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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

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

OMBUDSMAN – Mrs NEERJA SHAH

In the matter of Shri M S KRISHNA MURTHY V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED

Complaint No: BNG-G-044-1819-0133

Award No.: IO/(BNG)/A/GI/0289/2018-19

1 Name & Address of the Complainant Shri M S KRISHNA MURTHY,

# 138, 1st Cross,

Doddakatappa Road, Ulsoor,

BENGALURU – 560 008.

Mob.No. 99000 16161

Mail ID : [email protected]

2 Policy No.

Type of Policy

Duration of Policy/ Policy Period

P/141137/01/2018/000858

Senior Citizens Red Carpet Health Insurance Policy.

07.12.2017 to 06.12.2018

3 Name of the Insured/ Proposer

Name of the policyholder

Smt Neelavathi

Smt Neelavathi

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

5 Date of repudiation 24.04.2018 – Only cashless rejection.

6 Reason for repudiation Misrepresentation/non disclosure of material facts

7 Date of receipt of Annexure VI-A 27.06.2018

8 Nature of complaint Repudiation of claim.

9 Amount of claim ₹.1,00,000/-

10 Date of Partial Settlement NA

11 Amount of relief sought ₹.10,00,000/-

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

13 Date of hearing/place 05.12.2018 / Bengaluru

14 Representation at the hearing

a) For the Complainant Self

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

Pushpa - Legal

15 Complaint how disposed Dismissed

16 Date of Award/Order 06.12.2018

17. Brief Facts of the Case: It is a case of repudiation of mediclaim for hospitalisation on the ground of

misrepresentation & non disclosure of previous ailments. The Complainant took up the matter with the

Grievance Cell of the Respondent Insurer (RI) and the same was not considered favourably.

18. Cause of Complaint:

a) Complainant’s arguments:

The Complainant‟s submission was that his mother with the RI from 07.12.2017 and had declared pre-existing

diseases as diabetes, hypertension and also the medication honestly to best of his knowledge. His mother

consulted Dr. Uday A Murgod, Neurologist on 18.04.2018 and as advised various tests were done and, he

admitted her mother to Manipal Hospitals, Bengaluru on 20.04.2018. He had preferred a claim relating to

Urinary Tract Infection and claim was rejected stating non disclosure of Normal Pressure Hydrocephalus. RI

also stated that his mother had undergone VP Stent Surgery was not disclosed at the time of obtaining the

policy. The request for cashless was rejected and policy was also cancelled. The approach to Grievance also did

not yield any result and hence, the Complainant had approached this Forum.

b) Respondent Insurer’s Arguments: The RI has submitted their Self Contained Note dated 22.06.2018

admitting coverage with declared diseases as PED, and preferring of claim during the 4th

month of the policy.

Pre-authorisation was submitted for cashless facility of ₹.1,00,000/- for the admission to Manipal Hospitals,

Bengaluru on 20.04.2018. As per clinical summary, insured was diagnosed as „Urosepsis with Upper GI bleed

and newly diagnosed Liver Disease‟. On scrutiny of claim documents, it was observed that as per Discharge

Summary (previous treatment) of Department of Neurosurgery of Manipal Hospital for the period of

hospitalisation from 08.11.2017 to 18.11.2017, she was diagnosed as „Normal Pressure Hydrocephalus‟. From

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the above, it is confirmed that the insured was diagnosed for the above ailment which was not disclosed prior to

inception of policy. Though the present ailment is diagnosis of Urosepsis, the insured had failed to disclose the

earlier treatment and hence cashless request was rejected. It was also noticed that the patient had undergone

Burr hole surgery and VP shunt placement on 10.11.2017, which amounts to non disclosure of material facts

and hence, claim was rejected. The Complainant has disclosed only Diabetes & Hypertension in the proposal

but has omitted to disclose about Normal Pressure Hydrocephalus under the column 2(l) in the proposal.

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

19. Reason for Registration of complaint:-

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

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):

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

parties during the personal hearing. After analysing the same, this Forum noted that the present dispute is

rejection of settlement of claim on cashless basis for non-disclosure of pre existing ailments and cancellation of

policy.

The complainant disputed the contention of RI and submitted that he had answered the given column of pre-

existing diseases and whatever was asked while obtaining the policy.

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

records and other documents.

The Forum noted that the policy was obtained for the first time on 07.12.2017 and as per Discharge Summary of

Department of Neurosurgery of Manipal Hospital for the period of hospitalisation from 08.11.2017 to

18.11.2017, she was diagnosed as „Normal Pressure Hydrocephalus‟. The Complainant had disclosed Diabetes

& Hypertension in the proposal form, but had not disclosed „Normal Pressure Hydrocephalus‟ which was

evidently known to the Complainant, which amounted to non-disclosure.

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”.

As the decision of RI is based on the medical records/documents and policy terms and conditions, this Forum

does not find any flaw with their decision in rejecting the claim and cancellation of policy.

The Complaint is Dismissed.

A W A R D

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

both the parties, this Forum does not find any flaw with the decision of Respondent Insurer in rejecting the claim

and cancellation of policy.

Hence, the complaint is Dismissed.

Dated at Bangalore on the 6th

day of December, 2018.

(NEERJA SHAH) INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA

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In the matter of Smt LAKSHMI S V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Smt LAKSHMI S

No. 48, 8th

Cross, Opp to Santhosh Gym,

Shivanandanagar, Near GKW Layout, Vijayanagar,


Mob.No. 99863 68051 / 94485 03943


2 Policy No.

Type of Policy


P/141125/01/2017/012585

Senior Citizens Red Carpet Health Insurance Policy

30.12.2016 to 29.12.2017



Smt Lakshmi S

Smt Prema B R - Mother


5 Date of repudiation 28.03.2018

6 Reason for repudiation Misrepresentation/Non disclosure of material facts.


8 Nature of complaint Repudiation of claim & cancellation of Policy


10 Date of Partial Settlement N.A.







Pushpa - Legal



17. Brief Facts of the Case: It is a case of denial of mediclaim on the ground that there was mis-representation/non-disclosure of

hypertension, Chronic Kidney Disease and Pulmo Kochs prior to the inception of policy. The Complainant took

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

favourably.


a) Complainant’s arguments: The Complainant‟s submission was that she obtained insurance for her mother with the above RI from

30.12.2016. She had told the executive who had come to take the proposal that her mother had Pulmo Kochs in

the year 2006 & cataract eye surgery and the said person informed that the ailments before 10 years need not be

mentioned and only existing ailments to be informed and hence, she declared only diabetes. Her mother was not

having CKD and HTN and the hospital have wrongly mentioned in the Discharge Summary and she is not well

versed with the medical terms. She had preferred a claim for the hospitalisation at Shobha Hospital, Bengaluru

for the period 18.12.2017 to 27.12.2017. The RI‟s investigator insisted for agreeing to CKD, HTN etc.,

mentioned in the Discharge summary failing which reimbursement will not be considered and finally claim was

rejected and policy was also cancelled.

The approach to Grievance also did not yield any result and hence, the Complainant had approached this Forum.

b) Respondent Insurer’s Arguments:

The RI vide their Self Contained Note dated 12.06.2018 admitted insurance coverage for ₹.2,00,000/- preferring

of claim for ₹.1,42,393/- during the 1st year of policy. As per Discharge Summary, the insured was diagnosed as

„Type 2 DM, HTN, UTI, Sepsis, Pyelonephritis, Acute on CKD and Dyselectrolytaemia‟. As per Indoor case

paper dated 18.12.2017 patient was k/c/o Old Pulmonary TB since 2008 and the claim verification report signed

by the Insured patient on 14.03.2018, she was suffering from HTN, CKD & Pulmonary Kochs since 2008. As

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the said ailments were not disclosed, it amounted to non-disclosure of material facts. With regard to a specific

question in the proposal for Tuberculosis, the insured had answered „NO‟. Tuberculosis is a major declined risk

and has the insured answered in the affirmative, proposal would not have been accepted and hence, claim was

repudiated as per condition no. 9 and policy was cancelled as per condition no. 13 of the policy.

As the decision was based on the terms and conditions of policy, requested the Forum to absolve them from the

complaint made.









parties during the personal hearing. After analysing the same, this Forum noted that the dispute is for

repudiation of claim for non disclosure and cancellation of policy.

As the decision of RI was based on terms and conditions of policy, the said conditions are reproduced below:

Condition No.9 – The Company shall not be liable to make any payment under the Policy in respect of any

claim if information furnished at the time of proposal is found to be incorrect or false or such claim is any

manner fraudulent or supported by any fraudulent means or device, mis-representation whether by the Insured

Person or by any other person acting on his behalf.

Condition No. 13 – The Company may cancel this policy on grounds of mis-representation, fraud, moral

hazard, non-disclosure of material fact as declared in the proposal form/at the time of claim, or non-co-

operation by the Insured person, by sending the Insured 30 days‟ notice by registered letter at the Insured‟s last

known address.

The complainant disputed the contention of RI and submitted that she had disclosed all the ailments to the

executive of RI and that as advised him, she did not disclose the treatment underwent earlier except DM. She

also alleged that the investigator forced her to put signature on the form agreeing to the disclosures in the

hospital records which is not acceptable as no one could have forced her to put her signature without her

consent.

The RI reiterated their contentions stated in SCN and submitted that their decision is based as per the terms and

conditions of policy.

The complainant pleads in the complaint and other correspondence that she is not familiar with the medical

terms and hence, she did not take up the issue of disclosures made in the Discharge summary. During the

hearing the Forum noted that the Complainant is fluent in submission of facts and well educated. As regards the

allegation about investigator, Complainant should have taken up the issue with the RI.

The Forum noted from the proposal that she had disclosed only about Diabetes under column 3 a, but had not

disclosed the ailments mentioned under 3b, 3e & 3i, establishing non disclosure.

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”.

The Complaint is hereby Dismissed.

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

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any interference at the hands of the Ombudsman.

Hence, the Complaint is Dismissed.








In the matter of Shri SRINIVASA MURTHY K J V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED



1 Name & Address of the Complainant Shri SRINIVASA MURTHY K J

No. 191, Maruti Nilaya,

13 th Cross Road, 2nd

Main Road,

Kaveripura, Kamakshipalya,


Mob.No.92438 01586 / 94810 06454


2 Policy No.

Type of Policy


P/141125/01/2017/013098

Family Health Optima Insurance Plan

09.01.2017 to 08.01.2018



Shri Srinivasa Murthy

Self



6 Reason for repudiation Pre existing ailments not covered.


8 Nature of complaint Repudiation of claim & cancellation of Policy

9 Amount of claim ₹.22,002/- & ₹.49,951/-


11 Amount of relief sought ₹.71,953/-






Pushpa - Legal

15 Complaint how disposed Allowed in Part.


17. Brief Facts of the Case: It is a case of denial of mediclaim on the ground that the treatment was for pre-existing disease and the same is

not covered during waiting period. The claims for hospitalisations were chest pain and Psoriasis. The

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

considered favourably.


a) Complainant’s arguments: The Complainant‟s submission was that he was insured with the above RI from 02.01.2015 and at that time he

was not suffering from Psoriasis. Due to high fever, he was unconscious and got treated at Madhu Hospital. His

claim for the said treatment was settled by the RI.

He was admitted into Panacea Hospital, Basaveswaranagar on 11.10.2017 with complaints of chest pain and

was diagnosed as „Non Cardiac Chest Pain, TMT positive, IHD-Minimal CAD & Psoriasis‟ and Angiogram was

done on the same day. He was discharged on 14.10.2017.

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He was again admitted into the same Hospital on 02.11.2017 with complaints of fever and Bilateral upper limb

swelling. He was diagnosed as „Psoriatic Erythroderma with Arthritis and IHD-Minimal CAD‟. He was

discharged on 06.11.2017.

His claim was rejected and the policy was also cancelled. The approach to Grievance also did not yield any

result and hence, the Complainant had approached this Forum.


The RI vide their Self Contained Note dated 12.05.2018 admitted insurance coverage for ₹.3,00,000/- and that

the policy was issued with treatment of diseases to Cardiovascular System as declared PED and are excluded for

the first 48 months of continuous coverage.

The Complainant preferred 1st claim for ₹.49,954/- during 3rd

year of the policy for the hospitalisation on

11.10.2017 and the treatment related to Cardiovascular System which was declared PED. Hence, request for

cashless as well as reimbursement was rejected as per exclusion no.1 of the policy.

The Complainant preferred 2nd

claim for ₹.22,005/- during 3rd

year of the policy for the hospitalisation on

20.11.2017 and the treatment related Psoriatic Erythroderma. As per the History and Progress sheet dated

02.11.2017 and the Indoor care records, the Complainant was a known case of Psoriasis for many years and on

regular treatment. As the same was not disclosed, it amounts to mis-representation. The Complainant

subsequently submitted a letter from Dr.C.Ranganathan stating that the said ailment is only for the past 1 month.

He has also not submitted previous documents relating to Psoriasis, which amounted to non co-operation and

hence, the claim was rejected. On receipt of representation, their Grievance cell also reviewed the claim and the

request could not be considered favourably and the same was communicated.


complaint made.










repudiation of claims and cancellation of policy.

The complainant disputed the contention of RI and submitted that he was not suffering from any ailment as on

the date of insurance with RI.

The RI reiterated their contentions stated in SCN and submitted that their decision is based as per the terms and

conditions of policy.

The Forum on perusal of the claim for the 1st hospitalisation on 11.10.2017 noted that the treatment pertained to

Cardiovascular System for which a waiting period of 48 months is applicable and does not find flaw with the

decision of the RI in repudiating the said claim.

The 2nd

claim was for the treatment of Psoriatic Erythroderma for which hospitalisation was on 20.11.2017. The

Forum noted that the Complainant had undergone pre-medical check up which included General Physician

Examination before acceptance of the proposal. On perusal of the information available on public domain, the

ailment is such that the symptoms can easily be seen on the person and in the instant case Forum did not observe

any such symptom.

The Forum also referred to the medical records and noted that the duration of the ailment has not been

confirmed. The RI has also not established to the satisfaction of the Forum that the ailment existed prior to the

inception of the policy and hence extends the benefit of doubt to the Complainant.

The Forum directs the RI to settle the claim for hospitalisation on 20.11.2017, as per the terms and conditions of

policy and to continue the benefits under the policy.

The Complaint is Partly Allowed.

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, this Forum is of the opinion that the decision of the Respondent Insurer is not in accordance with the

terms and conditions of policy and not found to be in order.

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This Forum directs the Respondent Insurer to settle the claim as above as per the terms and conditions of policy.

Hence, the complaint is ALLOWED in part.

22. Compliance of Award:

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

Ombudsman Rules, 2017, where under 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.






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

OMBUDSMAN – NEERJA SHAH

Case of: MR. B N BHASKAR v/s STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED


Award No: IO/(BNG)/A/GI/0295/2018-19

1 Name & Address of the Complainant Mr. B N Bhaskar

S/o Late Narayana

Janatha Colony, Bannur

BALEHONNUR – 577 112

N R Pura Taluk

Chikkamagalur Dist.

Mobile # 94480 25847

2 Policy No.

Type of Policy


P/141121/01/2018/004880


30.12.2017 to 29.12.2018

3 Name of the Insured/Proposer

Name of the Insured Person

Mr. B N Bhaskar


5 Date of Repudiation 05.03.2018

6 Reason for repudiation Non-disclosure of PED


8 Nature of complaint Rejection of hospitalisation claim

9 Amount of claim ₹. 76,000/-

10 Date of Partial Settlement 24.04.2018

11 Amount of relief sought ₹. 76,000/-

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

13 Date of hearing/place 05.12.2018 /Bengaluru



b) For the Respondent Insurer 1) Ms. Pushpa, Legal Officer

2) Dr. Umadevi M B, Sr. Manager

15 Complaint how disposed Disallowed


17. Brief Facts of the Case: -

The complaint arose out of the repudiation of health claim on the ground of non-disclosure of Pre-Existing

Diseass (PED). It was represented to Grievance Redressal Officer (GRO) of the Respondent Insurer stating that

the patient was not suffering from Rheumatoid Arthritis (RA) duly submitting the doctor‟s certificates, his claim

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

18. Cause of Complaint: -

a) Complainants argument:

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The Complainant obtained the cited policy covering himself, his spouse and daughter for a floater sum insured

of ₹.3,00,000/- and Recharge Benefit of ₹.75,000/-.

The Complainant (44 Years) was admitted to Father Muller Medical College Hospital, Mangaluru on

04.01.2018. As per Discharge Summary (DS) he was admitted for complaints of lower limb swelling since 31/2

months, giddiness followed by headache, profuse sweating since 2 weeks. He was diagnosed as B/L lower limb

chronic lymphangitis, ? TIA, BPPV, Autonomic Neuropathy, Hypertension and Type 2 Diabetes Mellitus and

was discharged on 12.01.2018.

Cashless was denied by the Respondent Insurer stating that the patient was diagnosed with RA/Chronic

lymphangitis which was not disclosed at the time of taking the policy.

The Complainant represented to GRO vide letter dated 07.05.2018 that the DS clearly mentioned that it was not

suggestive of RA. Further, the Complainant submitted a Doctor‟s certificate (Dr. Sudeep K) dated 13.03.2018

stating that the diagnosis of Pheochromocytoma was proved negative. Another certificate dated 28.04.2018

from the same hospital (Dr. Venkatesh, Professor) was submitted stating that though the RA factor was found to

be 19.4Iu, there was no evidence of suggestive of RA. Rheumatologist opined that there was no evidence of

rheumatic disorder and positive RA may be false positive state. The patient did not show any clinical evidence

of RA. He was treated for mediastinal tubercular lymphadentis.

However, the Respondent Insurer did not either settle the claim or revive the cancelled policy. Hence the

Complainant approached this Forum for settlement of the claim.


The Respondent Insurer, in their Self Contained Note (SCN) dated 24.07.2018 whilst admitting the insurance

coverage, submitted that the claim occurred in the 3rd

month of commencement of the policy. It was submitted

that as per the pre-authorisation form, the patient was diagnosed as Phechromocytoma.

Though the present admission was for Phechromocytoma, the insured was symptomatic of RA at the time of

taking the policy.

As per ICP dated 19.12.2017 of Father Muller Medical College Hospital in response to their query dated

03.03.2018, the insured patient was a case of Bilateral Leg Pain/Swelling since 31/2 months. It was further

submitted that the patient took treatment in Narayana Hrudayalaya Limited, Bangalore during 22.12.2017 to

24.12.2017 and as per DS of the said hospitalisation he was diagnosed Hypoglycaemia, Transient Ischemic

Attack and Type II Diabetes Mellitus. The above medical condition existed prior to taking the first policy.

The Complainant stated „No‟ to a specific query (2) „Has the person proposed for insurance

consulted/diagnosed/taken treatment/been admitted for any illness/injury‟, 4 (f) „Has the person proposed for

insurance suffered or suffering from any of the following – „Disease of bones/joints/slipped disc, spinal

disorder, injury to ligaments‟ as „No‟. Thus the Complainant failed to disclose the above medical condition in

the proposal which amounted to non-disclosure of material fact.

It was submitted that as per condition no. 6 of the of the policy reading as „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 pay in respect of any claim‟. Hence the claim settlement was

in accordance with the policy conditions.

They relied on the decision of Supreme Court in Satwant Kaur Sandhu vs. The New India Assurance Company

Limited (2009) 8 SCC 316 (citation).

The Respondent Insurer sought for absolving them from the complaint.

19. Reason for Registration of Complaint: -

The Complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and hence it was registered.

20. The following documents were placed for perusal: -


b. SCN of the Respondent Insurer along with enclosures along with the enclosures and

c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.

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

The issues which require consideration are (1) whether the insured patient was suffering from RA, (2) whether

the insured patient was also suffering from Transient Ischemic Attack and Type II Diabetes Mellitus and (3)

whether the Complainant failed to disclose the said pre-existing medical condition in the proposal form.

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21.1. During the personal hearing both the parties reiterated their earlier submissions.

21.2.1. The Forum notes that claim was preferred within 31/2 months from the date of taking the policy. It is

observed from DS of Narayana Hrudayalaya Limited, Bangalore that the complainant took treatment during

22.12.2017 to 24.12.2017 for complaints of generalised weakness, giddiness since a day and as per the DS was

diagnosed as Hypoglycaemia, Transient Ischemic Attack and Type II Diabetes Mellitus. It is further noted from

the 2D Echo Report in the said DS that he had „Grade I LV diastolic dysfunction‟, which supports the

malfunctioning/ill health of his heart.

21.2.2. The Forum further notes from DS of Father Muller Medical College Hospital dated 12.01.2018 that the

complainant was admitted for complaints of lower limb swelling since 31/2 months, giddiness followed by

headache, profuse sweating since 2 weeks. He was diagnosed as B/L lower limb chronic lymphangitis, ? TIA,

BPPV, Autonomic Neuropathy, Hypertension and Type 2 Diabetes Mellitus.

21.3. As regards the contention of the complainant that he was not suffering RA and relied on the treating

doctor‟s statement dated 28.04.2018 issued by Dr. Venkatesh, Professor from the same hospital that the

symptoms of the complainant did not fit into criteria of RA. It was further submitted that though the RA factor

was found to be 19.4Iu, there was no evidence suggestive of RA.

21.3.1. The Complainant confirmed during the personal hearing that the patient was given treatment taken for

mediastinal tubercular lymphadentis which is different from RA. However, the Complainant has also failed to

disclose the medical condition which existed as per the DS of Narayana Hrudayalaya Limited and also of

mediastinal tubercular lymphadentis in the proposal form submitted by him at the time of taking the policy

which amounted to non-disclosure of material information.

21.4. The Forum also relies on the Supreme Court‟s decision in the case of Satwant Kaur Sandhu vs The New

India Assurance Company Limited dated 10.07.2009 and National Consumer Disputes Redressal Forum‟s

decision in the case of LIC Vs. Smt. Neelam Sharma to arrive at this decision.

AWARD

Taking into account the facts & circumstances of the case, the information and the documents placed on record

and the personal submissions made by both the parties hereto, the repudiation of the claim is found in order and

does not require any interference at the hands of the Ombudsman.


Dated at Bengaluru on the 6th

day of December, 2018

(NEERJA SHAH)

INSURANCE OMBUDSMAN





Case of: MS. MEHRU NISA GOPALAKRISHNAN v/s STAR HEALTH AND ALLIED INSURANCE

COMPANY LIMITED



1 Name & Address of the Complainant Ms. Mehru Nisa Gopalakrishnan

Flat 203, Block – 8, Heritage Estate

Doddaballapur Road

Yelahanka

BANGALORE – 560 064

Mobile # 98867 26253

E-mail: [email protected]

2 Policy No.

Type of Policy


P/141123/01/2018/005874


24.09.2017 to 23.09.2018

3 Name of the Insured/Proposer Ms. Mehru Nisa Gopalakrishnan

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5 Date of Repudiation Not Applicable

6 Reason for repudiation Not Applicable


8 Nature of complaint Short settlement of hospitalisation claim

9 Amount of claim ₹. 2,04,003/-

10 Date of Partial Settlement Not Applicable

11 Amount of relief sought ₹. 1,23,410/-







15 Complaint how disposed Allowed



The complaint arose out of the short settlement of the health claim. It was represented to Grievance Redressal

Officer (GRO) of the Respondent Insurer stating that the settlement offered was not in consonance with the

terms and conditions of the offer. Subsequent to filing the case with Forum the Respondent Insurer offered a

revised settlement which was not accepted by the Complainant. Hence this complaint.



The Complainant obtained the cited policy covering herself for a floater sum insured of ₹.10,00,000/-,

Cumulative Bonus of ₹.95,000/-. She took her first policy on 13.08.2008 and renewed continuously without

any break.

The Complainant (66 Years) was admitted to Breach Candy Hospital, Mumbai on 28.02.2018. As per

Discharge Summary (DS) she was admitted with complaints of loss of sense of taste and running nose since 2

months. She was diagnosed as Right sphenoid allergic fungal sinusitis and underwent Endoscopic sinus surgery

and was discharged on 02.03.2018.

As against the claim of ₹.2,09,003/- an amount of ₹.80,593/- was settled by the Respondent Insurer. Being

aggrieved she represented to the GRO stating that disallowance on the grounds of „unnecessary and

unreasonable‟ was arbitrary and deduction based on the proportionate room charges should only be effected.

Further the deductions made were not as per the terms and conditions of the policy. However the balance claim

of ₹.1,28,410/- was not settled. Hence she approached this Forum for settlement of her balance claim amount.


The Respondent Insurer submitted vide their letter dated 18.10.2018 that they settled the reimbursement claim

for ₹.80,593/- on 28.05.2018.

Upon lodging the complaint with this Forum, the claim was reviewed again by them and offered to settle further

amount of ₹.41,454/-. They sought to mediate and absolve them from the complaint.




d. Complaint along with enclosures,

e. SCN of the Respondent Insurer along with enclosures along with the enclosures and

f. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.


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The issues which require consideration are (1) whether there any deductions on the ground of reasonable and

customary charges and (2) whether the final payment offered is in consonance with the terms and conditions of

the policy.


21.2. The Respondent Insurer offered revised settlement for ₹.41,454/- and the same was not accepted by the

Complainant.

.

21.2.1. The practice observed in this case by the Respondent Insurer in providing a revised settlement after

reporting the matter to this Forum is unbecoming and the Forum expresses its displeasure over the same.

21.3. The Forum notes from the revised working that deduction of proportionate expenses on account of

occupying the room for ₹.7,250/- as against the eligibility of ₹.5,000/-, is found to be in order and in consonance

with the terms and conditions of the policy.

21.3.1. The other deductions like disallowance of medicines, investigations and miscellaneous expenses were

confirmed to be in order and in line with the policy terms and conditions, as per the Respondent Insurer.

21.3.2. Therefore the contention of the Complainant that the claim was settled without observing the terms and

conditions of the policy are unsustainable.

21.4. The Complainant submitted a certificate of the Dr. Nishit J Shah dated 16.08.2018.

21.5. As regards disallowance of post hospitalisation expenses of ₹.5,000/- on the ground that the prescription

dated 05.03.2018 was not available. During the course of the hearing, the Complainant submitted prescription

for the said medicines. Original bill was handed over to the Representatives of the Respondent Insurer with an

advice to settle the said post-hospitalisation expense.

AWARD


and the personal submissions made by both the parties hereto, the Respondent Insurer is advised to settle the

balance claim of ₹.41,454/- along with interest @ 8.5% (Bank rate of 6.5% + 2%) from 30 days 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 Respondent Insurer is also advised to pay the disallowed post hospitalisation expenses of ₹.5,000/-

The Complaint is Allowed.

22) Compliance of Award:

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


Dated at Bengaluru on the 6th day of December, 2018

(NEERJA SHAH)

INSURANCE OMBUDSMAN


of 279


(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)


Case of: MR. ANOOP NAMBIAR V/s APOLLO MUNICH HEALTH INSURANCE COMPANY LIMITED



1) The Complainant obtained Easy Health Individual Exclusive Policy No. 120100/11002/1000315942-05

for the period from 21.11.2017 to 24.11.2018 covering himself, his spouse and son for a Floater Sum

Insured of ₹. 5,00,000/- each. He took his first policy on 06.08.2012 and renewed continuously.

1) The Complainant (50 years) was admitted to Arya Vaidya Sala, Kottakkal, Kerala on 21.06.2018 for

complaints of low back pain, cervical pain, stress and was diagnosed as Kateegraham. He was

diagnosed as Kateegraham and was discharged on 05.07.2018 after undergoing Manhalkizhi,

Mathuthailaka Vasty, Navarakizhi+ pichu, navarakizhi + pichu, Snehavasthi and thailadhara + pizhichi.

2) Reimbursement claim was repudiated by the Respondent Insurer vide their letter dated 21.07.2018

stating that the management of ailment could have been done on Out Patient basis without

hospitalisation and OPD treatment was not covered under the policy.

3) The Complainant represented to Grievance Redressal Officer (GRO) stating that AYUSH treatment

was covered under the policy for Rs. 25,000/- under 1 (h) of the policy. He further submitted that as

the OPD treatment did not provide him relief, upon advice of the doctor he was admitted to the

hospital. He also submitted a copy of Ayush guidelines of Ministry giving details of treatment for the

ailments. However his claim was not settled. Hence, the complainant approached this Forum for

settlement of his claim.

4) Complaint was taken up for further process.

5) Meanwhile the Respondent Insurer settled the claim for ₹. 25,000/- through NEFT on 03.12.2018. The

Complainant consented for the said claim settlement and withdrew his complaint.

6) As the Complaint was resolved on Compromise, the complaint is Closed and disposed off accordingly.



(NEERJA SHAH)

INSURANCE OMBUDSMAN



(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)


Case of: MR. TEJA S R GOWDA V/s UNITED INDIA INSURANCE COMPANY LIMITED



1) The Complainant obtained Synd Arogya (Group Health Insurance Scheme) No.

0726002815P11393389 for the period from 15.12.2015 to 14.12.2016 covering himself for a Sum

Insured of ₹. 3,00,000/-. He took his first policy on 15.12.2013 and renewed continuously without any

break.

2) The Complainant (28 years) was admitted to Apollo Hospitals, Bengaluru on 26.09.2016 for

complaints of seizures since childhood, increased since one month and had history of fall and sustained

injury to right shoulder before a day. He was diagnosed as medically refractory epilepsy for video EEG

fracture lateral end of rt clavicle and was discharged on 29.06.2016.

3) The reimbursement claim was preferred for Rs. 1,11,909/- and the same was approved by Vidal Health,

TPA for Rs. 1,09,095/- on 06.09.2017.

4) Despite taking up with the Grievance Redressal Officer (GRO), the claim payment was not released.

Hence, the complainant filed complaint with this Forum for payment of sanctioned claim.

5) The complaint was scheduled for personal hearing.

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6) Meanwhile, upon mediation of this Forum, the Respondent Insurer effected the payment of Rs.

1,09,095/- through NEFT on 05.11.2018 and receipt of the same was confirmed by the Complainant.

The Complainant withdrew his complaint.

7) As the Complaints was resolved on Compromise with the mediation of this Forum, the complaint is

Closed and disposed off accordingly.



(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of Shri B SRINIVAS V S V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Shri B SRINIVAS

M/s Geetanjali Agro industries,

Plot No. 212/P4, Raichur Growth Centre,

Hyderabad Road,

RAICHUR – 584 134. Mob.No. 94485 70550


2 Policy No.

Type of Policy


P/141121/01/2017/000628


29.07.2016 to 28.07.2017



Shri B Srinivas

Self



6 Reason for repudiation Misrepresentation/Non-disclosure of material facts.


8 Nature of complaint Repudiation of claim











17. Brief Facts of the Case: It is a case of denial of mediclaim on the ground that the Complainant was a known case of pancreatitis and

Vitiligo on pulse steroid therapy and had not disclosed about the said ailments, which amounted to mis-

representation/non disclosure of material facts. The Complainant took up the matter with the Grievance Cell of

the Respondent Insurer (RI) and the same was not considered favourably.


a) Complainant’s arguments: The Complainant‟s submission was that he was insured with the RI from

29.07.2015 and policy was valid upto 28.07.2017. He was admitted into HG Hospital, Bengaluru on 09.03.2017

with complaints of pain in abdomen. He was diagnosed as „Gastric Carcinoid Diabetes Mellitus‟. He underwent

Laparoscopic Partial Gastrectomy under GA and was discharged on 16.03.2017. The request for cashless and

also reimbursement was rejected. The ground for rejection was pre existing disease which is not correct. He also

contends that he had orally informed RI‟s sales manager who filled the proposal form about the previous

treatment. The rejection of claim and cancellation of policy is unjustified.

