. On going through the various day care procedures in relation to eye

surgery it is observed that due to rapid technological advancement in the medical field most of the surgical

procedures on eye do not require hospitalization as it used to be few years back and even the smallest

excision/incision on eyes are covered under day care procedures. Since the administration of injection

lucentis/avastin requires highly sophisticated procedure done under the supervision of a consultant eye

specialist in an operation theater, in my view the case is covered under eye surgery and hence payable. The

decision of the insurance company to reject the claims of the complainant in respect of the said treatment

taken by him at Sankara Eye Hospital is not proper and devoid of merits. The insurance company is directed

to settle the claims within 30 days after the receipt of copy of award

AWARD


parties during the course of personal hearing, admissible claim amount is hereby awarded to be

paid by the Insurer to the Insured, towards full and final settlement of the claims.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Kulwinder V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Kulwinder Kumar

Ward No.- 02, Bareta, Punjab- 151501

Mobile No.- 9569450001

2. Policy No:

Type of Policy


233500/48/2019/965

Mediclaim Policy

28-06-2018 To 27-06-2019



Mr. Kulwinder Kumar





8. Nature of complaint Short payment of claim.



11. Amount of relief sought Rs36410/-



2017





For the Complainant Sh. Kulwinder Kumar





On 12-09-2019, Mr. Kulwinder Kumar had filed a complaint against the oriental insurance company Ltd for

the short payment of medicalim. The complainant stated that he is having health insurance policy from 26th

June 2010. In the month of February 2019, the complainant was hospitalized from 26/02/2019 to

28/02/2019 and took treatment for BPH. He filed reimbursement claim for Rs.95839/- out of which

Rs.55487/- was paid to him after deductions of Rs.40352/- and has sought intervention of this office for

payment of Balance deducted amount of Rs.36410/-as worked out by him.



was made available to this office on 28/02/2020.

As per the SCN, the insured Mr. Kulwinder Kumar purchased PNB-Oriental Royal Mediclaim policy on

28/06/2012.The policy was renewed thereafter and present complaint has been filed under policy no

233500/48/2019/965. The patient Kulwinder Kumar was admitted at Aykai Hospital Ludhiana from

26/02/2019 to 28/02/2019 with chief complaints of retention of urine with difficulty in voiding since two

years. As the hospital was not empaneled, therefore the insured preferred reimbursement claim, post

discharge. On receipt of the claim papers by Raksha Health Insurance TPA, it was duly processed and

settled for Rs.55487/- as per terms and conditions of the policy. Further, the insured represented to the

company vide mail dated 16/05/2019 and made queries regarding deductions made in the claimed amount

of Rs.96,820/- The matter was taken up with the TPA and as per reply deductions made were as:

1. Rs.2850/- deducted for admission charges, diet charges, patient kit charges, without medicine

charges, non payable.

2. Rs.3203/- deducted for consumable charges, not payable

3. Rs.150/- deducted for shipping charges are not payable.

4. Rs.1796/- deducted for outside 30 days not payable.

5. Rs.32353/- deducted as per reasonable customary rate non payable.

REASONABLE AND CUSTOMARY CHARGES: the charges for services or supplies which are standard

charges for specific provider and consistent with the prevailing charges in the geographical area for

identical or similar services, taking into account the nature of illness/injury involved.The insured

was informed about the above deductions vide mail dated 29/05/2019. As per insurers, the

deductions made are as per policy terms and conditions.



a) Complainant’s argument: The deductions made from the claim amount under customary &

reasonable and other heads, not justified as per policy terms & conditions.

b) Insurer’s argument: The deductions made are as per policy terms and conditions.






On perusal of various documents placed on record including the copy of the complaint, SCN of insurer and

submission made by both the parties during personal hearing, it is observed that complaint has been

lodged against the oriental insurance company limited for the unreasonable deductions amounting to

Rs.36410/-made from hospitalization claim of complainant due to urine problem at Akai Hospital Ludhiana.

According to insurer, as the hospital was not empaneled, the insured preferred reimbursement claim post

discharge from the hospital which was duly settled by them for Rs.55487/- against the claimed amount of

Rs.96820/- as per terms and conditions of the policy. On the contrary the complainant pleaded that the

deductions have been made arbitrarily and without any justification. While going through the details of

deductions.it is observed that all the deductions made by the insurer are as per policy terms and condition

except the deduction made for Rs.32353/- under the head customary reasonable rate. The deduction of the

claimed amount under self-created and amorphous clause of “reasonable and customary charges” is not

correct and reasonable. The policy is only subject to certain limits in case of room rent/doctor’s fee/OT

charges/medicines etc. which they are entitled to deduct as per terms of the policy. In view of the above

the insurance company cannot deduct expenditure on account of reasonable & customary charges. As

such, the insurance company is directed to pay balance sum of Rs.32353/- as per terms and conditions of

the policy to the insured within 30 days from the date of receipt of copy of the award.

AWARD


parties during the course of personal hearing, Rs.32353/- is hereby awarded to be paid by the




D.K. VERMA

INSURANCE OMBUDSMAN


(UNDER INSURANCE OMBUDSMAN RULES, 2017) INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Sanjeev Jain V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Sanjeev Jain

House No.- 567 R, Model Town, Panipat,

Haryana-132103

Mobile No.- 9034371478

2. Policy No:

Type of Policy


261493/48/2019/443


09-03-2019 To 08-03-2020



Mr. Sanjeev Jain





8. Nature of complaint Short payment settled


10. Date of Partial Settlement

11. Amount of relief sought Balance Rs. 1,18,464/-, plus interest

+1,00,000/-for harassment



2017





For the Complainant Sh. Sanjeev Jain

For the insurer Sh. Ashok Baroka , Dy. Manager




On 02-09-2019, Mr. Sanjeev Jain had filed a complaint against the oriental insurance company for making short payment of claim under the mediclaim for the treatment of his father. The complainant submitted that his father Sh. Karam Chand Jain was hospitalized in Metro Hospital Faridabad w.e.f 25/03/2019 to 29/03/2019 and Rs.357825/-was incurred for treatment. Bill payment was made by complainant due to non cashless hospital and later on all the original bills were submitted to TPA through Oriental Branch. But after a long period, they approved the claim for Rs.2,00,471/- only and deducted Rs.1,18,464/- on account of reasonable and customary clause. The complaint in this regard was made underwriting office and their head office but till date did not get any response. On 20-09-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office, Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case, which was not received.



a) Complainant’s argument: The deductions of Rs.1,18,464/-made from the claim amount, under customary & reasonable and other heads, not justified as per policy terms & conditions.

b) Insurer’s argument: The deductions made are as per policy terms and conditions.




21) Result of Personal hearing with both parties(Observations & Conclusion) On perusal of various

documents placed on record including the copy of the complaint, SCN of insurer submitted during hearing

and submission made by both the parties during personal hearing, it is observed that complaint has been


Rs.1,18,464/-made from hospitalization claim of complainant due to hospitalization at Metro Faridabad

from 25/03/2019 to 29/03/2019 for treatment of HTN T2DM, CAD, Acute Inferior wall MI. According to

insurer, as the hospital was not empaneled, the insured preferred reimbursement claim post discharge

from the hospital which was duly settled by them for Rs.2,00,471/- against the claimed amount of

Rs.357825/- as per terms and conditions of the policy. On the contrary the complainant pleaded that the


deductions.it is observed that all the deductions made by the insurer are as per policy terms and condition

except the deduction made under the head reasonable & customary clause. The deduction of the claimed

amount under self-created and amorphous clause of “reasonable and customary charges” is not correct

and reasonable. The policy is only subject to certain limits in case of room rent/doctor’s fee/OT

charges/medicines etc. which they are entitled to deduct as per terms of the policy. In view of the above

the insurance company cannot deduct expenditure on account of reasonable & customary charges. As

such, the insurance company is directed to pay balance admissible amount on account of the deduction

made under reasonable and customary head as per terms and conditions of the policy to the insured within

30 days from the date of receipt of copy of the award.

AWARD


parties during the course of personal hearing, admissible balance claim amount is hereby awarded

to be paid by the Insurer to the Insured, towards full and final settlement of the claim.


Dated at Chandigarh on 23rd day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Amit Goyal V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Amit Goyal

House No.- 62, Veer Colony, Amrik Singh Road,

Bathinda, Punjab- 151001

Mobile No.- 9646115179

2. Policy No:

Type of Policy


233200/48/2019/158

Mediclaim Policy

16-04-2018 to 15-04-2019



Mr. Amit Goyal





8. Nature of complaint Partial payment of Medi claim.


10. Date of Partial Settlement Not provided

11. Amount of relief sought Rs.87757/- (balance amount)



2017

Rule 13 (1)(b) any partial or total repudiation of

claim by an insurer



For the Complainant Sh. Amit Goyal

For the insurer Sh. P.K. Kalra, Dy. Manager




On 10-09-2019, Mr. Amit Goyal had filed a complaint against the oriental insurance company limited for

less payment of claim under the mediclaim policy. The complainant stated that he met with an accident on

06/09/2018, in which shoulder was fractured and operated by Dr. Nikhil in Darshan Super specialty

hospital , Bathinda on the same date. All the documents for the claim were submitted in Bathinda office in

the month of sept 2018.After almost 10 months, the complainant received only Rs.80,000/- from the

insurance company as final settlement of claim against claim of Rs.167757/-. As per insurance policy full

amount has to be reimbursed by insurer and they cannot deduct any payment without explaining and

replying to complainant’s requests. The insurer paid only Rs.80,000/-which was accepted by the

complainant under resentment. As per the advice of DR. Nikhil, Darshan Super specialty Hospital, Bathinda,

the complainant had availed medical leave for two months from 06/09/2018 to 31/10/2018 and has sought

the intervention of this office for release of balance amount.



was made available to this office on 03/03/2020. As per SCN, the claim has been revisited with the

following observations:

Claimed amount: Rs.1,75,563/-

Paid amount : Rs.80,000/-

Non payable amount: Rs.95563/-

Claim paid as per Raksha TPA note and investigation of hospital by TPA, as per reasonable

customary charges clause amount deducted as below:

Rs.4,000/- room charges deducted for overstay charges (only 4 days payable)

Rs.2,000/-doctor fee deducted as per reasonable customary rates

Rs.11,000/-anesthesia charges deducted as per reasonable customary rates

Rs.9000/- surgeon fee deducted as per reasonable customary rates

Rs.12,000/-investigation charges deducted as per reasonable customary rates

Rs.5500/- hospital services deducted as per reasonable customary rates.

Rs.6348/- consumable charges non payable

Rs.13,000 operation theater charges deducted as per reasonable customary rates.

Rs. 32715/-implant cost deducted as per reasonable customary rates.



a) Complainant’s argument: The deductions of Rs.1,18,464/-made from the claim amount, under

customary & reasonable and other heads, not justified as per policy terms & conditions.

b) Insurer’s argument: Deductions have been made as per policy terms and conditions.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman Rules, 2017.




21)Result of Personal hearing with both parties (Observations & Conclusion) :On perusal of various

documents placed on record including the copy of the complaint, SCN of insurer submitted during hearing

and submission made by both the parties during personal hearing, it is observed that complaint has been


Rs.87757/-made from hospitalization claim of complainant due to hospitalization at Darshan Super

Specialty Hospital from 06/09/2018 to 10/02/2018 for treatment of fractured shoulder due to accident.

According to insurer, as the hospital was not empaneled, the insured preferred reimbursement claim post

discharge from the hospital which was duly settled by them for Rs.80,000/- against the claimed amount of

Rs.1,57,757/- as per terms and conditions of the policy. On the contrary the complainant pleaded that the


deductions, it is observed that all the deductions made by the insurer are as per policy terms and

conditions. The claim was duly investigated by the insurer and on the basis of investigation report of TPA it

was paid as per terms and conditions of the policy. It has been observed that no additional amount is

admissible to the complainant. As such, the complaint is dismissed being devoid of merits and no relief is

granted.

ORDER





D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. I.S. Singla V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. I.S. Singla

14/106-2, Ram Colony, Barnala Road, Sirsa,

Haryana-125055

Mobile No.- 8901372555

2. Policy No:

Type of Policy


1119002817P116693246

Mediclaim Policy

27-02-2018 to 26-02-2019



Mr. Naveen Kumar Singla

Mr. Naveen Kumar Singla



6. Reason for repudiation PED, Misrepresentation


8. Nature of complaint Non payment of claim






2017





For the Complainant Mr. I.S.Singla, Complainant

For the insurer Mr. Rajinder Pal Kamboj, Dy.Manager




On 27-09-2019, Mr. I.S. Singla had filed a complaint that claim of Rs. 56282/- of his son Naveen Kumar

Singla was submitted to the designated TPA, E-Mediteck, Gurgaon on 06.02.2019 and was acknowledged by

them on 08.02.2019. Matter is being persuaded since Feb.2019 and complaints were also lodged but not

even a single communication has been responded by the company at any level. He requested for payment

of said claim for Rs. 56282/- without any further delay.



was made available to this office on06.03.2020. The complainant was sent Annexure VI-A for compliance,


As per SCN submitted by insurance company, insured has taken their mediclaim policy no.

1119002817P116693246, with sum insured of Rs. 2 lac, valid from 27.02.2018 to 27.02.2019, running in

third year from inception date. Insured Mr. Naveen Kumar Singla lodged a claim with M/s E-Mediteck TPA

on 27.01.19 for his admission in Sarvodaya Multispecialty & Cancer Hospital from 26.01.19 to 31.01.19. As

per discharge summary of hospital, insured was diagnosed for BBPV / Acute Viral Labrinthitis and C 5-6 left

paracentral PIVD. On 10.01.19, IRDAI canceled the certificate of M/s E-Meditek Health Insurance TPA Ltd.

Later on office received back claim file of Mr. Naveen Singla, which was sent to Raksha TPA Pvt. Ltd. Now,

as per opinion of M/s Raksha TPA, insured having previous history of lumbar spondolysis. On 04.09.19, TPA

sought some clarification and insured’s father Sh.I.S.Singla submitted reply on 09.09.2019, vide which

insured Mr. Naresh has taken treatment from Sanjeevni Hospital ,Sirsa for lumbar spondolysis. But insured

did not give any document about this treatment. As per report submitted by TPA to company, indoor case

paper were not shown and maintained by the hospital and hospitalization was for investigation purpose.

Neither hospital nor patient is providing past treatment record to the company. Further as patient is k/c/o

Lumbar Spondylosis which is acute on chronic in nature and policy is in third year of its inception, so as per

policy clause no. 4.1, claim is not payable. Due to concealment of facts and misrepresentation of the claim,

pre-existing disease, which is chronic in nature, the claim is repudiated by company.


a) Complainants argument: Company rejected claim of his son on false grounds, although he has submitted all documents and replied all their queries.

b) Insurers’ argument: Complainant not co-operated and has not provided documents of past treatment. Company has repudiated the claim as per terms and conditions of the policy.






During personal hearing the complainant as well as insurance company reiterated versions made by them

in complaint and SCN respectively. On perusal of various documents available in the file it is observed that

as per repudiation letter dt.07.01.2020 issued by company, inception of first policy was 27.02.2016 and

claim was lodged in 3rd policy with sum insured of Rs. 2 lacs. Claim of Mr. Naveen Kumar Singla was lodged

on 27.01.19 for admission in Sarvodya Hospital, Hisar, who was diagnosed for BBPV (Benign Paroxysmal

Positional Vertigo)/ Acute Viral Labrinthitis and C5-6 LEFT PARACENTRAL PIVD. The matter was investigated

by new TPA. Patient was a k/c/o Lumber spondyloisis. Headache and giddiness are the symptoms of

Lumber spondylosis which is acute and chronic in nature. As per this letter, it is clearly established that this

disease did not occur instantly and patient was having disease, which became acute and chronic in 3rd year

of policy. As such it is not covered. Claim is not payable due to concealment of facts and misrepresentation

of the claim, pre-existing disease which is chronic in nature. As such, company’s prime plea is complainant

was having pre existing disease and not providing any document related to it. As per discharge summary,

patient is a k/c/o Lumber spondylosis, but duration of previous disease is not written. Regarding non

supply of old record, complainant argued that patient is not supposed to keep all records of all his ailments

and past treatment supposing the same may be required by insurance company on future date. As per

complainant, nowhere he mentioned to company regarding taking any treatment from Sanjeevani Hospital,

Sirsa. As company has repudiated the claim on pre existing disease basis, onus to prove the same was on

insurance company, but they fail to do so. Insurance company never investigated the matter properly and

not come out with any concrete proof to establish pre existing disease of patient. Company admitted in

hearing that they even never arranged any investigation from Sanjeevni Hospital, Sirsa. In absence of any

documentary evidence, company could not prove that insured patient was suffering from any pre existing

chronic disease and has taken treatment of same under present claim. As such repudiation of claim by

company is not justified and they are directed to pay admissible claim to insured, subject to terms and

conditions of policy within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claim subject to terms and conditions of

policy, is hereby awarded to be paid by the Insurer to the Insured, towards full and final

settlement of the claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Satish Kumar Malhotra V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Satish Kumar Malhotra

House No.-152, Kidwai Nagar, Ludhiana,

Punjab-0

Mobile No.- 8146767393

2. Policy No:

Type of Policy


2007002816P112877970

Individual Mediguard Policy

06-01-2017 to 05-01-2018



Mr. Satish Kumar Malhotra



6. Reason for repudiation Late intimation and late submission of doc.








2017





For the Complainant Mr.Kamal Malhotra, Son of complainant

For the insurer Mr.Davinder Sharma, A.O.




On 07-11-2019, Mr. Satish Kumar Malhotra had filed a complaint that his genuine claim has been rejected

without natural justice and ignoring the genuine circumstances, which were beyond his control. He not

submitted his third claim as his first two claims were just thrown away as non admissible. He applied to

Ombudsman Office and got most deserved justice from there. Award was of 28.05.2019 but he got the

claims on two different dates on 07.06.19 for Rs. 22340/- and 18.06.19 for Rs. 24514/-. After receiving his

claims, he submitted his third claim on 08.07.2019, but no one accepted the claim with the plea that

Divisional Manager was not available in the office. Then he was forced to sign 08/26.07.2019 and his claim

was shown as received on 29.07.2019. Then simple rejection letter on flimsy ground is of dt. 29.07.2017.

There is a gap of 11 days in receiving the two claims but company decided the fate of his claim in single day

and rejection replied on same day but dispatched on 26.08.2019. As per complainant, senior citizen (actual

age 75 yrs) with only one right eye and damaged left eye deserve sympathetic view. He requested for




a) Complainant’s argument: The denial of mediclaim is not justified as his earlier two claims were

rejected and he was waiting for Ombudsman’s decision to proceed in this claim.

b) Insurers’ argument: Complainant has given late intimation and submitted documents late by eight

months as such claim is not paid as per terms and conditions of the policy.




c) Annexure VI-A d) Reply of the Insurance Compan


On perusal of related documents, and after lessoning submissions made by both parties during personal

hearing, it is observed that claim of right eye treatment of Mr.Satish Kumar Malhotra taken at Advanced

centre for eyes, is not paid by insurance company. As per no claim letter of insurance company, insured

was admitted in the hospital on 12.10.2018, but never informed the company, as such violated condition

no. 5.3 of the policy. Further related documents were submitted by insured to company after a gap of 8

months and 17 days, as such violated condition no. 5.4 of policy, which states that all supporting

documents relating to the claim must be filed within 15 days from the date of discharge from the hospital.

Complainant argued that as similar two claims were not paid by company, he waited for decision of

Ombudsman in the matter, and only after getting award in his favour he filled this claim. Although this is

true that complainant received two awards in his favour from this forum against insurance company, but

every claim is treated as an independent claim. Complainant admitted in the hospital on 12.10.18.

Complainant vide his letter dt. 08.07.19 to company himself admitted that he waited for award and did not

submit the bill of relevant claim earlier and filled the same only after getting award. It confirms extra

ordinary delay in intimating and submission of documents to the insurance company. As per policy

condition, upon the happening of any event which may give rise to a claim under this policy notice with full

particulars shall be sent to office immediately and in case of emergency hospitalization, within 24 hours

from the time of hospitalization. As insured, violated policy terms and conditions and further delay is

deliberate and is extra ordinary in nature, this forum see no reason to interfere in decision of insurance

company, i.e. non admissibility of claim. Keeping in view of the above facts, the said complaint is hereby

dismissed and no relief is granted

AWARD





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Suresh Chopra V/S Max Bupa Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Suresh Chopra

BLE-094, The Belaire, DLF PH-V,

Sector-54, Gurugram Haryana- 122011

Mobile No.- 9899790280

2. Policy No:

Type of Policy


30326961201905

Health Policy

12-05-2019 to 11-05-2020



Mr. Suresh Chopra

4. Name of the insurer Max Bupa Health Insurance Co. Ltd.


6. Reason for repudiation Less than 24 hrs hospitalization





11. Amount of relief sought Not provided



2017





For the Complainant Absent (written statement)

For the insurer Dr. Abhishek, Manager




On 20-09-2019, Mr. Suresh Chopra had filed a complaint regarding rejection of his claim by

Max Bupa Company. As per complainant, his claim has been unjustly rejected and requested for


On 15-10-2019, the complaint was forwarded to Max Bupa Health Insurance Co. Ltd. Regional Office,

Delhi, for Para-wise comments and submission of a self-contained note about facts of the case, which


As per SCN submitted by insurance company, initially on the basis of declaration, the company has

issued a heartbeat Gold 5L + 1 Adult policy bearing no. 3032961201400 commencing from 12.05.14 in

the name of the complainant for a sum insured of Rs. 5,00,000/-. On 10.08.19, a claim was filed by the

complainant for the reimbursement of expenses of Rs. 25,354/- incurred during hospitalization of the

complainant himself on 27.03.19 wherein the patient was dog bite. As per the submitted documents,

hospitalization was of less than 24 hours. Hence as per policy terms and conditions the claim stands

repudiated under clause 12.32. Patient was admitted due to dog bite and in this condition there was no

need of hospitalization and can be managed on OPD basis.


a. Complainants argument : Complainant stated that insurance company has rejected their

claim on flimsy ground .

b. Insurers’ argument: Insurance Company stated that treatment not required hospitalization

and claim is repudiated as per terms and conditions of the policy.


Rules, 2017.




21. Result of Personal hearing with both parties(Observations & Conclusion)

Both Parties were called for hearing on 13.03.2020. Mr.Suresh Chopra, complainant vides his e-

mail informed that he is an old senior citizen and being not keeping well suffering from Vertigo,

he requested for consideration of his case in absentia.

On pursuance of various documents available in file including copy of complaint, contents of

SCN filed by insurance company, and submissions made by both parties, it is seen that Mr.

Suresh Chopra, complainant admitted in Fortis Hospital on 27.03.19 and discharged on same

day as a case of dog bite. His mediclaim is denied by insurance company vide letter dt. 17.10.19,

on the basis of hospitalization less than 24 hrs as per policy clause 12.32. They repeated their

stand in SCN as well as in hearing that complainant, who was admitted due to dog bite, there

was no need of hospitalization and treatment can be managed on OPD basis. As per discharge

summary of Fortis Hospital, patient was admitted and bed no. 2 was allotted to him, which

means treatment was taken as in-door patient. It is true that patient was discharged on same day

but policy condition allow him less than 24 hrs hospitalization if the same is due to technical

advancement. On dog bite, patient cannot wait for OPD treatment and his initial care including

vaccination require special attention of doctor. As such, insurance company is not right while

rejecting claim of complainant and is directed to pay his admissible claim as per terms and

conditions of the policy within 30 days of receipt of award copy.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by

both the parties, the insurance company is directed to pay the admissible claim as per

terms and conditions of policy within 30 days after the receipt of copy of award.



day of May, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Manoj Kumar V/S Max Bupa Health Insurance Co. Ltd.


1. On 11.11.2019, Mr. Manoj Kumar had filed a complaint in this office against Max Bupa

Health Insurance Co. Ltd. for not settling the health claim. The required documents

were submitted to the insurance company but they rejected the health claim under

policy no. 3052192201903.



3. Mr. Manoj Kumar confirmed vide e-mail dated 03.03.2020 that his complaint has been resolved

by insurance company and he has received payment of his claim and wants to withdraw his

complaint from this forum.


disposed off accordingly.






Case of Mr. Rajeev Kumar V/S Max Bupa Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajeev Kumar

S/o Sh. Raj Kumar, VPO- Mirpur, Rewari,

Haryana- 122502

Mobile No.- 9466041888

2. Policy No:

Type of Policy


30588879201802

Health Policy

04-10-2018 to 03-10-2019



Mr. Rajeev Kumar

Mr. Rajeev Kumar



6. Reason for repudiation Hospitalization not justified





11. Amount of relief sought Rs. 27207/-+Rs.10000/-(harassment)



2017



13. Date of hearing/place 13-02-2020 / 13.03.2020/Chandigarh


For the Complainant 13.02.2020 – Absent

13.03.2020 - Absent

For the insurer 13.02.2020 – Mr.Bhuwan Bhashkar

13.03.2020 – Dr. Abhishek

15 Complaint how disposed Dismissed in default



On 13-09-2019, Mr. Rajeev Kumar had filed a complaint vide which he informed that on 07.01.2019, he

approached Life Care Hospital, Rewari due to deteriorating health condition where doctor had advised him

to get admitted in the hospital for further investigation. He discharged on 09.01.2019 and bill of Rs. 27207/-

was paid by him. Thereafter all the documents were sent to Max Bupa Health Insurance Company for

reimbursement but they informed through email that the said claim is not admissible. Complainant

requested for payment of his claim and action against the erring officials.



made available to this office on 06-11-2019.

As per SCN received from insurance company, on the basis of declaration made by insured, company has

issued a health companion policy commencing from 04.10.16 in the name of complainant for a sum insured

of Rs.5 lacs. On 07.01.19, company received a preauthorization request for cashless facility from Lifecare

Hospital, Rewari for the patient Mr.Rajiv Kumar who was admitted on 07.01.19 with the complaint of fever

off and off since 1 week, weakness, vomiting, cough, pain left testis, burning micturition with the estimated

cost of Rs. 25000 to Rs. 30000/-. On the basis of submitted documents, company issued a letter of denial of

authorization as liability cannot be established and case needs a depth verification. Complainant filed a

reimbursement claim of Rs. 25,518/- on 01.02.19 for hospitalization of 07.01.19 to 09.01.19 wherein the

patient was diagnosed as Enteeric Fever/Epidydimo orchitis. During investigation of the case, it was found

from the medical record that there is tempering with the lab report and lab report was not made by the

pathologist, hence not valid. Further, there was no other patient and the bed was also in shabby condition

and the mattress was also in torn condition and there was tempering with the lab register etc. Hence, claim

declined as per policy terms and conditions.

18) Neither the complainant nor his representative appeared for the personal hearing on 13.02.2020 &

13.03.2020. The case is thus, dismissed in default and closed due to non-perusal of case by complainant.

Dated at Chandigarh on 13th day of Marach, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Raj Kumar V/S Max Bupa Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Raj Kumar

House No.- 144, Housing Board Colony, Sector-

7, Extn., Gurugram,

Haryana- 122001

Mobile No.- 9871278615

2. Policy No:

Type of Policy


30794282201800

Health Policy

07-08-2018 to 06-08-2019



Mrs. Sunita, Mr. Puneet Verma

Mr. Raj Kumar











2017





For the Complainant Mr. Raj Kumar, Complainant

For the insurer Dr. Abhishek Srivastava, Manager




On 10-10-2019, Mr. Raj Kumar had filed a complaint vide which he informed that his son Puneet Verma had

experienced severe unbearable stomach pain on 08.07.19 and admitted in Aryan Hospital,Gurgaon where

after CT scan doctor diagnosed his son with ruptured appendices and advised him for immediate

operation/surgery due to life threatening effect. There was no prior history of this problem with his son and

doctor also issued certificate in this regard. Max Bupa initially gave pre-authorization approval for

Rs.30000/-, but later rejected the same with assurance of reimbursement. He paid final bill of Rs. 79000/-

to the hospital and his son was discharged from hospital. Complainant pursed for reimbursement but

instead of reimbursing the bill, Max Bupa itself cancelled his policy after treatment even before expiration

date to save its cost and informed him through email dt. 15th July. After regular follow up, on 05.09.19, he

had received an email that his claim has been denied for settlement.



made available to this office on 26-12-2019. The complainant was sent Annexure VI-A for compliance,


As per SCN, company received a preauthorization request on 09.07.19 for cashless facility from Aaryan

Hospital Pvt. Ltd. for patient Puneet Verma who was admitted on 08.07.19 with the complaint of sudden

onset, severe pain right iliac fossa right lumber region, recurrent episode of vomiting against which

company issued a letter of authorization for a sum of Rs. 30,000/-. On the date of discharge, company

received discharge summary and other medical documents and issued a letter of denial of authorization

due to possibility of pre-existing conditions. Complainant filed reimbursement claim of Rs.79,575/- for

hospitalization from 08.07.19 to 12.07.19 in Aaryan Hospital wherein complainant’s son was diagnosed as

perforation peritonitis with pyoperitoneum. As per submitted documents, it was found that the insured

has past history of pain abdomen on and off since 2 years which was prior to policy inception, which as per

policy terms and conditions falls under material non disclosure. Hence claim stands denied as per policy

clause 5.1 and company also issued a notice of cancellation of policy.


they are ready to pay a claim amount of Rs 79000/- under policy no– 30794282201800 without any interest

and without deduction of any charges. Company also agreed to reinstate the relevant policy as per

applicable terms and conditions.

19) Accordingly, an agreement was signed between the Company and the complainant on 13.03.2020.

20. The complaint is closed with a condition that the company shall comply with the agreement and shall

send a compliance report to this office within 30 the days of receipt of this order for information and

record.

To be communicated to the parties.

Dated at Chandigarh on 13th day of March, 2020.

(Dr. D. K. VERMA)

INSURANCE OMBUDSMAN




Case of Mr. Sahil Mahajan V/S The United India Insurance Co. Ltd.


1. On 11.10.2019, Mr. Sahil Mahajan had filed a complaint in this office against United

India Insurance Co. Ltd. for deduction of Rs.5088/- made in the health claim under

policy no. 19701462.



3. Insurance company vide their e-mail dt. 06.03.2020 confirmed payment of Rs.2838/- on 04.11.2019

and processing of remaining amount of Rs. 2250/- on 06.03.2020.








Case of Mr. Hari Om Dhanuka V/S The National Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-048-1920-0400

1. Name & Address of the Complainant Mr. Hari Om Dhanuka

6-RB Rattan Chand Road, Near Ramdham

Mandir, Lawrance Road, Amritsar,

Punjab-0

Mobile No.- 9814667899

2. Policy No: 401900501810001113

Type of Policy


Mediclaim Policy

06-10-2018 to 05-10-2019



Mr. Hari Om Dhanuka





8. Nature of complaint Deduction in claim amount



11. Amount of relief sought Not provided (ded. Of 14608 in claim)



2017





For the Complainant Mr.Hari Om Dhanuka, Complainant

For the insurer Mr. Akantik, A.O.




On 24-09-2019, Mr. Hari Om Dhanuka had filed a complaint that company approved Rs. 23,382/- against

claimed amount of Rs. 37990/-, as such deducted Rs. 14608/-.

On 16-10-2019, the complaint was forwarded to The National Insurance Co. Ltd. Regional Office, Ludhiana,


available to this office on 11-11-2019.

As per SCN submitted by insurance company, patient Hari Om Dhanuka 66 years old covered under policy

no. 401900501810001113 with sum insured of Rs. 5,00,000/-, admitted in the hospital with the diagnosis of

Cataract and underwent PHACO surgery for which claim have been processed and settled for Rs. 23382/- as

per admissibility under the policy T & C. The patient has chosen to opt for treatment in a hospital which is

PPN in a PPN city and have gone for reimbursement and not opted for cashless facility. The reimbursement

of expenses incurred in PPN for the procedure shall be subject to the rates applicable to PPN, pkg pricing

and reimbursement of the claim in other than PPN hospital shall be guided by the reasonable and

customary charges only. Hence claim has been processed as per the applicable clause with the parameters

of the policy T & C without prejudice. Since the procedure done during hospitalization falls under the list of

PPN pkg of Cataract Rs. 22000/-. Thus authorization is done as per the PPN pkg only.


a) Complainants argument : Complainant requested for payment of his balance claim amount which

has wrongly been deducted by insurance company

b) Insurers’ argument: Insurance Company stated that they have logically deducted as per the terms

and conditions of the policy






After examining the documents submitted by both the parties, submissions made in hearing, it is seen that

there is no dispute regarding admissibility of claim of complainant Mr. Hari Om, who admitted in Dr. Om

Parkash Eye Institute Pvt. Ltd.,Amritsar with the diagnosis of Cataract and underwent PHACO surgery. But

against claimed amount of Rs. 37990/-, insurance company paid Rs. 23,382/- only. As per company, insured

has chosen to opt for treatment in PPN hospital but not opted for cashless facility. The reimbursement of

expenses incurred in PPN for the procedures shall be subject to the rates applicable to PPN package pricing

and other claims shall be guided by the reasonable and customary charges only. As per company, since the

procedure done during hospitalization falls under the list of PPN package of cataract, i.e. Rs.22000/-, thus

authorization is done as per the PPN pkg only. As such besides other deductions, against procedure charges

of Rs. 35000/-, company paid Rs. 22000/- under reasonable and customary charges clause to the

complainant. It has been observed that PPN rates have not been specified for various ailments/ diseases in

the policy for different locations. As per complainant, he never availed cashless facility as he want to use

better lens. There is no condition in policy which restricts him from doing so within the limits of sum

insured. Hence, Insurance company has arbitrarily made deduction in claim in the name of PPN package

rates/reasonable and customary charges clause although complainant has paid in full to the hospital.

Further, reasonable and customary charges rates between TPA / Hospital/ Insurance company were never

provided to client for specific procedure. If company, feels that hospital has charged higher rates from

complainant, they may recover the same from concerned hospital as per their PPN agreement and should

not made complainant scapegoat under this clause. Therefore, besides already paid claim, insurance

company is directed to pay Rs 13000/- to the insured, subject to terms and condition of policy within 30

days after receipt of award copy.

AWARD


parties during the course of personal hearing, the balance amount of Rs. 13000/- subject to

terms and condition of policy is hereby awarded to be paid by the Insurer to the Insured, towards

full and final settlement of the claim.



day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Bhim Sain Jain V/S The United India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-051-1920-0471

1. Name & Address of the Complainant Mr. Bhim Sain Jain

# 26, Veer Nagar, Shivpuri Road, Ludhiana,

Punjab- 141008

Mobile No.- 9888017250

2. Policy No:

Type of Policy


2010002818P103147747

Individual Health Policy

18-06-2018 to 17-06-2019



Mr. Bhim Sain Jain





8. Nature of complaint Less payment of claim






2017





For the Complainant Mr. Bhim Sain Jain, Complainant

For the insurer Mr. Avtar(Co.) & Dr.Amardeep(TPA)




On 06-11-2019, Mr. Bhim Sain Jain had filed a complaint vide which he informed that he has undergone

heart surgery at Hero Heart DMC Ludhiana and hospitalized from 20.01.19 to 29.01.19. He has applied for

cash less claim through Raksha TPA Pvt. Ltd. and spend Rs. 2,84,000/- on his surgery and treatment, but he

received Rs. 1,50,000/- against claimed payment. Complainant is a senior citizen and had mediclaim policy

for last 25 years. He requested for payment of difference of claim.


Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 23-12-2019. The complainant was sent Annexure VI-A for compliance,


As per SCN submitted by insurance company, deductions in claim are made as under:

Expense Name Billed Amt Deductions Approved Reasons for deductions

Surgeon Fee 226000 68500 157500 70% non payable as per policy, 70%

major surgeries of applicable S.I.

Invest. Charges 200 200 0 Non payable as SI exhausted

Hospital Services 814 814 Rs.614 Gen. charges, Rs.200 Misc.

charges, non payable

Medication

charges

57177 57177 0 Non payable as SI exhausted

TDS deducted 12600 10% TDS deduction

Hospital Disc. 31500 0 20% hospital discount on bill.


a) Complainants argument : He has policy since 1992. Company has paid less claim although bills

were of about three lacs.

b) Insurers’ argument: Insured has history of HTN and Diabetes, so as per policy terms and conditions ,

applicable sum insured is considered of year 2014-15.






After going through the complaint and documents, SCN of the insurance company and submission made by

both the parties during personal hearing, it is observed that Mr.Bhim Sen Jain, Complainant has undergone

heart surgery and remain hospitalized from 20.01.2019 to 29.01.2019. According to insurance Company, as

per policy condition, in major surgeries, actual expenses incurred or 70% of the sum insured, whichever is

less, is payable. Hence company has paid claim of 70% of applicable sum insured. It is observed that

company paid claim considering sum insured as Rs. 2,25,000/- although sum insured of relevant policy no.

2010002818P103147747 was Rs. 3,00,000/-. Company’s plea is that as per discharge summary and other

related documents of hospital, patient was having history of Hypertension (1-2 yr) and DM Type 2 (15-20

yrs). Hence, as per policy condition, they have taken sum insured of 48 months back , i.e. Rs.2,25,000/- of

year 2014-15 and paid the claim accordingly. But company’s decision is not fair in view of the fact that

diabetes can be controlled through medicines and has no relevance with the current claim of insured which

otherwise admitted and paid by company. Therefore, Company who paid the claim as per lesser sum

insured, is directed to pay the difference of admissible claim to insured by considering 70% of sum insured

Rs. 3,00,000/- instead of 70% of sum insured Rs. 2,25,000/- subject to policy terms and conditions within 30

days of receipt of award copy.

AWARD


parties during the course of personal hearing, balance admissible claim is hereby awarded to be

paid by the Insurer to the Insured, considering 70% of sum insured Rs. 3,00,000/- subject to policy

terms and conditions towards full and final settlement of the claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Chander Shekhar V/S The National Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Chander Shekhar

House No.- B-IX/1079, Sangla Shivala Road,

Ludhiana, Punjab-0

Mobile No.- 8054857548

2. Policy No:

Type of Policy


401603/48/17/8565000001

Mediclaim Policy

29-06-2017 to 28-06-2018



Mr. Chander Shekhar








11. Amount of relief sought Rs. 1,10,000/- with interest

12. Complaint registered under Rule 13 (1)(b) – any partial or total repudiation


2017




For the Complainant Mr. Chander Shekhar, Complainant

For the insurer Mr. Harbilas Singh, A.O.




On 27-09-2019, Mr. Chander Shekhar had filed a complaint regarding rejection of his claim due to PED. On 21-10-2019, the complaint was forwarded to The National Insurance Co. Ltd. Regional Office, Ludhiana,


available to this office on 20-11-2019. The complainant was sent Annexure VI-A for compliance, which

reached this office on 06-11-2019.

As per SCN submitted by insurance company, as per discharge summary of Global Heart and Super

Specialty Hospital, patient is k/c/o – BA from many years, H/O HTN from 2-3 years on regular treatment.

The claim is being denied on account of that this is a third year of policy and patient is suffering from PED of

Bronchial Asthma, which is not covered under the policy.


a) Complainant’s argument: Complainant requested that insurance company has repudiated claim on

flimsy ground of pre existing disease and he requested for settlement of his claim.

b) Insurers’ argument: Insurance Company on other hand requested for dismissal of complaint as

repudiation is based on logical grounds as per terms and conditions of policy.





On perusal of various documents available in file including the copy of complaint, SCN of insurance

company and submissions made by the both parties during personal hearing, it is observed that

Mr.Chander Shekhar hospitalization claim is repudiated by insurance company. As per reasons for

repudiation given in repudiation letter dt. 11.05.18, the patient presented with complaints of pain on deep

breathing on 25.03.18 at Global Heart and Super Specialty Hospital. Insured was diagnosed with Acute

Exacerbation of Bronchial Asthma. The submitted documents indicate Oral Medicines was administered.

The discharge summary submitted /retrieved in the documents indicate, date of inception of policy is

28.06.2015. As per discharge summary, patient is a k/c/o asthma for many years. Hence the ailment is per-

existing. As per policy, pre-existing disease is covered after 4 years of continuous coverage under the policy.

Hence the claim is denied under clause no. 4.1 of the policy related with pre-existing disease. It is seen that

complainant has policy since 28.06.2015 and period of insurance of current policy is 29.06.2017 to

28.06.2018. Representative of insurance company underlined that it is third year of policy and insured have

problem/disease since many years, as such treated as pre existing disease. Concerned hospital vide their

letter dt. 11.06.2018 had clarified that attendant of patient has not aware of exact history and they verified

that there is no past H/o Brochial Asthma. Further it is observed that in discharge summary, instead of

specifying exact period, under past history, K/C/O – BA from many years, is written. Moreover in discharge

summary of Kalyan Hospital, in which complainant remain hospitalized due to fracture, from 11.03.17 to

16.03.17, it is specifically written that there is no past medical h/o DM, Hypertension, Asthma, Drug Allergy,

Cardiac problem of any other chronic illness. In the absence of any concrete evidence of exact period of

alleged pre-existing disease, decision of insurance company to repudiate of claim on the basis of same, is

not in order. Keeping in view all above facts, insurance company is directed to pay admissible claim of

complainant as per terms and conditions of the policy within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, Admissible claim is hereby awarded to be paid by

the Insurer to the Insured as per terms and conditions of the policy, towards full and final




day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Ajay Dang V/S Future Generali India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ajay Dang

H. No.- 166, Sector-2, Rohtak, Haryana-0

Mobile No.- 9871634825

2. Policy No:

Type of Policy


HTO-37-18-7243215-01-000

Family Floater Policy

20-02-2019 to 19-02-2020



Mr. Ajay Dang

4. Name of the insurer Future Generali India Insurance Co. Ltd.


6. Reason for repudiation Dental treatment on OPD not covered



9. Amount of Claim Rs. 1.35 lakh


11. Amount of relief sought Rs. 1.35 lakh



2017





For the Complainant Mr. Ajay Dang, Complainant

For the insurer Ms. Deepa Bisht, Legal Officer




On 28-10-2019, Mr. Ajay Dang had filed a complaint that intimation of accidental case causes trauma on

the upper Jaw alongwith reimbursement claim of Rs.1.35 lacs was submitted to M/s Future Generali on

25.08.19. Original documents were sent through courier on 05.09.19. Company vide e-mail dt. 23.09.19

send repudiation letter that claim does not fall under the preview of the policy. It is told that medical

expenses incurred on dental treatment done on OPD basis are not payable as per policy. Hence this claim

stands repudiated on the basis of exclusion clause benefit 13. Complainant told company that treating

doctor clearly mentioned that this is a accidental case and treatment given under day care procedure under

clause 125 of the policy, under which hospitalization is not mandatory. Company regularly changed their

stand and conveyed vide e-mail dt. 14.10.19 that dental treatment is not covered under policy Health Total

Family floater policy(Vital Plan) OPD treatment (applicable for superior plan and premiere plan). In case of

dental consultation and diagnostic company’s liability will be restricted to 70% of the admissible bills. As

per complainant, this case is accidental in nature and rejection criteria adopted by FGH has no relevance in

contrast of policy conditions. He requested for settlement of his claim.

On 27-11-2019, the complaint was forwarded to Future Generali India Insurance Co. Ltd. Regional Office,

Mumbai, for Para-wise comments and submission of a self-contained note about facts of the case, which



As per SCN submitted by insurance company, they issued policy from 20.02.2019 to 19.02.2020 in favour of

Mr.Ajay Dang. Company received claim intimation from the insured on 09.10.19 for treatment taken on

25.08.19 at Sunflag Multispecialty Hospital. Insured was treated for ‘Dent alveolar Fracture and Luxation of

Tooth’ due to an alleged RTA on OPD basis. Company has referred the policy terms and conditions which

clearly stated that the exclusion of ‘Dental treatment or surgery of any kind unless requiring Hospitalization

as a result of injury’. Claim of complainant/insured was therefore repudiated in a bonafide manner as the

same falls under Exclusion clause of terms and conditions of the policy.

18)Cause of Complaint:

a) Complainants argument : His genuine claim is not paid by insurance company, on pretext of one

reason or other.

b) Insurers’ argument: Claim is denied as per policy terms and conditions, which not allowed payment

of OPD treatment.






On perusal of related documents, and after lessoning submissions made by both parties during personal

hearing, it is observed that claim of dental treatment due to accident is repudiated by insurance company

stating dental treatment done on OPD is not payable as per policy. During personal hearing, complainant

told that he was hit by scooterist on back side. Due to same, four teeth implants were done on same day

and treatment continued. Mr. Ajay Dang, complainant also sent to this office by post, cash receipt

dt.25.08.19 of Rs. 79000/- & cheque receipt dt.14.03.2020 of Rs. 56000/- issued in his favour by Sunflag

Global Hospital, Rohtak to confirm payment made by him. As per treatment papers of Sunflag Global

Hospital, Mr.Ajay Dang met with a road side accident in sector 2 area. Insurance company neither

investigates nor raises any doubt regarding injury due to accident, as claimed by complainant & hospital,

which leads to this treatment. In other words, company accepted that this was not a routine dental

treatment but was due to an accidental injury. Further, as per SCN of the company, they received claim

intimation from the insured on 09.10.19 for treatment taken on 25.08.19. But again, this fact of late

intimation is ignored while dealing the claim and objection in this regard is not rose at any stage by

company. It indicates the casual approach of the company in dealing the matter. It’s true that patient was

admitted and discharged on same day but as per policy, under day care treatment, surgical procedure

undertaken under general or local anesthesia in a hospital/day care centre, which is less than 24 hours

because of technological advancement, is allowed. Keeping in view, facts of the case, it is observed that

company denied the claim on wrong grounds and is directed to pay admissible claim as per other terms and

conditions of the policy within 30 days of receipt of award copy.

AWARD


parties during the course of personal hearing, Admissible claim as per terms and conditions of the

policy is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement

of the claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Basant Kumar Goyal V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Basant Kumar Goyal

House No.- 342, Sector- 20, Huda, Sirsa,

Haryana-0

Mobile No.- 9896413644

2. Policy No:

Type of Policy


1202002818P114211757

Health Policy

15-01-2019 to 14-01-2020



Mr. Basant Kumar Goyal



6. Reason for repudiation Hormonal Therapy not covered.


8. Nature of complaint Nonpayment of claim



11. Amount of relief sought Rs. 19504/- + interest



2017





For the Complainant Mr.Basant Kumar Goyal,Complainant

For the insurer Ms. Mamta Bansal, Dy.Manager




On 18-09-2019, Mr. Basant Kumar Goyal had filed a complaint that he is suffering from Protesrate Cancer

since 2013 and after Biopsy and after radiation he has been under treatment for hormonal therapy by the

doctors and have been reimbursed under cashless facility by Sarvodya Hospital, Hisar on 05.10.2016 and

after wards his claim were reimbursed. The last bill for treatment 01.01.2019 for Rs. 19552/- was

reimbursed on 24.01.2019. Company renewed his policy for the period 15.01.2019 to 14.01.2020. He again

got the treatment from the same doctors and hospitalized under day care on 04.06.2019 and was given

same treatment. Now the company has taken U turn and advised him on phone that his bill has been

denied for payment as Hormonal Therapy alongwith injection Leoprolide are not payable.





As per SCN received from insurance company, the patient Basant Kumar Goyal was admitted in N C Jindal

Institute of Medical Care Research Hisar as a case of Prostate CA (Stage IV). Patient was given Zoledronic

Acid and Leoprolide which is Hormonal Therapy, which is not covered under day care list of disease neither

required 24 hours hospitalization and payable only under domiciliary option. In current year, the insured

has not opted for Domiciliary option, hence the claim has been repudiated. In previous policy, insured

opted the Domiciliary Option, so the previous claims were paid.


a) Complainants argument : Complainant stated that insurance company has arbitrarily denied his

claim although earlier same type of claims were paid by them.

b) Insurers’ argument: Complainant has opted for non domiciliary option, under which the current

claim is not payable as per terms and conditions of the policy.






After going through the complaint and documents, SCN of the insurance company and submission made by

both the parties during personal hearing, it is seen that claim of complainant has been repudiated by the

insurance company, claiming that hormonal therapy (injection Leoprolide) is not covered under the policy.

Complainant, who is suffering from Protestrate cancer informed that company has earlier reimbursed him

treatment for hormonal therapy, but now took u-tern and denied the claim. As per insurance company,

insured has not opted for domiciliary option in current policy under which the relevance claim arises, the

fact to which complainant also not denied. As per annexure-1, special condition no. 8 of policy, for cancer

treatment(advanced), Adjuvant/Neo-Adjuvant Caner treatment to be covered with domiciliary policy only,

OPD basis not possible for non-domiciliary policies. Accordingly, claim is denied by insurance company as

per policy terms and conditions. Complainant underlined that reason for rejection given by insurance

company was use of Leoprolide injection / Harmonal Therapy and not for obtaining domiciliary option.

Although insurance company has not elaborated the reason of rejection in their letter to insured, but it not

allow superseding policy conditions of relevant policy in favour of insured. Keeping in view the above facts,

in my opinion, decision of insurance company does not require any interference. As such, the said

complaint is hereby dismissed and no relief is granted.

AWARD





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mrs. Sunita Khurana V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mrs. Sunita Khurana

5 N/ 20 A N.I.T., Faridabad,

Haryana- 121001

Mobile No.- 9818487096

2. Policy No:

Type of Policy


P/700001/01/2019/046877

Star Comprehensive Insurance Policy

15-02-2019 To 14-02-2020



Mrs. Sunita Khurana

Mrs. Sunita Khurana



6. Reason for repudiation Internal congenital disease not covered in first

two years of policy



9. Amount of Claim Rs 6.00 Lakhs


11. Amount of relief sought Rs 6.00 Lakhs



2017





For the Complainant Mrs. Sunita Khurana





On 11-11-2019, Mrs. Sunita Khurana had filed a complaint to this office that she has purchased Star

Comprehensive Insurance policy for her family. She was admitted in Asian institute of Medical

sciences, Faridabad on 29th April 2019 due to severe Aortic regurgitation, isolated small restrictive

inlet, VSD, complete heart block, Aortic valve replacement permanent pacemaker implantation done

LVEF 55%. She completed all the formalities with regard to her claim. But the Insurance Company

repudiated the claim on the ground that patient has undergone treatment for bicuspid Aortic wall-

severe AR and small VSD, which is a congenital internal disease during the second year of policy. As

such, as per exclusion number 3 of the policy, the company is not liable to make payment in respect of

any expenses incurred by the complainant for treatment of the above mentioned disease during the

first two years of continuous operation of the insurance cover. According to her she had a policy from

15-09-2011 and is continuously renewing her policy in time. She incurred an expense of Rs 6.00 lacs

for her treatment. She requested this office for payment of her claim.


they are ready to pay a claim amount of Rs 4,55,077/- under policy no– P/700001/01/2019/046877 for

hospitalization bill without any interest and without deduction of any charges. Further, complainant

was also directed to submit pre and post hospitalization bills, if any to the insurance company within

30 days.

19) Accordingly, an agreement was signed between the Company and the complainant on 18.03.2020.

20. The complaint is closed with a condition that the company shall comply with the agreement and shall

send a compliance report to this office within 30 the days of receipt of this order for

information and record.

To be communicated to the parties.


day of March, 2020.

(Dr. D. K. VERMA)

INSURANCE OMBUDSMAN




Case of Mr. Praveen Kumar V/S Star Health and Allied Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-044-1920-0455

1. 01-11-2019, Mr. Praveen Kumar had filed a complaint in this office against Star Health and Allied

Insurance Co. Ltd for not settling the health claim. The required documents were submitted to the

insurance company but the insurance company did not settle the health claim under policy no.

P/161131/01/2019/002780.



3. Mr. Praveen Kumar confirmed telephonically that his complaint has been resolved by insurance

company and he has received payment of his claim and wants to withdraw his complaint from this

forum.








Case of Mr. Parveen Singla V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Parveen Singla

8/196, Ward No.- 5, Housing Board,

Hanumangarh, Rajasthan-0

Mobile No.- 9461564846

2. Policy No:

Type of Policy


P/211125/01/2020/000632

Health Policy

13-08-2019 To 12-08-2020



Mr. Parveen Singla

Mrs. Parneet Rani



6. Reason for repudiation Non-disclosure of PED - CA Gall Bladder


8. Nature of complaint Non-disclosure of PED - CA Gall Bladder

9. Amount of Claim Rs 12 Lakhs


11. Amount of relief sought Rs 12 Lakhs



2017





For the Complainant Mr. Parveen Singla, Complainant



16 Date of Award/Order 19-03-2020


On 20-11-2019, Mr. Parveen Singla had filed a complaint that his wife had taken a policy from Star Health

and Allied Insurance Co. Ltd on 13-08-2019. His wife Mrs. Parneet Rani visited Mahaveer Hospital

Hanumangarh on 04-09-2019 for the first time. Doctor advised to go in for various diagnostics test. After CT

scan, it was found that “a well defined homogeneously enhancing intra luminal GB lesion without any

extra-luminal extension” was found. She was detected with gall bladder mas on 05-09-2019 and the gall

bladder was removed by surgery on 08-09-2019. She was discharged from hospital on 11-09-2019. Gall

bladder Mas was sent for biopsy. And on 17-09-2019, tumor was detected for the first time in

histopathology report. His wife underwent surgery for removal of tumor from Rajiv Gandhi Cancer Institute

and research on 03-10-2019. Insurance company denied the cashless on the basis of discharge summary of

Chawla Nursing Home dated 08-09-2019. They stated that discharge is of 08-08-2019 which is prior to

inception of the policy. The date on the discharge slip is 08-09-2019 and not 08-08-2019. The doctor

handwriting is as such which is not very clear. Even duplicate discharge summary was given from doctor.

Inspite of giving all documents and clarification to insurance company they denied his genuine claim and

also cancelled the policy on 12-11-2019 on the ground of PED. He requested for payment of his claim.

On 28-11-2019, the complaint was forwarded to Star Health and Allied Insurance Company Ltd Regional

Office, Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 16-03-2020.

In the SCN insurance company stated that the complainant took Family Health Optima Insurance Plan

through Branch Office - Hisar 2 covering Mr. Parveen Singla (Self), Mrs. Praneet Rani Singla (Spouse),Mr.

Mukesh Kumar Singla and Ms. Ankita (Dependent Children) for the floater Sum Insured of Rs. 5,00,000/-

vide policy no. P/211125/01/2020/000632 for the period from 13/08/2019 to 12/08/2020 for the first time.

The Insured reported the claim during the 2nd month of the Medical Insurance Policy. As per pre-

authorization form, the insured claimed approval for an amount of Rs. 3,56,985/- to avail cashless facility.

The Insured was admitted on 01/10/2019 at Rajiv Gandhi Cancer Institute and Research Centre, Delhi.

Complainant was diagnosed with CA Gall Bladder. On perusal of the claim documents, it is observed that,

the Discharge Ticket from the Laxmi Bai Memoral Chawla Nursing Home, Rajasthan for the period of

hospitalization from 08/08/2018 to 11/08/2018 states the insured was operated for open Cholecystectomy.

The letter dated 21/08/2019 of Dr Aditya Chawla addressed to Dr Naveen Sharma of Apex Hospital, states

that the patient is a K/c/o Papillory Adenolocins. From the above finding it is confirmed that, the insured

had CA Gall Bladder was operated for Cholecystectomy prior to the commencement of the medical

insurance policy, the same was not disclosed in the proposal at the time of taking the policy which amounts

to non-disclosure of material facts. The present admission and treatment of the insured patient is for the

non-disclosed pre existing disease. Whereas, these facts were not disclosed at the time of taking the policy

which amounts to non-disclosure of materials. Information was sought from the insurer on PED if any, in

column 5, for a specific query-the insured answered in the negative. The exact information on queries and

reply given by the insured is reproduced below:

Health History

1. Is the person proposed for Insurance in good health and free from physical and mental disease or

infirmity. If not give details – Yes

2. Has the person proposed for Insurance consulted / diagnosed / taken treatment / been admitted for any

illness / injury – If yes, details – “NO”

4 (j). Has the person proposed for insurance ever suffered or suffering from any of the following – Disease of Stomach, Intestine, Liver, Gall bladder/ Pancreas, Kidney, Urinary Bladder, Urinary Tract diseases If yes Since When – “NO”

The Insured answering – “No” for the above specific questions relating to medical history which is clearly a

Non–disclosure of material fact making the Contract of Insurance voidable as confirmed by the Supreme

Court in Satwant Kaur Sandhu v. New India Assurance Co. Ltd. (2009) 8 SCC 316 (citation). At the time of

commencement of the first year policy which is from 13/08/2019 to 12/08/2020, the insured have not

disclosed the above mentioned medical history/health details of the insured-person in the proposal which

amounts to misrepresentation / non-disclosure of material facts. As per Condition No.6 of the policy, “if

there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other

person acting on his behalf, the Company is not liable to make any payment in respect of any claim”. Hence,

the claim is not liable under Condition no. 6 of the policy. As per Condition No.12 of the policy, “the

company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non disclosure of

material fact as declared in the proposal form /at the time of claim or non-co-operation of the insured

person”. Hence, the policy was cancelled with effect from 12/11/2019 due to non-disclosure of PED - CA

Gall Bladder after sending a 30 days notice on cancellation of policy to the Insured vide letter dated

03/10/2019. They requested to dismiss the complaint.



a) Complainant’s argument: Complainant stated that he had completed all claim related formalities

and documents were sent to the company but claim was repudiated on the ground of PED.

b) Insurers’ argument: Insurance Company stood to their stand and contents of SCN. They requested

for dismissal of complaint as their denial is as per policy terms and conditions. Complainant has

misrepresented and suppressed his medical condition and as per exclusion clause the policy does

not have coverage for pre existing illness.






I have gone through the various documents available in the file, complaint copy, SCN submitted by

insurance company and submission made by both the parties during the personal hearing. The insurance

company however, was represented by their executive who reiterated the contents of the SCN and the

repudiation letter dated 03.10.2019 issued to complainant for denying the claim. As per documents

available in the file complainant is covered under Family Health Optima Insurance Plan taken by him for

covering his family. The claim filed by complainant was repudiated vide repudiation letter dated 03.10.2019

taking recourse to policy condition no-15 which refers to the denial of the claim in respect of illness

directed attributable to any illness that is pre existing before taking the policy. The same stand of

repudiation has been taken by insurance company at the time of personal hearing. Further, in SCN,

insurance company has also taken the stand that the complainant is a known case of Papillory Adenolocins

which amounts to non-disclosure at the time of taking the policy. On scrutiny of various documents it is

seen that the repudiation letter doesn’t mention anything about the nature of pre-existing illness, even

OPD slip of Chawla Nursing Home, Hanumangarh records in support of the claim by insurance company

about pre-existing illness has been placed before this Forum by insurance company is not acceptable.

Insurance company claims the date on OPD slip as 21/25-08-2019 but whereas the date is 21-09-2019. As

such insurance company has failed miserably to produce any documents in support of their contention

about the pre-existing Papillory Adenoca Carcinoma. The denial of claim by insurance company being

totally unjustified and arbitrary. The insurance company is directed to settle the claim subject to

submission of complete documents / bills relating to treatment taken by insured within 30 days after the

receipt of the award copy in accordance with sum assured.

AWARD


both the parties during the course of personal hearing, the insurance company is

directed to settle the claim subject to submission of complete documents / bills relating

to treatment taken by insured within 30 days after the receipt of the award copy.



day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Diwakar Bhatia V/S Bajaj Allianz General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Diwakar Bhatia

H. No.- 1407, Sector- 44-B,

Chandigarh- 160047

Mobile No.- 9855701600

2. Policy No:

Type of Policy


OG-19-1201-8430-00000512

Health Policy

28-03-2019 To 27-03-2020



Mr. Diwakar Bhatia

Mr. Diwakar Bhatia

4. Name of the insurer Bajaj Allianz General Insurance Co Ltd

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not applicable


8. Nature of complaint Non-issuance and cancellation of policy

9. Amount of Claim Not applicable


11. Amount of relief sought Non-issuance and cancellation of policy

12. Complaint registered under Rule no:

Insurance Ombudsman Rules, 2017

Rule 13 (1) (g) – issuance of policy which is

not in conformity with the proposal

submitted by the proposer.



For the Complainant Mr. Diwakar Bhatia, Complainant

For the insurer Mr. Saurav Khullar, Senior Executive

Ms. Simarpreet Kaur, Executive




On 21-11-2019, Mr. Diwakar Bhatia had filed a complaint that he has purchased one Health guard policy

after duly completing all formalities. He purchased a floater health policy with sum assured of Rs 3.00 Lacs.

Subsequently, he submitted an application for enhancement of cover through Extra Care Plus- a Top up

policy to increase the cover and all formalities were completed as per their direction. To his utter surprise,

Insurance Company not only rejected his proposal for enhancement of cover but also issued a notice of

non-disclosure of material fact for base policy. Inspite of replying to all the queries the company, the

company maintain that enhancement proposal has been rejected and issued a proposal rejection letter

dated 28-07- 2019 for Extra Care Plus. However, company remained silent on his request for withdrawal of

notice on base policy. Surprisingly, the policy has been withdrawn from his DIGI locker as well as mobile

application of the company. He was surprised that in spite of giving clear details relating to ailment suffered

by Ms. Shashi Bhatia his policy was cancelled. He requested that company may be directed for restoration

of base policy number OG-19-1201-8430-00000512 for Rs 300000/- and to provide smooth access of the

said policy. Further, he also requested that company may be directed to issue the extra care plus policy of

Rs 10 lakh vide proposal application number 117346625.

On 29-11-2019, the complaint was forwarded to Bajaj Allianz General Insurance Co. Ltd Regional Office,



Insurance Company stated in the SCN that the complainant in his complaint had asked the insurance

company to restore the Health guard policy and to issue the Extra care policy. Insurance company as per

the relief sought has restored the health guard policy vide policy number OG-19-1201-8430-00000512 and

issued the extra care policy vide policy number OG-20-1201-8432-00000262. The relief/claim of

complainant has already been provided by this opposite party insurance company. The said complaint of

complainant is liable to be dismissed as both the policies of the complainant are now active. Therefore, in

view of the foregoing submission, this case may kindly be dismissed.



a) Complainant’s argument: Complainant stated that inspite of assurance given to this forum by

insurance company, he has an apprehension that insurance company may again resort to same

tactics after hearing. He stressed that insurance company has never responded to him in writing

about his complaint. Only verbal assurance has been given. He requested that written

communication may be given to him by insurance company.

b) Insurers’ argument: Insurance Company stated that since they have already redressed the grievance of

the complainant, hence complaint may be dismissed.






After hearing both the parties and examining the documents available in the complainant file, It has been

observed that there is no disagreement between both the parties that policy has been restored.

Complainant was of view that he has an apprehension that insurance company may again cancel his policy

since they have not given him any communication with regard to restoration of his policy. Insurance

company stated in the SCN that they have already reinstated both policies. Hence, the insurance company

is directed to give in writing to complainant information with regard to redressal of his grievance within 10

days after the receipt of copy of award.

AWARD


parties during the course of personal hearing, insurance company will intimate in writing to

complainant for restoration of both policy.


Dated at Chandigarh on 23rd

day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Akhil Arora V/S IFFCO-TOKIO General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Akhil Arora

1492, Sector-15, Sonipat, Haryana-0

Mobile No.- 9873122823

2. Policy No:

Type of Policy


52732251

Health Policy

18-01-2019 to 17-01-2020



Mr. Akhil Arora

Mrs. Manisha Arora

4. Name of the insurer IFFCO-TOKIO General Insurance Co. Ltd.


6. Reason for repudiation No Active line of treatment








2017





For the Complainant Mr. Akhil Arora, Complainant

For the insurer Ms. Monika Sharma, Senior Executive




On 20-11-2019, Mr. Akhil Arora had filed a complaint that his wife Mr. Manisha Arora was admitted in

Mednata Medicity due to illness. But his claim has been rejected by the insurance company on the ground

of general definition no -12. But, as per general definition no 12 (1), any treatment, test or medication of

stay in hospital or part of stay in hospital which is required for the medical management of illness by the

insured person and as per point (3) must have been prescribed by the medical practitioner. However, his

wife claim has been rejected when he followed all the prescribed procedure and treating doctor advice to

ruled out the cause of illness. As per doctor advice to find the cause of illness 24 hour hospitalization was

must as they have advised 24 hour continuous ECG which was possible under IPD. He requested for


On 28-11-2019, the complaint was forwarded to IFFCO-TOKIO General Insurance Co. Ltd. Regional Office,

New Delhi, for Para-wise comments and submission of a self-contained note about facts of the case, which


In the SCN insurance company stated that complainant was issued a Swasthya Kavach Policy no. 52732251

to Mr. Mohan Lal Chopra for the period from 18/01/2019 to 17/01/2020 strictly subject to terms and

conditions of the policy. As per the Policy terms and condition specifically mentions as “GENERAL

DEFINITONS” POINT NO. 12 which reads as under:

“GENERAL DEFINITION”

12. Medically Necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part

of a stay in hospital which

a) Is required for the medical management of the illness or injury suffered by the insured person

b) Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care

in scope, duration, or intensity

c) Must have been prescribed by a medical practitioner

d) Must conform to the professional standards widely accepted in international medical practice or by

the medical community in India.