The approach to Grievance also did not yield any result and hence, the Complainant had approached this Forum.

of 279


The RI vide their Self Contained Note dated 09.07.2018 admitting insurance coverage for ₹.5,00,000/-

preferring of claim for ₹.3,34,642/- during the 2nd

year of policy. On scrutiny of the claim documents, the

prescription of Apollo Hospitals, Hyderabad dated 09.08.2016 stated that the patient had history of Acute

Pancreatitis – Hypertriglyceridemia. The Discharge summary of the said hospital for the period 06.02.2015 to

09.02.2015 confirmed the same and it was a known case of Vertiligo since 2 years on pulse steroid therapy. The

treating hospital certificate dated 11.03.2017 also stated that the patient had pancreatitis in February 2015,

which was prior to inception of policy.

RI submit that though the present admission was for Gastric Carcinoid, the complainant had omitted to disclose

about Acute Pancreatitis, which amounted to non-disclosure of material facts. The Complainant had answered to

a specific question under 4(i) of the proposal as „No‟. Pancreatitis being the major declined risk, had the

complainant disclosed the same in the proposal, policy would not have been issued. Hence, claim was rejected

as per condition No.8 and policy was cancelled as per condition No.12 of the policy.


complaint made.










repudiation of claim on the ground of non disclosure of material facts.

The complainant disputed the contention of RI and submitted that he had disclosed about the PED to the agent

of the RI who only filled up the proposal form and that the present treatment was not for a PED. Hence, he

should not be penalised for the lapse of RI‟s representative.

RI reiterated their contentions in SCN and submitted that their decision was based on the terms and conditions

of policy. For the sake of clear understanding the relevant conditions are reproduced below:

Condition No.8 – The Company shall not be liable to make any payment under the Policy in respect of any

claim if information furnished at the time of proposal is found to be incorrect or false or such claim is any

manner fraudulent or supported by any fraudulent means or device, mis-representation whether by the Insured

Person or by any other person acting on his behalf.

Condition No. 15 – The Company may cancel this policy on grounds of mis-representation, fraud, moral

hazard, non-disclosure of material fact as declared in the proposal form/at the time of claim, or non-co-

operation by the Insured person, by sending the Insured 30 days‟ notice by registered letter at the Insured‟s last

known address.

RI drew the attention of this Forum about the declaration 4(i), which is as under:

4. Have you ever suffered or suffering from any of the following:

(i) Diseases of stomach, intestine, liver, gall bladder/Pancreas, Kidney, Urinary bladder, Urinary tract diseases

– If yes, since when.

The Complainant has stated as „NO‟ in respect of all the persons insured under the policy. The Complainant has

not disputed about the pre existing ailments, but submitted that he had disclosed the details to the sales manager

of the RI orally. In the absence of any evidence, this Forum is not in a position to accept the contention of the

Complainant.




A W A R D



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In the matter of Shri SURESH BABU P V S V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED



1 Name & Address of the Complainant Shri SURESH BABU P V

# 1, 4th

Cross, Ramaswamy Layout,

New Byappanahalli, Indiranagar,


Mob.No. 98445 32304


2 Policy No.

Type of Policy


P/141137/01/2018/000920


11.12.2017 to 10.12.2018



Shri Suresh Babu P V

Self



6 Reason for repudiation Claim within waiting period of 48 months.



9 Amount of claim ₹.8,302/-


11 Amount of relief sought ₹.8,302/- or refund of premium








17. Brief Facts of the Case: It is a case of denial of mediclaim on the ground that the Complainant had history of left shoulder dislocation 8

years back which is prior to the commencement of policy and hence, it is a pre-existing disease and is within the

waiting period of 48 months since inception of policy. The Complainant took up the matter with the Grievance

Cell of the Respondent Insurer (RI) and the same was not considered favourably.


a) Complainant’s arguments: The Complainant‟s submission was that he was admitted to Chinmaya Mission

Hospital, Bengaluru with chief complaints of pain in left shoulder on 22.03.2018 at 03.04 pm. On evaluation he

was found to have dislocation of left shoulder joint. Closed reduction of left shoulder was done and discharged

on the same day at 6.37 pm. As per past history he had left shoulder dislocation 8 years back and treated

conservatively.

The Complainant submits that dislocation is for the first time and he had a fall from motor cycle 8-10 years back

and was treated for leg and hand pain at that time. He had never been treated for dislocation or any surgery done

in this regard. The approach to Grievance also did not yield any result and hence, the Complainant had

approached this Forum.

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The RI vide their Self Contained Note dated 22.06.2018 admitted insurance coverage for ₹.3,00,000/- preferring

of claim for ₹.7,206/- during the 2nd

year of policy. As per Discharge Summary, the insured had history of Left

Shoulder Dislocation 8 years back and at present he was diagnosed as Left Shoulder Dislocation and closed

reduction of Left Shoulder was done. As the claim was for pre-existing disease and within the waiting period,

claim was repudiated.


complaint made.










repudiation of claim on the ground of PED.

The complainant disputed the contention of RI and submitted that he was never treated earlier for injury to

shoulder.


of policy.

As the rejection of claim was on the ground of Pre-existing disease, Forum is reproducing the definition as per

policy:

“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 noted that the inception of the policy was on 07.12.2016 and the injury as per Discharge Summary dated

22.03.2018 was 8 years back and hence the same is beyond 48 months as stipulated in the policy terms and

conditions.

The Forum is not in favour of the decision of the RI in rejecting the claim and directs them to settle the same as

per the terms and conditions of policy with interest.


A W A R D

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


terms and conditions of policy and not found to be in order.

This Forum directs the Respondent Insurer to settle the claim as above as per the terms and conditions of policy

along with interest @ 6.50 % + 2% from the date of receipt of last necessary documents to the date of payment of

claim, as per regulation 16 (1) (ii) of Protection of Policy holders‟ Interests of IRDA Regulations, 2017 issued vide

notification dated 22.06.2017.

Hence, the complaint is ALLOWED.

22. Compliance of Award:

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

Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of


Dated at Bangalore on the 2nd

day of January, 2019.



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In the matter of Shri VISHAL KUMAR S V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED



1 Name & Address of the Complainant Shri VISHAL KUMAR

C/o Dr B C Patil, H.No.244,

Sajjala Sri Nivas, Veerendra Patil Layout,

Near M B Nagar Police Station,

KALABURGI – 585101

Mob.No. 98453 14728 / 83107 19561

2 Policy No.

Type of Policy


P/141215/01/2017/002820


13.03.2017 to 12.03.2018



Smt Vidyavathi

Shri Vishal Kumar - Son



6 Reason for repudiation Treatment within waiting period





11 Amount of relief sought ₹.19,027/-








17. Brief Facts of the Case: It is a case of denial of mediclaim on the ground that the treatment undergone by the insured person is not

payable during first two years of policy. The Complainant took up the matter with the Grievance Cell of the

Respondent Insurer (RI) and the same was not considered favourably.


a) Complainant’s arguments: The Complainant‟s submission was that exclusion criteria no. 3 of the policy

had not been solicited. The issue on hand is that the patient was treated for acute perianal abscess and not for pre

existing fistula as per surgeon‟s report and scan report. The rejection of the claim is not in order. The approach

to Grievance also did not yield any result and hence, the Complainant had approached this Forum.


The RI vide their Self Contained Note dated 14.07.2018 admitted insurance coverage, preferring of claim for

₹.18,299/- during the 7th

month of policy. The patient was admitted on 23.10.2017 in Sanjeevini Hospital,

Gulbarga on 23.10.2017 and discharged on 24.10.2017. As per Discharge Summary, the insured was diagnosed

as Perianal Abscess with low level fistula in ano (L) side Anterior and he underwent Inversion and drainage

with Fistulotomy under GA + SA. As the same is not payable during the first two years of the policy, claim was

repudiated and communicated to the Insured.


complaint made.




g. Complaint along with enclosures,

h. Respondent Insurer‟s SCN along with enclosures and

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i. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A




repudiation of claim was as per the waiting period stated in the policy.

The complainant disputed the contention of RI and submitted that the treatment undergone by him is for acute

perianal abscess and not for pre existing fistula. It is also contended that exclusion criteria no.3 was not

solicited. l


of policy.

As the rejection of claim was on the grounds of Policy conditions, the relevant terms are reproduced:

Section 3 deals with Exclusions.

Exclusion 3.3 –During the first two years of continuous operation of insurance cover any expenses on

a) Cataract, Diseases of the Vitreous and Retina, Glaucoma, diseases of ENT, Mastoidectomy,

Tympanoplasty, Stapedectomy, diseases related to Thyroid, Prolapse of inter vertebral disc (other than

caused by accident), varicose veins and varicose ulcers, all diseases of prostate, Stricture Urethra, all

obstructive-uropathies, all types of hernia, varicocele, fistula / fissures in ano, Hemorrhoids, Pilonidal

sinus and fistula, Rectal prolapse, stress incontinence and Congenital Internal disease/defect.

Insurance policy is a contract and the terms and conditions are binding on both the parties. As the hospitalisation

was during 7th

month of the policy, the decision of RI in invoking the above exclusion no. 3, is as per the terms

and conditions of policy and hence, the Forum does not interfere with the decision of rejection of claim.

The Complaint is hereby Dismissed.

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 claim is in consonance with the terms and conditions of the policy and does not warrant

any interference at the hands of the Ombudsman.






PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA


OMBUDSMAN - NEERJA SHAH

In the matter of SHRI K BALAJI V/s MAX BUPA HEALTH INSURANCE COMPANY LIMITED


Award No. : IO/(BNG)/A/GI/0311/2018-19

1 Name & Address of the Complainant SHRI K BALAJI

# 139/3, Ananda Nivas, 16th

Main,

Near P E S College, BSK 1st Stage, Banashankari,


Mob.No. 98457 58218

E Mail : [email protected]

2 Policy No.

Type of Policy


30600893201600

Health Companion 020.0

08.12.2016 to 07.12.2017

of 279



Shri K Balaji

Smt Roopa Balaji K

4 Name of the Respondent Insurer Max Bupa Health Insurance Company Limited

5 Date of repudiation/rejection 26.10.2017

6 Reason for repudiation Non disclosure of material facts

7 Date of receipt of the Annexure VI-A 09.07.2018

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



11 Amount of relief sought ₹.68,190/- & restoration of policy

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




b) For the Respondent Insurer Shital Patva, Manager, Legal

15 Complaint how disposed Allowed.


17. Brief Facts of the Case: The Complainant emanated from the rejection of mediclaim on a ported policy on

the ground of non disclosure of PCOD ( Polycystic Ovarian Syndrome) 8 years back and for cancellation of

policy. His request to Grievance cell was also not considered. The Complainant having aggrieved with the

attitude of the Respondent Insurer (RI) has approached this Forum.


a) Complainant’s arguments: The Complainant submitted that he and his wife were insured continuously with

M/s Oriental Insurance from 08.12.2003 to 07.12.2016 and the same was ported to the above RI w.e.f.

08.12.2016. His wife was admitted to Drs 7 Maiya Multispeciality Hospital, Bengaluru on 03.09.2017 with

complaints of abdomen pain. She was diagnosed as „Acute Appendicitis‟ and Laparoscopic Appendectomy and

excision of Sebaceous cyst was done under GA and discharged on 05.09.2017. His wife had history of PCOD 8

year back and claim was rejected on the ground of non disclosure of the said pre-existing ailment. Appendicitis

was in no way related to pre-existing ailment and hence, claim to be considered.

Complainant had taken up the dispute of rejection of claim and cancellation of policy with the GRO of RI and

the same did not yield any positive results. Hence, he has approached this Forum.


The Respondent Insurer submitted their Self Contained Note dated 03.09.2018 admitting insurance through

portability. It is stated that the Complainant had signed and submitted a declaration in the proposal. As per the

verification done by them patient was suffering from PCOD since 8 years and the same was not disclosed during

portability. The Complainant has failed to substantiate that his wife was not suffering from PCOD (polycystic

ovary syndrome) from 8 years and hence, claim was repudiated for non disclosure and policy was also

cancelled.









parties during the personal hearing. After analysing the same, this Forum noted that the dispute is with regard to

repudiation of claim on the ground of non-disclosure and cancellation of policy.

The Complainant reiterated that he was continuously insured and hence, the applicability of non disclosure of

pre-existing ailment is not applicable.

RI reiterated their contention in SCN and submitted that their decision is based on the terms and conditions of

policy which are binding on both the parties to the contract.

of 279

The Forum on perusal of the policy noted that RI has waived exclusions applicable of base sum insured and the

same are applicable on incremental sum insured. The same is reiterated in portability benefit policy condition 4

– i (4).

The definitions on which complainant/RI is relying are reproduced below: Definition 14. Disclosure to

information Norm: The Policy shall be void and all premiums paid hereon shall be forfeited to the Company, in

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

Definition 44. 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 received medical advice/treatment,

within 48 months prior to the first policy issued by us.

The Forum notes that the Complainant had erred in not mentioning about the fact of PCOD 8 years back in the

proposal form of the RI at the time of portability, which strictly amounts to non disclosure. At the same time, the

Forum observes that the condition of PED is not applicable as per the policy and the definition. From the

discharge summary, it is noted that the present treatment is for „Acute Appendicitis‟ which is sudden and

independent of earlier treatment. The Complainant was insured continuously for the past 14 years and the

purpose of portability will be defeated if a claim for an independent ailment is denied for non disclosure of the

ailment suffered 8 years back. This Forum extends the benefit in favour of the Complainant and directs the RI to

settle the claim as per the terms and conditions of policy and to continue the benefits under the policy. There is

no order as to the interest in as much as the claim was denied by the RI giving a strict interpretation of the terms

and conditions of policy.


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


terms and conditions of policy and not found to be in order. The Forum directs the RI to settle the claim as per the

terms and conditions of policy and to continue the benefits under the policy.

Hence, the complaint is ALLOWED. There is no order as to interest.

22. Compliance of Award: The attention of the Complainant and the Respondent Insurer is hereby invited to

Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under 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





Case of: MR. K VASANTHAKUMAR v/s STAR HEALTH AND ALLIED INSURANCE COMPANY

LIMITED



1 Name & Address of the Complainant Mr. K Vashanth Kumar

# 12/2, 9th

Cross

Ganapathi Nagar, Near Avalahalli

BDA Park Bus Stand

Batarayanapura

BANGALORE – 560 026

Mobile # 94488756407/9035586343


2 Policy No.

Type of Policy


P/141123/01/2018/005874


24.09.2017 to 23.09.2018

3 Name of the Insured/Proposer Mr. K Vasanth Kumar

of 279






8 Nature of complaint Denial of claim for fibroid uterus


10 Date of Partial Settlement Not Applicable








15 Complaint how disposed Disallowed



The complaint arose out of the repudiation of health claim on the ground of non-disclosure of Pre-Existing

Diseases (PED). It was represented to Grievance Redressal Officer (GRO) of the Respondent Insurer stating

that the earlier treatments were taken 11 years back and would not fall within the definition of PED. However

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



The Complainant obtained the cited policy covering himself, his spouse and son for a floater sum insured of

₹.3,00,000/-, Bonus of ₹.1,05,000/- and Recharge Benefit of ₹.75,000/-. He took his first policy on 19.08.2013

and renewed continuously.

Mrs. Jayalakshmi V, wife of the Complainant (46 Years) was admitted to Vinayaka Hospital, Bengaluru on

07.11.2017. As per Discharge Summary (DS) she was admitted with a history of Dysmenorrhoea since 1 year.

She was diagnosed as Fibroid Uterus and underwent Right Saphingo Oopherectomy and was discharged on

10.11.2017.

Cashless was denied by the Respondent Insurer stating that the patient underwent Thyroidectomy for papillary

carcinoma in 2002 and the same was not disclosed at the time of taking the policy.

The Complainant represented to GRO vide letter dated 05.12.2017 that the insured person underwent

Thyroidectomy in 2002 (i.e., 11 years back) and thereafter she did not consult any doctor/received any medical

advice/treatment for Thyroid problem and hence the concept of PED would not arise. It was submitted that PED

was defined in the Policy under the head definitions as “any condition, ailment or injury or related condition(s)

for which the insured person had signs or symptoms, and/or were diagnosed, and/or received medical

advice/treatment within 48 months prior to the insured person first policy with any Indian Insurer”. However

the Respondent Insurer did not settle the claim and also revived the cancelled policy. Hence the Complainant

approached this Forum for settlement of the claim and reinstatement of cancelled policy.


The Respondent Insurer, in their Self Contained Note (SCN) dated 13.08.2018 whilst admitting the insurance

coverage, submitted that the claim occurred in the 5th

policy period. It was submitted that as per ICP dated

07.11.2017 the insured patient was a known case of Thyroidectomy in 2001 for papillary carcinoma of thyroid.

It was further submitted that as per I-131 Treatment Summary for CA Thyroid dated 02.01.2002 from the

Department of Nuclear Medicine, Bangalore the insured patient was diagnosed as CA Thyroid, Papillary variant

and 3.7 GBQ O-131 administered orally on 22.12.2001. Therefore it was confirmed that the complainant was

diagnosed for papillary carcinoma prior to commencement of the policy.

Complainant stated „No‟ to a specific query (2) „Has the person proposed for insurance

consulted/diagnosed/taken treatment/been admitted for any illness/injury‟. Further, for the question no. 4 (g)

„Has the person proposed for insurance suffered or suffering from any of the following – „Cancer, Pre

Cancerous Lesion – If yes, since when, it was stated as‟ as „No‟.

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The Complainant failed to disclose papillary carcinoma in the proposal form which amounted to non-disclosure

of material information.

It was submitted that as per condition no. 6 of the of the policy which reads as „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 pay in respect of any claim‟. Hence the claim settlement was

in accordance with the policy conditions. Further, as per the condition no. 12, „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 and the premium was refunded to the Complainant.

They relied on the decision of Supreme Court in Satwant Kaur Sandhu vs. The New India Assurance Company

Limited (2009) 8 SCC 316 (citation).

The Respondent Insurer sought for absolving them from the complaint.





b. SCN of the Respondent Insurer along with enclosures along with the enclosures and

c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.


The issues which require consideration are (1) whether the insured person suffered from CA Thyroid, Papillary

variant and (2) whether the non-disclosure of the above disease amounted to terms and conditions of the policy

after 16 years.


21.2.1. The Forum notes that it is established from Treatment Summary for CA Thyroid dated 02.01.2002 from

the Department of Nuclear Medicine – Bangalore that the insured patient was diagnosed as CA Thyroid,

Papillary variant and 3.7 GBQ O-131 was administered orally on 22.12.2001. The Complainant too confirmed

the same.

21.2.2. The dispute of the complainant was that the said event occurred about 15 years back and as neither the

doctor was consulted nor the treatment was received for the said ailment, it was covered under the policy as per

the definition of the PED.

21.2.3. The Forum notes that the PEDs were covered after 48 months provided the same were disclosed. The

Forum agrees with the Complainant that Thyroidectomy carried out in 2002 does not fall within the definition of

PED as it was carried out nearly 11 years before taking the policy. But this is a case of non-disclosure.

21.3. The Forum concurs with the Respondent Insurer‟s contention that the complainant failed to disclose the

above disease/illness (about cancer) despite the proposal form contained a specific question which amounted to

non-disclosure of material fact. The said disclosures would help the insurer to evaluate the proposal and fix the

appropriate premium and appropriate terms and conditions of the policy which the Respondent Insurer is

deprived of.

21.4. The Respondent Insurer further contended that had it been disclosed the proposal would not have been

accepted as Carcinoma was a declined risk.

21.5. In the light of the above, the Forum concurs with the Respondent Insurer that the Complainant committed

breach of condition no. 6 of the policy.

21.6. The Forum also relies on the Supreme Court‟s decision in the case of Satwant Kaur Sandhu vs The New

India Assurance Company Limited dated 10.07.2009 and National Consumer Disputes Redressal Forum‟s

decision in the case of LIC Vs. Smt. Neelam Sharma to arrive at this decision.

21.7. The Representative of the Respondent Insurer confirmed that the policy was cancelled and a fresh policy

was issued in respect of the other members of the policy except the affected person viz., Mrs. Jayalakshmi.

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AWARD


and the personal submissions made by both the parties hereto, the repudiation of the claim done by the Insurer is

found to be in consonance of the terms and conditions of the Policy issued and does not require any interference

at the hands of the Ombudsman.


Dated at Bengaluru on the 6

th day of December 2018

(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: DR. B KRISHNA PRASAD V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No: IO/BNG/A/GI/0298/2018-19

1 Name & Address of the Complainant Dr. B Krishna Prasad

# 309, Sherwood Apartments

4th

A Cross, Kagadasapura

C V Raman Nagar

BENGALURU – 560 093

Mobile # 094482 74401


2 Policy No.

Type of Policy

Duration of Policy/Policy Period

041100/28/17/p103305667



Mrs. Kala Prasad

4 Name of the Respondent Insurer United India Insurance Company Limited

5 Date of Repudiation Not Applicable

6 Reason for repudiation Not Applicable

7 Date of receipt of Annexure VI A 30.07.2018

8 Nature of complaint Non-payment of pre & post hospitalisation expenses




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



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a) For the Complainant Absent

b) For the Respondent Insurer Mr. C A Chandrasekhar, Dy. Manager



17. Brief Facts of the Case:

The complaint arose out of the short settlement of hospitalisation claim and non-payment of pre and post

hospitalisation expenses. The Complainant represented to Grievance Redressal Officer (GRO) stating that the

capping was not applicable where multiple diseases were involved and pre and post hospitalisation expenses

were not part of the said package/ceiling. However his short settled claims were not settled in full. Hence, the

Complainant approached this Forum for settlement of his claims.

18. Cause of complaint:

a. Complainant’s argument:

The Complainant along with his wife was covered under the Group Policy taken by SAIL for their reired

employees.

The Complainant‟s wife, Mrs. Kala Prasad (64 years) was admitted to Gunasheela Surgical & Maternity

Hospital, Bengaluru on 19.01.2018. As per the Discharge Summary, the patient was admitted for complaints of

right side of upper abdomen pain since 2 months, belching+. The insured person underwent SPTA + stenting in

2001, diabetic since 16 years and on tab. Piosys and was diagnosed as Cholelithiasis, Diabetes, CAD – Post

PTCA + stenting and underwent Laparoscopic cholecystectomy and was discharged on 23.01.2018.

The Complainant preferred a claim for ₹. 84,450/- towards hospitalisation expenses, ₹. 4,050/- and ₹.

12,915/- towards pre and post hospitalisation expenses. The Respondent Insurer settled the claim for ₹.45,000/-

stating that was the maximum amount payable for Cholecystectomy.

The Complainant represented to GRO stating that the capping/ceiling was applicable per hospitalisation and pre

and post hospitalisation expenses were not part of the said ceiling. He further contended that the ceiling was

applicable where there were no complications/multiple diseases. However his claims were not settled. Hence,

he approached this Forum for settlement of her claim.

b. Respondent Insurer’s argument:

The Respondent Insurer in their Self Contained Note (SCN) dated 10.07.2018 whilst admitting the insurance

coverage, submitted that there was capping of ₹.45,000/- was for Cholecystectomy in other words that was the

maximum payable as per the policy and accordingly the said amount paid to the complainant on 16.03.2018

through NEFT.

19. Reason for Registration of complaint:

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

20. The following documents were placed for perusal:


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 issue which require consideration is whether the claim settlement was in accordance with the terms and

conditions of the policy issued.

21.1. The Complainant expressed his inability to attend the personal hearing as he was out of country. However

he requested to proceed with the personal hearing.

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21.2. During the personal hearing, the Respondent Insurer reiterated their earlier submissions.

21.3. The Forum notes from the policy that capping of ₹.45,000/- was applicable where there were no

complications/multiple diseases. The Forum notes from the DS that the insured patient underwent Laparoscopic

Cholecystectomy only and no complications arose from the said procedure/surgery. It is further noted that her

hospitalisation was for treatment of abdominal pain and the surgery underwent was Cholecystectomy alone.

Hence the application of ceiling for Cholecystectomy was in order.

21.3.1. However the treatment charges of the other diseases/illnesses diagnosed in the DS besides

Cholecystectomy are also to be paid by the Respondent Insurer as per the terms of the policy.

21.3.2 The Policy provides that the capping is per hospitalisation and the said ceiling is not inclusive of pre and

post hospitalisation expenses. Therefore the Complainant is entitled for the pre and post hospitalisation expenses

as per the time limits specified in the policy i.e., 30 days and 60 respectively.

21.3.3. Since the policy copy is not made available by the Respondent Insurer, the details of the policy are not

furnished in the first part of this Award except the details of the relevant clause for the subject complaint.

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 is hereby advised to settle the pre and post hospitalisation expenses

as per para 21.3.2 supra and the treatment expenses of other illnesses diagnosed in the Discharge Summary

besides Cholecystectomy along with interest @ 8.5% (Bank rate of 6.5% + 2%) from 30 days 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.


23) Compliance of Award:

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




(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of Shri BALAKRISHNAN N P V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED



The Complaint emanated from the rejection of mediclaim under policy number

P/141128/01/2018/006105 for 2 hospitalisations.

The claim was repudiated on the ground of misrepresentation & non disclosure of previous ailments.

The Complainant had taken up with the GRO of Respondent Insurer (RI), who had also not considered

his request favourably. Hence, the Complainant has approached this Forum.

The complaint is posted to 28.12.2018 for Personal Hearing.

In view of the mediation of this Forum, the RI vide their mail dated 13.11.2018 have confirmed the

settlement of both the claims for ₹.62,073/- & ₹.36,045/- respectively.

The Complainant had confirmed his consent to RI vide his mail dated 16.11.2018 and to this office

vide mail dated 11.12.2018 and has requested us to close the Complaint as withdrawn.

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.

The Forum appreciates the approach of RI in resolving the Complaint.

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day of December of 2018.






In the matter of Shri VIJAYA KUMAR S V/s STAR HEALTH & ALLIED INSURANCE COMPANY

LIMITED



1 Name & Address of the Complainant Shri VIJAYAKUMAR S,

Sri Revanasiddeswara Hiils,

Avverahalli Post, Kailancha Hobli,

Ramanagara Taluk & District – 562 159.

Mob.No. 99018 30769


2 Policy No.

Type of Policy


P/141131/01/2018/001772

Star Comprehensive Insurance Policy.

21.02.2018 to 20.02.2019



Shri S. Vijayakumar

Self


5 Date of repudiation 16.06.2018 by Grievance by mail

6 Reason for repudiation Intentional Self injury not covered













17. Brief Facts of the Case:

It is a case of repudiation of mediclaim for hospitalisation for the injuries while trying to walk on the fire on the

ground that the Complainant had intentionally exposed to the risk. The Complainant took up the matter with the

Grievance Cell of the Respondent Insurer (RI) and the same was not considered favourably.


a) Complainant’s arguments: The Complainant‟s submission was that he was insured with the RI from 11.02.2018 (correct date 21.02.2018)

for ₹.5,00,000/-. There is a ritual of crossing pile of fire at Sri Revanasiddeswara Hills. While doing so on

29.04.2018 at about 6.30 am, he was accidentally sustained serious fire injuries and was admitted to St. John

Medical College Hospital, Bengaluru on 29.04.2018 and discharged on 28.05.2018. The tradition of crossing

pile of fire is in practice for several years and such accident has never taken place before. But, unfortunately, he

along with many devotees were injured on 29.04.2018. He has incurred expenses of ₹.3,50,000/-(approx.). The

contention of the RI that the injuries are intentional is not correct. 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 18.07.2018 admitting coverage for ₹.5,00,000/-,

preferring of claim for Pre-authorisation for cashless facility for ₹.2,00,000/- during the 2nd

month of the policy.

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As per pre-authorisation form, complainant was diagnosed as 31% flame burns. As per Indoor case paper dated

29.04.2018 of the St. John Medical College Hospital, the Complainant had a history of flame burns when he fell

over the coal in religious ceremony. As it was a self inflicted thermal burn injury, the same is not payable as per

Exclusion No. 9 of the policy and hence, the same was rejected.

Further, as per Indoor case papers of St. John Medical College Hospital dated 29.04.2018, the patient had

history of Hypertension since 7 months and was on T.Telma 400D and as per Intensive care unit records of the

same hospital, admission document dated 03.05.2018, he had history of Kidney stone since 2 years and was on

medication. As the said ailments were pre-existing, RI is not liable for preceding 12 months of inception of

policy as exclusion No.1 and the same will be incorporated in the policy by passing endorsement.

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









parties during the personal hearing. After analysing the same, this Forum noted that the present dispute is as to

whether rejection of claim is as per the exclusions stated in the policy.

The complainant disputed the contention of RI and submitted that the injuries were purely accidental and not

self injury.

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

records and as per the terms and conditions of policy.

As the RI is relying on Exclusion No. 9, the same is reproduced below:

9. Convalescence, general debility, Run-down condition or rest cure, nutritional deficiency states, psychiatric,

Psychosomatic disorders, Congenital external disease or defects or anamolies (except to the extent provided

under Section2 for New Born) sterility, veneral disease, Intentional self injury and use of intoxicating

drugs/alcohol.

The Forum on a careful examination noted that apart from the belief and traditions, the Complainant has not

acted as a reasonable and prudent man and he voluntarily exposed himself to the hazards of fire, which

amounted to intentional self injury.




A W A R D









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Mr.Sandeep Mittal ……………….……….…..…………...…. Complainant

V/S

Oriental Insurance Co. Ltd………..………….…......................……………Respondent

COMPLAINT NO: BHP-G-050-1718-0115 ORDER NO: IO/BHP/A/GI/ 0088 /2018-2019

Mr. Sandeep Mittal (Complainant) has filed a complaint against Oriental Insurance Co.Ltd. (Respondent)

alleging partial settlement of claim.

Brief facts of the Case - The complainant has stated that he has purchased mediclaim policy from

respondent since 24.07.1992 and having continuous renewal and at present sum insured is of Rs.6 Lac.

He was suffering from Chronic kidney disease and hospitalized from 03/05/2017 to 06/05/2017. After

discharge he has filed claim for reimbursement of incurred amount of Rs.45554/- but respondent has

deducted Rs.18,156/- and informed that Rs.18156/- is not allowable for various reason. Respondent

company has arbitrarily deducted such amount. The complainant approached this forum for payment of

balance amount.

The respondent in their SCN/reply have stated that as per discharge summary insured was diagnosed as a

case of chronic kidney disease stage V, NKD-diabetic kidney disease and was k/o/c/ of DM since 10-12

years, hypertension since 1 year, old CVA and Psoriasis 8-10 years. They have received cashless request

for hospitalization of 03.05.2017 to 06.05.2017 and accordingly cashless of Rs.38,054/- has been

sanctioned in this case. As per disease history eligible sum insured for processing of claim was

2,00,000/- . In policy from 24.07.2012 to 23.07.2015 sum insured was Rs.2 lacs after that policy of

24.07.2015 to 23.07.2016 sum insured was enhanced as Rs.4,00,000/- and policy of 24.07.2016 to

23.07.2017 SI was Rs. 6,00,000/-. Since the diagnosed diseases are pre-existing they have taken the sum

insured 4 year ago as Rs.2 lac to calculate the liability as per clause 4.1 of policy. Clause 9(iv) clearly

1. Name & Address of the Complainant Mr. Sandeep Mittal

553, Usha Nagar Extension,

Indore.

2. Policy No:

Type of Policy

Duration of policy/Policy period

151301/48/2017/2376

Happy Family Floater Policy

24/07/2016 to 23/07/2017

3. Name of the insured


Mr. Sandeep Mittal

--DO--

4. Name of the insurer Oriental Insurance Co. Ltd.,

5. Date of Repudiation/ Rejection --

6. Reason for Repudiation/ Rejection --

7. Date of receipt of the Complaint 31/10/2017

8. Nature of complaint Partial settlement of claim

9. Amount of Claim Rs.45554/-

10. Date of Partial Settlement 12/07/2017

11. Amount of relief sought Rs.18156/-

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

13. Date of hearing/place On 06.12.2018 at Bhopal

14. Representation at the hearing


b) For the insurer Mr. Tarun Bagdi, BM

15. Complaint how disposed Dismissed

16. Date of Award/Order 06.12.2018

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states that if the policy is renewed for enhanced SI then the clauses 4.1, 4.2 and 4.3 as applicable to a

fresh, shall apply to additional SI as if a separate policy has been issued for the difference. In respect of

pre-existing disease or for a disease/ ailment/ injury for which treatment has been taken in the earlier

policy period the enhanced SI will be available only after 4 continuous renewals with the increase sum

insured. In view of above provisions applicable SI is Rs.2 Lacs. Insured‟s entitlement for room rent is

Rs.2,000/- per day but he opted room @ Rs.4500/- per day, hence room rent has been restricted to Rs.

2,000/- per day. For other expenses also insured shall be entitled as per room category. Calculation of

claim is mentioned in SCN.

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

respondent have filed alongwith SCN annexure and hospital records.

Complainant remained absent during hearing. I have heard respondent‟s representative at length and

perused written submission and papers filed on behalf of the complainant as well as the Insurance

Company.

Complainant has sought relief of Rs.18,156/-. A policy was purchased by complainant for his and his

family members wef.24.07.2012 to 23.07.2013 for SI of Rs. 2 lac. This policy was renewed from

24.07.2013 to 23.07.2014 for SI Rs.2 lacs which was further renewed from 24.07.2014 to 23.07.2015 for

SI Rs.2 Lacs. This policy was further renewed from 24.07.2015 to 23.07.2016 for enhanced sum insured

for Rs.4 lac and further renewed from 24.07.2016 to 23.07.2017 for enhanced sum insured of Rs. 6 lacs.

Respondent have settled the claim treating sum insured as Rs.2 lac as per policy clause no. 4.1. Discharge

summary of Muljibhai Patel Urological Hospital, Nadiad shows that the insured was diagnosed with

CKD stage IV, NKD diabetic kidney disease, DM, HTN, old CVA psoriasis, anemia and was a k/c/o DM

since 10-12 years, k/c/o psoriasis since 8-10 years, k/c/o hypertension since 1 year. Hence above medical

record shows that complainant was having a history of pre-existing disease such as DM, psoriasis and

hypertension. Clause 4.1 provides that the company shall not be liable to make any payment under this

policy in respect of any expense whatsoever incurred by any insured person in connection with or in

respect of all pre-existing disease (whether treated/ untreated, declared or not declared in the proposal

form), which are excluded upto 48 months of the policy being in force and pre-existing disease shall be

covered only after the policy has been continuously in force for 48 months. Clause 4.3 provides that if

the sum insured is enhanced subsequent to the inception of first policy clauses 4.1, 4.2 and 4.3 shall

apply a fresh on the enhanced portion of the sum insured. In this case enhancement of the sum insured

from 2 lacs to Rs.4 lacs was made on 24.07.2015 and from Rs.4 lacs to Rs.6 lacs was made on

24.07.2016 hence, these policies shall be treated as fresh policy for enhanced sum insured. CKD and

NKD diseases are the ramification of DM and hypertension. Claim sought is for May 2017, hence sum

insured shall be taken into consideration as Rs.2 lacs as per above clauses. As per clause 1.2 of policy

room rent is payable @ of 1% of sum insured, hence room rent shall be Rs.2,000/- per day, which is

calculated by the respondent. Other expenses shall also be calculated as per clause 1.2 of policy i.e. in the

ratio of room rent. Respondent have calculated other expenses also in accordance with above clause,

hence deduction of Rs. 18,156/- as shown in calculation is in accordance with policy terms & conditions.

In view of the above facts & circumstances, I arrive at the conclusion that the respondent has not erred in

settling the claim, hence there is no reason to interfere with the decision of respondent company and

complaint is liable to be dismissed.

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The complaint filed by Mr. Sandeep Mittal is dismissed herewith.

Let copies of Award be given to both the parties.

Dated : December 06, 2018 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

Mr.Divyanshu Jain…….……….…..…………....……… Complainant

V/S

United India Insurance Co. Ltd ……………….…..........……………Respondent


Mr.Divyanshu Jain (Complainant) has filed a complaint against United India Insurance Co.Ltd.(

Respondent) alleging non settlement of claim.

Brief facts of the Case - The complainant has stated that he is an employee of Central Bank of India. His

Bank is having a Corporate Tie up with respondent for insurance coverage of bank employees and their

dependents. He has submitted hospitalisation claim for delivery expenses of his wife along with

hospitalization expenses of his daughter. When he enquired about the status of the claim then he was

informed that his wife and his daughter were not added as dependent in policy. He has requested

respondent to include name of his wife and daughter‟s on 23/08/2016 and addition was done on

07.12.2016. He approached this forum for redressal of his grievance.

The respondent in their SCN have stated that they have issued a group mediclaim policy to Central Bank

of India‟s bank employees covering the employee for the period from 01.10.2015 to 30.09.2016.

Complainant employee no. 126453 was included by the bank in the list of insured persons with his

dependent mother and father. Claim documents for Mrs. Anima Jain and baby were submitted in August

2016 in which hospitalization was in July 2016. Hospitalization claim was falling under policy year

2015-2016. Request to enrolled the names of dependents was given to bank by employee in August 2016

1. Name & Address of the Complainant Mr.Divyanshu Jain

D-3, Nandanvan Colony, Navlakha Sqaure,

Behind AB Tower, Indore.

2. Policy No:

Type of Policy


500100/48/15/41/00000425

Corporate Mediclaim Policy

01/10/2015 to 30/09/2016



Mr. Divyanshu Jain

--

4. Name of the insurer United India Insurance Co. Ltd.,

5. Date of Repudiation/ Rejection -

6. Reason for Repudiation/ Rejection -


8. Nature of complaint Non settlement of claim

9. Amount of Claim

10. Date of Partial Settlement

11. Amount of relief sought


13. Date of hearing/place On 11.12.2018 at 11.15 A.M. at Bhopal


c) For the Complainant Mr. Divyanshu Jain

d) For the insurer Mr. Badal Jain, AM



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i.e. after hospitalization and the dependent was added in HRMS of bank in December, 2016 which is

after expiry of policy period and bank has given request for addition of member for the year 2017.

Dependent of the insured was hospitalized on 25.07.2016 and the insured forwarded the request for

addition of dependent member to the bank processed in December 2016. They have received the request

on 27.09.2017. Hence, they are unable to process the claim for the member which was neither declared

nor covered during the policy period.


respondent have filed SCN with enclosures.

Efforts for mediation failed. I have heard both the parties at length and perused paper filed on behalf of

the complainant as well as the Insurance Company.

In their SCN respondent have stated that they are unable to process the claim for the member which was

neither declared nor covered during the policy period. Respondent have argued that request to enroll the

names of dependent was given to the bank by employee in August 2016 i.e. after hospitalization and

dependent were added in HRMS of Bank in December, 2016 which is after expiry of policy period. They

further stated that hospitalization was on 25.07.2016 and request for addition of dependent member to

bank processed in December, 2016. Complainant has opposed the above argument and admitted during

hearing that his wife was hospitalized in July, 2016 and baby daughter in first week of August, 2016.

Complainant in his complaint has admitted that request for dependent addition was submitted on

23.08.2016 and addition was done on 07.12.2016. He further admitted that claim of Mrs. Anima Jain of

hospital Bhorsakar and her daughter of Dolphin Hospital were filed on 01.08.2016. Complainant had not

disclosed treatment dates of her wife and daughter in complaint. He has not filed hospitalization papers

also. Respondent has told the hospitalization in July, 2016. As per complaint both the claims were filed

on 01.08.2016. If both the claims were filed on 01.08.2016 then hospitalization must be before

01.08.2016. Request for addition of names of dependents was made on 23.08.2016 i.e. after

hospitalization. On the date of treatment or hospitalization complainant‟s wife and daughter were not

enrolled as dependents of the complainant. As complainant‟s wife and daughter were not enrolled or

declared as dependents on the date of hospitalization, hence respondent has rightly repudiated the claim.

In view of the above facts & circumstances, I come to the conclusion that respondent has not erred in

repudiating the claim of complainant and there is no reason to interfere with the decision of respondent

company and hence complaint is liable to be dismissed.

The complaint filed by Mr. Divyanshu Jain is dismissed herewith.




Mr. K.L.Murjani……….. ……………….………....………………. Complainant

V/S

Religare Health Insurance Co. Ltd………………………....….……Respondent


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Mr.K.L.Murjani (Complainant) has filed a complaint against Religare Health Insurance Co. Ltd.

(Respondent) alleging wrong repudiation of claim.

Brief facts of the Case - The complainant has stated that his daughter was feeling acute weakness,

headache and vomiting on 19.07.2017 and was fallen down on the floor at residence. She was admitted

from 19.07.2017 to 21.07.2017 at Suyash Hospital, Indore where Acute Gastritis with Dimorphic Anemia

with blood pressure disorder was diagnosed. After discharge claim was filed before the respondent

company which was repudiated by the respondent. Insured‟s father has approached this forum for payment

of incurred amount.

The respondent in their SCN have stated that as per discharge summary prepared by the concerned

hospital authorities, the complainant on admission was found to be in stable condition with all body

vitals including Temperature, Pulse rate, Respiration Rate & Blood pressure well within limits. Even

though the patient is specified to be having episode of vomiting 4-5 times, Patients blood pressure is

perfectly stable and within limits indicating the stable condition of the patient. It is further specified in

the Discharge Summary that the patient was evaluated for her presenting complaints clinically

examined and investigated with routine tests. As per the Vital Charts the patient is specified to be in

Stable condition and afebrile throughout the entire period of hospitalization which does not necessitate

hospitalization. As per In-Patient History Record the patient is specified to be admitted for “Vertigo”

for Evaluation” Even though the pain score is specified to be “Uncomfortable Pain” the said condition

does not necessitate in-patient care and could have been managed on Out-patient basis. During

hospitalization various investigations such as Test for stool test, Complete Blood Tests, Sugar Fasting,

Vitamin deficiency, Ultrasound whole Abdomen and Urine Examination were conducted. On perusal it

was observed that complainant was not diagnosed with any active disease or ailment necessitating In-

1. Name & Address of the Complainant Mr. K. L. Murjani

95/2, Bairathi Colony, No.2.

Indore.

2. Policy No:

Type of Policy


10763263

Health Insurance Policy

20.08.2016 to 19.08.2017



Ms.Vradhi Bashani

-----same--------

4. Name of the insurer Religare Health Insurance Co. Ltd.

5. Date of Repudiation/ Rejection 15.08.2017

6. Reason for Repudiation/ Rejection Investigation/ Evaluation are not covered and

admission not justified

7. Date of receipt of the Complaint 17.10.2017

8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs.12,862/-

10. Date of Partial Settlement Nil

11. Amount of relief sought Rs.12,862/-


13. Date of hearing/place On 13.12.2018 at 11.00 A.M.at Bhopal


e) For the Complainant Shri K.L.Murjani

f) For the insurer Dr.Nisha Sharma, Manager Claims



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patient treatment. All the investigations conducted were doable on Out-patient Basis. Therefore, claim

was rejected under exclusion clause 4.3(A)(i) read with annexure C (71).



Efforts for mediation failed. I have heard both the parties at length and perused papers filed on behalf of the

complainant as well as the Insurance Company.

Hospitalization claim from 19.07.2017 to 21.07.2017 pertains to the policy period from 20.08.2016 to

19.08.2017. Claim was rejected on the ground that for the treatment, hospitalization was not necessary and

admission in hospital for investigation and evaluation is not covered as per policy. Discharge summary

shows that insured was admitted to Suyash Hospital, Indore on 19.07.2017 and discharged on 21.07.2017

and was diagnosed with acute gastritis with dimorphic anemia with BPPV. As per discharge summary,

insured was admitted with a case of headache off & on, vomiting 4-5 times, chakkar since 2 days.

Discharges summary reveals that insured was clinically examined and investigated with routine test such as

SGPT, FBS, vitamin B-12 Iron and TIBC, CBC, Urine R/M, USG W/A, Stool R/M. She was given

injection Orofer-s 100mg and Neumec fort 1amp. On clinical examination she was found with pulse 84/

min BP 120-70 and chest clear. In investigation except hemoglobin other reports including USG are shown

as normal and she was administered with injection of iron. Medical record shows that insured was not

diagnosed with any active disease or ailment necessitating hospitalization. As per report of Dr. Manish

Shetty filed on behalf of respondent shows that investigation as well as orofer administration are OPD

procedures and hospitalization was not warranted. Hence, it is clear that all the investigations and

administration of injection orofer were doable on outpatient basis and hospitalization was not necessary.

Admission in the hospital for the purpose of investigation and evaluation, is not covered under the policy as

per clause 4.3(A)(i) read with annexure C(71).

In view of the above facts & circumstances, I come to the conclusion that the respondent has not erred in

repudiating the claim. Therefore, I am of the opinion that there is no reason to interfere with the decision of

respondent company and hence complaint is liable to be dismissed.

The complaint filed by Mr. K.L.Murjani stands dismissed herewith.




Dr.Balwant Singh……………….…….………....………………. Complainant

V/S

Star Health and Allied Ins.Co.Ltd. .………….……………….……Respondent

COMPLAINT NO: BHP-G-044-1718-0120 ORDER NO: IO/BHP/A/GI/ 0094/2018-2019

1. Name & Address of the Complainant Dr.Balwant Singh

Suryadev Nagar, Indore

2. Policy No:

Type of Policy


P/201119/01/2017/005619

Star Comprehensive Insurance Policy

12/03/2017 to 11/03/2018



Mrs.Rekha Singh

Dr.Balwant Singh

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17. Dr.Balwant Singh (Complainant) has filed a complaint against Star Health & Allied Ins. Co.Ltd.,

(Respondent) alleging wrong rejection of two claims.

18. Brief facts of the case - The complainant has stated that he and his family members were covered under

mediclaim policy issued by the respondent. It is further said that complainant‟s wife Mrs.Rekha Singh was

hospitalized in Suyash Hospital, Indore on 10/05/2017 to 17/05/2017 and again on 26/05/2017 to

29/05/2017 for the treatment of disease diagnosed HTN/Rt.Acousstic Schwanomma/ UTI (GNB growth).

He has preferred two claims for reimbursement of medical expenses with the respondent company for

incurred amount but respondent insurance company has rejected both the claims.

The Respondent in their SCN have stated that complainant has submitted 2 claims. First claim no. 60210

was reported in the 2nd

month and second claim no, 88310 in the third months of the policy. As per

discharge summary the insured had complaints of hearing loss, Imbalance, Facial spasm, Tinnitus Right

since one year. Insured patient had ENT related problem before porting of policy and same was not

disclosed. Complainant had not disclosed medical history/ health details of the insured person in proposal

form which amounts to misrepresentation/ non disclosure of material facts and as per clause 9 of the policy

company is not liable to make any payment in respect of any claim. Due to non discloser of material facts

policy was cancelled as per clause 14 and premium amount was refunded.

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


20. I have heard both the parties at length and perused papers filed on behalf of the complainant as well as the

Insurance Company.

21. Two claims no. 60210/2018 and 88130/2018 were lodged with respondent which were repudiated and

policy with respect to insured Smt.Rekha Singh W/o Shri Balwant Singh was cancelled on the ground of

non disclosure of material facts of medical history. Discharge summary of Suyash Hospital Pvt.Ltd. Indore

shows that insured was admitted to above hospital on 10.05.2017 and discharged on 17.05.2017. As per

discharge summary insured was diagnosed with Right Acoustic Schwanomma and having a history of

hearing loss, imbalance, facial spasm, tinnitus Rt. since 1 year, Right Acoustic Schwanomma. Prescription

dated 07.05.2017 of Suyash Hospital Pvt.Ltd. Indore also shows that insured was having Right Acoustic

Schwanomma with tinnitus Rt. since one year. Star medical officer FVR is on record which shows that

insured was having pre-existing disease Right Acoustic Schwanomma. Hence, according to discharge

summary and above prescription insured was suffering from tinnitus rt. since 1 year i.e. from May 2016.

4. Name of the insurer Star Health and Allied Ins.Co.Ltd.,

5. Date of Repudiation/ Rejection 20/06/2017

6. Reason for Repudiation/ Rejection Non disclosure of Pre-existing disease



9. Amount of Claim Rs.2,50,596/- & Rs.24,895/-

10. Date of Partial Settlement -

11. Amount of relief sought Rs.2,75,491/-


13. Date of hearing/place 18.12.2018 at Bhopal


g) For the Complainant Shri Balwant Singh

h) For the insurer Shri Ravi Tiwari, AGM Claims



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As policy inception date is 12.03.2017, hence Right Acoustic Schwanomma with tinnitus Rt. was pre-

existing before inception of policy. In proposal form insured had mentioned that questioned insured was

not suffering from any disease of ENT. Vestibular Schwanomma (Acoustic neuroma) is ENT disease

which results in gradual loss of hearing, often accompanied by ringing in the year (tinnitus) or feeling of

fullness in the year. Insured was a case of hearing loss, imbalance and tinnitus as per discharge summary.

Hence, insured was suffering from ENT disease prior to inception of policy which was not disclosed and

concealed. As per clause 9 of policy terms & conditions company is not liable to make payment in respect

of any claim if information furnished at the time of proposal is found to be incorrect and false. Clause 14

of policy provides that the company may cancel any policy on grounds of mis-representation and non

disclosure of material facts. In this case material fact of ENT disease was not disclosed by the policy

holder at the time of inception of policy, hence respondent may cancel policy as per above clause.

22. In view of the above facts & circumstances, I come to the conclusion that the respondent has rightly

repudiated the claim and cancelled the policy with respect to insured in question. Therefore, I am of the

opinion that there is no reason to interfere with the decision of respondent company and hence complaint is

liable to be dismissed.

23. The complaint filed by Mr. Balwant Singh stands dismissed herewith.

24. Let copies of Award be given to both the parties.



Mr. M.S. Raghuwanshi ………………….……...………………. Complainant

V/S

Star Health and Allied Ins.Co.Ltd., .……………………..….……Respondent


1. Name & Address of the Complainant Mr. M.S. Raghuwanshi

Chuna Bhatti Bhopal

2. Policy No:

Type of Policy


P/201100/01/2017/002849


13/12/2016 to 12/12/2017



Mr. M.S. Raghuwanshi

Mr. M.S. Raghuwanshi



6. Reason for Repudiation/ Rejection Non-disclosure of material facts.


8. Nature of complaint Repudiation of claims

9. Amount of Claim Rs.2,57,129/-


11. Amount of relief sought Rs.2,57,129-




i) For the Complainant Absent

j) For the insurer Shri Ravi Tiwari, AGM Claims

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17. Mr. M.S. Raghuwanshi (Complainant) has filed a complaint against Star Health & Allied Ins. Co.Ltd.,

(Respondent) alleging wrong rejection of his claim.

18. Brief facts of the Case - The complainant has stated that he and his wife were covered under mediclaim

policy issued by the respondent. In April 17 he was diagnosed with cancer and operated on 15.04.2017

and 29.09.2017 and was hospitalized in Prince Aly Khan Hospital, Mumbai. He has preferred claim for

reimbursement of medical expenses towards the above mentioned treatment with the respondent

company for incurred amount but respondent insurance company has rejected the claim. The complainant

approached this forum for payment of his claim.

The Respondent company in their SCN have stated that above policy was effective from 13.12.2016 to

12.12.2017 for sum insured as Rs.5 Lac. Insured has reported two claims towards two hospitalization.

First claim was reported in the fourth month and second claim in the 10th

month of policy inception. As

per discharge summary insured was diagnosed with CA right BM and CA right Cheek. Insured was a

known case of Diabetes Mellitus since many years and was on regular treatment, surgical treatment

history of Right Tibia Fracture, platting done 1 yr back and also Biopsy from Right Buccal Mucosa

Grade 1 S/o Squanous cell carcinoma grade 1. As per discharge summary of Bhopal Fracture Hospital,

from 07.02.2016 to 17.02.2016, the insured was diagnosed with fracture tibia/fibula right with depressed

fracture frontal bone with multiple small hemorrhagic contusion and SAH with fracture maxilla,

hypertension and diabetes mellitus. As per consultation slip dated 20.09.2016 of Dr.Rajneesh Goar,

insured was a followup case of head injury on Feb.2016 and consulted for case of and on headache. At

the time of inception of policy insured had not disclosed above mentioned medical history which

amounts to misrepresentation/ non disclosure of material facts. As per clause 9 of policy, if there is

misrepresentation/ non discloser of material facts, company is not liable to make any payment in respect

of any claim. First claim was repudiated and second was closed due to non submission of claim

documents.



20. During hearing complainant remained absent. I have heard respondent‟s representative at length and

perused papers filed on behalf of the complainant as well as the Insurance Company.

21. Respondent have argued that complainant/ policy holder has not disclosed DM, HTN, head injury and

surgical treatment of Tibia Fracture in proposal form. They further argued that discharge summary also

shows that insured was having a history of carcinoma grade 1. These diseases were not disclosed at the

time of inception of policy and as per clause 9 of policy for misrepresentation / non disclosure of material

facts company shall not be liable to make payment. Discharge summary of Prince Aly Khan Hospital,

Mumbai shows that complainant was admitted in above hospital on 15.04.2017 and discharged on

16.04.2017 and was diagnosed with CA Right BM, CA Right Cheek. In column of past history/

investigations & history it is mentioned that insured is a k/c/o DM since many years on regular RX, SX

H/O Right Tibia # Platting Done 1 year back evaluated by Biopsy from right buccal mucosa-S/O

Squamous Cell Carsinoma grade 1. All above disease in discharge summary are shown under head past

history/ investigations & history. Discharge summary of Bhopal Fracture Hospital and Surgical Centre



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also shows that insured was admitted on 07.02.2016 and discharge on 17.02.2016 and was diagnosed

with fracture, HTN and DM type II. Prescription of Dr.Rajneesh Gour of Bhopal Fracture Hospital and

Surgical Centre dated 20.09.2016 shows that insured was a followup case of head injury Feb,2016.

Policy was incepted on 13.12.2016, hence it is clear that insured was suffering from DM, HTN, head

injury and undergone surgical treatment of fracture and platting of right tibia prior to the inception of the

policy. From perusal of proposal form it is clear that insured had not disclosed his surgical treatment of

fracture, head injury disease of HTN and DM type II and also denied of having above, while in

declaration proposer/ insured has confirmed that he has mentioned health status correctly in proposal

form. Hence claim was rightly repudiated by the respondent under clause 9 of policy terms & conditions.

22. In view of the above facts & circumstances, I come to the conclusion that the respondent has not erred in

repudiating the claim. Therefore, I am of the opinion that there is no reason to interfere with the decision

of respondent company and hence complaint is liable to be dismissed.

23. The complaint filed by Mr. Mahendra Singh Raghuwanshi stands dismissed herewith.




Shri Vinod Lohokare ………………….……...………………. Complainant

V/S

Star Health and Allied Ins.Co.Ltd., .……………………...……Respondent

COMPLAINT NO: BHP-G-044-1718-0111 ORDER NO: IO/BHP/A/GI/0096/2018-2019

17. Shri Vinod Lohokare (Complainant) has filed complaint against Star Health and Allied Insurance Co.Ltd.,(

Respondent) alleging wrong rejection of claim.

1. Name & Address of the Complainant Shri Vinod Lohokare

59-C,Vandana Nagar,Indore

2. Policy No:

Type of Policy


P/201114/01/2017/013684


16/02/2017 to 15/02/2018



Smt.Sahana Lohokare

Mr. Vinod Lohokare



6. Reason for Repudiation/ Rejection Disease excluded under clause 6


8. Nature of complaint Repudiation of Claim




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



k) For the Complainant Absent

l) For the insurer Shri Ravi Tiwari, AGM Claims



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18. Brief facts of the Case - The complainant has stated that his wife was covered under mediclaim policy

issued by the respondent. She was hospitalized in Vishesh Hospital, Indore on 27/07/2017 and discharged

on 29/07/2017. She was diagnosed with Anxiety Neurosis. Thereafter he preferred claim before the

respondent company which was rejected. The complainant approached this forum for payment of his

claim.

The respondent in their SCN have stated that the above policy was effective from 16.02.2017 to

15.02.2018 for sum insured of Rs.5 lac. This policy was in continuation of policy effective from

16.02.2016 to 15.02.2017. Insured was diagnosed with Syncope with anxiety neurosis which is a

Psychiatric disorder. As per clause 6 of the policy company is not liable to make payment in respect of

expenses for the treatment of Psychiatric, mental and behavioral disorders.



During hearing complainant remained absent and had sent a letter dated 30.11.2018 for his absence. I have

heard respondent‟s representative at length and perused paper filed on behalf of the complainant as well as

the Insurance Company.

20. Claim was repudiated on the ground that the disease diagnosed and treated for is a psychiatric disorder

which is excluded under clause 6. Discharge summary of Vishesh hospital Indore shows that insured was

admitted to above hospital on 27.07.2017 and discharged on 29.07.2017. She was diagnosed with Syncope

with anxiety neurosis and treated with Tab Etizola 0.5mg, Pantocid 40 mg, Ibugesic plus, Caldikind plus

and inj Architol. Tab Etizola is an effective anti-anxiety medicine. Disease Syncope with anxiety neurosis

is psychiatric, mental and behavioral disorder. As per Clause 3 (6) company shall not be liable to make

payment of the expenses incurred in disease such as psychiatric, mental and behavioral disorders, hence

respondent has rightly repudiated the claim as per policy terms & conditions.

21. In view of the above facts & circumstances, I come to the conclusion that the respondent has not erred in

repudiating the claim. Therefore, I am of the opinion that there is no reason to interfere with the decision of

respondent company and hence complaint is liable to be dismissed.

22. The complaint filed by Mr. Vinod Lohokare stands dismissed herewith.




Mr.Kamal Nayan Patel.…..…………..………….……………….. Complainant

V/S

Life Insurance Corporation of India…………………………....……Respondent

COMPLAINT NO: BHP-L-029-1819-0090 ORDER NO: IO/BHP/A/LI/0283/2018-2019

1. Name & Address of the Complainant Mr. Kamal Nayan Patel

Anu Nagar, Tehsil Tandla,

Dist Jhabua (MP)

2. Policy No:

Type of Policy


347382530

LIC’s Jeevan Arogya Without Profit)

10.07.2014



Mr. Meet Patel

Mr. Kamal Nayan Patel

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Mr. Kamal Nayan Patel (Complainant) has filed a complaint against Life Insurance Corporation of

India (Respondent) alleging non settlement of claim.

Brief facts of the Case - The complainant has stated that his son was covered under above health

insurance policy issued by respondent company. His son was admitted in Saifi hospital Dahod on

02.10.2017 for operation of his hand. Thereafter he preferred claim before the respondent company but

no replay was given to him. The complainant approached this forum for payment of his claim.

The respondent in their SCN have stated that complainant had taken Jeevan Arogya plan in which his

son was covered. It is a fixed benefit plan in which a fixed amount is paid in case of hospitalization of

insured or treatment mentioned in policy taken. The claim was rejected on the ground of pre-existing

illness irrespective of prior medical treatment or advise- repudiated under PED M02 clause (for

fracture in hand- surgery on 04.09.2015). The claim is rejected for Rs.22,100/- on account of patient

with a history of surgery for fracture in hand in 04.09.2015 and now admitted for implant removal and

underwent the same on 02.10.2017. The respondent further stated that policy was issued on 10.07.2014

which was discontinued on 11.08.2015 which was revived on 10.10.2015.



During hearing complainant remained absent. I have heard respondent‟s representative at length and

perused papers filed on behalf of the complainant as well as the Insurance Company.

Above policy was issued with commencement date as 10.07.2014 in which mode of premium was

yearly. Claim is filed for the treatment from 02.10.2017 to 03.10.2017 in which implant removal was

done. Claim form shows that insured had been hospitalized in past on 04.09.2015 for fracture in hand

and surgery was done. Bill of Saifee Orthopaedic Hospital, Dahod also shows admission on 04.09.2015

with diagnosis of left side fracture distal 1/3 radius and ulna. Above policy was in discontinued status

on 04.09.2015 and revival took place on 10.10.2015, hence treatment taken for the fracture of

04.09.2015 shall be pre-existing for revived policy. Clause 7 of policy terms & condition provides that

no benefit are available and no payment will be made by the corporation for any claim on account of

hospitalization or surgery for any pre-existing condition unless disclosed to and accepted by the

corporation prior to the date of revival (if the policy is revived after discontinuance of the cover).

During hearing respondent‟s representative revealed that at the time of revival, pre-existing disease i.e.

4. Name of the insurer Life Insurance Corporation of India

5. Date of Repudiation/ Rejection 14.12.2017

6. Reason for Repudiation/ Rejection Pre-existing disease




10. Date of Partial Settlement





m) For the Complainant Absent

n) For the insurer Sh. K.Ganga, ADM (Manager HI)



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surgery of fracture of 04.09.2015 was not mentioned by the complainant. Hence, the respondent has

rightly repudiated the claim in accordance with policy terms & conditions.

In view of the above facts & circumstances, I come to the conclusion that the respondent has not erred

in repudiating the claim as per terms & conditions of the policy. Therefore, I am of the opinion that

there is no reason to interfere with the decision of respondent company and hence complaint is liable to

be dismissed.

The complaint filed by Mr. Kamal Nayan Patel stands dismissed herewith.




Mr. Amit Chouhan……..…. ……………….………....………………. Complainant

V/S

United India Insurance Co. Ltd………………………....………….……Respondent


Mr. Amit Chouhan (Complainant) has filed a complaint against United India Insurance Co.

Ltd.(Respondent) alleging wrong repudiation of claims.

Brief facts of the Case - The complainant has stated that his mother was covered under above mentioned

policy issued by the respondent. In October 2017 his mother was detected Pots Spine Tubercluosis. The

cashless treatment request was accepted and 50% of hospital bill was paid by the insurance company. She

got a attack on 22nd

Nov.2017 and hospitalized at Maheshwari Hospital. On submitting the bills of 3 days

1. Name & Address of the Complainant Mr. Amit Chouhan

H.No.26, Gali No. 1, Mahamai ka Bag,

Railway Station Road, Bhopal.