Complainant lodged a claim in furtherance to care of right eye pain, right fronto temporal pain, vertigo,

headache, staring look which was diagnosed as Seizure on 20/06/2019, and was admitted in Medanta

Hospital for 1 day regarding the same. As per discharge summary and final hospital bill it has been noticed

that patient was given only Tab. Pansec 40mg during the period of admission. Tab. Pansec helps in

decreasing the acid produced in the stomach and helps in promoting healing of ulcers and is used for other

acidity-related disorders. Thus this shows that there was no therapeutic treatment done and the patient

was admitted only for assessment purposes. In furtherance to this the MRI report was also normal and

VEEG report was awaited. The patient can be managed on OPD basis. Under the captioned claim patient

was admitted and underwent MRI brain with EEG which is done for evaluation purpose and there is no

active line of treatment present under current hospitalization, hence claim is not admissible as per terms &

conditions of the policy. As such, Insurance company was left with no other option and was constrained to

reject the claim vide letter dated-18/07/2019. Insurance company submitted that the present complaint is

devoid of any merits and is hence liable to be dismissed forthwith.


a) Complainant’s argument: Complainant requested that his claim has been repudiated on flimsy

ground and his wife was admitted in the hospital as per advice of doctor only. He requested for

payment of claim for his wife treatment.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN and stated that their

decision is as per policy terms and conditions.





21) Result of Personal hearing with both parties(Observations & Conclusion) On going through the complaint and other documents in file, and submission made by both the party




complainant was admitted in Medanta- Medicity Hospital, Gurugram on 20-06-2019 to 21-06-2019 with a

diagnosis of? Seizure. On going through discharge summary Medanta- Medicity Hospital, Gurugram, it is

observed that main reason for admission was investigation. Further, his MRI brain and EEG was normal. He

was managed with tablet Pansec only. It clearly brings out that no active line of treatment was given to the

patient during admission and hospitalization was only for investigation purpose. Hence, the decision of the

insurance company is in order and no interference is required in their decision. Keeping in view of the

above facts, the said complaint is hereby dismissed and no relief is granted.

AWARD





day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Akhil Arora V/S IFFCO-TOKIO General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Akhil Arora

1492, Sector-15, Sonipat, Haryana-0

Mobile No.- 9873122823

2. Policy No:

Type of Policy


52732251

Health Policy

18-01-2019 to 17-01-2020



Mr. Akhil Arora

Mrs. Manisha Arora



6. Reason for repudiation No Active line of treatment








2017





For the Complainant Mr. Akhil Arora, Complainant

For the insurer Ms. Monika Sharma, Senior Executive




On 20-11-2019, Mr. Akhil Arora had filed a complaint that his wife Mr. Manisha Arora was admitted in

Mednata Medicity due to illness. But his claim has been rejected by the insurance company on the ground

of general definition no -12. But, as per general definition no 12 (1), any treatment, test or medication of

stay in hospital or part of stay in hospital which is required for the medical management of illness by the

insured person and as per point (3) must have been prescribed by the medical practitioner. However, his

wife claim has been rejected when he followed all the prescribed procedure and treating doctor advice to

ruled out the cause of illness. As per doctor advice to find the cause of illness 24 hour hospitalization was

must as they have advised 24 hour continuous ECG which was possible under IPD. He requested for





In the SCN insurance company stated that complainant was issued a Swasthya Kavach Policy no. 52732251

to Mr. Mohan Lal Chopra for the period from 18/01/2019 to 17/01/2020 strictly subject to terms and

conditions of the policy. As per the Policy terms and condition specifically mentions as “GENERAL

DEFINITONS” POINT NO. 12 which reads as under:

“GENERAL DEFINITION”

12. Medically Necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part

of a stay in hospital which

a) Is required for the medical management of the illness or injury suffered by the insured person

b) Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care

in scope, duration, or intensity

c) Must have been prescribed by a medical practitioner

d) Must conform to the professional standards widely accepted in international medical practice or by

the medical community in India.

Complainant lodged a claim in furtherance to care of right eye pain, right fronto temporal pain, vertigo,

headache, staring look which was diagnosed as Seizure on 20/06/2019, and was admitted in Medanta

Hospital for 1 day regarding the same. As per discharge summary and final hospital bill it has been noticed

that patient was given only Tab. Pansec 40mg during the period of admission. Tab. Pansec helps in

decreasing the acid produced in the stomach and helps in promoting healing of ulcers and is used for other

acidity-related disorders. Thus this shows that there was no therapeutic treatment done and the patient

was admitted only for assessment purposes. In furtherance to this the MRI report was also normal and

VEEG report was awaited. The patient can be managed on OPD basis. Under the captioned claim patient

was admitted and underwent MRI brain with EEG which is done for evaluation purpose and there is no

active line of treatment present under current hospitalization, hence claim is not admissible as per terms &

conditions of the policy. As such, Insurance company was left with no other option and was constrained to

reject the claim vide letter dated-18/07/2019. Insurance company submitted that the present complaint is

devoid of any merits and is hence liable to be dismissed forthwith.


a) Complainant’s argument: Complainant requested that his claim has been repudiated on flimsy

ground and his wife was admitted in the hospital as per advice of doctor only. He requested for

payment of claim for his wife treatment.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN and stated that their

decision is as per policy terms and conditions.






On going through the complaint and other documents in file, and submission made by both the party




complainant was admitted in Medanta- Medicity Hospital, Gurugram on 20-06-2019 to 21-06-2019 with a

diagnosis of? Seizure. On going through discharge summary Medanta- Medicity Hospital, Gurugram, it is

observed that main reason for admission was investigation. Further, his MRI brain and EEG was normal. He

was managed with tablet Pansec only. It clearly brings out that no active line of treatment was given to the

patient during admission and hospitalization was only for investigation purpose. Hence, the decision of the

insurance company is in order and no interference is required in their decision. Keeping in view of the

above facts, the said complaint is hereby dismissed and no relief is granted.

AWARD





day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Sohan Singh V/S The New India Assurance Co. Ltd.


1. Name & Address of the Complainant Mr. Sohan Singh

# 187-F, SBS Nagar, Pakhowal Road, Ludhiana,

Punjab- 141013

Mobile No.- 9417210031

2. Policy No:

Type of Policy


36020134181600000129

Mediclaim Policy

30-03-2019 To 29-03-2020



Mr. Sohan Singh

Mrs. Jatinder Kaur

4. Name of the insurer The New India Assurance Co. Ltd.


6. Reason for repudiation Battery not payable as per clause 4.4.4





11. Amount of relief sought Rs 1,50,000/- plus harassment and mental

agony Rs 1,50,000/-



2017





For the Complainant Mr. Sohan Singh, Complainant

For the insurer Mr. N.K.Jagwan, SBM


16 Date of Award/Order 23-03-2020.


On 08-11-2019, Mr. Sohan Singh had filed a complaint that he is regular medical customer since 10-01-2011.

In 2015, his wife Mrs Jitender Kaur got the claim for her health problem. Now again she got the health

problem on 28-06-2019 and was admitted in Max Hospital Delhi with a complaint of Parkinson disease with

DBS (non-chargeable) and this time insurance company has refused to pay the claim with the remark that

the patient was admitted with the complaint of Parkinson disease with DBS (non-rechargeable) (St Jude's)

for which patient has undergone battery replacement. As DBS is durable medical equipment, which is, non

payable as per company norms and terms noted in clause 4.4.4. Complainant stated that as per company

version this is a battery replacement but this battery is an instrument which is placed inside the body of a

human being and it is not the replacement of battery of TV remote and it can only be done by a specialist

surgeon. It is totally injustice with the policyholder if Insurance Company denies the claim. He stated that

he has incurred an expensive rupees Rs 920000/-. He requested for payment of his claim.

On 26-11-2019, the complaint was forwarded to The New India Assurance Co. Ltd, Regional Office,



In the SCN, insurance company stated that complainant was issued senior citizen mediclaim policy for the

period 30 03 2019 to 2903 2020 and the same is there renewal. Claim was reported to TPA on 28 June

2019.and based upon the documents that are the medical report investigation report and other relevant

document the file was process by the doctor of TPA and opinion that said claim is not payable as per their

policy terms and condition. Instant case patient was admitted with the complaint of Parkinson disease with

DBS non chargeable St Judas for which patient has undergone battery replacement. As DBS is durable

medical equipment which is non payable as per company norms and terms noted in the clause 4.4.4. Clause

4.4.4 reads that any medical expenses incurred for or arising out of braces equipment or external

prosthetic devices, non durable implants, eyeglasses, cost of spectacle and contact lenses, hearing aids

including cochlear implants, durable medical equipment are not payable. Accordingly, claim was repudiated

and complainant was informed. They requested for dismissal of the complaint.



a) Complainant’s argument: As per complainant, his wife has undergone battery replacement and

same was done by the treating doctor. He stressed that DBS battery replacement is done by the

specialist doctor by surgery. He has incurred an expenses of Rs 9,20,000/- . He requested that he is

claiming Rs 1,50,000/- which is an sum insured under the policy.

b) Insurers’ argument: Insurance Company on the other hand retaliated that DBS is not covered as

per Senior Citizen Mediclaim policy and same is specifically excluded under clause 4.4.4 of the

policy. They also reiterated that policy terms and condition were sent to the complainant and

there is no deficiency of service on their part. They requested for dismissal of the complaint.






On perusal of various documents including the copy of complaint, SCN of insurance company and

submissions made by both the parties during personal hearing, it is observed that the complainant’s wife

has undergone battery replacement of DBS at Max Healthcare. The claim for said treatment has been

denied by insurance company due to reason that the treatment by way of insertion of battery is excluded

as per clause 4.4.4 of terms and conditions of policy during the relevant period. According to the

complainant, the denial of the claim is not proper. The complainant in this case has taken the treatment

during June, 2019 by battery replacement for Parkinson Disease with DBS (Non- Rechargeable) (St Judes).

The contention of complainant that this is a battery replacement but this battery is an instrument which is

placed inside the body of a human being and it is not the replacement of battery of TV remote. It can only

be done by a specialist surgeon and as such he is entitled for the entire claim amount doesn’t hold ground

in view of terms and conditions of policy during the relevant period. As per Senior Citizen Mediclaim Policy

for the relevant period DBS (Non- rechargeable) is specifically excluded under clause 4.4.4 of terms and

conditions of policy. Hence, the decision of the insurance company is in order. Keeping in view the above

facts, the said complaint is hereby dismissed and no relief is granted.

AWARD





day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Vinay Bindlish V/S Reliance General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vinay Bindlish

Shikha Petro Chemicals, Timber Market, Near

Hindu School, Kaithal,

Haryana- 136027

Mobile No.- 9896600299

2. Policy No:

Type of Policy


920221728280041224

Health Gain Policy

15-10-2017 To 14-10-2019



Mr. Vinay Bindlish

Mr. Vinay Bindlish

4. Name of the insurer Reliance General Insurance Co. Ltd.


6. Reason for repudiation Treatment under Exclusion


8. Nature of complaint Repudiation of compliant

9. Amount of Claim Rs 6.00 Lacs


11. Amount of relief sought Rs 6.00 Lacs



2017





For the Complainant Mr. Vinay Bindlish, Complainant

For the insurer Ms. Simran Kathyal , Legal Claim Manager



17) Brief Facts of the Case: On 26-09-2019, Mr. Vinay Bindlish had filed a complaint that he has been

renewing his family Floater health Gain policy without any break for the last ten years without any claim.

His son (Master Sidhant Bindlish) had undergone Cochlear implant surgery on 19.07.2019. He filed

reimbursement of his claim with insurance but same was rejected by insurance company citing policy

wording. He stated that if at all cost of implant/ device is not payable under the said policy then also he is

entitled to cost of surgery of his son from insurance company. He requested for payment of his claim.

On 15-10-2019, the complaint was forwarded to Reliance General Insurance Co. Ltd Regional Office,



In the SCN insurance company pleaded that treatment taken by his son is not covered under the policy. The

factual matrix of the case is that son of the complainant undergone a Cochlear Implant surgery on

18.07.2019 and discharged on 20.07.2019. The complainant submitted claim for the amount of treatment

spent in hospital which was scrutinized by competent authority of company official in accordance with

policy terms and conditions. On scrutiny of documents submitted to the answering respondent company, it

has been found that Cochlear implant fall under the clause of permanent exclusion of the policy. Hence, the

claim of the complainant was repudiated by the company vide repudiation letter dated 05.08.2019. The

treatment taken by the son of the complainant does not cover under the terms and conditions of the

policy. The relevant part of policy exclusion is pasted below for kind perusal of Hon’ble Ombudsman:-

“3.3 Permanent Exclusions:

Claim in respect of any insured person arising directly or indirectly due to any of the following shall not be

admissible, unless expressly stated to the contrary in the policy.

3.3.6-That Charges incurred in connection with the cost of spectacles and contact lenses, hearing aids,

cochlear implants, routine eye and ear examinations, laser surgery for correction of refractory errors

dentures, artificial teeth and all other similar external appliances and/ or devices whether for diagnosis or

treatment are not payable.

In the light of above facts and circumstances the complaint of complainant is liable to be dismissed in the

interest of justice.



a) Complainant’s argument: As per complainant he is holding policy for the last 10 years. On the

advice of treating doctor cochlear implant was suggested for his son and same was done by the

treating doctor. He stressed that cochlear implant is a hearing aid and not a surgical aid. He

presented policy prospect before the forum during personal hearing and reiterated that the

exclusion of cochlear implant is mentioned in policy documents for external use. Whereas, in his

case, cochlear has been implanted inside after surgery.

b) Insurers’ argument: Insurance Company on the other hand retaliated that cochlear implant is not

covered as per Reliance Health Gain policy and same is specifically excluded under clause 3.3.6 of

the policy. They also reiterated that policy terms and condition were sent to the complainant and

there is no deficiency of service on their part. The requested for dismissal of the complaint.






On perusal of various documents including the copy of complaint, SCN of insurance company and

submissions made by both the parties during personal hearing, it is observed that the complainant’s son

has been treated for his hearing loss in both ears by insertion of cochlear implant at Rainbow Children

Hospital, New Delhi . The claim for said treatment has been denied by insurance company due to reason

that the treatment by way of insertion of cochlear implant is excluded as per clause 3.3.6 of terms and

conditions of policy. According to the complainant, the denial of the claim is not proper since he is holding

the policy for last 10 years and condition only mentions about external cochlear implant. As such he is

entitled for claim as well as surgery cost. The contention of complainant that cochlear was implanted after

surgery doesn’t hold ground in view of terms and conditions of policy. As per Reliance Health Gain Policy

the cochlear implant is specifically excluded under clause 3.3.6 of terms and conditions of policy. Hence,

the decision of the insurance company is in order. Keeping in view the above facts, the said complaint is

hereby dismissed and no relief is granted.

AWARD





day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Vinod Kumar V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vinod Kumar

H. No.- 98, Near Middha Chowk, Lajpat Nagar,

Ludhiana, Punjab-0

Mobile No.- 987207831

2. Policy No:

Type of Policy


P/161114/01/2019/003188

Mediclassic Insurance Policy

14-11-2018 to 13-11-2019



Mr. Vinod Kumar

Mr. Vinod Kumar


5. Date of Repudiation Not applicable

6. Reason for repudiation Not applicable


8. Nature of complaint PED



11. Amount of relief sought Rs 1,02,832/-

12. Complaint registered under Rule no:

Insurance Ombudsman Rules, 2017





For the Complainant Mr. Vinod Kumar, Complainant

For the insurer Ms. Mamta Gupta, Senior Manager Legal




On 08-11-2019, Mr. Vinod Kumar had filed a complaint that he is continuously renewing his mediclaim

policy without any break since 14.11.2015 with Star Health and Allied Insurance Co. Ltd for sum insured of

Rs 3.00 Lacs and cumulative bonus of Rs 45000/- . Unfortunately he was admitted in deep Hospital Nursing

Home and Children Hospital, Ludhiana due to severe pain in the right side and operated for renal Calculi

(Stone) under GA on 22-08-2019. His cashless was rejected on the ground that “the patient is suffering

from this disease of HDN for the past 5 years which is prior to inception of the first policy. Hence it is pre-

existing.” Complainant stated that as per exclusion 3.1 of the policy “the claim for treatment of the disease/

condition are not admissible until the expiry of 48 months from the date of inception of the first policy.” As

per policy also renal Calculi is having waiting period of two years. He requested for payment of his claim.

On 28-11-2019, the complaint was forwarded to Star Health and Allied Insurance Co. Ltd Regional Office,



In the SCN, insurance Company stated that, the Complainant took Mediclassic Insurance Policy (Individual)

through Branch Office – Ludhiana covering Mr. Vinod Kumar – Self for the sum insured of Rs. 3,00,000/-

vide Policy No. P/161114/01/2019/003188 – from 14/11/2018 to 13/11/2019. The Insured reported the

claim in the 4th year of the Medical Insurance Policy. As per Pre-authorization form, the insured claimed

approval for an amount of Rs. 1,32,000/- to avail cashless facility. The Complainant, Mr. Vinod Kumar, aged

39 years / Male, was admitted on 22/08/2019 at Deep Nursing Home and Children Hospital, Ludhiana. As

per the pre-authorization form, the insured was diagnosed with PUJ Calculi, B/L Renal Calculi and HDN. The

Discharge Summary of RG Stone and Super Speciality Hospital, Ludhiana for the period of hospitalisation

from 06/07/2015 to 07/07/2015 states the insured was diagnosed with B/L Renal & Right Upper Ureteric

Calculi and has C/O Right flank pain on & off * 2 years, H/O Right ESWL (Extracorporeal Shock Wave

Lithotripsy) twice last in 2011, H/O operated for Pilonidal sinus X 15 years back. From the above finding, it is

observed that, the insured patient is a known case of Calculus diseases of urinary system prior to the

commencement of the policy. Hence, it is a pre-existing disease. Pre Existing Disease means, any condition,

ailment or injury or related condition(s) for which the insured person had signs or symptoms and / or were

diagnosed and / or were received medical advice / treatment within 48 months prior to the policy. As per

Exclusion No. 3 (1) of the policy, “The Company shall not be liable to make any payments under this policy

in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:

Pre Existing Diseases as defined in the policy until 48 consecutive months of continuous coverage have

elapsed, since inception of the first policy with any Indian Insurer. However the limit of the Company's

liability in respect of claim for pre-existing diseases under such portability shall be limited to the sum

insured under first policy with any Indian Insurance Company”. Hence, the claim is not liable under

Exclusion No. 3 (1) of the policy. In this case, insurance company have rejected only the cashless

authorization and the insured has not approached for reimbursement of medical expenses. Hence, they are

not aware of the exact amount spent by the insured at the time of hospitalization. Therefore, the cashless-

authorization was rejected under Exclusion No. 3 (1) of the policy and communicated to the treating

hospital as well as the insured vide copy of our letter dated 23/08/2019.



a) Complainants argument : Complainant stated that his genuine claim is being repudiated on flimsy ground of PED.

b) Insurers’ argument: Insurance Company stated their ground of repudiation is as per terms and

condition of policy. They reiterated their contents of SCN and requested for dismissal of complaint.






On perusal of various documents available in the file including the copy of complaint, SCN submitted by the

insurance company, discharge summary, cashless rejection letter of the insurance company, it is seen that

the pre-authorization cashless filed by the complainant in respect of treatment taken by him has been

denied by insurance company vide letter dated 23.08.2019 and has been held to be in admissible as the

treatment taken falls under PED exclusion clause 3.1 of the policy which reads as “ all disease/ injuries

which are pre-existing when the cover incepts for the first time. However, those diseases will be covered

after four continuous claim free year.” As per documents available in the file, Mr. Vinod Kumar was

admitted in Deep Nursing Home and Children Hospital, Ludhiana with a follow up case of B/L Renal & Right

Upper Ureteric Calculi. He remained admitted in Hospital from 22-08-2019 to 23-08-2019. At the time of

treatment taken the policy is running in the 4th year. The repudiation of claim by insurance company in the

instant case on account of violation of policy condition 3.1 is neither proper nor reasonable. It is admitted

fact that complainant had underwent B/L Renal & Right Upper Ureteric Calculi on 06/07/2015 before

inception of the policy. Policy incepted from 14-11-2018 to 13-11-2019. As such there was no pre-existing

disease relating to Ureteric Calculi when policy was incepted since it was already operated. The insurance

company TPA decision for repudiation of the claim at their own level is not justified in the absence of

supporting documents relating past disease to the current episode. Simply stating and denying the claim

on the basis of PED is totally unwarranted and improper. Keeping in view the facts, the insurance company

is directed to settle the admissible claim subject to terms and conditions of the policy within 30 days after

the receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claim subject to terms and conditions of

the policy is hereby awarded to be paid by the Insurer to the Insured, towards full and final




day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Pankaj GuptaV/S Reliance General Insurance Co. Ltd.


1. On 24.10.2019, Mr. Pankaj Gupta had filed a complaint in this office against Reliance General Insurance

Co. Ltd for not settling the health claim. The required documents were submitted to the insurance

company but the insurance company did not settle the health claim under policy no.

200691928451000016.

2. This office pursued the case with the insurance company to re-examine the complaint and they agreed

to reconsider the claim.

3. Mr. Pankaj Gupta confirmed through email 30-01-2020 that his complaint has been resolved by

insurance company and he has received payment of his claim and wants to withdraw his complaint

from this forum.








Case of Mr. Vijay Bansal V/S Star Health and Allied Insurance Co. Ltd.


1. On 11-10-2019, Mr. Vijay Bansal had filed a complaint in this office against Star Health and Allied

Insurance Co. Ltd for not settling the health claim. The required documents were submitted to the

insurance company but the insurance company did not settle the health claim under policy no.

P/161131/01/2019/00579.



3. Mr. Vijay Bansal confirmed through email 27-02-2020 that his complaint has been resolved by

insurance company and he has received payment of his claim and wants to withdraw his

complaint from this forum.








Case of Mr. Vinod Kumar V/S IFFCO-TOKIO General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vinod Kumar

House No.- 31, Devi Lal Model Town, Sirsa,

Haryana- 125055

Mobile No.- 9992421155

2. Policy No:

Type of Policy


H0079528

Health Policy

28-03-2019 to 27-03-2020



Mr. Vinod Kumar

Mr. Vinod Kumar



6. Reason for repudiation Non-cooperation by Complainant and hospital





11. Amount of relief sought Requested for payment of his claim



2017





For the Complainant Mr. Vinod Kumar

For the insurer Ms. Monika Sharma




On 24-09-2019, Mr. Vinod Kumar had filed a complaint that insurance company has repudiated claim on

flimsy ground. Surveyor has never visited his house but rather he called him in hospital in Hissar for taking

his statement. Inspite of that the company has repudiated his claim. He requested for payment office

repudiated claim.




Insurance Company stated in the SCN that the Complainant was covered under Swasthya Kavach Policy, No

H0079528, for the period of 28/03/2019 to 27/03/2020. Complainant had submitted a claim of INR 23640/-,

wherein the patient was admitted to Shanti Devi GI Institute, Hisar, on 15/05/2019 with the diagnosis of

Acute enteritis with known case of Hypothyroidism. The patient managed conservatively and discharged on

19/05/2019. Accordingly, investigation was carried out in this case to ascertain the facts of the case and the

following points were noted: -

1. Hospital authorities refused to provide required documents and statement even after repeated

visits by our verifier.

2. As per available records (Dr Pradeep Jain – Psychiatrist consultation dated 8/5/2019), patient is a

known case of chronic alcoholism, with binge pattern of drinking for pleasure purposes, currently

on abstinence since one month.

3. As per insured’s statement, he had been suffering from upper side of abdominal pain since past 2

years, but no treatment details were provided.

4. Insured refused to provide his leave details and did not meet verifier at his home.

5. Patient is on psychiatric treatment for mood disorders.

In view of above point, the claim was denied, the claim was denied on following grounds: -

General Condition no 1:-Conditions Precedent- Where this Policy requires You/your family member(s) named

in the Schedule to do or not to do something, then the complete satisfaction of that requirement by You or

someone claiming on Your behalf is a precondition to any obligation We have under this Policy. If You or

someone claiming on Your behalf fails to completely satisfy that requirement, then We may refuse to

consider Your claim. You/your family member(s) named in the schedule will cooperate with Us at all times.

General Conditions no 8 :- Claim Procedure and Requirements - Notification of Claim: An event which might

become a claim under the Policy must be reported to Us as soon as possible, but not later than 7 days from

the date of Hospitalization. A written statement of the claim will be required and a Claim Form will be

completed and the claim must be filed within 30 days from the date of discharge from the Hospital or

completion of treatment, except in extreme cases of hardship where it is proved to Our satisfaction that

under the circumstances in which You / Insured Person or his/her personal representative were placed, it

was not possible for any one of You to give notice or file claim within the prescribed time limit. The Insured

Person must give all original bills, receipts, certificates, information and evidences from the attending

Medical Practitioner/Hospital/Chemist/Laboratory as required by Us in the manner and form as We may

prescribe. In such claims, Our representative shall be allowed to carry out examination and obtain

information on any alleged Injury or Disease requiring Hospitalization if and when We may reasonably

require at Our cost.

Exclusion no 9 under head “What is not Covered-We will not pay for”- Treatment of mental illness,

psychiatric or psychological disorders, Convalescence, general debility, run down condition or rest cure,

external congenital Disease or defects or anomalies, sterility, venereal Disease, intentional self-Injury, or

cause of accident/illness is use of intoxicating drugs/alcohols by the insured person(s).

Complainant and hospitals are highly non cooperative, due to which we are not able to determine the

admissibility of the claim as per policy. During hospitalization, consultation was taken from psychiatrist and

he has stated that the patient has history of chronic alcoholic and with binge pattern of drinking for

pleasure purpose. The patient is a government teacher and did not provide any leave records. Insurance

company stated that the claim is not recoverable as per policy conditions.

The complainant was sent Annexure VI-A for compliance, which reached this office on


a) Complainant’s argument: Complainant stated that the insurance company has repudiated his claim

on flimsy grounds and he requested for settlement of his claim.

b) Insurers’ argument: Insurance Company stated that the claim has been repudiated as per policy

terms and conditions.






I have gone through the various documents available in file including the copy of complaint, copy of

SCN submitted by insurance company and hospital records of complainant. The claim filed by

complainant duly covered under policy has been denied by insurance company on the basis of

investigation report and also due to non compliance of general conditions no. 1 & 8 of policy relating to

procedure and requirement for filing claim. On examination of various documents it is seen that the

claim pertains to hospitalization of complainant at Shanti Devi GI Institute & Advanced Endoscopy

Centre from 15.05.2019 to 19.05.2019 where he was diagnosed as a case of acute enteritis and known

case of hypothyroidism. As per hospital record the patient was a chronic alcoholic and had a habit of

pattern of drinking for pleasure purpose. As per investigation report dated 30.06.2019 the patient was

a case of abdomen pain since 1.5 years and was a government teacher, no leave records were given by

complainant during investigation. Even the hospital was not co-operative in furnishing information

relating to various aspects of patient hospitalization. As such by not co-operating and by not providing

relevant information/ documents to insurance company, complainant violated policy terms and

conditions. In view of what has been stated above the denial of claim by insurance company being in

order. Hence, the complaint is dismissed.

AWARD





day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Mukesh Kumar V/S Cigna TTK Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Mukesh Kumar

House No.- 242, Gali No.- 4, Mela Ground,

Sirsa, Haryana- 125055

Mobile No.- 9992421155

2. Policy No:

Type of Policy


LTPRC230000111

Critical Care

16-01-2018 to 15-01-2019



Mr. Mukesh Kumar

Mr. Mukesh Kumar

4. Name of the insurer Cigna TTK Health Insurance Co. Ltd.


6. Reason for repudiation History of being alcoholic


8. Nature of complaint Rejection of claim due to PED



11. Amount of relief sought N.A



2017



13. Date of hearing/place 06-01-2020,28-01-2020 & 10-02-2020 /

Chandigarh


For the Complainant Absent on 06.01.2020 & 28.01.2020,

Sh.Mukesh Kumar on 10/02/2020

For the insurer Sh. Jaswinder Singh Shekhawat ,Manager on

06/01/2020




On 21-05-2019, Mr. Mukesh Kumar had filed a complaint about the wrong rejection of his mediclaim by the Cigna Health Insurance Company. He submitted that when got ill, the company rejected his claim on the ground that he is not having salary statement for the last two months where as there was no such condition in the health policy. Secondly as per the insurance company the disease from which complainant suffered was pre existing before he took the insurance cover, whereas medical checkup was done at the time of purchase of policy.

On 11-06-2019, the complaint was forwarded to Cigna TTK Health Insurance Co. Ltd. Regional

Office, Mumbai, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 26/12/2019,

As per the SCN, the complainant approached the insurance company for purchasing a Lifestyle

Protection Critical Care Enhanced Plan and on the basis of proposal form the company issued policy

bearing number LTPRC230000111 on 16thJanuary 2018 for a term of one year having validity till 15th

January 2019 for Sum Insured of Rs. 10 lacs. The policy covers all the claims arising as a result of

listed critical illness under II.1as specified in the policy terms and conditions that occurred during

the policy period becomes payable, the company shall pay the benefits in accordance with the

terms and conditions and exclusions of the policy. The policy document along with the proposal

form and the terms and conditions were duly delivered on 13/02/2018 through speed post .The

complainant registered a claim under the policy and it was observed from the indoor case papers

that complainant was admitted for ALD (alcoholic liver disease) /CLD/Ascites/Cirrhosis and was

alcoholic from past 12 years which is prior to the policy inception date. The complainant did not

disclose regarding his Alcoholism. The company rejected the claim as per clause II.1,19 Critical

Illness Cover which specifically states that “Liver Disease secondary to alcohol or drug abuse is

excluded.”

As per repudiation letter the following are reasons for rejection:

1. As per indoor case records of Aditya nursing home and gastro centre dated 29th June 2018, the complainant was diagnosed for alcoholic liver disease and had history of being alcoholic since 12 years. Since liver disease secondary to alcohol abuse is excluded under the Signa TTK Lifestyle Prot Critical Care Enhanced Policy, Hence Claim is rejected as per clause II.1,19. End stage lever failure.

2. You have not submitted salary slips or bank statements for the last 6 months as a proof of income.

Additionally clause IV (Permanent Exclusions) of the policy terms and conditions clearly states :

“The company shall not be liable to make any payment under this policy towards a covered Critical

Illness, directly or indirectly caused by, based on, arising out of or howsoever attributable to any of

the following:

Any critical illness arising out of use, abuse or consequence or influence of any substance,

intoxicant, drug, alcohol or hallucinogen.



a) Complainant’s argument: The claim has been denied due to pre existing disease whereas medical

examination was done before issuance of the policy.

b) Insurer’s argument: The claim is not admissible as per clause II.1,19 of the policy. Liver disease

secondary to alcohol or drug abuse is excluded.




I have gone through the documents placed on record including the copy of Complaint, SCN of the

insurer and hospitalization record of the complainant whose claim, for the hospitalization at Aditya

Nursing Home & Gastro Centre from 29/06/2018 to 04/07/2018, where he underwent treatment of

alcoholic lever disease, has been denied by the insurance company under clause II.1,19 of the policy

terms and conditions. The issue here to be decided is as to whether the denial of claim for treatment of

alcoholic liver disease is in order or not. As per indoor case record of Aditya Nursing Home & Gastro

Centre dated 29/06/2018, the patient had history of being alcoholic since 12 years and was diagnosed

to have alcoholic liver disease. Since, the liver disease secondary to alcohol abuse is excluded as per

clause II.1,19 of the critical illness cover and the insured had not disclosed the history of alcoholism

while purchasing the policy, the insurance company rejected the claim as per terms and conditions of

the policy. The repudiation of claim by the insurance company is in order as per terms and conditions of

the policy and this office finds no reason for intervention in the same. Hence the complaint is dismissed

being devoid of merits.

AWARD


parties during the course of personal hearing, the complaint is hereby dismissed.



day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW


Mr. Devendra Nagayach…………..……....………………. Complainant

V/S

Star Health and Allied Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-044-1920-0023 Order No. IO/LCK/A/HI/0040/2019-20

1. Name & Address of the Complainant Mr. Devendra Nagayach

Y-1 , Yashoda Nagar, Near Bachpan School

Kanpur-208011

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

P/161130/01/2019/024946

Star Comprehensive Policy

19.10.2018 to 18.10.2019

3. Name of the life insured Mr. Devendra Nagayach

Name of the policyholder Mr. Devendra Nagayach

4. Name of the insurer Star Health & Allied Insurance Company Limited

5. Date of Repudiation/Rejection ---

6. Reason for repudiation/Rejection ---


8. Nature of complaint Customer information sheet description in Hindi

9. Amount of Claim ---



12. Complaint registered under Rule Rule No. 13(1)(h) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 18.03.2020 at 11.00 am at Lucknow



For the insurer Mr. C.S. Tandon,

15. Complaint how disposed Award


17. Mr. Devendra Nagayach (Complainant) has filed a complaint against Star Health and Allied Insurance

Company Limited (Respondent) alleging not providing the customer information sheet in Hindi language.


18. Brief Facts of the Case:- The Complainant has stated that he had purchased the aforesaid policy for

period 19.10.2017 to 18.10.2018 and further 19.10.2018 to 18.10.2019. The complainant has registered his

complaint on 08.01.2019 on insurer’s e-mail to provide all documents and terms & conditions in Hindi.

Being not provided the same by the insurer, he has approached this forum

In their SCN/reply, RIC has stated that the insured had proposed for aforesaid policy through online mode

and filled the queries using English words. The proposal was authenticated through OTP sent to the

insured on 18.10.2017. While approaching the insurer’s support Deptt vide E-mail on 07.01.2019 the

insured drafted the mail in English language. The insured is well proficient in English language because the

contract of insurance was entered into by the insurer and the insured only after acceptance of the terms

and conditions of the policy. They also submitted the insured has purchased the policy online through

Policy Bazaar which is an internet based sales agent of the insurer.

As per condition No. 13 of the policy “A free look period of 15 days from the date of receipt of

the policy is available to the insured to review the terms and conditions of the policy. In case the insured is

not satisfied with the terms and conditions, he may seek cancellation of the policy in free look period.

The respondents have filed a Judgment of Chennai High court in this connection. The

respondent has prayed to dismiss the complaint.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy

of policy document while respondent filed SCN with enclosures.

20. During hearing complainant remained absent. I have heard the representative of respondent at length

and perused paper filed on behalf of the complainant as well as the Insurance Company.

21. Complainant’s main contention is that the policy bond be provided in Hindi.

In the SCN, it is stated that it is not mandatory to provide terms/Conditions and Policy bond in vernacular language.

This contention of the respondent is not acceptable.

If the complainant wants that the policy terms and conditions alongwith policy bond be provided in Hindi,

respondents are under an obligation to provide the same. Respondents failed to show any rules or regulations

wherein policy bond can only be provided in English. Accordingly, complaint is liable to be allowed.


Order :

Complaint is allowed. Respondents are directed to provide the policy bond alongwith terms and conditions in Hindi to

the insured/complainant within 30 days.

22. Let copy of order be given to both the parties.

Dated : March 18, 2020 (Justice Anil Kumar Srivastava)

Place : Lucknow Insurance Ombudsman



Mr. Vinay Kumar Agarwal…………..……....………………. Complainant

V/S

United India Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Vinay Kumar Agarwal,

5/84, Vipul Khand, Gomtinagar,

Lucknow-226010.

2. Policy No:

Type of Policy


5001002817P110698951

Group Mediclaim Policy

01.10.2017 TO 30.09.2018

3. Name of the life insured


Employees and their dependent children

Indian Bank Assocaition A/c Allahabad Bank

4. Name of the insurer United India Insurance Company Limited

5. Date of Repudiation/Rejection 19.03.2019

6. Reason for repudiation/Rejection Ailment is not covered



9. Amount of Claim Rs.16738.00


11. Amount of relief sought Rs.16738.00

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017



For the Complainant Mr. Vinay Kumar Agarwal

For the insurer Mrs Monika Nishal, AM



17. Mr. Vinay Kumar Agarwal (Complainant) has filed a complaint against United India Insurance Company

Limited (Respondent) challenging repudiation of his mediclaim.


18. Brief Facts Of the Case:-. The complainant was insured with the respondent under Group Mediclaim Policy issued

to employees of Allahabad Bank for period 01.10.2017 to 30.09.2018. He was suffering from “Wegener’s

Granulomatosis”. Previously his 08 claims were paid by the respondent because domiciliary treatment for this

treatment is allowed as per policy and “Wegener’s Granulomatosis” and “Immuno Suppressants” are same ailments.

This time his three claims amounting to Rs.16738/- have been declined by the respondent. Aggrieved with the

decision of the respondent insurance company, the complainant has approached this forum.

In their SCN/reply, the respondent has stated that the complainant had registered three claims with them , claim no.

HH871907803, HH871929824 & HH871948629 for claim amounts Rs. 3,790/- , Rs. 7,390/- & Rs. 5,558/- respectively.

On reviewing the claims documents it was found that the patient took domically treatment for Wegener’s

Granulomatosos which is not mentioned in the list at domiciliary disease covered in IBA policy. Therefore all the three

claims were repudiated by the respondent insurance company.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy of policy

document while respondent filed SCN with enclosures.

20. I heard both the parties and perused paper filed on behalf of the complainant as well as the Insurance Company.

21. Undoubtedly the insured is covered under the policy with the respondent. Insured was suffering from Wegener’s

Granulomatosis and was under treatment at KGMU, Lucknow. Since 2016 till 2018, seven claims were preferred by

him which were allowed by the respondents but three claims under dispute of Year 2018, were not allowed.

Thereafter one more claim was allowed in the year 2019.

Admittedly seven claims prior to rejection and one claim after the rejection were allowed on the same ground. Now

there is no reason as to why three claims which are on the same footing should not be allowed. Accordingly

complaint is liable to be allowed.


Order :

Complaint is allowed and respondents are directed to make the payment of the claim to the complainant within a

period of 30 days.

22. Let copy of award be given to both the parties.





Mr. Kamal Bhatia…………..……....………………. Complainant

V/S

Oriental Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-050-1920-0085 ORDER NO. IO/LCK/A/HI/0045/2019-20

1. Name & Address of the Complainant Mr. Kamal Bhatia

79, Pirpur Square Narhi

Lucknow-226001

2. Policy No:

Type of Policy


221301/48/2018/158

PNB Oriental Royal Mediclaim

08.09.2017 to 07.09.2018

3. Name of the life insured Mr. Kamal Bhatia

Name of the policyholder Mr. Kamal Bhatia

4. Name of the insurer Oriental Insurance Company Limited


6. Reason for repudiation/Rejection Complication of HTN (falls under clause 4.2)









For the Complainant Mr. Kamal Bhatia

For the insurer Mrs. Shalini Pawah



17. Mr. Kamal Bhatia (Complainant) has filed a complaint against Oriental Insurance Company Limited

(Respondent) challenging the repudiation of his health claim.


18. Brief Facts of the Case:- The complainant purchased PNB Oriental Royal Mediclaim policy for period

08.09.2017 to 07.09.2018. On complaint of chest pain and discomfort he was admitted at Sahara Hospital

Lucknow on 07.08.2018 where procedure CART & primary PTCA + stent to OM was done. He was discharged

on 25.08.2018. A claim for Rs. 5,93,085/- was registered which was repudiated by the insurer on the ground

that complications of HTN have waiting period of 02 years whereas this claim is on Ist year of the policy. As

per policy exclusion clause 4.2 & 4.1, claim is not payable. Aggrieved with the decision of RIC, the

complainant has approached this forum for redressal of his complaint.

In their SCN/reply, the respondent has submitted that the insured was having direct complication of HTN

(history of hypertension) from last one year and was on anti-hypertensive treatment as per initial assessment

record provided by Sahara Hospital Lucknow- It was marked on Initial Assessment Record” H/o –HTN-Ist year

on AHT” (Anti Hypertensive treatment).

The complications of HTN have waiting period of 02 years but the claim is registered in Ist year of the policy.

As per company’s norms under General exclusion clause (4.2) this claim is not admissible. Respondent are

ready to reimburse this amount to the insured subject to submission of original payment receipt.



20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well as


21. Undoubtedly the complainant was insured with the respondent under PNB Oriental Royal Mediclaim

Policy. On complaint of chest pain and discomfort, he was admitted at Sahara Hospital, Lucknow on

07.08.2018 where procedure CART & Primary PTCA + Stent to OM was done. He was discharged on


25.08.2018. A claim for Rs.593085/- was registered which was repudiated by the insurer on the ground that

complication of HTN have a waiting period of two years whereas this claim is on first year of policy. As per

policy condition nos: 4.1 and 4.2, the claim was not payable. The relevant clauses read as under :

Exclusion Clause No:4.1

Pre-existing health condition or disease or ailment/injuries : Any ailment/disease/injuries/health condition

which are pre-existing (treated/untreated, declared/not declared in the proposal form). When the cover

incepts for the first time are excluded upto three completed years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of this mediclaim policy taken from The

Oriental Insurance Company Limited shall be considered, provided the renewals have been continuous and

without any break in period.

Exclusion Clause No:4.2

The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable

if contracted and/or manifested during the currency of the policy if these diseases are pre-existing at the time

of proposal the exclusion No:4.1 for pre-existing condition shall be applicable in such cases :

Xvii : Hypertension { 2 years waiting period ]

As per Initial Assessment Record of Sahara Hospital, Lucknow dated 07.08.2018, contains significant past

history were his ailment is mentioned as “H/o-HTN- 1 Year on AHT”. The blood pressure of the complainant

also measured at 190/106 mg/dl at the time of admission.

In view of the above policy clauses, I find that the claim has rightly been repudiated which does not warrant

for any intervention. The complaint lacks merit and is likely to be dismissed.


Order ;

Complaint is dismissed.


Dated : March 18, 2020 (Justice Anil Kumar Srivastava )




Mr. Bhagwati Pd. Saxena …………..……....………………. Complainant

V/S

Oriental Insurance Company Limited………..………..…………Respondent

COMPLAINT NO: LCK-H-050-1920-0056 Order No. IO/LCK/A/HI/0044/2019-20

1. Name & Address of the Complainant Mr. Bhagwati Pd. Saxena,

185, Ghooramau Bunglow,

Sitapur

2. Policy No:

Type of Policy


221301/48/2018/3035

PNB Oriental Royal Mediclaim Policy

31.03.2018 to 03.03.2019



Self and spouse

Mr. Bhagwati Pd. Saxena


5. Date of Repudiation/Rejection 14.04.2019 & 29.07.2019

6. Reason for repudiation/Rejection Exclusion clause 4.10 “No Active Treatment in Hospital”


8. Nature of complaint Unjustified Repudiation of claim





13. Date of hearing/place On 18.03.2020 at Lucknow


For the Complainant Mr. Bhagwati Prasad Saxena

For the insurer Mrs. Shalini Pawal



17. Mr. Bhagwati Pd. Saxena (Complainant) has filed a complaint against Oriental General Insurance Company

Limited (Respondent) challenging the repudiation of his health claim.

18. Brief facts of the case: The complainant was admitted in Career Institute of Medical Sciences on 09.03.2019

with complaint of severe low back pain. After investigation and medication, he was discharged on 11.03.2019. He

preferred a reimbursement claim for Rs.27070/- which was repudiated under Policy Clause No:4.10 mentioning that

no active treatment was given during the hospitalization and hospitalisation was made for investigation purpose. The

treatment given was OPD treatment which could be taken at home as only oral medicines were given.


In their SCN/reply dated 02.09.2019, the respondents have submitted that as per TPA’s letter dated 09.04.2019,

the insured patient was admitted in hospital with acute severe low back pain cause, cervical canal stenoses with L/s

degenerative spine. During hospitalisation of insured only investigations were done and oral medicines were given

which could be administered on OPD basis. Since there was no active line of treatment was provided during the

hospitalisation period, the claim was not admissible. Therefore the claim was repudiated in the light of the policy

clause No:4.10 which reads as under :

“Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by

active treatment for the ailment during the hospitalised period or expenses incurred for investigation or treatment

irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission, referral free to family

doctors, outstation consultants/surgeon’s fee, doctor’s home visit charges/attendant/nursing charges during pre and

post hospitalisation period etc.”

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly filled/signed

submitted by the complainant while respondent filed SCN along with enclosures.

20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well as insurance

company.

21. Claim was repudiated on the following ground :

“Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purpose of which is not followed by active treatment for the ailment during the hospitalised period or expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission, referral fee to family doctors, out station consultants, surgeon’s fees. Doctor’s home visit charges/attendant/nursing charges during pre and post hospitalization period etc.”

Repudiation is based on the discharge card. Discharge card alone could not be made basis to cover the case in the

exclusion clause. Neither the statement of the doctor was recorded nor Bed Head Ticket of the insured was obtained

which could show as to what treatment was given to the insured during 3 days of admission. In every case, merely

because oral medication is given, it should not be held that hospitalisation was not required. It is relevant to mention

that age of the insured is 79 years. In the old age some time hospitalisation becomes necessary.


Having considered facts and circumstances of the case, I am of the view that claim has wrongly been repudiated.

Complaint is liable to be allowed.

Order :

Complaint is allowed. Respondents are directed to settle the claim of the complainant within 30 days.

22. Let copy of the award be sent to both the parties.





Mr. Mridul Saxena …………..……....………………. Complainant

V/S

Oriental Insurance Company Limited………..………..…………Respondent

COMPLAINT NO: LCK-H-050-1920-0025 Order No. IO/LCK/A/HI/0041/2019-20

1. Name & Address of the Complainant Mr. Mridul Krishna,

3/391, Viram Khand,

Gomtinagar, Lucknow-226010

2. Policy No:

Type of Policy


221306/48/2018/1051


10.11.2017 09.11.2018



Self and spouse

Mr. Mridul Saxena



6. Reason for repudiation/Rejection Exclusion clause 4.8 of the Policy









For the Complainant Mr. Mridul Saxena

For the insurer Mr. Surendra Kumar, Sr. Branch Manager



17. Mr. Mridul Krishna (Complainant) has filed a complaint against Oriental Insurance Company Limited

(Respondent) challenging the repudiation of his health claim.

18. Brief facts of the case: The complainant was insured with the respondent for period 10.11.2017 to 09.11.2018.

He is purchasing health policy from the respondent regularly since 11.11.2010. On complaint of chest pain, he got

admitted at SGPGI, Lucknow on 20.03.2018 where he underwent angioplasty. He was discharged on 23.03.2018.

After discharge from SGPGI Lucknow, he preferred a claim with the respondent for Rs.81340/-. The claim was

repudiated under policy exclusion clause 4.8 because as per discharge summary of SGPGI, Lucknow, the insured

was having a habit of smoking


In their SCN/reply dated 13.06.2019, the respondent insurance company has submitted that the claim of

complainant stands repudiated in the light of discharge summary and Policy Clause 4.8 of the policy which reads as

under :

“Convalescence, general ability, run down condition or rest cure, congenital external disease or defects or anomalies,

sterility any fertility, sub fertility or assisted conception procedure, venereal diseases, intentional self injury/suicide,

all psychiatric and psychosomatic disorders, and diseases/accident due to and or use, misuse or abuse of

drugs/alcohol or use of intoxicating substances or such abuse or addiction etc any disease or injury as a result of

committing or attempting to commit a breach of law with criminal intent.”

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly filled/signed

submitted by the complainant while respondent filed SCN along with enclosures.

20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well as insurance

company.

21. Undisputedly complainant was insured with the respondent since 2005. Insured underwent treatment for his heart

ailment at SGPGI, Lucknow wherein he was admitted on 20.03.2018 and discharged on 23.03.2018. His coronary

angiography was done. He preferred the claim for reimbursement which was repudiated on the following ground :

“Patient Mr. Mridul Krishna 50 Y/M was admitted in SGPGIMS, Lucknow on 20.03.2018 as a case of CAD-ACS-IWMI,

underwent CART and PTCA to PLV and discharged on 23.03.2018. As per submitted discharge summary, patient has

history of smoking, which is one of the causes of above mentioned disease, hence this claim is recommended as not-

payable under Clause No: 4.8 use of intoxicating substances or such abuse or addiction etc, any disease or injury as a

result of committing or attempting to commit a breach of law with criminal intent.”

Complainant submits that he is not a regular smoker rather occasionally he smokes one or two cigarettes in 10 or 15

days. He has further submitted that smoking was not direct cause of his heart ailment. In the discharge summary,

insured was shown as smoker. It is relevant to note that neither admit card nor Bed Head Ticket are enclosed with

SCN. Even no opinion of treating doctor was obtained as to whether the smoking was the ultimate cause for the heart

ailment. Even in the Clause No:4.8, smoking is nowhere mentioned. So far as use of intoxicating substances is

concerned, no specific quantity is prescribed under Clause No:4.8.


On the basis of the discussions made above I am of the view that case of the insured is not covered under Clause

No:4.8 of the policy bond. Accordingly, claim has wrongly been repudiated by the respondent which is liable to be

allowed.

Order :

Complaint is allowed. Respondents are directed to the payment of claim amount in accordance with the terms and

conditions of the policy bond to the complainant within 30 days.






Mr. Arun Tiwari…………..……....………………. Complainant

V/S

New India Assurance Co. Limited…………..………..…………Respondent

COMPLAINT NO. LCK-H-049-1920-0029 ORDER NO. IO/LCK/A/HI/0035/2019-20

1. Name & Address of the Complainant Mr. Arun Kumar Tiwari,

Sales deptt. LIC of India,

Divisional office, MG Road, Kanpur-208001.

2. Policy No:

Type of Policy


12070034180400000004

Group Mediclaim Policy

01.04.2018 to 31.03.2019



Mr. Arun Tiwari

M/s Life Insurance Corporation of India

4. Name of the insurer New India Assurance Company Limited


6. Reason for repudiation/Rejection Hospitalization for diagnostic purpose not payable


8. Nature of complaint Repudiation of Claim








For the insurer Mr. Ashwini Kumar, AM



17. Mr. Arun Tiwari (Complainant) has filed a complaint against New India Assurance Company Limited

(Respondent) challenging repudiation of health claim of his wife.


18. Brief Facts Of the Case:- The complainant is insured under LIC Group Mediclaim policy issued by the

respondent for period 01.04.2018 to 31.03.2019. His wife Mrs. Seema Tiwari got admitted at Madhulok

Hospital on 08.10.2018. She was treated with injection and tablet and was discharged next day on

09.10.2018 after undergoing certain diagnostic tests such CBC, Blood sugar-R, sodium and potassium,

calcium. He submitted a reimbursement claim for Rs.6420/- which was repudiated on the ground that as per

Clause F-xi, for diagnostic and laboratory examination hospitalization not required. Aggrieved with the

repudiation, the complainant had approached this forum.

In their SCN/Reply dated 16.09.2019, Respondents have submitted that during hospitalization for one day

on 08.10.2018, the patient was diagnosed severe back pain and was administered following medicines :

1. Injection Justine AQ for pain relief.

2. Chymoral forte for pain relief.

3. Tab : Pantocid 40 mg for acidity

4. Tab : Gabapin NT for pain relief.

5. Tab Myospaz D for pain relief.

On 09.10.2018,the patient underwent diagnostic tests such as CBC, Blood sugar-R, sodium potassium and

calcium. Thereafter she was discharged in the noon at 12.17 pm. The claim was not payable and was

repudiated under policy exclusion clause-F point No:xi which reads as under ;

“Charges incurred at hospitals primarily for diagnosis, x-ray or laboratory, examinations or other

diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive

existence or presence of any illness or injury for which confinement is required at a hospital.”

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed submitted by the complainant while respondent filed SCN along with enclosures.


20. Despite notice complainant is not present. I have heard respondent representative and perused papers

filed on behalf of the complainant as well as respondent.

21. Undoubtedly Smt. Seema Tiwari wife of the complainant was insured with the respondent who got

treated at Madhulok Hospital, Kanpur wherein following treatment was under taken :

Injection Justine AQ for pain relief.

Chymoral Forte for pain relief.

Tab Pantocid 40 mg for acidity.

Gabapin NT for pain relief.

Myospaz D for pain relief.

Claim made by the complainant was repudiated by the respondent on the following grounds :

“Patient Mrs. Seema Tiwari admitted in Madhulok Hospital on 08.10.2018 as a case of severe back pain with

H/o fall from stairs & discharged on 09.10.2018 with follow up advice. As per case record of patient

underwent some investigations and took oral medication. No any specific procedure or management was

done during hospitalisation. As per Clause F-11 for Diagnosis or Laboratory Examination hospitalization not

required. Hence claim is recommended as non-payable.”

Clause F Exclusions Point No:xi of the policy bond reads as under :

“Charges incurred at hospitals primarily for diagnosis, x-ray or laboratory examinations or other diagnostic

studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of

any illness or injury, for which confinement is required at a hospital.”


Specifically, treatment undertaken by Smt. Seema Tiwari was such which did not require hospitalization

rather it could have been done in OPD. Accordingly, claim was rightly repudiated.

Under such circumstances, I do not find any infirmity in the order which does not require any interference.

Order :







Mr. Ashwini Kumar Nanda…………..……....………………. Complainant

V/S

Star Health & Allied Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Ashwini Kumar Nanda.

B1-62, Sector-D-1, LDA Colony,

Lucknow-226012

2. Policy No:

Type of Policy


P/230000/01/2019/000578

Family Health Optima Insurance Policy

11.05.2018 to 10.05.2019



Self, and spouse

Mr. Ashwini Kumar Nanda

4. Name of the insurer Star Health and Allied Insurance Company Limited


6. Reason for repudiation/Rejection Disease falls under Exclusion Clause No:3(iii) of the Policy







13. Date of hearing/place On 04.03..2020 at 10.15 am at Lucknow


For the Complainant Mr.Ashwini Kumar Nanda

For the insurer Mr.C.S. Tandon


16. Date of Award/Order 04.03..2020

17. Mr.Ashwini Kumar nanda (Complainant) has filed a complaint against Star Health and Allied Insurance

Company Limited (Respondent) challenging the repudiation of his medi claim.


18. Brief Facts Of the Case:- The complainant was insured with the respondent under Family Optima Policy

for period 11.05.2018 to 10.05.20190 This was his 4th policy. He was admitted at Noble Hospital, Bhopal on

26.04.2019 due to some heart trouble. He was discharged next day on 27.04.2019. Again same day he got

admitted at Bansal Hospital, Bhopal for bypass surgery which was done on 28.04.2019. He was discharged

on 06.05.2019. A claim of Rs.708706/- stands repudiated by the insurer on the ground of pre-existing

disease. As per insurers his claim was not admissible until expiry of 48 months from the date of inception of

the first policy. The complainant had lodged a complaint before this forum for unjustified repudiation of the

claim by the respondent.

In their SCN/reply submitted in this office on 19.12.2019, the respondents have contended that since the age of

proposer was above 60 years, pre medical examination was done prior to issuing the policy and the following diagnosis

were found in PMER :

1. Calculous diseases of Hepato Pancreatico-Biliary System

2. Treatment of diseases related to cardio vascular system.

Hence the same was incorporated as declared PED in the policy schedule. Here in the instant case, the procedure

performed was Coronary Artery Bypass Graft which is an excluded disease and not payable as per waiting period Clause

No:3 (iii) of the policy where pre-existing disease is excluded for first 48 months of inception of the policy.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy of policy

document while respondent filed SCN with enclosures.

20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well as the

Insurance Company.

21. Undoubtedly complainant was insured with the respondent. Claim for reimbursement for treatment of coronary

artery disease was made which was repudiated on the following grounds :


“It is observed from the submitted medical records that the insured has undergone treatment for the above disease i.e.

disease of cardio vascular system which is incorporated in the above policy as one of the pre-existing disease at the

time of inception of the policy.

As per waiting period 3(iii) of the policy issued to you, the company is not liable to make any payment in respect of

expenses for treatment of the pre-existing disease/condition until 48 months of continuous coverage has elapsed, since

the date of commencement of the first year policy on 11.05.2015.”

Complainant submits that they have been cheated by the concerned agent. Complainant was not suffering from any

disease as mentioned as pre-existing disease in the policy bond. It is noteworthy that policy of the complainant was in

effect since 2015, following pre-existing diseases were shown by the complainant which were mentioned in the policy

bond of each year :

Calculous diseases of Hepato Pancreatico – Biliary system.

Treatment of diseases related to Cardio Vascular System.

At no point of time any objection was ever raised by the complainant that these diseases have wrongly been mentioned

as pre-existing diseases in the policy bond. Accordingly, he was accepting the policy bond without any reservation.

One of the Exclusion Clause was treatment of disease related to Cardio Vascular System. Admittedly complainant have

under gone CAG which is directly connected with the disease shown in the Exclusion Clause. Accordingly, I am of the

view that respondents have rightly repudiated the claim which did not require any interference.

Order :


22. Let a copy of award be given to both the parties.





Mrs. Sudha Agarwal…………..……....………………. Complainant

V/S

Star Health & Allied Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-044-1920-0034 ORDER NO. IO/LCK/R/HI/0042/2019-20

1. Name & Address of the Complainant Mrs. Sudha Agarwal

Shree motors, Chilbila

Ranjeetpur, Pratapgarh-230403

2. Policy No:

Type of Policy


P/700016/01/2019/06360

Star Comprehensive Insurance Plan

09.01.2019 to 08.01.2020



Mrs. Sudha Agarwal

Mrs. Sudha Agarwal

4. Name of the insurer Star Health and Allied Insurance Company Limited

5. Date of Repudiation/Rejection ---

6. Reason for repudiation/Rejection ---


8. Nature of complaint Unjustified deduction under co-payment head

9. Amount of Claim Rs.5,35,186.00


11. Amount of relief sought Rs.1,84,186.00




For the Complainant Mr. Rahul Tulsian, Son

For the insurer Mr. C.S. Tandon

15. Complaint how disposed Recommendation


17. Mrs. Sudha Agarwal (Complainant) has filed a complaint against Star Health and Allied Insurance

Company Limited (Respondent) challenging the partial repudiation of her health claim.


18. Brief Facts of the Case:- The complainant ported her mediclaim insurance policy from Max Bupa to

respondent and purchased policy for period 09.01.2019 to 08.01.2020. She underwent both the knee

replacement surgery at Shalby hospital Ahmedabad under a package deal where she remained admitted

from 23.05.2019 to 29.05.2019. Out of total package amount Rs. 5,35,186/- , the respondent had deducted Rs.

53,369/- towards the co-payment as per terms and conditions of policy. The insured has contended that after

deducting Rs. 3,51,000/- (which stands already paid to the hospital by insurer under cashless benefit), the

insurer should reimburse Rs. 1,84,186/- to her, which has not been settled so far. Aggrieved with the decision

of RIC, the complainant has approached this forum for redressal of her complaint.

In their SCN/reply, the respondent has submitted that the policy of insured /complainant was ported from

Max Bupa Health Ins. Co. Ltd. under portability. As insured’s age is above 60 years ,co-payment of 10% of

each & every claims amount for fresh as well as renewal policies for insured persons whose age at the time of

proposing this insurance policy is above 60 years (condition 4(6)). The calculation the respondent has

submitted as under:-

Package Amount – Rs. 5,35,186/-

(-) Registration charges - Rs. 1,500/-

(-) Co-payment @ 10% - Rs. 53,369/-

(-) Cashless amount - Rs. 3,51,000/-

Net amount as re-imbursement - Rs. 1,29,317/-

The respondent are ready to reimburse this amount to the insured subject to submission of original payment

receipt.






Claim was made for Rs.535186/- for treatment of insured. Out of which an amount of Rs.351000/- was made as

cashless payment. So far as remaining amount is concerned, there is Clause No:4.6 of the policy bond which reads as

under :

“Co-payment : This policy is subject to co-payment of 10% of each and every claim amount for fresh as well as renewal

policies for insured persons whose age at the time of proposing this insurance policy is above 60 years. Co-payment is

applicable only for Section 1 A to F.”

Respondents are ready to pay the amount as per provision of the policy bond wherein co-payment would be adjusted.

Accordingly, Rs.129317/- is payable to the insured subject to submission of original receipt of payment to the

respondent by the complainant.

Accordingly, complaint is partially allowed.

Order :

Complaint is partially allowed. Respondents are directed to make the payment of Rs.129317/- to the complainant

alongwith 6.2% interest per annum from the date of claim till the date of actual payment within 30 days subject to

submission of original receipt of payment by the complainant to the respondent.






Mr. Manoj Kumar Kapila…………..……....………………. Complainant

V/S

Religare Health Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Manoj Kumar Kapila,

117/L/24, Naveen Nagar,

Kanpur-208025..

2. Policy No:

Type of Policy


12294787

Religare Heath Insurance Policy

31.03.2018 to 30.03.2019



Mr.Manoj Kumar Kapila

4. Name of the insurer Religare Health Insurance Company Limited


6. Reason for repudiation/Rejection Concealment of pre-existing disease


8. Nature of complaint Unjustified cancellation of Policy



11. Amount of relief sought Not Mentioned




For the Complainant Mr. Manoj Kumar Kapila

For the insurer Mr. Pratyush Prakash



17. Mr.Manoj Kumar Kapila (Complainant) has filed a complaint against United India Insurance Company

Limited (Respondent) alleging non settlement of his mediclaim.


18. Brief Facts Of the Case:- The complainant ported his medical insurance from The New India

Assurance Company Limited to Religare Health Insurance Co.Ltd and purchased health policy for period

31.03.2018 to 30.03.2019. On complaint of blood in stool, he contacted Dr. Rajan Luthra on 23.07.2018

who advised for some pathological tests. After going through all pathological tests on 06.08.2018 he was

admitted at Kanpur Medical Centre Pvt. Ltd on 08.08.2018 and underwent surgical procedure for

correction of hemorrhoid. A request for cashless treatment was made which was denied by the insurer

and later the policy was cancelled by the respondent on the ground of concealment of material fact at the

time of obtaining insurance cover. Aggrieved with the decision of the insurer, the complainant has

approached this forum.

In their SCN/Reply dated 11.02.2020, the respondents have submitted that at the time of porting the

policy from the New India Assurance Company Ltd to Religare Health Insurance Company Ltd, the

insured/complainant did not disclose history of Dislipdaemia Haemorrhoids and Hypertension. They also

concluded that :

That as per query reply the exact duration of the P/R bleeding is from November 2017 and the

patient first consulted to Dr.Ranjan on 23.07.2018.

That as per consultation sheet of Kanpur Medical Centre duly signed by Dr. Rajan Luthra insured

had bleeding R/R off and on since 1988 and since 2017 he was bleeding more.

That as per consultation sheet of Dr.R Kumar dated 23.10.2013 insured was suffering from

Dislipidaemia and was taking medication.

Since there was concealment of material fact on the part of the insured/complainant. Notice was given for

policy cancellation on 30.10.2018 and subsequently the policy was cancelled.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and

copy of policy document while respondent filed SCN with enclosures.

20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well

as the insurance company.

21. Undoubtedly complainant was a policy holder of New India Assurance Company Limited. He opted for

portability of his policy with the respondent. His policy was ported with the respondent. Policy bond was

sent to the complainant well in time. Complainant received the policy bond. When complainant visited Dr.

Rajan Luthra on 23.07.2018 and submitted the claim. Letter dated 30.10.2018 was sent to him by the

respondent with the following assertions:

“There has been non-disclosure of material facts/pre-existing ailments at the time of proposal. Patient Mr.

Manoj Kumar Kapila had a history/known case of hypertension, dyslipidaemia, anaemia and haemorrhoids

however this fact was not disclosed at the time of taking policy.’


In accordance with the policy terms and conditions, we hereby serve you a notice of 15 days, from the

date of this letter, within which you should furnish correct facts supported by valid documentary proof, in

case you dispute the same, failing which we would be entitled to cancel the policy as per policy terms and

conditions and forfeit the entire premium.”

Accordingly, policy got cancelled after the expiry of stipulated period.

Subsequently, complainant had taken an insurance cover from another company. Sh. Pratyush Prakash,

representative of the respondent submits that the policy was reinstated in the system upto 30th March

2019.

Complainant’s contention is that since the policy was cancelled hence, he was required to take a new

insurance cover, he is still ready to continue with the policy with the respondent but his premium paid to

another insurance company should be refunded by the respondent. This contention cannot be accepted.

Complainant was at his free will to take the insurance cover from any insurance company.

Respondents have given a notice for cancellation of the policy but renewed the same till the period

30.03.2019, then the respondent cannot be asked to refund the payment which was made by the

complainant to some other insurance company. Once period of insurance cover is over, the same could

not be continued without payment of the premium to the insurance company. Since the premium has not

been paid to the respondent after 30.03.2019 hence policy is not in-existence thereafter. Accordingly,

complaint lacks merit and is liable to be dismissed.