2. Policy No:

Type of Policy


0220002816P117591189

Family Medicare Policy

01/03/2017 to 28/02/2018



Mrs. Rashmi Chouhan

Mr. Amit Chouhan

4. Name of the insurer United Insurance Co. Ltd.

5. Date of Repudiation/ Rejection 19/12/2017 and 19/01/2018

6. Reason for Repudiation/ Rejection Pre-existing disease clause 4.1


8. Nature of complaint Repudiation of two claims.

9. Amount of Claim -

10. Date of Partial Settlement N.A.

11. Amount of relief sought -


13. Date of hearing/place On 20.12.2018 at 11.30 A.M.at Bhopal


o) For the Complainant Mr. Amit Chouhan

p) For the insurer Absent

15. Complaint how disposed Allowed


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treatment at Maheshwari hospital, the claim was rejected stating diabetes as a reason and being a pre-

existing disease. After 10 days suddenly she became unconscious and admitted at National hospital, Bhopal

on 04.12.2017 to 31.12.2017. Thereafter he submitted claim which was also repudiated on the same ground

of pre-existing disease as taken in earlier claim. The complainant has approached this forum for payments

of his both the claim.

The respondent in their SCN have stated that patient was hospitalized from 04.12.2017 to 31.12.2017 for

the procedure of Type II DM with Potts Spine DRG Induced. Patient was hospitalized for treatment of Potts

Disease with CVA (Intracerebral Hemorrhage) and CVA is due to complication of DM. The diabetes

mellitus is falling under pre-existing criteria i.e. before policy inception. Hence, the claim is denied under

exclusion clause No. 4.1. The indirect inguinal hernia is external congenital disease and same is not

admissible under United India Policy Clause no. 4.8.



During hearing none appeared on behalf of respondent. I have heard Complainant at length and perused

paper filed on behalf of the complainant as well as the Insurance Company.

Two claims, one of treatment from 22.11.2017 to 24.11.2017 and second of 04.12.2017 to 31.12.2017 were

lodged by complainant for the expenses incurred in his mother‟s treatment. First claim was repudiated on

19.12.2017 and second on 19.01.2018 by the respondent. Grounds taken for rejection of first claim is that

the insured‟s current ailment is complication of pre-existing DM and HTN and as policy was incepted in

2014, hence not covered under clause 4.1 of policy. Grounds taken for rejection of second claim is that the

insured‟s current ailment is complication of pre-existing DM and as policy was incepted in 2014, hence not

covered under clause 4.1 of policy. Respondent in their SCN dated 16.04.2018 has replied only with respect

to treatment from 04.12.2017 to 31.12.2017. Nothing has been mentioned with respect to claim for the

treatment from 22.11.2017 to 24.11.2017 in SCN. In first repudiation it is mentioned that insured was

diagnosed with potts spine, sezuires and hypertension. Discharge ticket of Maheshwari hospital, Bhopal

shows that insured was admitted on 22.11.2017, discharged on 24.11.2017 and diagnosed with Potts spine,

sezuires, hypertension and cold. In discharge summary of National Hospital Bhopal, date of admission and

discharge is mentioned as 04.12.2017 and 31.12.2017. This summary reveals that insured was diagnosed

with Pott‟s spine with TBN on ATT with drug induced hepatitis with GTCS HTN. In SCN respondent has

stated that from 04.12.2017 to 31.12.2017 insured was treated for Potts disease with CVA ( intracerebral

hemorrhage) and CVA is due to complication of DM. In discharge summary of National hospital Bhopal

DM type II is mentioned since 18 years to the insured. In both the discharge summary of Maheshwari

Hospital and National Hospital Bhopal, in diagnosed diseases, CVA is not mentioned. If as per SCN

insured was having Potts disease with CVA then CVA must be written in discharge summaries of above

hospitals. No other medical record shows that insured was suffering from CVA. Pott‟s spine is a tubercular

disease. There is nothing on record to show that since when insured was suffering from HTN, hence it is not

established that HTN was pre-existing. Nothing in respect that insured was having inguinal hernia is shown

by respondent. According to respondent CVA is the complication of DM but disease CVA has not

mentioned in any of the medical papers of insured. Thus it is clear that diseases mentioned in discharge

summary of Maheshwari Hospital and National Hospital Bhopal bears no disease as CVA which may be the

complication of DM, hence diseases diagnosed in both the treatment is not the complication of diabetes

mellitus which is said to be pre-existing. As diseases diagnosed on 22.11.2017 to 24.11.2017 and

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04.12.2017 to 31.12.2017 is not related with DM and not the complication of DM, hence repudiation of

both the claim is not justified.

In view of above facts and circumstances, I come to the conclusion that the Insurance Company has erred in

not allowing the claims under policy and respondent should have allowed the claims. In the result complaint

is allowed and respondent is directed to allow both the claim in accordance with terms and conditions of the

policy.

Let a copy of award be sent to complainant and respondent insurance company for compliance within 30

days.

Dated : December 20, 2018 (G.S.Shrivastava) Place

: Bhopal Insurance Ombudsman

Mr.Vijay Ahuja.. ……….……….…..…………………. Complainant

V/S

National Insurance Co. Ltd.………..……....……………Respondent

COMPLAINT NO: BHP-G-048-1718-0064 ORDER NO: IO/BHP/A/GI/0100/2018-2019

17. Mr.Vijay Ahuja (complainant) has filed complaint against National Insurance Co.Ltd. (Respondent)

alleging Partial settlement of claim.

18. Brief facts of the case - The complainant has stated that he was covered under mediclaim policy issued

by the respondent since last 3 years. He preferred a claim for reimbursement of incurred expenses in

his Bypass surgery of Heart in Feb.2017 but company had paid him only Rs.90,000/- while sum

insured of his policy was Rs.3 lac. He made request for less payment of claim but no reply was given to

him. The complainant approached this forum for payment of his claim.

1. Name & Address of the Complainant Mr,Vijay Ahuja

C/O. Umang Tredars

Station Road, Raipur ( C G )

2. Policy No:

Type of Policy


285101/48/15/8500001265

Mediclaim Policy

21/03/2016 to 20/03/2017



Mr.Vijay Ahuja

------do----

4. Name of the insurer National Insurance Co.Ltd.,

5. Date of Repudiation/ Rejection -

6. Reason for Repudiation/ Rejection -


8. Nature of complaint Partial Settlement

9. Amount of Claim -

10. Date of Partial Settlement 02/06/2017

11. Amount of relief sought -


13. Date of hearing/place On 09.10.2018 at 11.00 am at Bhopal


q) For the Complainant Mr.Vijay Ahuja

r) For the insurer Absent



of 279

The respondent in their SCN dated 02.11.2018 has stated that the insured had taken policy no.,

295101/48/12/85000001587 effective from 21.03.2013 to 20.03.2014 with sum insured as

Rs.2,00,000/-, 295101/48/13/85000001254 effective from 21.03.2014 to 20.03.2015 with sum insured

as Rs.2,00,000/-, 295101/48/14/85000001212 effective from 21.03.2015 to 20.03.2016 with sum

insured as Rs.2,00,000/- and 295101/48/15/85000001265 effective from 21.03.2016 to 20.03.2017 with

sum insured as Rs.3,00,000/-. All these policies insured with coverage of pre-existing disease of

Diabetes. Insured was admitted in hospital from 21.02.2017 to 08.03.2018 (wrongly mentioned in SCN

in place of 08.03.2017) and claimed Rs.2,79,446/-. They further stated that IHD is included in the

complication of DM and since the claim came in third and fourth year of policy and since disease was

pre-existing, the sum insured considered was 2 lac and amount was calculated as per clause 4.1. Total

expenses incurred for any one illness limited to Rs. 1 lac as per policy condition 1.0c(a)(sum insured

considered as 2 lac) and 10% of admissible claim i.e. Rs.10,000/- was deducted from claim amount as

per clause 4.1.1, hence Rs.90,000/- was paid to the complainant.


respondent have filed SCN dated 02.11.2018 with enclosures & Hospital papers.

Complaint was fixed for hearing on 09.10.2018 at 11 am but on the date only complainant was present

and none was present on the behalf of respondent. On the date of hearing i.e.09.10.2018 I have heard

complainant and perused paper filed on behalf of the complainant as well as the Insurance Company.

As SCN and claim settlement letter was not on record hence, for just decision of complaint, claim

settlement letter was called for from the respondent and ordered that let file be put up after receiving

settlement letter from respondent. After that respondent has filed SCN dated 02.11.2018 and letter

dated 17.12.2018.

According to SCN dated 02.11.2018 disease DM was pre-existing and IHD is the complication of the

DM and as the claim falls in third and fourth year of the policy, sum insured was taken as Rs.2 lac as

per clause 4.1. It is also mentioned that taking into consideration sum assured as Rs.2 Lac, claim of

Rs.90,000/- was allowed as per clause 1.0c(a) and 4.1.1. Complainant has argued that as sum insured

for the period of claim is Rs.3 lacs, hence as per policy total expenses insured for any one illness is

limited to 50% of overall sum insured and as being diabetic, deduction of 10% of admissible claim is

allowed, hence he should get total claim Rs.1,35,000/- accordingly.

As per discharge summary of Usha Mullapudi Cardiac Centre, Hyderabad insured was a known case of

diabetes. Respondent had already paid Rs.90,000/- as expenses incurred in the surgery of Coronary

Artery Bypass Graft, being in the coverage of policy for pre-existing disease of diabetes. Respondent

has considered insured amount as Rs.2 lac as per policy clause 4.1. Clause 4.1 deals with exclusions of

pre-existing disease upto four continuous claim free policy years. In this clause it is provided that pre-

existing disease as diabetes and hypertension will be covered from the inception of the policy on

payment of additional premium by the insured. In this case policy was in coverage of pre-existing

disease of diabetes and payment had already made to the complainant. As the claim is for the period

from 21.02.2017 to 08.03.2017, hence sum insured shall be taken as Rs.3 lac sum insured for the period

of 21.03.2016 to 20.03.2017 instead of Rs. 2 lac.

In view of above facts and circumstances, I come to the conclusion that the Insurance Company has erred

in considering, sum insured as Rs.2 lac instead of Rs.3 lac for calculation of the claim. In the result

of 279

complaint is allowed and respondent is directed to allow the claim treating sum insured as Rs.3 lac and

pay rest amount accordingly as per policy terms & conditions.

Let a copy of award be sent to complainant and respondent insurance company for compliance within 30

days.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – DR. D.K. VERMA

Case of Mr. Ritesh Shrivastav V/s Star Health and Allied Insurance Co. Ltd.

COMPLAINT REF.NO: CHD-G-044-1819-0547

1. On 10.10.2018, Mr. Ritesh Shrivastav had filed a complaint in this office against Star Health and

Allied Insurance Co. Ltd. for non settlement of his health claim despite several requests. The

required documents were submitted to the insurance company well in time but the insurance

company repudiated 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. The insurance company confirmed through mail that they have settled the health claim. The

claim amount of Rs. 22,777/- has been credited to bank account of Mr. Ritesh Shrivastav through

NEFT.

4. Mr. Ritesh Shrivastav has confirmed from his mobile that the insurance company has

settled his claim and he has received the claim amount and wanted to withdraw his

complaint.

5. In view of the above, no further action is required to be taken by this office and the complaint is

disposed off accordingly.

Dated : 03.12.2018 (Dr. D.K. VERMA)

PLACE: CHANDIGARH INSURANCE

OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH


OMBUDSMAN – DR. D.K VERMA

Case of Mr. Sohan Lal V/S The Oriental Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-050-1718-0421

1. Name & Address of the Complainant Mr. Sohan Lal

H.No.- 3, Devi Murti Colony,

Panipat, Haryana, Mobile No.- 9215500823

2. Policy No:

Type of Policy


261401/48/2016/2965

Happy Family Floater-2015 Policy

30-03-2016 To 29-03-2017



Mr. Sohan Lal

Mr. Sohan Lal

of 279

4. Name of the insurer The Oriental Insurance Co. Ltd.

5. Date of Repudiation 15-03-2017

6. Reason for repudiation PED

7. Date of receipt of the Complaint 11-09-2017

8. Nature of complaint Not settle the claim


10. Date of Partial Settlement N/a


12. Complaint registered under

Rule no: 13-1(b) of Insurance

Ombudsman Rules

Rule 13-1(b) – any partial or total repudiation of claims

by an insurer

13. Date of hearing/place 12-12-2018 /Chandigarh


s) For the Complainant Mr. Sohan Lal

t) For the insurer Mr. Prashant Vashisht

Mr. Ritesh Hiteshi

15 Complaint how disposed Award


17 Brief Facts of the Case:

On 11-09-2017 Mr. Sohan Lal, had filed a complaint to this office that he had a health insurance policy since

2014 and the said health insurance was ported to the OIC in the year 2016. He was admitted in the Aasthaa

Hospital, Panipat due to some health problem on 29-07-2016 and the said hospital referred to GB Pant Institute

of Post Graduate Medical Education & Research, Delhi on 30-07-2016 where angiography was done and they

recommended for heart operation. He again got admitted in the Medanta Hospital, Gurgaon for the heart

operation on 01-08-2016 and discharged on 09-08-2016. After discharge the claim bill submitted to the

insurance company but they rejected the claim on the ground that the patient was the history of hypertension

hence it was Pre existing when the cover incepts for the first time which falls under policy exclusion no. 4.1.

The insurance company decision was not justified. Whereas all the three hospital confirmed by way of issuing

certificates that patient was not having any pre-history of the hypertension.

On 21-09-2017, 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 11-12-2018

In the SCN insurance company stated that Sh. Sohan Lal was admitted at G. B. Pant hospital from 01.08.2016 to

19.08.2016 with a diagnosis CAD with recent ACS OPCABG x 4. From the discharge summary of G. B. Pant

hospital, it has been observed that complainant had history of hypertension. Therefore the claim is not payable

as the Happy family floater policy does not cover the expenses incurred on treatment of all diseases which are

pre-existing when the cover incepts for the first time vide exclusion clause 4.1 & 4.3 of the policy.

The complainant was sent Annexure VI-A for compliance, which reached this office on 04-10-2017.

18) Cause of Complaint:

a) Complainant’s argument: Complainant stated that he has ported his policy to insurance company in

third year and hence waiting period of two year will not be applicable for his case. He requested that

his genuine claim may be paid.

b) Insurers’ argument: Insurance Company stated that their TPA has rightly repudiated the claim as per

policy terms and conditions. It was also stated in the SCN that the patient has the history of

hypertension as per discharge summary of G. B. Pant hospital. The claim is not payable vide exclusion

clause no. 4.1 of the policy.

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

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21) Result of Personal hearing with both parties(Observations & Conclusion)

After careful examination of the complaint, SCN and submissions made by both complainant and the insurance

company during the personal hearing, it has been observed that complainant was having the health insurance

since 2014 with HDFC Ergo and said policy was ported to the present insurance company. They have issued the

policy 30-03-2016 and mentioned the previous policy number 90028221 on the face of the policy. It establishes

that the health insurance is running since 2014 without break. All three hospitals confirmed through specific

certificates that the patient was no history of the hypertension. Moreover, the hypertension is life style disease

and the insurance company has not quoted any reference of the PED treatment history in their No claim letter.

As per discharge summary dated 31-07-2016 of G. B. Pant Institute of Post Graduate Medical Education and

Research New Delhi, it is seen that the blood pressure during the time of admission was 120/70 which indicates

that the complainant was a case of controlled hypertension. Assuming that the complainant was a case of

hypertension as per version of insurance company, the same being a life style disease was well controlled

hypertension and the denial of the claim by insurance company on the ground is totally unjustified. The claim of

insurance company about the complainant being a case of hypertension is contradicted by the certificates issued

by the treating doctors of G. B. Pant hospital and Medanta hospital. As such the decision of the insurance

company is not in order. Hence, insurance company is directed to pay Rs 3,12,049/- as per terms and conditions

of policy to complainant within 30 days from the receipt of award copy.

AWARD

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

during the course of personal hearing, Rs 3,12,049/- as per 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.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 12th

day of December 2018.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Sanjeev Jain V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Sanjeev Jain S/o Daya Chand Jain,

R/o House No.- 102 A, Green Park,

Yamuna Nagar, Distt.- Yamuna Nagar,

Haryana- 135001Mobile No.- 9896769391

2. Policy No:

Type of Policy


261790/48/2016/885

Health Insurance policy

20-03-16 to 19-03-2017



Smt. Sapna Jain

Sh. Sanjeev Jain


5. Date of Repudiation N/a

6. Reason for repudiation N/a




10. Date of Partial Settlement Not provided




Ombudsman Rules


by an insurer


of 279


For the Complainant Sh. Sanjeev Jain, Complainant

For the insurer Sh. Jagdish Chander Lalhar, SDM

Dr. Sanjay Kumar


16 Date of Award/Order 12-12-2018


On 11.08.2017 Mr. Sanjeev Jain had filed a complaint to this office that he has the health insurance since 10

years on regular basis. His wife met with an accident burn during the Lohri celebration on 13.01.2017. She was

immediately taken to the local hospital and was further referred to another hospital. She was admitted in

Alchemist Hospital, Panchkula for the treatment but seeing no relief she was shifted to Mukat Hospitaial,

Chandigarh. Her condition further worsened and she was further shifted to Safdarjung Hospital, Delhi where

during the treatment, she expired. The total amount of Rs.67259/- was spent and claim bill was submitted to the

insurance company but insurance company settled the claim for Rs.14272/- only. Numbers of requests were sent

to the insurance company for making the balance payment but no reply received so far.

On 30.08.2017, the complaint was forwarded to The Oriental Insurance Co. Ltd Regional Office, Ambala, for

para-wise comments and submission of a self-contained note about facts of the case, which was made available

to this office till the date of hearing.

The complainant was sent Annexure VI-A for compliance, which reached this office on 21.09.2017.


a) Complainant’s argument: The complainant stated that his genuine claim has been partially paid to

him by insurance company without any justification and information. He requested for payment of entire

claim amount.

b) Insurers’ argument: Insurance company stated that deduction were made since complainant has not

submitted lab reports, radiology reports, pharmacy breakup etc with his claim bill and accordingly

deductions were made as per policy terms and conditions.





21) Result of Personal hearing with both parties (Observations & Conclusion): On examination of the

complaint and other documents in file, it has been found that no information has been given to complainant for

deduction of amount. Further, from the TPA file, it was observed that labs reports of Mukat Hospital are already

enclosed in file. Gross negligence and deficiency of service is noted on part of insurance company in dealing

with the claim lodged. Insurance Company has not even bothered to reply about the reason for deductions made

from claim amount. Therefore, insurance company is directed to pay admissible claim amount for bill submitted

by complainant of Rs 67304/-, out of which Rs. 14272/- is already been paid and also provide detailed reasons

to complainant for deduction if any made, as per terms of conditions of policy within 30 days from the receipt of

award copy.

AWARD


during the course of personal hearing, Rs 67304/- less 14272 (already paid) as per terms of condition of

policy is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement of

the claim subject to submissions of documents.




D.K. VERMA

INSURANCE OMBUDSMAN

of 279

PROCEEDINGS BEFORE




Case of Mr. Pawan Kumar Goel V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Pawan Kumar Goel

H.No.- 378, Khera Wali Gali,

Krishna Pura, Panipat, Haryana-0

2. Policy No:

Type of Policy


261400/48/2017/543

Happy Family Floater-2015 Policy Schedule

11/06/2016 To 10/06/2017



Mr. Pawan Kumar Goel

Mr. Pawan Kumar Goel



6. Reason for repudiation Required document not submitted








Ombudsman Rules

Rule 13 (1)(b) – any partial or total repudiation of

claim by an insurer

13. Date of hearing/place 09-11-2018, 12 /12/2018, Chandigarh


For the Complainant 09-11-2018 and 12-12-2018

Complainant was not present.

For the insurer 09-11-2018

Sh. Ashok Kumar Baroka, Deputy Manager

Dr.Ritish, MO TPA

12-12-2018

Mr. Prashant Vashishta, BM

Dr.Ritish, MO TPA




On 28.05.2017 Mr. Pawan Kumar Goel had filed a complaint to this office that he has the health insurance

since 11-06-2014 on regular basis. The last renewal was enforced from 11-06-2016 to 10-06-2017. The first and

second health insurance was issued by the Oriental Insurance company Divisional Office-4, New Delhi and the

third policy was issued by their Panipat Division Office. The complainant suffered some health problem on 10-

11-2016 and admitted in the Shree Balajee Hospital, Panipat. He was unconscious and not able to give any

statement. He stated in his complaint that he is non- smoker and non drinker. He did not know who gave the

statement to the doctor at the time of admission about his being chronic smoker and occasional alcoholic.

On 21.06.2017, 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 28.09.2018.

The insurance company stated that in their SCN that the insured was admitted in the hospital on 10-11-2016 to

15-11-2016 with diagnosis as Chronic Obstructive Pulmonary disease with acute Exacerbation with type -2

respiratory failures with LRTI with enteric fever. It has been observed from the health record that the patient

was hospitalized with complaints of Breathlessness since 4-5 years associated with chest pain and headache.

Further the patient was the history of being ex- smoker 4-5 years. The policy period start from 11-06-2014 and

patient was admitted in the hospital on dated 10-11-2017. The treatment of the disease falls under the PED

clause no 4.1 and claim was repudiated.



a) Complainant’s argument: The complainant was not present for personal hearing without any

intimation.

of 279

b) Insurers’ argument: Insurance Company stated that their repudiation is as per terms and conditions

of policy and requested for dismissal of complaint.





21) Result of Personal hearing with both parties (Observations & Conclusion): On going through the

complaint and other documents in file, it has been observed that neither the complainant nor his representatives

appeared for the personal hearing on 09.11.2018 and 12.12.2018 and remained absent without any intimation. It

seems that complainant is not interested in perusal of his case. The case is thus, dismissed in default and closed.

AWARD

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

company during the course of personal hearing, the said complaint is hereby dismissed in default.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Sunil Kumar V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Sunil Kumar S/o Kasturi Lal,

Kucha Mangat Ram Bajaj,

Kasuri Chowk, Ferozepur ,

Punjab-152002 Mobile No.- 9815402766

2. Policy No:

Type of Policy


233200/48/2016/4175

Oriental Bank Mediclaim Policy

21-03-2016 To 20-03-2017



Mr. Sunil Kumar

Mr. Sunil Kumar



6. Reason for repudiation Ailment falls under waiting period








Ombudsman Rules

Rule 13-1(b) – any partial or total repudiation of claims by

an insurer



For the Complainant Mr. Sunil Kumar, Complainant

For the insurer Mr. Balwinder Kumar Dhiman, Health Manager



17 Brief Facts of the Case;-

On 13-07-2017 Mr. Sunil Kumar, had filed a complaint to this office that he has the health insurance. He was

admitted in the DMC Hospital on 27-09-2016 due to left CSOM and got discharged on 30-09-2016.

Tympanomastoidectomy under GA was performed on 28.09.2016. After discharged from the hospital, the claim

of 279

bill was submitted to the insurance company and the insurance company rejected the claim on the ground that

the expenses related to ENT disorder are not admissible during first year of policy.

On 30-08-2017, 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 made

available to this office.



a) Complainant’s argument: Complainant stated that he has purchased oriental mediclaim policy on

21.03.2016 for health coverage and had undertaken treatment for left CSOM by hospitalization at

Dayanand Medical College and hospital, Ludhiana in September, 2016. The mediclaim submitted by him

has been repudiated by the insurance company which is totally unjustified.

b) Insurers’ argument: Insurance Company stated that treatment for ENT disorders falls under waiting

period of one year and therefore their repudiation is justified.





21) Result of Personal hearing with both parties (Observations & Conclusion): After careful examination of

the complaint filed by the complainant, the hospitalization record and the discharge summary of Dayanand

Medical College and hospital, Ludhiana and considering the submissions of both complainant and insurance

company during personal hearing, it is observed that the complainant has purchased the health insurance first

time in March, 2016. The ENT disorder claim was reported in the first year of the policy itself. As per the

discharge summary of the hospital, the patient was the history of HDBT 6 month since he is having ear

discharge from both ears, discharge is purulent in nature and copious in amount. As per policy conditions 4.2 (1)

the treatment of ENT disorders and surgeries for ENT disorders are not payable during the first year of currency

of the policy and there is waiting period of 1 year for these ENT disorders and their surgeries. 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


during the course of personal hearing, the said complaint is hereby dismissed on merits.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Gurdeep Singh V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Gurdeep Singh

Plot No.- 84, Guru Nanak Nagar,

B- Block, St No.- 02, Village Gill,

Maha Laxmi Gas Agency,

Ludhiana, Punjab- 141116

Mobile No.- 9510378633

2. Policy No:

Type of Policy


10732381

Health Insurance

26-07-2016 To 25-07-2017

of 279



Mr. Gurdeep Singh

Mr. Gurdeep Singh



6. Reason for repudiation Treatment fall under waiting period of two years


8. Nature of complaint Non settlement of the claim

9. Amount of Claim Rs. 1,86,640/-


11. Amount of relief sought Rs. 1,86,640/-


Rule no: 13-1(b) of Insurance Ombudsman

Rules

Rule 13 (1)(b) – any partial or total repudiation of claim

by an insurer



For the Complainant Mr. Gurdeep Singh, Complainant

For the insurer Dr. Poonam Bagga, Corporate Manager

Mr. Kashif Naska, Manager (Legal)




On 15-09-2017 Mr. Gurdeep Singh, had filed a complaint to this office that he has the health insurance since

26th July, 2016 and the same was renewed on 25-07-2017. He fell down from stairs on 06-05-2017. He

immediately consulted the doctor and the doctor recommended MRI. After investigation he was diagnosed as a

case of acute disc prolapse and recommended for spinal surgery. He got admitted in the Neuro Citi Hospital,

Ludhiana for the same on 09-05-2017. After discharge from the hospital, the claim bill was submitted to the

insurance company for reimbursement. The insurance company rejected the claim by stating that the ailment

falls under two year waiting period of the insurance policy. He stated that the insurance company version is not

justified since he met with an accident and the accident cover start from the day one of the policy and waiting

period is not applicable in this case.

On 22-09-2017, the complaint was forwarded to Religare Health Insurance Co. Ltd Regional Office, New Delhi,


available to this office on 23-01-2018.

The insurance company stated in their SCN that the claim was reported in the second year of the policy. As per

discharge summary dated 15-05-2017 confirmed that the complainant was diagnosed with acute disc prolapse

C5-6 level with Myelopathy which is a spinal disorder and was subsequently treated with Anterior Cervical

microdisectomy C5-6. The first policy period start on 26-07-2016 while the patient was admitted in the hospital

on 09-05-2017 before the ending of waiting period. As per policy condition the waiting period for the said

ailment is 24 month from the inception of the policy.



a) Complainant’s argument: Complainant stated his spinal injury is due to accidental fall and not

spinal disorder as claimed by insurance company so repudiation of his claim by insurance company is not

justified. He requested that his claim may be paid.

b) Insurers’ argument: Insurance Company stated that since complainant treatment relates to disease

falling under two year waiting period so their repudiation of claim is justified.





21) Result of Personal hearing with both parties (Observations & Conclusion)

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On examination of various documents, complaint, SCN and submissions of both complainant and insurance

company during the personal hearing, it is evident that complainant has a accidental fall resulting in spinal

injury and further hospitalization of complainant at Neuro Citi Hospital Ludhiana from 09.05.2017 to

15.05.2017.As per discharge summary he was diagnosed to be a case of Acute Disc prolapse C5-6 level with

myelopathy. Claim has been repudiated by the insurance company on the ground that complainant is an old case

of spinal disorder and as per policy clause 4.1 (b) (i) (I) the same falls under waiting period of two years from

policy inception. The said incident has occurred towards the end of the first year of the policy. On perusal of

various investigation reports, it is seen that the complainant was a case of acute disc prolapse at C5-6 level. As

per MRI dated 08.05.2017 done at Neuro Citi Hospital no evidence of abnormal marrow signal alternation/ bony

destruction is found that counters unjustified repudiation of insurance company. As per MRI report Sagittal

canal diameter at disc level are as follows:

C2-3 C3-4 C4-5 C5-6 C6-7

12.4 12.3 11.2 6.1 12.0

From above report it is amply clear that it is a case of accidental fall that has also not been countered by

insurance company either in SCN or at the time of personal hearing. The complainant having being diagnosed as

a case of acute disc prolapse as per the investigation reports including MRI, it is evident that the same was a

result of accidental fall. The insurance company is directed to settle the claim and also restore the policy from

the date of termination within 30 days after the receipt of award copy.

AWARD


during the course of personal hearing, Rs 186640/- 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

PROCEEDINGS BEFORE




Case of Mr. Parveen Jain V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Parveen Jain

S/o Sh. Ishwar Chand, H. No.-15,

Gandhi Mandi, Panipat, Haryana-0

Mobile No.- 9466775699

2. Policy No:

Type of Policy


261493/48/2017/126

Happy Family Floater-2015 Policy

15-06-2016 To 14-06-2017



Mr. Ishwar Chand Jain

Mr. Parveen Jain


5. Date of Repudiation N/a

6. Reason for repudiation N/a


8. Nature of complaint Less claim amount paid


10. Date of Partial Settlement Not provided




Rule 13-1(b) – any partial or total repudiation of

claims by an insurer

of 279

Ombudsman Rules



For the Complainant Mr. Ishwer Chand Jain, Complainant

For the insurer Mr. Prashant Vashishta, Branch Manager




On 24-08-2017 Mr. Parveen Jain, had filed a complaint to this office that his father was admitted in the Bajaj

Eye Centre, Panipat on 02-05-2017 for cataract surgery. After discharge the medical bill of Rs.31719/- was

submitted to the insurance for reimbursement. The insurance company reimbursed Rs.19719/- only. They have

deducted Rs.8000/- without any reason and no clarification was provided. Further they have deducted Rs.1750/-

for non receipt of the prescription which was provided to them.

On 18-09-2017, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office, Chandigarh,



In SCN insurance company stated that bills of Rs. 31,719/- were submitted, but as per TPA same procedure cost

for cataract was Rs 21968/- and after deducting 10% co-payment claim was approved for Rs 19771/-.

Reasonable and customary charges were deducted under clause 1.2 & 3.20 of policy.



a) Complainant’s argument: Complainant stated that insurance company has arbitrarily deducted

amount under reasonable and customary clause which has been never made known to him.

b) Insurers’ argument: Insurance Company stated that as per policy terms and condition the claim was

settled for eye surgery after considering the cost of this procedure in the best hospital. Further the policy

condition “Reasonable and Customary charges of policy will also apply on this claim. In accordance with

the policy conditions the claim was paid.





21) Result of Personal hearing with both parties (Observations & Conclusion): After examining the

documents submitted by both the parties, it has been observed that the eye surgery was covered under policy

terms and conditions. Insurance company applied policy condition no 1.2 i.e. Reasonable and Customary

charges for his claim. The application of reasonable and customary charges clause by insurance company and

thus deducting the amount from the total claim is totally unreasonable and without any basis since details of

such charges have not been made available to complainant along with the terms and conditions of the policy.

Therefore, policy clause no 1. 2 is not applicable for this claim. Therefore, insurance company is directed to pay

amount deducted under reasonable and customary charges clause subject to terms and conditions of policy

within 30 days after receipt of award copy.

AWARD

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

during the course of personal hearing, insurance company is directed to pay amount deducted under

reasonable and customary charges subject to terms and conditions of policy, towards full and final

settlement of the claim.



day of December 2018

D.K. VERMA

INSURANCE OMBUDSMAN

of 279

PROCEEDINGS BEFORE




Case of Mr. Jagmohan Singh Wadhawan V/S Apollo Munich Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Jagmohan Singh Wadhawan

House No.- 242-A, Near New Krishna Mandir

Model Town Extension, Ludhiana, Punjab

Mobile No.- 9815917313

2. Policy No:

Type of Policy


110600/11121/AA00101600-02 , SI- Rs 5.00 Lacs

Optima Restore health Policy

28-06-2016 To 27-06-2016 (as given in policy)



Mr. Jagmohan Singh Wadhawan

Mr. Jagmohan Singh Wadhawan

4. Name of the insurer Apollo Munich Health Insurance Co. Ltd.





9. Amount of Claim Rs.10.00.000/-





Rules

Rule 13-1(b) – any partial or total repudiation of claims by an

insurer



For the Complainant Mr. Jaswinder Singh (Son)

For the insurer Ms. Akanksha Kapoor




On 24-08-2017 Mr. Jagmohan Singh Wadhawan, had filed a complaint that he has purchased first time health

insurance from 28-06-2014 which covered him and his wife with sum insured of Rs 5.00 Lacs from Apollo

Munich. This policy was renewed in time and was continuously in force up to 27-06-2017. His wife has to be

hospitalized for carcinoma Gastrooesophageal Junction siewert surgery in SPS hospital and later on in Jaslok

Hospital, Mumbai. The total hospital bill was about Rs.12 lakh. After discharge from the hospital, the claim bill

was submitted to the insurance company but they rejected the claim and also cancelled his policy. They stated in

their letter that the past history of diabetes mellitus type 2 of the insured person was not disclosed in the

proposal form. He further stated that the proposal form was completed by the agent of the insurance company

and not by him. The sugar levels of his wife were within the prescribed parameters of the medical science.

On 11-09-2017, the complaint was forwarded to Apollo Munich Health 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


The insurance company confirmed in their SCN that the first health policy proposal form was received on 19-

06-2014 for sum insured of Rs.500, 000/-. It was the duty of the proposer to disclose all the material facts and

past medical history. On the basis of the proposal form which was signed by the insured, the policy was issued.

The patient was admitted in the SPS hospital on 26-08-2016 and got discharged on 02-09-2016. The patient was

admitted with complaints of difficulty in swallowing since 2/3 months and was diagnosed with Carcinoma

gastro-oesophageal junction seiwert type-III and type –II DM and underwent surgery on 27.08.2016. After

receiving the document, it has been observed that the patient was known case of DM Type –II and also as per

the indoor case papers, it is mentioned that patient is diabetic since 20 years and is on medication. Further, it

was noted that as per the medical record, patient has h/o of B/L TKR 8 years, Cholecystectomy GB removal 12

years back, hystercetomy 15 years back. The said past medical history was not disclosed by the insured at the

time of taking the policy. The claim was declined on the ground that the patient had a history of DM since 20

years and the policy was cancelled on the General condition of Non disclosure or Misrepresentation.

of 279



a) Complainants argument: The complainant stated that the insurance company is rejected his claim.

b) Insurers’ argument: The representative of insurance company stated that the claim is rejected on the

basis of non-disclosure of PED.





21) Result of Personal hearing with both parties(Observations & Conclusion):

I have gone through the various documents, the complaint filed by complainant Mr. Jagmohan Singh, discharge

summary of SPS hospital in respect of treatment taken by his wife Ms. Gurmeet Kaur, SCN submitted by

insurance company and also the submissions of both complainant‟s son who represented the complainant and

the representative of the insurance company during the course of personal hearing. On perusal of various

documents it is seen that the complainant was having medical insurance for him and his wife for basic sum

assured of Rs. 5 lakh with insurance company since 2014. As per discharge summary of his wife remained

hospitalization at SPS hospital from 26.08.2016 to 02.09.2016 and diagnosed to be a case of carcinoma gastro-

oesophageal junction siewert type-III, type-II diabetes mellitus. The policy was terminated by the insurance

company because of non disclosure of diabetes mellitus at the time of taking policy since last 20 years. The

medical claim is also rejected by insurance company on the basis of non-disclosure of diabetes mellitus for last

20 years by the complainant since the medical condition and the earlier treatment taken by the complainant‟s

wife was not disclosed at the time of taking policy. The claim was rejected by insurance company and the policy

was terminated. As per the facts of the case the complainant‟s wife has taken treatment for gal bladder problem

and cholecystectomy was performed about 12 years back and also had hystercetomy 15 years back. She was a

case of diabetes mellitus for last 20 years as per discharge summary. It is really ironical that insurance company

has chosen to repudiate the claim on the basis of non-disclosure of diabetes mellitus for last 20 years, When the

same has got no relation with present disease i.e. gastro-oesophageal carcinoma. Disclosure of material facts is

important only in the cases where the same is having a bearing on the current disease. Since there is no co-

relation between the old diabetes mellitus which is a life style disease and was well managed by medications in

the instant case as is evident from the investigation reports, the repudiation of claim by insurance company is

not in order. The insurance company is directed to settle the claim as per terms and conditions of policy within

the overall limit of the sum assured of Rs. 5 lakh, the sum assured in the policy.

AWARD


during the course of personal hearing, insurance company is directed to settle the claim as per terms

and conditions of policy within the overall limit of the sum assured of Rs. 5 lakh, the sum assured in the

policy.




D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Saswat Mohanty V/s Apollo Munich Health Insurance Co. Ltd.


1. On 24.07.2017, Mr. Saswat Mohanty had filed a complaint in this office against Apollo Munich

Health Insurance Co. Ltd. for not settling the health claim. The required documents were submitted to

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the insurance company but the insurance company did not settle the claim under policy no.

AA00483456.

2. The complainant confirms through email dated 08-12-2018 that he will not pursue his matter in

this office. Therefore, he wants to close the complaint in this office.

3. Hence, in accordance with Rule 14.5 of Insurance Ombudsman Rules, 2017 which states that “ No

complaint before the Insurance Ombudsman shall be maintainable on the same subject matter on

which proceedings are pending before or wants to file in the Consumer Forum or arbitrator”, the

complaint is closed.

To be communicated to the parties.


PLACE: CHANDIGARH INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Ashutosh Garg V/S Cigna TTK Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ashutosh Garg

Flat No.- 31, GHS- 37, Sector-20,

Panchkula, Haryana- 134116

Mobile No.- 8847038980

2. Policy No:

Type of Policy


PROHLTO10219001

Family Health Floater Policy

09-01-2017 To 08-01-2018



Mr. Ashutosh Garg

Mr. Ashutosh Garg

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







11. Amount of relief sought Rs.21940/- plus policy premium and cost.



Ombudsman Rules


by an insurer



For the Complainant Mr. Ashutosh Garg, Complainant

For the insurer Mr. Vikas Chauhan, Deputy Branch Manager


16 Date of Award/Order 13-12-2018.


On 23-08-2017 Mr. Ashutosh Garg, had filed a complaint to this office that he visited on 12-04-2017 the clinic

of Dr. Vikas Bhadu with a complaint of low energy and heaviness and he advised few test for diagnosing the

problem. Again he consulted, Dr. Rajat Gupta of Alchemist Hospital, Panchkula on 03-05-2017 and while

waiting for the turn he felt a sudden loss of energy and the doctor directed his nurse to check up the random

blood sugar and found that it was 57gm and gave glucon-D. He was admitted on 04.05.2017 and got discharged

on 06.05.2017. Dr. Rajat Gupta again examined on 08-05-2017 and blood sugar levels during the stay in the

hospital and confirmed that this is not a case of Hypoglycemia. He has been simply advised to change in the life

style and no medicine was prescribed for hypoglycemia. The claim bill of the treatment was submitted to the

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insurance company for re-imbursement and they rejected the claim on PED ground and also cancelled the policy

and forfeited the premium amount. He further stated that there was no past history of hypoglycemia nor he took

any medicine in the past hence there was not PED and the insurance company decision was not in order.

On 11-09-2017, the complaint was forwarded to Cigna TTK Health Insurance Co Ltd Regional Office, Mumbai



In the SCN insurance company stated that complainant during purchasing policy has mentioned in his proposal

form that he is not suffering from any pre-existing disease. But as per pre-authorization cashless form sent by

Alchemist hospital to their TPA on admission on 04-05-2017, it mentioned that there is a history of repeated

episodes of hypoglycemia from past 2-3 years mainly after breakfast. Policy incepted form 10-01-2016 and

same was renewed upto 08-01-2018. The liability cannot be ascertained at this juncture as the patient has history

of repeated episodes of Hypoglycemia since 3 years, which pre-exist to the policy inception and which is not

covered at this stage as per the policy condition. Accordingly policy was also cancelled.



a) Complainant’s argument: Complainant stated that he is not having any pre-existing disease and

insurance company repudiation is not justified. He requested that his claim may be paid.

b) Insurers’ argument: Insurance Company stated that since complainant has not disclosed about his

pre-existing disease in proposal form so their repudiation of claim is justified.





21) Result of Personal hearing with both parties(Observations & Conclusion)On perusal of various

documents available in the file and also considering the submissions made by both the complainant and the

insurance company during the course of personal hearing, it is seen that complainant remained admitted in

Alchemist Hospital, Panchkula from 04.05.2017 to 06.05.2017 and filed a claimed for medical reimbursement

after discharge from the hospital. The request for cashless was rejected by insurance company due to non-

disclosure of PED i.e. repeated episodes of Hypoglycemia for the last 3 years by no claim letter dated

05.05.2017 subsequently the policy was also terminated due to the said non-disclosure. The decision of

insurance company is based solely on the basis of provisional diagnosis of repeated episodes of Hypoglycemia

as stated in discharge summary and the policy is running in the second year. The final diagnosis at the time of

discharge is nowhere mentioned in discharge summary. It is indeed surprising that the insurance company has

chosen to repudiate the claim by addition of 3 years which however doesn‟t reflect anywhere in the hospital

record relating to the complainant. Even the investigation report dated 14.04.2017 relating to HBA1C % that

provides a reliable index of average blood glucose level doesn‟t in any way indicate that the complainant is a

case of Hypoglycemia, the reason for denial of claim. Since no investigation has conducted by insurance

company in respect of complainant hospitalization, the insurance company has failed to produce any evidence

regarding PED while rejecting the claim. The insurance company is directed to settle the claim and also restore

the policy from the date of termination.

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 insurance company is directed to settle the claim

amount of Rs. 21,640/- as per terms and conditions of the policy and also restore the policy from the

date of termination.




Dr. D. K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Deepak Mangla V/S Cigna TTK Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Deepak Mangla

House No.- 176, Sector-7 A, Faridabad,

NR YMCA Chowk, Faridabad,

Haryana- 121006, Mobile No.- 9311013444

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2. Policy No:

Type of Policy


PROHLR010050070

Family Floater Health Insurance

22-07-2016 To 21-07-2017



Mr. Deepak Mangla

Mr. Deepak Mangla

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


6. Reason for repudiation Injury falls under the policy exclusion



9. Amount of Claim Rs. 181529/-





Ombudsman Rules

Rule 13-1(b) – any partial or total repudiation of

claims by an insurer



For the Complainant Mr. Deepak Mangla

For the insurer Mr. Vikas Chauhan

15 Complaint how disposed Closed



On 22-08-2017 Mr. Deepak Mangla had filed a complaint to this office that on 29-05-2017 the both kids of the

complainant went to Splash Water Park, Delhi to enjoy water rides with him and his wife. It may be noted that

only kids were doing the rides and he and his wife were just there to take care of kids and didn‟t do any sport

activities. On the wet floor his wife slipped and got injured thereby got fracture of Tibia and fibula. She was

immediately taken to Savodaya Hospital, Faridabad, where her surgery was done. The cashless was denied due

to the reason stated by the insurance company that any injury and ailment occurred due to hazardous sports are

not payable as per policy condition. He requested that his claim be paid.

No SCN has been submitted by the insurance company till 06-12-2018. The no claim letter of the insurance has

stated that Hospitalization is due to injuries sustained and it is found that the injuries were intentionally self

inflected-falling under the policy exclusion.

On 11-09-2017, 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

not made available to this office till date.

The complaint was sent Annexure VI-A for compliance, which reached this office on 27-09-2017


a) Complainant’s argument: Complainant stated that denial and repudiation of his mediclaim is not

justified. Further he also requested that his genuine claim may be paid.

b) Insurers’ argument: Insurance Company stated that their repudiation is as per terms and conditions

of the policy.






After going through the various documents available in the file including the copy of complaint filed by Mr.

Deepak Mangla, the submissions made by the both the complainant and representative of insurance company

during the course of personal hearing and also the discharge summary of Survodaya hospital and research

centre, Faridabad where the wife of complainant remained admitted from 29.05.2017 to 01.06.2017 with

symptoms of pain and swelling in left leg due to accidental fall on 29.05.2017. The claim was rejected vide no

claim letter dated 04.08.2017 due to the fact that the injuries sustained by the complainant‟s wife was as a

consequence of hazardous sports that are not payable as per the terms and conditions of the policy. However,

during the course of personal hearing on 13.12.2018 the insurance company confirmed that they have settled the

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claim for an amount of Rs. 2,23,690/- as against the claim of Rs. 1,81,529/- filed by the complainant and the

amount has already been credited to bank account of Mr. Deepak Mangla through NEFT on 11.12.2018. In view

of the above, no further action is required to be taken by this office and the complaint is disposed off

accordingly.

AWARD


parties during the course of personal hearing, the insurance company has confirmed that they have

settled the claim for an amount of Rs. 2,23,690/- as against the claim of Rs. 1,81,529/- filed by the

complainant and the amount has already been credited to bank account of Mr. Deepak Mangla

through NEFT on 11.12.2018.




Dr. D. K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Ms. Krishna Pal V/s Star Health and Allied Insurance Co. Ltd.


1. On 05.08.2017, Ms. Krishna Pal had filed a complaint in this office against Star Health and Allied

Insurance Co. Ltd. for non settlement of her health claim despite several requests. The required

documents were submitted to the insurance company well in time but the insurance company

repudiated the claim.

2. Ms. Krishna Pal has confirmed through email dated 07.12.2018 that they have closed this

matter and withdraw their complaint. She also requested for closing the matter.





OMBUDSMAN

PROCEEDINGS BEFORE




Case of Ms. Geeta Bansal V/S The Star Health And Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Ms. Geeta Bansal

#B-XX-2997, Gurdev Nagar, Ludhiana,

Punjab, Mobile No.- 9463532788

2. Policy No:

Type of Policy


P/161114/01/2017/003301


20-07-2016 To 19-07-2017



Mr. Gautam Bansal

Ms. Geeta Bansal

4. Name of the insurer Star Health And Allied Insurance Co. Ltd.

5. Date of Repudiation Not provided

6. Reason for repudiation PED as per SCN


8. Nature of complaint Not settled the claim

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Rules


claim by an insurer

13. Date of hearing/place 13-12-2018/Chandigarh


For the Complainant 09-11-2018

Complainant was not present

13-12-2018

Mr. Gautam Bansal, Complainant Husband

For the insurer 09-11-2018 & 13-12-2018

Ms. Mamta Gupta, Manager




On 12.06.2017 Ms. Geeta Bansal had filed a complaint to this office that her husband Mr. Gautam Bansal

was admitted in the hospital due to food poisoning. He was earlier admitted in the hospital in 2009

for the treatment of T.B. After taking the treatment of T.B, her husband was fully cured. The hospital bill

of Rs. 40000/- of food poisoning was submitted to the insurance company but they rejected the claim

on the ground of PED. The previous ailment has permanently cured and the present ailment has no

relation with the previous disease. The insurance company decision was not in order and totally

unjustified.

On 21.06.2017, the complaint was forwarded to The 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 10-07-2017.

The insurance company stated in his SCN that the insured was holding the health insurance since 20th

July, 2015 and further renewed from 20-07-2016 to 19-07-2017. The claim was reported in the second

year. The insured was admitted in the Dayanand Medical College Hospital on 07-08-2016 with the

complaint of pain in abdomen since 4 days and vomiting for 2-3 days. The treating doctor of the hospital

diagnosed the disease as small bowel stricture. As per their in-house medical opinion, the patient has

history of Abdominal Tuberculosis in 2009 and ATT since 1 ½ year ago. The insured did not disclose the

previous history of the health and while completing the proposal form. On the basis of the facts the claim

was repudiated under misinformation/ non disclosure of material facts clause.



a) Complainant’s argument: Complainant stated that his genuine claim is being denied by insurance

company on flimsy ground of PED. He was not given any medicine of TB during his stay in

hospital. He is fully cured from TB and hence requested for payment of his claim.

b) Insurers’ argument: Insurance Company stated that it is a case of PED and their insurance company

has rightly repudiated the claim on policy terms and condition.

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):

After examining of complainant document, SCN and pleas of both parties in personal hearing, it has

been observed that insurance company is not able to prove how TB is related to present ailment or

complainant‟s TB was not fully cured. Non- disclosure of PED is immaterial because TB is fully

curable with medications and the patient has been fully cured after taking treatment for TB. The

decision of insurance company to repudiate the claim relating the present episode of food poisoning in

2016 the abdominal tuberculosis in 2009 is neither proper nor reasonable. Therefore, the insurance

company is directed to pay Rs 40,000/- as per terms and condition of policy to complainant within 30

days from the receipt of award copy.

AWARD


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parties during the course of personal hearing, Rs 40000/- 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.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Kuldip Singh V/S The New India Assurance Co. Ltd.


1. Name & Address of the Complainant Mr. Kuldip Singh

1442 HIG Flats, Phase-9, Mohali,

Punjab- 160062,Mobile No.- 9872892700

2. Policy No:

Type of Policy


35020034152500000279,

35020034162500000309

MEDICLAIM POLICY

19-03-2016 To 18-03-2017,

23-03-2017 To 22-03-2018



Mr. Kuldip Singh

Mr. Kuldip Singh

4. Name of the insurer The New India Assurance Co. Ltd.


6. Reason for repudiation Not cover under the policy condition


8. Nature of complaint Not settle the eye claims






Ombudsman Rules


an insurer



For the Complainant Mr. Kuldip Singh, Complainant

For the insurer Mr. Narinder Kumar Grover, Deputy Manager

Mr. Deep Chand, AM, Raksha TPA




On 30-08-2017 Mr. Kuldip Singh, had filed a complaint to this office that he is insured with the insurance

company since 15 years. He has submitted three claim of Rs.14100/-, Rs.7000/- and Rs. 6000/- for the treatment

of Eye problems. He is 80 years old and his treatment is continuing. The next bill of the treatment of Rs. 34000/-

yet to be submitted since the insurance company repudiated the earlier claim.

On 18-09-2017, the complaint was forwarded to The New India Assurance Co. Ltd Regional Office, Chandigarh



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The insurance company stated that complainant is a case of Wet age related macular degeneration Right eye and

got the treatment for the same on 20-02-2017 and 27-03-2017 respectively. Injection Avastin for treatment of

ARMD is a permanent exclusion under policy. Both the claims were not payable as the treatment for age related

Macular Degeneration (ARMD) treatment are not cover under the policy condition and its fall under the policy

exclusion no 4.4.22 which stated that „ No claim will be payable under this policy for treatment for age related

macular degeneration treatment such as Rotational Field Quantum Magnetic Resonance, Eternal Counter

Pulsation, Enhanced Eternal Counter Pulsation, Enhanced External Counter Pulsation, Hyperbaric Oxygen

Therapy. Hence, claim was not paid.



a) Complainant’s argument: Complainant stated that insurance company has repudiated his genuine

claim on flimsy ground and requested for payment of his claim.

b) Insurers’ argument: Insurance Company stated that their repudiation is justified because decision is

taken as per terms and condition of policy.






On examination of the complaint and other documents in file, it has been found that denial of claim by insurance

company is justified. Because as per claim form dated 03.04.2017 which was filled and submitted by

complainant, it is stated that he was admitted for treatment of ARMD (Right Eye). Even discharge summary of

Eye Sight and Dental Care Clinic Chandigarh, indicates that the complainant was admitted for Right eye ARMD

on 18.01.2017. As per policy terms and conditions Age Related Macular Degeneration (ARMD) treatment are

specifically not covered under the policy and it falls under the policy exclusion no 4.4.22. Hence, the decision of

the insurance company is in order. Keeping in view of the above facts, the said complaint is hereby dismissed

and no relief is granted.

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 said complaint is hereby dismissed on merits.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Rajeev Chawla V/S Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajeev Chawla

House No.- 2692, Upper Ground Floor,

Sector-57, Sushant Lok-III, Gurgaon,

Haryana- 122001Mobile No.- 9818010027

2. Policy No:

Type of Policy


P/700004/01/2017/005639


18.03.2017 To 17.03.2018



Mr. Rajeev Chawla

Mr. Rajeev Chawla

4. Name of the insurer Star Health and Allied Insurance Co. Ltd.

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6. Reason for repudiation PED not declared under portability








Ombudsman Rules


by an insurer



For the Complainant Mr. Rajeev Chawla

For the insurer Ms. Mamta Gupta




On 23-08-2017 Mr. Rajeev Chawla, had filed a complaint that he was insured with ICICI health insurance since

9 years up to 17-03-2017. Before expiry of the policy, the agent of the Star Health insurance company

approached and advised to port the health policy to their company under IRDAI portability rule since there

product is better than ICICI. Therefore he got the said health insurance policy renewed from 18-03-2017 to 17-

03-2018 from Star Health Insurance Company. The insurance company issued the policy under portability with

the assurance that the best after sale service will given. All of sudden in the month of May,2017 he got

hospitalized in the Max Hospital, Gurgaon and diagnosed with PTCA+DES+ to lead & OMI. Dr. Arvind Das,

HOD in Max hospital has confirmed that his problem is newly developed. The numbers of request were sent to

the insurance company for cashless but they did not consider. After discharge from the hospital, the claim bill

was submitted to the insurance company but they repudiated the claim on the PED ground.

On 11-09-2017, 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 31-10-2017.

The insurance company stated in the SCN that the health policy was shifted from ICICI to their company under

portability rule. The claim was reported in the 5th

year of the medical insurance policy and it was the second

month in the Star Health insurance company. The patient was admitted on 31-05-2017 and discharged on 01-06-

2017 and was diagnosed as a case of ACUTE CORONARY SYNDROME, CAG (31-05-2017) DOUBLE

VESSEL DISEASE HYPERTENSION AND NIDDM TYPE-II. As per insurance company in-house medical

opinion insured has history of CVA since 2 years and as per Pre authorized form, the patient was admitted with

the past history of Diabetes Mellitus (DM) and hypertension since 3 years and Cerebral Vascular Accident since

2015 before inception of the policy. This past history was not disclosed at the time of the portability which falls

under the PED rules of the policy. Hence the claim was repudiated on the PED ground.



a) Complainant’s argument: The complainant stated that the insurance company repudiated the claim

on the PED ground.

b) Insurers’ argument: The insurance company stated that the patient was admitted with the past history

of Diabetes Mellitus (DM) and hypertension since 3 years and Cerebral Vascular Accident since 2015

before inception of the policy. This past history was not disclosed at the time of the portability which falls

under the PED rules of the policy. Hence the claim was repudiated on the PED ground.






of 279

On perusal of various documents in the file including copy of complaint filed by the complainant, no claim letter

issued by insurance company, discharge summary of Max health care and the SCN submitted by the insurance

company, it is seen that the complainant Sh. Rajeev Chawla has been holding the medical insurance policy with

ICICI Lombard from 18.03.2013 to 17.03.2017 continuously and under portability switched over to Star Health

and Allied insurance company w.e.f 18.03.2017 and valid till 07.03.2018. As per discharge summary of Max

health care the complainant remained admitted in hospital from 31.05.2017 to 01.06.2017 with the symptoms of

chest discomfort for last few days and palpitation and diagnosed to be a case of diabetes mellitus, hypertension,

acute coronary syndrome and old CVA. As per the earlier discharge summary of year 2015 of same hospital

where the patient had remained admit, he was diagnosed to be case of diabetes mellitus, hypertension and CVA.

The treating doctor of Max hospital in the discharge summary has stated that the complainant did not have any

history of coronary artery disease in the past that also stands confirmed by the earlier discharge summary. The

rejection of claim by insurance company is based on the earlier history of diabetes mellitus, hypertension and

old CVA that according to insurance company was not disclosed at the time of portability of policy. No

enquiries however have been conducted by insurance company about the so called previous ailment at the time

of portability of policy from earlier insurance company. Coronary artery disease for which the complainant has

taken treatment in 2017 has no relation with the pre-existing diabetes mellitus, hypertension and old CVA.

Diabetes mellitus, hypertension being a life style disease are precipitating factors for heart problems but not the

only reason for coronary artery disease since the patient with these life style ailments can be easily treated by

proper medications. The certificate given by treating doctor that CAD for which the complainant was admitted

is a newly developed problem and has no relation with the earlier problems. The repudiation of claim by

insurance company is highly improper and also the complainant has continuous coverage since 2013 the

insurance company is directed to settle the claim amount and restore the policy from the date of cancellations of

policy.

AWARD


parties during the course of personal hearing, the insurance company is directed to settle the claim

amount as per terms and conditions of the policy and restore the policy from the date of cancellations

of policy.




Dr. D. K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Amit Khosla V/S Cholamandalam MS General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Amit Khosla C/o M/s Mahavir trading Co. SCF-

81,Super Market, Pehowa,

Distt.- Kurukshetra, Haryana-0

Mobile No.- 9812026741

2. Policy No:

Type of Policy


2856/00165179/000/02

Health insurance policy

04-01-2017 to 03-01-2018



Mr. Amit Khosla

Mr. Amit Khosla

4. Name of the insurer Cholamandalam MS Gen. Insurance Co. Ltd.


6. Reason for repudiation PED and falls under 48 months waiting period





11. Amount of relief sought Rs.85000/- plus Rs.15000/-




an insurer

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Ombudsman Rules



For the Complainant Mr. Amit Khosla

For the insurer Mr. Pradeep Pathak

Mr. Manish Batra




On 21-07-2017 Mr. Amit Khosla had filed a complaint that he has purchased the health insurance through their

authorized agency i.e. Central Bank of India on 04-03-2017. He went for angiography and blockage in heart was

deducted. He was further admitted in the Holy Heart Hospital, Amritsar for putting stunt. He was given

authorization for Rs 85000/- by insurance company but same was denied during discharge. After discharge from

the hospital, the claim bill was submitted to the insurance company for reimbursement. But they rejected the

claim and also cancelled the policy. He stated that he disclosed the past medical history to the Bank at the time

of taking first time health policy on 20-12-2014.

On 08-09-2017, the complaint was forwarded to Cholamandalam MS 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 was made available to this office on 19-12-2017.

The insurance company stated in the SCN that the insured has not disclosed the material facts as he was diabetes

patient since 10 years. Discharge summary of the hospital confirmed that he has diabetes since 10 years. The

present ailment (coronary artery disease) is complication attributable of diabetes which was pre-existing since

10 years and same is prior to the inception of the policy dated 20-12-2014. Hence, the ailment was pre existing

and same fall under the policy general exclusion no C-3 for 48 months. Therefore, the claim was repudiated

under clause C-3 and general condition -11which is non disclosure of material facts. Accordingly policy was

also cancelled.

The Complainant was sent Annexure VI-A for compliance which reached this office on 25-09-2017.


a) Complainant’s argument: The complainant stated that he had disclosed the past history to the Bank at the

time of taking first time health policy on 20-12-2014 but insurance company rejected the claim and also

cancelled the policy.

b) Insurers’ argument: The insurance company stated that the insured has not disclosed the material facts as he

was a diabetes patient since 10 years. The ailment was pre existing and same fall under the policy general

exclusion no C-3 for 48 months. Therefore, the claim was repudiated under clause C-3 and general condition -11

which is non disclosure of material facts. Accordingly policy was also cancelled.






On perusal of various documents in the file including copy of complaint filed by the complainant, no claim letter

issued by insurance company, discharge summary of Balaji Heart Institute Eye and Gen. Surgery Centre and the

SCN submitted by the insurance company, it is seen that the complainant Mr. Amit Khosla has been holding the

medical insurance policy continuously from 20.12.2014. The policy was cancelled due to non-disclosure of

material facts about past history of diabetes mellitus since 6 years as per policy termination letter. As per

discharge summary of Balaji Heart Institute Eye and Gen. Surgery Centre the complainant remained admitted in

hospital from 04.03.2017 to 04.03.2017 with the symptoms of chest pain and diagnosed to be a case of coronary

artery disease. The repudiation of claim by insurance company is based on exclusion clause C-3 due to non-

disclosure of diabetes mellitus i.e. the PED and the coronary artery disease being a complication directly

attributable to diabetes mellitus which the complainant has not disclosed. The claim is preferred in the 3rd year

of the policy. Coronary artery disease for which the complainant has taken treatment in 2017 has no direct

relation with the pre-existing diabetes mellitus. Diabetes mellitus being a life style disease is a pre disposing

factor for heart problems but not the only reason for coronary artery disease since the patient with these life style

ailments can be easily treated by proper medications. As such the repudiation of claim by insurance company

highly improper and also since the complainant has continuous coverage since 2014 the insurance company is

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directed to settle the claim as per terms and conditions of the policy and restore the policy from the date of

cancellations of policy.

AWARD


parties during the course of personal hearing, the insurance company is directed to settle the claim as

per terms and conditions of policy and restore the policy from the date of cancellations of policy.




Dr. D. K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Parveen Kumar Soni V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Parveen Kumar Soni

# 702/U1, AWHO, GH-79,

Sector-20, Panchkula, Haryana- 0

Mobile No.- 9816093302

2. Policy No:

Type of Policy


153900/48/2017/798

PNB- Oriental Royal Mediclaim Policy

27.05.2016 To 26.05.2017



Mr. Ajay Kumar Soni

Mr. Ajay Kumar Soni

4. Name of the insurer The Oriental Insurance Company Ltd

5. Date of Repudiation Not provided

6. Reason for repudiation Treatment fall under the waiting period








Ombudsman Rules


claim by an insurer



For the Complainant Sh. Praveen Kumar Soni, Complainant

For the insurer Sh. Hemant Kapoor, Deputy Manager




On 09.06.2017 Mr. Parveen Kumar Soni, had filed a complaint that his father was admitted in Smt. Sushilaben

Mehta and Sir Kilcabhai Premchand Cardiac Institute Hospital, Mumbai. Since his father was not well and he

consulted to Dr Ankit Agarwal and he recommended for detailed examination and treatment. He was admitted

on 11-11-2016 and discharged 14-11-2016. The cashless approval was denied by the TPA of the insurance

company. After discharge, the claim bills along with the documents were sent to insurance company and they

have rejected the claim on the ground that the treatment of the ailment is not covered in the first year of the

policy. He further stated that his father was the holding the health insurance since four years with other

insurance company on regular basis without break, prior to taking the health insurance from OIC. Moreover, the

OIC policy does not mention any exclusion of Angioplasty in first year. Therefore, the insurance company

decision was not in order.