Order :



Dated : March 12, 2020 ( Justice Anil Kumar Srivastava )




Mr. Shubham Parashar…………..……....………………. Complainant

V/S

Religare Health Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Shubham Parashar

C-2099/5, Indira Nagar

Lucknow(U.P.)-226016

2. Policy No:

Type of Policy


11920139

Floater Health Mediclaim Policy

09.01.2019 to 08.01.2020



Mr. Shubham Parashar

Mr. Shubham Parashar

4. Name of the insurer Religare Health Insurance Company Limited


6. Reason for repudiation/Rejection Disease caused due to smoking





11. Amount of relief sought Rs.4,80,000/-




For the Complainant Mr. Shubham Parashar

For the insurer Mr. Partyush Prakash, Manager



17. Mr. Subham Parashar (Complainant) has filed a complaint against Religare Health Insurance Company

Limited (Respondent) alleging repudiation of his health claim.


18. Brief Facts of the Case:- The complainant was covered under health insurance policy with Religare

Health Ins. Co. Ltd. for period 09.01.2019 to 08.01.2020. On 29.03.2019 he was clinically diagnosed in OPD

of Homi Bhabha Cancer hospital Varanasi as oral cancer in Left Bhuccal Mucosa. He was admitted in same

hospital on 26.04.2019.Surgery was done on 30.04.2019 and he was discharged on 17.05.2019. His

reimbursement claim was repudiated by the insurer on the ground that the disease was caused due to

smoking by the insured whereas the treating doctor has confirmed in writing that the etiology of the

disease is not known. Aggrieved with the decision of RIC, the complainant has approached his forum.

In their SCN/reply, RIC has submitted that complainant was insured with respondent for period 09.01.2019

to 08.01.2020. This was his second year’s policy. Query letters were sent on 19.06.2019 and 26.09.2019 for

providing treating doctor’s certificate for etiology of the present ailment. Exact duration and past history

of present ailment with Ist consultation paper and all past treatment records. In reply to the query letters

exact duration and past history of the present ailment was not clear. Therefore two more query letters

were sent on 30.07.2019 and 13.09.2019. However the documents were not provided. Respondent rejected

the reimbursement claim of the insured on the ground of deficiency not replied in accordance to the

policy terms and conditions and sent denial letter on 17.09.2019.




the insurance company.

21. Undoubtedly complainant was insured with the respondent insurance company. He underwent

following surgery at Homi Bhabha Cancer Hospital, Varanasi on 30.04.2019 :

“Wide local excision of buccal mucosa + orbital floor preserving total maxillectomy + segmental

mandibulectomy + high infra temporal fossa clearance + inferior and middle turbinater resection +

excision of TH sphenoid mucos + SND (I-IV) left side + reconstruction with free antero lateral thigh flap +

trach.”

He was discharged on 17.05.2019. He was diagnosed as CA Left Buccal Mucosa.Claim preferred by the

complainant was repudiated on the ground of “Permanent Exclusion for diseases caused due to smoking

use, misuse and abuse.”.


Complainant submits that he was not habitual of smoking but very casually he used to smoke one or two

cigarettes in one or two months period

Respondent submits that since complainant himself is admitting the consumption of cigarettes hence

claim was rightly repudiated.

Reliance was placed on an opinion of one Dr. H.C. Asrani, who is a private doctor, 5, Rajkamal Apts, Opp.

Vidyanagari, Kalina, Mumbai wherein he opined that smoking is an accepted and one of the most

significant predictor of oral cancer and insured’s oral cancer is attributed to his smoking even 1-2

cigarettes a month.

This opinion is of a private doctor which does not have any binding effect. A certificate dated 26.08.2019

was issued by Dr.Swagnik Chakrabarti, MS, Head and Neck Surgery Unit, Homi Bhabha Cancer Hospital,

Varanasi wherein insured was treated. As per certificate, insured was not addicted to tobacco, alcohol or

any other addictive substance. Therefore the aetiology is not known.

Claim was repudiated on the ground that disease was caused due to smoking. The Exclusion Clause 4.2(23)

reads as under :

Act of self-destruction or self inflicted injury, attempted suicide or suicide while sane or insane or illness or

injury attributable to consumption, use, misuse or abuse of intoxicating drugs, alcohol or hallucinogens.””

Certificate issued by Homi Bhabha Cancer Hospital, Varanasi itself is not challenged in the self contained

note. If the aetiology of the disease could not be established then exclusion clause would not be

applicable.

In order to bring the case under exclusion clause, respondents are under obligation to directly connect the

disease with smoking but in the present case, respondents failed to establish it. Accordingly, I am of the

view that the repudiation of the claim by the respondent is bad in law and against the terms and

conditions of the policy bond.


Accordingly complaint is liable to be allowed.

Order :

Complaint is allowed. Respondents are directed to make the payment of claim to the complainant within

30 days.






Mr. Satish Srivastava…………..……....………………. Complainant

V/S

HDFC Ergo General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-018-1920-0125 Order No. IO/LCK/R/HI/0037/2019-20

1. Name & Address of the Complainant Mr. Satish Srivastava,

E-2/253, Deen Dayal Puram,

Naubasta, Kanpur-208021.

2. Policy No:

Claim No.

Type of Policy


2864100317795301000

Health Medisure Classic Insurance Policy

05.06.2019 to 04.06.2020



Self and his wife

Mr. Satish Srivastava

4. Name of the insurer HDFC Ergo General Insurance Company Limited


6. Reason for repudiation/Rejection Forged and fabricated claim


8. Nature of complaint Repudiation of the claim







For the Complainant Mr. Satish Srivastava

For the insurer Mr. Shiv Prakash Singh

15. Complaint how disposed Recommendation


17. Mr.Satish Srivastava (Complainant) has filed a complaint against HDFC Ergo General Insurance

Company Limited (Respondent) challenging repudiation of his health claim.

COMPLAINT NO:LCK-H-018-1920-0125 Order No. IO/LCK/R/HI/0037/2019-20

18. Brief Facts of the Case:- The complainant purchased first medical policy from the respondent for

period 04.06.2018 to 03.06.2019 and got it renewed for period 05.06.2019 to 04.06.2020. On complaint of

high fever, vomiting and burning in urination, he got admitted at Family Hospital and Research Centre,

Kanpur on 09.07.2019. After his discharge from hospital on 14.07.2019, he preferred a claim for Rs.61228/-

with the insurer. The insurers repudiated his claim on 21.09.2019 on the ground of forged and fabricated

claim. Aggrieved with the decision of the insurer the complainant has approached this forum.


of policy document.



21. Sincere efforts were made for mediation to resolve the subject matter of complaint. The complainant

and the representative of the respondent company were heard. During course of the mediation, both the

parties filed joint application (Mediation Agreement) duly signed by the complainant and the

representative of the respondent mentioning therein about settlement of the matter willingly and mutually

and agreed to settle the subject matter of the complaint as follows:-

The respondent HDFC ERGO General Ins. Co. Ltd. has agreed to settle the RR_HS19-10719816 for Rs.

54218/- as full and final settlement to the policyholder/ complainant without interest. The

Complainant also agreed for the same.

22. As matter within in the parties has resolved mutually, hence the complaint is decided in terms of

mediation/mutual agreement between both the parties.

23. Let the copies of this award be given to both the parties.

Date: 12.03.2020 (Justice Anil Kumar Srivastava)

Place: Lucknow Insurance Ombudsman



Mr. Sanjai Tiwari…………..……....………………. Complainant

V/S

Apollo Munich Health Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Sanjai Tiwari

D-12/21, Neechi Bahmapuri , Bansphatak

Dashaswamedh, Garh

2. Policy No:

Type of Policy


111200/11001/AA00847014-01

Easy Health Individual Policy

18.06.2019 to 17.06.2020



Mr. Sanjai Tiwari

Mr. Sanjai Tiwari

4. Name of the insurer Apollo Munich Health Insurance Company Limited


6. Reason for repudiation/Rejection Concealment of material fact


8. Nature of complaint Repudiation of the claim & cancellation of policy

9. Amount of Claim Rs. 2.50 Lakh


11. Amount of relief sought Rs. 2.50 Lakh




For the Complainant Mr.Sanjay Tiwari,

For the insurer Mr.Gajendra Singh Chouhan



17. Mr. Sanjai Tiwari (Complainant) has filed a complaint against Apollo Munich Health Insurance

Company Limited (Respondent) challenging repudiation of his health claim and unjustified cancellation

policy.


18. Brief Facts of the Case:- The complainant purchased a health insurance policy from Apollo Munich

Health Insurance for policy period 18.06.2018 to 17.06.2019 and also got it renewed for period of

18.06.2019 to 17.06.2020. On complaint of heaviness in abdomen and chest he consulted a doctor who

advised him for certain tests. It was found that he was suffering from chronic stable Angina. His

angiography was done on 18.06.2019 and finally bypass surgery was done at Eternal hospital Jaipur on

05.07.2019. He was discharged on 11.07.2019. He submitted a claim for reimbursement of Rs. 2.50 lakh

spent by him on treatment which was repudiated by the insurer on the ground of pre-existing disease. His

policy was also cancelled on the ground of concealment of material fact as treating doctor has mentioned

that he was a known case of angina on exertion since 2 years. Aggrieved with the decision of insurer, the

complainant has approached this forum.

In their SCN/reply, the respondent have submitted that the complainant was insured with them primarily

for period 18.06.2018 to 17.06.2019 and further for period 18.06.2019 to 17.06.2020. In discharge summary

dated 11.07.2019 of eternal hospital, Jaipur. It was summarized that the patient was “presented with

history of angina on exertion for last two years”. This fact was not disclosed by the insured while

processing for medical cover on 12.06.2018. This concealment of material fact was an important factor in

the contract based on Utmost Goof faith. Therefore the claim was repudiated on 03.08.2019 and policy

was cancelled on 31.08.2019.





21.Undoubtedly complainant is insured with the respondent since 26.06.2018. It is also admitted that the

complainant had some problem at Jaipur wherein he consulted the doctor and he was advised to be

operated. He was operated upon in Eternal Hospital, Jaipur on 05.07.2019 and discharge on 11.07.2019.

Clinical summary shows that he was having a history of Angina on exertion for last two years. He was

operated upon for CABG.

Claim was submitted. It was repudiated vide letter dated 31.01.2020 on the ground that insured was

known case of angina on exertion since two years i.e. before policy inception.


So far as repudiation is concerned, nothing is available on record from the side of the respondent to show

that the complainant was a patient of angina on exertion for the last two years. He was diagnosed as

Angina Excursion which does not mean that he was a patient of Angina for last two years. It might have

been possible, he may not had any angina problem during the last two years. Had it been so, respondents

should have collected the relevant material from the hospital. Insured has shown to have angina on

excursion. Whether insured had such angina attack previously? Had he suffered such problem prior to

inception of the policy. Burden lies upon the respondent to prove it but they failed to discharge the

burden.

It is not in dispute that the claimant was not admitted in Eternal Hospital, Jaipur or was not treated there.

Having considered the material available on record, I am of the view that the claim of the complainant has

wrongly been repudiated.

Order :

Complaint is allowed. Respondents are directed to make the payment of the claim of the claimant in

accordance with terms and conditions of the policy bond within a period of 30 days.






Mr. Narendra Nath Sinha…………..……....………………. Complainant

V/S

Religare Health Insurance Co. Limited…………..………..…………Respondent

COMPLAINT NO. LCK-G-037-1819-0059 ORDER NO. IO/LCK/A/GI/0180/2019-20

1. Name & Address of the Complainant Shri Narendra Nath Sinha,

5/339, Viram Khand, Gomtinagar,

Lucknow-226010.

2. Policy No:

Type of Policy


11606926

Religare Health Insurance

02.10.2017 to 08.03.2018 [ 158 days ]



Self.

Mr. Narendra Nath Sinha



6. Reason for repudiation/Rejection Clause No: 2.6A (I) of the Policy Bond



9. Amount of Claim $1500


11. Amount of relief sought





For the insurer Mr. Pratyush Prakash



17. Mr. Narendra Nath Sinha (Complainant) has filed a complaint against Religare Health Insurance

Company Limited(Respondent) alleging repudiation of his dental claim.


18. Brief Facts Of the Case:- The complainant has stated that He fell down due to an accident and broke his

sound natural tooth in two pieces. Doctors advised me to treat the ailment with medicine and to make new

partial covering the area of broken tooth so that he may be able to eat and could restore the same state of

health. As per suggestion of the doctor the treatment was carried out. He submitted the claim bill $1500 to

the respondent for settlement of the claim alongwith related documents. Claim was rejected by the

respondent company. He had approached the grievance cell of the respondent but he received no response.

Aggrieved with the decision of RIC, the complainant has approached this forum for redressal of his

complaint.

In their SCN/Reply, RIC has stated that the said policy was issued from 02.10.2017 till 08.03.2018 subject to

the policy terms and conditions. In the said policy the complainant himself was insured. Complainant took

dental treatment on 23.12.2017 for treating injury due to alleged accident. The complainant filed for

reimbursement claim with the respondent company on 17.03.2018 for expense incurred in the dental

treatment. On the basis of the documents received by the respondent company from the complainant, it was

observed that the treatment taken by the complainant was for partial denture damaged due to the alleged

accident complainant was involved in. It is important to note here that as per the terms and conditions, claim

pertaining to dental treatment is admissible only cases where treatment is taken over sound natural teeth

during the policy period. The claim of the complainant was rejected vide e-mail/letter dated 09.04.2018 in

adherence of the policy terms and conditions No: 2.6 A(I).



20. Despite notice complainant is not present. I have heard respondent representative and perused papers

filed on behalf of the complainant as well as respondent.

21. Claim is made on the ground that the complainant had under took a treatment of his teeth when he fell

down at Dallas, USA. His sound natural teeth was broken into two pieces and the partial which he was

wearing adjacent to this tooth also got damaged due to injury. He had undertaken the treatment there but

the claim was repudiated on the ground of Exclusion Clause No:2.6A (I) which is produced as under :


“Dental treatment is limited only in case of injury to the insured person’s sound natural teeth during the

period of insurance”

On 13.11.2019 complainant was required to submit the prescription of treatment of Smile Refined Family

Dentistry alongwith bills including pathology/x-ray reports etc. Complainant failed to file/produce the

papers. Complainant had taken treatment endodontically for tooth which was not sound natural teeth.

As per Clause No:2.6 Benefit 6 : Dental Treatment : The company will indemnify up to the amount specified

against this benefit in the policy certificate, the medical expenses incurred for “Dental Treatment” during the

period of insurance in connection with any injury to the insured’s person sound natural teeth during the

period of insurance provided that :

“For the purpose of this benefit only : Sound Natural Teeth means natural teeth that are either unaltered or

are fully restored to their normal function and are disease-free, have no decay and are not more susceptible

to injury than unaltered natural teeth.”

Even as per doctor’s certificate dated 23.12.2017, new partial was required as the old ones could not be

repaired.

Treatment under taken by the complainant is not covered under the policy bond. Accordingly, claim has

rightly been repudiated by the respondent which did not call for any interference.

Order :


22. Let copies of award be given to both the parties.

Dated : March 12, 2020 ( Justice Anil Kumar Srivastava)




Mr. Govind Ballabh Joshi…………..……....………………. Complainant

V/S

HDFC Ergo General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-G-018-1819-0101 Order No. IO/LCK/A/GI/0182/2019-20

1. Name & Address of the Complainant Mr. Govind Ballabh Joshi,

529/599, New Rahimnagar,

Lucknow-226006.

2. Policy No:

Type of Policy


2825202046329400000

Health Surksha Policy [Silver Plan]

24.11.2017 to 23.11.2018



Self and his wife

Mr. Govind Ballabh Joshi

4. Name of the insurer HDFC Ergo General Insurance Company Limited


6. Reason for repudiation/Rejection Claim denied as per Policy Section 9C xvi.


8. Nature of complaint Repudiation of the claim







For the Complainant Mr. Govind Ballab Joshi

For the insurer Mr. Shiv Prakash Singh



17. Mr.Govind Ballabh Joshi (Complainant) has filed a complaint against HDFC Ergo General Insurance

Company Limited (Respondent) challenging repudiation of health claim of his wife.


18. Brief Facts Of the Case:- The insured complainant purchased Health Suraksha Policy for himself and

his wife for period 24.11.2017 to 23.11.2018. This was his first policy. On complaint of dryness in both

the eyes and knee joint pain, the complainant’s wife was admitted in Sreedhareeyam Ayurvedic Eye

Hospital & Research Centre Ltd, Ernakulum on 11.06.2018. She was treated and discharged on

27.06.2018. A claim for Rs.52500/ was lodged with the insurer which was repudiated on the ground that

for the ailment hospitalization was not needed and the disease was pre-existing. Aggrieved with the

decision of the insurer the complainant has approached this forum.

In their SCN/reply, RIC has stated that while filling of the proposal form, the insured did not disclose pre-

existing disease. As per discharge summary of the hospital the insured had a history of Branch Retinal

Arterial Occulation in the right eye in 2013 also she was suffering from knee joint pain for last two years.

Hence both the ailments were pre-existing at the time of inception of the policy. Hence claim is denied

under Section 9C xvi of the Policy terms and conditions. Communication regarding the said decision was

sent to the complainant through claim declination letters dated 23.07.2018 and 12.09.2018.



20. I have heard both the parties at length and perused paper filed on behalf of the complainant as well

as the insurance company.

21. Undoubtedly, insured Mrs. Deepa Joshi is insured with the respondent. She underwent treatment at

Sreedhareeyam Eye Hospital & Research Centre Pvt.Ltd. Koothattukulam. When the claim was submitted

with the respondent, it was repudiated vide letter dated 23.07.2018 on the following ground:

“As per the submitted claim documents, the claimant was hospitalized in a condition for which

hospitalization was not required and the patient could have been managed on OPD (Out Patient

Department) basis, The claim is denied under Section 9 c xvi which states “conditions for which

hospitalization is not required” is a part of general exclusions and hence beyond the scope of coverage of

the policy.”

When complainant made a request for reconsideration, another ground was added in the repudiation vide

letter dated 12.09.2018. Repudiation was made on the following ground :


“As per the submitted documents, the patient was admitted on 11.06.2018 with the complaints of dryness

and itching sensation in both eyes, photophobia, knee joint pain since 2 years and was treated for same.

As the date of inception of policy is 24.11.2017 and patient is under eye treatment since 2015 and knee

joint pain is also since 2 years, the ailment is pre-existing in nature. Hence this claim is being repudiated

under Section 9 A(iii) of policy terms and conditions. (any pre-existing disease/illness/injury will not be

covered until 48 months of continuous coverage have elapsed since inception of the first health suraksha

policy with us). Moreover, the patient is under eye treatment since 2015 insured had not disclosed the

ailment while purchasing the policy. Hence there is non- disclosure of material facts and thus this claim is

being repudiated under Section 10 r(ii).”

We shall deal both the repudiation letters separately.

Repudiation letter dated 23.07.2018 has no substance at all. Undisputedly insured was admitted in the

hospital wherein as per discharge summary, she was diagnosed as Sushkaakshi Dry Eye. She remained

there from 11.06.2018 to 27.06.2018. It cannot be believed that patient can be treated on OPD basis. She

would be admitted for such a long time. Further respondents have simply asserted that the treatment

could have been done on OPD basis but without any substance, repudiation on this count is bad in law.

When complainant moved a representation for reconsideration of the repudiation letter dated 23.07.2018,

an additional ground is added in the repudiation letter dated 12.09.2018 as referred above. So far as

question of pre-existing disease is concerned, no doubt in the proposal form, no prior history was given.

Even medical examiner did not find any prior history. Further even in the discharge summary, there is

complaint of knee joint pain in both lower limbs which could not amount to any ailment in the knees. Now

a days, it is life style problem. It could not be bracketed in pre-existing disease.

So far as eye ailment is concerned, very fairly complainant submits that his wife was not suffering from

any prior eye ailment. She was even checked for the same at Dr.Rajendra Prasad Centre for Ophthalamic

Sciences, AIIMS, New Delhi wherein only cardiology evaluation was advised. When she checked herself at

North Eastern Indira Gandhi Research Institute of Health & Medical Sciences, Shillong, it was opined on

05.11.2013 that no cardiac intervention is required at present. Hence, even the repudiation on the ground

of pre-existing ailment of eye could not be substantiated on record. Accordingly, I am of the view that

the claim of the complainant has wrongly been repudiated by the respondent.


Complaint is liable to be allowed.

Order :

Complaint is allowed. Respondents are directed to pay the claim of Mrs. Deepa Joshi as per terms and

conditions of the policy bond within 30 days.




PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD

CASE OF MR. PARMOD KUMAR V/S ICICI LOMBARD GENERAL INSURANCE COMPANY LTD.

COMPLAINT REF: NO: NOI-G-020-1920-0167

AWARD NO:

1. Name & Address of the Complainant Mr. Parmod Kumar,

Village Barola, Sector – 49, Noida, UP-201304.

2. Policy No:

Type of Policy


4128i/IHP/166266370/00/000

Health Insurance

03.03.2019 to 02.03.2020



Mr. Parmod Kumar

Mr. Parmod Kumar



6. Reason for repudiation

Clause 12 of the policy – Fraudulent Claim




10. Date of Partial Settlement Nil



IOB rules

13 (1) (b)

13. Date of hearing/place 20.02.2020 at Noida


For the Complainant Mr. Parmod Kumar, Self

For the insurer Ms. Sanskriti Mishra, Legal Manager



17) Brief Facts of the Case: This complaint is filed by Mr. Parmod Kumar against ICICI Lombard General Insurance

Co. Ltd. for repudiation of his health claim.


Complainant’s argument: The complainant had taken Health Insurance Policy bearing Policy No.

4128i/iHP/166266370/00/000 from ICICI Lombard, for the period from 03.02.2019 to 02.03.2020. He was admitted in

Arogya Hospital on 04.05.2019 and was discharged on 08.05.2019. He was diagnosed with UTI & E.G. He submitted

claim reimbursement documents to the insurance company which was rejected by them on the grounds that the lab bill

no. 422 was fraudulent, whereas, the bill was genuine.

Insurers’ argument: The insurance company submitted their SCN dated 18.02.2020 that the complainant had taken

health insurance policy for the period from 03.03.2019 to 02.03.2020 covering himself and his wife. The complainant

submitted claim reimbursement form for hospitalization from 04.05.2019 to 08.05.2019 on 25.05.2019. He was

admitted in Arogya Hospital for treatment of fever, vomiting and pain in abdomen. He submitted discharge summary

dated 08.05.2019 which hand written. Further, they received lab reports which were signed by Dr. Swati Chandel dated

04.05.2019 and there was pathology receipt for Rs. 4,850/- issued on 04.05.2019. After receipt of claim documents, the

insurance company conducted investigation. The investigator met with Dr. Swati Chandel who confirmed that the

pathology reports submitted by the complainant dated 04.05.2019 was fake and false. She also confirmed that she had

not conducted tests of Mr. Parmod Kumar. The investigator met the complainant who gave statement that he was

discharged at 10.20 pm but the discharge summary shows the time as 8.20 pm. The insurance company repudiated the

claim on 14.06.2019 as per Part III General Terms and Conditions – 12. Fraudulent Claim. They have terminated the

policy on 30.10.2019 on the ground of fraud committed by the complainant.

19) Reason for Registration of Complaint: -


a) Complaint letter

b) Discharge Summaries

c) Policy document

d) SCN

21) Observations and Conclusion: Both the parties were present in the personal hearing on 20.02.2020. The

complainant stated that he was admitted in hospital for fever. The insurance company repudiated his hospitalization

claim for the reason that the lab bills were false. He further stated that he was hospitalized and was not aware about the

lab. The insurance company reiterated that they investigated the claim and it was found that the lab bills submitted by

the complainant were fake. Dr. Swati Chandel has given in writing that the lab reports were fake and false.

During the hearing, it was found that the evidences produced by the insurance company were inadequate and the case

required more investigation. The insurance company was directed to conduct more investigation and adduce sufficient

and credible evidence in support of their repudiation. The complainant was also directed to submit report from the

hospital as to where his pathology tests were performed and why Dr. Swati Chandel was certifying that the lab reports

produced alongwith the bills were false and fake. Both the parties were given 15 days time to submit their replies.

The complainant submitted a fresh Discharge Summary of Arogya Hospital and Claim Form Part B filled in by the

treating doctor on 25.02.2020. These documents do not speak about the lab reports which were alleged to be false and

fake. On the other hand, the insurance company stated vide their email dated 03.03.2020 that the company‟s

representative met with Dr. Swati Chandel wherein she clearly highlighted that she was not practicing at Arogaya

Hospital and confirmed that the Arogaya Hospital was using her name and signature in all the pathology reports

fraudulently without her knowledge. She had given the warning to the said hospital several times. She further confirmed

that she is pathologist at Genesis Pathology not at Arogaya Hospital. The hospitalization was recommended based

upon the pathology reports of Dr. Swati Chandel who confirmed that she never conducted any tests in Arogaya

Hospital nor was she associated with Arogaya Hospital. The insurance company produced certificate dated

28.02.2020 from Dr. Swati Chandel. They also attached audio recording of Dr. Swati Chandel.

On going through the documents exhibited and the oral submissions made during the hearing and documents received

after the hearing by both the parties, it is noted that the complainant could not produce any credible evidence from the

hospital that can prove that the lab reports of Dr. Swati Chandel were genuine. He only submitted a fresh discharge

summary and claim form issued by the hospital. The insurance company has submitted a certificate from Dr. Swati

Chandel dated 28.02.2020 where she clearly wrote that she was not involved in any processing of blood tests and

insurance claims taking place in Arogaya Hospital. It is to be noted that the hospitalization was recommended

consequent upon the pathology lab reports which were found to be fake and fraud. The insurance company

repudiated the claim as per Part III of the Policy Schedule: General Terms and Conditions – 12. Fraudulent Claims.

I see no reason to interfere with the decision of the insurance company to repudiate the claim. The complaint is

dismissed.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance


a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty

days of the receipt of the award and intimate compliance of the same to the Ombudsman.

Place: Noida. C.S. PRASAD

Dated: 12.03.2020 INSURANCE OMBUDSMAN

(WESTERN U.P. & UTTARAKHAND)

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both

the parties, the insurance company had rightly repudiated the claim as per Part III of the

Policy Schedule : General Terms and Conditions – 12. Fraudulent Claims.

The complaint is dismissed accordingly.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C.S. PRASAD

CASE OF SH. JYOTI PRAKASH SRIVASTAVA V/S BAJAJ ALLIANZ GENERAL INS. CO. LTD.

COMPLAINT REF. NO. : NOI-H- 005-1920-0246

AWARD NO:

1. Name & Address of the Complainant Sh. Jyoti Prakash Srivastava,

J-103, Neel Padam Kunj,

Sector-1, Vaishali,

Ghaziabad, U.P.201010.

Ph. No.08130103412

2. Policy No:

Type of Policy


Sum Insured

OG-19-1000-6021-00009382

Mediclaim Insurance Policy

29.07.2018 to 28.07.2019

Rs.10,00,000/-



Sh. Jyoti Prakash Srivastava

Sh. Jyoti Prakash Srivastava

4. Name of the insurer Bajaj Allianz General Ins. Co. Ltd.


6. Reason for repudiation Non disclosure of PED



9. Amount of Claim N.A.


11. Amount of relief sought Rs.94,641/- + interest + mental harassment

Rs.5,00,000/- as per Annex VI A


Rule no: of IOB rules, 2017

13 (1)(b)

13. Date of hearing/place 05.03.2020 / NOIDA


For the Complainant Sh. Jyoti Prakash Srivastava

For the insurer Sh. Shyama Vats, Manager Legal



17) Brief Facts of the Case : Sh. Jyoti Prakash Srivastava, the complainant had taken a Mediclaim Insurance Policy

No. OG-19-1000-6021-00009382 for the period from 29.07.2018 to 28.07.2019 for the Sum Insured of

Rs.10,00,000/-. Claim of the Complainant was rejected by the Insurance Company on the ground of PED.

Aggrieved, he requested the insurer including its GRO to reconsider the claim but failed to get any relief.

Thereafter, he has preferred a complaint to this office for resolution of his grievance.


a) Complainant’s argument : The Complainant stated that on 23.10.2018, he was quite normal. While, he was

returning from Old Delhi by Metro, all of a sudden, he fell down in the Metro due to giddiness and became

unconciousness. His family carried him to Max Hospital, Vaishali in Emergency Ward.

On 27.10.2018, the Max Hospital discharged him and has submitted final bill to the Insurer. No reply was received

by the Insurer. On 28.10.2018, the Max Hospital again submitted their final bill. After continuous follow up by the

complainant and hospital staff, the Insurer sent a letter “Denial of Cashless facility”. The complainant was

discharged on 28.10.2018. On 30.10.2018, the complainant submitted the documents for reimbursement to the

Insurer. On 15.11.2018, the Insurer‟s representative visited the complainant.

On 12.12.2018, the complainant received a query letter asking him to submit treating Doctor‟s Certificate regarding

exact cause and duration of Anaemia and Posterior circulation TIA. The same was submitted by the complainant on

13.12.2018. On 19.01.2019, the Insurer denied the claim as pre-existing disease and not disclosed in the Proposal

Form at the time of taking the insurance.

The complainant stated that no proposal form has been put before him neither on internet nor physically. Only a

phone call has been made to him and on phone, he had explained the fact that a test Angiography has been

conducted in June 2016 in Max Hospital and nothing has been found serious.

b) Insurers’ argument: The Insurance Company stated in their SCN that the verification of the claim documents

revealed that the complainant was hospitalized for the treatment of Posterior circulation TIA/stroke, vitamin B 12

deficiency, and anemia and is claiming for the expenses incurred in the treatment. However, the complainant is

known to be suffering from the Coronary artery disease/small vessel disease since 2016, which is pre-existing to the

policy. The complainant was hospitalized on 23.10.2018 after the incident when the complainant had become

unconscious during the transit at the metro station. The complainant was evaluated with history of Coronary Artery

disease/small vessel disease, Right bundle branch block since 2016 and diagnosed as Posterior circulation TIA/

stroke with the above mentioned problems and was treated accordingly and was discharged on 27.10.2018. The

Discharge Summary evidently mentions the past history of Known Case of CAD with RBBB (A right bundle branch

block) since 2016.

It is submitted that the claim of the complainant has been rightly repudiated vide letter dated 18.01.2019 after the

detailed scrutiny of the claim as it does not fall within the purview of the policy.

The Clinical Progress Notes further clearly mention that the date of the pre-existing condition specifically as

21.06.2016 against the conditions mentioned as CAD/SVD/RBBB, it is humbly submitted that the first policy was

issued on 29.07.2016. These are technically the terms for the heart condition in a way that CAD means impedance

or blockage of one or more arteries that supply blood to the heart. On the other hand, SVD is a condition in which

the walls of the small arteries in the heart are damaged, whereas, RBBB is right bundle branch and is related to

electrical conduction system of heart for and responsible for heart contraction to regulate blood flow. Hence, it is

very clear if the pieces are brought together that the complainant was admitted for Posterior circulation TIA which is

transient ischemic attack also called referred as a mini stroke and is very much associated with the pre-existing heart

ailment that had been concealed by the complainant.

That it is evident on the perusal of the Proposal Form, that the complainant did not disclose anything regarding the

heart ailment on the proposal form. If the complainant had the bona fide intention while purchasing the policy then

he would have definitely mentioned YES under the last point mentioned under the Health Related Questions column

on the Proposal form. The above mentioned conditions prior to the inception of the policy and had concealed the

material fact of the heart ailment, therefore, the policy clause of non-disclosure is sufficient to cancel the policy and

the claim.

That on placing reliance on the previous treatment record of the complainant, it is apparent that as per the Coronary

Angiography dated 21.06.2016, the complainant was diagnosed with CAD-ACS (Trop Positive) and the final

impression of the Report mentioned CAD – Small Single Vessel Disease (D1). This report at hand evidently

establishes the pre-existing condition mentioned in the present medical treatment record of 2018.

Non disclosure of pre-existing ailment is violation of principle of insurance contract i.e. Utmost good faith. The

complainant had pertinently given a false declaration that had no pre-existing disease, he further undertook that if

his declaration is found to be incorrect, all benefits under the policy taken from the Insurer in the impugned Policy

shall stand forfeited. In view of the false declaration having been given, the claim has rightly been repudiated.

19) Reason for Registration of Complaint:- Rejection of Mediclaim.


a) SCN.

b) Annexure VI A

c) Complaint copy

d) Discharge summary.

21) Observations and Conclusion :-

Both the parties appeared for personal hearing and reiterated their submissions. The Insurance Company stated that

the insured was suffering from Coronary artery disease/small vessel disease since June, 2016. From the previous

treatment records of the complainant, it is apparent from the Coronary Angiography dated 21.06.2016 that the

complainant was diagnosed with CAD-ACS (Trop Positive) and the final impression of the Report mentioned CAD

– Small Single Vessel Disease (D1). This report evidently established the pre-existing condition mentioned in the

present medical treatment record of 2018. This is pre-existing to the policy and though, the first policy was issued

on 29.07.2016 with the Bajaj, the illness was pre-existing disease to the policy starting with Bajaj which was not

disclosed in the proposal form submitted at the time of taking the policy. The complainant did not disclose anything

regarding the heart ailment in the proposal form. If the complainant had the bona fide intention while purchasing

the policy then he would have definitely mentioned YES under the last point mentioned under the Health Related

Questions column on the Proposal form. The complainant argued that no proposal form was put before him, neither

on internet or physically. Only a phone call has been made to him and on phone, he had explained the fact that a test

Angiography has been conducted in June 2016 in Max Hospital wherein nothing has been found serious. The

Insurance Company explained that E-Proposal was filled up by the complainant through phone call and copy of the

same was submitted by the Insurer wherein „NO‟ was mentioned under the last point of the Health Related

Questions column on the Proposal form.

The Insurance Company explained that the claimant is known to be suffering from Coronary Artery Disease/SVD

since June, 2016 which is pre-existing to the policy and as per Exclusion No.1 of the Policy which states “Benefits

will not be available for Any Pre-existing condition, ailment or injury, until 36 months of continuous coverage have

elapsed after the date of inception of the first Mediclaim Insurance Policy”, the claim is not payable. The Coronary

Angiography Report dated 21.06.2016 has already been submitted along with AIIMS‟s Report dated 22.05.2017.

I have closely examined the documents exhibited and oral submissions made by both the parties during personal

hearing. The complainant was diagnosed as Posterior circulation TIA/ stroke. The insurer has repudiated the claim

of the complainant on 18.01.2019 on the ground of PED i.e. Coronary Artery Disease/SVD from 21.06.2016. The

same is mentioned in the Discharge Summary and the Progress Notes of Max Hospital and is corroborated with

Angiography Report dated 21.06.2016 and the AIIMS‟s report dated 22.05.2017. The decision of the Insurance

Company is as per the Exclusion Clause No.1 in the policy bond. Hence, I see no reason to interfere with the

decision of the Insurance Company in repudiating the claim.






Dated:12.03.2020 INSURANCE OMBUDSMAN


AWARD

Taking into account the facts and circumstances of the case and the submissions

made by both the parties during the course of hearing, I see no reason to interfere

with the decision of the Insurance Company in repudiating the claim.

Hence, the complaint is dismissed.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD

CASE OF ANIMESH SINGH V/S ICICI LOMBARD GENERAL INSURANCE COMPANY LTD.

COMPLAINT REF: NO: NOI-H-020-1920-0196

1. Name & Address of the Complainant Mr. Animesh Singh

H.No. BX-1010, Tower-2, Ashiana Upwan,

Ahinsa Khand, Phase-2, Indirapuram,

Ghaziabad, UP-201014.

2. Policy No:

Type of Policy


4128i/IH/164766174/00/000

Health Insurance

09.02.2019 to 08.02.2020



Mr. Animesh Singh

Mr. Animesh Singh




1. 2 year’s waiting period

2. Clause 12 of the policy – Fraudulent

Claim




10. Date of Partial Settlement Nil



IOB rules

13 (1) (b)

13. Date of hearing/place 20.02.2020 at Noida


For the Complainant Mr. Animesh Singh, Self

For the insurer Ms. Sanskriti Mishra, Legal Manager



17) Brief Facts of the Case: This complaint is filed by Mr. Animesh Singh against ICICI Lombard General Insurance

Co. Ltd. for repudiation of his health claim.


Complainant’s argument: The complainant had taken Health Insurance Policy bearing Policy No.

4128i/IH/164766174/00/000 from ICICI Lombard, for the period from 09.02.2019 to 08.02.2020. He was suffering

from high fever and dysuria and got admitted in Max Healthcare Hospital on 05.08.2019. He was diagnosed with

Urosepsis with AKI. He was also diagnosed with Choleithiasis and Prostatomegaly as secondary diagnosis. He stated

that he was treated only for Urosepsis with AKI and no medication/treatment was done for secondary diagnosis of

Cholelithiasis and Prostatomegaly. The same was mentioned in his discharge summary and doctor‟s certificate. The

insurance company rejected his claim on the basis of waiting period clause 3.3. The complainant further stated that he

was treated for urosepsis which was covered under the policy and incidental findings during treatment of another

disease did not qualify for rejection of expenses occurred during treatment of primary disease.

b. Insurers’ argument: The insurance company submitted their SCN dated 11.02.2020 wherein they stated that the

complainant had taken online policy from their company. They received cashless request from Max Healthcare Hospital

and they initially approved cashless request for Rs. 35,000/- vide their letter dated 07.08.2019. The insurance company

received discharge summary from the hospital duly signed and sealed by the doctor issued at 08.08.2019 at 11.29 pm,

wherein it was clearly mentioned that the complainant was diagnosed for Prostatomegaly (grade-1) and Cholelithiasis

which was exclusion as per the terms and conditions of the policy. They rejected the initial approval amount as the

disease would be covered after 2 years of policy (waiting period of 2 years was applicable). After denial of cashless

authorization, the treating doctor gave statement on 08.08.2019 at 3 pm that because of ultrasound the Prostatomegaly

(grade-1) and Cholelithiasis was incidental findings. The complainant was not treated for the same. It was wrong and

fraudulent statement of the doctor. Further, they received second discharge summary dated 08.08.2019 at 05.11 pm

wherein it was clearly mentioned that the complainant was diagnosed with Prostatomegaly (grade-1).

The insurance company received claim reimbursement form from the complainant for the treatment of Urosepsis with

AKI and he submitted third discharge summary which was printed on 08.08.2019 at 08.00 pm. The insurance company

stated that the treatment of Prostomegaly (grade-1) and Cholelithiasis were the policy exclusion and there was 2 year‟s

waiting period for the same. As per Clause 3.3 waiting period of two years applied for – Benign Prostatic Hypertrophy.

Further, they received 3 different discharge summaries which were issued by the hospital on 08.08.2019 but at 3

different times. After investigating the discharge summaries and statement of doctor, they repudiated the case as per

Part III General Terms and Conditions – 12. Fraudulent Claims.

19) Reason for Registration of Complaint: -


a) Complaint letter

b) Discharge Summaries

c) Policy document

d) SCN

21) Observations and Conclusion: Both the parties were present in the personal hearing on 20.02.2020. The

complainant stated that he was admitted in Max Hospital for the treatment of UTI. After performing ultrasound, he was

also diagnosed with Choleithiasis and Prostatomegaly as secondary diagnosis. But he was treated only for Urosepsis

with AKI and no medication/treatment was given for secondary diagnosis of Cholelithiasis and Prostatomegaly. The

insurance company rejected his claim. The insurance company reiterated that the complainant submitted three discharge

summaries from the same hospital issued at three different times. First of all, they received cashless request from Max

Healthcare Hospital and the same was Rs. 35,000/- on 07.08.2019. The insurance company received discharge summary

from the hospital duly signed and sealed by the doctor issued at 08.08.2019 at 11.29 pm, wherein it was clearly

mentioned that the complainant was diagnosed for Prostatomegaly (grade-1) and Cholelithiasis which was exclusion as

per the terms and conditions of the policy. They rejected the initial approval amount as the disease would be covered

after 2 years of policy (waiting period of 2 years was applicable). After that the treating doctor gave statement on

08.08.2019 at 3 pm that because of ultrasound the Prostatomegaly (grade-1) and Cholelithiasis were incidental findings.

Then they received second discharge summary dated 08.08.2019 at 05.11 pm wherein it was clearly mentioned that the

complainant was diagnosed with Prostatomegaly (grade-1). The insurance company received claim reimbursement form

from the complainant for the treatment of Urosepsis with AKI and he submitted third discharge summary which was

printed on 08.08.2019 at 08.00 pm. The insurance company stated that the treatment of Prostomegaly (grade-1) and

Cholelithiasis were the policy exclusion and there was 2 year‟s waiting period for the same.

During the hearing the complainant was advised to approach the hospital and take a clear report with regard to three

different discharge summaries within a period of one week.

The complainant submitted a Certificate in this Office on 05.03.2020 issued by Max Healthcare, wherein the treating

doctor, Dr. Vimal Dassi and Medical Superintendent of the hospital have certified that the patient got discharged from

the hospital on 08.08.2019 and the discharge summary dated 08.08.2019 at 08.00 pm is the final and complete discharge

summary mentioning all the details related to the patient and the diagnosis and treatment accorded to him. They have

further stated that the two other discharge summaries dated 08.0-8.2019 issued at 11.29 am and 05.11 pm were

provisional drafts which were neither seen nor bear signature of the consultant.

On going through the documents exhibited and the oral submissions made by both the parties during the hearing, it is

evident from the certificate of Max Healthcare dated 08.08.2019 and certificate received in this office on 05.03.2020 of

Max Healthcare that the complainant was treated for Urosepsis with AKI and Cholelithiasis and Prostatomegaly were

the secondary diagnosis for which he was not treated. The insurance company is directed to pay the claim as per the

terms and conditions of the policy.








PROCEEDINGS BEFORE


UNDER THE INSURANCE OMBUDSMAN RULES, 2017


CASE OF SH. ASHISH AGARWAL V/S NATIONAL INSURANCE CO. LTD.

COMPLAINT REF. NO. : NOI- H- 048- 1920 – 0229

1. Name & Address of the Complainant Sh. Ashish Agarwal

Flat No.1103, Indigo Tower,

SG Impressions-58,

Raj Nagar Extension,

Ghaziabad, U P-201017.

Ph. No.09910096206

2. Policy No:

Type of Policy


S.I.

361700501910001949

National Parivar Mediclaim Policy

05.08.2019 to 04.08.2020

Rs.10,00,000



Sh. Ashish Agarwal

Sh. Ashish Agarwal

4. Name of the insurer National Ins. Co. Ltd.

5. Date of Repudiation N.A.

6. Reason for repudiation Exclusion clause under 4.9


8. Nature of complaint Claim repudiated for Morbid-Obesity,

Obstructive Sleep Apnea which was not covered

under clause no.4.9 of the policy

9. Amount of Claim Not mentioned by Insurer

AWARD


the parties, the insurance company is directed to pay the claim as per the terms and conditions

of the policy.

The complaint is closed accordingly.


11. Amount of relief sought Not mentioned by the complainant in the

Annex VI A


IOB Rules, 2017

13 (1) b

13. Date of hearing/place 05.03.02020 / Noida


For the Complainant Sh. Ashish Agarwal

For the insurer Sh. Ramesh Kumar Taneja, Asstt. Manager



17) Brief Facts of the Case:- Sh. Ashish Agarwal, the Complainant was covered under National Parivar Mediclaim Policy No.

361700501910001949 for the period from 05.08.2019 to 04.08.2020 for the S.I. of Rs.10,00,000. The Complainant stated

in his complaint that his claim of treatment for Morbid Obesity and other co-morbidities of DM-II, HTN etc. was repudiated

by the insurance company. Aggrieved, he requested the TPA/insurer to reconsider the claim but failed to get any relief.



a) Complainant’s argument:- The Complainant stated that on 17.10.2019, he registered his claim

no.191300187103 pertaining to Cashless Hospitalisation and treatment for Laproscopic Bariatric Surgery on

advice of his Doctor Sushant Wadhera of Yashoda Hospital, Ghaziabad with the HITPA (TPA).

On 18.10.2019, the TPA denied his claim on ground of Policy Clause No.4.9. He contacted the TPA seeking

clarification on the cause of denial referencing to the IRDAI Guidelines dated 27.09.2019 (ref. no.

IRDAI/HLT/REG/CIR/177/09/2019 regarding standardization of Exclusion in Health Insurance Contracts

(Chapter III (F) Page 7) (regarding Excl. Code: Excl 06) and Chapter 1 (5) Page 4 (regarding effective date)

but he did not receive any clarification.

b) Insurers’ argument:- The Insurer stated in their SCN that the National Parivar Mediclaim Policy No.

361700501910001949 was issued on 05.08.2019 for the period from 05.08.2019 to 04.08.2020 for the S.I. of

Rs.10,00,000.

Sh. Ashish Agarwal was hospitalized at Yashoda Super Speciality Hospital, Ghaziabad from 24.10.2019 to

29.10.2019 as a case of Morbid Obesity with DM, HTN, Obstructive Sleep Apnea with BMI-40. Insured was

admitted for bariatric surgery. The cashless claim was denied since the treatment was excluded from the scope

of policy as per clause no.4.9.

Clause No.4.9 speaks regarding the exclusion of “treatment for obesity or condition arising from (including

morbid obesity) and any other weight control and management program/services/supplies or treatment”.

The Policy under which the insured is covered was issued on 05.08.2019, while the IRDAI Circular, which is

under discussion from IRDAI guidelines Chapter-3 and Health Regulations, 2019 and exclusion code-06 was

issued on 27.09.2019 i.e. after the issuance of Policy.

Please refer to clause of IRDAI Circular:

Clause No.2 – Applicability:

These guidelines are applicable to all General and Health Insurers offering indemnity based health insurance

(excluding PA and domestic/Overseas Travel) polices offering hospitalization, domiciliary hospitalization and

day care treatment.

Clause No.5 – Effective date:

Referred in clause (2) above filed on and after 01.10.2019, all existing health insurance products that are not in

compliance with these guidelines shall not be offered and promoted from 01.10.2020 onwards.

Therefore, as per the above facts and documents, the Insurer had processed the claim as per the policy terms

and conditions of National Parivar Mediclaim Policy issued on 05.08.2019.

19) Reason for Registration of Complaint: - Repudiation of mediclaim


a) Policy copy

b) Complaint letter

c) Form VI A

d) SCN of the insurer


Both the parties appeared for personal hearing and reiterated their submissions. The complainant reiterated that his

treatment for Laproscopic Bariatric Surgery was done on advice of his Doctor Sushant Wadhera of Yashoda

Hospital, Ghaziabad. He contacted the TPA, seeking clarification on the cause of denial, pointing to the IRDAI

Guidelines dated 27.09.2019 (ref. no. IRDAI/HLT/REG/CIR/177/09/2019 regarding standardization of Exclusion

in Health Insurance Contracts (Chapter III (F) Page 7) (regarding Excl. Code: Excl 06) and Chapter 1 (5) Page 4

(regarding effective date) but he did not receive any clarification.

The Insurance Company reiterated that the complainant was a patient of Morbid Obesity with DM, HTN, and

Obstructive Sleep Apnea with BMI-40. The complainant was admitted for bariatric surgery. The cashless claim

was denied since the treatment was excluded from the scope of policy as per clause no.4.9. The Insurance

Company clarified regarding the IRDA Circular which was mentioned by the complainant that the said Policy was

issued on 05.08.2019 and the said circular was issued on 27.09.2019 i.e. after the issuance of Policy. Hence, it is

not applicable. Furthermore, all existing health insurance products that are not in compliance with these

guidelines shall not be offered and promoted from 01.10.2020 onwards.

Ongoing through the documents exhibited and the oral submissions, it is observed that the Complainant had taken

the treatment for Morbid Obesity. The claim was not payable since the treatment was excluded from the scope of

policy as per clause no.4.9 which states exclusions of treatment for obesity or condition arising from (including

morbid obesity) and any other weight control and management program/services/supplies or treatment. The

IRDA Circular mentioned by the complainant was issued after the issuance of policy. Therefore, it is not

applicable.

Hence, I see no reason to interfere with the decision of the Insurance Company. The complaint is thus dismissed.




PROCEEDINGS BEFORE

AWARD


the parties during the course of hearing, I see no reason to interfere with the decision of the

Insurance Company.

Hence, the complaint is thus dismissed.

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTRAKHAND

UNDER INSURANCE OMBUDSMAN RULE 2017

OMBUDSMAN : SH. C.S. PRASAD

CASE OF SH. SOMNATH SAINI V/S NATIONAL INSURANCE CO. LTD.

COMPLAINT REF. NO.: NOI-H-048-1920-0242

AWARD NO:

1. Name & Address of the Complainant Sh. Somnath Saini

A-76, Swaran Nagri

District Gautam Budh Nagar,

Greater Noida, U.P.201301

Phone No.09810506426

2. Policy No:

Type of Policy


Sum Insured

366011501910000172

National Mediclaim Policy

28.06.2019 to279.06.2020

Rs.5,20,000/-



Sh. Somnath Saini

Sh. Somnath Saini

4. Name of the insurer National Insurance Company Ltd.


6. Reason for repudiation/Partial Settlement Admitted for evaluation & management with

oral medicine


8. Nature of complaint Rejection of Medi-claim By Insurance

Company


10. Date of Partial Settlement N.A.

11. Amount of relief sought Rs.77,105/- as per Annex. VI A

12. Complaint registered under Insurance

Ombudsman Rule 2017

13 (1)b



For the Complainant Sh. Somnath Saini

For the insurer Sh. Madhur Sood, Asstt. Manager



17. Brief Facts of the Case:- Sh. Somnath Saini, the Complainant had taken National Mediclaim Policy No.

366011501910000172 for the period from 28.06.2019 to 27.06.2020 for the S.I. of Rs.5,20,000. The Complainant

lodged the claim for reimbursement of bills of Rs.77,105/- which was rejected by the Insurance Company.

Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get any relief.


18. Cause of Complaint:-

a) Complainant’s argument:- Sh. Somnath Saini, the Complainant stated the point wise queries as mentioned below:

i. He has taken the subject policy from the Insurer.

ii. On 28.07.2019, when he was on personal visit to Faridabad, he suddenly felt un-easiness and heavy

sweating, he rushed to a nearby hospital ORG Health City, Faridabad wherein after preliminary checkup;

he was advised by the doctor for immediate angiography, and on this advice, rushed to Medanta Global

Health Pvt. Ltd., Gurugram.

iii. On reaching the Medanta Hospital, he was immediately checked up in emergency and was advised

admission for further check-ups on 28.07.2019.

iv. Various tests were conducted viz. Renal Function Test, Lipid Profile, Troponin-1 and other tests.

v. On 29.07.2019, the hospital conducted other tests viz Transthoracic/echo/Halter Monitoring/ECG etc.

vi. On 29.07.2019, the hospital sought approval of Rs.75,000/- as Cash Less Approval from TPA stating that it

pertains to diagnosis of HTN, Spondylitis, Coronary Artery Disease.

vii. On 30.07.2019, hospital conducted Endoscopy and other tests and was kept on continuous medication.

viii. On 31.07.2019, the hospital conducted CT Coronary Angio and other tests

ix. On 31.07.2019, the TPA denied the Cash less.

x. He was discharged on 31.07.2019 and was advised to continue with the prescribed medicine.

xi. On 05.08.2019, the complainant filed a claim of Rs.77,105/-.

xii. On 16.09.2019, the Insurance Company rejected his claim.

xiii. On receipt of Denial Letter, the complainant made a representation on 18.09.2019.

xiv. In reply of complainant‟s representation, the Insurance Company again denied the claim on 05.11.2019.

xv. On 13.11.2019, he wrote to the General Manager for re-consideration but no reply has since been received.

The Insurance Company denied his claim on the ground that hospitalization was not medically necessary in case

of the said Diagnosis and Evaluation. This plea taken by the Insurance Company is not a practical since it does

not specify as to who will decided that medically hospitalization is required or not. Hence his claim of Rs.77,105/-

+ Rs.50,000/- as cost of mental agony should be paid.

b) Insurers’ argument:- The Insurance Company stated in their SCN that their para wise replies are as under:

Para 1 to 11 -Self statement of the Insured does not need any explanation by the Company

Para 12 to 13- The Patient Sh. Somnath Saini, Age 60 years was admitted in Medanta Hospital, Gurugram for

the period from 28.07.2019 to 31.07.2019.

Diagnosis : HTN, Spondylitis, Coronary Artery Disease, Gastritis Treated with : Upper GI Endoscopy.

As per Discharge Card and IPD papers notes: admitted in hospital with chief complaints: Ghabrahat,

uneasiness, chest heaviness on and off since 2 days.

Past history: recurrent UTI, h/o diabetes mellitus and hypertension

As per course in the hospital, patient was admitted for evaluation and management with oral medicine.

The claim was repudiated under clause 4.19 and 4.22 explanation remark: “As per discharge summary received, it

is observed that during the hospitalization only oral tablets are advised and given hence treatment given to patient

does not support the need for hospitalization, hence claim is not payable”.

Clause 4.19 : Diagnostic and evaluation purpose where such diagnosis and evaluation can be carried out as

outpatient procedure and the condition of the patient does not require hospitalization.

Clause 4.22 : Stay in hospital which is not medically necessary

As per clause 4.19 and 4..2, the claim was repudiated.

19) Reason for Registration of Complaint: - Rejection of Mediclaim


a) Customer complaint

b) Annexure vi and vi (a)

c) Reply of Insurance Company

d) SCN


Both the parties appeared for personal hearing and reiterated their submissions. The Insurance Company reiterated

that the claim was not admissible as per Clause no. 4.19 which states “Diagnostic and evaluation purpose where

such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not

require hospitalization.”

The complainant reiterated that he had taken the said policy since 2015. On 28.07.2019, he was admitted in nearby

hospital ORG Health City, Faridabad wherein after preliminary checkup; he was advised by the doctor for

immediate angiography. On this advice, he rushed to Medanta Global Health Pvt. Ltd., Gurugram. On reaching the

Medanta Hospital, he was immediately checked up at Emergency and was advised admission for further check-ups

on 28.07.2019. Various tests were conducted viz. Renal Function Test, Lipid Profile, Troponin-1 and other tests.

On 29.07.2019, the hospital sought approval of Rs.75,000/- as Cash Less Approval from TPA stating that it pertains

to diagnosis of HTN, Spondylitis, Coronary Artery Disease. On 31.07.2019, the hospital conducted CT Coronary

Angio and other tests. The TPA denied the Cash less on 31.07.2019. After that, on 05.08.2019, the complainant

filed a claim of Rs.77,105/- and the same was rejected by the Insurance Company on 16.09.2019.

I have examined the documents exhibited as evidence and oral submissions made by both the parties. It is observed

that the complainant, 60 years was admitted in the hospital as per advice of the doctor and not out of luxury or

without viable reason. If the doctor, who examined him in Emergency, advised admission, could he have refused

the hospitalization? The treating doctor is the best judge of the line of treatment and the tests to be done to eliminate

any other possibility of ailment. That the tests were done is not in dispute. In fact, the hospital has sought cashless

approval, which was approved on 29.07.2019 and withdrawn on 31.07.2019 by the Insurer. Further, the policy is

going on since 2015, and the complainant made no claim earlier. I am not convinced with the opinion of the

Insurance Company that course of treatment or management could be done on OPD basis. The Insurance Company

has no valid reason in repudiating the claim under Clause No.4.19. Hence, the Insurance Company is directed to

pay the admissible claim to the complainant.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of

Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within

thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.




AWARD

Taking into account the facts and circumstances of the case and the submissions

made by both the parties during the course of hearing, the Insurance Company is

directed to pay the admissible claim to the complainant.

The complaint is treated as disposed off accordingly.

PROCEEDINGS BEFORE


UNDER THE INSURANCE OMBUDSMAN RULES, 2017


CASE OF SH. ANIL KUMAR GARG V/S NATIONAL INSURANCE CO. LTD.

COMPLAINT REF. NO. : NOI- H- 048- 1920 – 0255

AWARD NO :

1. Name & Address of the Complainant Sh. Anil Kumar Garg

Hanuman Road, Shamli,

Uttar Pradesh-247776.

Ph. No.09412111775

2. Policy No:

Type of Policy


S.I.

461902501910000002

National Mediclaim Policy

29.04.2019 to 28.04.2020

Rs.5,00,000/- for each Individual



Late Ms. Babita Garg (Spouse)

Sh. Anil Kumar Garg

4. Name of the insurer National Ins. Co. Ltd.


6. Reason for repudiation Exclusion clause under 4.9


8. Nature of complaint Claim repudiated for Morbid-Obesity which

was not covered under clause no.4.9 of the

policy

9. Amount of Claim NA


11. Amount of relief sought Rs.5,00,000/- as per Annex VI A


IOB Rules, 2017

13 (1) b

13. Date of hearing/place 05.03.02020 / Noida


c) For the Complainant Sh. Anil Kumar Garg

d) For the insurer Sh. Parveen Kumar, Branch Manager



17) Brief Facts of the Case:- Sh. Anil Kumar Garg, the complainant and the Complainant‟s wife Late Ms. Babita

Garg were covered under National Mediclaim Policy No. 461902501910000002 for the period from 29.04.2019 to

28.04.2020 for the S.I. of Rs.5,00,000 for each person. The Complainant stated in his complaint that claim of his

wife Late Ms. Babita Garg was repudiated by the insurance company. Aggrieved, he requested the TPA/insurer to

reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution

of his grievance.


a) Complainant’s argument:- Sh. Anil Kumar Garg, the complainant stated that his wife Ms. Babita Garg was

admitted to Sir Ganga Ram Hospital, New Delhi on 27.02.2019 for recovery of hernia surgery operated on

21.01.2019. The claim was submitted along with pre and post hospitalization expenses.

The hernia surgery problem with UTI infection still persisted and patient was again admitted to Sir Ganga Ram

Hospital, New Delhi on 05.05.2019 and eventually she passed away on 12.05.2019 in the hospital itself. The

claim was declined by the Insurer for reasons that hospital inadvertently mentioned bariatric surgery in the

discharge summary.

The complainant further represented his claim along with certificate of hospital doctor Dr. Tarun Mittal

certifying that Ms. Babita Garg was readmitted because of hernia surgery issues not because of bariatric

surgery. The claim was repudiated by the Insurance Company.

b) Insurers’ argument:- The Insurer stated in their SCN that the claim documents were submitted for expenses

incurred towards Abdominal Wall Infection post laparoscopic sleeve gastrectomy with laparoscopic

cholecytectotomy with open hernis repair of Ms. Babita Garg. The abdominal wound got infected as post

surgery patient had accidently removed the drain.

On scrutiny of claim documents, it is found that patient Ms. Bahita Garg was admitted in Sir Ganga ram

Hospital, New Delhi on 05.05.2019 as a case of post bariatric surgery for Morbid Obesity on 21.01.2019

presented with features of Volume Overload, Sepsis and Multi-organ dysfunction syndrome.

As per the records, patient is a case of Morbid Obesity with Body Mass Index (BMI) of 49 and underwent

laparoscopic sleeve gastrectomy with laparoscopic cholecystectomy with open ventral hernia on 21.01.2019.

As per the records, post operatively patient accidently removed drain tube which let to recurrent post-operative

infection of surgical wound for which multiple would explorations and SSGs are done.

As per indoor case records of present hospitalization, it is observed that post surgery, site of surgical incision

for bariatric surgery got infected for which wound exploration and wound debridement with skin grafting is

done 6-7 times. During the course of stay in hospital, patient developed severe metabolic acidosis, acute

kidney injury, multi-organ dysfunction syndrome, urinary tract sepsis with septic shock and efforts were made

to revive the patient but patient could not be revived and expired on 12.05.2019.

From the available documents and above mentioned facts, it is concluded that patient received treatment for

morbid obesity, post surgery site of surgical incision got infected which let to severe metabolic acidosis, acute

kidney injury, multi organ dysfunction syndrome, urinary tract sepsis with septic shock. Since, treatment for

obesity or condition arising there from (including morbid obesity) is excluded under the policy.

On the basis of the above facts the claim has repudiated under exclusion No.4.9 which states:

Clause No.4.9 speaks regarding the exclusion of “treatment for obesity or condition arising from (including

morbid obesity) and any other weight control and management program/services/supplies or treatment”.

19) Reason for Registration of Complaint: - Repudiation of mediclaim


a) Policy copy

b) Complaint letter

c) Form VI A

d) SCN of the insurer

21)Observations and Conclusion :-

Both the parties appeared for personal hearing and reiterated their submissions. The complainant reiterated that his

wife Ms. Babita Garg was admitted to Sir Ganga Ram Hospital, New Delhi on 27.02.2019 for recovery from hernia

surgery operated on 21.01.2019. The hernia surgery problem with UTI infection persisted and patient was again

admitted to Sir Ganga Ram Hospital, New Delhi on 05.05.2019 and eventually she passed away on 12.05.2019 in

the hospital itself. The claim was declined by the Insurer for reasons that hospital inadvertently mentioned bariatric

surgery in the discharge summary.

The complainant further represented his claim along with certificate issued by hospital doctor Dr. Tarun Mittal

dated 02.07.2019 certifying that Ms. Babita Garg was readmitted because of hernia surgery issues not because of

bariatric surgery. This certificate also has a signature of treating doctor Dr. Manish Malik but his signatures differ

from the signatures done on Death Summary. After the date of hearing, the complainant again sent a mail to this

office on 07.03.2020 wherein he had attached another certificate issued by hospital doctor Dr. Tarun Mittal dated

07.09.2019 certifying that “Ms. Babita Garg was a case of morbid obesity, ventral hernia and cholelithiasis. Hernia

Surgery was done and drain tube was inserted. Post surgery hernia wound was infected. The infection was

because of hernia surgery not bariatric surgery”.

The Insurance Company reiterated that Ms. Babita Garg was admitted in Sir Ganga ram Hospital, New Delhi on

05.05.2019 as a case of post bariatric surgery for Morbid Obesity on 21.01.2019 presented with features of Volume

Overload, Sepsis and Multi-organ dysfunction syndrome. As per the records, patient was a case of Morbid Obesity

with Body Mass Index (BMI) of 49 and underwent laparoscopic sleeve gastrectomy with laparoscopic

cholecystectomy with open ventral hernia on 21.01.2019. As per the records, post operatively patient accidently

removed drain tube which led to recurrent post-operative infection of surgical wound for which multiple wound

explorations and SSGs were done. During the course of stay in hospital, patient developed severe metabolic

acidosis, acute kidney injury, multi-organ dysfunction syndrome, urinary tract sepsis with septic shock and efforts

were made to revive the patient but she expired on 12.05.2019.

On going through the documents exhibited and the oral submissions, it is observed that as per certificate issued by

hospital doctor Dr. Tarun Mittal dated 02.07.2019; the Insured Ms. Babita Garg, 58 year old was a case of morbid

obesity, ventral hernia and cholelithiasis. She underwent hernia repair and laproscopic sleeve gastrectomy, which

is a treatment for morbid obesity, in the same setting on 21.01.2019.

It is observed on perusal of the Death Summary of Sir Ganga Ram Hospital, that treatment of hernia was not

mentioned in the Death Summary. It was also mentioned that the patient had taken the treatment for Morbid

Obesity and underwent bariatric surgery on 21.01.2019, followed by post surgery re-exploration which is an

undisputed fact. The contention of the complainant that, the contents of the Death Summary inadvertently included

the reference to bariatric surgery is not supported by any documentary evidence from the hospital admitting this

inadvertent mistake. Therefore, the remarks of the Death Summary cannot be ignored, as these described the

course of the treatment given to the patient during her stay in the hospital. In the absence of any evidence to the

contrary, it is an inacceptable conclusion that the deceased was admitted for the complications arisen due to the

treatment taken on 21.01.2019 (As per the records, patient was a case of Morbid Obesity with Body Mass Index

(BMI) of 49 and underwent laparoscopic sleeve gastrectomy with laparoscopic cholecystectomy with open ventral

hernia on 21.01.2019). The treatment was excluded from the scope of policy as per clause no.4.9 which states

exclusions of “Treatment for obesity or condition arising from (including morbid obesity) and any other weight

control and management program/services/supplies or treatment”. Moreover, the Discharge/Death Summary dated

05.05.2019 is not having any mention of Dr. Tarun Mittal as treating doctor. Therefore, the clarification dated

07.09.2019 issued by him cannot be given precedence over the Discharge Summary. Therefore, the repudiation of

the claim by the Insurance Company seems justified.

Hence, I see no reason to interfere with the decision of the Insurance Company. The complaint is thus dismissed.




AWARD


the parties during the course of hearing, I see no reason to interfere with the decision of the

Insurance Company.


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTRAKHAND

UNDER INSURANCE OMBUDSMAN RULE 2017

OMBUDSMAN: SH. C.S. PRASAD

CASE OF SH. ATUL AGARWAL V/S NATIONAL INSURANCE CO. LTD.

COMPLAINT REF. NO.: NOI-H-048-1920-0228

AWARD NO:

1. Name & Address of the Complainant Sh. Atul Agarwal

B-319, Sector-122,

Noida, U.P.201309.

Phone No.09634445700

2. Policy No:

Type of Policy


Sum Insured

461301501810000089

Baroda Health Policy

05.07.2018 to 04.07.2019

Rs.5,00,000/-



Sh. Atul Agarwal

Sh. Atul Agarwal

4. Name of the insurer National Insurance Company Ltd.

5. Date of Repudiation --

6. Reason for repudiation/Partial Settlement --


8. Nature of complaint Delay in settlement of Medi-claim By Insurance

Company


10. Date of Partial Settlement N.A.

11. Amount of relief sought Rs.14,845/- as interest on paid claim amount of

Rs.4,51,550/- + Rs.5,00,000/- for mental agony

as per Annex. VI A

12. Complaint registered under Insurance

Ombudsman Rule 2017

13 (1)b




For the insurer Sh. Vivek Bhatnagar, Divl. Manager



17. Brief Facts of the Case:- Sh. Atul Agarwal, the Complainant had taken National Baroda Health Policy No.

461301501810000089. The Complainant lodged the claim for reimbursement of bills of Rs.4,51,550/- which was

settled by the Insurance Company but after a delay of more than 3 months. Aggrieved, he requested the Insurer

including its GRO to consider the interest on settled claim amount but failed to get any relief. Thereafter, he has

preferred a complaint to this office for resolution of his grievance.

18. Cause of Complaint:-

a) Complainant’s argument:- Sh. Atul Agarwal, the Complainant stated that on 11.06.2019, he had admitted in the

Kailash Hospital, Noida due to serious illness of acute medical problem of stomach disorder, body ache and high

fever.

The TPA had given pre-authorization to the Hospital for Rs.2,00,000/- during the course of treatment and the rest

of amount was supposed to be given on completion of the treatment and final bills from the hospital.

On completion of the treatment on 27.06.2019, the Hospital submitted the complete documents along with Final

Bill of Rs.6,32,962/- to the TPA. But, even after, it was cashless, the TPA had unreasonably delayed even more

than a day for their sanction to the Hospital, that too for Rs.48,450/- only.

On 10.07.2019, the complainant submitted the claim documents amounting to Rs.5,90,808/- to the TPA for which

the admissible claim amount was paid to him on 25.10.2019 i.e. after a delay of more than 3 months.

b) Insurers’ argument:- The Insurance Company stated in their SCN that on receipt of pre authorization request on

11.06.2019, an initial approval of Rs.48,450/- was given to the hospital as per GIPSA rates for cholecystectomy.

The associated papers did not reveal any pre-existing disease or conditions. TPA again received a request for

enhancement of interim bill upto Rs.74,995/- on 14.06.2019. This time again, no pre-existing disease was revealed

to the Insurance Company or TPA.

On 19.06.2019, request for enhancement of bill upto Rs.3,08,071/- was received from the hospital. In this, the

case summary revealed that the condition of the patient got adverse and diagnosis had been changed from

cholelithiasis to portal vein splenic and mesenteric vein thrombosis. Enhancement approval of Rs.2,00,000/- given

conditionally. Case was sent for investigation and it was found that the patient had a history of surgery of left leg

amputation stump revision on 17.04.2019 in Max Hospital, Saket. The above mentioned history was found to be

somewhat related to medical management of patient for vein thrombosis. Current policy was in it‟s third year

from inception and pre-existing clause was not waived off. Therefore, the approval was restricted to treatment for

cholecystectomy i.e. Rs.48,450/- and the patient was advised to file for reimbursement claim. The reimbursement

claim was received on 10.07.2019. The case was investigated and it was found that the ulcers at the site of

amputation were not related to the current ailment of portal vein splenic and mesenteric vein thrombosis and it was

decided to settle the claim upto the limit of Sum Insured. In this policy, S.I. is Rs.5,00,000/- hence, Rs.4,51,550/-

was reimbursed to the complainant.

It is wrong to allege that Insurer or TPA intentionally caused delay in settlement of claim. Since, the complainant

purposely concealed the treatment taken by him and also necessary investigation was required by TPA before

coming to final conclusion.

19) Reason for Registration of Complaint: - Delay in settlement of Mediclaim


a) Customer complaint

b) Annexure vi and vi (a)

c) Reply of Insurance Company

d) SCN


The personal hearing in the case was fixed on 05.03.2020. The Complainant did not attend the personal hearing

and none represented him. The Insurance Company attended the hearing. As per complaint of the complainant, he

submitted the claim documents amounting to Rs.5,90,808/- to the TPA for which the admissible claim amount was

paid to him on 25.10.2019 i.e. after a delay of more than 3 months. Hence, the complainant demanded Rs.14,845/-

as interest on balance paid claim amount of Rs.4,51,550/- alongwith Rs.5,00,000/- for mental agony.

The Insurance Company reiterated their submissions and explained that it is wrong to allege that Insurer or TPA

intentionally caused delay in settlement of claim. Current policy was in it‟s third year from inception and pre-

existing clause was not waived off. The complainant purposely concealed the treatment taken by him before the

inception of the policy. Therefore, at the time of the settlement of the claim, some necessary investigation was

required by TPA. So, the case was sent for investigation and it was found that the patient had a history of surgery

of left leg amputation stump revision on 17.04.2019 in Max Hospital, Saket. The above mentioned history was

found to be somewhat related to medical management of patient for vain thrombosis. Therefore, the approval was

restricted to treatment for cholecystectomy i.e. Rs.48,450/- and the patient was advised to file for reimbursement

claim. The reimbursement claim was received on 10.07.2019. The case was investigated and it was found that the

ulcers at the site of amputation were not related to the current ailment of portal vein splenic and mesenteric vein

thrombosis and it was decided to settle the claim upto the limit of Sum Insured i.e. Rs.5,00,000/-.

I have examined the documents exhibited as evidence and oral submissions made by both the parties. It is

observed that there is no deficiency in the service at the end of the Insurer. The Insurance Company has paid the

full sum insured as claim amount to the complainant well within the time. The complaint is thus dismissed.

RECOMMENDATION

Taking into account the facts and circumstances of the case and the submissions made by

both the parties, I see no reason to interfere with the decision of the Insurance Company.





PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

STATE OF TAMILNADU & PUDUCHERY

(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN– Shri. M.Vasantha Krishna

Case of Mr. N Chandrasekaran Vs Star Health and Allied Insurance Company Ltd

REF: NO: CHN-H-044-1920-0471

Award No: IO/CHN/A/HI/0215/2019-2020

1. Name & Address of the Complainant

Mr. N. Chandrasekaran F-3, A-Block 1st Floor, K A Orchard Apartments 11th Street, Pudur Thirumalai Priya Nagar, Ambattur Chennai-600 053

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

P/111111/01/2019005985 Family Health Optima Insurance 20.10.2017-19.10.2018 INR 2 lakhs ( Floater basis)

3. Name of the Insured Name of the Policyholder/Proposer

Mr. N Chandrasekaran Mr. N. Chandrasekaran

4. Name of the Insurer Star Health and Allied Insurance Co. Ltd


6. Reason for Repudiation

Exclusion clause no 8- Use of Alcohol


8. Nature of Complaint Claim Repudiation

9. Date of receipt of Consent (Annexure VI A)

27.12.2019

10. Amount of Claim INR 2,11,846

11. Amount paid by Insurer, if any NIL

12. Amount of Monetary Loss (as per Annexure VI A)

INR 1,20,715

13. Amount of Relief sought (as per Annexure VI A)

INR 1,20,715

14.a. Date of request for Self-Contained Note (SCN)

16.12.2019

14.b. Date of receipt of SCN 06.02.2020


Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 12.02.2020 at Chennai

17. Representation at the Hearing

a) For the Complainant Mr. N. Chandrasekaran

b) For the Insurer Dr. Elangovai and Ms Hemalatha

18. Complaint how disposed By Award


20. Brief facts of the case:

The Complainant and his wife were covered under Family Health Optima Insurance

Policy with the Respondent Insurer (RI) for a floater Sum Insured of INR 2 lakhs. The

insurance first incepted in 2009-2010 and the same was renewed continuously

without any break. On 09.08.2019 the complainant was admitted in Apollo First Med

Hospitals, Chennai and was diagnosed with Chronic Liver Disease. He submitted the

claim documents for reimbursement of treatment expenses to the extent of INR

2,11,846. However the claim was repudiated by the insurer under Exclusion no.8 of

the Policy relating to “Use of Alcohol”. The complainant sent a representation dated

16.10.2019 for reconsideration of the claim which was responded to on 21.10.2019

by the insurer, expressing their inability to reconsider the same. He has therefore

approached this Forum for Relief.

21 a Complainant’s submission:

The Complainant stated that his claim for reimbursement of hospital expenses

was repudiated by the insurer on the ground that claims relating to use of

alcohol are not payable under the subject Policy.

He contended that there is no mention of alcohol in the discharge summary and

that he had not seen the Indoor Case Papers (ICP) wherein use of alcohol is

recorded.

The complainant stated that he was admitted for Jaundice and was discharged

after the treatment of the same. It is painful to note that the Insurer is seeking to

recover the amount of the previous claim paid by them.

He requested the Forum to direct the insurer to settle the claim.

21 b. Insurer’s submission:

As per the ICPof the treating hospital, the insured patient is a chronic alcoholic

and is diagnosed with Alcoholic Hepatitis.

The Progress Report of the Hospital dated 09.08.2019 stated that he was a

known case of Ethanolic since 15 years.

Hence the claim was repudiated under exclusion clause 8 of the Policy.

22) Reason for Registration of Complaint: - Rule 13(1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with “Any partial or total repudiation of

claims by the Life insurer, General insurer or the health insurer”.

23) Documents placed before the Forum for perusal.

Written Complaint to the Ombudsman dated 15.11.2019

Representation dated 05.03.2020 of the complainant (post-hearing)

Claim repudiation letter of Insurer dated 14.09.2019

Complainant‟s representation to the Insurer dated 16.10.2019

Insurer‟s response to the Complainant dated 21.10.2019

Consent (Annexure VI A) submitted by the Complainant

Request for Cashless Hospitalization

Cashless Authorization dated 10.08.2019

Withdrawal of Cashless Authorization dated 15.08.2019

Claim form dated 19.08.2019

Policy copy, terms and conditions

Self-Contained Note (SCN) of Insurer dated 31.01.2020

ICP and Discharge Summary of Apollo First Med Hospitals, Chennai

Medical Opinion of Dr.V S Sankaranaryanan , Gastroentrologist, B R S

Hospital, Chennai dated 24.02.2020

24) Results of hearing of both the parties ( Observations and Conclusion):

The Complainant Mr. N Chandrasekaran, and the Insurer‟s representatives Dr.

Ilangovai and Ms.Hemalatha were present for the hearing.

The Forum records its displeasure over the delay in submission of Self

Contained Note (SCN) by the Insurer. The Insurer is hereby directed to

henceforth submit SCN on time.

During the hearing the Complainant stated that his claim was repudiated by

the Insurer on the ground that information about alcohol consumption was

noted in the Hospital records. He contended that he was never in the habit of

consuming alcohol and the claim for his previous hospitalization was settled by

the RI.

The Insurer repudiated the claim invoking Exclusion Clause no 8 of the Policy

which states that „the Company shall not be liable to make any payments

under this policy in respect of any expenses whatsoever incurred by the

Insured person in connection with or in respect of Use of intoxicating

substance, substance abuse, drugs/alcohol, smoking and tobacco chewing‟.

The first insurance incepted in the year 2009-10 and the subject claim was

reported in the 10th year of the policy.

The Complainant stated that he was admitted for Jaundice at a 24 hours

hospital in Ambattur and later at the insistence of his relatives was admitted in

Apollo First Med Hospitals. He contended that he is not aware of any report or

indoor case paper having recorded use of alcohol and according to him the

discharge summary has not mentioned anything about Alcohol. However, it is

noted that the discharge summary too refers to past history of ethanolic on

page three thereof while recording the course in the hospital.

The Complainant‟s request for pre-authorisation for cashless treatment for INR

40,000 was initially approved and later withdrawn by the Insurer as the same

was not utilized by the Complainant.

Diagnosis as per the Discharge Summary is Chronic Liver Disease, Sepsis

and Leptospirosis; Past history recorded – Appendectomy and Open reduction

and internal fixation left elbow. Chief complaints- Patient admitted with

?Hepatitis A; H/o Fever, abdominal distention since 5 days. As stated earlier,

it also refers to past history of ethanol consumption.

ICP contains several references to complainant‟s habit of alcohol consumption,

Alcoholic hepatitis, Alcohol induced liver injury and ethanol related CLD

(Chronic Liver Disease).

The Insurer, while rejecting the current claim vide their letter dated 14.09.2019

asked the complainant to refund the amount of INR 79,285, being the claim

paid by them earlier for treatment of hepatitis on 11.07.2019. The insurer

explained that the information about complainant‟s chronic alcoholism was not

known at that time and hence the said claim was paid.

The Forum obtained an Expert Medical Opinion. As per the Medical Opinion

given by Dr V S Sankaranaryanan, Gastroentrologist, B R S Hospital, the

Insured patient was suffering from Alcoholic Liver Disease (ALD) – Chronic

with superadded acute infection, which is revealed by the Hospital records.

Post-hearing, the complainant submitted a representation to the Forum stating

that the noting made in the ICP about his history of alcohol consumption and

alcoholic hepatitis disease is false and made out of ill-motive by the hospital

since he did not accept their advice of liver transplant. He has also alleged

collusion between the hospital and the insurer, to deprive him of his claim. It is

also his contention that the discharge summary is the official document of his

treatment and the same does not contain any remarks about alcoholism.

As already observed, the discharge summary does refer to past history of

ethanol consumption by the complainant and there is no inconsistency

between the ICP and discharge summary as claimed by him. His allegations

against the hospital and the insurer are far fetched not backed by any proof. In

the opinion of the Forum, the ICP constitute the first-hand record of the

diagnosis and treatment of the complainant and their contents cannot be

ignored.

The repudiation of claim by the Insurer is therefore justified.

25. If the decision of the Forum is not acceptable to the Complainant, he is at liberty

to approach any other Forum/Court as per laws of the land against the respondent

insurer.

Dated at Chennai on this 11th day of March 2020

(Sri M Vasantha Krishna)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

AWARD


both the parties during the course of hearing, the Forum is of the view that the

repudiation of the claim by the insurer is in order and does not warrant any intervention.

Thus the complaint isNot allowed.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERY



Case of Mr. J Selvakumar vs Star Health and Allied Insurance Company Ltd

REF: NO: CHN-H-044-1920-0475



Mr J Selvakumar No 1/1A, Raja Street Perambur Chennai- 600 011


P/11113/01/2019/21849 Family Health Optima Insurance Plan 25.02.2019 to 24.02.2020 INR 10 lakhs( Floater)


Mr J Selvakumar Mr J Selvakumar




Not applicable


8. Nature of Complaint Non- inclusion of baby in the Policy and non-settlement of claim


27.12.2019

10. Amount of Claim INR 45,460

11. Amount paid by Insurer, if any Nil


INR 45,460


INR 10 Lakhs + INR 45,560 and inclusion of Child in the Policy


16.12.2019



Rule 13(1)(f) of the Insurance Ombudsman Rules, 2017



c) For the Complainant Mr .J. Selvakumar

d) For the Insurer Dr. Ilangovai Ms. M Hemalatha




The Complainant and his spouse were covered under Family Health Optima

Insurance Plan for a floater Sum Insured (SI) of INR 10 lakhs. The period of

insurance is 25.02.2019 to 24.02.2020. On 23rd February 2019, the Insured sent a

mail to the Insurer for inclusion of his Baby at the time of renewal of the Policy. The

baby was admitted in Dr. Mehta‟s hospital on 18.04.2019 with complaints of vomiting

and fever and was discharged on 23.04.2019. It was only after admission of the baby

in the hospital that the complainant realised that it was not included in the Policy at

renewal, despite his request. He made a representation to the insurer in the matter

on 29.04.2019 stating that baby was born on 05.06.2018 which was intimated to the

Insurer after one week of birth with a request to include the baby in the policy.

However the child was not included in the Policy. On 30.04.2019 the Insurer replied

that since the policy period is from 25.02.2019 to 24.02.2020 and the baby was born

on 5.6.2018 and as the birth date of the baby was prior to policy renewal it was not

possible to include the baby in the existing policy and that they would include the

baby from the next renewal. Hence the claim for hospitalization of the baby was

rejected by the Insurer. Not satisfied with their response, the Complainant has

approached this Forum for relief.


The insurer failed to include the baby in the existing policy which came to light

only at the time of hospitalization of the baby.

The intimation to add the baby was made to the insurer well in time. Due to the

negligence of theinsurer, the hospitalization claim of the baby was not paid by

the insurer.

He requested the Forum to direct the insurer to reimburse the claim amount of

INR 45,560 and to include the baby in the Policy.


The Complainant availed Family Health Optima Insurance plan covering self

and spouse. He had approached them for coverage of the child in the policy

which was not done due to some technical error.

The insurer expressed their willingness to include the child and process the

claim.

They have requested the Forum to mediate in the matter.

23) Reason for Registration of Complaint: - Rule 13(1) (f) of the Insurance

Ombudsman Rules, 2017, which deals with “policy servicing related grievances

against insurers and their agents and intermediaries”.



Complainant‟s representation to the Insurer vide email dated 29.04.2019





Discharge Summary/invoice of Dr Mehta‟s Hospital, Chennai

Complainant‟s mail dated 23.02.2019 requesting inclusion of child at the time

of renewal

24. Results of the hearing of both the parties (Our observations and

Conclusion):

The Complainant Mr J Selvakumar, the Insurer‟s representative Dr. Ilangovai and

Ms. M Hemalatha were present for the hearing.

The Forum records its displeasure over the delay in submission of Self-

Contained Note (SCN) by the Insurer. They are hereby directed to henceforth

submit SCN on time.

During the hearing, the insurer informed the Forum their willingness to include the

child retrospectively and process the claim, subject to the payment of premium by

the Complainant.

The complainant has also claimed compensation for mental agony to the extent

of INR 10 lakhs. He was informed in the hearing that this Forum does not have

the power to offer compensation for mental agony and that he would be entitled

only to interest as provided under the provisions of the Insurance Ombudsman

Rules, 2017.

25. The attention of the Insurer is hereby invited to the following provisions of the


a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the

insurer shall comply with the award within thirty days of the receipt of the

award and intimate compliance of the same to the Ombudsman

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as

specified in the regulations, framed under the Insurance Regulatory and

Development Authority of India Act, 1999, from the date the claim ought to

have been settled under the regulations, till the date of payment of the

amount awarded by the Ombudsman.

AWARD


both the parties during the course of hearing, the Forum hereby directs the insurer to

include the child of the complainant in the subject policy for the period 25.02.2019 to

24.02.2020 and also process and settle the claim of INR 45,460, subject to terms and

conditions of the Policy. In addition interest at applicable rates becomes payable on the

claim amount as provided under Rule 17 (7) of the Insurance Ombudsman Rules, 2017.

Thus the complaint is allowed.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the

award of Insurance Ombudsman shall be binding on the insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY

(UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna

Case of Dr. N Kalaimani Vs Star Health and Allied Insurance Company Limited COMPLAINT REF: NO: CHN-H-044-1920-0485



Dr. N Kalaimani, 3/2, Lake Area III Cross Street, Nungambakkam, Chennai – 600 034.


P/700001/01/2019/041460 Senior Citizens Red Carpet Health Insurance Policy 31.01.2019 to 30.01.2020 INR 4 lakhs


Dr. N Kalaimani Dr. N Kalaimani

4. Name of the Insurer Star Health and Allied Insurance Company Limited


6. Reason for repudiation EECP procedure excluded as per Policy Exclusion No.12


8. Nature of Complaint Repudiation of claim


06.01.2020


The complainant has taken Senior Citizens Red Carpet Health Insurance Policy

issued by the respondent insurer covering self for a Sum Insured (SI) of INR 4 lakhs.

The policy is live since January 2016.

As per Discharge Summary, the complainant was admitted in Heal Your Heart, Vaso-

Meditech (EECP Center) on 14.08.2019 with the chief complaints of chest pain CCS

Class II and was diagnosed with Coronary Artery Disease (CAD), Dissociated Vertical

Deviation (DVD) and normal L V Function. He underwent Vaso-Meditech Enhanced

External Counter Pulsation (EECP) Treatment spread over 35 sessions from

14.08.2019 to 25.09.2019.

On 15.10.2019 he submitted a claim to the tune of INR 85,000 to the insurer for the

above treatment. The claim was repudiated by the insurer vide their letter dated

23.10.2019 citing Exclusion No.12 of the policy, whereby they are not liable to make

any payment in respect of expense incurred for EECP therapy.

The complainant represented to the insurer in the matter and they responded vide

their mail dated 26.11.2019 stating that EECP procedure is excluded as per policy




INR 85,000


INR 85,000

14. a. Date of request for Self-Contained Note (SCN)

17.12.2019

14. b. Date of receipt of SCN 04.02.2020

15. Complaint registered under Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 12.02.2020 - Chennai


a) For the Complainant Dr. N Kalaimani

b) For the Insurer Dr. Asiya Shahima



and upheld their earlier decision. Aggrieved by the reply, he has approached this

Forum vide his letter dated 30.11.2019 for redressal of his grievance.

21 (a) Complainant’s Submission:

The complainant has stated that his claim for the expenses incurred towards

Enhanced External Counter Pulsation (EECP) was repudiated as per

Exclusion no.12 of the policy.

He has referred to two previous cases wherein the respondent insurer has

given approval for EECP therapy.

He has also referred to the judgment of the Madras High Court in the case of

M.D. Venugopal Vs The Director General of Police wherein the respondent

was directed to settle the expenses incurred towards EECP procedure.

He has therefore requested the Forum to direct the insurer to reimburse the

expenses incurred for his treatment.

21 (b) Insurer’s Submission:

The respondent insurer vide their SCN has stated that the complainant was

diagnosed as a case of CAD/DVD, with normal LV Function.

He underwent EECP therapy in Heal Your Heart, EECP Center from

14.8.2019 to 25.09.2019.

The above therapy is not covered as per Exclusion No. 12 of the policy and

hence the claim was repudiated on 23.10.2019.

Exclusion No. 12 reads as “The Company shall not be liable to make any

payments under this policy in respect of any expenses what so ever

incurred by the insured person in connection with or in respect of:

Expenses incurred on High Intensity Focused Ultra Sound, Uterine fibroid

embolisation, Balloon Sinoplasty, Enhanced External Counter Pulsation

Therapy and related therapies, Chelation therapy, Deep Brain

Stimulation, Hyperbaric Oxygen Therapy, Rotational Field Quantum

Magnetic Resonance Therapy, Photodynamic therapy and such other

therapies similar to those mentioned herein under exclusion No. 12”.

The terms and conditions of the policy were served along with the Policy

Schedule.

Upon issuance of the policy, the insurer undertakes to indemnify the loss

suffered by the insured on account of risks covered by the policy; its terms

have to be strictly construed to determine the extent of liability of the

insurer.

Both the Insurance Company and the Insured are to follow all terms and

conditions of the policy correctly and based on the above, the claim was

repudiated under Exclusion No.12 of the policy.

Therefore, the insurer requested the Forum to dismiss the complaint.

22. Reason for Registration of Complaint:- Rule 13(1) (b) of the Insurance

Ombudsman Rules, 2017, which reads as “Any partial or total repudiation of claims

by the Life Insurer, General Insurer or the Health Insurer”.

23. Documents placed before the Forum for perusal.

Written Complaint dated 06.01.2020 to the Insurance Ombudsman

Claim repudiation letter of the Insurer dated 23.10.2019

Complainant‟s representation and insurer‟s response dated 26.11.2019




Claim Form dated 25.09.2019

Copies of authorisation letters issued by the insurer for EECP (other cases)

Judgment in the case of M.D. Venugopal Vs The Director General of Police

Discharge summary/Bills of Heal Your Heart, Chennai

Mail correspondence of the complainant with the Insurer

Certificate of Dr. S Ramasamy, PhD (Cardio), EECP Consultant, Heal Your

Heart, dated 18.09.2019

Medical literature on EECP treatment and FDA certificate submitted by the

complainant

24. Result of hearing with both parties (Observations & Conclusion)

Dr. N Kalaimani, Complainant and Dr. Asiya Shahima Insurer‟s representative

attended the hearing.

There is a delay of one month in submitting the SCN by the insurer. This

Forum records its displeasure over late submission of SCN and advises the

insurer to be prompt in complying with the Forum‟s requirements in future.

During the hearing the complainant submitted that he underwent EECP

treatment which has the approval of FDA of United States of America (USA).

The procedure is also covered under the Government of Tamil Nadu‟s New

Health Insurance Scheme.

He also submitted that the respondent insurer had earlier settled claims of

EECP procedure and produced copies of authorisation letters issued by them.

The respondent Insurer contended that EECP procedure is specifically

excluded in the policy issued to the complainant.

It is observed by the Forum that the authorisations issued by the insurer were

under Government of Tamil Nadu‟ Scheme in which the procedure is

specifically covered. The judgment cited by the complainant also pertains to

the same Scheme and hence has no relevance to the present complaint.

On going through the policy terms and conditions, it is observed that as per

Exclusion 12, EECP and related therapies are specifically excluded.

Based on the above the Forum is of the view that the insurer has rightly

rejected the claim under Exclusion 12 of the policy.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by both the parties during the course of hearing, the Forum is of the view that

the repudiation of the claim by the insurer is in order and does not warrant any

intervention.

Thus the complaint is Not Allowed.

If the decision of the Forum is not acceptable to the Complainant, he is at liberty to

approach any other Forum/Court as per laws of the land against the respondent

insurer.

Dated at Chennai on this 11th day of March 2020.

(M Vasantha Krishna)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY

(UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)


CASE OF Mr. R Abdul Sithikque Vs Star Health & Allied Insurance Company Limited COMPLAINT REF: NO: CHN-H-044-1920-0487



Mr. R Abdul Sithikque, 13/6, Dr. Zahir Hussain Street, Behind Periyar Statue, Karaikudi – 630 001.


P/121318/01/2018/000228 Family Health Optima – Accident Care Insurance Policy 21.06.2017 to 20.06.2018 INR3,00,000 - Bonus INR 1,05,000


The complainant holds Family Health Optima – Accident Care Insurance Policy

issued by the respondent insurer covering self, spouse and his first son for a floater

Sum Insured (SI) of INR 3 lakhs since 21.06.2014. He covered his second son in the

next renewal i.e. from 21.06.2015.

The policy was shown to have earned bonus and recharge benefit periodically as

detailed below:


Mr. R Abdul Sithikque Mr. R Abdul Sithikque


5. Date of Repudiation / Short Settlement

N A

6. Reason for repudiation/ Short settlement

N A


8. Nature of Complaint Discrepancy in No Claim Bonus (NCB)


09.01.2020

10. Amount of Claim N A

11. Amount paid by Insurer, if any N A


N A


N A


17.12.2019


15. Complaint registered under Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017



a) For the Complainant Mr. Abdul Sithikque

b) For the Insurer Dr. Asiya Shahima



Policy No. Period of Insurance Floater

S I Bonus

Limit of coverage

Recharge Benefit

P/121314/04/2015/000056 21.06.2014 to 20.06.2015 300000 0 300000 0

P/121318/04/2016/000058 21.06.2015 to 20.06.2016 300000 75000 375000 75000

P/121318/01/2017/000150 21.06.2016 to 20.06.2017 300000 105000 405000 75000

P/121318/01/2018/000228 21.06.2017 to 20.06.2018 300000 105000 405000 75000

P/121318/01/2019/000274 22.06.2018 to 21.06.2019 300000 75000 375000 75000

P/121318/01/2020/000303 22.06.2019 to 21.06.2020 300000 0 300000 75000

Upto 2016-17, the policy was allowed periodical bonus but no bonus was given

during 2017-18 and 2018-19. His grievance is with respect to non-provision of Bonus

for the said policy years. He represented to the insurer about the same vide his letter

dated 15.10.2018. Since there was no response from the insurer, he has approached

this Forum for redressal of his grievance.


The complainant submits that as per policy condition, when there is no claim,

bonus will be added to the SI and there will be increase in the overall coverage

limit.

For the first three years, there were no claims and in turn the insurer provided

bonus.

During the year 2017-18, the insurer maintained the same bonus as given

during 2016-17.

In August 2018, the complainant made a claim towards his first son‟s

hospitalisation.

He also submits that the bonus was reduced in 2017-18 and 2018-19 even

without his lodging any claim.

He has requested the Forum to rectify the issue.


The insurer vide mail dated 10.02.2020 have stated that as per policy clause,

for a sum insured of INR 3 lakhs and above in a claim free year, the insured

would be entitled for 25% bonus of the expiring basic sum insured in the

second year and an additional 10% of the expiring sum insured in the third

year.

The maximum allowable bonus shall not exceed 35% of the expiring sum

insured.

The bonus will be calculated on the expiring sum insured or on the renewed

sum insured whichever is less.

Bonus will be given on that part of sum insured which is continuously renewed.

If the insured opts to reduce the sum insured at the subsequent renewal, the

limit of indemnity by way of such Bonus shall not exceed such reduced sum

insured.

Bonus shall be available only for timely renewal without break or upon renewal

within the grace period allowed.

In the event of a claim, bonus so granted will be reduced at the same rate at

which it has accrued. However, the basic sum insured will not be reduced.

They explained the entitlement of the complainant for Bonus for various years,

as shown in the table below.

Policy No. Product Name Claim Status Sum Insured - INR 3 lakhs

P/121314/04/2015/000056 Family Health Optima Accident Care Nil Fresh

P/121318/04/2016/000058 Family Health Optima Insurance - Revised Nil Bonus (25%) = INR 75000

P/121318/01/2017/000150 Family Health Optima Insurance - Revised Nil Bonus (Additional10%) = INR105000

P/121318/01/2018/000228 Family Health Optima Insurance - Revised Claim settled Bonus = INR105000 (Remains same - max

35%)

P/121318/01/2019/000274 Family Health Optima Insurance - 2017 Claim settled Bonus decreased by one slab (10%) = INR 75000

P/121318/01/2020/000303 Family Health Optima Insurance - 2017 Claim settled Bonus decreased by one more slab (25%) = Nil

They have submitted that the complainant is not entitled to bonus for the

current year policy and requested the Forum to absolve them from the

complaint.

22. Reason for Registration of Complaint:- Rule 13(1) (f) of the Insurance

Ombudsman Rules, 2017, which deals with “policy servicing related grievances

against insurers and their agents and intermediaries”.



Complainant‟s representation dated 15.10.2018



Addendum SCN dated 10.02.2020 and 27.02.2020

Copies of relevant Policies , terms and conditions


Mr. Abdul Sithique, Complainant and Dr. Asiya Shahima and Mrs. M

Hemalatha, Insurer‟s representatives attended the hearing.

During the hearing the complainant submitted that his complaint is on account

of wrong calculation of Bonus by the insurer. He made a claim during 2017-18

and the company has reduced the bonus which was already granted in the

previous year.

He also argued that he is eligible for a maximum of 100% bonus as per policy

issued to him in 2017-18 and admitted that he had made a claim in the year

2019-20.

The Respondent Insurer contended that the complainant is eligible for a

maximum bonus of 35% of sum insured as per Family Health Optima Policy

and a claim was settled in 2018-19.

The insurer was advised to submit the correct bonus due as per revision of

policy in 2017-18 and the details of claim during 2018-19.

They have submitted the Addendum SCN dated 27.02.2020 and have stated

that the insured took Family Health Optima – Accident Care Insurance Policy

covering self, spouse and first child from 21.06.2014 and subsequently

converted the policy to Family Health Optima Insurance Plan 2014-15 and

included their second child from 21.06.2015. From 22.06.2018 he opted for

Family Health Optima Insurance Plan 2017-18 which is in force till date.

The complainant reported a claim during the 4th year of the policy (2017-18)

and an amount of INR 8,236 was settled on 30.08.2017. The claim is for

admission in Kauvery Medical Centre, Karaikudi on 17.08.2017 and discharge

on 19.08.2017. Hence the bonus was reduced by 10% during the renewal

period of 22.06.2018 to 21.06.2019.

Again the complainant reported a claim during the 5th year of the policy (2018-

19) and an amount of INR 18,612 was settled on 20.03.2019. The claim is for


on 10.03.2019. Hence the bonus was further reduced by 25% during the

renewal period of 22.06.2019 to 21.06.2020.

The complainant reported one more claim during the 6th year of the policy

(2019-20) and an amount of INR 30,520 was settled on 27.11.2019 for


on 14.11.2019.

As per Family Health Optima Insurance Plan 2017-18, in respect of a claim

free year of insurance, the insured would be entitled to benefit of bonus of 25%

of the expiring Basic Sum Insured in the second year and additional 10% of

the expiring Basic Sum Insured for the subsequent years. The maximum

allowable bonus shall not exceed 100%.

Based on the information and explanations provided by the respondent insurer

and the relevant terms and conditions of the Policy, the Forum is of the view

that the insurer‟s calculations of Bonus for various policy periods are in order.

AWARD


made by both the parties during the course of hearing, the Forum is of the view that

there is no merit in the complaint and it and does not warrant any intervention by this

Forum.




insurer.



INSURANCE OMBUDSMAN





OMBUDSMAN – SHRI M VASANTHA KRISHNA

Case of Mr D B Suriya Prakash Sah Vs ICICI Lombard General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-020-1920-0481



Mr D B Suriya Prakash Sah No.49/23, Iyyah Mudali Street, Chintadripet, Chennai 600002

2. Policy No: Type of Policy Duration of policy/Policy period Sum Insured (SI)

4128i/iH85285735/02/000 ICICI Lombard Complete Health Insurance Policy 28/11/2017-27/11/2019 INR 3,00,000

3. Name of the insured Name of the policyholder/Proposer

Mr D S Balavignesh Sah Mr D Suriya Prakash Sah 4. Name of the insurer ICICI Lombard General Insurance

Company Ltd 5. Date of Repudiation/short

settlement 02/07/2019

6. Reason for Repudiation/short settlement

Obesity (weight management services), sleep disorder exclusion

7. Date of receipt of the Complaint 29/11/2019 8. Nature of complaint Non- settlement of claim

9 Date of receipt of consent ( Annexure VIA)

31/12/2019

10 Amount of Claim INR 5,11,475

11

Amount ofMonetary Loss (as per Annexure VIA)

Not furnished

12. Amount paid by Insurer if any Nil

13. Amount of Relief sought (as per Annexure VIA)

INR 4,20,000

14.a. Date of request for Self-contained Note (SCN)

17/12/2019

14.b. Date of receipt of SCN 31/01/2020



16. Date of hearing/place 12/02/2020, Chennai


a) For the Complainant Mr D Suriya Prakash Sah

b) For the insurer Mr M Karthikeyan


19. Date of Award/Order 12/03/2020


Complainant‟s son covered under respondent insurer‟s Complete Health Insurance

Policy with cover period as from 28/11/2017 to 27/11/2019 for a sum insured of INR 3

lacs, was admitted in Apollo Hospitals, Chennai on 23/05/2019 and undergone

Laparoscopic One Anastomosis Gastric Bypass for treatment of Metabolic Syndrome,

BMI 54.2 & OSA (Obstructive Sleep Apnea). Claim preferred for the above treatment

was repudiated by insureron the ground that the treatment undergone was for obesity

and OSA by invoking permanent exclusion 3.4. xix of the policy. Aggrieved by the

repudiation of the claim, complainant escalated the matter to Customer Support Dept.

of the insurer twice. Since there is no reply from them he has approached this Forum

for relief.

21)a) Complainant’s submission:

Insurer repudiated the claim on the ground that the treatment was related to weight

management services. Insurer didn‟t send any repudiation letter. Complainant came

to know about the same only through their website. Insured patient has been with the

insurer for several years, didn‟t make any claims and had earned a bonus coverage

of INR 1,20,000.

Insured patient faced illness and the doctor team only concluded to go for surgery on

emergency basis to cure illness. Decision about the surgery was taken by doctors

and complainant‟s son was not admitted voluntarily to the hospital.

While repudiating the claim it has been stated that the treatment was undertaken in

Apollo Hospitals, MRC Nagar, whereas the treatment was actually undertaken at

Apollo Hospitals, Greams road, Chennai. Forum‟s intervention is requested for


b) Insurer’s contention:

Complainant has been with the insurer since 28/11/2013. Reimbursement claim

preferred was for the treatment of OSA, Metabolic Syndrome & BMI of 54.2. Insured

patient was suffering with difficulty in sleeping, snoring and was diagnosed as OSA.

BMI of 54.2 indicates that the patient was suffering with obesity and he underwent

Gastric Bypass surgery (Bariatric Surgery) for these complaints. Aim of the Bariatric

Surgery is to reduce the size of stomach to overcome obesity. As per permanent

exclusion 3.4.xix of the policy which reads as under

―3.4 Permanent Exclusions

Unless covered by way of an appropriate Extension/Endorsement, We shall not

be liable to make any payment under this Policy in connection with or in

respect of any expenses whatsoever incurred by you in connection with or in

respect of:

xix. Weight management services and treatment, vitamins and tonics related to

weight reduction programmes including treatment of obesity (including morbid

obesity), any treatment related to sleep disorder or sleep apnoea syndrome,

general debility, convalescence, run-down condition and rest cure‖

any expenses towards obesity, sleep disorder & weight management program is not

covered.

In the light of above submissions, the claim being outside the scope of the policy

coverage, is not payable. Hence Forum is requested to absolve the insurers of

liability.

22)Reason for Registration of Complaint: - Rule 13(1)(b)of the Insurance

Ombudsman Rules, 2017, which deals with” Any partial or total repudiation of claims

by the life insurer, General insurer or the health insurer”

23)The following documents were placed for perusal.

Written Complaint dated 23/11/2019 to the Insurance Ombudsman

Claim repudiation letter of the Insurer dated 02/07/2019

Complainant‟s representations dated 23/07/2019 & 03/08/2019 to the Insurer


Self-Contained Note (SCN) of insurer dated 28/01/2020

ICICI Lombard Complete Health Insurance policywith terms and conditions


Discharge summary of Apollo Hospitals, Chennai

24) Result of hearing with both parties (Observations & Conclusion)

1. The Forum records its displeasure over delay in submission of SCN by the

insurer. Similarly the lack of response to the representations made by the

complainant is a matter of concern. It is hoped that the insurer will strengthen

its customer grievance redressal mechanism and avoid such lapses infuture.

2. Insurer repudiated the Claim by invoking permanent exclusion clause 3.4.xix of

the policy which excludes treatment towards obesity and sleep disorder.

3. As per discharge summary, the diagnosis arrived by the hospital was

Metabolic syndrome, (BMI-54.2) & OSA.

4. Metabolic syndrome is a cluster of conditions that occur together, increasing

the risk of heart disease, stroke and type 2 diabetes. These conditions include

increased blood pressure, high blood sugar, excess body fat around the waist,

and abnormal cholesterol or triglyceride levels. Metabolic syndrome occurs

when the patient has three or more of the above stated abnormalities. Insured

patient met with the condition of excess fat around the waist as demonstrated

by BMI of 54.2. However, there are no recordings in the discharge summary

about any abnormal cholesterol or triglyceride levels. He is also not a case of

diabetes and increased blood pressure as per discharge summary submitted

by the complainant. Since insured patient didn‟t suffer a minimum of three of

the conditions described above to classify his illness under metabolic

syndrome, Forum concludes that the treatment undergone was not for

metabolic syndrome but to treat obesity and sleep disorder and as such the

treatment falls under the exclusion specified above. As against normal BMI in

the 18.5 to 24.9 range, insured patient‟s BMI of 54.2 and the surgery

undergone being Gastric Bypass points to the fact that the insured patient

undergone weight management treatment as stated by insurer. Hence

insurer‟s repudiation of the claim under policy exclusion 3.4.ixi is in order.

5. Complainant‟s contention in his representation to the customer support that the

surgery was done on an emergency basis is devoid of any merit since in the

discharge summary there is no such mention of emergency admission and it

was stated under the complaints column that the insured patient came with

complaints of difficulty in sleeping, excessive snoring, sleep apnoea and day

time somnolence.

AWARD


made during the course of hearing by both the parties, it is proved that the

repudiation of the claim by insurer is in order and there is no further scope for

reviewing the claim. Hence, the Forum is not inclined to intervene in the decision of

the insurer.


25) If the decision of the Forum is not acceptable to the Complainant, he is at liberty


insurer.

Dated at Chennai on this12th day of March 2020


INSURANCE OMBUDSMAN



STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna Mr E R Jayaprakash Vs HDFC ERGO General Insurance Co. Limited

COMPLAINT REF: NO: CHN-H-018-1920-0478 Award No: IO/CHN/A/HI/0220/2019-2020

1. Name & Address of the Complainant Mr E R Jayaprakash B C N Kandigai, Kasuvarajapet 631211


2952 2012 9625 2901 002 Health Suraksha Policy 14/01/2018-13/01/2020 INR 3,00,000


Mr E R Jayaprakash Mrs Rajitha K

4. Name of the Insurer HDFC ERGO General Insurance Company Ltd

5. Date of Repudiation 20/12/2018 (denial of cashless request)

6. Reason for repudiation 48 months waiting period for declared Pre-existing disease (PED)

7. Date of receipt of the Complaint 26/11/2019

8. Nature of Complaint Non-settlement of Claim


07/01/2020

10. Amount of Claim Not furnished



INR 60,500


INR 10,00,000


17/12/2019

14. b. Date of receipt of SCN 20/01/2020

15. Complaint registered under Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 19/02/2020, Chennai


a) For the Complainant Mr E R Jayaprakash

b) For the Insurer Mr V Karthikeyan




Complainant Mr E R Jayaprakash covered under respondent insurer‟s Health

Suraksha policy since 14/01/2016 was admitted in MIOT Hospital, Chennai on

18/12/2018 to undergo Fistulectomy for treatment of Fistula in Ano. Cashless request

raised for the above treatment was initially approved by insurer for INR 70,000.

Subsequently insurer sent a denial letter (without withdrawing the earlier cashless

approval), on the ground that the disease was pre-existing and the prescribed waiting

period of 48 months had not elapsed for the disease to become eligible for claim, as

per section 9.a.iii of the policy. Aggrieved by the denial of cashless request,

complainant escalated the matter to Grievance Dept. of the insurer for

reconsideration of the claim and they replied that they stood by their earlier decision.

Not satisfied with the response from Grievance Dept to his representation,

complainant has approached this Forum for relief.


1. Policy was availed on 14/01/2016 mainly to avail the benefit for surgical

treatment of Fistula in Ano.

2. Cashless request raised for the surgery performed in MIOT Hospital was

approved by insurer for INR 70,000. Insurer even requested for submission of

KYC form vide letter dated 18/12/2018 to facilitate payment of claim and the

same was submitted by complainant‟s spouse, being the proposer and

policyholder.

3. Surprisingly insurer sent a further communicationdated 20/12/2018 that

cashless facility can‟t be extended since the treatment is in respect of an

ailment diagnosed prior to the inception of the first policy.

4. Denial of cashless facility by insurer resulted in complainant paying INR

60,500 to the hospital.

5. As insurer had already promised to meet the hospitalization expenses in the

form of cashless approval, Forum‟s intervention is requested for payment of

the amount sanctioned of INR 70,000.

b)Insurer’s contention:

1. Complainant‟s spouse availed Health Suraksha policy on 14/01/2016 covering

self and her spouse, the complainant. The policy was renewed subsequently

and the current policy period is 14/01/2018-13/01/2020.

2. Cashless request for complainant‟s hospitalization at MIOT Hospital from

19/12/2018 to 21/12/2018 for recurrent Fistula in Ano was received from the

hospital

3. Based on the medical documents submitted by the hospital, it was observed

that the current ailment was diagnosed on 30/12/2015 whereas the policy first

incepted on 14/01/2016. Thus the current ailment is a Pre-Existing Disease

(PED) which has been defined in the policy as under

―Pre Existing Disease meansany condition, ailment or Injury or related

condition(s) for whichyou had signs or symptoms, and/or were diagnosed,

and/or received medical advice / treatmentwithin 48 months prior to the first

policy issued by the insurer.”

Hence request for pre-authorization (for cashless treatment) was denied, initial

approval stood cancelled and the claim was repudiated as per section 9.a.iii of

the policy which excludes PED for the first 48 months.

4. Complainant has made an earlier request for Pre-Authorization vide cashless

claim no RC-HS15-10341574 for the admission for the period 13/03/2016 to

19/03/2016 at Sri Ramachandra Hospital for Fistulectomy undergone on

19/01/2016. Pre-Authorization was denied on the grounds of ailment being

PED as the same was diagnosed on 30/12/2015 as demonstrated by Pre-

Authorization Request Form submitted by Sri Ramachandra Hospital wherein it

was stated that the date of onset of first symptom was 30/12/2015. Before

issuance of the policy, customer service agent of the insurer had spoken to Ms

Rajitha K, the proposer and she was asked whether the insured or her spouse

has been suffering from any illness to which the reply was that both were hale

and healthy. Though non- disclosure clause was not invoked in this case,

insurance being a matter of utmost goodfaith, the insured should have acted

prudently and disclosed his December 2015 ailment of Fistula in Ano.

In view of the above submission, Forum is requested to dismiss the complaint.

22)Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with “Any partial or total repudiation of claims

by the life insurer, General insurer or the health insurer”.



Insurer‟s cashless denial dated 11/03/2016

Insurer‟s cashless approval undated for INR 70,000

Insurer‟s Cashless denial dated 20/12/2018

Complainant‟s representation dated 07/11/2019 to insurer

Insurer‟s response dated 11/11/2019 to complainant


Self-Contained Note (SCN) of the Insurer dated 14/01/2020

Health Suraksha policy with terms and conditions

Cashless request of Sri Ramachandra Hospital, Chennai for admission on

02/03/2016

Cashless request of MIOT Hospital, Chennai for admission on 18/12/2018

Discharge summary of Sri Ramachandra Hospital, Chennai

Package Breakup and invoice of MIOT Hospital, Chennai

MR Fistulogram dated 07/01/2016


6. Recurrent Fistula in Ano is a PED as admitted by complainant in his

complainant submitted to the Forum and as per Pre-Authorization request

Form submitted by Sri Ramachandra Hospital, Chennai for complainant‟s

admission in their hospital on 02/03/2016 wherein it has been mentioned that

the date of first onset of symptom was 30/12/2015 which is prior to the first

policy incepted on 14/01/2016.

7. It is also observed that the diagnosis of Fistula was conclusively made through

MR Fistulogram undergone by the complainant on 07/01/2016, which was too

prior to inception of the first insurance policy.

8. Initially insurer authorized cashless request of MIOT Hospital for the surgical

procedure for Fistula in Ano for an amount of INR 70,000 and this

authorization was valid till 02/01/2019.

9. As per authorization letter issued, insurer will not be liable for the payment in

the event of any discrepancy between the facts presented at the time of

admission & mentioned in the final documents submitted.

10. But vide letter dated 20/12/2018 insurer informed the hospital that they are

unable to extend the cashless facility since the treatment was for a PED.

11. Insurer in their SCN stated that they were aware of the pre-existing nature of

the current ailment in 2016 itself when they denied a cashless request for the

same ailment on the ground of PED. In such a situation they should not have

issued a cashless authorization for the surgery performed on 20/12/2018. The

said approval was never withdrawn but another communication dated

20/12/2018 was sent stating that cashless facility can‟t be extended, without

any reference to the sanction already given and without highlighting any

discrepancy (as per 4 above).

Cashless request was denied by insurer as per section 9.a.iii of the policy

which reads as under

“All claims payable will be subject to the waiting periods specified below:

48 months waiting period for all Pre-existing Conditions declared and/or

accepted at the time of application.”

Hence as per above clause, only declared and or accepted PED falls under 48

months waiting period exclusion. The clause is silent regarding status of PEDs

not so declared and Insurer themselves stated in their SCN that insured didn‟t

declare his PED in the proposal.

12. Having sanctioned the cashless request of INR 70,000 even after knowing fully

well that the treatment was for a PED, insurers are bound to honour the

sanction given. Hence insurer is liable up to INR 70,000, being the amount

sanctioned. Since the amount spent by complainant is only INR 60,500 for the

surgery on a package basis, amount payable in settlement of claim is INR

60,000 after deducting the documentation charges of INR 500.

The attention of the Insurer is hereby invited to the following provisions of the







AWARD


made during the course of hearing, by both the parties, Forum concludes that the

repudiation of the claim by insurer is not in order and the insurer is directed to settle

the claim of the complainant for INR 60,000 along with interest as defined under

Rule 17 (7) of the Insurance Ombudsman Rules, 2017.

Thus the complaint is Allowed









INSURANCE OMBUDSMAN






CASE OF Mr. Thanigaivelan Vs National Insurance Company Limited

REF: NO: CHN-H-048-1920-0502



Mr. Thanigaivelan Flat 412, Rajendra Apartments 158, Berracca Road Kilpauk Chennai- 600 010


500200501810001022 Baroda Health Policy 12.08.2018-11.08.2019 INR 5 lakhs( floater)


Mr V Thanikaivelan Mr V Thanikaivelan

4. Name of the Insurer National Insurance Company Limited



Exclusion clause 3.23- Out-patient (OPD) treatment




03.01.2020




INR 4,040


INR 4,040


20.12.2019






a) For the Complainant Mr. Thanigaivelan

b) For the Insurer Mrs. Shyamala Ramani




The Complainant and his spouse were covered under Baroda Health Policy with the

Respondent Insurer for a floater Sum Insured (SI) of INR 5 lakhs. He took treatment

for removal of Chalazion - right eye on 24.05.2019 at Deepam Eye Hospital, Chennai

and submitted a claim for reimbursement of treatment expenses to the tune of INR

4,055. The claim was repudiated by the insurer on the ground that the treatment

undergone was an Out-Patient Department (OPD) treatment which is excluded under

clause 3.23 of the subject policy. The Complainant sent a representation to the

insurer dated 16.12.2019 for reconsideration of the claim. The insurer responded on

22.11.2019 expressing their inability to do so. He has therefore approached this

Forum for relief.


The Complainant stated that he underwent surgery as Day Care patient. The claim

was then submitted to the insurer for reimbursement.The insurer rejected the claim

contending that it was not a day care procedure.He has requested the Forum to direct

the Insurer to settle the claim and has sought a compensation of INR 10,000.


The subject claim was repudiated on the ground that the treatment for Chalazion-

Right eye is an OPD treatment and the same is not payable as per clause 3.23 of the

Policy.



by the Life insurer, General insurer or the health insurer”.



Claim Repudiationletter of Insurer dated 05.11.2019







Discharge Summary and invoice of Deepam Eye Hospital, Chennai

24. Results of hearing of both the parties (Observations and Conclusion):

The Complainant Mr. Thanigaivelan and the Insurer‟s representative Mrs.

Shymala Ramani were present for the hearing.

During the hearing the Complainant stated that prior to admission for removal

of cyst in the eye lid he had enquired with the TPA and Insurer. He contended

that the procedure undergone viz. Incision Curettage was done as a day care

procedure like cataract. However the claim submitted to the insurer for

reimbursement was repudiated on the ground that the treatment undergone is

an OPD treatment which is not covered under the subject policy under clause

3.23 thereof.

The Insurer contended that as per clause 3.13 of the subject policy, there was

no hospitalization for 24 hours and that the procedure undergone does not fall

under the category of day care procedure. Hence the claim was not payable.

They further stated that all the bills submitted by the Complainant were for OPD

treatment.

Clause 3.23 of the Policy defines Out-Patient treatment as treatment in which

the insured person visits a clinic/hospital or associated facility like a consultation

room for diagnosis and treatment based on the advice of the medical

practitioner and the insured person is not admitted as a day care patient or in-

patient.

The Forum pointed out that the Insurer has quoted a definition clause 3.23 and

not any exclusion clause of the policy at the time of claim repudiation.

Further, the Forum questioned the Insurer as to whether removal of cyst

comes under the category of day care procedure or not. The Insurer responded

stating that removal of cyst comes under day-care procedure provided treated

under day care- norms.

Day care treatment is defined in clause 3.8 of the Policy as any medical

treatment, and/or surgical procedure which is undertaken under Local or

General Anesthesia in a hospital/day care centre in less than 24 hours because

of technological advancement and which would have required hospitalization of

more than 24 hours.

Further, as per clause 3.13 of the Policy, defining Hospitalization, the condition

regarding minimum period of stay of 24 hours in hospital is waived, among

others, for eye surgery.

As per the Information provided in Wikepedia, Incision and Curettage, is a

surgical method of treatment for a Chalazion. Chalazion is a condition of

swelling in the eyelid. It is usually non-infective and painless and can occur in

both upper and lower eye lids. Incision and curettage is performed under

general anesthesia. A clamp is placed to hold the eyelid backwards. A small

cut is made with a surgical blade from underside the eyelid. The inflammatory

debris is removed from the cyst and the cavity is cleaned thoroughly. An

antibiotic ointment will be applied and the eye is padded for 24 hours. Patient

will be advised to apply antibiotic ointment for at least 3-4 times a day for one

week.

Hence the Forum concludes that the treatment undergone by the complainant

qualifies as a day care procedure under the Policy and the claim is payable.


Insurance


a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, The



b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, The








Dated at Chennai on this12th day of March 2020


INSURANCE OMBUDSMAN


AWARD

In view of the above and taking into account the facts & circumstances of the case and

the submissions made by both the parties during the course of hearing, the Forum

hereby directs the Insurer to settle the claim of the complainant for INR 4,055, subject to

other terms and conditions of the Policy. In addition interest at applicable rate becomes

payable as provided under Rule 17(7) of the Insurance Ombudsman Rules, 2017.

Thus the complaint is Allowed.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mrs. Shanta Shankar Rao Vs National Insurance Company Limited


1. Name & Address of the Complainant Mrs. Shanta Shankar Rao, Flat No.3, Sivam Apartment, Old No.50 B, New No.40, Seethammal Road, Alwarpet, Chennai – 600 018.

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)/Cumulative Bonus (CB)

500411501910000392 National Mediclaim Policy 29.06.2019 to 28.06.2020 INR 1 lakhs / INR 50000


Ms. Sadhika Shankar Rao Mrs. Shanta Shankar Rao



6. Reason for repudiation Policy Condition 4.14 – Treatment for cosmetic purpose is non-admissible




29.01.2020




INR 1,50,750


INR 1,50,750


19.12.2019





c) For the Complainant Mrs. Shanta Shankar Rao

d) For the Insurer Mr. Murugan




The complainant had taken National Mediclaim Policy issued by the Respondent

Insurer (RI) covering self and her dependent daughter under Policy No.

500411501910000392 for the period 29.06.2019 to 28.06.2020. The policy is live

since June 2014.

As per Discharge Summary, on 15.07.2019 the complainant‟s daughter Ms Sadhika

Shankar Rao was admitted in Tamira Aesthetic Healthcare & Lifestyle Pvt. Ltd.,

Chennai with the chief complaints of Lumps in both Axilla for 5 years and pain. She

was diagnosed as a case of Bilateral Accessory Breast and on the same day she

underwent Excision & Primary Closure and was discharged on the next day.

On 29.07.2019 the complainant submitted a reimbursement claim to the insurer for

the cost of treatment and the same was repudiated on the ground that as per Policy

Condition 4.14 “Cosmetic, plastic surgery, sex change, hormone replacement

cosmetic or aesthetic treatment of any description of life or sex change operation,

hormone replacement therapy” is not covered in the policy.

She represented to the insurer to reconsider her claim and they reiterated that the

claim stands repudiatedas per Clause 4.14 of the policy. Aggrieved by the insurer‟s

response, she has approached this Forum vide her letter dated 02.12.2019 for

redressal of her grievance.


The complainant submits that her daughter had lumps in both Axilla for the

past 5 years with gradual increase and was suffering from severe pain.

The treating doctor advised for removal of lumps through surgery.

The surgery is not cosmetic in nature but the insurer has rejected the claim on

that ground.

She also submits that inspite of having paid the premium without any break for

so many years, her genuine claim was rejected.

She requested the Forum to direct the insurer to settle the claim at the earliest.


The insurer has submitted SCN vide their letter dated 08.01.2020.

The insured person was admitted in Tamira Aesthetic Healthcare and Lifestyle

P Ltd on 15.07.2019 and discharged the next day.

She underwent Bilateral Accessory Breast treatment and preferred a

reimbursement claim for an amount of INR 1,50,000.

Policy exclusion 4.14 reads as “Cosmetic, plastic surgery, sex change,

hormone replacement, cosmetic or aesthetic treatment of any description,

change of life or sex change operation, hormone replacement therapy.

Expenses for plastic surgery other than as may be necessitated due to

illness/disease/injury”, in accordance of which treatment or management for

cosmetic purpose is not-admissible under the Policy.

The insurer concluded that the treatment was taken without approval of TPA

and the policy does not cover cosmetic surgery. They requested the Forum to

dismiss the complaint.







Complainant‟s representation dated 25.11.2019 to the Insurer




Claim form

Discharge summary/Bills of Tamira Aesthetic Healthcare & Lifestyle Pvt. Ltd.,

Chennai

Expert Opinion of Dr. B Madhusudhan, MS., M.Ch., DNB, BRS Hospital,

Chennai dated 28.02.2020


Mrs. Shanta Shankar Rao, Complainant, Mr. K Murugan, Insurer‟s

representative and Dr. Deepthi/ Dr. Abhisha, representatives of TPA attended

the hearing.

During the hearing the complainant was questioned as to why she preferred a

non-network hospital for the treatment. She submitted that she preferred the

treating doctor due to his competence and she did not want to take any risk

with other hospital considering her daughter‟s marriageable age, at the time of

surgery.

The complainant was asked to produce the past consultation records of her

daughter‟s treatment for which she responded that she did not preserve any.

The RI contended that the diagnosis is breast axilla and excision is not

warranted since it is non-carcinogenic. Moreover, Histopathology/Investigation

is not available post surgery. The procedure comes under the category of

cosmetic treatment as the condition of the insured person did not appear that

serious and the treatment is taken in a non-network hospital.

The said case was referred to BRS Hospital, Chennai for their expert opinion.

They have observed that “As per the documents provided, the condition of the

patient is one of Bilateral Accessory axillary breasts. The condition causes

increasing size of the accessory axillary breasts, especially painful during the

menstrual cycle, due to cystoglandular Hyperplasia and fibroadenosis

warranting surgical excision – by a qualified General or Plastic Surgeon. The

procedure is more of functional in nature”.

On goingthrough the documents submitted it is observed that the treatment

was taken in a cosmetic speciality centre when the same could have been

managed in a regular hospital. The expert opinion also confirms the same.

In view of the medical opinion, the Forum concludes that the repudiation of the

claim by the RI is not in order and hereby directs them to settle the claim as

per policy terms and conditions.



a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer

shall comply with the award within thirty days of the receipt of the award and

intimate compliance of the same to the Ombudsman.


complainant shall be entitled to such interest at a rate per annum as specified

in the regulations, framed under the Insurance Regulatory and Development

Authority of India Act, 1999, from the date the claim ought to have been settled

under the regulations, till the date of payment of the amount awarded by the

Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award

of Insurance Ombudsman shall be binding on the insurers.



INSURANCE OMBUDSMAN


AWARD


made by both the parties during the course of hearing, the Forum hereby directs

the respondent insurer to settle the claim of the complainant for INR 1,50,750

subject to the terms and conditions of the Policyalong with interest as provided

under Rule 17(7) of the Insurance Ombudsman Rules, 2017.


PROCEEDINGS BEFORE




Case of Mr.K Jaganathan Vs National Insurance Company Limited

REF: NO: CHN-H-048-1920-0506



Mr K Jaganathan 13/2 Subhash Nagar, FCI Road Ganapathy, Coimbatore Tamilnadu- 641 006


650104501810001070 National Mediclaim Policy 19.11.2018 to 18.11.2019 INR 1 lakh


Mr K Jaganathan Mr K Jaganathan



6. Reason for Short settlement

Application of Preferred Provider Network (PPN) tariff


8. Nature of Complaint Short settlement of claim

9. Date of receipt of Consent (Annexure VI A) 09.01.2020


11. Amount paid by Insurer, if any INR 29,488


INR 25,031


INR 25,031


26.12.2019






a) For the Complainant Mr. K. Jaganathan

b) For the Insurer Mr. Udayakumar




The Complainant, his wife and dependent children were covered under National

Mediclaim Policy for individual Sum Insured (SI) of INR 1 lakh each with the

Respondent Insurer (RI). The period of insurance was 19.11.2018 to 18.11.2019. On

10.03.2019 the Complainant was diagnosed with Side Perianal Abscess for which he

underwent surgery at Sri Ramakrishna Hospital. The pre- authorization request to

avail cashless facilityfor INR 80,000 was submitted to the Insurer by the hospital

which is a PPN hospital. The complainant also submitted a network declaration form

giving his consent to bear the cost charged over and above the agreed PPN tariff by

the hospital for the surgery undergone. The claim was accordingly settled by the

Insurer/TPA with the hospital for INR 23,000, being the PPN tariff. When the insured

submitted a claim for reimbursement of the balance amount incurred by him, an

amount of only INR 6,488 was settled. The complainant sent a representation dated

23.07.2019 to the insurer requesting settlement of the unpaid amount. The Insurer

responded expressing their inability to consider the same as the claim was already

settled as per the PPN tariff. Not satisfied with the response, the Complainant has



The Complainant stated that he was admitted in Sri Ramakrishna Hospital from

10.03.2019 to 13.03.2019 for treatment of left Perianal Abcess.The claim for the

treatment was short settled by the insurer.

The Insurer informed him that the hospital has signed an MOU with them and as

per the mutually agreed tariff, the amount chargeable for the said procedure is

INR 23,000. But the hospital charged an amount of INR 54,489 from the

Complainant.

An additional amount of INR 6,488 only was settled by the Insurer on

21.05.2019 towards Colonoscopy and Echo charges, based on his

representation.

He has therefore requested the Forum to direct the insurer to settle hisclaim, in

full.


The Insurer contended that the complainant underwent treatment after signing a

Network Declaration Form giving his due consent to bear the cost charged over

and above the PPN tariff sincehe opted for a room which was higher than his

eligibility. The agreed PPN tariff for Perianal Abscess is INR 23,000 andthe

same was paid to the hospital on Cashless basis.

Later when the complainant submitted a representation to reimburse the claim

for Colonoscopy and Echo Charges, the insurer settled an amount of INR 6,488

on 21.05.2019.

The insurer therefore contended that the amount settled is as per Policy terms

and conditions.

22)Reason for Registration of Complaint: -

Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017, which deals with “Any

partial or total repudiation of claims by the Life insurer, General insurer or the

health insurer”.


Written Complaint to the Ombudsman dated 13.11.2019.

Request for Cashless approval

GIPSA Network Declaration Form dated 10.03.2019

Claim settlement details submitted by the TPA/Insurer

Complainant‟s representation to the Insurer dated 03.06.2019 and 17.10.2019





Operation Notes of Sri Ramakrishna Hospital, Coimbatore

PPN tariff of various hospitals in Greater Coimbatore Region

24. Result of the hearing of both the parties (Observations and Conclusion):

The Complainant Mr. Jaganathan and the Insurer‟s representative Mr

Udayakumar, were present for the hearing.

During the hearing the Complainant stated that the hospital bill for the procedure

undergone was INR 56,427 but was short settled by the Insurer by INR 25,031.

The Insurer applied PPN tariff for settlement of claim. They settled an amount of

INR 23,000 by way of Cashless approval to the hospital and later paid INR 6,488

as reimbursement claim. The Insurer argued that the Complainant had signed a

Network declaration wherein he agreed to bear the cost charged over and above

the tariff rate by the hospital.

The Insurer submitted the agreed PPN rates for Ramakrishna Hospital where the

complainant underwent treatment. The following are the rates for Perianal

abscess (sl. no 40):

Procedure/Ailment General Ward

(INR)

Single Room Non

A/c (INR)

Single Room A/c

(INR)

Perianal Abscess 23,000 25,000 27,000

During the hearing the Forum questioned the Insurer whether explanation was

sought by them from the concerned hospital for charging over and above the tariff

rate. The Insurer stated that the co-morbid conditions of the insured patient were

the reasons given by the Hospital for such over-charging.

The Insurer also informed that in the instant case, they had applied the tariff rate

applicable to General ward which is INR 23,000 whereas the complainant stayed

in a single room for which the PPN tariff is INR 25,000. As per Network

Declaration Form signed by the complainant‟s attender (son), the opted room

category was single room for which PPN tariff of INR 25,000 exists and the

hospital should have charged the same. Nevertheless, the hospital charged in

excess of the tariff, ostensibly citing the co-morbid conditions of the complainant.

The insurer/TPA too failed to question the hospital regarding the violation of PPN

tariff.

In view of the above, Forum concludes that insurer should have settled the claim

on the basis of hospital bill (open billing basis) and not as per PPN tariff, subject

to the terms and conditions of the Policy.