On 28.06.2017, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office, Chandigarh,



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The insurance company in their SCN stated that their TPA had conveyed to the complainant that OIC policy

was in the first policy and they confirmed that as per the claim form insured was having the history of DM and

HTN for the last one year. Since, the policy was in first year with inception from date 27-05-2016 and as per

policy condition 4.2 (xvii and xvii) waiting period for treatment of the ailment related to DM/HTN is two years

from the inception of policy. Hence, under this clause claim was not payable.



a) Complainant’s argument: Complainant argued that insurance company has wrongly denied his

father‟s claim in first year whereas he is holding health policies for last four years.

b) Insurers’ argument: Insurance Company stated their repudiation of claim as per terms and conditions

of the policy.






complaint papers and the no claim letter in case file, it has been observed that the complainant was holding the

health insurance since last five years with three different insurance companies. Detail of insurance policy is as

under:

S.no Insurance Company Date of insurance Remarks

1 Bajaj Allianz Gen Insurance Company 04-10-2013 to 03-10-2014 NIL

2 Bajaj Allianz Gen Insurance Company 04-10-2014 to 03-10-2015 Renewal of previous

policy

3 Iffco- Tokio Gen. Insurance Company 21-05-2015 to 20-05-2016 No evidence of portability

4 The Oriental Insurance Company Ltd 27-05-2016 to 26-05-2017 No evidence of portability

5 The Oriental Insurance Company Ltd 27-05-2017 to 26-05-2018 Renewal of previous

policy

6 The Oriental Insurance Company Ltd 27-05-2018 to 26-05-2019 Renewal of previous

policy

From the above details, it has been observed that the complainant father had taken the first and second health

insurance since 04-10-2013 to 03-10-2015. Before expiry of Bajaj Policy he purchased new health policy from

IFFCO from 21-05-2015 to 20-05-2016. After expiry of IFFCO- Tokio insurance, he again purchased next

health insurance policy from The Oriental Insurance Company Limited which had a seven day gap and policy

commenced from 27-05-2016 to 26-05-2017. It is clear from the said policies that the complainant had the

regular first two policy without break but other two health insurance purchased on different dates shall be

considered as fresh policies. There is also no document in record to show that it is a portability case. Portability

benefit can only be availed by complainant had he applied for portability as per laid down rules of IRDAI.

Insured had also never requested to any company for condoning delay for their renewal in case of break. It is

found that there is a break of policy period for IFFCO-Tokio to Oriental. Hence, Oriental insurance Company

decision in respect of the claim appears to be in order since disease falls under waiting period. Keeping in view

of the above facts, the said complaint is hereby dismissed and no relief is granted.

AWARD






D.K. VERMA

INSURANCE OMBUDSMAN

of 279

PROCEEDINGS BEFORE




Case of Mr. Kuljeet Singh Shan V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Kuljeet Singh Shan

# 605, Sector- 16 -D, Chandigarh,

Mobile No.- 9872816605

2.

Policy No:

Type of Policy


231290/48/2016/1037

PNB Oriental Royal Mediclaim Policy

17-09-2015 To 16-09-2016



Mr. Kuljeet Singh Shan

Mr. Kuljeet Singh Shan



6. Reason for repudiation PED fall under the policy clause 4.1








Rules

Rule 13 (1)(b) – any partial or total repudiation

of claim by an insurer



For the Complainant Mr. Kuljeet Singh Shan, Complainant

For the insurer Mr. Hemant Kapoor, Deputy Manager

Ms. Maninder Kaur, Assistant Manager




On 10.03.2017 Mr.Kuljeet Singh Shan, had filed a complaint that he has given the intimation in advance for his

treatment on 10-06-2016 and the approval was received vide TPA reference no 10360841. He took the

treatment of Myasthenia gravis and chafers with polyposis. After discharge the medical bill was submitted to the

insurance company TPA on 24-06-2016 and they received on 29-06-2016. The insurance company did not settle

the claim; hence he lodged the complainant in this office on 10-03-2017. The insurance companies repudiated

the claim and sent him letter on 28-06-2017 i.e. after his filing the complaint to this office. The insurance

company had already paid the other claim of the same disease under the same policy period.

On 28.06.2017, the complaint was forwarded to The Oriental Insurance Co. Ltd.Regional Office, Chandigarh,



The insurance company stated in their SCN that the patient was known case of Nasal Polysois and previously

underwent sinus surgery 3 years back which falls prior to the inception of the policy. Since the treatment

expenses on pre-existing diseases and related complications were not admissible under the policy. Hence the

claim was repudiated under policy clause no 4.1.



a) Complainant’s argument: Complainant stated that denial and repudiation of his mediclaim is not

justified. Further he also requested that his genuine claim may be paid.

b) Insurers’ argument: Insurance Company stated that being PED their decision is justified.




of 279


21) Result of Personal hearing with both parties (Observations & Conclusion): After examine the

complaint papers, SCN and the no claim letter in case file, it has been observed that the complainant was

holding the health insurance since three years. The complainant has sent intimation in advance to TPA/

insurance company for his treatment on 10-05-2016. The final treatment bill was received by TPA on dated 29-

06-2016. As per IRDAI regulation, the insurance company / TPA have to take decision within 30 days after

receipt of the final bill or required queries. In the instant case the insurance company / TPA have not taken any

decision on the claim lodged by complainant after his treatment for a period of about one year. Surprisingly they

took a decision to repudiate the claim and communicated the same vide letter dated 22.06.2017 after the

complainant filed a complaint to this office. The decision of the insurance company to repudiate the claim on the

basis of the previous sinus surgery 3 years back in the absence of any documentary evidence which they have

failed to produce is highly improper and unwarranted. Hence, insurance company is directed to pay Rs 60581/-

as per terms and condition of policy within 30 days from the receipt of award copy.

AWARD


during the course of personal hearing, Rs 60581/- subject to terms and condition 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 November 2018.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Aman Bansal V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Aman Bansal

H. No.- 16, Sector-7, Karnal,

Haryana-0

Mobile No.- 9812036433

2. Policy No:

Type of Policy


261191/48/2017/266

Happy Family Floater-2015 Policy Schedule

04.10.2016 To 03.10.2017



Ms. Adya Bansal

Mr. Aman Bansal



6. Reason for repudiation Treatment can be manage in OPD





11. Amount of relief sought Rs. 34760/-



Ombudsman Rules


by an insurer



For the Complainant Mr. Aman Bansal, Complainant

For the insurer Mr. S.K.Goel, Assistant Manager

Dr. Rakesh, TPA




of 279

On 15.06.2017 Mr. Aman Bansal had filed a complaint that his child Adya, age 7 years, hot/boiling tea fell

down on her and it was an accident. She was crying and weeping and did not want to stay in the hospital. After

taking the emergency treatment the child was shifted to home. The further treatment was arranged in day care.

The claim bill was submitted to the insurance company and the same was rejected.

On 29.06.2017, the complaint was forwarded to The Oriental Insurance Co. Ltd Regional Office, Ambala, for


to this office on 06-07-2017.

The insurance company stated in his SCN that the daughter of the insured Ms. Adya Bansal suffered a burn

injury that was covered under the health insurance. The patients treated in OPD and as per policy condition no

4.24, there is exclusion of the OPD treatment. On the basis of the document the claim was repudiated.



a) Complainant’s argument: Complainant stated that her genuine claim has been repudiated on flimsy

ground and requested for justice from this office.

b) Insurers’ argument: Insurance Company argued that their repudiation is justified because

hospitalization is less than 24 hours.






After careful examination the complainant documents and the SCN, it has been observed that insurance

company had repudiated the claim since hospitalization was less than 24 hour and treatment was taken as

outpatient. But after examination of discharge summary and hospital documents that it is a case of accidental

thermal skin burn. Since in instant case accident is not denied by insurance company and further accident/ injury

are covered under policy. Hence, the insurance company is directed to settle the claim as per policy terms and

condition within 30 days from the receipt of award copy.

AWARD


during the course of personal hearing, is directed to settle the claim as per 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.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mrs. Nirmal Sharma V/S The National Insurance Co. Ltd.


1. Name & Address of the Complainant Mrs. Nirmal Sharma

# 7, Rajgur Nagar Extension, Via Threekay, Ludhiana,

Punjab- 142021

Mobile No.- 9780516106

2. Policy No:

Type of Policy


401314/48/14/8500000921

BOI, National Swasthya Bima Policy

27.03.2015 To 26.03.2016



Mrs. Nirmal Sharma

Mrs. Nirmal Sharma

4. Name of the insurer The National Insurance Co. Ltd.

of 279


6. Reason for repudiation Treatment of the ailment falls under exclusion clause no,

4.13








Ombudsman Rules


by an insurer



For the Complainant Mrs. Nirmal Sharma, Complainant

For the insurer Mr. Ravinder Sidana, Divisional Manager




On 10.07.2017 Mrs. Nirmal Sharma, had filed a complaint that she was suffering with pain in the right knee.

She consulted orthopedic surgeon of Bassi Nursing Home Pvt. Ltd, Ludhiana and she was hospitalized from

02.12.2015 to 05.12.2015 as advised by the doctor. Admission in the hospital was intimated to the TPA of the

insurance company immediately. The claim bill of the hospital relating to medicine and the physiotherapy was

submitted to the TPA of the insurance company for reimbursement. The insurance company rejected the claim

on flimsy ground.

On 26.07.2017, the complaint was forwarded to The National Insurance Co. Ltd Regional Office, Ludhiana, for


to this office on 04-08-2017.

The insurance company stated in their SCN that the complainant was admitted in the Bassi Nursing home with

pain in Right Knee joint. During the period of hospitalization, the patient underwent various investigations and

was managed conservatively with oral medication only which could have been managed through OPD. It

appears from the hospital record that no active treatment was done during the course of the hospitalization. This

type of treatment falls under exclusion no 4.13 of the policy. Hence, claim was repudiated.

The complainant was sent Annexure VI-A for compliance, which reached this office on 08.08.2017


a) Complainant’s argument: Complainant stated that his hospitalization was being done on the advice

of treating doctor and therefore her claim should be paid.

b) Insurers’ argument: Insurance Company stated their repudiation of claim as per terms and conditions

of the policy.






complainant documents, insurance company SCN placed in the file and submission made during the personal

hearing, it is observed that complainant got admitted for right knee pain in the hospital. On going through the

treatment record of M/s Bassi Nursing home Private Limited, Ludhiana it is amply clear that patient was

managed conservatively with oral medicines which could have been managed in OPD. As per available

documents in case file, it is found that only analgesic/ anti-inflammatory medicines in the form of tablets/

capsules, Gel, antibiotic and physiotherapy were given during his course of stay in the said hospital. Since the

claim squarely falls under exclusion clause 4.13 of BOI National Swasthya Bima policy, the decision of the

insurance company is in order. No relief can be granted.

AWARD




of 279



D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mrs. Jaswinder Kaur V/S IFFCO TOKIO Gen. Insurance Co. Ltd.


1. Name & Address of the Complainant Mrs. Jaswinder Kaur

H.No.- 97, Madhuban Enclave extension,

Barewal Road, Ludhiana,Punjab- 141012,

Mobile No.- 8437000629

2. Policy No:

Type of Policy


52642947

Family Health Insurance

24.06.2016 To 23.06.2017



Mrs. Jaswinder Kaur

Mrs. Jaswinder Kaur

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


6. Reason for repudiation Congenital disease are not covered


8. Nature of complaint Not settled the claim






Ombudsman Rules


claim by an insurer



For the Complainant Mrs. Jaswinder Kaur, Complainant

For the insurer Dr. Monika Sharma, Sr. Executive




On 27.06.2017 Mrs. Jaswinder Kaur, had filed a complaint to this office that his 3 years old son was admitted

in Deep Hospital on 30-09-2016 for operation of RT hernia inguinal and same was diagnosed on 03-09-2016.

The health insurance policy was in force since 2014 on regular basis. The treating doctor of the hospital issued a

certificate dated 10.12.2016 that the patient was treated for hernia disease and this is idiopathic. The insurance

company rejected the claim under policy condition of SKP policy wording under the heading what is not

covered-and will not pay for point no 9 i.e. convalescence, general debility, run down condition or rest sure,

congenital disease or defects or anomalies, sterility, venereal disease.

On 05.07.2017, the complaint was forwarded to IFFCO TOKIO Gen. 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 27.07.2018.

The insurance company stated in his SCN that in this case pathogenesis and path physiology

of inguinal hernia was asked from concerned hospital. In response to which treating Doctor Dr Balddep Singh

has given a written statement on 10-12-2016 that he cannot conjecture on the cause of hernia in this case and

mentioned the aetiology is idiopathic. The hernia has not been established by the treating doctor, hence there

could not any other specific cause other than congenital in three years baby. The congenial is not covered in the

policy hence claim does not sustain under definition of ward no 37 and exclusion clause no 9 of the policy.

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The complainant was sent Annexure VI-A for compliance, which reached this office on 11.06.2018


a) Complainant’s argument: Complainant stated that her genuine claim is repudiated on the flimsy

ground by the insurance company. She pleaded that in case of 3 year old baby hernia is not congenial as

claimed by the insurance company since it is detected for the first time and swelling was noticed only

about a month back.

b) Insurers’ argument: Insurance Company pleaded that their repudiation is justified since it is a case of

inguinal hernia which is congenial in a 3 year old baby.






On perusal of various documents available in the file including the copy of complaint dated 27.06.2017,

company reply dated 27.07.2018 about the rejection of the health claim in respect of the treatment taken by

Gurshan Singh son of the complainant treatment record of Deep Nursing Home and Children hospital, Ludhiana

and also after consideration of submission made by both parties during the course of personal hearing, it is seen

that Gurshan Singh son of complainant was treated for right sided inguinal hernia and remained hospitalized at

Deep Nursing Home and Children hospital, Ludhiana from 30.09.2016 to 01.10.2016. The claim for

reimbursement of the expenses incurred on the treatment filed for Rs. 25,995/- under the policy no. 52642947

was rejected by insurance company under definition word no 37 and exclusion no 9 of policy terms and

conditions which provides exclusion of congenial disease. The patient in the instant case was a three and half

year child which was admitted and treated for right inguinal hernia. On going through the various documents

available in the file, it is evident that the patient has been treated for right inguinal hernia which was diagnosed

for the first time in the hospital and subsequent treatment was taken by the patient at Deep Nursing Home and

Children hospital, Ludhiana hospital for the same. As per definition of word no. 37 Congenital anomaly refers to

a condition which is present since birth and which is abnormal with reference to form, structure of position.

a. Internal congenital anomaly: Anomaly which is not in the visible and accessible parts of the

body.

b. External congenital anomaly: Anomaly which is in the visible and accessible parts of the

body.

In the instant case the swelling in right inguinal region diagnosed as inguinal hernia was first time noticed at the

age of about 3 and half year and the treating doctor has confirmed that the cause of the same is idiopathic and

the insurance company has not been able to prove that the inguinal hernia was congenital in nature. Simply

affirming the hernia to be of congenital nature because of age of child doesn‟t help the insurance company.

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.




Dr. D. K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Upkar Singh Sadana V/S The United India Insurance Co. Ltd.

of 279


1. Name & Address of the

Complainant Mr. Upkar Singh Sadana

# 105-D, Kitchlu Nagar, Ludhiana,

Punjab- 141001

Mobile No.- 7973335034

2.

Policy No:

Type of Policy


2008002816P110843623

Individual Health Policy

25.11.2016 To 24.11.2017



Mr. Balwinder Singh Sadana

Dr. Upkar Singh Sadana

4. Name of the insurer The United India Insurance Co. Ltd.


6. Reason for repudiation Not provided



9. Amount of Claim RS.28411/-

10. Date of Partial Settlement Not settle the claim




Ombudsman Rules


claim by an insurer



For the Complainant Mr. Upkar Singh Sadana, Complainant

For the insurer Mr. Parminder Batra, AO

Dr. Sanjay Kumar Shukla, TPA




On 18.07.2017 Mr. Upkar Singh Sadana, had filed a complaint to this office that Dr. Balwinder Singh Sadana

is suffering from Chronic lymphocytic leukemia ( Blood Cancer) and underwent for treatment at PGIMER,

Chandigarh on 07-01-2017 and she discharged on 08-01-2017.The insurance company raised a query that the

hospitalization was less than 24 hours hence the claim was not payable. As per the discharge summary, the total

period of the hospitalization is 26 hours. The detailed request letter was send to the insurance company to re

examine the case but no action has been taken.

On 31.07.2017, the complaint was forwarded to United India Insurance Co. Ltd Regional Office, Ludhiana, for

para-wise comments and submission of a self-contained note about facts of the case, which was made not

available to this office even on date of hearing.



a) Complainant’s argument: Complainant stated that her wife is suffering from blood cancer and her

hospitalization was more than 24 hour in PGIMR, Chandigarh. Her claim is justified.

b) Insurers’ argument: Insurance Company argued that their decision is justified that the period of

hospitalization being less than 24 hours.





21) Result of Personal hearing with both parties (Observations & Conclusion): After hearing both the

parties and examining the papers on record and discharge summary, it has been observed that hospital receipt

clearly confirms about time of admission and time of discharge which is more than 24 hours. Further, it has also

been observed that insurance company has issued a repudiation letter dated 31.01.2017 for this claim whereas

hospitalization query is again raised 20.02.2017. It speaks about lackluster and casual approach of insurance

company towards customer claims and service. Gross deficiency in customer service is noted on part of

insurance company.

of 279

Keeping in view the facts as stated above, the insurance company is directed to pay the claim amount for Rs.

28,411/- along-with simple interest of 8% from date of repudiation i.e 31.01.2017 subject to terms and

conditions of the policy within 30 days after receipt of the award copy.

AWARD


during the course of personal hearing, Rs 28,411/- along-with 8% simple interest from the date of

repudiation i.e 31.01.2017 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

PROCEEDINGS BEFORE




Case of Mr. Ram Vinay Kumar V/S ICICI Lombard General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ram Vinay Kumar S/o Sh. Uma Sankar Prasad, # 367,F.F.

Phase-1, Mohali, Punjab-160055

Mobile No.- 9041197955

2. Policy No:

Type of Policy


4034i/FPP/W-5891819/00/000

Family Protect Premier

21.01.2012 To 20.01.2013



Mr. Ram Vinay Kumar

Mr. Ram Vinay Kumar

4. Name of the insurer ICICI Lombard Gen. Insurance Co. Ltd.


6. Reason for repudiation PED not disclosed at the time of insurance



9. Amount of Claim Rs.69551/- plus pre& post hospitalization expenses


11. Amount of relief sought Rs.69551/- plus pre& post hospitalization expenses



Ombudsman Rules

Rule 13 (1)(b) – any partial or total repudiation of claim by an

insurer



For the Complainant Not present but requested on email dated 15.11.2018 to give

decision on the basis of available documents in the file

For the insurer Mr. Aditya Sharma, Manager Legal

Mr. Manoj Mehta, Manager Legal




On 05.07.2017 Mr. Ram Vinay Kumar, had filed a complaint to this office that he was having a health insurance

policy since 2012 without break and further renewed time to time and this was valid up to January, 2018. He

never lodged any health claim during the policy period. In the month of April, 2017 he suffered the Appendix

problem and went to Max Super Specialty Hospital, Mohali for the treatment. The hospital have sent claim bill

for cashless which was denied by the insurance company. After discharge, the health bill was submitted to the

insurance company and they rejected the claim on the ground that the previous ailment of TB and heart disease

was not declared at the time of the insurance. The present ailment related to Appendix has no relation with the

Heart problem and till date no heart problem he face.

The insurance company stated in his SCN that the health insurance policy was issued from 21-01-2012 and

renewed well in time in force till 20-01-2018.From the previous health record, it was notice that the insured has

underwent TOF in the year 1998 and the same had annual follow up review in CardioThoracic and

of 279

Neuroscienses centre, AIIMS since then. The past history of the said disease was not disclosed by the insured at

time of taking the insurance policy. The discharge summary of the hospital confirmed that the patient was

admitted in the hospital from 07-04-2017 to 11-04-2017 and underwent treatment for Recurrent Appendicitis

and cholelithiasis. Since the complainant had not disclosed the material facts of the past history, on this ground

the claim was rejected



a) Complainant’s argument: Complainant was not present but requested vide email dated 15.11.2018 to

give decision on the basis of available documents in the file as he is posted at Ahmadabad now.

b) Insurers’ argument: Insurance Company stated that patient has case of operated TOF in 1998. He

has not disclosed this fact to company while purchasing the policy for the first time on 21.01.2012. Since,

he has no disclosed about his PED status while taking policy. They have rightly repudiated this claim on

PED ground and requested for rejection of the claim.






After hearing company and examining the papers on record and discharge summary, it has been observed that

the TPA of the insurance company stated the patient was an operated case of TOF in 1998. But the insurance

company has not produced any evidence which could prove that present ailment i.e. recurrent appendicitis,

Cholelithiasis is directly related or due to result of TOF. Moreover there doesn‟t seem to be any correlation

between treatment for TOF in 1998 and problem appendicitis for which the patient has taken treatment in year

2017. Complainant has taken health insurance on 21.01.2012 and date of admission is 07.04.2017 which clearly

shows that he is having continuous health insurance for five years. As per IRDAI regulation all ailments are

covered after four continuous years. 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, Rs. 69551/- plus pre& post hospitalization expenses 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.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Ayub Khan V/S The National Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ayub Khan

H/o Mrs. Farida, Village Dhunela,

P.O. Sohna, Gurgaon, Haryana- 0

Mobile No.- 9911128106

2. Policy No:

Type of Policy


362001/48/14/8500000668

National Mediclaim Policy

06.10.2014 To 05.10.2015



Mr. Ayub Khan

Mr. Ayub Khan

4. Name of the insurer The National Insurance Co. Ltd.

5. Date of Repudiation Not mentioned on the letter

of 279

6. Reason for repudiation Misrepresentation, mis-description or non –

disclosure of any material facts








Ombudsman Rules


claim by an insurer



For the Complainant Mr. Ayub Khan, Complainant

For the insurer Mr. Vikram Sen, Senior Branch Manager




On 05.07.2017 Mr. Ayub Khan, had filed a complaint of that his wife was admitted at Vinayak Hospitial,

Gurgaon on 17-11-2014 and got discharged on 20-11-2014. The complete claim was submitted to the TPA of

the insurance company for reimbursement. After he received no claim letter, he found that company has

repudiated the claim on various discrepancies like date of admission/ discharge, hospital bills etc which he could

not understand how it happened. He stated that his claim was genuine and the rejection of the claim by the

insurance company was not in order.

On 14.07.2017, the complaint was forwarded to The National Insurance Co. Ltd Regional Office, Chandigarh,



The insurance company stated in his SCN / No claim letter that their TPA observed as there is misrepresentation

of facts i.e. as per investigations there are discrepancies in the date admission & discharge. Further there are

discrepancies in the hospital bills & IPD register regarding discharge date. Keeping in view, the genuineness of

hospital bills becomes doubtful. Moreover the registration certificate of the treating Dr.Tarun and Dr. Kandarp

were not provided by the hospital. Therefore, it seems that bills are not genuine. In the light of the investigation

report/facts the claim was repudiated under policy condition no 5.1 under disclosure to information norms.


a) Complainant’s argument: Complainant stated that he is insured with same insurance company for

many years. He produced several annual health / TPA cards issued by insurance company to him amongst

which oldest valid card was for the year 2005 (06-10-2005 to 05-10-2006). He pleaded that his genuine

claim is being repudiated on flimsy grounds of IPD register entries.

b) Insurers’ argument: Insurance company pleaded that complainant had produced registration

certificate of the treating Dr.Tarun Jhamb and Dr. Kandarp Vidyarthi which are in order. But still there

are discrepancies relating to IPD register entries in hospital. There are no bills issued for patient which

have been admitted after him.






After hearing both the parties, SCN, it has been observed the Insurance Company mainly repudiated the claim

due to anomalies pertaining to date of admission and discharge of succeeding admitted patient entries made in

the IPD register. Bills of these succeeding patients in IPD register were not raised. But nowhere insurance

company has raised any doubt on IPD entry made for Complainant‟s wife Mrs. Farida admission. Further,

Complainant is having continuous coverage of health insurance since 2005 and has shown TPA card in support

of his version which insurance company never objected. Company denial of claim totally based on flimsy

ground under condition 5.1 doesn‟t pass litmus test. Registration certificate of the treating Dr.Tarun Jhamb and

Dr. Kandarp Vidya are also in order. Therefore, deficiency in service has been noticed on the part of the

insurance company based on the available documents. The insurance company is directed to pay Rs 40666/-

subject to the terms and condition of policy to the complainant within 30 days from the receipt of the copy of the

award.

AWARD


during the course of personal hearing, Rs 40666/- subject to terms and condition of policy is hereby awarded

of 279

to be paid by the Insurer to the Insured, towards full and final settlement of the claim.




D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Suresh V/s Cigna TTK Health Insurance Co. Ltd.


1. On 03.07.2017, Mr. Suresh had filed a complaint in this office against Cigna TTK Health

Insurance Co. Ltd. for non settlement of his health claim despite several requests. The required

documents were submitted to the insurance company well in time but the insurance company

repudiated 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. The insurance company confirmed through mail dated 29.11.2018 that they have settled the health

claim an amount of Rs. 15,880/- . The claim amount has been credited to bank account of Mr. Suresh

through NEFT.

4. Mr. Suresh has also confirmed telephonically that the insurance company has settled his

claim and he has received the claim amount and wanted to withdraw his complaint.





OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu, IRS

Case between: Mrs. Hemina A. Mehta ……………The Complainant

Vs

M/s National Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).G .11.048.0005/2018-19

Award No: I.O.(HYD)/A/GI/0151/2018-19

1. Name & address of the complainant Mrs. Hemina A. Mehta,

H.No.4-1-442, Flat No.401, Cedar Elight Home,

Next to Hi Line Arcade, Kavadiguda,

Hyderabad – 500 080

2. Policy No. /Collection No.

Type of Policy

Duration of Policy/Policy period

552900/50/15/10000169

Parivar Mediclaim Policy

From 20.11.2015 to 19.11.2016


Name of the Policyholder

Mr. Atul Jayantilal Mehta

Mrs. Hemina A. Mehta

4. Name of the insurer M/s National Insurance Co. Ltd.

5. Date of Repudiation 29.05.2017

6. Reason for repudiation As per policy exclusion 4.6 – Cosmetic in nature

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8. Nature of complaint Rejection of Mediclaim


10. Date of Partial Settlement NA

11. Amount of Relief sought Rs.500000/-


Rule No.13.1 (b) of Ins. Ombudsman

Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of

Claims by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 30.11.2018 & 21.12.2018 / Hyderabad


a) For the complainant Self

b) For the insurer Sri T. Bhimeswara Rao, Manager

Dr. Leela Brindavanam, AO


16. Date of Order/Award 31.12.2018

17) Brief Facts of the Case:

The complainant, Mrs. Hemina Atul Mehta along with her husband and son took Parivar mediclaim policy with

the insurer in November, 2013 for a floater SI of Rs.5.00 lakhs and since then it was continuously renewed till

date. The present policy was renewed from 20.11.2015 to 19.11.2016. As per the complaint filed, the

complainant‟s husband was hospitalized in Asian Bariatrics/Ahmedabad Bariatrics & Cosmetics Pvt. Ltd.,

Hyderabad due to uncontrolled blood sugar levels and he underwent a procedure - Laparoscopic Duodenal

(Diverted) Ileal Interposition with BMI-adjusted, Sleeve Gastrectomy under GA. He was admitted in hospital on

13.08.2016 and discharged on 18.06.2016. The complainant filed reimbursement claim for Rs.773791/-. The

insurer rejected her claim stating that the line of treatment was for weight control and management and it falls

within the purview of the policy exclusion no. 4.6 of the policy. The complainant represented to the grievance cell

of the insurer to review the decision, but in vain. Aggrieved, Mrs. Hemina A. Mehta filed complaint with this

Forum.

18) Cause of Complaint: Rejection of mediclaim.

a) Complainant’s argument:

The complainant submitted that her husband, Mr. Atul Jayantilal Mehta was hospitalized as he was suffering

from uncontrolled blood sugar levels despite being on high doses of insulin and drugs at Asian Bariatrics from

13.08.2016 to 18.08.2016 and incurred Rs.7,73,791/- for the treatment. The reimbursement claim filed by her

was rejected by the TPA stating that the line of treatment was for weight control and management program and

was in cosmetic in nature. She pleaded that she had represented to the insurer to review the decision stating that

it was a life saving surgery and not a cosmetic surgery done for beautification. She further stated that she had

submitted a certificate from the treating doctor to that extent. She further stated that her husband was 55 years

old and he will not be keen for cosmetic enhancement and beautification treatment and risk a surgery unless it

was rather mandatory and strictly under medical advice and so denial of the claim by the insurer was unjustified.

The complainant further submitted that she was not given policy terms and conditions and she was

given only policy schedule. After rejection of claim, she collected policy terms and conditions and after

thoroughly going through the terms and conditions, she came to know that the exclusion No. 4.6, quoted by the

insurer to reject her claim, does not state that the treatment undergone for the condition arising out of

uncontrolled blood sugar levels was excluded but on the contrary exclusion 4.1 says that PEDs like diabetes and

hypertension will be covered from the inception of the policy on payment of additional premium by the insured.

She stated that she had paid 10% additional premium for coverage of diabetes. She stated that her husband did

not have any hypertension. There was abnormal delay in issuing rejection letter by the insurer. After several

appeals only the rejection letter dated 29.05.2017 was issued by the policy issuing DO. After rejection she

approached grievance cell of the insurer to review the decision once again on 22.06.2017 but they too took lot of

time and finally issued their rejection letter on 12.01.2018. She pleaded for the intervention of this Forum for

settlement of her claim by the insurer and to award suitable compensation for mental harassment and abnormal

delay.

b) Insurer’s argument:

In the Self Contained Note, the insurer submitted that the insured person was known diabetic since 19 years and

his BMI was below 35 and hence he was not morbidly obese. For pre-anesthetic tests, the patient was advised to

go for tests without taking insulin previous day night and in the morning. As such the sugar levels were high on

the date of surgery. All other test reports viz. C-Peptide, C-reactive proteins, US abdomen, creatinine, uric

nitrogen, calcium, uric acid, Thyroid function, Liver function tests, 2D Echo, venous Doppler of lower limbs,

chest x-ray, eye test for diabetic retinopathy were all found to be normal. No abnormality was found. The

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complainant had not submitted any previous test reports to confirm that her husband was suffering from

uncontrolled diabetes for some reasonable time to warrant surgery. As the complainant has not established that

the surgery was undergone for uncontrolled diabetes only, the claim was rejected under exclusion No. 4.6, i.e.

cosmetic or aesthetic treatment of any description.

With the above submissions, the insurer pleaded for dismissal of the complaint.

19) Reason for Registration of Complaint:

The claim preferred by the complainant was rejected by the insurer. As the complaint falls under Rule 13(b) of

Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal:

a) Policy with terms and conditions.

b) Rejection letter.

c) Correspondence with insurer

d) Doctor certificate

e) Self contained note with enclosures.

21) Result of hearing with both parties:

Pursuant to the notices given by this Forum both the parties attended personal hearing on 30.11.2018 at

Hyderabad. Both the parties reiterated their contentions for and against the complaint. On hearing both the

parties, the complainant is directed to furnish lab reports, prior to the date of surgery, to establish that the

insured person was suffering from uncontrolled diabetes and surgery was warranted for its controlled.

Accordingly, the hearing was adjourned.