25)The attention of the Insurer is hereby invited to the following provisions of the

Insurance














AWARD

In view of the above observations and taking into account the facts & circumstances of

the case and the submissions made by both the parties during the course of hearing, the

Forum hereby directs the Insurer to settle the balance claim of INR 26,939 of the

Complainant, subject to other terms and conditions of the Policy. In addition interest at

applicable rate becomes payable as provided under Rule 17(7) of the Insurance

Ombudsman Rules, 2017.

Thus the complaint is allowed.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna Case of Mrs. Sripriya Vs Star Health and Allied Insurance Company Limited


1. Name & Address of the Complainant Mrs. Sripriya, 1-B, Max Sarathy Apartments, 32, Parthasarathy Street, S S Colony, Madurai – 625 010.


P/700001/01/2019/017486 Family Health Optima Insurance Plan 09.08.2018 to 08.08.2019 INR 5 lakhs


Mrs. Sripriya Mrs. Sripriya



6. Reason for repudiation Pre-existing Disease (PED)/ Non - disclosure




10.01.2020




Not furnished


INR 66,720


20.12.2019




The complainant is covered under Family Health Optima Insurance Plan issued by

the respondent insurer covering self and her two daughters for a floating Sum Insured

(SI) of INR 5 lakhs.

As per Discharge Summary, the complainant was admitted in Dr. S Dhanvanthri

Premvel‟s Dhanvanthri Nilayam Ayurveda Vaidhyasalai Pvt. Ltd. Madurai on

11.07.2019 with the complaints of pain and stiffness in neck and left shoulder region

associated with difficulty in lifting left upper limb. She was diagnosed as a case of

Cervical Spondylosis, Ligament Tear (Left Shoulder) and was treated with

Abyangam, Patra Pinda Swedanam, Lepanam, Pichu, Snehavasthi,

Ksheeradhoomam, Spl. Kizhi and Baspaswedanam. She was discharged on

24.07.2019.

Her reimbursement claim for the treatment was repudiated by the insurer vide their

letter dated 13.09.2019 on the ground that she had a fall 3 years back followed by

pain in the neck region which confirms that she had the above disease prior to

inception of policy and the present admission and treatment is for sequelae to

previous fall – pre-existing disease. As per waiting period clause 3(iii) of the policy,

the Company is not liable to make any payment in respect of expenses for treatment

of the pre-existing disease/condition, until 48 months of continuous coverage has

elapsed, from the date of commencement of first policy i.e. 09.08.2018. In addition,

they have repudiated the claim invoking non-disclosure of the said pre-existing

condition in the proposal.




b) For the Insurer Dr. Asiya Sahima



She represented to the insurer vide her letter dated 13.10.2019 to reconsider her

claim. But they refused to entertain her representation. Not satisfied with the

insurer‟s reply, she has approached this Forum vide her letter dated 06.12.2019 for

redressal of her grievance.


o The complainant submits that she had an accidental fall in her house and in

the event there was ligament tear in her left hand.

o She was hospitalised from 11.07.2019 to 24.07.2019 for the same and

underwent treatment.

o She submits that as per claim form the present ailment is not a complication of

PED as claimed by the insurer.

o She expects the Forum to do justice in her case.


The insurer has submitted their SCN dated 30.01.2020. They have stated that

the claim has been lodged in the first year of the policy.

As per Discharge Summary of the treating hospital the insured patient had a

fall 3 years before followed by pain which started in the neck region. This

proves that the insured has symptoms of the ailment prior to the

commencement of the policy. Hence it is a pre-existing disease.

Pre Existing Disease means, any condition, ailment or injury or related

condition(s) for which the insured person had signs or symptoms and / or were

diagnosed and / or were received medical advice/ treatment within 48 months

prior to the policy.

Since the insured had symptoms of the ailment prior to the commencement of

the policy, the claim was repudiated vide letter dated 13.09.2019 invoking

Waiting Period clause 3 (iii) of the policy, which reads as “Pre Existing

Diseases as defined in the policy until 48 consecutive months of continuous

coverage have elapsed, since inception of the first policy with any Indian

General / Health Insurer”.

Under Health History section of the proposal, in response to the question “Do

you have any health problems”? - the proposer has replied in negative.

The medical history / health details of the person(s) proposed for insurance are

to be disclosed in the proposal form at the time of inception of the policy. Since

the same was not disclosed earlier, the insurer by passing an endorsement

has now incorporated and included “All Neurological diseases and its

complications as pre existing disease/condition”, apart from rejecting the claim

on the basis of non-disclosure of material facts as well.

The terms and conditions of the policy were explained to the complainant and

it is a settled law that both the parties have to abide by the definitions given

therein and all those expressions appearing in the policy should be interpreted

with reference to the terms of policy.

Upon issuance of an insurance policy, the insurer undertakes to indemnify the

loss suffered by the insured on account of risks covered by the policy; its terms

have to be strictly construed to determine the extent of liability of the insurer.

Therefore, the insurer requested the Forum to dismiss the complaint.








Insurer‟s response dated 02.11.2019 to the Complainant





Proposal form (extract)

Discharge summary/Bills of Dr. S Dhanvanthri Premvel‟s Dhanvanthri Nilayam

Ayurveda Vaidhyasalai Pvt. Ltd. Madurai

Treating doctor‟s certificate dt. 04.03.2020


The complainant vide her letter dated 31.01.2020 informed the Forum her/ her

representative‟s inability to attend the hearing due to personal reasons. Dr.

Asiya Sahima and Mrs. Hemalatha represented the insurer.

During the hearing the RI submitted that though there is no relation between

ligament tear and spondylosis, they are unable to differentiate the treatment

between the first incident and the current hospitalisation since ayurvedic

massage was the treatment given for both conditions. The complainant has not

submitted any reports to establish the ligament tear.

It was decided during the hearing to obtain previous treatment records from

the complainant and a mail was sent to her on 21.02.2020 to submit the

documents. The complainant responded vide mail dated 04.03.2020 stating

that she does not maintain any records since she is not having any chronic

illness. She had approached the treating doctor who has issued a certificate

stating that “the treatment provided was for ligament tear in left shoulder region

and the treatment to the neck region was for the radiating pain left due to the

ligament tear in left shoulder region. The medicines she took previously has no

relation to the ligament tear in left shoulder region for which she was admitted

and treated between 11.07.2019 to 2.07.2019 and hence not a sequel to pre

existing disease”.

Post hearing the RI had contacted the treating doctor to verify the line of

treatment provided and expressed their willingness to consider the claim for

settlement under Coverage Q of the Policy which deals with AYUSH treatment.

They have responded that the maximum claim payable under the AYUSH

treatment as per the terms and conditions of the policy is INR 15,000 as

detailed below.

Coverage Q of the Policy - “AYUSH Treatment : Expenses incurred on

treatment under Ayurveda, Unani, Sidha and Homeopathy systems of

medicines in a Government Hospital or in any institute recognized by the

government and / or accredited by the Quality Council of India / National

Accreditation Board on Health is payable up to the limits given below:

Sum Insured Rs. Limit per policy period Rs.

1,00,000/-

Up to 10,000/- 2,00,000/-

3,00,000/-

4,00,000/-

5,00,000/- to 15,00,000/- Up to 15,000/-

20,00,000/- and 25,00,000/- Up to 20,000/-

Note: Payment under this benefit forms part of the sum insured and will impact

the Bonus.




Based on the above facts, the Forum is of the opinion that the settlement of

INR 15,000 now offered by the RI is in order.

AWARD



the respondent insurer to pay a sum of INR 15,000/-to the complainant in full and

final settlement of her claim along with interest as provided under Rule 17(7) of

the Insurance Ombudsman Rules, 2017.












Ombudsman.



Dated at Chennai on this18thday of March 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




Case of Dr. R. Padmavathy Vs Star Health and Allied Insurance Company Ltd

REF: NO: CHN-H-044-1920-0477



The Complainant, is a retired medical doctor from Tamil Nadu Medical Service. Since

the year 2009, she is covered under Senior Citizens Red Carpet Policy with the

Respondent Insurer (RI) for a Sum Insured (SI) of INR 10 lakhs. The Policy was

issued after duly incorporating “Diabetes and its complications‟‟ as Pre-Existing

Disease (PED). The period of Insurance under the subject policy was 17.11.2018 to


Dr. R. Padmavathy New No 14 Old No 13, III Cross Street, Karpagam Gardens, Adayar,Chennai- 600020


P/111113/01/2019/013894 Senior Citizens Red Carpet Policy 17.11.2018-16.11.2019 INR 10 lakhs


Dr. R. Padmavathy Dr. R. Padmavathy



6. Reason for short settlement

Co-pay clause




17.12.2019


11. Amount paid by Insurer, if any INR 1,48,961


Not mentioned


Not mentioned


17.12.2019






a) For the Complainant Mr. Srinivasan

b) For the Insurer Dr. Asiya Sahima Ms. M Hemalatha



16.11.2019. On 23.08.2019, the Complainant was admitted in G. Kuppuswamy Naidu

Memorial (GKNM) Hospital, Coimbatore, for treatment of Urinary Tract Infection

/Diabetes Mellitus. The insured raised pre-authorisation request to avail cashless

facility, against which an amount of INR 1,45,906 was settled directly to the hospital

by the Insurer. Subsequently the Complainant submitted the claim for reimbursement

of medical expenses which was settled for INR 3,055.The Complainant complained

that the claim was short settled and she has approached this Forum for settlement of

the balance claim amount. Now the Insurer has reviewed the claim and have

expressed their willingness to settle an additional amount of INR 24,957.


The Complainant stated that on August 23, 2019 she was admitted at Karunya

Rural Community Hospital (KRCH) with complaints of high sugar and fits. Later

she was advised to be shifted to GKNM Hospital in an unconscious state, was

in ICU till August 27, 2019, then shifted to ward and finally got discharged on

September 13, 2019.

She further stated that the Insurer settled her claim arbitrarily and paid only

around 36 to 40% of the claim made without giving reasons for amount rejected.

The claim submitted was for INR 4,20,640 which was settled by the insurer for

only INR 1,49,020(correct amount is INR 1,48,961).

Complainant contended that certain items like gloves, masks, needles etc have

been disallowed by Insurer citing frivolous reasons.

She requested the Forum to direct the insurer to pay the claim in the ratio of

50:50 as provided in the Policy.


The Insurer has submitted the billing sheet showing the details of claim

settlement. Out of the total claimed amount of INR 4,02,271 the gross amount

payable works out to INR 3,47,835. The policy is subject to a Co-pay of 50% for

all treatment relating to Pre Existing Diseases (PED). Hence the net amount

payable works out to INR 1,73,918 after Co-pay, out of which an amount of INR

1,45,906 was already settled with the Hospital as cashless claim. Later an

amount of INR 3,055 was settled as reimbursement. They are now willing to

settle the balance amount of INR 24,957.







Bill assessment sheet of Insurer


Copy of policy with terms and conditions



Discharge Summary and invoice of GKNM Hospital, Coimbatore

24) Results of the hearing of both the parties (Observations and Conclusion):

The Complainant expressed her inability to attend the hearing. Her brother in

law Mr. Srinivasan, was duly authorized to represent the Complainant and to

appear before the Forum. The Insurer‟s representative Dr. Asiya Sahima and

Ms Hemalatha M were also present.




During the hearing, the Complainant‟s representative stated that the

hospitalization claims of the complainant were short settled. Though co-pay was

50%, the amounts settled by the insurer were much below 50% in respect of the

current claim and the previous claim for hospitalization in February, 2019. He

contended that there were disallowances in medical bills, room rent etc.

The Insurer was asked to provide the details of claim settlements made for

hospitalization in Feb 2019 as well as August 2019.

The Insurer vide mail dated 13.03.2020 informedthat the claim no

CLI/2020/11113/0679470 mentioned in the Complaint does not exist and Claim

no CLI/202/111113/0376470, pertains to the present claim for hospitalization in

August 2019. The Complainant has confirmed to them that the additional

documents submitted now do not form part of the complaint before the Forum.

The Insurer has reviewed the latest claim (for admission in August 2019) and is

now willing to settle an additional amount of INR 24,957. They have submitted

the detailed worksheet.

As regards claim for hospitalization at GKNM Hospital in Feb 2019 (claim no.

CLI/2019/111113/0632302, the insurer informed that the Complainant submitted

a claim for INR 49,720 and the same was settled for INR 23,025 applying co-

pay of 50% after deducting an amount of INR 3,669 towards non-medical and

non- payable items. Upon perusal of the working sheet submitted by the Insurer

it is observed that the claim settlement of the insurer is in order.

From the claim worksheet submitted by the Insurer for the subject claim

(admission in August 2019), the following are Forum‟s observations:

The insured patient incurred a total amount of INR 4, 02,271.

The non- payable items on account of non- medical and other deductions

(IRDAI prescribed and incorporated in Policy terms and conditions)

worked out to INR 45,036.

An amount of INR 9,400 towards MRI scan was not allowed by the

Insurer as not relevant to the illness for which treatment was

given.However it is observed that the complainant had seizures

during her hospitalization and hence Forum is of the opinion that

MRI was necessary and relevant.

The gross claim payable was worked out as INR 3,47,835 by the insurer

excluding the cost of MRI. Including the same in the gross amount, the

net amount payable after co-pay works out to INR 1,78,617 as shown

below.

Description Amount(INR)

Complainant‟s claim 402271

Less: Non-payable items 45036

Gross Amount payable according

to insurer

347835

Add: Cost of MRI 9400

Gross Amount payable according

to Forum

357235

Less Co-pay (50%) 178618

Net payable 178617

Less; Amount already paid (INR

145906 + INR 3055)

148961

Balance payable 29656

Since the amount of non- medicals items and other deductions has been

reduced from the claim amount, the overall percentage of settlement

(after application of Co-pay of 50%) worked out to 36-40% instead of

50%, as contended by the Complainant.

The Insurer submitted that the treatment underwent was for DM and its

complications which is a pre-existing disease and hence co-pay of 50% was

applied on the eligible claim amount. Hence the Forum holds the application of

50% Co-pay to be in order.

AWARD


both the parties during the course of hearing, the Forumhereby directs the insurer to pay

the complainant an additional amount of INR 29,656 in full and final settlement of her

claim along with Interest at applicable rate as provided under Rule 17(7) of the

Insurance Ombudsman Rules, 2017.

Thus the complaint isAllowed


Insurance


a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, The



b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, The










INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mr. R Ravichandran Vs Star Health and Allied Insurance Company Ltd




The Complainant, his spouse and dependent child were covered under Star Health


Mr. R. Ravichandran 53/D, Vinayaga Nagar Poolapalayam Periyapuliyur, Bhavani (Tk) Erode, Tamilnadu- 638 455


P/121115/01/2019/010524 Star Health Gain Insurance Policy 28.02.2019-27.02.2020 INR 3 Lakhs


Mr. R. Ravichandran Mr. R. Ravichandran

4. Name of the Insurer Star Health and Allied Insurance Co Ltd



Pre-existing Disease (PED )– waiting period of 48 months as per clause 3(iii) of the Policy




30.01.2020




Not mentioned


INR 2,81,715


17.12.2019






a) For the Complainant Mr. R Ravichandran

b) For the Insurer Dr. Asiya Sahima & Ms Hemalatha



Gain Insurance Policy with the Respondent Insurer (RI) for a floater Sum Insured of

INR 3 lakhs. The period of insurance under the policy is 28.02.2019-27.02.2020. On

06.07.2019 the complainant was admitted in G Kuppusamy Naidu Memorial (GKNM)

Hospital, Coimbatore and underwent surgery for replacement of Aortic valve. The

pre-authorization request for cashless treatment dated 24.06.2019 was denied on the

ground that the treatment was for a Pre-Existing Disease (PED). All PEDs have a

waiting period of 48 months as per the Terms and Conditions of the Policy. However

he was requested to submit documents for reimbursement of claim expenses. On

24.08.2019 the Insurer processed the reimbursement claim and repudiated the same

too on the ground of PED. The complainant sent a representation for reconsideration

of the claim; however the insurer responded expressing their inability to do so. He

has therefore approached this Forum for relief.


The Complainant submitted that he was suffering from breathlessness and

swelling in legs for which he underwent some tests and diagnosed of heart

disease. He contended that prior to this he had neither suffered from any

ailment nor had undergone any treatment.

On 14.06.2019, he was advised by a doctor in Erode to undergo Coronary

Angiogram and the diagnosis was further confirmed by the doctors in GKNM

Hospital, Coimbatore. The Complainant claims to have informed this to the

Insurer‟s agent. He contended that the treatment details were also informed to

the agent, who confirmed that the claim would be paid by the Insurer.

The Complainant stated that he had submitted all the documents requested by

the Insurer. However the claim was repudiated.

He requested the Forum to direct the insurer to settle the claim and in addition

provide compensation to the extent of INR 5 lakhs for mental agony.


The Complainant‟s pre-authorisation request to avail cashless facility was

denied as the exact duration of the ailment could not be ascertained with the

available documents.

However, from the records submitted along with reimbursement claim, it was

observed from the Echo report dated 12.07.2019 that the insured patient was

suffering from Calcific Aortic Stenosis with moderate regurgitation and mild

Pulmonary Artery Hypertension.

Thus the present treatment was for a Pre-Existing Disease (PED) which has a

waiting period of 48 months as provided under Condition no 3(iii) of the Policy.

Hence the claim was repudiated and communicated to the Complainant on

23.08.2019.






Request for cashless hospitalization

Denial of pre-authorisation request for cashless dated 24.06.2019

Claim Repudiation letter dated 24.08.2019.





Proposal form (extract)


Endorsement dated 22.08.2019 for incorporation of PED in policy

Self-Contained Note (SCN) of Insurer dated 31.01.2020.

Echocardiogram dated 16.05.2019, 27.06.2019& 12.07.2019 (post-operative).

Discharge Summary and outpatient record of GKNM Hospital, Coimbatore

Discharge summary of Bharathi Heart & Maternity Hospital

Medical opinion of Dr Arun Kumar K dated 09.12.2019

Medical Opinion dated 24.02.2020 of Dr Refai Showkathali, Senior Consultant

Interventional Cardiologist, B R S Hospital, Chennai

24. Results of the hearing of both the parties (Observations and Conclusion):

The Complainant Mr. R. Ravichandran, and the Insurer‟s representatives Dr.

Asiya Sahima and Ms.Hemalatha were present for the hearing.




During the hearing the Complainant stated that subsequent to swelling of his

legs and breathing difficulty he was admitted and diagnosed with heart

problem. He also stated that he did not suffer from any health problem prior to

current illness. It was only from the Angiogram taken on 14.06.2019at a

Hospital in Erode he came to know about the heart ailment. However his claim

was rejected by the insurer on the ground that the current illness was Pre-

Existing.

The Insurer stated that the subject claim was repudiated under Condition 3(iii)

of the Policy wherein there is a waiting period of 48 months for all Pre-Existing

Diseases.

The Insurer contended that ECHO report dated 12.07.2019 showed Calcific

Aortic Setnosis with moderate regurgitation, mild pulmonary artery

hypertension. Hence the present treatment was for a PED. Further the

Complainant had not disclosed about his medical history/conditions in the

proposal at the time of taking the policy. The insurer also submitted a copy of

the medical opinion obtained from Dr. Arunkumar Krishnasamy, wherein it was

stated that as per the Echo report dated 27.06.2019 the insured was suffering

from severe calcific aortic stenosis and LV dysfunction which suggest that the

insured patient had a chronic valvular heart disease. The patient underwent

Aortic Valve Replacement on 08.07.2019.Based on this opinion, the Insurer

had repudiated the claim on the ground that the present ailment was a PED.

However, the Insurer did not submit any records of treatment/diagnosis

predating the policy in support of their contention

The Insurer did not take the plea of non- disclosure for repudiation of the

Claim.The Complainant had availed the policy online on 28.02.2019. The claim

was reported in the first year of the policy.

Subsequently, the insurer incorporated “Diseases relating to cardiovascular

system” as PED in the policy.

The Forum observed that all the Echo reports are dated after the inception of

the Policy in Feb 2019. As per letter of repudiation of the insurer and the SCN,

the Echo done on 12.07.2019 showed severe Calcific Aortic Stenosis which is

an incorrect observation. The Echo done on 12.07.2019 was post-surgery and

hence does not show any stenosis. It is the Echo test done on 16/05/2019 at

Kovai Medical Center and Hospital which revealed the condition of Aortic

Stenosis as also the Echo done on 27/06/2019 at GKNM Hospital. As per out-

patient record dated 27.06.2019 of GKNM Hospital, the complainant had

breathlessness for 2 months and swelling in legs for one month and there was

no past history of IHD (Ischemic Heart Disease), HTN (Hypertension),

DM(Diabetes Mellitus) or Dyslipidemia. This is also confirmed by the

discharge summary of Bharathi Heart & Maternity Hospital, Erode where the

complainant underwent Coronary Angiogram (CAG) on 14.06.2019. The

remarks made in the said discharge summary under the heading Past History

are ‟No history of CAD (Coronary Artery Disease)/DM/HTN‟. The history of

symptoms (of breathlessness and swelling in legs) is well within the policy

period and hence cannot be categorized as pre-existing. Even the opinion of

Dr. Arun Kumar Krishnasamy, based on which insurer rejected the claim does

not comment on the duration of the illness but only states that the Echo is

suggestive of chronic valvular heart disease. The Forum too obtained medical

opinion from Dr. Refai Showkathali, Senior Consultant Interventional

Cardiologist, B R S Hospital, Chennai. The doctor opined that in the absence

of any previous echo cardiogram, the report dated 16.05.2019 wherein the

insured patient was diagnosed with Aortic stenosis is a new diagnosis and

hence the present ailment is not a pre-existing disease.

Therefore, Forum is of the conclusion that rejection of claim by the insurer on

the ground of PED is not justified.

The compensation of INR 5 lakhs for mental agony sought by the Complainant

cannot be considered as it is beyond the purview of this Forum.











Ombudsman.

AWARD


both the parties during the course of hearing, the Forum hereby directs the Insurer to

settle the claim of the complainant for INR 2,81,715 subject to other terms and

conditions of the policy along with Interest at applicable rates as provided under Rule

17(7) of the Insurance Ombudsman Rules, 2017. The endorsement passed by the

insurer incorporating Diseases relating to Cardiovascular System as pre-existing should

also be withdrawn.

Thus the complaint isAllowed.





INSURANCE OMBUDSMAN



OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. D Vinod Vs Manipal Cigna Health Insurance Company Limited



1. Name & Address of the Complainant Mr. D Vinod, No.28, 8th Avenue, Sabari Garden, Sanganur, Coimbatore – 641 027.


PROHLN980589027 ProHealth – Protect Plan 12.04.2019 to 11.04.2020 INR 4,50,000


Mr. V Dhyan Mr. D Vinod

4. Name of the Insurer Manipal Cigna Health Insurance Company Limited


6. Reason for repudiation Ailment pre-existing (PED) and non-disclosure thereof




06.01.2020




INR 3,10,219


INR 3,10,219


19.12.2019





a) For the Complainant Mr. D Vinod

b) For the Insurer Mr. Vinod Babu



The Complainant has taken Family Floater Pro Health Insurance – Protect Plan

Policy issued by the Respondent Insurer (RI) covering self, spouse and his son for

the period 12.04.2019 to 11.04.2020. It is a fresh policy.

The complainant registered a cashless request through Amrita Institute of Medical

Sciences & Research Centre (AIMS), Kochi on 19.04.2019 for the admission of

Master V Dhyan, his son who was diagnosed with Global Developmental Delay and

Epileptic Encephalopathy with tonic seizures. He was treated for recurrent aspiration

pneumonia and was discharged on 07.05.2019 after starting NG feeds. Cashless

request for the treatment was rejected by the RI on the ground that the claim was not

admissible as the hospitalisation was within 30 days from policy inception.

On 17.05.2019 the complainant‟s son was once again admitted in AIMS with the chief

complaints of fever, cough, poor feeding and lethargy. He was diagnosed with

Acquired Seizure disorder, GERD and Aspiration Pneumonia. As per discharge

summary he has a past history of recurrent Aspiration Pneumonia. He was treated

and discharged on 28.06.2019.

The complainant‟s cashless request for INR 61,750 for the second admission was

initially approved for INR 40,000 vide letter dated 22.05.2019 of the insurer. However,

the approval given was withdrawn/ rejected on 26.06.2019 at the time of discharge.

He submitted a reimbursement claim for INR 3,28,619 on 18.07.2019 and the same

was also rejected by the insurer on the ground that the ailment of Developmental

Delay and epileptic encephalopathy was pre-existing (PED) and the same was not

disclosed at the time of inception of the policy.

He represented to the insurer vide mail dated 29.08.2019 to reconsider his claim and

they responded stating that the claim was rejected on the ground of PED and non-

disclosure. This was followed by termination of policy with effect from 09.09.2019.

Aggrieved by the response of the insurer, the complainant has approached this

Forum for redressal of his grievance vide his letter dated 04.12.2019.


The complainant submits that the insurer‟s sales team approached him in

March 2019 to avail policy and he took the policy in April 2019 due to their

persistence, despite already having insurance coverage through his employer.

He specifically asked the sales team whether the policy will cover all medical

treatment including Seizures etc., to which they replied that except maternity,

all others treatments will be covered.

The entire process was done online and no documents were signed by the

complainant.

On 19.04.2019 his son was admitted in AIMS and the cashless request made

was rejected under 30 days‟ waiting period clause of the policy. He also

submits that he was not informed of the said clause at the time of sales.

The child got hospitalised again on 17.05.2019 with multiple ICU admissions in

the course of his treatment. Cashless request made was initially approved for

INR 40,000 but was rejected on 26.06.2019, on the date of discharge. Since

cashless was rejected, the child had to stay in the hospital for two more days

to enable the complainant raise funds for settlement of the hospital bill and

was discharged on 28.06.2019.

On 16.08.2019 the reimbursement claim preferred by the complainant was

rejected and the policy terminated.

The complainant has alleged that since the bill amount is on the higher side,

the insurer is finding reasons to reject the claim. It is purely a case of mis-

selling by the insurer.

The complainant escalated his grievance to IRDAI and finally approached this

Forum for relief.


The respondent insurer submitted their SCN dated 07.02.2020.

They have stated that the complaint is misconceived and not maintainable and

liable to be dismissed.

The complainant had approached them for porting of health insurance policy.

A Family Floater Pro-Health – Protect policy was issued with effect from

12.04.2019.

On 19.04.2019 a cashless request was submitted for the admission of

complainant‟s son for treatment due to Global Developmental Delay, Epileptic

Encephalopathy with tonic seizures.

Since the hospitalization was within 30 days from the policy inception, the

same was rejected vide letter dated 23.04.2019 under Clause V 2 which reads

“any disease contracted and/or Medical Expenses incurred in respect of any

Pre-existing Disease/illness by the Insured/Insured Person during the first 30

days from the inception date of the Policy will not be covered”.

On 17.05.2019, another cashless request was submitted for his son‟s

hospitalization for treating LRTI, Global Developmental delay and Epileptic

Encephalopathy.

In response to a query raised by the insurer, the treating doctor had clarified vide his

letter dated 22.05.2019 that the “Child was under Pediatric Neurology follow-up for

seizure disorder. Seizure disorder started at 3 months of age and was admitted under

Paediatric Neurology for evaluation. Current admission is for pneumonia and is

unrelated to seizure disorder”.This fact was not disclosed at the time of purchasing

the policy. Therefore, the cashless request was denied on the grounds of non-

disclosure of material information under Clause VIII.1 of the terms and conditions of

the policy. The reimbursement claim too was rejected on the same grounds and the

policy was terminated, forfeiting the premium paid.






Request for Cashless Hospitalisation for admission in April 2019

Request for Cashless Hospitalisation for admission in May 2019

Rejection of cashless request dated 23.04.2019

Approval of cashless request dated 22.05.2019 for INR 40,000

Rejection of cashless request dated 26.06.2019


Reimbursement Claim repudiation letter of the Insurer dated 16.08.2019


Complainant‟s representation dated 24.09.2019 to IRDAI




Welcome letter of the insurer


Policy termination letter

Proposal form

Discharge summary/Bills of Amrita Institute of Medical Sciences and Research

Centre

Mail correspondence with the Insurer and TPA

Certificate of Dr. C Jayakumar dated 22.05.2019

Opinion dated 23.02.2020 of Mr. M B Raghavan, Advocate


Mr. D Vinod, complainant and Mr. Vinod Babu, Insurer‟s representative

attended the hearing.

During the hearing the complainant submitted that he had disclosed his child‟s

history of seizure to the agent through whom he availed insurance who in turn

advised him that seizure is not a material information to be disclosed in the

proposal and he was asked to proceed with signing the proposal. He also

submitted that the child had an attack of pneumonia during both

hospitalizations (current and the previous admission in the month of April,

2019.

The RI informed the Forum that the policy was sold by a Sales Manager and

the cashless request for the second admission in May 2019 was denied on the

grounds of non-disclosure of pre-existing disease of Seizure.

The RI was directed by the Forum to submit the copies of both pre-

authorisation requests.

It is observed that the cashless request for the admission on 10.04.2019 was

for the complaints of Developmental delay with epilepsy, fever and lethargy

and the provisional diagnosis was Global Developmental delay, Epileptic

Encephalopathy with tonic seizures and the same was rejected on the grounds

of 30 days waiting period clause.

The cashless request for the admission on 17.05.2019 was for the complaints

of fever and breathlessness for the previous two days. The request was

approved on 22.05.2019 for INR 40,000. Later at the time of discharge, the

cashless was rejected on 26.06.2019 on the grounds that the patient was

suffering from seizure disorder since 6 months of age, that is even before

policy inception and the same was not disclosed during policy inception. As

per policy condition, non-disclosure of any medical history in the proposal form

leads to repudiation of claim under clause VIII.1.

As per Discharge Summary, the diagnosis is “Acquired Seizure Disorder,

GERD and Aspiration Pneumonia” and the reimbursement claim too was

rejected on the grounds of Pre-existing Disease (PED) and non-disclosure.

The proposal was completed online and there is no disclosure of the previous

illness therein. A copy of the proposal form has apparently been provided to

the complainant along with policy as per Regulations, but the welcome letter is

silent regarding the same and also does not mention the free-look cancellation

option. Nevertheless, the complainant had an opportunity to peruse the

proposal and bring the discrepancies therein if any, to the notice of the insurer,

for corrective action. But he failed to do so.

The RI did not take the plea of PED and non-disclosure while rejecting the

cashless request for the admission on 10.04.2019 which was denied on the

ground of 30 days waiting period and for the next admission i.e. on 17.05.2019

they invoked PED and non-disclosure clauses. It is observed from the

discharge summary that the patient also suffered from seizures while in PICU

and was treated for the same, although primarily admitted for treatment of

Pneumonia. Hence a case for rejection of the claim on the additional ground

of PED is also made out.

The Forum obtained legal opinion from Mr. M B Raghavan, Advocate on

whether the insurer is estopped from invoking the plea of PED and non-

disclosure in future claims since they have not invoked the same while

rejecting the first cashless request.

He has opined that “Each claim has to be decided independently. If the policy

contains an exclusion and a claim, on facts, falls within the exclusion, the

Insurer would be entitled to deny liability on the basis of the particular

exclusion applicable to the claim. Basis of the first denial (30 days clause), it

cannot be said that the Pre Existing exclusion stood cancelled or ineffective

thereafter. The said exclusion is also part of the contract and applicable

throughout the Policy period. Perhaps for the particular claim, if repudiation

was based on one ground alone then other grounds cannot be invoked later to

defend a litigation. However, for subsequent claims, the policy terms fully apply

and the exclusions as may be found applicable can be invoked. Merely

because the insurer chose to invoke 30 days exclusion clause at a time when

further claims cannot be foreseen it would be unreasonable to deny them the

right to invoke the Pre-Existing exclusion, if the claim pertains to pre-existing

condition”.

The Forum also examined the validity of the cashless authorisation for INR

40,000 given by the insurer in the first instance and later withdrawn. It is noted

that the request for cashless treatment mentioned the presenting complaints

as fever and breathlessness for 2 days and there was no suggestion or hint

therein about any pre-existing illness. However, the insurer did obtain a

clarification from the treating doctor on 22.05.2019 which brought out the fact

that the patient had a seizure disorder from the age of three months.

Nevertheless, the insurer approved cashless facility for INR 40,000, ignoring

the possible vitiation of claim due to non-disclosure, if not due to PED (waiting

period) clause. The approval given did not have any conditions attached

thereto and was termed as an initial approval and not provisional. Hence the

Forum is of the considered view that the said approval becomes binding on the

insurer, notwithstanding its subsequent withdrawal and rejection of the

reimbursement claim.

Based on the above, the Forum is of the view that while the rejection of the

claim by the insurer is in order, they are liable for the amount of INR 40,000

being the cashless approval.

AWARD


made by both the parties during the course of hearing, the Forum directs the insurer

to pay an amount of INR 40,000 to the complainant in full and final settlement of his

claim along with interest as applicable under Rule 17(7) of the Insurance


The complaint is disposed off accordingly.



insurer.





award and intimate compliance of the same to the Ombudsman.









Dated at Chennai on this19thday of March 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE


(UNDER RULE NO: 16 /17 of the INSURANCE OMBUDSMAN RULES, 2017)


CASE OF Mr Gautam Bhargava Vs The New India Assurance Co. Ltd


Award No: I0/CHN/A/HI/0231/2019-2020


Mr Gautam Bhargava B-12, Tirumalai Complex, ICF Link Road, Villivakkam,Chennai- 600049


71290034199500000137 New India Mediclaim Policy 31/05/2019 to 30/05/2020 INR 1,00,000


Mr Gautam Bhargava Mr Gautam Bhargava

4. Name of the Insurer The New India Assurance Co. Ltd

5. Date of Short Settlement 16/08/2019

6. Reason for Short Settlement

Proportionate Deductions Clause Applied


8. Nature of Complaint Short Settlement of Claim


06/01/2020




INR 20,000


INR 20,000

14.a. Date of request for Self- Contained Note (SCN)

18/12/2019






a) For the Complainant Mr G Bhargava

b) For the Insurer Ms K R Sunitha




The complainant had taken a Mediclaim Policy with the respondent insurer for a sum

insured of INR 1,00,000 for the period from 31/05/2019 to 30/05/2020. He was

admitted in Madras Medical Mission Hospital, Chennai from 01/06/2019 to

06/06/2019 for Peripheral Vascular Disease, Left Leg Cellulitis, Diabetes Mellitus,

Hypertension and Vertigo. He submitted his claim for INR 70,733 for the treatment

which Raksha Health Insurance TPA settled for INR 25,128. Not satisfied with the

short settlement, the complainant escalatedthe matter to the insurer‟s Grievance

Department who replied that the short settlement was because of the higher room

rent the complainant had availed in the Hospital, leading to application of

proportionate deduction clause as per the policy. Aggrieved, the complainant has

approached this Forum seeking justice.

21(a) Complainant’s submission:

The complainant has been insuring with the respondent insurer since 2001 and he

had stated in his complaint that it was not right on the part of the insurer to deduct

Lab Charges, Consultation fees and Investigation charges proportionately on the

basis of the room rent.

21(b) Insurer’s submission:

The insurer stated that the complainant‟s room rent eligibility was only INR 1,000 per

day but he had availed room with rent of INR 7,100 per day.

As per Clause 3.2 of the policy when the insured avail room rent beyond their

eligibility as per the sum insured, other expenses incurred at the hospital, with the

exception of the cost of medicines will be proportionately reduced.

Details of Claim calculation are as under

Item of

Expense

Amount(I

NR)

Deduction(I

NR)

Approved

(INR)

Reason for deduction

Room rent 35500 30500 5000 Restricted to 1% of SI per day

Consultation 3520 3024 496 Proportionate Deduction

InvestigationCh

arges

10480 9236 1244 Proportionate Deduction INR 7586 and

INR1650 Blood

sugar report not available

Hosp. Services 740 636 104 Proportionate Deduction

Medicines 19618 1334 18,284 Non Medical items dis-allowed

Diet Charges 875 875 000 Disallowed

Thus the insurer contended that they were right in applying the Proportionate

Deductions Clause while settling the complainant‟s claim.

22) Reason for Registration of Complaint: - Rule 13(1)(b) of the Insurance





Claim settlement letter of the Insurer dated 16/08/2019

Complainant‟s representation dated 20/08/2019 to the Insurer

Consent (Annexure VI A) submitted by the Complainant dated 06/01/2020

Self-Contained Note (SCN) of Insurer dated 10/01/2020


Claim form

Discharge summary/Bills of The Madras Medical Mission Hospital


1. Forum regrets to note the lack of response from the insurer to the representation

made by the complainant.

2.The complainant stated that it was not right on the part of the insurer to deduct the

Lab Charges, Consultation fees and Investigation charges on a pro-rata basis relating

the same to the room rent.

3.The complainant had availed room at a rent of INR 7,100 per day whereas he was

eligible for a room rent of INR 1,000 per day. In view thereof, insurer applied Policy

Clause No 3.2 which deals with ―Proportionate deductions on the other expenses

incurred at the Hospital, with the exception of cost of medicines, if room

rent/ICU/ICCU charge exceeds the aforesaid limit.‖ Thus the insurer was right in

applying the Proportionate Deductions Clause while settling the claim.

4. Therefore this Forum is of the view that the settlement of the claim by the insurer

was as per terms and conditions of the Policy.



insurer.



INSURANCE OMBUDSMAN

FOR THE STATE OF TAMILNADU AND PUDUCHERRY

AWARD

Taking into account the facts & circumstances of the case and the submissions made

by both the parties during the course of hearing, this Forum is of the view that the

settlement made by the insurer is in order and does not warrant any intervention by this

Forum.

Thus the complaint is NotAllowed

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERY (UNDER RULE NO: 16 /17 of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Ms M Sowmiya Vs Universal Sompo General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-052-1920-0489 Award No: I0/CHN/A/HI/0233/2019-2020


Ms M Sowmiya 33 A, Balaji Castle, Balaji Nagar 5th Cross Street,2nd Main Road Ekkattuthangal,Chennai-600032


2817/56528496/02/000 IOB- Health Care Plus Policy 03/09/2018 to 02/09/2019 INR 3,50,000


Mr P U Madhavan Ms M Sowmiya

4. Name of the Insurer Universal Sompo General Insurance Co. Ltd



Pre-existing disease (PED) exclusion


8. Nature of Complaint Rejection of claim


10/01/2020

10. Amount of Claim Not Furnished



Not Furnished


Not Furnished


18/12/2019



Rule 13(1)(b)of the Insurance Ombudsman Rules, 2017



a) For the Complainant Ms M Sowmiya

b) For the Insurer Absent




The complainant had obtained IOB- Health Care Plus Policy through the respondent

insurer covering herself and her parents for the period from 03/09/2018 to 02/09/2019

for a floater sum insured of INR 3,50,000. The first Policy was taken on 03/09/2016

and renewed continuously thereafter. Her father got admitted in Sri Ramachandra

Medical Centre, Chennai from 05/06/2019 to 14/06/2019 and underwent Coronary

Artery Bypass Grafting (CABG)during the third year of the policy. His request for

cashless treatment was denied on the ground of Pre-existing Disease (PED) as well

as non-disclosure of PED, since the discharge summary mentioned that the patient

was a known case of Type 2 Diabetes Mellitus (DM) and Systemic Hypertension

(SHTN) and had a history of CVA in 2004. The reimbursement claim preferred

subsequently was also rejected on the same grounds. The complainant made a

representation to IRDAI vide token no 06-19-000077 regarding non-settlement of the

claim, in response to which the insurer reiterated the reasons given earlier and

rejected the representation. Aggrieved by the insurer‟s stand, the complainant has

approached this Forum seeking justice.


The complainant submitted that at the time of taking the Policy, she did not sign any

proposal form and the agent who canvassed the business was informed about her

father‟s pre-existing diseases. The insurer had issued policy to the complainant

without any pre medical check-up which they were supposed to carry out before

granting health insurance to insured who are aged 45 years above.

The complainant disowned her signature in the proposal form and questioned how

the insurer could conclude that she did not declare her father‟s pre-existing disease

without obtaining her signature in the proposal form.


1.The insurer repudiated the claim relying on the discharge summary of Sri

Ramachandra Medical Centre which mentioned that the patient was a known case of

Type 2 diabetes mellitus and systemic hypertension and also had a history of CVA in

2004. Since this information has come on record, they have construed that these are

pre-existing diseases which are not covered under the policy till 48 months from

03/09/2016 which was the policy inception date and moreover the Complainant did

not disclose these diseases in the proposal form when the policywas taken .



by the Life insurer, General insurer or the health insurer”


Written Complaint dated 17/06/2019to the Insurance Ombudsman (received

on 20/08/2019)

Cashless Request Form

Cashless Denial letter dated 04/06/2019


Complainant‟s representations dated 31/05/2019 and 19/11/2019 to the

Insurer



Discharge summary/bill of of Sri Ramachandra Medical Centre

Proposal form dated 03/09/2016

Copy of policy with terms and conditions


1.This Forum records its displeasure over the delayed submission of SCN by the

insurer. They are strictly advised to send the SCN in time in future. The Forum also

takes a serious view of the non-participation of the insurer in hearing without prior

intimation.

2.The insurer repudiated the subject claim on the ground of Pre-existing Disease

waiting period clause as well as non-disclosure (of material facts).

3. As per discharge summary of Sri Ramachandra Medical Centre, the insured was

suffering from DM and SHTN and had a history of CVA (Cerebro Vascular Accident) in

2004. Although the duration of DM and SHTN was not mentioned therein, it is

observed that in the cashless request from submitted by the hospital the duration was

mentioned as 15 and 20 years respectively for DM and SHTN. The complainant too

did not deny that her father and the insured was suffering from pre-existing diseases

at the time of taking the policy. In fact her contention is that the same were disclosed

to the agent who solicited the business.

4. As regards the rejection of claim on the basis of non-disclosure, citing the

Disclosure to Information Norm clause of the policy, the Forum notes that the

complainant has consistently and vehemently denied having signed any proposal

form. When the proposal submitted by the insurer was shown to her in the course of

hearing, she disputed her purported signature therein and claimed that it was not her

signature. The Forum too has noted that there is some discrepancy in the signature in

the proposal when compared to complainant‟s signature in other documents submitted

by her to the Forum. Hence the benefit of doubt is given to the complainant and the

Forum considers that the allegation of non-disclosure against the complainant is not

established.

5. The insured was admitted for CABG following a diagnosis of Coronary Artery

Disease (CAD) – Triple Vessel Disease (TVD). It is a known and medically

established fact that DM and SHTN are related conditions and major risk factors for

CAD. The policy definition of Pre-existing Disease (PED) encompasses not only the

disease concerned but also its related conditions. Hence in the considered view of the

Forum, the waiting period for PED applies in the present case. Since the claim has

arisen in the third year of the policy before the expiry of waiting period of 48 months,

the insurer‟s decision to reject the claim invoking the said clause is justified.

6. Complainant‟s argued that the insurer did not carry out any medical examination at

the time of issuing the policy, in violation of its own norms. The complainant cited the

norms applicable to Individual Health Insurance Policy of the insurer appearing on

their website in this regard. The policy issued to the complainant and her parents is

IOB Health Care Plus Policy, a different product to which said norms may not

necessarily apply. Also, conducting medical examination prior to acceptance is not

mandatory and can be waived by the insurers at their discretion. Moreover, there is

no waiver of waiting period for PED even if policy has been issued after medical

examination. Hence the argument of the complainant is neither tenable nor relevant

for the case on hand.

25. If the decision of the Forum is not acceptable to the Complainant, she is at liberty


insurer.



INSURANCE OMBUDSMAN


AWARD


by both the parties during the course of hearing, this Forum is of the view that the

decision of the insurer to repudiate the claim is in order and does not warrant any

intervention.



OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. S Selvaraj Vs United India Insurance Company Limited



Dr. S Selvaraj, 31, 3rd Main Road, Ponnagar, Trichy 620 001.


0906022818P114069204 Individual Health Policy - Gold 16.03.2019 to 15.03.2020 INR 1 lakh


Mr. S Kawshik Mr. S Selvaraj

4. Name of the Insurer United India Insurance Company Limited

5. Date of Short settlement 16.10.2019

6. Reason for Short settlement Proportionate clause and disallowance of non-medical items




23.12.2019




INR 35,121


INR 35,121


16.12.2019






b) For the Insurer Mr. A B Bhaskaran




The complainant has taken Individual Health Policy with the Respondent Insurer (RI)

covering self, spouse and his dependent son. The policy is live since March 2004.

On 27.09.2019 the complainant‟s son Mr. Kawshik was admitted in Sreshta Sri

Kamala Hospitals, Hyderabad and was diagnosed of Dengue Fever with

Thrombocytopenia and Leucopenia. He was treated in ICU and was discharged on

02.10.2019.

The complainant submitted a reimbursement claim of INR 55,318 for the treatment of

which an amount of INR 20,197 was settled on 16.10.2019 after disallowing INR

35,121 towards non-medical expenses and proportionately restricting the cost of

room rent, ICU charges, professional and investigation charges and other

miscellaneous charges.

He represented to the insurer regarding the short settlement and they responded that

the deductions were made as per policy terms and conditions. Not satisfied with the

insurer‟s reply, he has approached this Forum vide his letter dated 2.11.2019 for

redressal of his grievance.


The complainant has submitted that he has taken a Health insurance policy for

a Sum Insured of INR 1 lakh for his son and the policy is claims free since

2004.

His son fell ill and was admitted in ICU of Sreshta Sri Kamala Hospitals and

was treated.

Against the bill of INR 55,318, the insurer settled only INR 20,197.

Expenses deducted as non-allowable are not explained in the policy.

Lab Investigation charges, Doctor Fees and ICU charges are short settled.

He also submits that he is yet to receive the ID Cards.


The respondent insurer has stated that the ID cards were handed over to the

complainant at his residence through the agent.

The E cards were also made available to him by Paramount TPA Ltd.

The claim was short settled by INR 35,121 due to deduction towards non-

medical expenses and restricting the claim proportionate to eligible room rent.

They submit that they have settled the claim as per terms and conditions of the

Individual Health Insurance Policy.

As per condition 1.2 A of policy, coverage is for “Room, Boarding and Nursing

Expenses as provided by the Hospital/Nursing Home upto 1% of Sum Insured

per day. This also includes Nursing Care, RMO charges, IV Fluids/Blood

Transfusion/Injection administration charges and similar expenses”.

As per Note-1 to condition 1.2 - “The amount payable under 1.2 C & D above

shall be at the rate applicable to the entitled room category. In case the

insured person opts for a room rent higher than the entitled category as in 1.2

– A above, the charges payable under 1.2 C & D shall be limited to the

charges applicable to the entitled category”.

Since the claim was settled as per Policy Terms and Conditions, they

requested the Forum to award in their favour.






Additional submissions of the complainant dated 10.02.2020

Claim settlement letter of the Insurer dated 26.10.2019






Discharge Summary of Sreshta Sri Kamala Hospitals, Hyderabad


The complainant vide his letter dated 10.02.2020 informed the Forum of his

inability to attend the hearing. Mr. A B Bhaskaran and Mr Ananda Jawahar,

Insurer‟s representatives and Ms. Amrita and Mr. Mohan, representatives of

the TPA attended the hearing.

There is a delay of one month in submitting the SCN. The Forum records its

displeasure over the late submission of the SCN and hereby directs the insurer

to strictly follow the timelines in future.

During the hearing the RI submitted that some of the diagnostic tests

conducted were under surgical package and not for medical management.

Policy provisions do not allow for surgical package.

The proportionate clause applied for other charges is as per entitled room

category. They had requested the complainant to produce a declaration from

the hospital stating that professional charges are not related to room rent to

enable them to settle the amount deducted. But there was no response from

him.

It is observed that though the insurer interprets that as per Clause 1.2, Note 1,

Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees etc.

are payable in proportion to availed room category, the policy wording states

that “The amount payable under 1.2C & D above shall be at the rate applicable

to the entitled room category. In case the insured person opts for a room with

rent higher than the entitled category as in 1.2A above, the charges payable

under 1.2C & D shall be limited to the charges applicable to the entitled

category. This will not be applicable in respect of Medicines & Drugs and

implants”. Nowhere it is mentioned in the Note that the charges will be reduced

proportionately to the room rent. The clause only speaks of payment of

charges under 1.2 C and D at the rate applicable to the entitled room category.

While the entitled room category is clearly defined in the policy as a

percentage of the sum insured per day, the corresponding “rates applicable”

to charges under 1.2 C and D have not been specified in the policy

The Forum is of the view that wording of Note 1 to condition 1.2 as above is

defective and hence the complainant is eligible for anadditional amount of INR

14,048 in settlement of his claim being the proportionate deductions made as

per said condition.








AWARD



the respondent insurer to pay an additional sum of Rs.14,048 to the complainant

along with interest as provided under Rule 17(7) of the Insurance Ombudsman

Rules, 2017.





Ombudsman.





INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERY (UNDER RULE NO: 16 /17 of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr N Sridhar Kumar Vs The New India Assurance Co. Ltd

COMPLAINT REF: NO: CHN-H-049-1920-0495 Award No: I0/CHN/A/HI/0236/2019-2020


Mr N Sridhar Kumar New no 19, Old no 10, 42nd Jagajeevanram Street, GKM Colony,Chennai- 600082


71010034157800000048 New India Asha Kiran Policy and Top up Policy 01/11/2018 to 31/10/2019 INR 5,00,000 + INR 15,00,000


Ms S Maheesha Mr N Sridhar Kumar

4. Name of the Insurer The New India Assurance Co. Ltd



Pre-existing disease(PED)


8. Nature of Complaint Non- Settlement of Claim


07/01/2020


11. Amount paid by Insurer, if any INR 2,17,170 under Asha Kiran Policy


INR 7,42,815


INR 7,42,815


19/12/2019



Rule 13(1)(b)of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 12/02/2010


a) For the Complainant Mr N Sridhar Kumar

b) For the Insurer Mr V Saravanan




The complainant had taken Mediclaim Policy on Floater basis from the respondent

insurer covering himself, spouse and three children for a sum insured of INR 5,00,000

and the period being 01/11/2015 to 31/10/2016 The policy was renewed thereafter for

the same sum insured till 2018. Then it was migrated to Asha Kiran Policy for a sum

insured of INR 5,00,000 covering himself, spouse and his daughter for the period

from 01/11/2018 to 31/10/2019.

The complainant had also taken aTop Up Policy in the year 2015for a sum insured of

INR 5,00,000 for the period from 27/11/2015 to 26/11/2016 and the policy was

continuously renewed with the same sum insured till 2018 and the sum insured was

increased from INR 5,00,000 to INR 15,00,000 in 2018.

The complainant‟s daughter was admitted in Bharathiraja Hospital, Chennai for Renal

transplant from 04/06/2019 to 17/06/2019 and a claim was preferred with the insurer.

The amount claimed was INR 9,75,085, of which an amount of INR 15,100 was not

payable. The insurer settled an amount of INR 2,17,170 under the base policy (Asha

Kiran Policy) being the available sum insured there under and denied the balance

amount of INR 7,42,815 which was claimed under the Top Up policy on the ground of

treatment being for a Pre-existing Disease. The complainant escalated the issue to

the insurer‟s Grievance Department for which there was no reply. Aggrieved by this,

he has approached this Forum for redressal of his grievance.


The complainant had stated that he has been having Mediclaim policy since 2009

with the respondent insurer. His daughter had first consultation on 20/01/2016 and

subsequently had a renal biopsy on 23/01/2016 which revealed features of C3

glomerulopathy and she progressed to end stage renal disease and haemodialysis

was initiated in June 2016.

The insurer had settled claims previously for the same ailment to the tune of INR

17,803 in 2018 and INR 1,08,020 in 2019 under the Top Up policy. Even after the

discharge on 17/06/2019 following current admission, they have settled claims to the

extent of INR 2,14,590 in June and August 2019.

The complainant contended that after settlement of the above mentioned claims by

the insurer, he still had sum insured of more than INR 12,00,000 available under the

Top Up policy at the time of admission of his daughter on 03/06/2019.If only the

previous claims under the Top Up policy were not settled by the insurer, he would

have waited for another six months to complete the 48 months waiting period as this

was the reason for their denial of the claim. Since they paid some claims earlier under

the Top Up policy, he was under the impression that the present hospitalization claim

also would be paid.

The complainant added that after settling all the earlier claims, the insurer suddenly

took a stand to repudiate the claim citing the Pre-existing disease waiting period

clause which had taken him by surprise and caused lot of mental agony.


The insurer stated that the complainant has taken a Top Up policy from 27/11/2015

for a sum insured of INR 5,00,000 and the waiting period for the pre-existing diseases

under the policy is 48 months. Hence any claim for a pre-existing disease will be

eligible for payment under the Top Up policy only after 27/11/2019.

Whereas the complainant stated that the first consultation for the illness leading to

transplant was only in January 2016 (one week before admission in Apollo Hospital),

the investigation and lab reports of the Hospital dated 05/11/2015 and 06/11/2015

clearly show that Azotemia was detected on 05/11/2015 and the insured person was

suffering from renal failure since that date. As per discharge summary of the Hospital,

there was history of symptoms of illness for 6 months before the hospitalization, i.e.

around July 2015.

The insurer had earlier settled claims under the Top Up policy inadvertently to the

tune of INR 3,40,430 without considering the waiting period and requested the

complainant to refund the said amount to them as he was not entitled to receive the

same.

The insurer invoked Clause 4.1 of the Top Up policy which excludes “Treatment of

any pre-existing condition/disease, until 48 months of continuous coverage of

such insured person has elapsed from the date of inception of his/her first top

up policy as mentioned in the schedule‖ and repudiated the claim.






Complainant‟s submission dated 13/02/2020 (post-hearing)




Self- Contained Note (SCN) of Insurer dated 20/01/2020

Policy copy, terms and conditions (Asha Kiran and Top Up)

Indoor Case Papers (ICP) of Apollo Hospital for admission in January 2016

Discharge summary/In-patient Bill of Bharathiraja Hospital, Chennai

Treating doctor‟s certificates dated 07/09/2017 and 16/09/2017

Investigation Report of TPA

Reports of SRS Diagnostic Centre dated 05/01/2016 (3 nos.)

Email correspondence of the complainant with insurer and TPA

24)Result of hearing with both parties (Observations & Conclusion)

The Top-Up Policy was availed by the complainant for the first time on 27/11/2015

with Sum Insured of INR 5 lakhs. Hence insurer is right in taking the stand that any

pre-existing disease shall be covered under said Policy only from 27/11/2019, i.e.

after a waiting period of 4 years, as per clause 4.1 of the Policy. Similarly, the

additional Sum Insured of INR 10 lakhs due to increase in Sum Insured from INR 5

lakhs to INR 15 lakhs from 27/11/2018 shall be available only from 27/11/2022, as

per clause 5.12 of the Policy.

The insurer repudiated the claim on the ground that the insured person had history of

symptoms of illness before six months from 22/01/2016 which was the date of

admission and even the lab reports dated 05/11/2015 and 06/11/2015 showed that

she was suffering from renal failure. Although the treating doctor of Apollo Hospital

certified (vide his certificate dated 07/09/2017) that the date of first consultation was

20/01/2016 and that she had no similar complaints in the past, the ICP of the Hospital

speak to the contrary. As per ICP, the insured person had complaints of foamy

urination, headache and nausea for 6 months, Hypertension for 2 weeks and

Azotemia (elevation of Blood Urea Nitrogen and Creatinine) was detected on

05/11/2015. The discharge summary of Bharathirajaa Hospital, where she underwent

renal transplant also records the history of Systemic Hypertension and Chronic

Kidney Disease since November 2015. The investigation report of the TPA records

the values of various tests carried out on 05/11/2015 and 06/11/2015, although

copies of relevant reports are not produced. These values too establish kidney

disease of the insured person. In a written submission made to the Forum post-

hearing, the complainant put forth the following arguments.

Based on the certificate issued by Dr. B. Subba Rao of the Apollo

Hospital, the complainant reiterated that his daughter‟s kidney disease

was detected only in January 2016 (post inception of the Top Up

Policy).

The repudiation letter of the insurer dated 05/09/2019 was dispatched

only on 28/12/2019 and delivered to him on 30/12/2019. He also

questioned how the repudiation letter was dated 05/09/2019 when he

submitted the diagnostic reports of SRS Diagnostic Centre to the

insurer only on 18/09/2019.

The rejection of the present claim by the insurer under Top Up Policy

after having earlier admitted a few claims under the same Policy, has

placed severe financial burden on him.

As already observed, the certificate dated 07/09/2017 issued by Dr. Subba Rao is in

contradiction of the ICP of Apollo Hospital and hence cannot be relied upon. So far as

the test reports of SRS Diagnostic Centre of 05/01/2016 are concerned, the same are

not the basis for rejection of claim by the insurer. Insurer relied upon the tests of

05/11/2015 and 06/11/2015 and the diagnosis of Azotemia on 05/11/2015 to deny the

claim. No doubt, the respondent insurer acted negligently in honouring the previous

claims under the Top Up Policy. However, they cannot be stopped from denying the

present claim on that ground.

The medical records conclusively establish that the illness (Chronic Kidney Disease)

of the insured person was detected before inception of the Top up Policy under which

the claim had been preferred. Therefore this Forum is of the view that the repudiation

by the insurer on the grounds of pre existing disease is in order. Howeverthe Forum

places on record its dissatisfaction over the negligent manner in which the previous

claims were settled. The Forum also deeply regrets the lack of response of insurer to

representation made by the complainant.

AWARD


by both the parties during the course of hearing, the Forum is of the view that the

repudiation of the claim by the insurer is in order and does not warrant any intervention

by this Forum.

Thus the complaint is NotAllowed

.



insurer.



INSURANCE OMBUDSMAN



OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. O A Dinesh Kumar Vs Reliance General Insurance Company Limited

COMPLAINT REF: NO: CHN-H-035-1920-0482 Award No: IO/CHN/A/HI/ /2019-2020


Mr. O A Dinesh Kumar, No.32/38, Narasinga Perumal Koil Street, F3 – 1st Floor, Choolai, Chennai 600 112.

2.

Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

120121728280000661 Reliance Health Gain Policy – Plan A 08.01.2018 to 07.01.2020 INR 3,00,000


Mr. O A Dinesh Kumar Mr. O A Dinesh Kumar

4. Name of the Insurer Reliance General Insurance Company Limited

5. Date of Short Settlement 28.05.2018

6. Reason for Short settlement Due to exhaustion of Sum Insured




06.01.2020


11. Amount paid by Insurer, if any INR 2,750 (on cashless basis)


INR 9,25,924


INR 8,37,524


17.12.2019





a) For the Complainant Mr. O A Dinesh Kumar

b) For the Insurer Dr. Harikrishnan




The complainant was covered under Reliance Health-Wise Policy – Gold Plan issued

by the Respondent Insurer (RI) from 08.01.2016 to 07.01.2017 for a Sum Insured (SI)

of INR 1 lakh. The insurance was continuous from 08.01.2007. For the period

08.01.2017 to 07.01.2018, the insurance was ported to Reliance Health Gain Policy –

Plan A of the RI for an enhanced SI of INR 3 lakhs. The Health Gain policy was

further renewed for a period of two years from 08.01.2018 to 07.01.2020, for the

same SI of INR 3 lakhs.

As per Discharge Summary, the complainant was admitted on 29.05.2018 in Apollo

Hospitals with the chief complaint of Chronic Kidney Disease Stage 5 D and on

dialysis since October 2016. He is diabetic and hypertensive for the past 18 years. He

underwent Spousal Renal Transplant on 30.05.2018and was discharged on

06.06.2018.

Post discharge, he submitted a reimbursement claim of INR 9,25,924 to the insureron

21.06.2018. The insurer vide their letter dated 19.07.2018advised him that the claim

was under a policy with portable Sum Insured of INR 1,00,000 which was already

exhausted and hence the subject claim was not payable.

He represented to the insurer vide his letter dated 11.02.2019 to reconsider his claim

and the insurer replied to him on 13.02.2019 that since his chronic kidney disease

was prior to his roll-over to Health Gain policy in 2017, portability limit is applicable as

per clause 3.2.3 of the policy. Not satisfied with the response of the insurer, the

complainant has approached this Forum vide his letter dated 25.11.2019 for redressal

of his grievance.


The complainant submits that he was treated for chronic kidney disease Stage

5 since October 2016 and was on dialysis since April 2017.

He was admitted to Apollo Hospitals, Chennai on 29.05.2018for renal

transplantation along with his wife and donor Mrs. O D Shanthi. He underwent

transplantation on 30.05.2018 and was discharged on06.06.2018.

He also underwent for Flexible Cystoscopy + DJ stent removal on 02.07.2018.

Pre-authorisation request for INR 8 lakhs was submitted on 21.05.2018 for

renal transplantation undergone and the same was approved for only INR

2,750 on 28.05.2018.

His reimbursement claim of INR 9,25,924 submitted after discharge was

rejected by the insurer.

His representation to the Customer Care of the insurer is not responded to till

date.

He has requested the Forum to direct the insurer to settle his claim.


The insurer have submitted their SCN dated 12.02.2020.

They contend that the complaint is false, unfounded and is not sustainable.

The complainant has not disclosed the facts and has not provided all

necessary documents/information.

The complainant was explained the features of the policy and only after

understanding the same, he has opted for the Health Gain Plan.

They also submit that earlier multiple claims were approved by them and the

present claim is under policy with portability SI limited to INR 1 lakh.

As per Insurer‟s letter dated 13.02.2019 in reply to the representation of the

complainant, the previous settlements are as detailed below:

Claim No. 201180024433 - INR 88,400

Claim No. 201180017662 - INR 8,850

Claim No. 201180041182 - INR 2,750 (cashless approval)

Since the portable SI of INR 1 lakh got exhausted under the policy due to

payment of the aforesaid claims, the reimbursement claim was not payable

and hence repudiated.

They requested the Forum to dismiss the complaint against them in the

interest of justice.






Request for pre-authorisation dated 21.08.2018

Cashless authorisation letter of the Insurer dated 28.05.2018

Reimbursement Claim form dated 21.06.2018

Reimbursement Claim repudiation letter dated 19.07.2018

Complainant‟s representations dated 03.09.2018, 06.03.2019and 16.06.2019

to the Insurer

Insurer‟s letter dated 13.02.2019 to the Complainant



Terms and conditions of Health Gain Policy

Health Gain Policy Schedule for the period 08.01.2017 to 07.01.2018

Health Gain Policy Schedule for the period 08.01.2018 to 07.01.2020

Health Wise Policy Schedule for the period 08.01.2016 to 07.01.2017

Proposal form for Health Gain Policy - Gold Plan for the period 08.01.2017 to

07.01.2018

Discharge Summaries/Bills of Apollo Hospital, Chennai

Certificate of Dr.Rajeev A Annigeri of Apollo Hospital dated 28.05.2018

advising admission

Mail correspondence of the complainant with the Insurer

Claim settlement details submitted by the RI

Insurer‟s email dated 25.02.2020


The Complainant Mr. O A Dinesh Kumar and Dr. Harikrishnan and Ms. R

Sangeetha, Insurer‟s representatives attended the hearing.

The complainant submitted that he is a policyholder of the RI since 2007 and

the Health Wise policy he was holding with them was migrated to Health Gain

policy during 2017-18 with enhanced SI of INR 3 lakhs. However, his claim

during the policy period of 2018-20 was short settled on the ground that the

ported SI of INR 1 lakh was exhausted.

The insurer‟s representative stated that Cumulative Bonus was not taken into

consideration while arriving at settlement and that the complainant is not

eligible for Reinstatement of SI benefit. They also clarified that the Donor

expenses are payable only as part of Base SI and not in addition to the same.

During the hearing the RI was directed to specify the exact clause under which

the indemnity was restricted by them to INR 1 lakh, while the SI under the

policy is INR 3 lakhs. They have responded vide their mail dated 25.02.2020

that in the present year i.e. 2018-2020, the patient was admitted for Post LRRT

claim for Renal Transplant complication. As per Clause 3.2.2 sub clause „e‟ the

present ailment falls under pre-existing category as it was present prior to

porting of policy from Health Wise to Health Gain. As policy is a portable

policy, they have restricted to portability SI of INR 1 lakh and there is no

cumulative bonus in Health Wise policy.

As per Clause 3.2.2 „e‟ “Waiting Periods shall apply afresh to the amount

which is equal to the difference between the Base Sum Insured opted with the

Company and the expiring policy sum insured as mentioned in the schedule”.

The insurer rejected the claim vide their letter dated 19.07.2018 on the ground

that the claim was under a policy with Portable Sum Insured of INR 1 lakh and

the Sum Insured was already exhausted due to settlement of previous claims.

However, it is noted that the relevant policy schedule for the period 2018-2020

does not show any Sum Insured limit for Portability. On the contrary, the

schedule of the policy for the previous period 2017-18, which is the first Health

Gain Policy, shows a limit of INR 1 lakh for portability. Strangely and

inexplicably, the insurer settled the claims of the complainant up to the Base

Sum Insured of INR 3 lakhs under said policy, while invoking the non-existent

portable limit for policy period 2018-2020.

In response to the representation made by the complainant against repudiation

of the claim, the insurer advised that his current disease was pre-existing at

the time of roll-over to Health Gain policy and hence portability was applicable

as per clause 3.2.3 of the policy. In the opinion of the Forum, 3.2.3 was a

wrong clause to be invoked for rejection of the claim, since it only specifies that

the waiting periods under the policy shall be applicable individually for each

insured person.

As mentioned earlier, subsequent to the hearing the insurer clarified to the

Forum that the disease suffered by the complainant was pre-existing to the

first Health Gain policy and hence the waiting periods shall apply afresh as per

clause 3.2.2 – e. It is observed that the complainant is continuously insured

since 08.01.2007 with the insurer for a period exceeding 12 years. Hence the

stand taken by the insurer that the disease was pre-existing is in contravention

of clause 3.2.1 which prescribes that the waiting periods under the policy shall

be reduced by the number of years of continuous coverage. So far as clause

3.2.2 – e is concerned, the same provides that the waiting periods shall apply

afresh to the amount which is equal to the difference between the Base Sum

Insured and the expiring policy Sum Insured. First of all, the waiting periods

relate to specified diseases (clause 3.1.2) and pre-existing diseases (3.1.3)

and the disease suffered by the complainant was neither pre-existing nor one

of the specified diseases. Secondly, the Base Sum Insured was INR 3 lakhs

under the current policy for 2018-2020 as well as under the expiring policy for

2018-2019 and hence there is no difference in Sum Insured to which the

waiting period will apply afresh. Hence the stand taken by the insurer post-

hearing is also not in order.

It is noted that the RI took not only inconsistent, but wrong stands to reject the

claim. If their intention is to subject any enhancement of Sum Insured under

the policy to a fresh waiting period, the same is not spelt out in the policy

wording.

For the reasons cited above, the Forum concludes that the complainant is

eligible for the Base Sum Insured of INR 3 lakhs for the policy period 2018-

2020. Since an amount of INR 1 lakh is already settled, he is entitled to

payment of the remaining amount of INR 2 lakhs towards the subject claim.

He will also be eligible for the Benefit of Reinstatement of Base Sum Insured

as per Benefit no. 8 of the policy, since the Base Sum Insured will be

exhausted on payment of INR 2 lakhs. However, the reinstated Sum Insured

shall be available only for subsequent claims, if any, under the subject policy.

The Forum holds that the complainant is not eligible for Cumulative Bonus, in

view of settlement of claims under the expiring policy, although the copy of

policy schedule submitted by the insurer to the Forum wrongly showed that he

was eligible for a Cumulative Bonus of INR 1 lakh. Incidentally, the policy

issued to the complainant does not show the Bonus and rightly so.

The Forum records its displeasure over the delay of one month in submission

of SCN by the insurer. Similarly the lack of response to the representations

made by the complainant is a matter of concern. It is hoped that the insurer will

strengthen its customer grievance redressal mechanism and avoid such

lapses in future.







complainant shall be entitled to such interest at a rate per annum as specified in

the regulations, framed under the Insurance Regulatory and Development



Ombudsman.



Dated at Chennai on this 27th day of March2020.


INSURANCE OMBUDSMAN


AWARD



the respondent insurer to pay an additional sum of INR 2 lakhs to the

complainant towards full and final settlement of the claim along with interest as

provided under Rule 17(7) of the Insurance Ombudsman Rules, 2017.



OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. F. Wilson Vs Star Health and Allied Insurance Company Limited



Mr. F Wilson, Plot No. 25, 1st Main Road, Thanigaivel Nagar, Thiruninravur, Trivellore – 602 024.

2.


P/111113/01/2020/013597 Senior Citizens Red Carpet Health Insurance Policy

22.10.2019 to 21.10.2020 INR 4 lakhs


Mrs. Rani Aarokiyameri Francis Mr. F Wilson



6. Reason for repudiation Non - disclosure and Pre-existing Disease (PED)


8. Nature of Complaint Rejection of cashless request and cancellation of policy


07.01.2020




Not furnished


Not furnished


19.12.2019





a) For the Complainant Mr. F Wilson

b) For the Insurer Dr. Asiya Sahima and Mrs. M Hemalatha




The complainant has covered his mother Mrs. Rani Arokiyamary Francis under

Senior Citizens Red Carpet Health Insurance Policy issued by the respondent insurer

(RI) for a Sum Insured (SI) of INR 5 lakhs, since 22.10.2017.

As per Discharge Summary, she was admitted in Sri Ramachandra Medical Centre

on 11.10.2019 with complaints of recent history of fall and new onset of slurred

speech. She was a known case of Parkinson disease for the previous one year and

was diagnosed with Parkinson Disease, Type 2 Diabetes Mellitus and Right Hip Soft

Tissue Contusion. During hospitalisation she was subjected to many baseline

investigations and was treated. Her discharge from the hospital was on 15.10.2019.

The cashless request for her treatment was rejected by the insurer on the ground that

as per consultation paper dated 28.08.2019 of Dr. U Meenakshisundaram, she has

been suffering from Parkinsonism for the previous four years, which means the

disease was existing even prior to inception of the first policy and the same was not

disclosed in the proposal form.

He represented to the Grievance Department of the insurer vide his mail dated

06.11.2019 stating that his mother was suffering from Parkinson disease only for the

past one year. However, the insurer rejected the representation reiterating that

Parkinsonism was a pre-existing disease (PED) which was not disclosed at the time

of taking the first policy. The also cancelled the policy vide Endorsement No.

P/111113/01/2020/ 013597/001 dated 15.11.2019 on the ground of non-disclosure of

Pre-Existing Disease (PED) – Parkinsonism, after serving one month‟s notice.

Aggrieved by the insurer‟s response and action, he has approached this Forum for

redressal of his grievance.


The complainant, vide his letter dated 05.12.2019 stated that his mother is

covered with Star Health Insurance since October 2017.

His request for cashless facility for her treatment was rejected on the ground

of PED and non-disclosure.

His mother is taking treatment for Parkinson disease as advised by Dr. N.

Murugapandian, only since June 2018.

Dr. Meenakshisundaram in his prescription dated 28.08.2019 has wrongly

stated that she is suffering from Parkinson disease for the past four years.

He has therefore sought the support of the Forum for settlement of the claim.


The insurer submitted their SCN vide letter dated 31.01.2020.

The Complainant declared vide his mail dated 25.04.2018 to the insurer, that

his mother is “Taking Tablet in the morning for sugar control – Tablet name:

GLIMETRA”. Based on the above, Diabetes Mellitus and its complications

were included as PED in the next renewal.

The claim is reported in the second year of the policy and pre-auth request for

INR 50,000 was submitted for approval.

As per the prescription dated 28.08.2019 of Dr. U Meenakshisundaram, Arunai

Neuro Centre, the insured was suffering from Parkinson‟s disease for the past

4 years.

It is observed that the insured is a known case of Parkinsonism prior to the

inception of the policy which fact was not disclosed in the proposal amounting

to non-disclosure of material facts. Hence the cashless request was rejected.

For the query in the proposal, “Have you or any member of your family

proposed to be insured, suffered or are suffering from any

disease/ailment/adverse medical condition of any kind especially Heart /

Stroke / Cancer / Renal disorder / Alzheimer‟s disease / Parkinson‟s disease”,

the proposer replied in negative.

Thus, at the time of commencement of the first year policy, the complainant did

not disclose the medical history/health details of the insured which amounts to

misrepresentation / non-disclosure of material facts and as per Condition No.9

of the policy, “if there is any misrepresentation/non-disclosure of material facts

whether by the insured person or any other person acting on his behalf, the

Company is not liable to make any payment in respect of any claim”. Hence

the claim was repudiated.

The details of insured‟s past medical history help the insurer to evaluate the

material facts and to decide whether to accept the proposal or not. As per

Condition No. 13 of the policy, “the company may cancel this policy on

grounds of misrepresentation, fraud, moral hazard, non-disclosure of material

fact as declared in the proposal form /at the time of claim or non-co-operation

of the insured person”. Accordingly, the policy was cancelled with effect from

23.11.2019 after sending 30 days notice due to non-disclosure of PED –

Parkinsonism. Premium of INR 21,240 was refunded to the insured.

Post cashless rejection, the insured has not approached the insurer for any

reimbursement claim.

For the above reasons, the insurer requested the Forum to dismiss the

complaint.


Ombudsman Rules, 2017, which relates to “Any partial or total repudiation of claims




Request for cashless hospitalisation

Cashless rejection letter of the Insurer dated 14.10.2019

Notice for cancellation of policy dated 14.10.2019

Endorsement dated 15.11.2019 for cancellation of policy





Field Visit Report of the insurer


Record of Consultation with Dr. U Meenakshisundaram, MD, DM, Arunai

Neuro Centre, dated 28.08.2019

Record of consultation with Dr. N. Murugapandian dated 13.06.2018,

01.08.2018, 20.10.2018, 31.10.2018 and 30.01.2019

Record of consultation with Dr. T. Vijay dated 10.05.2019, 21.05.2019 and

12.07.2019

MRI report dated 12.06.2018

Proposal form (summary of information provided online)

Discharge summary/Bills of Sri Ramachandra Medical Centre


Mr. Wilson, Complainant, Dr. Asiya Sahima and Mrs. M. Hemalatha, Insurer‟s

representatives attended the hearing.




During the hearing the complainant submitted that he took the policy in 2017.

His mother had an incidence of fall in June 2018 and at that time MRI was

taken when it was revealed that she was suffering from Parkinson disease.

He had consulted three doctors and one of them Dr. Meenakshisundaram had

mentioned the duration of the disease as 4 years. He had also approached the

doctor for correction of the duration, for which the latter was unwilling. He

hassubmitted that he was never aware of the disease prior to June 2018 and

Dr. Murugapandian was the first to diagnose his mother‟s Parkinson disease.

The consultation record dated 13.06.2018 wherein the doctor concerned has

recorded the findings of MRI and the diagnosis of DM (Diabetes Mellitus) and

IPD (Idiopathic Parkinson‟s Disease) substantiates the contention of the

complainant.

The respondent insurer contended that they relied on the prescription given by

Dr. Meenakshisundaram to reject the claim.

As per discharge summary of Sri Ramachandra Medical Centre as also their

letter dated 12/10/2019, the insured was suffering from Parkinson‟s disease

for only 1 year.

During the hearing the insurer were advised to submit evidence of sending

proposal form to the complainant, since the same was completed online. They

have replied by mail on 24.02.2020 stating that the proposal form, policy

schedule and policy terms were sent to the registered mail

id [email protected] of the insured and the same is authenticated

through OTP at 2017-10-21 11:40:26.0

It is observed that the proposal was completed online and the proposal form

along with policy schedule and terms are sent to the registered mail id of the

proposer, authenticated through OTP. The RI was advised to demonstrate the

above process live.

The RI along with their IT team were present on 04.03.2020 and gave a live

demonstration when it was observed that any proposal opted through online

system is forwarded to the proposer along with the policy copy.

The insurer has rejected the claim both on the grounds of PED as well asnon-

disclosure of material fact. Forum is of the view that except for the noting made

by Dr. Meenakshisundaram, there is no evidence to prove that the insured was

suffering from Parkinson‟s disease for 4 years. Insurer has not produced any

evidence of treatment for said disease prior to policy inception, whereas

complainant has submitted prescriptions and consultation papers, in support of

his submission that the diagnosis was in June 2018. Also, as per discharge

summary of the treating hospital, the duration of the disease was only one

year. Hence, Forum concludes that the benefit of doubt should go to the

complainant and the complaint is upheld.

The complainant has not indicated the monetary relief sought from the Forum

in the Annexure VI A submitted by him. Nevertheless, it is noted from the In-

patient Bill of Sri Ramachandra Hospital that an amount of INR 47,486 was

incurred towards the hospitalisation of the insured. The said amount is

considered to be the claim of the complainant for the purpose of this award.

AWARD

Taking into account the facts & circumstances of the case and the

submissions made by both the parties during the course of hearing, the Forum

is of the view that the repudiation of the claim by the insurer is not in order

and the insurer is directed to settle the claim of the complainant for an amount

of Rs. 47,486, subject to the terms and conditions of the policy along with

interest as applicable under Rule 17(7) of the Insurance Ombudsman Rules,

2017. The policy may also be reinstated with continuity benefit.

Thus, the complaint is Allowed.


InsuranceOmbudsman Rules, 2017:












Dated at Chennai on this 31st day of March 2020.

(M. Vasantha Krishna)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mr. P Gopalakrishnan VsThe Oriental Insurance Co. Ltd




Mr. P Gopalakrishnan No.43, 5th Cross Street, Thirumagalnagar, Velrampet, Pondicherry 605004


411500/48/2017/821 PNB Oriental Royal Mediclaim Policy 22/04/2017-21/04/2018 INR 5,00,000

3. Name of the insured Name of the policyholder/proposer

Mrs. G Kanagamani Mr. P Gopalakrishnan

4. Name of the insurer The Oriental Insurance Co. Ltd 5. Date of Repudiation 22/02/2018

6. Reason for Repudiation Hospitalization was primarily for evaluation

7. Date of receipt of the Complaint 03/11/2018 8. Nature of complaint Non-settlement of claim

9. Date of receipt of consent (Annexure VIA)

26/12/2019


11.

Amount of Monetary Loss (as per Annexure VIA)

Not furnished



INR 31,437


12/12/2019







b) For the insurer Mr. B. Sounderrajan




Complainant‟s spouse Mrs. G Kanagamani, covered under respondent insurer‟s PNB

Oriental Royal Mediclaim Policy, was admitted in St. John‟s Medical College Hospital,

Bangalore on 16/10/2017 with complaints of headache for 6 days and memory loss

for 5 minutes following physical activity. Reimbursement claim preferred for the above

hospitalization was repudiated by the insurer on the ground that the hospitalization

was primarily for evaluation and not followed by active treatment. Aggrieved by the

repudiation of the claim, complainant escalated the matter to Grievance Dept. of the

insurer. Since there is no reply from them, he has approached this Forum for relief.

21) a) Complainant’s submission:

Complainant‟s spouse was admitted in the hospital for personal observation on

16/10/2017 as per advice of Dr. Thomas Mathew of Neurology Department of St.

John‟s Hospital, consequent to her loss of memory for 5 minutes. During

hospitalization she was examined and given treatment for 3 days in accordance with

the medication record and was discharged on 18/10/2017. At the time of discharge,

she was prescribed two more drugs namely T. Meconerv 1500 mcg and T. Famocid

20 in addition to the drugs already taken. She continues to be on T Eritel LN 40 and

Ecosporin AV. The complainant submits that his wife is better after taking medicines.

Hence her hospitalization was not only for diagnosis but also for treatment. Therefore,

Forum‟s intervention is requested for settlement of the claim.


Complainant has been covered with the insurer along with his wife under PNB

Oriental Royal Mediclaim Policy since 21/04/2015 and the current policy period is

22/04/2017 to 21/04/2018. He preferred a claim for hospitalization of his wife with the

diagnosis of TIA (Transient Ischemic Attack) and Hypertension. On scrutiny of the

claim papers submitted, it was observed that the insured patient had undergone only

laboratory tests during her hospitalization. Her admission was primarily for evaluation

and there was no active line of treatment. Hence the claim was repudiated as per

exclusion clause 4.9 of the policy which reads as under:

“The Company shall not be liable to make any payment under this policy in respect of

any expenses whatsoever incurred by any Insured Person in connection with or in

respect of:

Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic

purposes which is not followed by active treatment for the ailment during the

hospitalised period.”






Claim repudiation letter of the insurer dated 22/02/2018

Complainant‟s representations dated 10/12/2018 to the Insurer



Copy of PNB-Oriental Royal Mediclaim policy with terms and conditions

Discharge summary/Bill of St. John‟s Medical College Hospital, Bangalore

Expert Medical opinion of Dr Mahesh, BRS Hospital, Chennai


a) The Forum records its displeasure over the lack of response to the

representations made by the complainant. It is hoped that the insurer will strengthen

its customer grievance redressal mechanism and avoid such lapses in future.

b) Claim was repudiated on the ground that the hospitalization was primarily for

evaluation and not followed by active treatment for the ailment during the hospitalized

period, as per exclusion 4.10 of the policy. Forum observes that the relevant clause

no. is 4.9 and not 4.10. However, the contents of the clause have been correctly

quoted in the letter of repudiation.

c) As per discharge summary, complainant‟s spouse was admitted with

complaints of headache and memory loss for 5 minutes following physical activity.

Diagnosis was HTN & TIA besides suspected TGA (Transient Global Amnesia). All

the tests conducted were found to be normal.

d) During hospitalization, insured patient was treated with anti-hypertensive tablet

(T Eritel LN 40) and vitamin injection (Vitneurin).

e) The Forum obtained expert opinion from Dr Mahesh, of BRS Hospital. In his

opinion, the patient who is 69 years old was admitted with history of headache and

transient memory impairment. Any patient with such complaints will be evaluated and

then only treated. Her provisional diagnosis was transient global amnesia and she

was treated with antiplatelet drug. Hence the admission was for diagnosis and

treatment.

f) In view of the above, repudiation of claim by the Insurer on the ground that the

treatment was for diagnosis purposes and that there was no active line of treatment is

not justified.

AWARD


made during the course of hearing, Forum concludes that repudiation of the claim by

insurer is not in order and insurer is directed to settle the claim of the complainant for

INR 31,437 subject to other terms and conditions of the Policy, along with interest at

applicable rate as provided under Rule 17 (7) of the Insurance Ombudsman Rules,

2017.

Thus, the complaint is Allowed




shall comply with the award within thirty days of the receipt of the award and intimate

compliance of the same to the Ombudsman


complainant shall be entitled to such interest at a rate per annum as specified in the

regulations, framed under the Insurance Regulatory and Development Authority of

India Act, 1999, from the date the claim ought to have been settled under the

regulations, till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of

Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on this 31st day of March 2020


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mr. P Prabhu Vs The Oriental Insurance Co. Ltd




Mr. P Prabhu Old No. 5/160, New No. 1/454, NGGO Colony, Rangaswamy Naidu Street, Asokapuram, Coimbatore 641022


451102/48/2019/943 Happy Family Floater 2015 Policy 31/07/2018-30/07/2019 INR 2,00,000


Mrs. P Nirmala Mr. P Prabhu

4. Name of the insurer The Oriental Insurance Co. Ltd


6. Reason for Repudiation Four year waiting period clause

7. Date of receipt of the Complaint 12/12/2019 8. Nature of complaint Non-settlement of claim

9 Date of receipt of consent (Annexure VIA)

06/01/2020

10 Amount of Claim INR 2,55,694

11


Not furnished



INR 2,00,000


26/12/2019






a) For the Complainant Mr. K K Palaniswamy (Father)

b) For the insurer Mr. Ganesh Shankar




Complainant‟s mother, Mrs. P Nirmala, covered under respondent insurer‟s Happy

Family Floater Policy,was admitted in Kovai Medical Center and Hospital, Coimbatore

on 15/07/2019 in the fourth year of the policy and had undergone Total Knee

Replacement (TKR) for treatment of left knee Osteo Arthritis (OA) Grade 4 and

Rheumatoid Arthritis (RA). Reimbursement claim of INR 2,55,694 preferred by the

complainant for the cost of treatment was repudiated by insurer on the ground that

the treatment undergone being TKR for OA, Grade 4 falls under 4 year waiting period

clause whereas the policy was in its fourth year at the time of the procedure.

Aggrieved by the repudiation, complainant represented to insurer stating that the

claim is for RA not for OA falling under 4-year exclusion. Since there is no reply from

them, he has approached this Forum for relief.


Claim is for treatment of RA as evidenced by the diagnosis in the discharge summary

of PSG Hospitals dated 22/02/2019, which was 4 months prior to current

hospitalization. Treating doctor S G Thirumalaisamy has also confirmed vide his

certificate dated 23/09/2019 that TKR undergone was due to RA of 2 years duration.

Complainant became aware of the clause 4.3 (waiting period clause) only through

TPA‟s communication dated 22/10/2019, since complainant has not been provided

with detailed terms and conditions of the policy. Had insurer provided the same,

complainant could have waited for 4 years to pass, before undertaking the surgery.

In view of above, claim is payable and Forum‟s intervention is requested for

settlement of the same.


Subject Policy incepted on 31/07/2015 and the Complainant‟s mother underwent TKR

for treatment of OA of Grade 4 which is subject to 4-year waiting period clause

(clause no. 4.3), in the fourth year of the policy. Since the complainant contended that

the treatment was for RA and not for OA by producing the discharge summary of

PSG Hospitals, opinion was sought from Chief Medical Officer (CMO) of the TPA and

he noted that the insured patient was hemodynamically stable and systemic review

revealed no positive findings. She had an antalgic gait with swelling of left knee,

Varus deformity with medial joint tenderness, Crepitus and 15-degree fixed flexion

deformity. All these clinical findings are consistent with Osteo Arthritis. Operative

notes recorded grade 4 changes of OA. There was no mention in the operative notes

about Synovitis or synovial thickening with cartilage and bone destruction as in the

case of RA. He further concluded that OA appears to be the predominant and

longstanding problem for which TKR was required. Hence, the claim was repudiated

under the 4-year waiting period clause no. 4.3.

22) Reason for Registration of Complaint: - Rule 13(1)(b)of the Insurance







TPA‟s response dated 19/10/2019



Copy of Happy Family Floater Policy – 2015 with terms and conditions

Discharge summary of Kovai Medical Center & Hospital, Coimbatore

Discharge summary of PSG Hospitals, Coimbatore

Treating doctor‟s certificates dated 12/08/2019, 23/09/2019 & 17/02/2020

Opinion dated 17/10/2019 of Dr. G. Sunavala, CMO of the TPA

Expert Medical Opinion of Dr Nalli Gopinath, Ortho Surgeon, BRS Hospital


On the basis of documents placed before it and the submissions by the parties, the

Forum observes as below.

Exclusion clause no. 4.3 (relevant portion) of the policy reads as below.

“The expenses on treatment of following ailments / diseases / surgeries, if

contracted and / or manifested after inception of first Policy (subject to

continuity being maintained),are not payable during the waiting period

specified below.

It may therefore be noted that the waiting period of 4 years applies not only to

treatment for age related Osteo Arthritis (OA) but also for joint replacement

due to degenerative condition.

The insurer repudiated the claim vide their letter dated 12/09/2019 on the

ground that the insured underwent total knee replacement and since there is a

4-year waiting period for joint replacement, the claim is not admissible.

The complainant contended that TKR was performed for RA which is an auto

immune deficiency and does not come within the purview of clause 4.3 as

above.In support of his contention he has submitted discharge summary of

PSG Hospital in respect of the treatment taken some 4 months prior to

patient‟s hospitalizationfor TKR, wherein the final diagnosis was RA. He has

also submitted treating doctor‟s certificate dated 23/09/2019 stating that the

surgery was performed due to RA. However, this certificate is at variance with

the discharge summary which suggests that TKR was performed due to

severe OA Grade 4.

TPA, while replying to complainant‟s representation made the observation that

operation notes recorded grade 4 OA changes. Synovitis or synovial

thickenings with cartilage and bone destruction which are the characteristic

Sl.No Ailment / Disease / Surgery Waiting Period

xxiii Joint replacement due to Degenerative Condition

4 years

xxiv Age related Osteoarthritis and Osteoporosis

4 Years

changes in RA were not recorded in the operation notes.The complainant

submitted yet another certificate dated 17/02/2020 of the treating doctor at the

time of hearing, in which the doctor confirmed that intra-operative findings

were Synovitis, erosion and severe arthritis with cartilage loss, which may or

may not have been recorded in notes. The purpose of the certificate seems to

be to counter the observation made by the TPA that said symptoms/ findings

which substantiate RA were not mentioned in the operative notes.

The treating doctor has stated vide his certificate dated 12/08/2019 that the

duration of OA as well as RA was 2 years. However, for the purpose of

applying the waiting period under clause 4.3, the duration of the illness and

whether it was pre-existing or not, is not of any relevance.

The Forum obtained expert medical opinion from Dr Nalli Gopinath, Ortho

Surgeon, BRS Hospital, Chennai. As per his opinion, the patient is a known

case of OA and RA. Flares or exacerbation of symptoms and degeneration

/cartilage damage/erosion are common in inflammatory arthritis like RA.

Patient had acute exacerbation of RA on 21.02.2019 at PSG Hospital. An

aggravation or increase of degeneration takes place in a flare of RA and

degeneration damage is rapid in RA. Patient had RA factor-Positive, ESR and

CRP elevated as in RA when investigated. Clinically patient had antalgic gait,

deformity and 15-degree fixed flexion deformity indicating severity. Hence, he

concluded it to be a case of RA.

It is significant to note that while the doctor who has given the opinion has

confirmed that insured had RA, he has also commented that the said disease

causes rapid degeneration. Similarly, the treating doctor has also not denied

that RA causes degenerative conditions, in the certificates issued by him.

Hence it is very clear that both OA and RA cause degeneration and the

present case falls under exclusion 4.3 (xxiii), since insured underwent TKR

due to degeneration caused by RA. The insurer too repudiated the claim on

the ground of waiting period for joint replacement and not citing OA or

Osteoporosis as per exclusion clause 4.3 (xxiv).

The complainant claimed in his representation to the Forum that he was never

provided the terms and conditions of the policy and hence he was not aware of

the same. The policy schedule states that the insurance under the policy is

„subject to conditions, clauses, warranties, endorsements as per forms

attached‟. If the forms were not attached as claimed by the complainant,

nothing prevented him from asking the insurer to send him the same. Forum is

of the view that he cannot take the plea of non-receipt of terms and conditions

4 years after taking the policy and post insurer‟s decision to reject the claim.

In view of the above the repudiation of claim by the insurer on the ground that

the treatment was joint replacement due to degenerative conditions which has

a waiting period of 4 years is justified.

AWARD

Taking into account the facts & circumstances of the case and the

submissions made during the course of hearing, Forum concludes that

repudiation of the claim by insurer is in order and does not warrant any

intervention by the Forum.

Thus, the complaint is not allowed

25. If the decision of the Forum is not acceptable to the Complainant, he is at

liberty to approach any other Forum/Court as per laws of the land against the

respondent insurer.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mrs R Navarathinam Vs Star Health and Allied Insurance Co. Ltd




Mrs. R Navarathinam No. 17/1, Venkatachalapathy Nagar, Melakkal Road, Madurai 625019


P/111113/01/2020/008948 Senior Citizens Red Carpet Policy 03/09/2019-02/09/2020 INR 5,00,000

3. Name of the insured Name of the policyholder/proposer

Mrs. R Navarathinam Mrs. R Navarathinam

4. Name of the insurer Star Health and Allied Insurance Co.

Ltd

5. Date of Repudiation 14/10/2019 (Cashless rejection)


Non-disclosure of Pre-existing disease(PED)


8. Nature of complaint Non-settlement of claim

9 Date of receipt of consent ( Annexure VI A)

23/01/2020

10 Amount of Claim INR 14,350

11

Amount of Monetary Loss (as per Annexure VI A)

INR 66,830



INR 24,350


09/01/2020



Rule no. 13(1)(b) of the Insurance Ombudsman Rules, 2017



a) For the Complainant Mrs. R Navarathinam

b) For the insurer Dr. Asiya Sahima

18. Disposal of complaint By Award



Complainant has availed respondent insurer‟s Senior Citizens Red Carpet Health

Insurance policy on 02/09/2017 and has been renewing it continuously and the

current policy period is 02/09/2019 to 01/09/2020 with Sum Insured of INR 5 lacs.

Chettinad Super Speciality Hospital, Chennai raised a request for cashless

authorization for the complainant‟s admission in the hospital on 14/10/2019 for

undergoing Coronary Angiogram. Insurer rejected the request since the treatment

was for a pre-existing disease (PED) and the complainant didn‟t disclose the same in

the proposal form. Subsequently insurer also cancelled the policy on the basis of the

alleged non-disclosure. Aggrieved by the rejection of cashless request as well as

cancellation of the policy, complainant sent several E Mails to the Grievance

Department of the insurer stating that there was no non-disclosure and all PEDs

were disclosed at the time of proposal. But insurer still maintained their earlier stand

of rejection of claim and cancellation of policy. Therefore, complainant has


21.a) Complainant’s submission:

Even before issuance of the policy, insurer was appraised about the surgery, the

complainant had undergone for breast malignancy in 1994 as well as treatment of

heart disease with fitting of 2 stents in February 2013. This has been acknowledged

by Mr. P Mukesh Kumar (of MPN Capital, the intermediary firm) vide his E Mail dated

01/09/2017. Hence there was no suppression of information regarding PEDs and

insurer‟s action of rejecting the claim and cancellation of the policy is unjustified.

Complainant has been continuously covered under medical insurance since 2017.

Since PEDs are covered after 12 months of coverage, claim is payable and Forum‟s

intervention is requested for settlement of the claim besides reinstatement of the

policy.


Complainant is a known case of (k/c/o) heart disease prior to the commencement of

the policy as evidenced by the pre-authorization form wherein it has been stated that

complainant is a k/c/o of CAD (Coronary Artery Disease) and undergone PTCA

(Percutaneous Transluminal Coronary Angioplasty) in 2013. In the initial assessment

sheet of the doctor too it has been mentioned that she is a k/c/o CAD, had undergone

PTCA on 19/02/2013 and was on regular medication. Thus, it has been proved that

CAD was pre-existing as the policy first incepted on 02/09/2017.

For the query in the proposal, “Have you or any member of your family proposed to

be insured, suffered or are suffering from any disease/ailment/adverse medical

condition of any kind especially Heart/Stroke/ Cancer/ Renal disorder/ Alzheimer‟s

disease/ Parkinson‟s disease”, the proposer replied in negative and thus it is clearly a

case of non-disclosure of material fact making the contract voidable as confirmed by

the Supreme Court in the case of Satwant Kaur Sandhu vs New India Assurance Co.

Ltd. (2009) 8 SCC 316 (citation).

As per condition no. 6 of the policy, “If there is any misrepresentation/non-disclosure

of material facts whether by the insured person or any other person acting on his

behalf, the Company is not liable to make any payment in respect of any claim.”

Hence the claim is not payable under condition no. 6 of the policy.

As per condition no. 12 of the policy, “the company may cancel this policy on grounds

of misrepresentation, fraud, and moral hazard, non disclosure of material fact as

declared in the proposal form / at the time of claim or non co-operation of the insured

person”. Hence the policy was cancelled with effect from 26/11/2019 due to non-

disclosure of PED-CAD (Coronary Artery Disease) after sending 30 days‟ notice to

the insured on 17/10/2019.

Complainant has not approached for reimbursement of medical expenses,

subsequent to rejection of the request for cashless facility and hence insurer is not

aware of the exact amount spent during her hospitalization.

In view of the above, Forum is requested to dismiss the complaint.





Written Complaint dated 21/12/2019 and 21/01/2020 to the Forum

Request for cashless hospitalization from Chettinad Hospital, Chennai

Cashless rejection letter of the Insurer dated 14/10/2019

Complainant‟s representations to the Insurerdated 17/10/2019 and

18/11/2019

Insurer‟s response dated 30/11/2019 to the Complainant

Notice for cancellation of policy dated 17/10/2019

Endorsement dated 19/11/2019 towards cancellation of policy


Self-Contained (SCN) of the insurer dated 10/02/2020 received on 02/03/2020

Senior Citizens Red Carpet Health Insurance Policy with terms and conditions

Proposal form (completed online and authenticated on 02/09/2017)

Doctor‟s Initial Assessment Sheet dated 14/10/2019

Copy of complainant‟s letter dated 26/08/2017 to Mr Dinesh of Star Health

Reply vide E Mail dated 29/08/2017 from Star Health to Mr R Mukesh Kumar

E Mail dated 01/09/2017 of Mr. R Mukesh Kumar to husband of the

complainant.


a) The Forum records its displeasure over the delay of in submission of SCN by

the insurer.

b) Claim was repudiated by insurer on the grounds of non disclosure of PED-

CAD

c) CAD is a PED as admitted by the complainant herself and insurer also proved

it through submission of request for cashless hospitalization and initial

assessment sheet of the doctor dated 14/10/2019.

d) Insurer also proved non-disclosure of PED by complainant, through

submission of proposal wherein CAD was not disclosed.

e) Before availing the policy, complainant‟s spouse sought some clarification from

Mr Dinesh of Star Health on 26/08/2017 and Mr. K N Srinivas, DM (Marketing)

of Star Health replied to the queries through Mr. R Mukesh Kumar of MPN

Capital, the intermediary firm.

f) Complainant has submitted the copy of E Mail dated 01/09/2017 received from

Mr R Mukesh Kumar of MPN Capital wherein he has replied to various queries

sought by complainant‟s spouse and in the same E mail he sought the details

of medical documents for treatment undergone for the heart disease and

breast malignancy.

g) Thus, it is evident that Mr R Mukesh Kumar of MPN Capital has been informed

by the complainant‟s husband about the PED before availing the policy, while

raising certain queries regarding coverage Former in turn took up the queries

with the respondent insurer. Reply to the said queries by Mr. K.N. Srinivas,

Divisional Manager (Marketing) vide his mail dated 29/08/2017 clearly

establishes that the insurer was made aware of the medical history of the

complainant. Since intermediary as well as the insurer were aware of the

complainant‟s history of CAD breast malignancy, even before issuance of the

policy, insurer‟s contention of non-disclosure does not stand to reason. Hence

Forum concludes that insurer‟s repudiation of the claim as well as subsequent

cancellation of the policy is not in order.

h) The Forum has no authority to award compensation for mental agony as

claimed by the complainant. Her request for refund of premium under the

previous policies is also not tenable as the insurer has borne the risk during

the said periods.

AWARD


made during the course of hearing by both the parties, Forum concludes that the

repudiation of the claim by insurer is not in order. Insurer is directed to settle the

claim of the complainant for INR 14,350 subject to the terms and conditions of the

Policy along with interest as defined under Rule 17 (7) of the Insurance Ombudsman

Rules, 2017. Insurer is also directed to reinstate the policy with continuity benefits.

Thus, the complaint is Allowed

25. The attention of the Insurer is hereby invited to the following provisions of

the Insurance Ombudsman Rules, 2017:

1. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer



2. According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as specified in

theregulations, framed under the Insurance Regulatory and Development Authority

ofIndia Act, 1999, from the date the claim ought to have been settled under the


3. According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of




INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE


(UNDER RULE NO: 16/17 of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M. Vasantha Krishna

CASE OF Mr. K.N. Thirukkuralkani Vs Star Health and Allied Insurance Co. Ltd




Mr. K. N. Thirukkuralkani No 246 Raja Kounder Street Kararampatti Main Road Salem- 636 015

2. Policy No. Type of Policy Duration of Policy/Policy Period Floater Sum Insured(SI)

P/70001/01/2019/040949 Family Health Optima Insurance 13/01/2019 to 12/01/2020 INR 4 lacs


Mr K M Nagarajan Mr. K.N. Thirukkuralkani

4. Name of the Insurer Star Health and AlliedIns. Co. Ltd


6. Reason for Repudiation Waiting period of 48 months for Pre-existing Diseases (PED)


8. Nature of Complaint Claim rejection


30/01/2020




Not stated


As per Rules


20/01/2020




16. Date of Hearing/Place 09/03/2020/Chennai

17. Representation at the Hearing For the Complainant Mr. K N Thirukkuralkani For the Insurer Dr. Asiya Sahima & Ms Hemalatha 18. Disposal of Complaint By Award 19. Date of Award/Order 31/03/2020

20.Brief Facts of the Case:

The complainant had covered his dependent parents under Family Health Optima

Insurance with the Respondent Insurer (RI) for a floater Sum Insured (SI) of INR 4

lakhs. The period of insurance under the subject policy which is the first policy is

13/01/2019 to 12/01/2020. On 22/09/2019, the complainant‟s father, Mr.

K.M.Nagarajan was admitted in GKNM Hospital, Coimbatore and was diagnosed with

Diabetes Mellitus (DM)&Triple Vessel Disease (TVD) for which he underwent

Coronary Artery Bypass Graft (CABG) surgery. The request for pre-authorisation for

cashless hospitalisation and subsequently the claim submitted for reimbursement

were both rejected by the insurer on the ground that the treatment was for a Pre-

Existing Disease (PED) which has a waiting period of 48 months under the policy.

The complainant sent a representation dated19.10.2019 to the insurer for

reconsideration of the claim which was responded to on 08.11. 2019 by the insurer,

expressing their inability to reconsider the same. He has therefore approached this

Forum for relief.


a) The policy was taken in January, 2019 at which time his parents were healthy.

On 12.07.2019 his father was admitted in EkaHospital, Salem with complaint

of chest pain and the claim for the same was settled for Rs.26,659 by the

insurer.

b) On 19/09/2019, his father was again admitted in Sri Gokulam Super Speciality

Hospital, Salem, where he underwent Coronary Angiogram (CAG), as advised

by Dr.Krishnakumar. Based on the findings of the CAG, he was advised and

underwent CABG at GKNM Hospital.

c) The complainant stated that he submitted all the records/reports sought by the

insurer at the time of request for cashless authorization.

d) The ECG taken at the time of first admission in Salem (in July 19) was normal.

Hence the present ailment is not a PED as alleged by the insurer.

He has therefore requested the Forum to direct the insurer to settle the claim.

21(b) Insurer’s submission

a) As per the case sheet dated 9.7.19 from EKA hospital, Salem, the insured

patient was a known case of chest pain left side radiating to back for the previous

2 years. This shows that the insured patient had symptoms of heart disease

prior to commencement of the policy. So, the current treatment is for a PED

which has a waiting period of 48 months under the policy. Hence the request for

cashless facility and subsequently the reimbursement claim was repudiated.

b) In addition, treatment of diseases relating to Cardio Vascular System has now

been incorporated as PED in the policy.


Ombudsman Rules, 2017, which deals with “any partial or total repudiation of

claims by the life insurer, General insurer or the health insurer”

23) Documents placed before the Forum:


Request for cashless hospitalization by Eka Hospital

Response dated 11.07.2019 of Dr K Prabhakaran of Eka Hospital to Insurer‟s

query letter of the same date.

ECG Report dated 09.07.2019

CAG report dated 19.09.2019 of Sri Gokulam Speciality Hospital, Salem

Certificate dated 24.09.2019 of Dr. S. Natarajan of GKNM Hospital,

Coimbatore

Certificate dated 25.10.2019 of Dr. K. Prabhakaran of Eka Hospital, Salem

Denial of request for pre-authorisation for cashless hospitalization dated

24.09.2019

Complainant‟s representation to the insurer dated 19.10.2019

Insurer‟s response to the Complainant dated 08.11. 2019





Proposal form (completed online and authenticated)


Indoor Case Papers (ICP) and Discharge Summary of GKNM Hospital,

Coimbatore

ICP and Discharge Summary of EKA Hospital, Salem

Opinion dated 05.02.2020 of Dr. Arun Kumar Krishnasamy (obtained by

insurer)

24) Results of hearing(Observations and Conclusion):

The Complainant Mr. Thirukkuralkani, and the Insurer‟s representatives Dr.

Asiya Sahima and Ms Hemalatha were present for the hearing.

The Forum records its displeasure over the delay in submission of SCN by the

Insurer. The insurer is hereby directed to henceforth submit SCN on time.

During the hearing, the Complainant stated that when his father was admitted

for atypical chest pain in July 2019, the duration of the same was wrongly

stated in the medical records as 2 years which was later corrected as 2

months. The claim submitted to the Insurer for his hospitalization for CABG in

September 2019 was rejected by the Insurer on the ground that the current

ailment was a PED. He clarified that during the admission in Eka Hospital,

Salem in July 2019 his father was treated for Anemia and not for Heart

problem. Further, the ECG taken in July 2019 was normal.

The Insurer contended that no clarification for overwriting of the duration was

given by the treating doctor as stated by the Complainant. However, it is

observed that Dr. K. Prabhakaran of Eka Hospital has confirmed vide

certificate dated 25.10.2019 that the history of symptoms was of only 2

months. The insurers also confirmed that they had neither rejected the claim

submitted in July 2019 nor had endorsed the Policy for incorporating heart

disease as PED.

The insurer submitted a copy of proposal (online) where no previous history of

PED was declared by the Complainant. However, the subject claim was

rejected under PED clause and not on the ground of non-disclosure. .

The insurer repudiated the claim based on case sheet dated 09.07.2019 of

EKA hospital, Salem wherein the history of chest pain for 2 years was

recorded.

However, from the medical records it was observed that the Insured patient

was admitted only for Anemia and atypical chest pain which was medically

managed. Since the ECG taken was normal, it cannot be said with certainty

that symptom of chest pain (atypical) was indicative of heart disease.

In reply to the query letter of Insurer Dated11.07.19, raised in response to the

request for pre-authorisation for cashless hospitalization at Eka Hospital,

Dr.K.Prabhakaran, the treating doctor confirmed that patient had chest pain for

only 2 months and he was seen at OPD (Out-patient Department) on 9.7.19.

The Forum observes that the case sheet of EKA hospital recorded history of

chest pain radiating to back for 2 years (overwritten). However, in the

discharge summary of GKNM hospital,diagnosis was recorded “as newly

detected DM, exertional Angina, TVD, CAD & Sinus Rhythm”. Tread Mill Test

(TMT) done in July, 2019 (report not available) is said to be inconclusive, but

the CAGreport dated19.09.2019 showed TVD for which the insured

underwent CABG. Dr. S. Natarajan of GKNM Hospital has also issued a

certificate dated 24.09.2019 confirming that the insured has no previous

history of coronary artery disease.

It was also observed from the case record of GKNM hospital dated 22.09.19,

that the insured patient was a case of TVD andatypical chest pain..

Insurer obtained an opinion from Dr. Arun Kumar Krishnasamy dated

05.02.2020 which suggested that the insured had chronic CAD. However,

they did not refer to the same in the SCN submitted.

The insurer confirmed settlement of claim for treatment in Eka Hospital in July

2019. The insurer did not repudiate the claim on the grounds of PED then.

Further, the subject policy was also not endorsed for incorporation of PED at

that time. The discharge summary of GKNM Hospital has also recorded the

history of hospitalization in July 2019 for anemia for which one bottle of blood

was transfused. However, the respondent insurer sought to reject the present

claim based on the contents of the discharge summary and other records of

Eka Hospital of July 2019, which is not justified.

In view of the foregoing the repudiation of the claim by the insurer on the

ground of PED is not tenable.












AWARD


by both the parties during the course of hearing, the Forum hereby directs the insurer

to settle the claim of the complainant for INR 3,10,553 subject to other terms and

conditions of the Policy along with interest at applicable rates as provided under Rule

17(7) of the Insurance Ombudsman Rules, 2017.

Thus, the complaint isAllowed.





INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE


(UNDER RULE NO: 16 of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri. M. Vasantha Krishna

CASE OF Mr. G.Naresh Vs Star Health and Allied Insurance Co. Ltd


Award No: I0/CHN/R/HI/0244/2019-2020


The Complainant‟s mother was covered under Star Comprehensive Policy with the

Respondent Insurer (RI) for a Sum Insured (SI) of INR 10 lakhs. The period of

insurance was 13/02/2019 to 12/02/2020. She was admitted in Christian Medical

College (CMC) Hospital on 02/09/2019 with complaints of cough and sneezing and

was diagnosed with Bronchial Asthma (BA). A pre-authorisation request for cashless

treatment was submitted to insurer for her treatment, which was denied by the RI on

the ground that the current treatment was for a Pre-Existing Disease (PED).

However, the insured patient was advised to submit claim for reimbursement of

expenses after completing the treatment. Later, the reimbursement claim was also

denied on the ground of waiting period of 48 months for PED under the policy. The

Complainant sent a representation to the Insurer for reconsideration of the claim, but

the insurer expressed its inability to reconsider the same. He has therefore



a) His mother‟s claim for treatment of BA at CMC, Vellore was denied by the

insurer. Initially the pre-authorisation request for availing cashless was denied

on the ground that the tampered/over written document by the doctor is not

acceptable. Later the claim for reimbursement was also denied on the ground

that one-year treatment record was not given by the doctor.

b) The Complainant contended that even after the doctor had given treatment

documents correcting the errors/mistakes, the insurer refused to process the

claim.

He has requested the Forum to direct the insurer to pay the claim.


a) Insurer submitted their SCN, expressing their willingness to settle the claim for

INR 64,645, following a review by their medical panel and submitted the Billing

sheet (calculation) for the same.



claims by the life insurer, General insurer or the health insurer”.

23) Documents placed before the Forum.



Denial of pre-authorisation request for cashless dated 05.09.2019

Claim Repudiation letter dated 03.10.2019

Complainant‟s representation to the Insurer dated “Nil”



Claim form

Policy terms and conditions

Renewal Endorsement dated 30.09.2019 (for the period 13.02.2019 to

12.02.2020)

Proposal form


Discharge Summary / In-patient Bill of CMC, Vellore

Bill Assessment Sheet of the Insurer

24) Results of hearing ( Observations and Conclusion):

The Complainant Mr. G.Naresh, and the Insurer‟s representatives Dr. Asiya

Sahima and Ms.Hemalatha were present for the hearing.

The Forum records its displeasure over the delay in submission ofSCN by the

Insurer. The Insurer is hereby directed to henceforth submit SCN on time.

During the hearing the Complainant was informed about the Insurer‟s decision

to settle the claim for INR 64,645. The Complainant sought compensation for

mental agony. He was informed that this Forum does not have the powers to

grant the same but can award interest for delayed payment as per Rules

Insurer agreed to settle the claim along with interest and the complainant too

accepted their offer at the time of hearing.


Insurance


25. The attention of the complainant and the respondent insurer is drawn to the

following provisions of Rule no. 16 of the Insurance Ombudsman Rules, 2017

According to Rule 16(2) of the Insurance Ombudsman Rules, 2017, if the

recommendation of the Ombudsman is acceptable to the complainant, he

shall send a communication in writing within fifteen days of receipt of the

recommendation, stating clearly that he accepts the settlement as full and

final.

As per Rule 16(3) of the said Rules, the Ombudsman shall send to the

insurer, a copy of its recommendation, along with the acceptance letter

received from the complainant and the insurer shall, thereupon, comply

with the terms of the recommendation immediately but not later than

fifteen days of the receipt of such recommendation, and inform the

Ombudsman of its compliance.



INSURANCE OMBUDSMAN


RECOMMENDATION

Taking into account the facts of the case, documents submitted and submissions made

by both the parties during the hearing, the Forum hereby recommends to the Insurer to

settle the claim of the complainant for INR 64,645 along with interest at applicable rates

as provided under Rule 17(7) of the Insurance Ombudsman Rules,2017.

The Complaint is disposed accordingly.

PROCEEDINGS BEFORE



OMBUDSMAN : SHRI M. VASANTHA KRISHNA

CASE OF Mrs. M. Thilagavathi Vs Manipal Cigna Health Insurance Co. Ltd




Mrs. M. Thilagavathi Door No 19, Plot No 119, Third Main Road, E B Colony, Vadavalli, Coimbatore 641041


PROHLT155005136 ProHealth-Plus Family Floater 09/12/2018-08/12/2019 INR 4,50,000


Mrs. Manickam Thilagavathi Mrs. Manickam Thilagavathi

4. Name of the insurer Manipal Cigna Health Insurance Co. Ltd



Due to non-disclosure of Pre-existing disease (PED) as per Clause VIII.1




29/01/2020

10 Amount of Claim INR 20,677

11


Not furnished



INR 27,783 plus interest


14/01/2020







b) For the insurer Mr. Vinu Nair

18. Disposal of Complaint disposed By Award



Complainant had availed respondent insurer‟s Pro Health Plus Family Floater Policy

covering self, and her children for SI of INR 4,50,000 on 09/12/2015 and the policy

was renewed up to 08/12/2019. On 01/10/2019 she was admitted in G. Kuppuswamy

Naidu Memorial Hospital (GKNM), Coimbatore for treatment of multiple Oesophageal

Ulcers (Adrenaline injected), multiple small polyps in stomach and Hypertension.

Reimbursement claim preferred for the above hospitalization was repudiated by

insurer on the ground that complainant did not disclose in the proposal, her condition

of (c/o) Gastric Ulcer for 10 years and Haemorrhoids in 2000, at the time of policy

inception. Aggrieved by the repudiation of the claim, complainant escalated the

matter to Customer Care Dept. of the insurer and they in turn reiterated the earlier

decision of repudiation. Not satisfied with insurer‟s response to her grievance

representation, she has approached this Forum for relief.

21. a) Complainant’s submission:

Complainant has been continuously covered under medical insurance since 2015.

Her claim for reimbursement was repudiated on the ground that c/o Gastric Ulcer for

10 years and Haemorrhoids in 2000 was not disclosed in the proposal. Disclosure

was not made by oversight and was not intentional. In any case, the said ailments are

covered after 24 months of waiting period as per clauses V.3.vii & ix of the policy. The

policy having run more than 24 months, even if the current claim pertains to the two

ailments, it is still payable.

While repudiating the claim, insurer mentioned the ailment wrongly as ”Ulcer of

esophagus without bleeding” whereas as per discharge summary it is ”Bleeding

esophageal ulcers”.

Complainant submitted the screen shot of the proposal wherein ‟NO‟ buttons appear

as default replies for the questions regarding pre-existing disease (PED). One can

answer correctly a question in respect of the diseases contracted within 48 months.

But it is foolish to ask a question such as ‟Have you ever suffered from or taken

treatment or hospitalized for or have been recommended to take

investigation/medication/surgery or undergone a surgery for a medical condition‟,

since every person would have undergone at least one investigation during his or her

life period.

In view of the above Forum‟s intervention is requested to settle the claim besides

awarding appropriate compensation for mental agony undergone.


As per initial assessment sheet, complainant was diagnosed with gastric ulcers 10

years ago and she was operated for Haemorrhoids in 2000. But complainant did not

disclose the said medical history at the time of porting the policy. Instead she

answered No‟ to the below mentioned specific question under Section 5 of the

proposal form. ‟Have

you ever suffered from or taken treatment or hospitalized for or have been

recommended to take investigation/medication/surgery or undergone a surgery for a

medical condition? f)

Liver Disease/ Ulcers/ Gall Bladder or any other digestive tract or gastro intestinal

disorders?‟

Hence, the claim was repudiated under clause VIII. 1 which reads as under:

―VIII.1. Duty of Disclosure

The Policy shall be null and void and no benefit shall be payable in the event of

untrue or incorrectstatements, misrepresentation, mis-description or non-disclosure of

any material particulars in theproposal form, personal statement, declaration, claim

form declaration, medical history on the claimform and connected documents, or any

material information having been withheld by You or any oneacting on Your behalf,

under this Policy. You further understand and agree that We may at Our sole

discretion cancel the Policy and the premium paid shall be forfeited to Us.”

Insurer cited the following cases of the Supreme Courtin support of the repudiation of

claim.

Satwant Kaur Sandhu V New India Assurance Company Ltd, SC 2776 of

(2006)

P C Chacko and another Vs Chairman, Life insurance Corporation of India and

others AIR 2008 SC 424

Life Insurance Corporation of India Vs Manish Gupta, Civil Appeal No. 3944 of

2019

Reliance Life Insurance Co. Ltd Vs Rekhaben Nareshbhai Rathod in Civil

Appeal No. 4261 of 2019

General Assurance Society Limited vs Chandumull Jain & Another, (1966) 3

SCR 500

Suraj Mal Ram Niwas Oil Mills (P) Ltd. Versus United India Insurance Co.

Ltd.[(2010) 10 SCC 567]

Export Credit Guarantee Corporation of India Ltd. vs Garg Sons International

2013 (1) SCALE 410

Since claim is not payable as per policy terms, Forum is requested to absolve insurer

of the liability.

22) Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with ‟Any partial or total repudiation of claims

by the life insurer, General insurer or the health insurer‟.



Claim repudiation letters of the Insurer dated 13/11/2019 and 20/12/2019

Complainant‟s representation to the Insurerdated 14/11/2019



Self-Contained Note (SCN) of the insurer dated 26/02/2020

Pro Health Insurance policy with terms and conditions

Proposal (submitted online)

Claim form dated 11/10/2019

Discharge summary of GKNM Hospital, Coimbatore

Initial Assessment Chart and Progress Notes of GKNM Hospital, Coimbatore

24) Result of hearing (Observations & Conclusion)

1. The Forum records its displeasure over the delay in submission of SCN by the

insurer.

2. Claim was repudiated by insurer on the ground of non-disclosure of

complainant‟s c/o Gastric Ulcer for 10 years and treatment for Haemorrhoids in

2000.

3. Insurer proved the pre-existing nature of the above referred two diseases by

submitting the initial assessment sheet of GKNM Hospital. Complainant too

accepted in her complaint that those conditions were not disclosed by

oversight.

4. Insurer also proved non-disclosure of the said diseases by submitting a copy

of the proposal completed online, wherein complainant replied ‟No„ to the

question on past diseases.

5. Insurers took the stand that the complainant has replied ‟No‟ to the specific

question on past ulcers on the basis of negative reply to the general question

on past diseases in the online proposal. Once the complainant answered „No‟

to the question on past diseases, system captured the reply as ‟No‟ to all other

specific questions on various diseases.The complainant too highlighted this

issue in her submission to the Forum. Nevertheless, this Forum is of the

opinion that the PED not disclosed being chronic in nature, the explanation of

the complainant that she did not declare them by oversight and that the

question asked was not specific enough, is not acceptable.

6. Thus, there was non-disclosure of PED by the complainant and Forum

concludes that repudiation of the claim under clause VIII.1 of the policy is in

order.

7. As regards complainant‟s contention that the two pre-existing conditions are

covered after 24 months, Forum notes that the insurer repudiated the claim on

account of non-disclosure and not on the ground of waiting period as per

clause V.3 of the policy. It is also observed that if the PED were declared,

insurer would have accepted the proposal, with a loading of premium by 7.5%

for each of the PED and increase in the waiting period to 4 years from 2 years,

as per Clause VIII.20 - Loadings & Special Conditions of the policy. Hence

the non-disclosure was material to the acceptance of the risk and the insurer is

justified in rejecting the claim.

AWARD


made during the course of hearing by both the parties, this Forum is satisfied that

repudiation of the claim by insurer is in order and that there is no scope for its

intervention.

Thus, the complaint is not allowed.

25) If the decision of the Forum is not acceptable to the Complainant, she is at liberty


insurer.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE



OMBUDSMAN : Shri M. Vasantha Krishna

CASE OF Mr V. Chella Ganesan Vs Star Health and Allied Insurance Co. Ltd


Award No: I0/CHN/A/HI/0247/2019-2020


Mr. V. Chella Ganesan 3/444, Sundaram Street, Dinamani Nagar Kovilpapakudi, Madurai 625018


P/121312/01/2020/000458 Family Health Optima Insurance Plan15/05/2019 to 14/05/2020 INR 4.05 lacs


Master C. Sivarupan Mr. V. Chella Ganesan

4. Name of the Insurer Star Health and AlliedInsurance Co. Ltd



Congenital (external) disease excluded under the policy




14/02/2020




INR 66,485


INR 66,485


27/01/2020





17. Representation at the Hearing a) For the Complainant Mr. V Chella Ganesan b) For the Insurer Dr. Asiya Sahima & Ms Hemalatha 18. Disposal of Complaint By Award



The complainant, his spouse and dependent children were covered under Family

Health Optima Insurance Plan with the respondent insurer (RI) for a floater Sum

Insured (SI) of INR 4,05,000. The period of insurance under the subject policy is

15/05/2019 to 14/05/2020. On 24/05/2019, the complainant‟s son Master Sivrarupan,

was admitted in Vijaya Hospital, Madurai, with complaints of passing urine under the

shaft of penis (splaying urine) since birth. The diagnosis was Hypospadias – Mid

Penile with minimal Chordee for which he underwent Snodgross Urethroplasty. The

claim submitted for reimbursement of treatment expenses was repudiated by the

insurer on the ground that the treatment was for a congenital problem which is

excluded under the subject policy. The complainant sent a representation dated

15/10/2019 to the insurer for reconsideration of the claim but the insurer expressed

their inability to consider the same. He has therefore approached this Forum for

relief.


The first insurance policy with the RI was taken 3 years ago and since then it

has been renewed continuously.

His son had complaints of pain while passing urine for two months for which he

underwent a surgery. Only at the time of Hospital admission, they came to

knowthat the problem was congenital.

As per the doctor‟s advice, surgery was performed to give relief for sudden

pain which his son was suffering from for more than 2 months.

He has requested the Forum to direct the insurer to pay the claim.


As per the discharge summary the Insured was diagnosed with

Hypospadias- Mid Penile with Minimal Chordee for which he underwent

Urethroplasty. He had a history of passing urine from under the shaft of

penis since birth. Thus, the treatment was for a congenital external defect

which is not covered under exclusion no. 4(3) of the subject policy. Hence

the claim was repudiated.

Reason for Registration of Complaint: - Rule 13(1)(b) of the Insurance

Ombudsman Rules, 2017, which deals with ”any partial or total repudiation of



Written Complaint to the Ombudsman dated 06/01/2020

Claim Repudiation letter of Insurer dated 26/06/2019

Complainant‟s representation to the Insurer dated 15/10/2019.

Insurer‟s response to the Complainant dated 02/11/2019



Proposal form dated 15/05//2017



Discharge Summary of Vijaya Hospital, Madurai

24) Results of hearing (Observations and Conclusion):

The Complainant Mr V Chella Ganesan and the Insurer‟s representative

Dr. Asiya Sahima were present during the hearing.


Contained Note (SCN) by the Insurer. The insurer is hereby directed to

henceforth submit the SCN on time.

During the hearing, the Complainant stated that he was not aware of his

child‟s difficulty in passing urine. Surgery was done immediately when his

son complained of pain while passing urine and he became aware of the

same.

The insurer stated that the Claim was repudiated as the treatment was for

external congenital / defect / anomalies which is not covered under

Condition 4(3) of the subject Policy.

Upon perusal of the discharge summary it is observed that the insured

patient had complaint of passing urine from under the penis since birth &

the diagnosis was Hypospadias, which is a congenital problem/condition.

The Complainant contended that even though the problem may be since

birth his son was asymptomatic until he developed pain for which he had

to undergo surgery.

Wkipedia: In medical terms Hypospadias is a congenital abnormality. It is

most often noticed at birth. Chordee is a condition where bands of tissue

pull on the penis, making it appear bent or curved. It usually occurs in

children with hypospadias. Chordee is normally diagnosed shortly after

birth when doctors observe hypospadias. In cases of chordee without

hypospadias, the parents are the first to noticethat the penis is

curved.Sometimes there is extra foreskin on the top of the penis, giving it

a hooded appearance, which can be a sign that chordee is present. Thus,

Hypospadias is an external congenital anomaly. The repudiation of the

claim by the insurer under the above stated exclusion is therefore in order.

AWARD


both the parties during the course of hearing, the Forum is of the view that the repudiation

of the claim is in order and does not warrant any intervention.

The Complaint is notallowed.



insurer.


(M Vasantha Krishna) INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE



OMBUDSMAN - Shri M. Vasantha Krishna

CASE OF Mr. Dhanaraj Rajarathinam Vs Star Health and Allied Insurance Co. Ltd




Mr Dhanaraj Rajarathinam Quanta Fort W 273/3 16th Cross Street, C Sector 3rd Avenue, Anna Nagar West Extn Chennai - 600 101


P/111113/01/2019/021258 Mediclassic Individual Policy 28.02.2019-27.02.2020 INR 10 lakhs

3. Name of the Insured & Name of the Policyholder/Proposer

Ms. Angelin Ranjitham R Ms. Angelin RanjithamR




Non-disclosure of material fact of Pre-Existing Disease (PED)


8. Nature of Complaint Claim rejection


22.01.2020




INR 6,69,474


INR 6,69,474


08.01.2020





17. Representation at the Hearing For the Complainant Mr. Dhanaraj Rajarathinam For the Insurer Dr. Asiya Sahima & Ms Hemalatha 18. Disposal of Complaint By Award 19. Date of Award/Order 31.03.2020


The complainant is the father of the deceased insured person. She was covered

under Mediclassic Insurance Policy with the Respondent Insurer (RI) for a Sum

Insured (SI) of INR 10 lakhs. The period of insurance was 28.02.2019 to 27.02.2020

and the Policy first incepted in the year 2015. The insurance was thereafter renewed

continuously without any break. On 10.05.2019 the insured Ms. Angelin Ranjitham

was admitted in Sundaram Medical Foundation, Chennai for Diabetes related illness

and Root Canal treatment (dental) and died on 03.06.2019 in the course of treatment

in hospital.

The claim submitted to the insurer for reimbursement of treatment expenses was

rejected on the ground of non-disclosure of Pre-Existing Disease (PED) in the

proposal form at the time of inception of insurance.The complainant sent a

representation dated 30.05.2019 to the insurer for reconsideration of the claim which

was rejected by the insurer. He has therefore approached this Forum for relief.


a) The Complainant stated that the hospitalisation claim of his daughter was

repudiated by the insurer on the ground of non-disclosure of PED in the

proposal form at the time of inception of Insurance in the year 2015. Providing

further details, he informed the Forum that the request for pre-authorisation of

cashless hospitalization was denied on 14.05.2019. Subsequently the claim

submitted for reimbursement was also repudiated on 23.08.2019.

b) The Complainant also stated that in the year 2015 (during the first year of the

policy) his daughter was admitted in Dr. Mohan‟s Diabetic Specialty Centre

and the request for cashless hospitalization made at that time was rejected by

the insurer. The Complainant contended that in the year 2015 also the treating

hospital would have provided the medical history to the Insurer in the same

manner in which Sundaram Medical Foundation had provided the history for

the latest hospitalisation. It means that the information about PED would have

been known to the Insurer even in 2015.

c) He contended that a copy of the proposal form was not given to his daughter in

the year 2015, along with the policy.

d) Therefore, the action of the insurer to repudiate the present claim on the ground

of non-disclosure is arbitrary and illegal and he has requested the Forum to direct

the insurer to settle the claim.


As per the outpatient (OP) prescription dated 25.02.2019 of Dr Usha, the insured

patient is a known case of Lymphocytic Infundibuloneuro Hypophysitis since

2009. This fact was not disclosed by the insured at the time of taking the policy.

Hence the claim was repudiated invoking Condition no. 7 of the Policy relating to

non-disclosure of material facts. They also cancelled the policy by serving notice

of cancellation of 30 days as per condition no. 13 of the policy (although the

cancellation became infructuous due to the unfortunate demise of the insured).






Request for cashless hospitalization dated 10.05.2019

Rejection of Authorisation for cashless treatment dated 14.05.2019


Notice for cancellation of policy dated 20.05.2019

Complainant‟s representation to the insurer vide email dated 30.05.2019

Response of the Insurer dated 01.06.2019.




Copy of Proposal form


Progress Notes and Death Summary of Sundaram Medical Foundation

OP prescription of Dr Ayyagari Usha of Apollo Specialty Hospital dated

25.02.2019.

Discharge summary of Dr Mohan‟‟Diabetic Specialty Centre, dated 7.10.2015

24) Results of hearing(Observations and Conclusion):

The Complainant Mr. Dhanaraj Rajarathinam, and the Insurer‟s

representatives Dr. Asiya Sahima and Ms. Hemalatha were present for the

hearing.




During the hearing, the Complainant stated that the subject policy was availed

by his daughter in the year 2015. Although the insurance was solicited directly

by the insurer, someone has been included as agent in the policy. He further

stated that although the existence of Hypothyroidism and all PED were

declared to the agent at the time of taking the policy, only Diabetes was

included as PED in the Insurer‟s records.The Insurer failed to take any Know

Your Customer (KYC) documents. The subject claim submitted to the insurer

for his daughter‟s hospitalisation was rejected by the insurer on the ground that

the current ailment was a PED and that the same was not disclosed in the

Proposal Form at the time of taking the policy in the year 2015.

The insurer submitted that the Proposal Form was signed by the deceased

insured who was also the proposer. Only Diabetes was declared in the

Proposal Form and the existence of Lymphocytic Infundibuloneuro

Hypophysitis (pituitary gland related ailment) was not disclosed. The Company

would not have issued the Policy, had the same been disclosed.

However, in the letter sent by the Complainant to the Insurer‟s Grievance

Department dated 30.05.2019, he has claimed that the agent was informed

about his daughter suffering from pituitary ailment and being on hormone

supplements since 2009.

The Insurer repudiated the claim on the ground of non-disclosure of PED,

relying on the OP prescription dated 25.02.2019 of Dr Usha Ayyagari of Apollo

Speciality Hospitals and the progress note dated 12.05.2019 of Sundaram

Medical Foundation, wherein the history of PED was recorded. In their

repudiation letter dated 23.08.2019 the insurer has stated that although the

present admission was for treatment of Nosocomial pneumonia, MSSA

pneumonia with septic shock, as per the OP prescription dated 25.02.2019 of

Dr Usha, submitted at the time of cashless processing, the insured patient had

Lymphocytic Infundibuloneuro Hypophysitis from the year 2009 which is prior

to the inception of the insurance in the year 2015. The said medical history

was not disclosed in the Proposal Form which amounts to misrepresentation /

non-disclosure of material facts.