During the re-hearing of the complaint on 21.12.2018, the complainant furnished lab reports of her

husband dated 07.01.2016, 14.03.2016 & 15.07.2016 of Fasting Plasma Glucose and Post Prandial Plasma

Glucose, HbA 1c and findings showed high sugar levels and HbA 1c was above 13.5%. The same was shared to

the representatives of the insurer for their perusal.

The insurer rejected the claim under 4.6 exclusion of the policy stating that the surgery was performed

for cosmetic or aesthetic purpose. The complainant strongly contended that in spite of insulin and other drugs

the high blood sugar levels of her husband could not be controlled and sleeve Gastrectomy was performed as a

life saving surgery to control blood sugar levels. The treating doctor also certified the surgery was performed to

reduce his sugars and body weight and cardiac risk factors only and it was not a cosmetic surgery or treatment.

The insurer stated in their self contained note that the insured patient was not obese and it was not a case of

morbid obesity. The complainant established by submitting past medical reports that the insured person was

suffering from uncontrolled diabetes in spite of insulin and other medication. The complainant paid additional

premium for coverage of diabetes related complications and the present surgery/procedure was performed to

control it only.

In view of the facts stated above, this Forum is of the opinion that the insurer erred in repudiating the

claim under policy exclusion 4.6 and directed to admit the claim in terms of the policy.

The policy had a sub-limit on admissible claim amount. Total expenses incurred for any one illness are

limited to 50% of the sum insured. The policy also had a co-payment condition. Co-payment of 10% shall

apply to all the admissible claims arising out of diabetes and/or hypertension. The policy was taken by the

complainant for Rs.5.00 Lakhs. The incurred amount by the complainant being Rs. 7,73,791/- the admissible

claim amount works out to Rs. 2.50 Lakhs after application of sub-limit of 50%. On this admissible claim

amount of Rs.2.50 Lakhs the co-pay amount of 10% is applicable. After this co-payment the net admissible

claim works out to Rs.2,25,000/-.

A W A R D Taking into account the facts & circumstances of the case, the documents on record and the submissions made

by both the parties during the course of personal hearing, the insurer is directed to admit the claim for

Rs.2,25,000/- ( Two Lakhs twenty five thousand only) towards full and final settlement of the claim. The

insurer is also directed to pay interest in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017.

In the result, the complaint is allowed.

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

2017: a) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award

and intimate compliance to the same to the Ombudsman.

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b) According to 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 & Development Authority of India Act 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) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at HYDERABAD on 31st day of DECEMBER, 2018.

(I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. Mahmood Hussain ………………The Complainant

Vs

M/s Star Health and Allied Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD) G .044.1819.0032

Award No. : I.O.(HYD)/A/GI/0152/2018-19

1. Name & address of the complainant Mr. Mahmood Hussain,

H.No.11-5-409, Red Hills,

Hyderabad – 500004.

2. Policy No./Collection No.

Type of Policy


P/700004/01/2018/005238


From: 19.11.2017 to 18.11.2018

3. Name of the insured-person


Mrs. Rubina Begum

Mr. Mahmood Hussain

4. Name of the insurer M/s Star Health and Allied Ins. Co. Ltd.


6. Reason for repudiation Non disclosure of material facts


8. Nature of complaint Rejection of Mediclaim & cancellation of policy



11. Amount of Relief sought Rs.20,000/-


Rule No.13 (b) of Ins. Ombudsman

Rules, 2017

Rule 13 (b) – any partial or total repudiation of claims by the

Life insurer, General Insurer or the Health insurer

13. Date of Hearing 21.12.2018 / Hyderabad



b) For the insurer Sri M. Ravi Kumar, AGM (Legal)




The Complainant, Mr. Mahmood Hussain, proposed cover to his wife and son under Family Health Optima

Insurance Plan and policy was issued by Respondent Insurer for a floater SI Rs.4.00 lakhs from 19.11.2017 to

18.11.2018. The policy was ported from ICICI Lombard General Ins. Co. Ltd., and health insurance cover was

first incepted to his wife and son on 19.11.2015. As per the complaint filed, the complainant‟s wife was admitted

in Shalini Hospital, Hyderabad on 26.02.2018 for severe knee pain due accidental fall at her home. She underwent

procedure, under local anesthesia, Intra Arterial Steroidal injection to her right knee and was discharged on

28.02.2018. The complainant‟s request for cashless treatment was declined by the insurer alleging that there was

non-disclosure of material facts, i.e. previous health conditions of diabetes, hypertension and morbid obesity. The

complainant filed reimbursement claim and it was also rejected on the same grounds and coverage to the insured

patient was deleted. The complainant represented to the insurer to review the decision but in vain. Aggrieved, Mr.

Mahmood Hussain filed complaint with this Forum.

of 279

18) Cause of Complaint: Rejection of Mediclaim.


The complainant submitted that his wife had an accidental slip at their home and there was swelling in her right

knee. As there was no relief from the medication, the doctor advised admission and she got admitted in Shalini

Hospitals on 26.02.2018. She underwent medical procedure and got relief from the pain. After denial of cashless

treatment request, he filed reimbursement claim for Rs.18048/- and insurer rejected the same alleging that there

was non-disclosure of material facts regarding previous health conditions viz. diabetes, hypertension and morbid

obesity. The complainant stated that the policy was ported to the respondent insurer from ICICI Lombard General

Ins. Co. and all details were furnished to the agent. The complainant further stated that there was no pre-

acceptance medical check-up and no cross-checking of information was done by the insurer but alleged that he had

misrepresented the facts. He further stated that his signatures were forged on the portability forms by Star health

sales team. He filed review application to review the decision. Without reviewing the claim, the insurer cancelled

the coverage to his wife under the policy and refunded the premium of Rs.6142/- by DD and the DD was not

accepted by him and it was again returned to the insurer. The complainant pleaded for the intervention of this

Forum for settlement of his claim and restoration of policy coverage to his wife.

b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the insured patient Mrs. Rubina Begum had insurance cover

earlier with ICICI Lombard from 19.11.2015 for a SI of Rs.2 Lakhs and switched over to their Company under

portability on 19.11.2017. The complainant reported claim during 3rd

month of coverage with the company and

claimed Rs.18048/- for the treatment expenses of his wife at Shalini Hospitals from 26.02.2018 to 28.02.2018. It

was noted from the discharge summary the diagnosis was „Acute Right Knee pain, Type II DM, Morbid Obesity

and underwent surgical procedure – Under Local Anesthesia under full aseptic precautions IAS right knee. On

perusal of the claim documents it was noted by the medical team that the insured patient is a known case of

Morbid Obesity with BMI of 46.7 and also k/c/o of diabetes and hypertension since June 2017. It was further

observed that the weight of the insured patient was recorded as 135 Kgs in hospital records where as the weight of

the insured patient was declared as 73 Kgs in the proposal form. The above findings confirm that the insured

patient was suffering from morbid obesity prior to inception of cover with the company and these material facts

were omitted to declare in the proposal form at the time of portability and it amounts to non-disclosure of material

facts. The insurer further stated that since policy was ported from ICICI Lombard, the necessary details such as

past medical history and claim history was verified through web portal of the IRDAI and ICICI Lombard replied

that there were no claim and no PED. Basing on the information furnished in the proposal and based on the

declaration the proposal on portability was accepted and policy was issued. Since there was mis-representation of

the material facts, the coverage under the policy, in respect of insured patient, was cancelled and premium of

Rs.6142/- was refunded vide DD No. 833529 dated 17.04.2018. The insurer further submitted that the contention

of signatures are forged/misrepresented by the insurer was denied.

With the above submissions, the insurer pleaded for dismissal of the complaint as it was rightly rejected

in terms of the policy.


The claim preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of



a) Policy copy with terms and conditions

b) Correspondence with insurer

c) Self Contained Note with enclosures

d) Discharge summary

e) Rejection letter

f) Proposal & portability forms

g) Indoor case sheets

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on

21.12.2018.

The complainant stated that his wife was covered under Health Insurance Policy from 19.11.2011 with

ICICI Lombard and the policy was ported to Star Health insurer on 19.11.2017 as he was assured of continuity of

all benefits. He stated that he asked the agent of the insurer whether the insured persons need to undergo any

medical examination. He was told that as it was on portability there was no need for any such pre-medical

examination. He further stated that at the time of proposal no one asked about weight of the insured persons.

After preferring the claim, insurer‟s investigator visited their house and enquired about the facts. As his son was

also obese he asked the investigator to see him also. After collecting all the information, the claim was rejected

alleging that he had not disclosed his wife‟s previous medical history. He strongly contended that the signatures

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on the portability forms were forged by sales team and he had not signed them.

The representative of the insurer on the other hand, while reiterating the contents of the self contained

note stated that due to non-disclosure of material facts, i.e. long standing diabetes, knee pain and BMI exceeding

46.7 the claim was rejected. As per their underwriting guidelines, if insured person had disclosed her morbid

obesity they could not have accepted the proposal on portability. By misrepresenting the facts the policy was

ported. Hence, the claim was rejected and coverage to the insured person was cancelled and relevant premium

was refunded.

The insured patient was covered under Health Insurance Policy continuously for more than 48 months

prior to her hospitalization. Under previous health insurance policies no pre-existing conditions were noted. It

was not known since when she had her present ailments/conditions. Whether they were present prior to inception

of first policy or contracted after inception of coverage under the first policy. No evidence was produced by

the insurer about duration of pre-existing ailments of the insured patient. In the absence of supporting medical

evidence, this Forum holds that the grounds relied upon by the insurer are presumptive and not acceptable. The

insurer is directed to settle the claim and to restore the coverage to the insured patient.

A W A R D

Taking into account the facts & circumstances of the case, the documents on record and the submissions made


Rs.14,457/- (as per the claim working sheet furnished by them) towards full and final settlement of the claim.

The insurer is also directed to pay the interest in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017.

The complaint is allowed.


2017:

a) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the

award and intimate compliance to the same to the Ombudsman.

b) According to 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 & Development Authority of India

Act 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) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 31st day of DECEMBER, 2018

(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mrs. Hemina A. Mehta ……………The Complainant

Vs




1. Name & address of the complainant Mrs. Hemina A. Mehta,

H.No.4-1-442, Flat No.401, Cedar Elight Home,

Next to Hi Line Arcade, Kavadiguda,

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Type of Policy


552900/50/15/10000169

Parivar Mediclaim Policy

From 20.11.2015 to 19.11.2016



Mr. Atul Jayantilal Mehta

Mrs. Hemina A. Mehta



6. Reason for repudiation As per policy exclusion 4.6 – Cosmetic in nature








Rules, 2017



13. Date of hearing/place 30.11.2018 & 21.12.2018 / Hyderabad



b) For the insurer Sri T. Bhimeswara Rao, Manager





The complainant, Mrs. Hemina Atul Mehta along with her husband and son took Parivar mediclaim policy with

the insurer in November, 2013 for a floater SI of Rs.5.00 lakhs and since then it was continuously renewed till

date. The present policy was renewed from 20.11.2015 to 19.11.2016. As per the complaint filed, the

complainant‟s husband was hospitalized in Asian Bariatrics/Ahmedabad Bariatrics & Cosmetics Pvt. Ltd.,

Hyderabad due to uncontrolled blood sugar levels and he underwent a procedure - Laparoscopic Duodenal

(Diverted) Ileal Interposition with BMI-adjusted, Sleeve Gastrectomy under GA. He was admitted in hospital on

13.08.2016 and discharged on 18.06.2016. The complainant filed reimbursement claim for Rs.773791/-. The

insurer rejected her claim stating that the line of treatment was for weight control and management and it falls

within the purview of the policy exclusion no. 4.6 of the policy. The complainant represented to the grievance cell

of the insurer to review the decision, but in vain. Aggrieved, Mrs. Hemina A. Mehta filed complaint with this

Forum.



The complainant submitted that her husband, Mr. Atul Jayantilal Mehta was hospitalized as he was suffering

from uncontrolled blood sugar levels despite being on high doses of insulin and drugs at Asian Bariatrics from

13.08.2016 to 18.08.2016 and incurred Rs.7,73,791/- for the treatment. The reimbursement claim filed by her

was rejected by the TPA stating that the line of treatment was for weight control and management program and

was in cosmetic in nature. She pleaded that she had represented to the insurer to review the decision stating that

it was a life saving surgery and not a cosmetic surgery done for beautification. She further stated that she had

submitted a certificate from the treating doctor to that extent. She further stated that her husband was 55 years

old and he will not be keen for cosmetic enhancement and beautification treatment and risk a surgery unless it

was rather mandatory and strictly under medical advice and so denial of the claim by the insurer was unjustified.

The complainant further submitted that she was not given policy terms and conditions and she was

given only policy schedule. After rejection of claim, she collected policy terms and conditions and after

thoroughly going through the terms and conditions, she came to know that the exclusion No. 4.6, quoted by the

insurer to reject her claim, does not state that the treatment undergone for the condition arising out of

of 279

uncontrolled blood sugar levels was excluded but on the contrary exclusion 4.1 says that PEDs like diabetes and

hypertension will be covered from the inception of the policy on payment of additional premium by the insured.

She stated that she had paid 10% additional premium for coverage of diabetes. She stated that her husband did

not have any hypertension. There was abnormal delay in issuing rejection letter by the insurer. After several

appeals only the rejection letter dated 29.05.2017 was issued by the policy issuing DO. After rejection she

approached grievance cell of the insurer to review the decision once again on 22.06.2017 but they too took lot of

time and finally issued their rejection letter on 12.01.2018. She pleaded for the intervention of this Forum for

settlement of her claim by the insurer and to award suitable compensation for mental harassment and abnormal

delay.


In the Self Contained Note, the insurer submitted that the insured person was known diabetic since 19 years and

his BMI was below 35 and hence he was not morbidly obese. For pre-anesthetic tests, the patient was advised to

go for tests without taking insulin previous day night and in the morning. As such the sugar levels were high on

the date of surgery. All other test reports viz. C-Peptide, C-reactive proteins, US abdomen, creatinine, uric

nitrogen, calcium, uric acid, Thyroid function, Liver function tests, 2D Echo, venous Doppler of lower limbs,

chest x-ray, eye test for diabetic retinopathy were all found to be normal. No abnormality was found. The

complainant had not submitted any previous test reports to confirm that her husband was suffering from

uncontrolled diabetes for some reasonable time to warrant surgery. As the complainant has not established that

the surgery was undergone for uncontrolled diabetes only, the claim was rejected under exclusion No. 4.6, i.e.

cosmetic or aesthetic treatment of any description.







b) Rejection letter.


d) Doctor certificate

e) Self contained note with enclosures.


Pursuant to the notices given by this Forum both the parties attended personal hearing on 30.11.2018 at

Hyderabad. Both the parties reiterated their contentions for and against the complaint. On hearing both the

parties, the complainant is directed to furnish lab reports, prior to the date of surgery, to establish that the

insured person was suffering from uncontrolled diabetes and surgery was warranted for its controlled.

Accordingly, the hearing was adjourned.

During the re-hearing of the complaint on 21.12.2018, the complainant furnished lab reports of her

husband dated 07.01.2016, 14.03.2016 & 15.07.2016 of Fasting Plasma Glucose and Post Prandial Plasma

Glucose, HbA 1c and findings showed high sugar levels and HbA 1c was above 13.5%. The same was shared to

the representatives of the insurer for their perusal.

The insurer rejected the claim under 4.6 exclusion of the policy stating that the surgery was performed

for cosmetic or aesthetic purpose. The complainant strongly contended that in spite of insulin and other drugs

the high blood sugar levels of her husband could not be controlled and sleeve Gastrectomy was performed as a

life saving surgery to control blood sugar levels. The treating doctor also certified the surgery was performed to

reduce his sugars and body weight and cardiac risk factors only and it was not a cosmetic surgery or treatment.

The insurer stated in their self contained note that the insured patient was not obese and it was not a case of

morbid obesity. The complainant established by submitting past medical reports that the insured person was

suffering from uncontrolled diabetes in spite of insulin and other medication. The complainant paid additional

premium for coverage of diabetes related complications and the present surgery/procedure was performed to

control it only.

In view of the facts stated above, this Forum is of the opinion that the insurer erred in repudiating the

claim under policy exclusion 4.6 and directed to admit the claim in terms of the policy.

of 279

The policy had a sub-limit on admissible claim amount. Total expenses incurred for any one illness are

limited to 50% of the sum insured. The policy also had a co-payment condition. Co-payment of 10% shall

apply to all the admissible claims arising out of diabetes and/or hypertension. The policy was taken by the

complainant for Rs.5.00 Lakhs. The incurred amount by the complainant being Rs. 7,73,791/- the admissible

claim amount works out to Rs. 2.50 Lakhs after application of sub-limit of 50%. On this admissible claim

amount of Rs.2.50 Lakhs the co-pay amount of 10% is applicable. After this co-payment the net admissible

claim works out to Rs.2,25,000/-.

A W A R D



Rs.2,25,000/- ( Two Lakhs twenty five thousand only) towards full and final settlement of the claim. The

insurer is also directed to pay interest in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017.



2017:

d) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


e) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

f) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. Mahmood Hussain ………………The Complainant

Vs


Complaint Ref. No. I.O.(HYD) G .044.1819.0032


1. Name & address of the complainant Mr. Mahmood Hussain,

H.No.11-5-409, Red Hills,

Hyderabad – 500004.


Type of Policy


P/700004/01/2018/005238


From: 19.11.2017 to 18.11.2018

3. Name of the insured-person


Mrs. Rubina Begum

Mr. Mahmood Hussain





of 279







Rules, 2017



13. Date of Hearing 21.12.2018 / Hyderabad



b) For the insurer Sri M. Ravi Kumar, AGM (Legal)




The Complainant, Mr. Mahmood Hussain, proposed cover to his wife and son under Family Health Optima

Insurance Plan and policy was issued by Respondent Insurer for a floater SI Rs.4.00 lakhs from 19.11.2017 to

18.11.2018. The policy was ported from ICICI Lombard General Ins. Co. Ltd., and health insurance cover was

first incepted to his wife and son on 19.11.2015. As per the complaint filed, the complainant‟s wife was admitted

in Shalini Hospital, Hyderabad on 26.02.2018 for severe knee pain due accidental fall at her home. She underwent

procedure, under local anesthesia, Intra Arterial Steroidal injection to her right knee and was discharged on

28.02.2018. The complainant‟s request for cashless treatment was declined by the insurer alleging that there was

non-disclosure of material facts, i.e. previous health conditions of diabetes, hypertension and morbid obesity. The

complainant filed reimbursement claim and it was also rejected on the same grounds and coverage to the insured

patient was deleted. The complainant represented to the insurer to review the decision but in vain. Aggrieved, Mr.

Mahmood Hussain filed complaint with this Forum.



The complainant submitted that his wife had an accidental slip at their home and there was swelling in her right

knee. As there was no relief from the medication, the doctor advised admission and she got admitted in Shalini

Hospitals on 26.02.2018. She underwent medical procedure and got relief from the pain. After denial of cashless

treatment request, he filed reimbursement claim for Rs.18048/- and insurer rejected the same alleging that there

was non-disclosure of material facts regarding previous health conditions viz. diabetes, hypertension and morbid

obesity. The complainant stated that the policy was ported to the respondent insurer from ICICI Lombard General

Ins. Co. and all details were furnished to the agent. The complainant further stated that there was no pre-

acceptance medical check-up and no cross-checking of information was done by the insurer but alleged that he had

misrepresented the facts. He further stated that his signatures were forged on the portability forms by Star health

sales team. He filed review application to review the decision. Without reviewing the claim, the insurer cancelled

the coverage to his wife under the policy and refunded the premium of Rs.6142/- by DD and the DD was not

accepted by him and it was again returned to the insurer. The complainant pleaded for the intervention of this

Forum for settlement of his claim and restoration of policy coverage to his wife.

b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the insured patient Mrs. Rubina Begum had insurance cover

earlier with ICICI Lombard from 19.11.2015 for a SI of Rs.2 Lakhs and switched over to their Company under

portability on 19.11.2017. The complainant reported claim during 3rd

month of coverage with the company and

claimed Rs.18048/- for the treatment expenses of his wife at Shalini Hospitals from 26.02.2018 to 28.02.2018. It

was noted from the discharge summary the diagnosis was „Acute Right Knee pain, Type II DM, Morbid Obesity

and underwent surgical procedure – Under Local Anesthesia under full aseptic precautions IAS right knee. On

perusal of the claim documents it was noted by the medical team that the insured patient is a known case of

Morbid Obesity with BMI of 46.7 and also k/c/o of diabetes and hypertension since June 2017. It was further

observed that the weight of the insured patient was recorded as 135 Kgs in hospital records where as the weight of

the insured patient was declared as 73 Kgs in the proposal form. The above findings confirm that the insured

patient was suffering from morbid obesity prior to inception of cover with the company and these material facts

were omitted to declare in the proposal form at the time of portability and it amounts to non-disclosure of material

facts. The insurer further stated that since policy was ported from ICICI Lombard, the necessary details such as

past medical history and claim history was verified through web portal of the IRDAI and ICICI Lombard replied

that there were no claim and no PED. Basing on the information furnished in the proposal and based on the

declaration the proposal on portability was accepted and policy was issued. Since there was mis-representation of

the material facts, the coverage under the policy, in respect of insured patient, was cancelled and premium of

Rs.6142/- was refunded vide DD No. 833529 dated 17.04.2018. The insurer further submitted that the contention

of signatures are forged/misrepresented by the insurer was denied.

of 279

With the above submissions, the insurer pleaded for dismissal of the complaint as it was rightly rejected







b) Correspondence with insurer

c) Self Contained Note with enclosures


e) Rejection letter

f) Proposal & portability forms

g) Indoor case sheets

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on

21.12.2018.

The complainant stated that his wife was covered under Health Insurance Policy from 19.11.2011 with

ICICI Lombard and the policy was ported to Star Health insurer on 19.11.2017 as he was assured of continuity of

all benefits. He stated that he asked the agent of the insurer whether the insured persons need to undergo any

medical examination. He was told that as it was on portability there was no need for any such pre-medical

examination. He further stated that at the time of proposal no one asked about weight of the insured persons.

After preferring the claim, insurer‟s investigator visited their house and enquired about the facts. As his son was

also obese he asked the investigator to see him also. After collecting all the information, the claim was rejected

alleging that he had not disclosed his wife‟s previous medical history. He strongly contended that the signatures

on the portability forms were forged by sales team and he had not signed them.

The representative of the insurer on the other hand, while reiterating the contents of the self contained

note stated that due to non-disclosure of material facts, i.e. long standing diabetes, knee pain and BMI exceeding

46.7 the claim was rejected. As per their underwriting guidelines, if insured person had disclosed her morbid

obesity they could not have accepted the proposal on portability. By misrepresenting the facts the policy was

ported. Hence, the claim was rejected and coverage to the insured person was cancelled and relevant premium

was refunded.

The insured patient was covered under Health Insurance Policy continuously for more than 48 months

prior to her hospitalization. Under previous health insurance policies no pre-existing conditions were noted. It

was not known since when she had her present ailments/conditions. Whether they were present prior to inception

of first policy or contracted after inception of coverage under the first policy. No evidence was produced by

the insurer about duration of pre-existing ailments of the insured patient. In the absence of supporting medical

evidence, this Forum holds that the grounds relied upon by the insurer are presumptive and not acceptable. The

insurer is directed to settle the claim and to restore the coverage to the insured patient.

A W A R D



Rs.14,457/- (as per the claim working sheet furnished by them) towards full and final settlement of the claim.

The insurer is also directed to pay the interest in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017.



2017:

d) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the

award and intimate compliance to the same to the Ombudsman.

e) According to 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 & Development Authority of India

Act 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.

f) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

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(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. Y. Janardhan Rao ………………The Complainant

Vs


Complaint Ref. No. I.O.(HYD) G .11.044.0251/2018-19


1. Name & address of the complainant Mr. Y. Janardhan Rao,

# 10-3-32/9/7, East Marredpally,

Secunderabad – 500 026.


Type of Policy


P/131128/01/2018/019181

Medi Classic Insurance Policy (Individual)

From: 07.03.2018 to 06.03.2019



Mrs. Y. Sree Laxmi

Mr. Y. Janardhan Rao


5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Short settlement of mediclaim

9. Amount of Claim Rs. 193793/--

10. Date of Partial Settlement 03.09.2018 – Settled Rs.1,15,396/-.

11. Amount of Relief sought Rs. 83697/-



Rules, 2017


Life insurer, General Insurer or the Health insurer.

13. Complaint how disposed Allowed – (Statistical Purpose)



The Complainant, Mr. Y. Janardhan Rao took Medi classic Insurance Policy (Individual) for his wife in 2008 with

the insurer. The present policy was renewed for SI Rs.3.00 lakhs from 07.03.2018 to 06.03.2019. As per the

complaint filed, the insured person underwent treatment of CA Left Breast. The complainant submitted

reimbursement claim for Rs.1,99,093/- but the insurer settled the claim for Rs.115396/- only. The complainant

represented to the insurer to pay the balance amount by reviewing the settlement. But there was no revision in the

settlement. Aggrieved, the complainant filed complaint with this Forum for Redressal of his grievance.

16) Cause of Complaint: Short settlement of hospitalization claim.




After registration of complaint by this Forum, the insurer further reviewed the claim and processed it and agreed to

settle the claim for Rs.49,980/- as against the balance claim amount of Rs.83,697/-. The complainant accepted the

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settlement and the insurer settled the claim on 06.10.2018 through NEFT in favour of the complainant for

Rs.49,980/- (Rupees Forty Nine thousand nine hundred and eighty only). The insurer intimated about settlement of

the claim to this Forum by their mail dated 17.12.2018.

A W A R D

The complaint is treated as resolved and closed for statistical purposes.

Dated at Hyderabad on the 31st day of December, 2018.

(I.SURESH BABU)

INSURANCE OMBUDSMAN


TELANGANA AND YANAM CITY Copy to:

1. Mr. Y. Janardhan Rao,

# 10-3-32/9/7,

East Marredpally,


Mobile No.8688968435

3. The General Manager,

M/s. Star Health and Allied Ins. Co. Ltd.,

Reg. & Corporate Office, No.1,

New Tank Street, Valluvar Kottam High Road,

Nungambakkam, Chennai -600034.

2. The Zonal Manager

M/s Star Health and Allied Ins. Co. Ltd.,

# 1-8-167 to 179/3, Ground Floor,

Beside Usha Kiran Complex,

S. D. Road, Paradise Circle,

Secunderabad – 500003.

PROCEEDINGS BEFORE




Case between: Mr. Ch.N.V. Mallikharjuna Rao ………………The Complainant

Vs




1. Name & address of the complainant Mr. Ch.N.V. Mallikharjuna Rao,

H.No.1-2-44/52/80(P) & 81(P),

Mallikharjuna Nagar, Yellareddy Guda,

RTC Colony Extn., Saket Road, Kapra,

ECIL (Post), Hyderabad – 500 062.


Type of Policy


P/131136/01/2018/000424

Senior Citizens Red Carpet Health Ins. Policy

From: 10.06.2017 to 09.06.2018



Mr. Ch. Satyanarayana

Mr. Ch.N.V. Mallikharjuna Rao





8. Nature of complaint Short settlement of mediclaim – Settled Rs.10,446/- on

22/06/2018

of 279


10. Date of Partial Settlement 19.06.2018




Rules, 2017






The Complainant, Mr.Ch.N.V. Mallikharjuna Rao took Senior Citizens Red Carpet Health Insurance Policy from

Respondent Insurer and covered his father and mother on 10.06.2013. The Policy was continuously renewed since

then. The present policy was renewed from 10.06.2017 to 09.06.2018 for SI of Rs.3.00 lakhs each. As per the

complaint filed, his father admitted in KIMS Hospital, Hyderabad from 04.05.2018 to 07.05.2018 for severe tooth

ache and underwent treatment. The complainant submitted the reimbursement claim for Rs.46410/- and the insurer

settled the claim for Rs.10446/- only applying co-pay of 50% treating the ailment as pre-existing. The complainant

stated that he had represented to the insurer to review the co-pay percentage as tooth ache could not be a pre-

existing ailment to apply 50% co-pay. There was no review of settlement by the insurer. Aggrieved, the

complainant filed complaint with this Forum for Redressal of her grievance.





After registration of complaint by this Forum, the insurer further reviewed the claim, processed it, and agreed to

settle the claim for Rs.5,257/- considering the co-pay at 30% instead of 50% as applied earlier. The complainant

accepted the settlement. The insurer settled the claim on 14.11.2018 through NEFT in favour of insured Mr.

Ch.N.V. Mallikharjuna Rao for Rs.5,257/- (Rupees Five thousand two hundred and fifty seven only) and intimated

to this Forum about their settlement vide their E-mail dated 14.12.2018.

A W A R D

The complaint is treated as resolved and closed as allowed for statistical purpose.

Dated at Hyderabad on the 31st day of December, 2018.

(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. Ch.N.V. Mallikharjuna Rao ………………The Complainant

Vs




1. Name & address of the complainant Mr. Ch.N.V. Mallikharjuna Rao,

H.No.1-2-44/52/80(P) & 81(P),

Mallikharjuna Nagar, Yellareddy Guda,

RTC Colony Extn., Saket Road, Kapra,

ECIL (Post), Hyderabad – 500 062.

of 279


Type of Policy


P/131136/01/2018/000424

Senior Citizens Red Carpet Health Ins. Policy

From: 10.06.2017 to 09.06.2018



Mrs. Ch. Phani Rajya Lakshmi

Mr. Ch.N.V. Mallikharjuna Rao





8. Nature of complaint Claim settled under 50% co-pay instead of 70%


10. Date of Partial Settlement 22.02.2018




Rules, 2017






The Complainant, Mr. Ch.N.V. Mallikharjuna Rao took senior citizens red carpet health insurance policy for his

father and mother on 10.06.2013 and continuously renewed for further period. The present policy was renewed

from 10.06.2017 to 09.06.2018 for SI of Rs.3.00 lakhs each. As per the complaint filed, his mother admitted in

Prasad Hospital, Hyderabad from 18.02.2018 to 22.02.2018 and she underwent knee replacement operation on

19.02.2018. The insurer had released an amount of Rs.74,211/- by applying 50% co-pay on total hospital bill of

Rs.148422/-, as per the specialist opinion there is gross OA noted, which confirms that the insured patient has

Osteoarthritis prior to the inception of the policy. The complainant pleaded that as per policy, he is eligible for 70%

co-pay. The complainant represented to the insurer for payment of balance claim amount of Rs.29684/- to review

the decision but in vain. Aggrieved, the complainant filed complaint with this Forum for Redressal of her

grievance.





After registration of complaint by this Forum, the insurer further reviewed the claim, processed it, and agreed to

settle the claim for Rs29684/- for which the complainant consented. The insurer settled the claim on 05/07/2018

through NEFT in favour of insured and intimated settlement details to this Forum by their mail dated 14.12.2018.

A W A R D


Dated at Hyderabad on the 31st day of DECEMBER, 2018.

(I.SURESH BABU)

INSURANCE OMBUDSMAN



of 279

PROCEEDINGS BEFORE




Case between: Mr. K. Madhusudhan ………………The Complainant

Vs




1. Name & address of the complainant Mr. K. Madhusudhan,

F/o Mr. K. Srikar, # 16-144,

Thirumalarayuni peta,

Proddatur, AP – 516360.