The Insurer submitted the copy of the Proposal in which, under Health history

against query no. 2 relating to existence of illness/injury/diseases/surgery, the

proposer had replied “No”, which amounts to non-disclosure.

However, she had disclosed the fact that she was on medication for Diabetes,

in reply to question no. 4 (a).

In his representation to the Grievance Department of the insurer, the

Complainant stated that the policy was issued duly incorporating “Diabetes

and its complications” as PED and they were under the impression that the

complications of Diabetes included pituitary problem. However, medical

literature shows that Infundibuloneuro Hypophysitis is an autoimmune

condition of the pituitary gland which manifests itself as Diabetes Insipidus and

hence it cannot be termed as a complication of Diabetes.

During the hearing too, the Complainant denied having received a copy of the

Proposal along with the Policy document in the year 2015. The Insurer was

therefore asked to confirm whether a copy of the proposal was sent to the

Insured along with the Policy document as provided under the IRDAI

Protection of Policyholders Interest Regulations. The Insurer confirmed that

the copy of the proposal was sent to the Complainant along with Policy

Schedule and Terms and Conditions on 02.04.2015. In any case, Forum is of

the view that the proposal form submitted clearly establishes the non-

disclosure of the pituitary ailment by the insured. Since the proposal was

duly signed by the deceased insured, the complainant‟s contention that the

agent failed to record the PED therein, although they were disclosed, is not

acceptable. There is enough case law which establishes that an insured is

bound by the information disclosed and declarations made in a proposal form

duly signed by him/her and the fact that an agent or someone else completed

the form is not an acceptable defence.

Upon perusal of the in-patient death summary of Sundaram Medical

Foundation it was observed that the insured patient also underwent treatment

for Root Canal. The primary diagnosis recorded was Nosocomial pneumonia

and secondary diagnosis was Infundibuloneuro Hypophysitis and depressive

disorder. However, it has not recorded the details of past history of these

ailments. It only states that the patient is a known case of Diabetes and on

treatment.

The Complainant argued that the past history of the insured would have been

provided by Dr Mohan‟s Diabetes Specialty Centre in 2015 in the discharge

summary. The same was submitted to the insurer in support of the claim and

hence the Insurer would have been aware of the PED even then. The Insurer

was therefore asked to submit the subject claim papers to this Forum, which

they did post hearing. Upon perusal of the discharge summary of Dr Mohan‟s

Diabetic Specialty Clinic, it is observed that the insured was diagnosed with

Diabetes, Hypothyroidism, Panhypopituitarism, Elevated Liver Enzymes,

Lymphocytic Infundibuloneuro Hypophysitis and so on. The above claim which

was in the first year of insurance was repudiated by the insurer on the ground

of PED, since Diabetes was declared as PED which has a waiting period of 48

months under the Policy. This proves that the insurer had knowledge of the

undisclosed PED even in the year 2015.

Nevertheless, the insurer did not invoke the ground of non-disclosure to reject

the said claim but relied upon the waiting period of 4 years for PED, an equally

valid ground. However, this in no way prevents or disentitles the insurer from

repudiating the subject claim on the basis of non-disclosure of material fact.

Hence the repudiation of claim by the Insurer is in order.

It is the insurer‟s argument that the non-disclosure was of a material fact and

hence they cancelled the policy invoking condition no.13 thereof. Since the

insurer had knowledge of the non-disclosure even in the year 2015 when the

first-year policy was in force, they should have cancelled the policy even then.

On the contrary, they kept renewing the policy, despite the fact that any claim

reported would have been rejected by them on the ground of non-disclosure of

PED. Hence, Forum is of the opinion that the insurer should refund the

premium collected since inception of the policy to the legal heirs of the

deceased insured.



insurer.

Dated at Chennai on this 31st day of March, 2020.


INSURANCE OMBUDSMAN


AWARD


made by both the parties during the course of hearing, the decision of the Insurer to

repudiate the claim is in order and does not warrant the intervention of the Forum.

However, the insurer is directed to refund the premium collected under the policy

since inception after adjusting the refund already made, if any.

Thus, the Complaint is not allowed.

PROCEEDINGS BEFORE



OMBUDSMAN - Shri M. Vasantha Krishna

CASE OF Mr. J.Jayaraj Vs Star Health and Allied Insurance Co. Ltd


Award No: I0/CHN/A/HI/0249/2019-2020

1.

Name & Address of the Complainant

Mr. J. Jayaraj No.40/21, 4th Main Road Gangai Nagar, Velacherry Chennai- 600042


P/111128/01/2020/000860 Family Health Optima Insurance Plan16/06/2019 to 15/06/2020 INR 5 lacs

3. Name of the Insured & Policyholder/Proposer

Mr J Jayaraj




Non-disclosure of material facts




03/02/2020




INR 6,10,766


INR 3,50,000


27/01/2020




16. Date of Hearing/Place 09/03/2020;Chennai

17. Representation at the Hearing For the Complainant Mr. J Jayaraj For the Insurer Dr. Asiya Sahima & Ms. Hemalatha 18. Disposal of Complaint By Award



The complainant, his spouse and dependent children were covered under Family

Health Optima Insurance Plan with the respondent insurer for a floater Sum Insured

(SI) of INR 5 lakhs. The Bonus available is INR 1.75 lakhs and therefore the total limit

of coverage is INR 6,75,000. The policy first incepted in the year 2017 which was

renewed continuously without any break till date. The period of insurance under the

subject policy is 16/06/2019 to 15/06/2020. On 28/06/2019, the complainant was

admitted in Apollo Spectra Hospitals, Chennai with complaints of yellowish

discoloration of eyes and urine and complaints of itching. He was diagnosed with

Obstructive Jaundice and Portal Hypertension with Esophageal fundic varices and

discharged on 01/07/2019 after CBD stenting. He was subsequently admitted to Dr

Rela Institute & Medical Centre on three different occasions (on 07/07/2019,

18/07/2019 and 14/08/2019) for undergoing stent removal, evaluation and medical

management. The claims preferred for all the four admissions were settled by the

insurer. He was once again admitted to Dr Rela Institute & Medical Centre, Chennai

on 26/09/2019 for undergoing Splenectomy and Side to Side Collateral Caval Shunt

and was discharged on 04/10/2019 The hospitalisation claim submitted to the insurer

for reimbursement of treatment expenses to the extent of INR 6,10,766 was

repudiated on the ground of non-disclosure of Pre-existing Disease (PED) of Extra

Hepatic Portal Venous Obstruction (EHPVO) by invoking clause no. 6 of the policy.

The insurer also cancelled the insurance invoking Condition no 12 of the Policy. The

representation to insurer dated 25.11.2019 for reconsideration of the claim was also

rejected on 1/02/2020. He has therefore approached this Forum for relief.


a) Complainant stated that EHPVO was diagnosed only during the recent

admissions and therefore it is not a PED as alleged by the insurer.

b) He also pointed out that he was admitted in Hospital 4 times prior to the

current admission and all the related claims were settled by the insurer.

c) The discharge summary of the hospital had erroneously recorded the illness

as part of childhood history which was later corrected.

d) He contended that he was not aware of the problem till it was diagnosed. Had

he been aware, he would have certainly informed the insurer at the time of

taking the policy.

He has therefore requested the Forum to direct the insurer to pay the claim.


The Complainant submitted a claim of INR 6,10,766 for reimbursement of

treatment expenses incurred at Dr Rela Institute & Medical Centre, Chennai.

Upon scrutiny of the discharge summary of the treating hospital submitted by

the Complainant while requesting cashless authorization, it was observed that

he is a known case of EHPVO since childhood with umbilical sepsis and was

on Sclerotherapy and oral propranolol prophylaxis, which was not disclosed at

the time of inception of the policy. The present admission and treatment were

for the non-disclosed, pre-existing EHPVO. Therefore, the request for cashless

authorisation as well as the claim for reimbursement was repudiated and the

same was communicated to the Complainant on 05.10.2019 and 09.11.2019

respectively.


Ombudsman Rules, 2017, which deals with ”any partial or total repudiation of





Initial approval for Cashless hospitalization dated 26.09.2019

Query letter on enhancement of amount for cashless treatment dated

04.10.2019

Response letter of Dr Rela Institute & Medical Centre

Withdrawal of authorisation for cashless treatment dated 04.10.2019


Notice of policy cancellation dated 08/10/2019

Complainant‟s representation to the insurer vide email dated 25.11.2019

Response of the Insurer dated 01.02.2020




Copy of Proposal form dated16/06/2017


Discharge summary of Apollo Spectra Hospitals, Chennai

Discharge summaries of Dr Rela Institute & Medical Centre, Chennai (4 nos.)

Rectified Discharge Summary of Dr Rela Institute & Medical Centre, Chennai

Certificate (undated) of Dr. Rela Institute & Medical Centre Guidelines for medical underwriting of the insurer

24) Results of hearing (Observations and Conclusion):

The Complainant Mr J Jayaraj and the Insurer‟s representative Dr. Asiya

Sahima were present for the hearing.




During the hearing, the complainant stated that he was hospitalized in June

2019 for Jaundice. He was then advised by to approach Dr Ravi, Apollo

Spectra Hospitals for stent surgery. The surgery was finally performed after

three more hospitalizations due to complications of bleeding and infection. The

earlier 4 claims were settled by the Insurer. Only the present claim was

repudiated on the ground of non-disclosure of childhood history of illness

which was erroneously recorded in the discharge summary and later rectified.

He contended that EPHVO is not a PED and that he did not have any

episode or symptoms of it throughout his life (for the past 42 years).

He was only recently diagnosed and treated for Jaundice.

The insurer argued that from the discharge summary submitted at the

time of cashless authorization, it was observed that the insured patient

is a known case of EHPVO since childhood with umbilical sepsis and

was on sclerotherapy and oral propranolol prophylaxis. This medical

history was not disclosed at the time of taking the policy. Hence the

claim was repudiated under condition no. 6 of the policy. The cover in

respect of insured patient was also cancelled invoking Condition no 12

of the Policy.

The Insurer relied upon the history recorded in the Discharge Summary of the

treating hospital for repudiation of claim. As per the Discharge Summary the

complainant is a known case of EHPVO since childhood associated with

umbilical sepsis. He had a UGI bleed at the age of 5 years and managed with

sclerotherapy for 10 years and was on medication.

The insurer argued that as per the past history recorded in the discharge

summary, the Complainant was hypertensive, smoker and consumer of

alcohol and had history of childhood varices and underwent sclerotherapy

which was not disclosed in the proposal by the Complainant.

The Complainant contended that although the discharge summary duly

rectifying the error in recording the past history was submitted, the Insurer

refused to settle the claim.

The insurer also submitted a copy of proposal in support of their contention of

non-disclosure of material fact. Under the column Health history under query

no 4(m) the Complainant had stated ”No” against Pre-existing diseases.

Upon perusal of the proposal it was observed that the Complainant had

disclosed that he was a social drinker, but had not declared that he was

hypertensive for 15 years and on treatment (as per discharge summary of Dr.

Rela Institute & Medical Centre). However, the insurer did not invoke the non-

disclosure of Hypertension to repudiate the claim and only cited the non-

disclosure of EHPVO.

From the documents submitted by the insurer it was observed that the request

for pre-authorisation for cashless hospitalization was initially approved for INR

1 lakh on 26/09/2019 and was later withdrawn on 04/10/2019 (on the ground

of non-disclosure), although the treating hospital had issued a certificate to the

effect that EHPVO was diagnosed only in July 2019.

The Insurer submitted a copy of the Underwriting Policy to the Forum. They

contended that the Complainant was suffering from a disease akin to Cirrhosis

of liver which is a declined risk.

The insurer was asked to submit the copies of the discharge summary of the

previous 4 admissions for which the claim was settled by them, which they

submitted post-hearing.

Upon perusal of the previous discharge summaries of Dr. Rela Institute &

Medical Centre, it was observed that the history of EHPVO is recorded

therein. However, the Insurer settled the claims without invoking non-

disclosure EHPVO, apparently due to the fact that there was no indication of

the disease being present since childhood in the same.

It was only at the time of the latest admission to Dr. Rela Institute & Medical

Centre that a history of childhood EHPVO was recorded and later deleted.

There is no other record or evidence of the disease being present since the

childhood days of the complainant. Hence the benefit of doubt is given to the

complainant.

In view of the above, the decision of the insurer to repudiate the present claim

on the ground of non-disclosure is not justified.

Award


by both the parties during the course of hearing, the Forumhereby directs the Insurer

to settle the claim of the complainant for INR 3,50,000, subject to terms and

conditions of the Policy along with interest at applicable rates as provided under Rule

17(7) of the Insurance Ombudsman Rules, 2017. Coverage of the complainant may

also be reinstated with continuity benefits.

Thus, the complaint is allowed

25) The attention of the Insurer is hereby invited to the following provisions of the




intimate compliance of the same to the Ombudsman






Ombudsman.



Dated at Chennai on this 31st day of March, 2020

(Sri M. Vasantha Krishna)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE



OMBUDSMAN - SHRI M VASANTHA KRISHNA

CASE OF Mr. R Meganathan Vs Bajaj Allianz General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-005-1920- 0548

Award No: I0/CHN/A/HI/0250/2019-2020


Mr. R Meganathan No.38, Raghavan Nagar, Everady Colony, Kodungaiyur, Chennai 600118


OG-19-1518-8430-00000438 Health Guard policy 15/03/2019-14/03/2020 INR 3,00,000


Mr. R Meganathan Mr. R Meganathan

4. Name of the Insurer Bajaj Allianz General Insurance Co. Ltd

5. Date of repudiation 26/06/2019


Pre-existing disease (PED) as well as non-disclosure of the same


8. Nature of Complaint Non-settlement of the claim

9. Date of receipt of Consent (Annexure VI A) 06/02/2020




INR 2,94,461


INR 2,94,461


27/01/2020



Rule no. 13(1)(b)of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 09/03/2020; Chennai


c) For the Complainant Mr. R Meganathan

d) For the Insurer Mrs. N Thilagavathy

18. Disposal of Complaint By Award



Complainant Mr R Meganathan, covered under respondent insurer‟s Health Guard

policy was admitted in Vijaya Hospital, Chennai on complaint of severe chest pain

and was diagnosed to have block in the heart and stent procedure was advised.

Cashless request raised for the treatment of Acute Coronary Syndrome (ACS) was

denied by insurer on the ground that the disease was pre-existing and the same was

not disclosed in the proposal. Reimbursement claim preferred was also repudiated on

the same line. Aggrieved by the repudiation of the claim, the complainant represented

to insurer for reconsideration. Since there was no response from them, he has



Complainant‟s claim was repudiated on the ground that the treatment was for a pre-

existing disease (PED) and the same was not disclosed in the proposal. According to

the insurer, the fact that complainant was suffering from Hypertension (HT) for 6

years and Diabetes (DM) for 10 years was not disclosed. While the complainant was

in the Intensive Care Unit (ICU), his friend who had admitted him had wrongly

informed the hospital authorities about the duration of HT & DM. Complainant was in

fact diagnosed to have HT & DM in 2017 and the treating doctor‟s certificate

regarding the same is submitted to the Forum as proof. When the insurance was

availed in 2015, insurer conducted pre-medical tests and then only the policy was

issued. Hence claim is payable and Forum‟s intervention is requested for settlement

of the same.


On verification of the claim documents it was revealed that the claimant is known to

be suffering from HT for 6 years and DM for 10 years which were existing prior to

inception of the policy and had not been disclosed on the proposal form. The policy

does not extend coverage for any expenses incurred on the treatment of illness which

is pre-existing to the policy and is not disclosed in the proposal form. Hence the claim

was repudiated as per preamble, exclusion clause no. C1 & definition clause B-18 of

policy terms and conditions which read as under:

Preamble

Our agreement to insure You is based on Your Proposal to Us, which is the basis of

this agreement, and Your payment of the premium. This Policy records the entire

agreement between Us and sets out what We insure, how We insure it, and what We

expect of You and what You can expect of Us.

C) Exclusions under the Policy - We shall not be liable to make any payment for

any claim directly or indirectly caused by, based on, arising out of or attributable to

any of the following: 1. Benefits will not be available for Any Pre-existing condition,

ailment or injury, until 36 months of continuous coverage have elapsed, after the date

of inception of the first Health Guard policy, provided the pre-existing disease /

ailment / injury is disclosed on the proposal form. The above exclusion 1 shall cease

to apply if You have maintained a Health Guard policy with Us for a continuous period

of a full 36 months without break from the date of Your first Health Guard policy. In

case of enhancement of Sum Insured, this exclusion shall apply afresh only to the

extent of the amount by which the limit of indemnity has been increased (i.e.

enhanced Sum Insured) and if the policy is a renewal of Health Guard policy with Us

without break in cover.

Definition B.18

Disclosure to information norm: The Policy shall be void and all premium paid

hereon shall be forfeited to the Company, in the event of misrepresentation, mis-

description or non-disclosure of any material fact.


Ombudsman Rules, 2017, which deals with ”any partial or total repudiation of claims



Written Complaint to the Insurance Ombudsman submitted on 22/11/2019





Health Guard policy with terms and conditions

Proposal form dated 09/03/2015

Discharge Summary of Vijaya Hospital, Chennai

Patient record of Vijaya Hospital dated 29/05/2019

Prof. Dr M Vijayakumar‟s certificate dated 01/06/2019

Pre-acceptance Medical Examination Report of the complainant dated

17/03/2015


a) The Forum records its displeasure over delay in submission of SCN by the

insurer. Similarly, the lack of response to the representations made by the



b) Insurer relied on patient record of Vijaya Hospital, dated 29/05/2019 wherein

the duration of HT is mentioned as 5-6 years and that of DM as 10 years. But

the discharge summary of the hospital merely states that the complainant is a

known diabetic and hypertensive and there is no mention of the duration.

c) The complainant contended that the past history of DM & HT was wrongly

recorded by the hospital based on the statement given by his friend. He

submitted that he is diabetic and hypertensive from 2017 (after inception of the

policy).He has submitted a certificate from the treating doctor Prof. M

Vijayakumar who confirmed that the history of DM for 10 years and HT for 5-6

years was given by the accompanying person (friend). The doctor also has

stated that as per patient‟s declaration, the latter is diabetic and hypertensive

from 2017. However, the complainant did not produce any prescription or

other document to prove that he was diagnosed for DM and HT only in 2017.

At the same time, the insurer too didnot produce any other evidence to show

that DM & HT existed prior to the date of proposal. During hearing, insurer

submitted the pre-acceptance medical examination report of the complainant

which showed that HbA1C which is an indicator of DM was normal with a

reading of 5.5% and blood pressure (BP) was also normal at 120/80. Although

the insurer argued that the readings could have been normal due to

medication, Forum is of the view that the benefit of doubt on this issue should

go in favour of the complainant. Hence insurer‟s repudiation of the claim by

invoking the clause ofDisclosure to Information Norm is not in order.

d) The claim was repudiated by the insurer as per PED exclusion clause no. 1 of

the policy as well. Complainant‟ hospitalization was for treatment of Acute

Coronary Syndrome (ACS) whereas the alleged PED are DM & HT. Definition

of PED as per clause 42 of the policy reads as under

”Pre-Existing Disease means any condition, ailment or injury or related

condition(s) for which there were signs or symptoms and / or were

diagnosed, and / or for which medical advice / treatment was received

within 48 months prior to the first policy issued by the insurer and renewed

continuously thereafter”.

It is presumed that ACS was considered as a related condition of DM and HT

in order to bring it under the purview of PED. However, insurer failed to

elaborate this aspect in the letter of repudiation.

As per exclusion no. 1 of the policy which has already been cited, the waiting

period for PED declared in the proposal form is 36 months and the position

regarding undeclared PED is left unsaid. Hence there are three possibilities

with regard to waiting period for such undeclared PED.

i. There is no waiting period at all

ii. The same waiting period of 36 months (as applicable to declared

PED) shall apply.

iii. Undeclared PED are permanently excluded under the policy, without

any waiting period.

The present claim has been reported during the fifth policy period and is

allegedly in respect of undeclared PED. In view of the ambiguity of the

exclusion clause as discussed above, even assuming that the treatment was

for an undeclared PED, it does not come within the scope of the exclusion.










AWARD


during the course of hearing by both the parties, Forum concludes that repudiation of

the claim by respondent insurer is not in order and the insurer is directed to settle the

claim of the complainant subject to the terms and conditions of the policy along with

interest as defined under Rule 17 (7) of the Insurance Ombudsman Rules, 2017.

Thus, the complaint is allowed.


Ombudsman.



Dated at Chennai on this 31stday ofMarch, 2020


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mrs. R S Umamakeswari Vs Universal Sompo General Insurance Company Ltd

COMPLAINT REF.NO: CHN-H-052-1920-0538



Mrs. R S Umamakeswari 27/2249, Batcoswamy Vattaram, Manojiappa Street, Thanjavur 613009


2817/50455494/09/800 IOB Health Care Plus Policy 20/05/2019-19/05/2020 INR 2,00,000


Mrs. R S Umamakeswari Mrs. R S Umamakeswari

4. Name of the insurer Universal Sompo General Insurance

Company Ltd.

5. Date of Repudiation 25/11/2019 (Closure)

6. Reason for repudiation Non-submission of original documents requested




30/01/2020

10 Amount of Claim Not furnished

11


Not furnished



INR 2,00,000, the sum insured


14/01/2020






a) For the Complainant Mrs. R S Umamakeswari

b) For the insurer Absent



20)Brief Facts of the Case:

Complainant, Mrs R S Umamakeswari covered under respondent insurer‟s IOB

Health Care Plus policy with period of insurance of 20/05/2019 to 19/05/2020, was

hospitalized from 07/08/2020 to 24/08/2020 at Cancer Institute, Adyar, Chennai and

undergone left modified radical mastectomy for treatment of Carcinoma of left breast.

Reimbursement claim preferred for the said hospitalization was closed by insurer

since complainant did not submit the original documents requested. Aggrieved by the

closure, complainant represented to the insurer for reconsideration of the claim.

Insurer reiterated their earlier stand of repudiation. Not satisfied with insurer‟s

response to her representation, complainant has approached this Forum for relief.


Original documents were missed during travel and hence copies were submitted. As

per clause A of claim procedure, original or copies of the bills are to be submitted for

reimbursement of the claim. Complainant does not have any other policy to claim

either partially or fully. Further treatment is not pursued since the claim was not

settled. Hence Forum‟s intervention is requested for settlement of the claim and to

pursue further treatment.


Complainant was requested to submit the below mentioned documents

1. All the original documents i.e. discharge summary, final payment receipt,

medicine bill, investigation reports, histopathology, mammogram report in

support of diagnosis.

2. Doctor‟s consultation paper dated 27/08/2019 & 07/09/2019

3. Justification if partial settlement done from other insurance company, then

provide original claim settlement letter of that company

4. Proof of residence for the proposer.

Despite several reminders, complainant did not submit the same and the claim

was closed due to non-submission of documents. Therefore, Forum is requested

to dismiss the complaint.


Ombudsman Rules, 2017, which deals with ”Any partial or total repudiation of claims


23) Documents placedbefore the Forum.


Claim closure letter of the Insurer dated 25/11/2019


Insurer‟s reply dated 09/12/2019 to the complainant



IOB Health Care Plus Policy with terms and conditions

Discharge summary of Cancer Institute, Adyar, Chennai

Insurer‟s letter dated 26/10/2019 seeking original documents

Complainant‟s E Mail dated 08/11/2019 to insurer


a. Forum regrets insurer‟s non-participation in the hearing.

b. It is on record that insurer vide letter dated 26/10/2019 sought the

documents specified in para 21(b) above.

c. Complainant complied with two of the four requirements by submitting the

consultation papers dated 27/08/2019 & 07/09/2019 and proof of

residence through E Mail dated 08/11/2019.

d. As regards the third requirement of settlement done by other insurer,

complainant had already confirmed that she did not have any other

insurance.

e. The only requirement pending is submission of original documents.

Complainant stated that she lost all the originals while travelling.

f. Hence insurer‟s act of closing the claim on the ground that all the four

requirements were not complied with by complainant is not in order.

g. Treatment availed by the complainant is not in dispute. Forum is of the

view that insurer should settle the claim based on an Affidavit cum

Indemnity bond from the complainant duly confirming that original papers

were lost and she has no other health insurance at the material time.







complainant shall be entitled to such interest at a rate per annum as specified in the

regulations, framed under the Insurance Regulatory and Development Authority of

India Act, 1999, from the date the claim ought to have been settled under the


c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of


Dated at Chennai on the 31st day of March, 2020

(M. Vasantha Krishna) INSURANCE OMBUDSMAN FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

AWARD


made during the course of hearing, Forum concludes that closure of the claim by

respondent insurer is not in order and theyare directed to settle the claim after

obtaining an Affidavit cum Indemnity Bond from the complainant to the effect that

original claim papers were lost and there is no other subsisting insurance and

subject to the terms and conditions of the policy. In addition, interest as defined

under Rule 17 (7) of the Insurance Ombudsman Rules, 2017 is payable.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN STATE OF TAMIL NADU AND PUDUCHERRY

UNDER RULE NO: 17(1) OF THE INSURANCE OMBUDSMAN RULES, 2017 OMBUDSMAN – SHRI: M VASANTHA KRISHNA

Case of Mr Ramamoorthy Viswanathan Vs The New India Assurance Co. Ltd. COMPLAINT REF. NO: CHN-H-049-1920-0517

Award No. IO/CHN/A/HI/0253/2019-20

1.


Mr Ramamoorthy Viswanathan 6, Surya Apartments, 16, Baliah Avenue, Mylapore, Chennai – 600 004 2. Policy No:

Type of Policy Duration of policy/Policy period Sum Insured (SI)

7180034199500000429 New India Mediclaim Policy 21/09/2019 to 20/09/2020 Rs 3,00,000

3.

Name of the insured Name of the policyholder

Mr Ramamoorthy Viswanathan Mr Ramamoorthy Viswanathan

4

Name of the insurer

The New India Assurance Co. Ltd. 5. Date of Repudiation 06/12/2019

6. Reason for Repudiation Hormonal therapy not covered


8. Nature of complaint Rejection of claim

9. Date of receipt of consent (Annexure VI A)

10/01/2020


11. Amount of Monetary Loss (as per Annexure VIA)

Not furnished



INR 19,062

14.a Date of request for Self-contained Note (SCN)

06/01/2020

14.b Date of receipt of SCN 29/01/2020





26. For the Complainant Mr Ramamoorthy Viswanathan

27. For the insurer

Mr D Mohanraj




The complainant and his spouse are covered under Mediclaim Policy of respondent

insurer.The complainant had undergone treatment for Prostate cancer at Apollo

Hospital, Chennai and his hospitalization claim and post hospitalization claims have

been settled by the insurer. He had taken further treatment at Chennai Urology Clinic

by way of Hormonal Therapy in November 2019. The insurer rejected the claim on

the ground that hormonal therapy is not admissible as there was no hospitalization for

24 hours and claim cannot be considered as a post hospitalization claim too, since

the treatment was taken beyond the period of 60 days from the date of discharge

from hospital. The complainant made a representation to the insurer vide his letter

dated 09/12/2019, which was rejected by the insurer on 20/12/2019, reiterating the

previous grounds of repudiation. Hence, he has approached this Forum for relief.


(a) Complainant’s Version:

The complainant submitted that he was hospitalized and had undergone treatment of

Radical Robotic Prostatectomy on two occasions. His claims for hospitalization as

well as Pre & Post hospitalization expenditure were settled by the insurer. Since

February 2017, he is being administered hormonal therapy by way of injection once in

three months, on the advice of the treating doctor. The insurer had rejected

settlement of his claim for the cost of hormonal therapy on the grounds that (i) the

treatment was not a listed day care procedure and (ii) the treatment should have

been taken along with Chemotherapy /Radiotherapy to be eligible for reimbursement.

Though he argued that e chemotherapy and radiotherapy are covered as Day Care

Procedures under the policy, and in the same manner hormonal therapy also should

be covered,insurer didn‟t settle the claim.Hencethis Forum was approached and as

per Forum‟saward, claims were settled. Present claim is for the last hormonal

injection taken in November 2019 and insurer repudiated the claim stating that the

hormonal therapy is not admissible and the claim cannot be considered as pre and

post hospitalization claim either.They further quoted clause 1.0 of the policy, in

support of the rejection of claim. The complainant argues that nowhere in the policy

hormonal therapy is excluded. Clause 1.0 quoted by insurer allows medically

necessary treatment for any illness. Treating Doctor Ananthakrishnan Sivaraman has

already given a certificate stating that hormonal therapy is essential for the treatment

to suppress cancer cells. Medically necessary treatment is further amplified in clause

2.26 and all the requirements stated therein are met. Complainant‟s second claim for

hormonal injection vide claim no. 20171060 was settled by insurer. Hence Forum is

requested to set aside the rejection of the present claim and to advise the insurer to

settle the claim.

(b) Insurer’s Version:

Insurer repudiated the claim as per clause 1.0 of the policy which reads as under.

“If during the period of insurance, You or any insured person incurs Hospitalization

expenses which are Reasonable and Customary and Medically Necessary for

treatment of any illness or injury, we will reimburse such expenses incurred by you,

through the Third Party Administrator, in the manner stated herein.

Please note that the above coverage is subject to Limits, Terms and Conditions

contained in this policy and no Exclusion being found applicable”.

Complainant‟s claim for hormonal therapy in November 2019 is not payable as it can‟t

be considered under Pre & Post hospitalization section of the policy since main

hospitalization was from 22/05/2017 to 10/07/2017. As regards the decision of the

Forum in respect of the earlier complaint, it is observed that theForum has ruled that

the said award shall not be considered as a precedent for future claims for hormonal

therapy.


Ombudsman Rules, 2017 which deals with “Any partial or total repudiation of claims


23Documentsplaced beforethe Forum.



Complainant‟s representation dated 09/12/2019 to the insurer

Insurer‟s response dated 20/12/2019 to the complainant

Consent (Annexure VI A) submitted by the complainant

Self-Contained Note (SCN) of insurer dated 20/01/2020

New India Mediclaim policy with terms and conditions


Certificate dated 30/01/2019 issued by Dr Ananthakrishnan Sivaraman


a) Complainant‟s claim is for hormonal therapy undergone without 24 hours

hospitalization.

b) Complainant‟s earlier complaint to the Forum against rejection of claim by the

insurer for the same hormonal therapy (taken on 4 occasions in November

2017, February, May and August of 2018), was allowed by this Forum on the

ground that insurer had summarily repudiated the claim stating that hormonal

therapy is not payable without quoting any specific clause/condition of the

policy. While awarding in favour of the complainant,the Forum had specified

that the award shall not be considered as a precedent for any future claims for

hormonal therapy.

c) The complainant pointed out in his complaint letter to the Forum that

subsequent to the award by the Forum, the insurer voluntarily settled his

claims for 4 more hormonal injections taken by him in November 2018,

February, May and August 2019, without any intervention by the Forum.

However, Insurer has once again repudiated the current claim (for the last of

hormonal injections in November 2019) by invoking clause 1.0 of the policy

which is the operative clause of the policy and stipulates that policy covers

only hospitalization expenses. Hospitalization means 24 hours admission in

the hospital as per definition 2.16 of the policy which is reproduced below.

“HOSPITALIZATION means admission in a Hospital for a minimum period of

twenty four consecutive hours of Inpatient Care except for specified

procedures/ treatments as mentioned in Annexure I, where such admission

could be for a period of less than twenty four consecutive hours.”

In the instant case hospitalization was for a period less than 24 hours. and the

procedure undergone is also not listed in Annexure I of the policy as a

recognized Day Care Procedure.

d) Complainant‟s argument that the treatment undergone is medically necessary

since it has been prescribed by a medical practitioner as mandated in

definition 2.26 of the policy, is not tenable since there was no hospitalization

for a minimum period of 24 hours, as prescribed in clause 2.26.

e) Neither in the SCN nor during hearing, did the insurer explain how the

hormonal therapy claims of November 2018 to August 2019 were voluntarily

settled by them and why the current claim alone is rejected.

f) Forum is of the opinion that procedurally, hormonal therapy is identical to

chemotherapy which is recognized as a Day Care Procedure. It is also noted

that as per the latest guidelines of IRDAI, hormonal therapy is also included as

a listed Day Care Procedure. The treating doctor has also certified that the

treatment was essential for suppressing cancer cells. Hence Forum is of the

view that the current claim is also payable, considering especially the fact that

the previous 4 claims were paid by the insurer without demur.

AWARD


made by both the parties during the course of hearing, this Forum directs the

insurer to settle the claim of the complainant for INR 19,062, treating it as a Day

Care Procedure,subject to terms and conditions of the policy and in addition pay

interest as provided under Rule 17 (7) of the Insurance Ombudsman Rules, 2017.




a. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer



b. According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the





Ombudsman.

c. According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award

of the Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on the 31stday of March, 2020

(M VASANTHA KRISHNA)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU & PUDUCHERRY

PROCEEDINGS BEFORE




CASE OF Mr. M Baskar Vs The New India Assurance Company Ltd





Mr. M Baskar Sai Homes, Flat A, Plot No. 34, Ganesh Avenue, First Main Road, Sakthi Nagar, Porur, Chennai 600116


712500/GH/DEC2018/3566 Good Health Policy 01/12/2018-30/11/2019 INR 10,00,000


Mr. M Baskar Mr. M Baskar

4. Name of the insurer The New India Assurance Company Ltd

5. Date of short settlement 07/11/2019

6. Reason for short settlement

Deduction of non-medical items and application of Preferred Provider Network (PPN) tariff


8. Nature of complaint Short settlement

9. Date of receipt of consent ( Annexure VIA)

31/01/2020


11.


INR 1,35,218

12. Amount paid by Insurer, if any INR 1,05,040


INR 1,35,218


14/01/2020






a) For the Complainant Mr. M Baskar

b) For the insurer Mr. K Kalyanaraman



Complainant, Mr.M Baskar covered under respondent insurer‟s Good Health Policy

for the period from 01/12/2018 to 30/11/2019 with SI of INR 10 lacs was admitted in

MIOT International Hospital, Chennai on 14/10/2019 and had undergone open

reduction and plate osteosynthesis of right humerus for treatment of closed displaced

fracture of shaft of right humerus. His reimbursement claim of INR 2,40,258 for the

treatment was settled by the insurer‟s TPA for INR 1,05,040 resulting in short

settlement by INR 1,35,218. Not satisfied with the short settlement, complainant

escalated the matter to Customer Guidance Department of the insurer for payment of

the balance amount of the claim. Since there was no reply from them, he has

approached this Forum for redressal of his grievance.


Complainant has taken the policy in the year 2000 and at that time there was no

restriction under different heads as has been applied now by TPA. Since the current

policy is a renewal of 2000 policy, terms and conditions applicable to 2000 alone

should be applicable even now. The table below shows items disallowed by the

insurer along with the reasons and also the comments of the complainant .

Amount

deducted

(INR)

Reasons given by Insurer Comments of Complainant

82,924 As per PPN tariff Which clause of the policy allows

such deduction?

1,500 Daily cash benefit payable is INR

13,500

Reason for deduction not

explained

2,000 Operation theatre expenses already

charged and hence charges for

monitor / gases/Oxygen/Boyles

apparatus/Pulse Oxymeter charges

not payable separately

Which clause of the policy

prohibits oxygen provided during

surgery?

8,726 How this figure was arrived at

and which clause allows denial?

26,184 Assistant surgeon charges are not

payable

Which clause of the policy

prohibits such payment? 5,511 Non-medical expenses not payable

Insurer was asked to clarify the reasons for deduction of INR 1,35,218. But there was

no reply from them. Hence Forum‟s intervention is requested for settlement of the

deducted amount of INR 1,35,218.


Hospital, where complainant has undergone treatment is under PPN and hence

claim was limited to agreed PPN tariff for the procedure. Complainant has also signed

PPN Network declaration form wherein he has agreed to bear the difference in cost

between the agreed PPN tariff and the amount charged by the hospital.

Complainant‟s argument that the terms and conditions of 2000 policy alone are

applicable is not tenable since the current policy issued to him has been approved by

IRDAI and in the fourth page of the certificate issued, it has been specifically

mentioned that the policy issued is governed by Health Insurance Regulations 2016

and Protection of Policyholders Interest Regulations of IRDAI. Further it has been

mentioned that the policy schedule comes with policy clauses as attachment and if

not attached insured should ask for the same. Complainant did not make any such

request for policy clauses and hence it is presumed that he has received policy

schedule with clauses attached. Thus, settlement of the claim and deductions are in

order.




23)Documents placed before the Forum.


TPA‟s claim payment sheet dated 07/11/2019




Good Health Policy with terms and conditions

Certificate of insurance for the period 01/12/2018 to 30/11/2019

Claim form

PPN Network Declaration signed by the complainant

Discharge summary and bills of MIOT International Hospital


a) The Forum records its displeasure over the lack of response to the

representations made by the complainant. It is hoped that the insurer will

strengthen its customer grievance redressal mechanism and avoid such

lapses in future.

b)Insurers are well within their right in applying the current policy conditions and

complainant‟s argument that 2000 policy conditions alone are applicable is not

tenable since it has been specifically stated in the fourth page of the insurance

certificate submitted by the complainant that the current policy terms and

conditions are applicable.

c) In terms of PPN agreement insurer should have ensured that the complainant

was not overcharged beyond PPN package tariff. It is observed from the PPN

declaration signed by the complainant that no better or additional

facility/treatment was availed by him, warranting charging of additional amount

by the hospital. If so, the reasons for obtaining the said declaration from the

complainant are not clear, especially when it appears that no request was

made for cashless facility. During hearing the insurer submitted that they had

duly taken up the issue of overcharging with the hospital, but there was no

response from the latter. Having failed in their duty to enforce the PPN tariff on

the hospital, insurer cannot put the complainant to monetary loss. The

complainant is right in his observation that the policy does not speak of PPN

tariff and pricing, although it refers to Network Hospitals and provision of

cashless facility through them. Therefore, Forum concludes that complainant is

eligible to get reimbursement of his claim on open billing basis without

restricting it to the PPN tariff.

d) Forum‟s observations on the amount of INR 1,35,218 deducted from the claim

of the complainant are as below

Amount deducted

(INR)

Reasons Forum’s observations

7,199 Non-medical,non-

payable items

Agree with the insurer*

6,685 Food Agree with insurer

10,726 Not payable over and

above Operation

Theatre (OT)charges

Payable, if sum insured

under the relevant head

is available

26,184 Assistant surgeon

charges not payable 82,924 Claim restricted to PPN

tariff

Insurer to pay,having not

enforced the PPN

agreement on hospital

1,500 Maximum payable is

INR 13500 which is

already paid

Hospitalization was for

10 days and hence the

daily cash benefit @ INR

1500 is INR 15000.

Hence, payable (TOTAL) 1,35,218

*Complainant is advised to refer to the policy wording for list of non-medical,

non-payable items.











Ombudsman.



Dated at Chennai on the 31stday of March, 2020


INSURANCE OMBUDSMAN


AWARD


made during the course of hearing by both the parties, the Forum is of the view that

insurer‟s action of restricting the claim reimbursement to PPN tariff is not in order.

They are hereby directed to recalculate the claim without so restricting the claim

and keeping in mind the observations of the Forum. The additional amount arrived

at shall be paid to the complainant along with interest as defined under Rule 17 (7) of

the Insurance Ombudsman Rules, 2017.

Thus, the complaint is allowed


OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. K Narasimhan VsThe Oriental Insurance Company Limited



Mr. K Narasimhan, No.22, Gill Nagar, First Street, Choolaimedu, Chennai - 600 094.

2.


411100/48/2018/3762 Individual Mediclaim Policy 16.03.2018 to 15.03.2019 INR 2 lakhs


Mrs. S Lakshmi Mr. K Narasimhan

4. Name of the Insurer The Oriental Insurance Company Limited


6. Reason for repudiation Treatment could have been managed on outpatient (OPD) basis




06.02.2020




INR 60,000


INR 2,00,000


27.01.2020


15. Complaint registered under Rule no. 13(1) (b) of the Insurance Ombudsman Rules, 2017



a) For the Complainant Mr. K Narasimhan

b) For the Insurer Absent




The complainant has covered himself and his spouse under Individual Mediclaim

Policy issued by the Respondent Insurer (RI) for a Sum Insured (SI) of INR 2 lakhs

each. The policy is live since March 2012.

As per Discharge Summary, the complainant‟s wife Mrs. S Lakshmi was admitted in

Rajan Eye Care Hospital Pvt. Ltd., Chennai on 10.01.2019 with the complaints of

blurred vision and was diagnosed with Idiopathic Polypoidal Choroidal Vasculopathy

and was treated with intravitreal injection Eyelea administered under Local

Anaesthesia (LA). She was discharged on 11.01.2019 and a reimbursement claim for

INR 63,000 was submitted to the insurer on 14.01.2019 towards the cost of

treatment. But the claim was repudiated by the insurer under policy condition 2.11.

The complainant has therefore approached this Forum vide his letter dated

06.01.2020 for redressal of his grievance.


The complainant submits that he has been availing medical insurance with the

respondent insurer since the year 2000.

His wife underwent treatment for Age Related Macular Degeneration (ARMD)

in the right eye under LA in operation theatre.

There was no response from the TPA to the claim preferred for her treatment.

After a long follow up he came to know that the claim was rejected on the

ground that the treatment could have been managed on OPD basis.

The treating doctor has issued a certificate stating that the patient is a known

case of Choroidal neovascular membrane with history of multiple intravitreal

injection in the right eye. Since it was refractory to previous intravitreal

injection, a new VEGF trap Eylea is given on 10.01.2019. He has also certified

that post operation the patient was giddy and in discomfort and was under

observation for one day and discharged.

The complainant also submits that the insurer had sent an email confirming

TPA‟s rejection of the claim stating that the same falls outside scope of

policy, without quoting any policy condition or exclusion.

He has requested the Forum to render justice to him.


The insurer has submitted their SCN vide letter dated 07.02.2020.

They have stated that the patient was treated with intravitreal injection - Eylea

for the treatment of Idiopathic Polypoidal Choroidal Vasculopathy in the right

eye.

Though the injection is given in the operation theatre (OT), it is an OPD

treatment and not listed as a day care procedure in the policy.

As per Clause 2.11 of the policy, “Day care treatment refers to medical

treatment and/or surgical procedure which is undertaken under General or

Local Anaesthesia in a hospital/day care center in less than 24 hours because

of technological advancement and which would have otherwise required a

hospitalization of more than 24 hours.

Procedures/treatments usually done in OPD are not payable under the policy

even if converted to Day Care surgery/procedure or taken as an inpatient in a

hospital for more than 24 hours”.

Based on the above facts, the subject claim was repudiated.


Ombudsman Rules, 2017, which deals with”Any partial or total repudiation of claims


23. Documents placed before the Forum.







Discharge summary/Bills of Rajan Eye Care Hospital Pvt Ltd.

Mail correspondence of the complainant with the Insurer and TPA

Certificates (2 nos.) of Dr. Mohan Rajan dated 19.11.2019

24. Result of hearing (Observations & Conclusion)

Mr. K Narasimhan, complainant attended the hearing. The RI was absent and

no leave of absence was sought by them.

During the hearing the complainant submitted that his wife was administered

Eyelea injection in the operation theatre under local anaesthesia and since

she had giddiness, she was kept under observation for one day and was

discharged only on the following day. This has been duly certified by the

treating doctor. The RI has rejected the claim on the grounds that

administering of the above injection did not warrant hospitalisation.

Based on the documents submitted, it is observed that the procedure was

performed under LA in OT and hence the same cannot be termed as OPD

treatment. Though the procedure is not a listed day care procedure in

Appendix 1 of the policy, it meets the requirement of a day care procedure as

per clause 2.11 of the policy.

Moreover, the patient was admitted on 10.01.2019 and was discharged on

11.01.2019 whereby she was hospitalised for more than 24 hours. Clause

2.11 cited above, prohibits conversion of OPD treatment in to day care

treatment or to hospitalisation for more than 24 hours. Since the present

treatment is not an OPD treatment, rejection of claim under clause 2.11 is not

justified.

Complainant‟s demand for compensation for mental agony and harassment is

beyond the purview of this Forum.











Ombudsman.





INSURANCE OMBUDSMAN


AWARD



the respondent insurer to settle the claim of the complainant for INR 63,500

subject to the terms and conditions of the Policy along with interest as provided

under Rule 17(7) of the Insurance Ombudsman Rules, 2017.




(UNDER RULE NO: 16 /17 of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - Shri M Vasantha Krishna

CASE OF Mr R Santhanakrishnan Vs National Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-048—1920-0525

Award No: I0/CHN/A/HI/0257/2019-2020

1.


Mr R Santhanakrishnan F-1,Sri Sai Sarvesh, No 5(Old no 15) Avenue Road, Nungambakkam, Chennai 600034


500505/50/18/10000738 National Mediclaim Policy 18/09/2018 to 17/09/2019 INR 3,00,000


Mr R Santhanakrishnan Mr R Santhanakrishnan

4. Name of the Insurer National Insurance Co. Ltd



Admitted for diagnostic and evaluation purpose


8. Nature of Complaint Non-Settlement of Claim


23/01/2020




INR 3,39,304


INR 3,39,304


09/01/2020






8. For the Complainant Mrs Goda S Krishnan (Complainant’s wife)

9. For the Insurer Mr M Srinivasan




The complainant had taken a Mediclaim policy with the respondent insurer covering

himself, his spouse and his daughter for the period from 18/09/2018 to 17/09/2019 for

SI of INR 3 Lacs for himself. He was admitted twice in BRS Hospital, Chennai. The

first hospitalization was from 06/01/2019 to 12/01/2019 for Diabetes, Hypertension,

and Hypothyroidism and the second was from 18/01/2019 to 25/01/2019 for severe

obstructive Sleep Apnea, Diabetes and Hypertension. The complainant submitted the

bills for both the hospitalization to the insurer. The insurer after going through the

claim documents, rejected the first claim on the ground that the admission was for

diagnostic and evaluation purpose which did not warrant hospitalization and the

second claim was rejected for non-submission of claim related documents by the

complainant. The complainant escalated the matter to the insurer‟s Grievance

Department who reiterated their earlier decision. Aggrieved by the response of the

insurer, the complainant has approached this Forum seeking justice.


Insurer had rejected his claim on the ground that the treatment given to himdid not

require hospitalization. The decision whether the patient requires hospitalization or

not has to be taken by the treating doctor and not by the insurer.

The insurer‟s denial of claim was a misconceived assumption of reasons and not on

any reasonable conclusion and they have not applied their mind before rejecting.

Hence Forum‟s intervention is requested for settlement of the claims.


The insurer stated in their SCN that in the first claim, the patient was administered

with only oral medicines and there was no active line of treatment given by the

Hospital. The admission was mainly for evaluation purpose and so they invoked

policy exclusion clause 4.19 which reads as below.

“The company shall not be liable to make any payment under the policy in respect of

any expenses incurred in connection with or in respect of:

Diagnostic and evaluation purpose where such diagnosis and evaluation can be

carried out as outpatient procedure and the condition of the patient does not require

hospitalization”.

The insurer had invoked the same clause to reject the second claim too.

22) Reason for Registration of Complaint: - Rule no. 13(1)(b) of the Insurance





Claim repudiation letters of the Insurer dated 20/05/2019 and 03/07/2019






Claim form

Discharge summaries/Bills of BRS Hospital


a) The diagnosis mentioned in the discharge summary for the first admission is

Severe Lumbar Spondylosis with Radiculopathy, Obstructive Sleep Apnea,

Hypothyroidism besides Diabetes and Hypertension. The complainant was

admitted in the ICU for six days and was monitored as he was having Lumbar

Spondylosis. He was advised Physiotherapy – IFT, lower back IPT. He was

also treated by a dermatologist for bedsores.

b) Insurer repudiated the claim on the ground that the admission was only for

diagnosis and evaluation which could have been carried out as outpatient and

the condition of the patient did not require hospitalization, by invoking clause

4.19 of the policy quoted earlier.

c) Though many diagnostic tests were conducted in the course of hospitalization,

it cannot be presumed that the hospitalization was purely for diagnosis which

could have been managed on outpatient basis. The fact that the complainant

was in ICU for few days though the reason for the same was not explained in

the discharge summary proves that hospitalization was essential, especially

considering his co-morbid conditions and advanced age. Hence Forum

concludes that the treatment including the diagnostic tests required for

treatment of the complaints of slurring of speech and difficulty of using left

lower limb and tenderness of left calf muscle is payable to the complainant.

d) Second claim was for treatment of watery stools of 4-5 episodes and difficulty

in sitting. Though the claim was repudiated on the grounds of non-submission

of documents requested, insurer in their SCN stated that this claim too was

repudiated on the same ground that the hospitalization was for diagnosis

which could have been carried out as outpatient and hence hospitalization was

not necessary (clause 4.19).

e) Discharge summary revealed that the complainant was treated with I/V fluids

and insurer did not substantiate as to how the hospitalization was only for

diagnostic purpose. Hence Forum concludes that the claim for treatment

including the diagnostic tests required for treatment of the complaints of watery

stools of 4-5 episodes and difficulty in sitting is also admissible.

AWARD


by both the parties during the course of hearing, Forum concludes that repudiation of

the claims by insurer is not in order and insurer is directed to settle the claims of the

complainant for INR 3,39,304, subject to terms and conditions of the policy and in

addition pay interest as provided under Rule 17 (7) of the Insurance Ombudsman

Rules, 2017.












Ombudsman.


of the Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on the31st day of March, 2020

(M VASANTHA KRISHNA)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU & PUDUCHERRY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. Surendra J Shah Vs United India Insurance Company Limited


1. Name & Address of the Complainant Mr. Surendra J Shah, 3rd Floor, Flat No.3 A Palace Regency, 80-93, Purasawalkam High Road, Kellys, Chennai – 600 010.


0108022819P100207816 Individual Mediclaim Policy 01.04.2019 to 31.03.2020 INR 5 lakhs


Mr. Surendra J Shah Mr. Surendra J Shah

4. Name of the Insurer United India Insurance Company Limited

5. Date of Short Settlement 18.09.2019

6. Reason for Short settlement Reasonable & Customary Charges Clause


8. Nature of Complaint Short Settlement of claim


11.02.2020




INR 8,571


INR 8,571


30.01.2020


15. Complaint registered under Rule no. 13(1) b) of the Insurance Ombudsman Rules, 2017



For the Complainant Mr. Surendra J Shah

For the Insurer Mr. Vijay Shankar




The complainant was covered under Individual Mediclaim Policy issued by the

Respondent Insurer (RI) for the period 01.04.2019 to 31.03.2020 for a Sum Insured

(SI) of INR 5 lakhs.

As per Discharge Summary, on 17.08.2019 the complainant was admitted in Dr. U

Mohan Rau Memorial Hospital, Chennai with the complaint of swelling in left side

upper back for two years, was diagnosed with infected sebaceous cyst and

underwent excision of the cyst under local anesthesia. He was discharged on

19.08.2019. He submitted a reimbursement claim of INR 31,351 to the insurer for his

treatment. The claim was settled for INR 22,780 invoking the Reasonable and

Customary Charges Clause of the policy, disallowing an amount of INR 8,000 from

the Surgeon fees of INR 18,500. In addition, an amount of INR 571 was deducted

towards non-medical items.

He represented to the RI on 04.12.2019 to reconsider the amount deducted.

However, the insurer reiterated that the settlement is in order, vide their letter dated

18.12.2019. Not satisfied with the insurer‟s reply, the complainant has approached

this Forum vide his letter dated 08.01.2020 for redressal of his grievance.


The complainant submits that the policy is live for the past 20 years and this is

the first time he has submitted a claim.

The insurer has settled an amount of INR 22,780 against his claim of INR

31,351.

They have disallowed INR 8,000 towards surgeon fees.

Surgeon fees may vary from surgeon to surgeon and in his case, it is very

reasonable.

He has requested the Forum to do the needful.


The insurers have submitted their SCN and have stated that the complainant

underwent excision of infected sebaceous cyst on 17.08.2019.

The surgery is a minor surgery for which the amount charged towards the

surgeon‟s fee was huge and therefore INR 8,000 was deducted towards

Reasonable and Customary Charges under Clause 3.34.

Clause 3.34 states that ”Reasonable and Customary Charges means the

charges for services or supplies, which are the standard charges for the

specific provider and consistent with the prevailing charges in the geographical

area for identical or similar services, taking into account the nature of illness

involved”.

Hence the claim settlement is in order.

22. Reason for Registration of Complaint:- Rule no. 13(1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with”Any partial or total repudiation of claims


23. Documents placed before the Forum.


Claim settlement letter of the Insurer dated 18.09.2019






Discharge summary/Bills of Dr. U Mohan Rau Memorial Hospital, Chennai

24. Result of hearing (Observations & Conclusion)

Mr. Surendra J Shah, Complainant and Mr. Vijay Shankar, insurer‟s

representative attended the hearing.

The Forum records its displeasure over the delay of two months in submission

of SCN by the insurer. The insurer is hereby directed to henceforth submit the

SCN on time.

The RI submitted that the patient underwent sebaceous cyst excision in a non-

network hospital and the surgeon fees charged by the hospital is INR 18,500

which is very high compared to charges of similar hospitals. Hence the claim

was subjected to Reasonable and Customary Charges clause and an amount

of INR 8,000 was disallowed from the surgeon‟s fee.

The Forum observed that the insurer had not produced proof of prevailing

charges for the procedure and directed the insurer to submit evidence of

comparable rates charged by the nearby hospitals based on which the claim

was settled by them.

The RI responded that earlier they had verbally contacted the nearby hospitals

for the approximate amount for the subject surgery and since the Forum

directed them to produce the hard copy, the same will be procured and

submitted. They have responded subsequent to the hearing vide their mail

dated 14.03.2020 that they could submit details from only one hospital and the

other hospitals could provide the details only if the patient gets admitted in

their hospital or if they have taken consultation with their inhouse consultant.

The insurer submitted their inability to provide the details in hard copy. It is

observed that as per their verbal communication with the hospitals, the

charges are in the range of INR 25,000 to INR 28,000 . Hande Hospital has

stated that the open (non-PPN) package charges for Infected Sebaceous cyst

excision is INR 27,500, as against the amount of INR 29,070 billed by the

treating hospital.

Based on the foregoing, the Forum is of the view that the variation in the

charges of the treating hospital and other hospitals is not significant and the

deduction made by the insurer is not justified.

AWARD



the respondent insurer to pay the complainant a further sum of INR 8,000

towards full and final settlement of the claim along with interest as provided under

Rule 17(7) of the Insurance Ombudsman Rules, 2017.












Ombudsman.



Dated at Chennai on the 31st day of March, 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY (UNDER RULE NO: 17(1) ofTHE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M.VASANTHA KRISHNA

CASE OF:Ms S.SANTHI VsLIFE INSURANCE CORPORATION OF INDIA

REF: NO: CHN-H-029-1920-0527

AWARD NO: IO/CHN/A/HI/0262/2019-20

1. Name & Address of the Complainant Ms S.Santhi W/o Shri L.Subramanian No. 53/B-40, Rani Anna Nagar, Chinna Thirupathi, Salem-636 008

2. Policy No. Date of Commencement (DOC) of policy Name of the Plan Mode of premium payment Instalment Premium Term of the policy No. of members covered (other than principal insured)

709610036 21/08/15 LIC’s Jeevan Arogya (Table 904) Yearly Rs. 3,196 28 years Nil

3. Name of the principal Insured S.SANTHI

4. Name of the insurer Life Insurance Corporation of India, DO, Salem



Suppression of Pre-existing Illness in the Proposal

7. Date of registration of the complaint 10/01/20

8. Date of receipt of Annexure VI-A from the complainant

13/01/20

9. Nature of complaint Repudiation of health claim

10. Amount of (admissible) Claim Nil


12. Amount of relief sought Rs. 5,500

13. Complaint registered under Rule No. 13 (1) (b) of the Insurance Ombudsman Rules, 2017

14. Date of hearing& Place of hearing 21/02/20&Chennai


a) For the Complainant Complainant was absent

b) For the insurer Shri V.Rajamani,

Administrative officer,LICI, DO, Salem


17. Date of Award 31/03/2020


In the year 2015, Ms S.Santhi, the complainant herein, took Jeevan Arogya (Table 904)

policy from Life Insurance Corporation of India, herein the insurer. During June 2019, the

complainant underwent Cataract surgery (PHACO with Aurofold IOL). After intimating the

TPA of the insurer regarding the surgery, the complainant submitted claim form dated

12/06/19 to the insurer along with Hospital Treatment Form dated 12/06/19, completed by the

Medical officer of Aravind Eye Hospital, Salem. After processing the claim, the insurer found

that the complainant had suppressed details pertaining to pre-existing condition/disease of

Diabetes Mellitus (DM) while effecting the subject policy. Whileso, the insurer, repudiated the

claim and communicated the same to the complainant, vide its letter dated 21/11/19.

Aggrieved, the complainant has filed this complaint.



The complainant‟s case is that the treatment rendered to her is sudden and in no way

connected to Diabetes Mellitus (DM). Although the complainant didn‟t attend the hearing, she

submitted a written statement wherein she stated that when the policy was taken in August

15 she was suffering from DM and after taking medicines for the last two years the disease is

under control. She has further stated that the physician by mistake mentioned (in the

Discharge Summary) that she had DM for a long time.


As per the Discharge Summary (DS) of the hospital, the patient, herein the complainant, was

diabetic for last 10 years. As pre-existing disease was not disclosed, the claim was rejected

under H01 code.

20) Reason for Registration of Complaint: This is a case of repudiation of health claimand

hence, comes within the scopeof Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017.

21) Documentssubmitted to the Forum:

Proposal form dated 11/08/15 Policy document dated 18/09/15 Claim Intimation form dated 12/06/19 Claim Form dated 12/0619 Hospital Treatment form dated 12/06/19 Discharge Summary of Aravind Eye Hospitals, Salem Opinion of Divisional Medical Referee (DMR) dated 18/07/19 Opinion of Divisional Office Disputes Redressal Committee (DODRC) Repudiation letter dated 21/11/19 of the insurer Complaint dated 24/12/19 to the Forum Annexure VI-A dated nil submitted by the complainant Self-Contained Note (SCN) dated 20/01/20 of the insurer Complainant‟s letter dated 16/02/20

22) Result of hearing(Observations & Conclusion): Based on the submissionsmade by

the insurer during the hearing and the documents submitted by both the parties, it is

observed as under:

a) The complainant is the principal insured and the policy provides health insurance coverage

to the complainant. Jeevan Arogya is a non-linked health insurance plan providing pre-

determined benefits for hospitalization and scores of surgical procedures, irrespective of

actual cost incurred on treatment.

b) The Insurer, vide its letter dated 21/11/19, informed the complainant that the claim was

repudiated under repudiation code “H01-Pre-existing illness irrespective of prior medical

treatment or advice”. The insurer‟s contention is that the insured member suppressed the

details pertaining to pre-existing condition/disease in the proposal form and hence, the claim

was not considered for admission and payment as per the pre-existing clause 1(xii)/clause

1(xxv)/clause 6(11)(ii)/clause 6(1)(i) and/or as per Fraud clause 22(xii)/clause 19(xii) specified

in the policy. The insurer further added that the policy became “void”, effective from 21/11/19,

as per the terms and conditions of the policy. The repudiation letter didn‟t spell the details

regarding “pre-existing illness” which was alleged to have been suffered by the complainant.

c) i) The insurer has provided copy of the “Claim form & other documents to be submitted to

LIC” dated 12/06/19, completed by the complainant and also, “Hospital treatment form” dated

12/06/19, completed by the Medical officer, Aravind Eye Hospital, Salem.

ii) In “Claim form & other documents to be submitted to LIC”, the complainant mentioned “LE-

defective vision: LE-immature cataract” as the “nature of disease/illness/injury”. While

replying to the question, viz. Date of disease/illness/injury first detected, the complainant

mentioned “6 months”. The complainant had replied in negative to the question, “details of

past history of disease with initial diagnosis”.

iii) In the “Hospital Treatment form”, the Medical Officer, in reply to the question, “Brief

description of the treatment given for present hospitalization”, mentioned “PHACO with

Autofoldable IOL”. To the question, “whether the present ailment/disease is a complication of

any pre-existing condition that the patient is suffering from”, the Professor didn‟t furnish any

details and kept it blank. Same is the case with regard to the question, “Diagnosis”.

iv) In the Discharge Summary (DS) of Aravind Eye Hospitals, Salem where the complainant

underwent cataract surgery, it is mentioned as “Diabetes, 10 years” against “Systemic”.

v) A plain reading of the above hospital record reveals that the complainant was suffering

from DM for 10 years immediately preceding her hospitalization. The date of hospitalization

being 11/06/19, it follows that the complainant would have been suffering from DM since the

year 2009. The complainant too admitted in her letter dated 16/02/20 to the Forum that she

was suffering from DM at the time of taking the Policy in the year 2015. However, she has

disputed the duration of 10 years mentioned in the discharge summary of Aravind Eye

Hospital. It is her contention that the disease is under control after taking medicines for the

past two years. Therefore, the contention of the insurer that the complainant had a pre-

existing illness of DM which was not disclosed in the proposal form is well established.

vi) The subject policy was issued in the year 2015 and hence, it was complainant‟s bounden

duty to disclose the said information in the proposal form while taking the subject policy.

Perusal of the proposal form dated 11/08/15, however, reveals that the complainant failed to

disclose details of her suffering from “DM” while replying to Q no. 7 (ii) of “Health Details and

Medical information” section of the proposal form. The relevant question is: “Has the life to be

insured ever suffered or is suffering from Diabetes or raised blood sugar?”

d) i) Clause 7 (i) of the policy document stipulates that no payment shall be made for any

claim on account of hospitalization or surgery directly or indirectly caused by, based on,

arising out of howsoever attributable to any pre-existing condition unless disclosed to and

accepted by the insurer prior to the date of cover commencement or the date of revival (as

the case may be).

ii) As per the policy document, the term “Pre-existing disease” is defined as “any condition,

ailment or injury or related conditions (s) for which the policyholder had signs or symptoms

and/or were diagnosed and/or received medical advice/treatment within 48 months prior to

the date of commencement of the policy”.

iii) The insurer‟s stand is that the insured member, herein the complainant, suppressed

details pertaining to pre-existing condition/disease in the proposal form. However, going by

the language employed in the repudiation letter, it is clear that the insurer repudiated the

claim only for non-disclosure of material fact (DM) in the proposal form dated 11/08/15, by

invoking clause no. 15 (Forfeiture in certain events).

__________________________________________________________________________

There is no doubt that Diabetes can certainly damage specific parts of the eye including the

retina, optic nerve, lens, etc which would ultimately contribute to cataract and hence, there is

direct relationship between the PED (Diabetes) and the surgery undergone by her (cataract)

for which claim was made. This being so, the claim under the subject policy is not payable in

accordance with the provisions contained in PED clause also, viz. clause no. 7(i) of the policy

document.

e) As mentioned above, the discharge summary reveals that the complainant was suffering

from DM for the last 10 years which fact was not disclosed in the proposal form dated

11/08/15. Clause 15 of the Policy document (Forfeiture in certain events), “inter alia”,

provides for declaring the policy “void”, in case the proposal form contains any untrue or

incorrect statement. Whileso, the insurer‟s action of repudiating the claim and declaring the

policy “void” is in accordance with the terms and conditions of the subject policy.

f) The insurer, in its repudiation letter dated 21/11/19, quoted irrelevant clauses (of the policy

document) concerning Pre-Existing disease/illness. Another aspect which deserves mention

is that the insurer didn‟t advise the complainant to approach its Grievance Redressal Officer

(GRO), in case she disagrees with the decision of the insurer. Instead, it advised the

complainant to directly approach this Forum which is in violation of “Grievance Redressal

Procedure”, outlined in Regulation No. 17 (read with Annexure-I) of the IRDAI (Protection of

Policyholders‟ Interests) Regulations, 2017. The insurer is, therefore, advised to take note of

these observations and take appropriate corrective action.

23)

In case the decision of this Forum is not acceptable to the complainant, she is at

liberty to approach any other Forum/Court as she may deem fit, against the

respondent insurer.

Dated at Chennai on this 31stday of March, 2020

(M.VASANTHA KRISHNA)

INSURANCE OMBUDSMAN

STATE OF TAMIL NADU & PUDUCHERY

AWARD

Taking into account the facts and circumstances of the case & the submissions made by

both the parties during the course of hearing, this Forum is of the view that Insurer’s

decision to repudiate the health claim under Policy Nos. 709610036 and also, declaring the

policy “void”, is justified and hence, does not warrant intervention by this Forum.

The Complaint is, therefore, NOT allowed.

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)


CASE OF Mr. Kamalesh Jain vs National Insurance Company Limited COMPLAINT REF: NO: CHN-H-048-1920-0537



Mr. Kamalesh Jain A-10, Ray Shrene Apartments No.27, Ritherdon Road, Vepery, Chennai-600007

2.


500411501810001356 National Mediclaim Policy 28/12/18 to 27/12/19 INR 5,00,000 plus Cumulative Bonus (CB) INR 1,48,750


Mrs. Chandan Jain Mr. Kamalesh Kumar Jain

4. Name of the Insurer National Insurance Company Ltd

5. Date of Short Settlement Not Available

6. Reason for Short settlement Claim exceeds Preferred Provider Network (PPN) tariff


8. Nature of Complaint Short settlement of Claim


29/01/2020

10. Amount of Claim INR 1,94,843+ INR 25,285 (Pre & Post Hospitalisation expenses)

11. Amount paid by Insurer, if any INR 90,000 + INR 9,319


INR 1,20,909


INR 1,20,909

14. a.

Date of request for Self-Contained Note (SCN)

14/01/2020

14. b.

Date of receipt of SCN 31/01/2020

15. Complaint registered under Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017



e) For the Complainant Absent

f) For the Insurer Mr Murugan K & Dr Deepti, Heritage TPA




The complainant had covered himself, his spouse and dependent children under

National Mediclaim Policy with the Respondent Insurer (RI). The policy first incepted

in the year 2014 and was renewed continuously without any break. . On 09/07/19,

during the policy period of 28/12/2018 to 27/12/2019, his wife Mrs. Chandan Jain was

admitted in Apollo First Med Hospital and underwent hysterectomy. The pre-

authorisation request for cashless hospitalisation for INR 1,30,000 was approved for

an amount of INR 90,000 and subsequently the claim submitted for reimbursement of

pre and post hospitalisation expenditure and balance of hospital expenditure (not

approved through cashless mechanism) was short settled by the Insurer. There was

no response to the representation made by the complainant on 13/09/2019 to the

Grievance Department of the insurer, seeking full settlement. He has therefore



i. He stated that his wife was admitted in hospital and the claim submitted to

Insurer was short settled by INR 1,20,909. He was informed by the insurer

that the claim was settled as per „PPN/GIPSA‟ declaration.

ii. The subject policy is in force from 2014 and renewed continuously without any

break.

iii. He has requested the Forum to direct the insurer to pay him the deducted

amount.

b) Insurer’s submission:

i. The Insurer stated that thesurgery/procedure was carried out in a PPN

Hospital. Hence the PPN tariff was applied for claim settlement. They

further stated that the complainant was clearly explained at the time of

admission that the reimbursement of hospital expenses would be as per

the tariff applicable under PPN agreement which in this case was INR

90,000.

ii. Sum Insured (SI) in respect of the insured person under the subject

policy is INR 5 lakhs and in addition she was eligible for a Cumulative

Bonus (CB) of INR 1,48,750. As per the Policy terms and conditions,

the Complainant was eligible for a room rent including nursing of 1% of

the SI per day subject to a maximum of INR 5,000. But the Complainant

availed deluxe room @ Rs.7450 per day. Hence the pre-authorisation

for cashless facility was restricted to INR 90,000, as applicable to

private room package (based on room rent of INR 4,600 per day). The

final bill for hospitalisation was for INR.2,04,843 and after adjusting the

pre-authorisation approval for INR 90,000, the complainant paid an

amount of INR 1,04,483 in settlement of the bill, with INR 10,000

allowed as discount by the hospital.

iii. Pre and Post Hospitalisation Claim submitted for INR 25,385 was

settled for INR 9,319.

Therefore, the settlement is as per the PPN agreement.





Written Complaint to the Ombudsman dated 27/11/2019 (received on

18/12/2019)

Complainant‟s representation to the insurer dated 09/09/2019

Request for cashless hospitalisation dated 10/07/2019

GIPSA Network declaration form dated 09/07/2019

Authorisation for cashless hospitalisation dated 13/07/2019





Insurer‟s Claim settlement advice mail dated 26/08/2019


Bills and Discharge Summary of Apollo First Med Hospitals

24. Results of hearing (Observations and Conclusion):

The Complainant was absent for the hearing. The Insurer‟s representative

Mr. K. Murugan and the TPA‟s representative Dr Deepti were present.

During the hearing the Insurer stated that open billing was done by the hospital

since there was no PPN tariff for Deluxe room opted by the Complainant. The

amount of INR 90,000 was settled as per the PPN package applicable to

single room. The Policy is not subject to Proportionate clause.However, the

room charges and related expenses as per clause 2.1 of the policy are

restricted to 1% of SI per day and a maximum of 25% of the SI. Similarly,

medical practitioner‟s fees are limited to a maximum of 25% of the SI and other

expenses to 50% of the SI. The insurer contended that the complainant had

signed GIPSA declaration whereby he opted for deluxe room and agreed to

bear the cost over and above PPN tariff. It was also explained to the insured at

the time of admission by the hospital authorities that the hospital falls under

PPN and reimbursement of expenses by the insurance company towards PPN

procedures is subject to PPN package pricing.

The Forum is of the view that since there is no PPN tariff for deluxe room

occupied by the insured, the claim should have been settled as per open billing

and not on the basis of PPN tariff for single room (described however as Semi

Private room in the cashless authorization letter dated 13/07/2019 of the TPA).

The Insurers were therefore asked to submit revised calculation showing

admissible amount under open billing which they did post hearing vide their

email dated 17.03.2020. Accordingly, the admissible amount towards

hospitalisation works out to INR 1,60,809 as shown in the table below.

Sl

no.

Head of

account

Amount

claimed(

INR)

Amount

allowed

(INR)

Amount

deducted

(INR)

Remarks

1 Room rent 29800 20000 9800 Eligible room rent per

day INR 5000 *4 days

2 Professional

charges

63550 63550 0 25% of Sum Insured

(162188)

3 Others 111493 77259 34234 50% of SI ( 324375)

Non-Medical Items

(NMI)-11,633, Misc-

4581, Infusion Pump-

920; Non medical

equipment- 7100;

Hospital discount-

10,000

Total 204843 160809 44034

The amount of INR 7,100 disallowed is towards use of laparoscopic camera for

the purpose of surgery. In the opinion of the Forum, the amount is payable

since it is not towards the cost of the equipment but for its use. Hence the

correct amount payable in settlement of the claim is INR 1,67,909 (INR

1,60,809 plus INR 7,100). Since an amount of INR 90,000 is already settled on

cashless basis, the balance amount payable to the complainant is INR 77,909.

The settlement made by the insurer towards pre and post hospitalisation claim

is in order and does not warrant any intervention by the Forum.

AWARD

Taking into account the facts of the case, submissions made during the hearing and

the documents submitted, the Forum hereby directs the insurer to pay the

complainant an additional amount of INR77,909 along with interest at applicable rates

as provided under Rule 17(7) of the Insurance Ombudsman Rules, 2017.

The Complaint is thus allowed.














Dated at Chennai on the 31st day of March, 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Mr. K Jawarilal VsThe New India Assurance Company Ltd




Mr. K Jawarilal No. 96, Govindappa Naicken Street, Parrys, Chennai 600001


71090534189500000541 New India Mediclaim Policy 27/12/2018-26/12/2019 INR 6,00,000


Mr K Jawarilal Mr K Jawarilal

4. Name of the insurer The New India Assurance Company Ltd



Exclusion clause 4.4.11 of the policy


8. Nature of complaint Non-settlement of the claim


22/01/2020

10 Amount of Claim Not furnished

11


INR 1,34,784



INR 1,34,784 plus interest


06/01/2020




16. Date of hearing/place 10/03/2020/ Chennai


For the Complainant Mr. Dilip Kumar (Complainant’s son)

For the insurer Mr. R Subramanian




The Complainant Mr K Jawarilal, was covered under respondent insurer‟s New India

Mediclaim Policy for the period from 27/12/2018 to 26/12/2019 for a Sum Insured of

INR 6 lacs. He was admitted in Sri Singhvi Health Center on 16/02/2019 with several

complaints such as severe generalized weakness progressing slowly from the lower

limbs ascending upwards to the hands and chest over the past 20 days, difficulty in

lifting or moving the hands for 4-5 days, altered gait, severe nausea, vomiting on and

off, difficulty in taking oral foods, loss of appetite, difficulty in walking and fever of 10

days and the diagnosis was HIV-Encephalopathy/Subcortical Infarcts and Right

Upper Trunk (C5-C6) Brachial Plexopalsy. Claim preferred for his hospitalization

was repudiated by insurer as per exclusion 4.4.11 of the policy which excludes AIDS.

Aggrieved by the repudiation of the claim, he represented to the insurer for

reconsideration of the claim. Since there is no reply from them, complainant has

approached this Forum for redressal.


Complainant submitted that he has been holding the subject policy with respondent

insurer for more than 20 years and the infection was diagnosed after taking the

policy. Hence the claim is payable and Forum‟s intervention is requested for

settlement of the same.


Insurer‟s TPA in their repudiation mail dated 24.10.2019 stated that the diagnosis

arrived at was HIV-Encephalopathy/Subcortical Infarcts, Right Upper Trunk (C5-C6)

Brachial Plexopalsy. Hence the claim was repudiated as per clause no. 4.4.11 of the

policy which reads as under:

“No claim will be payable under this Policy for the following:

4.4.11. Sexually Transmitted Diseases, any condition directly or indirectly caused to

or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or

lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation

Deficiency Syndrome or any syndrome or condition of a similar kind commonly

referred to as AIDS.”

However, in the SCN submitted, the Insurer stated that the claim was rejected under

clause 4.4.46 of the policy reading as under

“No claim will be payable under this Policy for the following:

Convalescence, general debility, 'Run-down' condition or rest cure, obesity treatment

and its complications, treatment relating to all psychiatric and psychosomatic

disorders, infertility, sterility, Venereal disease, intentional self-Injury and Illness or

Injury caused by the use of intoxicating drugs/alcohol.”

22)Reason for Registration of Complaint: - Rule no.13 (1) (b) of the Insurance



23)Documents placed before the Forum.


Claim repudiation E Mail of insurer‟s TPA dated 24/10/2019




Self-Contained Note(SCN) of the insurer dated 27/02/2020

Discharge summary of Sri Singhvi Health Center, Chennai

Certificate from Dr Sunil Singhvi dated 26.07.2019

1. 24) Result of hearing (Observations & Conclusion)

1. The Complainant authorized his son Mr. Dilip Kumar to

attend the hearing. Mr. R Subramanian was present at the

hearing on behalf of the insurer.

2. The Forum records its displeasure over the delay in submission of SCN by the

insurer. Similarly, the lack of response to the representations made by the



3. During the hearing the Complainant‟s son stated that the claim preferred by his

father was rejected as he was diagnosed with HIV. He contended that his

father was hospitalized for encephalopathy and was treated for the same and

not for HIV.

4. The Insurer argued that the medical records showed that the patient was

suffering from HIV. Hence exclusion clause 4.4.11 relating to HIV was invoked

and the claim was rejected.

5. Upon scrutiny of the discharge summary, it was observed that the complainant

was treated for HIV-Encephalopathy/Subcortical Infarcts, Right Upper Trunk

(C5-C6) Brachial Plexopalsy.

6. AIDS is a permanent exclusion as per condition 4.4.11 of the policy.

7. Complainant‟s argument is that HIV was diagnosed after the inception of the

policy. He submitted a certificate from Dr Sunil Singhvi dated 26.07.2019

wherein it is stated that the Complainant was diagnosed with HIV in August

2010 and is under treatment for the last 9 years. He developed HIV

Encephalopathy in February 2019 and had no similar symptoms in the past.

The contention of the complainant that HIV was diagnosed only after taking the

policy is not tenable as AIDS is a permanent exclusion under the policy.

8. Although the insurer stated in the SCN that the claim was repudiated under

clause 4.4.6 of the policy relating to general debility, run down condition, etc.,

the claim repudiation mail sent by the TPA to the Complainant states that the

claim was denied under exclusion clause 4.4.11 of the policy relating to AIDS.

The Forum regrets to note that the SCN was prepared by the insurer without

diligence, citing a wrong exclusion.

9. The claim repudiation mail dated 24.10.2019 was sent by the TPA to the

Complainant. This is a violation of IRDAI Health Regulations, 2016. The said

regulations provide that the TPA can only process the claim and the rejection

of claim should be communicatedto the insured only by the insurer. The

insurer is advised to strictly comply with the Regulations.

10. The medical records and the certificate from the treating doctor confirm that

the complainant was suffering from HIV and on treatment. The present

treatment was also for HIV encephalopathy. Any treatment relating to HIV is

not payable under clause 4.4.11 of the policy which states that any condition

directly or indirectly caused to or associated with Human T-Cell Lymphotropic

Virus Type III…” is not payable.

Hence the repudiation of claim by the insurer is in order.

AWARD


made by both the parties during the course of hearing, Forum is of the view that the

repudiation of claim by the insurer is in order and does not warrant any intervention.

Thus, the complaint is notallowed.



insurer.

Dated at Chennai on the 31st day of March, 2020


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




CASE OF Dr. V. R. Deiva Prasath Vs Star Health and Allied Insurance Co. Ltd


Award No: I0/CHN/A/HI/0267/2019-2020


Dr. V. R. Deiva Prasath Door No 16/16 Main Road Colachel Post Kanyakumari District Tamilnadu – 629 251

2. Policy No. Type of Policy Duration of Policy/Policy Period Basic Floater Sum Insured(SI)

P/181114/01/2020/000097 Family Health Optima Insurance - 2017 11.04.2019 to 10.04.2020 INR 5 lacs

3. Name of the Insured & Name of the Policyholder/Proposer

Dr. V. R. Deiva Prasath Dr. V. R. Deiva Prasath




Pre-existing Disease (PED) related waiting period




24.01.2020




Not mentioned


Not mentioned


06.01.2020




16. Date of Hearing/Place 09.03.2020/Chennai

17. Representation at the Hearing For the Complainant Dr. V R Deiva Prasath For the Insurer Dr Asiya Sahima & Ms Hemalatha 18. Disposal of Complaint By Award 19. Date of Award/Order 31.03.2020


The complainant and his spouse were covered under Family Health Optima

Insurance Policy with the respondent insurer (RI) for a floater Sum Insured (SI) of INR

5 lakhs. The policy first incepted on 11.04.2019 and the period of insurance under the

subject policy is 11.04.2019 to 10.04.2020. The complainant was admitted in Kerala

Institute of Medical Sciences (KIMS), Trivandrum with complaints of chest pain and

underwent Coronary Artery Bypass Graft (CABG). A claim for reimbursement of

hospitalization expenses to the extent of INR 4,04,807was submitted to the insurer.

The insurer repudiated the claim on the ground that the treatment was for a Pre-

Existing Disease (PED) which has a waiting period of 48 months under the subject

policy. The complainant sent a representation to the insurer for reconsideration of the

claim, but the insurer expressed their inability. He has therefore approached this

Forum for relief.


1. The complainant stated that he was hale and healthy, non-diabetic and

normotensive, used to climb a three-storey building (his nursing home cum

residence) 4-5 times a day and go for regular walk every day for 40 minutes.

He stated that he suffered chest pain (for the first time) on 7.08.2019 after

driving for 2 hours, which subsided after rest.

2. On 10.08.2019, he consulted Dr. Jayaseelan of JK Hospital, Nagercoil, who

advised him to take ECG. He was then referred him to KIMS, Trivandrum,

where he underwent Coronary Angiography (CAG) and CABG.

3. However, the claim submitted to insurer for reimbursement of treatment

expenses to the extent of INR 3.80 lakhs was rejected, on the ground of

disease being pre-existing.

He has therefore requested the Forum to direct the insurer to pay the claim.


In the SCN submitted by them, the insurer confirmed that the complainant had

preferred a claim for CABG undergone by him, in the fourth month of the very

first Family Health Optima Insurance policy availed. The pre-authorisation

request for cashless treatment and subsequently the claim submitted for

reimbursement of expenses by the Complainant was rejected on the ground

that the admission and treatment was for a Pre-Existing Disease (PED).

PEDs have a waiting period of 48 months under clause no 3(iii) of the Policy.

The insurer argued that as per the discharge summary of the treating hospital,

the insured patient had complaints of Dyspnea on exertion for the past 1 year,

which is prior to the inception of the Policy. Further the Coronary Angiography

(CAG report) dated 12.08.2019 showed diagnosis as Coronary Artery Disease

(CAD) – Left Main Coronary Artery (LMCA) and Critical Triple Vessel Disease

(TVD).

From the above facts it was confirmed that the Complainant had symptoms of

heart ailment prior to the commencement of insurance and hence it was a PED

which is not payable under waiting period clause 3(iii) of the Policy and the

same was communicated to him on 18.09.2019.

Diseases of Cardio Vascular system were then incorporated as PED in the

Policy by passing necessary endorsement.



claims by the life insurer, General insurer or the health insurer.



Request for cashless hospitalization dated 12.08.2019

Denial of pre-authorisation request for cashless treatment dated 13.08.2019


Complainant‟s representation to the insurer dated 21.10.2019

Consent (Annexure VI A) submitted by the Complainant dated 20.01.2020


Copy of Proposal Form dated 10.04.2019



Discharge Summary and Indoor Case Papers (ICP) of KIMS, Trivandrum

CAG report dated 12.08.2019

Certificate of Dr. Shantala K Prabhu, KIMS, Trivandrum, dated 24.09.2019

Opinion dated 02.03.2020 of Dr. ArunKumar Krishnasamy

Opinion of Dr. Refai Showkathali, Senior Interventional Cardiologist of BRS

Hospital

Opinion of Dr. Thillai Vallal, Cardiologist of Venkataeaswara Hospitals,

Chennai

24) Results of hearing (Observations and Conclusion)

The Complainant Dr. Deiva Prasath and the insurer‟s representatives Dr Asiya

Sahima and Ms Hemalatha were present for the hearing.




During the hearing, the Complainant stated that he availed the insurance after

his retirement. He never experienced chest pain prior to commencement of the

policy. It is when he could not walk beyond a distance, he consulted a

cardiologist who said he was suffering from Dyspnea but it was not significant

considering his age. The complainant contended that the symptoms of Dyspnea

had nothing to do with the heart.

The Insurer stated that as per the opinion of their panel doctor the symptom of

Dyspnea was suggestive of cardiac disease prior to availing the insurance.

Further the medical records revealed that the extent of occlusion with respect to

Triple Vessel Disease was more than 70%. As per the discharge summary of

the treating hospital, the complainant had symptoms of Dyspnea for past 1-year

andthe CAG report showed diagnosis as CAD- LMCA and Critical TVD. The

insurer argued that it was evident from medical records that the insured patient

was suffering from the disease prior to commencement of the policy i.e.

11.04.2019 andthe claim is in the first year of the policy, coming within the

waiting period exclusion.

The Insurer also submitted a copy of proposal wherein against a specific

question on existence of Heart diseases the Complainant had replied “No”

which amounts to non-disclosure of material facts. However, the Insurer did not

invoke non-disclosure at the time of rejecting the claim.

Upon perusal of the discharge summary it is observed that that the complainant

was admitted with recently developed chest pain. He had history of Dyspnea on

exertion for 1 year. CAG revealed left main stem stenosis with triple vessel

disease and he was advised surgical revascularisation.

The complainant submitted a certificate from the treating surgeon dated

24.09.2019, wherein it is confirmed that the chest pain suffered by the

complainant is a new onset symptom for which he underwent CABG on

14.08.2019. The patient had mild dyspnea for one year after exerting for more

than one hour. It is observed that even in response to the query raised by the

insurer at the time of processing the request of the hospital for cashless facility,

the treating surgeon had clarified that there was no previous history of heart

disease.

The insurer submitted to the Forum the opinion obtained by them from Dr.

ArunKumar Krishnasamy. While he has confirmed the diagnosis of Acute

Coronary syndrome, no view is expressed by him on the issue whether the

disease was pre-existing.

The Forum also obtained expert Medical Opinion from Dr. Refai Showkathali,

Interventional Cardiologist, BRS Hospital, Chennai, who opined that reliance has

to be placed on the Out-Patient (OP) consultation record of the hospital, rather

than the discharge summary since the OP record is made by the consultant. As

per OP record, the complainant had reported with new onset angina of 2 weeks

duration. One more opinion has been obtained by the Forum from Dr. Thillai

Vallal, Cardiologist of Venkataeaswara Hospitals, Chennai, who too is of the

opinion that the available medical records do not establish that the disease was

pre-existing.

As per definition of pre-existing disease in the policy, there should be signs or

symptoms and or diagnosis and or treatment of the disease or a related

condition prior to inception of the policy, in order to constitute a pre-existing

disease. In the present case, there was no diagnosis or treatment of heart

disease prior to policy inception and the insurer relied upon the reported

symptom of Dyspnea on walking to conclude that complainant had a pre-existing

heart disease. However, causes for Dyspnea are many, including heart disease

and there is no hard evidence that complainant‟s Dyspnea was due to heart

disease.

The Forum notes from the ICP of KIMS that the complainant had an episode of

acute tracheobronchitis prior to surgery and was seen by Dr. P. Arjun,

Respiratory Consultant. As per notes made by the Consultant, the complainant

had stopped smoking three months before and hence the possibility of

Dyspnea being due to his smoking habit cannot be ruled out.

Based on the foregoing, the Forum gives the benefit of doubt to the complainant

and concludes that there is no reasonable and satisfactory evidence to show

that his heart disease was pre-existing.



AWARD


both the parties during the course of hearing, Forum is of the opinion that the rejection of

the claim by the insurer is not justified. The insurer is hereby directed to settle the claim

of the complainant for INR 4,04,870 subject to other terms and conditions of the Policy

along with interest at applicable rates as provided under Rule 17(7) of the Insurance


Thus, the complaint isAllowed.









Ombudsman.



Dated at Chennai on this 31st day of March, 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF : : Complainant MRS. GAYATRI DAS PURKAYASTA VS ADITYA BIRLA HEALTH INSURANCE CO.

COMPLAINT REF NO:: GUW-H-055-1920-0144 Award No

1. Name & Address of the Complainant MRS.GAYATRI DAS PURKAYASTHA

2. Policy No:

Type of Policy


11-19-0014652-00

MEDICLAIM

24/08/2019 TO 23/08/2020



MRS GAYATRI DAS PURKAYASTHA MRS.GAYATRI DAS PURKAYASTHA

4. Name of the insurer ADITYA BIRLA HEALTH INSURANCE CO.

5. Date OF OCCURANCE OF LOSS/CLAIM 19/09/2019

6. DETAILS OF LOSS Rs.60441/-

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance ombudsman

Rule 2017

8.a

8.b

Nature of complaint

Date of receipt of the complain

WITHDRAW THE POLICY & REFUND THE

MONEY

04/03/2020

9. Amount of Claim RS.60441/-

10. Amount of Partial settlement NIL

11 Amount of relief sought RS.60441/-

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati,

17/03/2020


For the Complainant

For the insurer

15 Complaint how disposed Through personal Hearing


17) Brief Facts of the Case: As stated by the complainant Mrs Gayatri Das Purkayastha that ,policy

No.1119001465200 was sold to her by Aditya Birla Health Insurance Co. Ltd. for the period from

24/08/2019 to 24/08/2020.An amount of Rs 60441/- was paid by the complainant to Aditya Birla

Health Ins Co. Ltd. As the policy was issued to her on misinformation, she addressed them a letter

dt.19/09/2019 in which she stated that on 13/08/2019 one Mr. Subarna Changmai Borgohain sold

the policy to her for which she provided all information about her pre-existing diseases (diabetes,

pressure, retinopathy and hematological problems.)The information provided by Mr. Borgohain did

not match with the policy conditions. She immediately contacted branch manager and conveyed

her displeasure of providing wrong information and also about manipulation of the medical test

reports. Mr. Borgohain even instructed her not to disclose about diseases other than diabetes to

the person coming for blood sample collection. The policy holder expressed dissatisfaction over the

medical report done initially; a second test was carried out to reconfirm which was also

manipulated not only in report but also showing it a regular testing for reimbursement without her

knowledge. Under the circumstances, she appealed to the insurance co to withdraw the policy and

refund the money to her account. The complainant also had telephonically discussed the matter

with officials of insurance co. several times, but there was no proper response. So the complainant

has written to us to pass necessary order for immediate payment of refund of premium with

interest and compensation.

18a) Complainant’s Argument: As the policy has been issued to her by giving wrong information

and on the basis of misrepresentation of benefits available under the policy, full refund of premium

should be made to her along with interest @ 12 % up to the date of payment.

18 b) Insurers’ Argument:

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule

after proper approval from honorable ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N Result of hearing with both parties (Observations & Conclusion):- Both the parties were called

for hearing on 21/02/2020. The complainant was represented by Mr.Bikash Dutta and the insurer was represented by Mr.Arif Hussain.

DECISION We have taken in to consideration the facts and circumstances of the case from the

documentary as well as verbal submission made by the claimant and representative of

Insurance Co. We have also gone through the records. The Insurance co. repudiated the claim

stating that the insured patient was diagnosed of ESRD/HYPERTENSIVE NEPHRO PATHY and

HTN was endorsed PED. On receipt of the Notice from our office,the claim was once again

reviewed.On the day of Hearing i.e.21.02.2020 the insurance co informed us by email that they

have already settled the claim amicably with the insured and if the client wishes to continue

the policy the renewal block would also be removed. During the course of hearing the

complainant expressed his satisfaction over the agreed amount of Rs.535974/(Patient

Exp.Rs.460690/-+Donor Exp.Rs.75284/-).Under the circumstances, the Forum directs the

insurance co. to pay the settled amount to the insured.


The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rules, 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of

the receipt of the award and intimate compliance of the same to the Ombudsman.

. Dated at- Guwahati, The 21ST day of February 2020

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri Suresh Chandra Panda CASE OF Mr. Saumindra Prasad Das Vrs. M/S United India Insurance Co Ltd

COMPLAINT REF: NO: BHU-H-051-1920-0086

AWARD NO: IO/BHU/A/GI/ /2019-20


Mr. Saumindra Prasad Das Plot No-591, Sahidnagar, Bhubaneswar- 7978764873


2601002816P113701112 Family Medicare Policy 09.02.2017 to 08.02.2018 (DoA-25.07.2017 and 03.08.2017) Rs.5.00 lac for self and spouse Policy started from 01.02.2012 till 31.01.2015 SIV Rs.2.00 lac yearly basis 09.02.2015 to 08.02.2016 SIV Rs.2.00 lac (Gap of 8 days) 09.02.2016 to 08.02.2017 SIV Rs.3.00 lac (diagnosis of cataract) 09.02.2017 to 08.02.2018 Rs. Rs.5.00 lac (Hopsitalisation period)


Mr. Saumindra Prasad Das Mr. Saumindra Prasad Das

4. Name of the insurer United India Insurance Co Ltd, DO I, Bhubaneswar

5. Date of Repudiation Partially settled It is a case of partial settlement 6. Reason for repudiation

7. Dt of receipt of the Complaint 28.02.2018

8. Nature of complaint For Payment of difference amount of hospitalization expenses


10. Date of Partial Settlement Partially paid Rs.90000/- against Rs.244920/- and Rs.3506/- against Rs.10351/-

11. Amount of relief sought Rs.163673/- (including interest Rs.6900/- + Incidentals Rs.5000/-)

12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 03.03.2020, Bhubaneswar


e) For the Complainant Self

f) For the insurer Mr. P K Rout, Manager

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017

16 Date of Award/Order 03.03.2020, Bhubaneswar

17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant had taken a health insurance policy from United India Insurance Co Ltd for self and spouse for Rs.5,00,000/- the period from 09.02.2017 to 08.02.2018. As per the petition filed by the complainant, on 16.12.2016 he was diagnosed with Nuclear cataract-grade 2, in both eyes by LV Prasad Eye hospital and was advised for planned cataract surgery. On 14.06.2017 as per advice of the Doctor (AMRI Hospital) he underwent MRI test which detected Pituitary Macroadenoma. He was admitted in KIMS hospital on 25.07.2017 for surgery of Pituitary adenoma and got discharged on 31.07.2017. The TPA settled the claim for Rs.90000/-. Again, he was admitted on 03.08.2017 in KIMS for treatment of Hyponatremia (Post Op case) at 7.31 PM on 03.8.2017 and was discharged at 07.33 PM on 04.08.2017. The TPA settled Rs.3506/-/- against expenditure of Rs.10351/-. The complainant wrote to the TPA on 31.08.2017 for payment of balance amount of Rs.151773/-. He also wrote to the insurer on 25.10.2017, and to the Grievance Redressal Officer of the insurer on 09.01.2018, but after not getting the settlement, he has got aggrieved and preferred an appeal before this forum for redressal.

b. The insurer (UIIC) has submitted the SCN on 13.02.2020 and received in this office on

17.02.2020 after the reminder sent from this office for the same. The insurer states that due to 24 months’ waiting period condition, the sum insured taken for the claim was Rs.2,00,000/- and the claim assessment is done as per limits of the policy on Rs.2,00,000/- sum insured but not on Rs.5,00,000/-. The Room-rent eligibility is Rs.2000/- per day while the insured patient opted for higher category room rent of Rs.7000/-. The problem was pre-existent before 30.06.2015 and the sum insured during 2015-16 was Rs.2,00,000/-. 18. a) Complainant’s Argument: - The complainant states the insurer to settle the balance

amount of claims.

b) Insurer’s Argument: - The Insurer states that they have settled the claim based on SIV of Rs.2.00 lac and not Rs.5.00 lac as the sum insured was increased from Rs.2.00 lac to 5.00 lac.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017

20. The following supporting documents are placed in the file.

a. Photocopies of Two discharge Summary, Inpatient Bills

b. Copy of Policy Schedule

c. Copies of letters sent to insurer and TPA

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully

gone through all the documents submitted relating the complaint and heard both the parties. it is

observed that the patient was diagnosed on 16.12.2016 with Nuclear Cataract Grade 2 in LV Prasad

Eye Hospital, which comes under policy period of 2016-17 with SIV of Rs.3.00 lac. The patient was

admitted on 25.07.2017 for treatment of Pituitary Adenoma in KIMS hospital. However, the letter

dated 25.07.2017 of KIMS hospital addressed to the TPA states that the patient had difficulty in vision

in both eyes for last six months, who was advised to take neurological opinion. The neurologist

advised for MRI test, which revealed Pituitary Macroadenoma.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rules, 2017:

a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply

with the award within 30 days of the receipt of the award and shall intimate the


b. As per the Rule 17(7) the complainant shall be entitled to such interest at a rate per

annum as specified in the regulations framed under the Insurance Regulatory and

Development Authority of India Act 1999, from the date of the claim ought to have been

settled under the regulations, till the date of payment of amount awarded by the

Ombudsman.

c. As per Rule 17(8) of the said rules and award of the Insurance Ombudsman shall be

binding on the Insurers.

Dated at Bhubaneswar on the 03rd day of, March 2020

Shri Suresh Chandra Panda

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the

parties during the course of hearing, the Forum finds that though the hospitalization for diagnosis

of Pituitary Macroadenoma was done during the policy period of 2017-18 (with SIV of Rs.5.00 lac),

the medical report dated 16.06.2017 suggests the condition was existent 6 months before. It

means the condition was in existence during the policy period of 2016-17, which carries sum

insured of Rs.3.00 lac. Therefore, the assessment made by the insurer on the basis of Rs.2.00 lac

taking into account the policy period of 2015-16 is not correct as the complainant is eligible to get

benefits under the policy period of 2016-17 having sum insured of Rs.3.00 lac. Accordingly, the

insurer is directed to assess the reimbursement of hospitalization on SIV of Rs.3.00 lac and pay the

differential amount to the complainant along with penal interest in accordance with the IRDAI

(Protection of Policyholders’ Interests) Regulations, 2017.

Hence, the complaint stand admitted.

Therefore, the insurer is directed to recalculate the claim taking into account the sum insured of

Rs.3.00 lac in stead of Rs.2.00 lac and pay the differential amount to the complainant, subject to

consideration of sub-limits, co-pay, non-payable items etc under the policy terms and conditions.

Hence, the complaint is admitted.

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA,

BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mr. Dipti Praksah Pattnaik Vrs. M/S TATA AIG GENERAL Insurance Co.Ltd.

COMPLAINT REF: NO: BHU-H-047-1920-0066



Mr. Dipti Praksah Pattnaik K3A 103, Kalinga Nagar Ghatikia, Bhubaneswar 751003 (7381095901/ 8018042219)


0235072935 02 (1st inception of policy- 30.03.2016) Family Floater Plan (Self & Spouse) Rs.2.00 lac 03.04.2018 to 02.04.2019 DoA: 06.08.2018


Mr. Dipti Praksah Pattnaik Mr. Dipti Praksah Pattnaik

4. Name of the insurer M/S TATA AIG GENERAL Insurance Co.Ltd.

5. Date of Repudiation 27.09.2018 Non-disclosure of facts 6. Reason for repudiation

7. Dt. of receipt of the Complaint 26.09.2019

8. Nature of complaint Health reimbursement claim

9. Amount of Claim Rs.100218/- (Out of which Rs.43790/- is medical expenses)


11. Amount of relief sought Rs.100218/- (Out of which Rs.43790/- is medical expenses)


13(1)b




b) For the insurer Mr. Kamljit Roy, Dy. Manager-Legal



17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant has purchased a health insurance policy under Floater SIV of Rs.2.00 lac from the above-mentioned insurer for the period from 03.04.2018 to 02.04.2019. The complainant had been to LV Prasad Eye Hospital, Bhubaneswar on 20.10.2017, who advised for Cataract surgery. The complainant has Undergone eye surgery on 06.08.2018 and submitted documents (on denial of cash-less) for reimbursement. The insurer declined the claim and terminated the policy for non-disclosure of facts. The complainant not being satisfied with the denial of the claim and cancellation of the policy, preferred an appeal before this forum for redressal.

b. The insurer has stated that in the pre-authorization form and consultation paper dated 20.10.2017, it is mentioned the history of diabetes since 10 years. The complainant declared as “NO” to one of the questions in proposal form which asked if the complainant was ever said by doctor that

he had Diabetes. Since the complainant had diabetes but did not declare, this amounts to non-disclosure of facts and therefore, the claim is not payable and also the policy is cancelled under the policy conditions. 18. a) Complainant’s Argument: - The complainant has stated that on being approached by the

insurer, he purchased the insurance in 2016 when they conducted health tests. He wanted to change

the insurance in 2018 but the insurer advised him to continue with them to avail surgery waiting

periods. Then he renewed with the same insurer. The hospital has erroneously mentioned DM as 10

years instead of 01 year.

b) Insurer’s Argument: - The Insurer has stated that since the complainant had diabetes for 10 years but did not declare, this amounts to non-disclosure of facts and therefore, the claim is not payable and also the policy is cancelled under the policy conditions.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017.

20. The following documents are placed in the file.

a. Photocopies of Proposal form, Policy, & policy wordings

b. Photocopies of all hospital records and bills


gone through all the documents and papers relating the complaint and heard both the parties. It is

observed that the insurer, during the process of the cash-less claim from pre-authorization paper

dated 20.10.2017, has come to know about the patient having diabetes Mellitus (DM) in 2017 itself.

But the insurer subsequently renewed the policy without any restriction even though the insurer had

the knowledge of the DM, which means the insurer has accepted with full knowledge of the alleged

past illness. Further, there is nothing to believe that cataract was only due to the DM. The insurer had

conducted pre-acceptance heath checks, the diabetes was within the limits. It is also observed that

the insurer has not issued the policy terms and conditions.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rules, 2017:

a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply

with the award within 30 days of the receipt of the award and shall intimate the


AWARD


the parties during the course of hearing, the Forum does not find any point in denial of the

claim by the insurer. Considering the above, the insurer is hereby directed to settle the claim

and pay the complainant Rs.43790/- subject to sub-limits, co-pay, deductibles, if any, towards

full and final settlement of the claim. The insurer is also directed to restore the cancelled policy

with all renewal benefits.

Accordingly, the complaint stands admitted.



Development Authority of India Act 1999, from the date of the claim ought to have been

settled under the regulations, till the date of payment of amount awarded by the

Ombudsman.



Dated at Bhubaneswar on the 04th day of March,2020


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR (UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)


CASE OF Mr. Girish Chandra Tripathy Vrs. M/S Star Health and Allied Insurance Co Ltd COMPLAINT REF: NO: BHU-H-044-1920-0068



Mr. Girish Chandra Tripathy, 3rd Lane, Meenakhi Nagar Near Mango Market,Berhampur, Dist Ganjam, Odisha


P/700004/01/2019/005793 Family Health Optima Insurance Plan 06/09/2018 to 05/09/2019 Date Admission 13/06/2019


Mrs. Prativa Tripathy (Wife of the complainant) Mr. Pritish Tripathy (Policyholder covering parents)

4. Name of the insurer Star Health and Allied Insurance Co Ltd, Bhubaneswar

5. Date of Repudiation 08/06/2019 Non-disclosure of existing disease at the time of proposal 6. Reason for repudiation

7. Dt. of receipt of the Complaint 13/08/2019

8. Nature of complaint For payment of hospitalisation expenses.


10. Date of Partial Settlement NOT APPLICABLE


12. Complaint registered under 13(1)b

Rule no: of IO rules

13. Date of hearing/place 05/03/2020, Bhubaneswar



b) For the insurer Dr. Biswaprakash Pati, CMO

15 Complaint how disposed U/R 16(1) of the Insurance Ombudsman Rules, 2017


17. a. Brief Facts of the Case/ Cause of Complaint: - Mr Pritish Tripathy has taken a policy covering his parents under Family Health Optima Insurance Plan from M/s. Star Health and Allied Insurance Company Ltd for a floater sum insured of Rs.5,00,000/- for the period from 06/09/2018 to 05/09/2019. The complaint is made by the father of the policyholder for the hospitalisation claim against the mother of the policyholder. On 13/06/2019 the wife of the complainant was admitted at Ashwini Trauma Centre, Cuttack whose cash less settlement was declined by the insurer as the insured patient was suffering from BILATERAL OSTEOARTHRITIS KNEE JOINTS prior to portability of the policy and he has not disclosed the medical history in the proposal form. It is understood that the policy was first taken from Religare Health insurance Co Ltd for the period from 06.09.2017 to 05.09.2018 for sum insured of Rs.5,00,000/-. Being aggrieved, the complainant preferred an appeal before this forum for redressal.

b. In the self-contained note the insurer stated that, the insured person, Mrs. Prativa Tripathy, aged about 56 years was admitted at Ashwini Trauma Centre, Cuttack on 13/06/2019 and was diagnosed as OSTEOARTHRITIS BILATERAL KNEE. The insured submitted a request for pre-authorisation for cashless treatment and the same was denied stating that insured person was suffering from above mentioned disease prior to porting the policy. Subsequently, the insured submitted a claim for reimbursement of medical expenses along with xerox copies of the documents and the same was repudiated for above mentioned reason. On receipt of the notice from Hon’ble Ombudsman, the claim was once again reviewed by the insurer, who offered for settlement for Rs.3,44,000/- only, on submission of all original documents.

18. a Complainant’s Argument: - The complainant has submitted bills amounting to Rs.4,68,119/- and

requested for payment of the amount along with 12 % interest from the date of lodging the claim.

b. Insurer’s Argument: - The Insurer has submitted in the SCN that they have offered for settlement of the claim for Rs. 3,44,000/-only, on submission of original documents. As per their calculation.

Total claim amount comes to Rs.3,98,000/- Less Deduction Rs. 54,000/- Balance payable Rs. 3,44,000/-

The insured did not provide Breakup for the package charges. Hence 20% of the charge was deducted towards Non-payables. Hence a sum of Rs. 54,000/- was deducted.



a. Photocopies of Policy, & policy wordings




observed that the complainant had not submitted the bills for insurer’s processing the claim. The

insurer submitted the originals today to the insurer, based on which the insurer re-calculated at

Rs.382849/-.

22. The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall

comply with the award within 30 days of the receipt of the award and shall intimate

the compliance of the same to the Ombudsman.



Development Authority of India Act 1999, from the date of the claim ought to have

been settled under the regulations, till the date of payment of amount awarded by

the Ombudsman.



Dated at Bhubaneswar on the 05th day of March, 2020


INSURANCE OMBUDSMAN


AWARD

Taking into account the facts and circumstances of the case and submissions made by both the

parties during the course of hearing, the forum finds that the insurer denied the claim for want

of original documents. Since, now the complainant has submitted the original documents to the

insurer, the latter re-calculated the claim at Rs.382849/-, which is reasonable as per policy

terms and conditions. Accordingly, the insurer is directed to settle and pay the complainant

Rs.382849/- towards full and final settlement of the hospitalisation, pre and post-hospitalisation

claim.

The complaint stands admitted.



CASE OF Mr. Raghu Ram Tangirala Vrs. M/S Star Health and Allied Insurance Co Ltd COMPLAINT REF: NO: BHU-H-044-1920-0022



Mr. Raghu Ram Tangirala, N-4/310(F), IRC Village, Bhubaneswar-751015, Odisha


P/191211/01/2018/006546 Family Health Optima Insurance Plan 30/11/2017 to 29/11/2018 Date Admission 27/02/2018


Mr. Hemanta Tangirala (Son of complainant/policyholder) Mr. Raghu Ram Tangirala




8. Nature of complaint For payment of hospitalisation expenses





13(1)b



c) For the Complainant Self

d) For the insurer Dr. Biswaprakash Pati, CMO



17. a. Brief Facts of the Case/ Cause of Complaint: - The complainant has taken a Family Health Optima Insurance Plan from M/s. Star Health and Allied Insurance Company Ltd for a floater sum insured of Rs.3,00,000/- for the period from 30/11/2017 to 29/11/2018 covering his wife and child. On 27/02/2018 the complaint’s son/insured was admitted at DEV ENT & EYE CARE HOSPITAL for treatment of Adenoid Hypertrophy. After discharge, he applied for reimbursement of hospitalisation expenses of Rs. 28,863/- on 21/03/2018. On going through the hospital papers, the insurer noticed that the insured patient had complaints of severe nasal obstruction for last 1 year, which was reflected in treating doctor’s letter dated 03/04/2018. But the policyholder/Insured had not disclosed above medical history in the proposal form while porting the policy, so they repudiated the claim. The complainant being aggrieved with repudiation of the claim, preferred an appeal before this forum for redressal.

b. The insurer has not submitted self-contained note. However, they send a mail to the insured on 4/01/2020 conveying that, their claims reviewing committee has considered to settle the claim for

Rs.23,936/- as against total submitted bill of Rs.28548/- with deductions being Rs.4612. Moreover, the insurer, requested to insured to send his consent for acceptance, to settle the claim. 18. a. Complainant’s Argument: - The complainant has submitted bills amounting to Rs.28,863/- The

deductions made by the insurer towards pre-hospitalisation expenses is not justified

b. Insurer’s Argument: - The Insurer has not submitted the SCN. However, from their calculation sheet it is observed that, they deducted Rs. 3612/-from the pre-hospitalisation expense.







observed that the insurer has now reconsidered the case and come forward offering settlement at

Rs.27321/- including pre and post-hospitalisation expenses. But as on date the complainant has not

yet received the payment keeping the complaint pending.




comply with the award within 30 days of the receipt of the award and shall

intimate the compliance of the same to the Ombudsman.

b. As per the Rule 17(7) the complainant shall be entitled to such interest at a rate

per annum as specified in the regulations framed under the Insurance Regulatory

and Development Authority of India Act 1999, from the date of the claim ought to

AWARD


parties during the course of hearing, the forum finds that the offer of the insurer for an amount

of Rs.27321/- is reasonable considering the non-payable items. Accordingly, the insurer is hereby

directed to settle and pay to the complainant Rs.27321/- towards full and final settlement of the

claim with Penal interest in compliance with IRDAI (Protection of Policyholders’ Interests)

Regulations, 2017.


have been settled under the regulations, till the date of payment of amount

awarded by the Ombudsman.

c. As per Rule 17(8) of the said rules and award of the Insurance Ombudsman shall

be binding on the Insurers.



INSURANCE OMBUDSMAN




CASE OF Mr. Arun Kumar Dey Vrs. M/S Star Health and Allied Insurance Co Ltd COMPLAINT REF: NO: BHU-H-044-1920-0082



Mr. Arun Kumar Dey, At: B.C. Sen Road, PO; Balasore, Dist; Balasore, PIN- 756001. Mobile -8598086188


P/191213/01/2018/003300 Mediclassic Insurance Policy (Individual) 19/03/2018 to 18/03/2019 Date of Admission 25/09/2018


Mr. Arun Kumar Dey Mr. Arun Kumar Dey



7. Dt. of receipt of the Complaint 12.09.2019

8. Nature of complaint For payment of hospitalisation expenses





13(1)b



e) For the Complainant Leave absent

f) For the insurer Dr. Biswaprakash Pati, CMO



17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant took a Medi-classic individual policy covering self for a sum insured Rs.2,00,000/- For the period 19/03/2018 to 18/03/2019 from Star Health and Allied Insurance Co Ltd, Bhubaneswar. The complainant took treatment at All India Institute of Medical Science, Bhubaneswar for the period 25/09/2018 to 04/10/2018. As per discharge summary of the treating doctor, the insured was diagnosed as BILATERAL RENAL MASS. He submitted claim documents to the insurer for reimbursement of hospitalisation expenses. The Insurer raised some queries to produce some medical papers vide their letter dated 14/03/2019 followed by reminders dated 29/3/2019,13/04/2019 and 28/04/2019. The complainant failed to submit the documents and therefore, the insurer repudiated the claim on 08/06/2019. Subsequently the complainant complied the required queries and requested to re-consider the claim for settlement. On going through the papers, insurer noticed from Anaesthetic report dated 01/08/2018 that, the complainant was symptomatic of the above disease prior to the inception of the policy. The insurer denied the claim vide their letter 21/08/2019. Being aggrieved on repudiation of the claim, the complainant preferred an appeal before this forum for redressal.

b. The insurer, in its Self-Contained note, mentioned that the complainant was suffering from the BILATERAL RENAL MASS prior to the date of commencement of the policy. However. this was not disclosed at the time of proposing the policy which would tantamount to Non-disclosure of Material Facts which deprived the right of the insurer to evaluate the risk before accepting the proposal. The present hospitalization of the insured person is for treatment of the complications of the pre-existing condition; hence it is not payable as per exclusion No.1 of the policy.

18. a) Complainant’s Argument: - The complainant has submitted bills amounting to Rs.28903/-

For his kidney operation at AIIMS. The expenses are only for medicines so the claim should be settled.

b) Insurer’s Argument: - As per the consultation report dated 01/08/2018 the insured patient is symptomatic of above disease for past 6 months: nephrectomy done for angiomyolipoma which confirms the insured patient has above disease prior to inception of the policy. Hence it is a pre-existing disease so claim was repudiated.



a. Photocopies of Policy

b. Photocopies of hospital records and bills


gone through all the documents and papers relating the complaint and heard the insurer during the

course of hearing as the complainant had requested to allow him leave absent due to his health

problems. The insurer submitted a copy of the Rogikalyan Samiti, Balasore dated 01.08.2018, where

it is written that the condition was 6 moths old. But it is not clear what exactly is written against the

remark of 6 months. Even the insurer was also not sure to convincingly say that the condition was

prior to inception of the policy.















INSURANCE OMBUDSMAN


AWARD

Taking into account the facts and circumstances of the case and submissions made the

insurer in absence of the complainant during course of hearing, the forum finds that the

insurer has no such document to say it certainly that the disease was pre-existent.

Therefore, the Forum finds that the complainant is entitled for the claim and

accordingly, the Forum hereby directs the insurer to settle and pay the complainant

Rs.9948/- towards full and final settlement of the claim.

The complaint stands admitted.



CASE OF Mr. GIDEON BEHERA Vs STAR HEALTH AND ALLIED INSURANCE LTD. COMPLAINT REF: NO: BHU-H-044-1920-0037



Mr. Gideon Behera, Mandapada, Doulatabad, Choudwar, Cuttack-754026


P/191212/01/2019/000357 Family Health Optima Insurance Plan 13/04/2018 to 12/04/2019 Date of treatment: 29/06/2018


Mr. Giedon Behera -do-

4. Name of the insurer Star Health and Allied Insurance Ltd.

5. Date of Repudiation 23/07/2018 Disease Falls under Waiting period clause. 6. Reason for repudiation


8. Nature of complaint Claim repudiated


10. Date of Partial Settlement Not Applicable

11. Amount of relief sought Rs71,000/-


13(1)b



g) For the Complainant Self

h) For the insurer Dr. Biswaprakash Pati, CMO



17. a. Brief Facts of the Case/ Cause of Complaint: - The complainant has taken a Family Health Optima Insurance Plan from Star Health and Allied Insurance company Ltd for the period 13/04/2018 to 12/04/2019 for a floater Sum Insured of Rs.5,00,000/-. The complainant availed medical treatment on 29/6/2018 at Dr Agarwal’s Health Care Ltd and the person was diagnosed with TRAUMATIC CATARACT WITH SPHINCTER TEAR WITH VITREOUS PROLAPSE RIGHT EYE. Dr. Agarwal’s Health Care Ltd, requested the Insurer for Pre-authorisation for cashless treatment which was denied by the Insurer as it is “Cataract” which falls under two years’ waiting period. But as per insured’s statement this has arisen out of an injury. Finally, the insurer repudiated the claim vide their letter dated 23/07/2018. Being aggrieved on the repudiation of the claim, the complainant preferred an appeal before this forum for redressal.

b. The insurer, in its Self-contained note (SCN), has stated that the complainant preferred cashless treatment on 30/06/2018. On scrutiny of the documents, it is observed that the present hospitalization of the insured person was for treatment of RIGHT EYE CATRACT, which falls under

waiting period exclusion. The insurer says that complainant had planned to undergo treatment for CATRACT during 3rd month of the policy, As per the waiting period No. 3(ii) (a) of the policy, the insurer is not liable to make any payment in respect of any expenses incurred in the treatment of above mentioned disease during first 24 months of continuous coverage under the policy. Thus, the pre-authorization was rejected and communicated to the insured vide letter 30/6/2018. Being aggrieved by the rejection, the complainant submitted a reconsideration request along with Treating Doctor’s certificate that the Cataract is a complication of Traumatic accident that took place 3 months ago which is prior to the commencement of the first-year policy. Since the treatment is CATARACT which is not payable as per waiting Period No.3(ii)(a) of the policy, the reconsideration request was repudiated.

18. a) Complainant’s Argument: - While operating a gas cylinder on his work on dated

22/05/2018 a heat iron particles spread away to his right eye, such incident is purely uncertain and

accidental in nature. On examination the doctor opined it is Traumatic subluxated cataractous lens

with traumatic tridodialyses vitreous prolapse into interior chamber. It is an accidental injury,

previously he has not cataract related disease.

b) Insurer’s Argument: - As per the waiting period No. 3(ii) (a) of the policy, the insurer is not liable to make any payment in respect of any expenses incurred in the treatment of CTARACT related disease during first 24 months of continuous coverage under the policy. The accident occurred 3months ago prior to commencement of the policy.

19 Reason for registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017. 20 The following documents are placed in the file.

a. Photocopies of Policy. b. Photocopies of Medical documents.



observed that the certificate issued by the treating hospital (Dr. Agarwal’s) states that the patient had

eye injury three months back. This means the incident happened prior to taking the policy. More so,

the policy does not cover cataract within 24 months of inception of the policy.


AWARD

Taking into account the facts and circumstances of the case and submissions made by both

the parties during the course of hearing, the forum does not find any merit in the complaint

and therefore, the complainant is not entitled for this claim.

Accordingly, the complaint stands dismissed.


INSURANCE OMBUDSMAN




CASE OF Mr. G.Guru Janarthanan Vrs. M/S Star Health and Allied Insurance Co Ltd COMPLAINT REF: NO: BHU-H-044-1920-0021



Mr. G. Guru Janarthanan, 726/1101, Tankapani Road B.J.B. Nagar, Bhubaneswar, Odisha-751014 (9443374752)


P/111200/01/2018/007063 Family Health Optima Insurance Plan 07/02/2018 to 06/02/2019 Date of Admission 23/02/2018


Mr. G. Guru Janarthanan Mr. G. Guru Janarthanan

4 Name of the insurer Star Health and Allied Insurance Co Ltd, Bhubaneswar

5. Date of Repudiation It is a case of partial settlement Not repudiated 6. Reason for repudiation

7. Dt of receipt of the Complaint 03/12/2018

8. Nature of complaint Against partial settlement of the claim

9. Amount of Claim Rs.5,83,466/- but the Insurer settled for Rs.3,68,098/- (Rs.3,60,648/-on 24/04/2018 and for Rs. 7450/- on 07/06/2018)

10. Date of Partial Settlement 24/04/2018



13(1)b



g) For the Complainant Self

h) For the insurer Dr. B Pati, CMO



17. a. Brief Facts of the Case/ Cause of Complaint: - The complainant has taken a Family Health Optima Insurance Plan from M/s. Star Health and Allied Insurance Company Ltd for a floater sum insured of Rs.5,00,000/-+ Bonus Rs.2,25,000/- for the period from 07/02/2018 to 06/02/2019. On 23/02/2018 the complainant got admitted at MADRAS MEDICAL MISSION, CHENNAI for CORONARY SURGERY and discharged on 06/03/2018. He submitted the Medical Papers to the insurer for settlement of the claim. The insurer settled the claim for Rs.3,68,098/- against the claimed amount of

Rs.5,83,466/-. Being aggrieved with the settlement of a lessor amount, the complainant preferred an appeal before this forum for redressal.

b. In the self-contained note the insurer stated that, the complainant, aged about 60 years took treatment at Madras Medical Mission, Chennai during the period 23/02/2018 to 06/03/2018. As per discharge summary of treating hospitals, the diagnosis was CORONARY ARTERY DISEASE, TRIPLE VESSEL DISEASE and underwent PTCA TO MID RCA. The complainant preferred a claim for reimbursement of Hospitalisation expenses and the same was approved for a sum of Rs.3,60,648/- and paid to the complainant vide NEFT Transaction No N114180525891885 dated 24/04/2018. The complainant made a request for reconsideration of the deductions made. The same was duly reviewed and approved for a sum of Rs.7450/- and paid vide NEFT Transaction No. N158180558382490 dated 07/06/2018. Again, being aggrieved by the deductions, the complainant requested for reconsideration of the deductions made. The same was duly reviewed and a query was raised calling for ABG report vide letter dated 25/09/2018. The insured did not provide the same even after their reminder letters dated 10/10/2018 and 25/10/2018. Hence the claim was closed vide letter dated 09/11/2018. 18. a) Complainant’s Argument: - The complainant has submitted bills amounting to Rs.5,88,188/.

Permissible dis-allowance as per the list of exclusions comes to Rs. 4,721.75. So net payable amount

is Rs. 5,83,466.25.

b) Insurer’s Argument: - Non payable items and deductions comes to Rs.2,20,090/-. After deduction

of the same, the net amount of Rs. 3,68,098/- was paid to the complainant, which is the maximum

amount settled as per the terms and conditions of the policy.







observed that the complainant is also eligible for reimbursement against medicines, investigation

charges and other related expenses.

AWARD

Taking into account the facts and circumstances of the case and submissions made by

both the parties during the course of hearing, the forum hereby directs the insurer to

pay the balance amount of Rs.174000/- to the complainant towards reimbursement of

medicine expenses, investigation charges and other related expenses as full and final
















INSURANCE OMBUDSMAN



STATE OF ODISHA, BHUBANESWAR (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)


CASE OF Mrs. RESHMA RAHAMAN Vrs. M/S STAR HEALTH AND ALLIED Insurance Co. Ltd. COMPLAINT REF: NO: BHU-H-044-1920-0097



Mrs. RESHMA RAHAMAN, PLOT NO. 6/379, JAYADEV VIHAR, Bhubaneswar (M.CORP + OG) Bhubaneswar, Dt. Khordha. PIN-751012 Mob.9861021107


P/19121/01/2019/001902 FAMILY HEALTH OPTIMA PLAN ( 1ST YEAR POLICY ) 25/05/2018 to 24/05/2019

D.O.Adm. 04/03/2019 and D.O.Disc 07/03/2019 (3 DAYS


Mrs. RESHMA RAHAMAN Mrs. RESHMA RAHAMAN

4. Name of the insurer M/S STAR HEALTH AND ALLIED Insurance Co. Ltd.CHENNAI

5. Date of Repudiation 14/09/2019 Non-disclosure of medical history in the proposal form. 6. Reason for repudiation

7. Date of receipt of the Complaint

24/09/2019

8. Nature of complaint Non settlement of claim due to pre-existing disease.

9. Amount of Claim Rs.2,69,254/-. (Rs.75,000/-of Apollo Hospital) (Rs.1,94,254/-of AMRI Hospital)

10. Date of Partial Settlement NOT APPLICABLE.

11. Amount of relief sought Rs.2,69,254/-.


13(1)b







17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant purchased Family Health Optima Insurance Plan for self, spouse and dependent child for the first time from M/S Star Health and Allied

Insurance Co. Ltd. Chennai for a floater sum insured Rs.5,00,000/- for the period 25/05/2018 to 24/05/2019. Prior to change in insurer the insured had policy from the Oriental Insurance Co. Ltd. from 2013 to 2018.The insured spouse complained of SUBMANDIBULAR REGION SWELLING WITH REPEATED INFECTIONPAIN and visited Apollo Hospital, Bhubaneswar for consultation with Dr. Sanjeev Gupta, ENT Specialist. The insured was admitted on 04/03/2019 and surgery was conducted on 05/03/2019 known as SUBMANDIBULAR GLAND EXCISION and discharged on 07/03/2019. The insured approached the insurance company for Pre-Authorization for cashless treatment which was rejected on 25/02/2018 on the ground that the disease/condition is of long-standing nature for the past 12 years but the same was not disclosed in the proposal form. The total hospital bill amounting Rs.75,000/-/- was paid by the insured on discharge date and approached the insurer for reimbursement. The insurer had called for all treatment papers vide letter dt.19/03/2019 & 03/04/2019 to enable them to process the claim. On 18/04/2019 the Insurer rejected the claim and finally repudiated the claim on 07/06/2019. The insurer had also passed the endorsement on 17/07/2019 by deleting the name of RESHMA RAHAMAN from the policy w.e.f.20/07/2019. The complainant not being satisfied with repudiation preferred an appeal before this forum for redressal.

b. The insurer in its Self-contained note (SCN) has stated that the insured was symptomatic from past 12 years which is prior to issuance of the first policy which amounts to non-disclosure of material facts. The insured approached for cash less authorization prior to admission in Apollo Hospital Bhubaneswar which was denied that disease /condition is of long-standing nature but the same has not been disclosed in the proposal form. The insured claimed bill for Rs.75,000/- for reimbursement which was repudiated on 07/06/2019.Since this being a ported policy the insurer had sought information from the previous Insurer about the medical history and claim history from Oriental Insurance Co. Ltd. but no reply was received from the previous Insurer. The proposal was accepted without past medical history reply by the insured of all the columns. In the SCN the Insurer has referred to policy condition no.6 and 12 which states that the company is not liable due to misrepresentation of facts in the proposal and also the company may cancel the policy and delete the name of the insured from the policy due to preexisting disease.

18. a) Complainant’s Argument: - The complainant has submitted bills amounting to Rs.75,000/-

which includes hospital expenses. The insured states that repudiation of the claim on disease/

condition is of long-standing nature is not acceptable. The insured states that the Insurer is citing

wrong policy conditions which is purely unjustified against the loss.

b) Insurer’s Argument: - The Insurer has submitted in the SCN that the complainant is not entitled to any benefit under the policy.







observed that the complainant has filed claim documents of two episodes of two different policy

periods. The policy number as mentioned by the complainant in the complaint relates to 2018-19 and

the amount of relief sought in this case is limited to Rs.75000/-. The other claim amounting to

Rs.194254/- relates to a different policy, which is not the subject matter of this complaint.













Dated at Bhubaneswar on the 06th day of March, 2020 INSURANCE OMBUDSMAN


AWARD


parties during the course of hearing, the forum finds that the complainant had been renewing the

policy since 2013 with another insurer and ported the same to Star Health and Allied insurance co

ltd in 2018-19. The insurer has claimed that the condition was in existence since last 12 years and

considered it to be pre-existing which was not declared. But the insurer failed to substantiate its

claim by way of any conclusive proof. And the complainant says it was not pre-existing. Finding no

conclusive evidence of pre-existing disease, the Forum hereby directs the insurer to settle and pay

the complainant Rs.74497/- as indicated by the insurer towards full and final settlement. As far as

the 2nd claim is concerned, the complainant is advised to take up the matter with the insurer for

reconsideration, failing which she may make an appeal to this office separately as a separate case.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mrs. SUJATA NAYAK Vrs. M/S STAR HEALTH AND ALLIED Insurance Co. Ltd. COMPLAINT REF: NO: BHU-H-044-1920-0090



Mrs. SUJATA NAYAK , PLOT NO. 1041, PRASANTI VIHAR, BARAMUNDA Bhubaneswar, Dt. Khordha. PIN-751003 Mob.9437230906


P/19121/01/2018/000462 FAMILY HEALTH OPTIMA PLAN ( 1ST YEAR POLICY ) 18/04/2017 TO 17/04/2018 D.O. Adm. 14/01/2018 and D.O. Disc. 19/01/2018 ( 05 days)


Mr. Subrat Kumar Nayak (22 Yrs.) Mrs. SUJATA NAYAK

4. Name of the insurer M/S STAR HEALTH AND ALLIED Insurance Co. Ltd.CHENNAI

5. Date of Repudiation 23/03/2018 Non submission of OP & IP treatment records during June 2015. 6. Reason for repudiation

7. Date of receipt of the Complaint

30/03/2018

8. Nature of complaint Non settlement of operation expenses at the hospital (KIMS)

9. Amount of Claim Rs.88,693/-. (Hospital Bills)

10. Date of Partial Settlement NOT APPLICABLE.

11. Amount of relief sought Rs.88,693/-.


13(1)b







17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant purchased Family Health Optima Insurance Plan for self and dependent child for the first time from M/S Star Health AND Allied Insurance Co. Ltd. Chennai for a floater sum insured Rs.3,00,000/- for the period 18/04/2017 TO 17/04/2018.The insured son complained of PAIN in the right leg knee since one month and was taken to joints & spine injury clinic for consultation on 03/01/2018.The doctor Dr Debashish Mishra examined and observed that there was pain & instability in the right leg. As per Doctors advice MRI was done on 05/01/2018 at Shri Med scan Imaging Centre and their impression was ACL tear. Along with the MRI report they consulted the Doctor on 09/01/2018 and suggested to admit the patient on 14/01/2018 and planned the surgery (Arthroscopic ACL Reconstruction) on 15/01/2018. The insured approached the insurance company for Pre-Authorization for cashless treatment which

was rejected on 10/01/2018 on the ground that the disease/condition is of long-standing nature but the same was not disclosed in the proposal form. The surgery was performed on 15/01/2018 and discharged as per Doctors advise on 19/01/2018. The total hospital bill was paid by the insured on discharge date and approached the insurer for reimbursement. The insurer had called for OP & IP treatment records during June 2015 to enable them to process the claim. The insurer repudiated the claim due to non-receipt of OP & IP records on 23/03/2018. The complainant not being satisfied with repudiation preferred an appeal before this forum for redressal.

b. The insurer in its Self-contained note (SCN) has stated that the claimant was treated between 14/01/2018 to 19/01/2018 at Kalinga Institute of Medical Sciences (KIMS), for surgery of ACL tear. The insured approached for cash less authorization which was denied as per MRI report which reveals that disease /condition is of long-standing nature but the same has not been disclosed in the proposal form. The insured claimed bill for Rs.88,693/- for reimbursement which was repudiated on 23/03/2018.On receipt of the notice from the Hon’ble Ombudsman the claim was once again reviewed and considered for settlement for Rs.79,739/-after deduction of some non-medical expenses and discount given by the hospital.

18. a) Complainant’s Argument: - The complainant has submitted bills amounting to Rs.88,693/-

which includes pre-hospitalization and hospital expenses. The insured states that repudiation of the

claim on disease/ condition is of long-standing nature is not acceptable. The insured states that the

Insurer is citing wrong policy conditions which is purely unjustified against the loss.

b) Insurer’s Argument: - The Insurer has submitted in the SCN that the complainant if liable then the maximum admissible amount is Rs.79,739/- after deductions of non-medical expenses and discount given by the hospital.







observed that the insurer asked for certain documents, which the complainant did not possess, which

was taken as one of the reasons for repudiation of the claim. Again, the complainant could come to

know about the condition only after the doctor advised for MRI test and undertook hospitalization. It

is understood from the SCN that the insurer has offered for settlement of the claim for Rs.79739/-,

which is reasonable.

AWARD


parties during the course of hearing, the forum hereby directs the insurer to settle and pay to

the complainant Rs.79739/- towards full and final settlement of the claim.

Accordingly, the complaint stands disposed of.














INSURANCE OMBUDSMAN