Type of Policy


P/131216/01/2018/001187

Family Health Optima Insurance Policy

From: 10.11.2017 to 09.11.2018



Mr. K. Madhusudhan

Mr. K. Srikar











Rules, 2017






The Complainant, Mr. K. Madhusudhan took Family Health Optima Insurance Policy for himself, spouse and two

children with the Respondent Insurer from 10.11.2017 to 09.11.2018 for a floater SI Rs.10.00 Lakhs. As per the

complaint filed, the complainant‟s son was admitted in Bhagvan Mahavir Jain Hospital, Bangalore for lower back

pain and was diagnosed as a case of L4-L5 disc prolapse. After rejection of cashless treatment request for surgical

management, the complainant preferred reimbursement claim for Rs.74,529/-. The insurer rejected the claim

alleging that the problem was long standing and there was non-disclosure of previous medical history. The

complainant represented to the insurer to review the decision but in vain. Aggrieved, the complainant filed

complaint with this Forum for Redressal of her grievance.

16) Cause of Complaint: Rejection of Hospitalization claim.




After registration of complaint by this Forum, the insurer further reviewed the claim and processed it and agreed to

settle the claim for Rs.68,738/-. The complainant accepted the settlement. The insurer settled the claim on

10.09.2018 through NEFT in favour of insured Mr. K. Madhusudhan for Rs.68,738/- (Rupees Sixty eight thousand

seven hundred and thirty eight only)

A W A R D


Dated at Hyderabad on the 31st day of DECEMER, 2018.

(I.SURESH BABU)

INSURANCE OMBUDSMAN



of 279

PROCEEDINGS BEFORE




Case between: Mr. S. Thirupathi Naidu ………………The Complainant

Vs




1. Name & address of the complainant Mr. S. Thirupathi Naidu,

H.No.1-17, Sree Nilayam, Sri Krishna Devaraya

Colony, Madinaguda, Behind Honda Showroom,

Hyderabad – 500 049.


Type of Policy


P/131115/01/2017/007542

Star Comprehensive Insurance - 2015

From: 31.01.2017 to 30.01.2018



Mr. S. Thirupathi Naidu

Mr. S. Thirupathi Naidu



6. Reason for repudiation Misrepresentation of material facts








Rules, 2017






The Complainant, Mr. S. Thirupathi Naidu took Star Comprehensive Insurance Policy for himself, wife and

daughter with the Respondent Insurer from 31.01.2017 to 30.01.2018 for floater SI Rs.5.00 lakhs. As per the

complaint filed, the complainant was admitted in Pranam Hospital, Hyderabad and took treatment for dengue fever

from 30.11.2017 to 04.12.2017. Upon rejection of pre-authorization request for cashless treatment, the complaint

applied for reimbursement claim for Rs.21,000/-. The insurer rejected the claim alleging that the need for admission

was not justified. The complainant represented to the insurer to review the decision but in vain. Aggrieved, the

complainant filed complaint with this Forum for Redressal of his grievance.





After registration of complaint by this Forum, the insurer further reviewed the claim, processed it and agreed to

settle the claim for Rs.21,000/-. The settlement was accepted by the complainant. The insurer settled the claim and

transferred the amount through NEFT to the complainant‟s bank account on 30.06.2018.

A W A R D

The complaint is treated as resolved and closed and treated as allowed for statistical purpose.


(I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND YANAM CITY

of 279

PROCEEDINGS BEFORE




Case between: Mr. K. Bhaskara Rao ………………The Complainant

Vs




1. Name & address of the complainant Mr. K. Bhaskara Rao,

LIG - 237, APHB Colony, Moula Ali,

Hyderabad – 500 040.


Type of Policy


P/131112/01/2017/004727


From: 28.12.2016 to 27.12.2017



Mr. K. Bhaskara Rao

Mr. K. Bhaskara Rao



6. Reason for repudiation Non submission of required documents








Rules, 2017






The complainant, Mr. K. Bhaskara Rao took Family Health Optima Insurance Policy with the Respondent Insurer,

from 28.12.2016 to 27.12.2017. As per the complaint filed, he took treatment for heart ailment in Yashoda

Hospital, Hyderabad from 26.06.2017 to 02.07.2017. He filed reimbursement claim for Rs.2,70,000/-. The insurer

raised a query and called for additional documents. The complainant submitted the available documents with him.

After submission of the additional documents, the insurer rejected the claim alleging that he had not submitted all

the required documents. The complainant represented to the insurer to review the decision and requested to settle

his genuine claim, but in vain. Aggrieved, the complainant filed complaint with this Forum for Redressal of his

grievance.



The insurer rejected the claim preferred by the complainant. As the complaint fell under Rule 13(b) of Insurance

Ombudsman Rules, 2017, it was registered.

After registration of complaint by this Forum, the insurer further reviewed the claim, processed it and agreed to

settle the claim for Rs.2,19,436/- in terms of the policy. The complainant accepted the settlement. The insurer

settled the claim and transferred the amount to the complainant‟s account through NEFT. The insurer intimated

about their settlement of claim to this Forum vide their mail dated 14.12.2018.

A W A R D



(I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P.,TELANGANA AND YANAM CITY

of 279

PROCEEDINGS BEFORE




Case between: Mr. N. Bhoopathi ………………The Complainant

Vs

M/s HDFC Ergo General Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. N. Bhoopathi,

# 2-2-1167/3/68, Tilaknagar,

New Nallakunta, Hyderabad – 500 044.


Type of Policy


2952 2007 7659 0202 000

Health Suraksha Policy – Silver Plan

From: 11.06.2016 to 10.06.2018 (two years)



Mr. N. Hemanth Kumar

Mr. N. Hemanth Kumar

4. Name of the insurer M/s HDFC Ergo General Ins. Co. Ltd.

5. Date of Repudiation Non settlement of mediclaim

6. Reason for repudiation Non submission of previous medical report and leave

certificate from employer


8. Nature of complaint Non settlement of mediclaim






Rules, 2017






Mr. N. Hemanth Kumar took Health Suraksha – Silver Plan policy with Respondent Insurer for himself from

11.06.2016 to 10.06.2018 for SI of Rs.3.00 lakhs. The insured person died while undergoing the treatment. As per the

complaint filed by father of the insured patient, Mr. N. Bhoopathi, he stated that initially his son was admitted in

Medicare Hospital, Hyderabad on 17.09.2017 for Scrotum pain. After surgery he was discharged on 21.09.2017. Again

he was admitted in Basavatarakam Hospital, Hyderabad on 06.10.2017 for chemotherapy and was discharged. Again he

fell sick on 19.10.2017 and approached Basavatarakam Hospital, Hyderabad they directed him to Century Super

Specialty Hospital, Hyderabad and while undergoing treatment he passed away due to cardiac arrest. The complainant

applied for reimbursement claim at Rs.1,98,648/-, but the insurer sent him a deficiency letter calling previous medical

reports and leave certificate from the employer. The complainant stated that he had furnished the documents called for

by the insurer and replied to their queries. In spite of that the insurer repeatedly asking the same documents repeatedly.

The complainant represented to the grievance cell for settlement of the claim, but in vain. Aggrieved, the complainant

filed complaint with this Forum for Redressal of his grievance.

16) Cause of Complaint: Non settlement of hospitalization claim.


The claim preferred by the complainant was not settled by the insurer. As the complaint fell under Rule 13(b) of


After registration of complaint by this Forum, the insurer reviewed the claim, processed it, and agreed to settle the claim

for Rs. 183745/- (Rupees One Lakh eighty three thousand seven hundred and forty five only). The complainant

accepted the settlement. The insurer settled the claim and transferred the amount through NEFT to the complainant‟s

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account. The Insurer intimated about settlement of the claim vide their e-mail dated 20.12.2018.

A W A R D



(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Sri B. Vinay Kumar ………………The Complainant

Vs

Max Bupa Health Insurance Co. Ltd…………The Respondent


Award No.: I.O.(HYD)/A/GI/0162/2018-19

1. Name & address of the complainant Mr. B. Vinay Kumar,

# 7-1-29,Plot No.8, Flat 5,

Krishna Apartments, Leela Nagar,

Ameerpet, Hyderabad – 500 016.


Type of Policy


30693902201700

Health Companion Ins. Policy

From 31.05.2017 to 30.05.2018



Mr. B. Vinay Kumar

Mr. B. Vinay Kumar

4. Name of the insurer Max Bupa Health Ins. Co. Ltd.


6. Reason for repudiation Non-disclosure of previous medical history





11. Amount of Relief sought Rs.3,07,457/-



Rules, 2017

Rule 13 (b) – any partial or total repudiation of claims

by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 27.12.2018 / Hyderabad

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b) For the insurer Ms. Shital Patwa, Manager (Legal)




The complainant, Sri B. Vinay Kumar took Health Companion Policy for himself and his wife from 17.09.2017

to 16.07.2018 for SI of Rs.5.00 Lakhs with Respondent Insurer on portability. As per the complaint filed, he was

hospitalized from 20.04.2018 to 27.04.2018 in Care Hospital, Hyderabad for heart ailment and underwent PTCA

with stent to LAD on 25.04.2018. The hospital charged him Rs.571457/- for the treatment. The complainant was

covered under a Corporate Group Mediclaim Policy, issued by HDFC Ergo General Ins. Co., and Rs.2 Lakhs was

approved under cashless treatment. The hospital sent pre-authorization request for the balance amount of

Rs.3,07,457/- to Max Bupa insurer and it was declined by them stating that the complainant was suffering from

hypertension since 20 years and this past medical condition was not disclosed at the time of porting the policy.

The complainant represented to the insurer to review the decision but in vain. Aggrieved, Sri B. Vinay Kumar

filed complaint with this Forum.



The complainant submitted that he was covered under Individual Health Insurance Policy since 2003 with New

India Assurance Co. Ltd., for a SI of Rs.2.50 Lakhs. He ported the Policy on 17.09.2017 to Max Bupa Health

Ins. Co., and enhanced the SI to Rs.5.00 Lakhs under Family Floater Policy. At the time of porting, the

representative of the Max Bupa insurer assured him that he would get all continuity benefits and all pre-existing

diseases exclusions were waived. He took his signature on proposal form and assured him that he would fill the

form as per the information furnished by him about his hypertension history and other details. Contrary to the

assurance, the agent not only misrepresented the fact of his hypertensive history but also declared him as a

retired employee though he was in service. This clearly indicated that the agent mixed-up the data of another

person in his application. The complainant stated that since he ported the policy after 13 years of continuous

coverage, he was under impression that all pre-existing ailments/diseases were covered. He suffered from chest

pain on 20.4.2018 and was admitted in Care Hospitals, Hyderabad. His ailment was diagnosed as „CAD-Double

Vessel Disease‟ and he underwent PTCA stent. The hospital charged him Rs.5,71.457/-. As he was covered

under his company‟s GMP taken with HDFC Ergo for a SI of Rs. 2.00 Lakhs they approved the same amount

under cashless treatment. The hospital sent pre-authorization request to Max Bupa for approval of balance

amount. The Max Bupa declined the request alleging that he had not disclosed his hypertensive history at the

time of porting the policy. He stated that he was not admitted for treatment of hypertension but his admission

was for treatment of heart ailment. He further stated that he had furnished his previous four years policies at the

time of porting the policy and insurer could have checked his medical history with previous insurer. Without

proper verification, the claim was rejected by the insurer and policy was also cancelled. He pleaded for

restoration of policy coverage as it was very difficult to obtain coverage from other insurers at his retirement

age. When he enquired for submission of his claim for reimbursement, the authorities told him that the policy

was cancelled and they cannot accept reimbursement claim. Hence, he did not file the claim. He further pleaded

for intervention of this Forum for settlement of his claim by the insurer.


In the Self Contained Note, the insurer submitted that the complainant submitted a proposal form on 09.08.2017

proposing the issuance of Health Companion policy under portability option to insure himself and his wife. The

details of the policy terms and conditions were explained by the sales team. He signed the declaration with full

knowledge of terms and conditions of the policy. The policy was issued and it was sent to the complainant. The

complainant had not raised any objections for incorrect information in the policy or exercised any option of

cancelling the policy during free look period of 15 days. The company rejected the cashless treatment request

sent by the hospital on noting adverse medical conditions, i.e. history of hypertension from last 20 years. On

perusal of the documents, it was noted that the complainant was suffering from hypertension and was on

medication since 20 years and this medical history was not disclosed at the time of porting the policy. The non-

disclosure of aforesaid medical ailments in the proposal form clearly establishes the malafide intention of the

complainant. Hence, cashless request declined and notice of cancellation of the policy was issued in accordance

with clause 3 of the policy. The complainant had not filed any reimbursement claim after rejection of cashless

treatment request.



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The cashless treatment request preferred by the complainant was declined and policy was cancelled by the

insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered.


a. Policy copy with terms and conditions

b. Discharge summary

c. Rejection letter

d. Correspondence with insurer

e. Self contained note

21) Result of the personal hearing with both the parties:

Pursuant to the notices issued by the Forum both the parties attended personal hearing at Hyderabad on

27.12.2018.

The complainant accepted that he was hypertensive and was on medication. He had disclosed his

medical condition to the agent at the time of porting the policy. He was covered under Health Insurance Policy

with New India Assurance Co. since 2003 year. When he wanted to enhance the sum insured, the insurance

officials told him that under new policy guidelines, he was covered under the policy for the maximum sum

insured and further enhancement of SI was not possible under the policy. The representative of the Max Bupa

approached him and told that their company would issue the policy with enhanced sum insured and also with all

continuity benefits and waiver of exclusions for all pre-existing conditions/ailments. Trusting him he had

signed the blank proposal form, took the policy and failed to verify it later. He further stated that he had

preferred a claim during 2010 for treatment of hypertension. He stated that his diabetes was detected during this

hospitalization period only. Earlier he did not have any diabetes. The insurer failed to verify past claims and

medical history with previous insurer even after collecting four years previous insurance policy copies from

him. The cancellation of policy by the Max Bupa put him to lot of hardship, ignoring his coverage under a

health insurance policy for 13 years before porting to them. He was unable to get any health insurance policy, at

his retirement age, from other insurance companies.

The representative of the insurer, on the other hand, reiterated the contentions of the self contained

note. She stated that when there was hypertension history over 10 years the proposal was not acceptable as per

their underwriting guidelines. If the complainant had disclosed his medical condition at the time of porting the

policy they would not have accepted the policy. Due to non-disclosure the cashless request was declined and

policy was cancelled and premium was refunded.

The complainant accepted that he was hypertensive and was on medication. He also accepted that he

failed to verify the policy as he trusted the agent of the respondent insurer. Only after rejection of the claim, he

came to know that there was non-disclosure of material facts by the agent. The complainant further stated that

he had preferred a claim on his previous insurance policy of 2010 year for hypertension treatment. If the Max

Bupa health insurer had verified the claim details properly they could have noticed it. It appears no

confirmation was obtained from the previous insurer about past medical and claims history. Without proper

verification of the details, the insurer cancelled the policy, totally ignoring the longevity of coverage of the

insured complainant. Considering the age of the insured persons, the insurer could have further

verified/enquired about pre medical conditions like diabetes and hypertension. The Hypertension and Diabetes

are presently life style diseases/conditions among most of the people in India. The rejection of claim, solely for

non-disclosure of hypertension is too technical and requires consideration considering the longevity of the

policy and complainant‟s age. Hence, the insurer is directed to admit the claim.

The complainant was covered under health insurance policy from 2003 year and he was covered for

Rs.2.50 Lakhs during past 4 years. In the current year policy the SI was enhanced to Rs.5.00 Lakhs. As per the

portability norms, the portability shall be applicable to the sum insured under the previous policy and also to an

enhanced sum insured, if requested for by the insured, to the extent of cumulative bonus acquired from the

previous insurer under the previous policies. In view of this clause, the entitlement of the complainant is

Rs.2.50 lakhs + Cumulative Bonus acquired under the policy, i.e. Rs.65000/- and total entitled amount is

Rs.3,15,000/-. The complainant is directed to submit his reimbursement claim along with all original bills and

report for processing and settlement of the claim. The complainant stated that he had not encashed the refund

premium cheque sent by the insurer and it was returned to them. Hence, insurer is directed to revive the

coverage under the policy for both the insured persons and also renew the policy by collecting the renewal

premium separately or by deducting the premium from claim amount.

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

the course of the personal hearing and the information/documents placed on record, the insurer is directed to

admit the claim, in terms of the policy by restoring the policy coverage. The insurer is also directed to accept

the renewal from its due date by collecting the premium separately or by deducting the premium from claim

amount.

The complaint is treated as Allowed.

of 279


2017:

g) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


h) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Sri AVN Srinivas Kumar ………………The Complainant

Vs




1. Name & address of the complainant Mr. AVN Srinivasa Kumar,

# 22-12-07, Bondavari Street,

Bhimavaram, Andhra Pradesh – 534201


Type of Policy


00213900201700

Group Health Ins. Policy

From 31.05.2017 to 30.05.2018



Mr. AVN Srinivasa Kumar

M/s Bajaj Finance Limited











Rules, 2017






of 279





The complainant, Sri AVN Srinivasa Kumar availed finance from M/s Bajaj Finance Limited and opted coverage

under Group Health Insurance Master Policy issued by Respondent Insurer to cover loners for the loan term. He

was first covered from 31.05.2016 to 30.05.2017 and it was subsequently renewed for one more year for SI of

Rs.5.00 Lakhs. As per the complaint filed, the complainant was diagnosed to have been suffering from carcinoma

glottis and underwent radiation treatment from 08.09.2017 to 23.10.2017 in Apollo Hospital, Hyderabad. The

pre-authorization request for cashless treatment sent by Apollo Hospitals was declined on the ground that the

ailment was pre-existing. There was history of insured patient undergoing Micro Laryngeal Surgery (MLS),

Septoplasty surgery at same place 3 years back. Since there was no 48 months of continuous coverage to the

insured patient cashless treatment request was declined. The complainant filed reimbursement claim for his

entitled amount of Rs.4,00,000/-. The insurer rejected the claim stating the above mentioned grounds. The

complainant represented to the insurer to review the decision but in vain. Aggrieved, Sri AVN Srinivasa Kumar

filed complaint with this Forum.



The complainant submitted that the insurer rejected his claim that his ailment was pre-existing and not covered

until 48 months of continuous coverage with them. He stated that he had discussed with the Medical team of the

insurer and explained that his ailment was not a pre-existing one. He strongly opposed the denial on the ground

of PED. He stated that he was hospitalized from 04.06.2014 to 06.06.2014 for nasal obstruction, difficulty in

breathing and change of voice since one month. He underwent MLS surgery. Biopsy of Vocal cord polyp was

sent for Histo Pathological Examination and Histopathology report stated that there was no evidence of

malignancy and features are suggestive of Squamous Papilloma. He was not advised any further treatment. Post

MLS he was perfectly fit and did not had any symptoms of the disease till May 2017 which was more than 3

years. Hence, the present malignancy does not fell under „pre-existing disease‟ definition of the insurer. The

present ailment was diagnosed after MLS surgery done in August 2017. He further contended that as per the

oncologist‟s review (PET CT Scan & DLDP) the malignancy was categorized as “T1A N0, M0” which was

very early stage of cancer. If assumed it was pre-existing since 2014 the stage would have been at very

advanced stage. He further stated that the other reports were normal; PET CT scan is negative for viable

tumors. These reports further prove that his present ailment was not a pre-existing ailment. The complainant

stated that as per the line of treatment decided by the oncologist, he had undergone radiation on

“TOMOTHERAPY” at Apollo Hospitals for 30 sittings from 08.09.2017 to 23.10.2017. He stated that he had

not preferred any claim earlier on his insurance policy. The insurer further cancelled the policy without

assigning any reason. He pleaded for the intervention of this Forum for Redressal of his grievance and renewal

of his policy by the insurer which was rejected.


In the Self Contained Note, the insurer submitted that the complainant is a beneficiary under Group Health

Insurance Policy issued by them to Bajaj Finance Limited for a SI of Rs. 5 Lakhs. The company received pre-

authorization request from Apollo Hospitals, Hyderabad for treatment of the complainant and it was denied as

the diagnosed ailment- Carcinoma Glottis- was pre-existing prior to inception of the first policy. The

complainant filed reimbursement claim for the radiation therapy from 08.09.2017 to 23.10.2017. The claim was

repudiated on the ground that the present disease/ailment was a complication which had arisen due to pre-

existing squamous papilloma. The insurer stated that the complainant had suffered and undergone MLS,

Septoplasty surgery at the same place three years back and HPE report stated it as squamous papilloma. The

present cancer is a squamous cell carcinoma of vocal cord itself (same site). The squamous papilloma, seen in

earlier histopath has high likelihood of turning into cancer and this is the reason he developed cancer at same

site. The present disease was a result of complication due to the pre existing condition which was evident from

the medical documents submitted by the complainant the rejection of claim on the ground of PED was justified.







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c. Rejection letter


e. Self contained note


Pursuant to the notices given by the Forum, both the parties attended personal hearing at Hyderabad on

27.12.2018. Both the parties reiterated their arguments for and against the complaint.

The complainant explained in detail the efforts made by him to convince the team of doctors and the e-

mails sent by him that his ailment was not to be considered as pre-existing ailment and specified the old reports

on which he relied upon and/or the enquiries he made with other oncologists in the subject matter. The

complainant further stated that he had Secure Mind Policy with ICICI Lombard Gen. Ins. Co. and they have

approved the claim after their through enquiries with the hospital and treating doctor about pre-existing nature

of the ailment. The Secure Mind policy also had an exclusion of PED and claim is not payable for PEDs. The

claim settlement details were shared by the complainant to this Forum.

He pleaded to direct the insurer to accept renewal of the policy as it was difficult for him to get an insurance

cover from other insurance companies with his diagnosed history of cancer.

The representative of the insurer, on the other hand, while reiterating the contents of the self contained

note, stated that as per the medical literature the papillomas are misdiagnosed or mislabeled as being other less

serious conditions. All papillomas are caused by virus and there was emerging evidence that viruses can cause

cancer. The laryngeal papillomas have a tendency to have “dysplastic” features. Dysplasia is frequently a

precursor to full-blown cancer. Hence, the claim of the complainant was declined under pre-existing disease

exclusion clause of the policy. The renewal of the policy could not be accepted as it was not sent by the

financier.

The insurer treated the ailment as pre-existing since malignancy was noticed at the same place where

there was earlier vocal cord growth. There was no medical document to establish that the old growth only

manifested into malignancy. The complainant was not advised by earlier treated doctor any medication or

advised regular examinations with scope for best cancer surveillance as majority of papillomas were benign.

The characteristic behavior of laryngeal papillomas was its recurrence after successful treatment. Since the

complainant had suffered from hoarseness again he was again subjected to the MLS and it was now found out to

be malignant. Since it was at larynx the insurer treated it as pre-existing and declined the claim. As there was

no supporting medical evidence, except assumption, this Forum directs the insurer to admit the claim in terms of

the policy. Since renewal of the policy based on other MOU terms there was no interference by this Forum on

the decision of the insurer.

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

the course of the personal hearing and the information/documents placed on record, the insurer is directed to

admit the claim in terms of the policy. The insurer is also directed to pay the interest in terms of Rule 17(7) of

Insurance Ombudsman Rules, 2017.



2017:

i) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


j) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

k) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



of 279

PROCEEDINGS BEFORE


(Under Rule 16(1)/17 of Insurance Ombudsman Rules, 2017)


Case between: Mrs. Rupa Josephine Samuel ………………The Complainant

Vs

HDFC ERGO General Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mrs. Rupa Josephine Samuel,

H.No.6-5-539, 7th

Lane, New Bhoiguda,



Type of Policy


2952200944031902-2825

Health Suraksha(Silver Plan) Policy

From 17.01.2017 to 16.01.2018

3. Name of the insured/Policy-holder Mr. Harold Nobert Samuel

Mrs. Rupa Josephine Samuel

4. Name of the insurer HDFC ERGO General Ins. Co. Ltd.




8. Nature of complaint Rejection of mediclaim


10. Date of Partial Settlement ---




Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the





b) For the insurer Mr. Aneesh Bhaskaran, Manager (Legal)




The complainant, Mrs. Rupa Josephine Samuel took Health Suraksha Policy (Silver Plan) for herself, husband

and son from 17.01.2011 for a floater SI Rs.3.00,000/- and it was continuously renewed, without any break, up

to 16.01.2018. As per the complaint filed, her husband was admitted in KIMS Hospital, Hyderabad on

14.09.2017 for the treatment of Pneumonia and Sepsis and it was diagnosed as H1N1 – Swine Flu Infection.

The insurer rejected the cashless treatment request alleging that there was non-disclosure of previous medical

history of long standing „diabetes‟ of insured patient. After discharge, she filed reimbursement claim for

Rs.4,51,950/-. The insurer rejected the same on the same ground. She represented to the insurer to review the

decision but in vain. Aggrieved, Mrs. Rupa Josephine Samuel filed complaint with this Forum.


a. Complainant’s argument: The complainant submitted that her husband fell sick after a brief cold, fever and breathlessness because of

congestion in the chest and was taken for a check up to KIMS Hospitals, Hyderabad on 14.09.2017. On seeing

the condition of her husband, the hospital doctors advised immediate admission and he was admitted in the

hospital. They suspected it as a case of H1 N1 and further tests confirmed it. The cashless treatment request sent

by the hospital was declined by the insurer alleging that there was non-disclosure of previous long standing

diabetic history. Due to rejection of cashless treatment request, she was forced into a situation of taking a

discharge of the patient from the hospital on 29.09.2017 as she could not afford to meet the treatment expenses.

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After a couple of days her husband passed away on 01.10.2017 due to swine flu infection. She stated that she

had filed reimbursement claim on 28.10.2017 and it was rejected by the insurer on 13.11.2017 alleging that her

husband had diabetes prior to inception of the policy. The complainant stated that diabetes of her husband was

diagnosed 3 years back and not 15 years as alleged by the insurer. At the time of taking the policy he was not

suffering from any diabetes. She further stated that her husband underwent treatment for H1 N1 infection and not

for diabetic related ailment. Rejection of claim, after 6 years of continuous coverage with the insurer, on

unrelated past history was unfair and not acceptable. She pleaded for the intervention of this Forum for

settlement of her claim by the insurer.

b. Insurer’s argument: The insurer, in their Self Contained Note, submitted that the complainant availed Health Suraksha Policy from

17.01.2017 to 16.01.2018 and covered herself, spouse and son for a floater SI of Rs. 3 Lakhs. Her husband was

admitted in KIMS Hospitals, Secunderabad for treatment of H1N1. The claim was rejected on the ground of

non-disclosure of previous medical history. The insurer further submitted that on perusal of discharge summary,

it was noted that the insured patient was k/c/o diabetes and was on regular medication. During the process of

verification, Hospital doctor, Dr. Swathi issued a letter dated 21.09.2017 confirming that the insured patient had

diabetes since 15 years and hypertension since 1 year. The insured first availed the policy on 17.01.2011 and

failed to disclose the diabetes condition of her husband at the time of taking the policy. The insurer further

submitted that the cover was provided based on the information furnished in the proposal and tele-call about

health and medical history of self and family. The complainant/insured was specifically enquired about previous

ailments, accidental injury if any, during tele-call which was denied. The complainant intentionally suppressed

the diabetes condition of her husband. Since, the complainant failed to disclose the true facts with regard to the

state of health which was relevant to the risk. If true information was furnished, the insurer could have made a

prudent decision whether to undertake the risk or not.

The insurer further submitted that, on the basis of the above facts, the repudiation of the claim of the

complainant is well justified and within the scope of the policy terms and conditions and does not constitute a

breach of duty or unfair practice on the part of the respondent insurer.



The claim preferred by the complainant was repudiated by the insurer. As the complaint falls under Rule 13.1(b)

of Insurance Ombudsman Rules, 2017, it was registered.



b) Repudiation letters



e) Dr. Swathi‟s letter dated 21.09.2017 and 31.12.2018


Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on

21.12.2018. Both parties advanced their arguments for and against the complaint.

The insurer relying upon a response sent to a query by the hospital doctor, Dr. Swathi, i.e. diabetes since 15

years and hypertension since 1 year, the insurer declined cashless treatment request and also reimbursement

claim. As seen from the discharge summary Dr. Swathi was not a part of team doctors who treated the insured

patient during hospitalization. On pointing out the same, the insurer obtained a letter from Dr.Swathi dated

31.12.2018 who stated that she had responded to the query of the insurer and furnished the duration history of

diabetes and hypertension as stated by the patient‟s attendar. During hearing the complainant stated that she was

only present throughout the period of hospitalization of her husband at KIMS Hospital and she had not told any

doctor about duration of her husband‟s diabetic history. She further stated that he had it for the past three years

and hypertension since one year only. The complainant did not have any evidence/consultation papers to prove

her statement.

In that event how did Dr. Swathi saying that the insured person/patient was having diabetes for the past

15 years? And on what basis? When the attendant, i.e. complainant was so emphatic and asserting that her

husband had diabetes only for the past three years, it is not clear and inexplicable as to how Dr. Swathi concluded

that the insured patient was having diabetes for the past 15 years. Even otherwise, pre-existing ailments were

taken into consideration after 48 months of continuous coverage. It appears that to negate the claim, the insurer

obtained the letter from Dr. Swathi, who was no way connected with the case of patient. The insured could not

even explain or given the status of Dr. Swathi in the medical administration of the Hospital.

The insurer relied upon voice log recorded at the time of issuance of the policy during 2011 year and

stated that the insured person failed to disclose his diabetic history when the tele-caller asked a question – “Do

you are your spouse in present or in the past have any health complaint or are taking any treatment or

hospitalized for any illness or accidental injury.” For which the insured person stated „No‟. Since the

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complainant had diabetes at the time of taking the policy, it was ought to have been disclosed by him for proper

evaluation and loading of premium by the company. Since it was not disclosed, which was material to

underwriting of the proposal, the claim was declined. At the time of giving policy, the terms and questions should

be specific and clear so that correct and right information necessary for assuming the risk is elicited. The insured

cannot be blamed for not giving the information when such vague and obscure questions are asked.

There was no medical document to pin-point exact duration of diabetes. The claim was reported during

7th

year policy period. The policy covers all pre-existing diseases after 48 months of continuous coverage. The

rejection of claim, harping upon non-disclosure of pre-medical conditions DM is not justified. The benefit of

doubt favours the complainant. The insurer is directed to admit the claim in terms of the policy.

A W A R D


during the course of the personal hearing, the insurer is directed to admit the claim in terms of the policy.

The insurer is also directed to pay the interest in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017.



2017: l) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


m) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

n) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Sri M. Venkatesham ………………The Complainant

Vs


Complaint Ref. No. I.O.(HYD).G -031-1819-0046


1. Name & address of the complainant Mr. M. Venkatesham,

# 9-140/9, Srinilayam, Chegunta,

Medak Dist., Telangana – 502 255.


Type of Policy


30471673201702

Family First Silver 1L + 3LPolicy

From .30.10.2017 to 29.10.2018



Mrs. M. Shantha

Mr. M.Venkatesham






9. Amount of Claim Rs.531402/- + Rs.2,69,332/-



of 279



Rules, 2017






Mr. Mahesh Kumar, Son





The complainant, Sri M. Venkatesham took Family First Silver Policy for himself and his wife on 30.10.2015 for

an individual sum insured limit of Rs.1.20 Lakhs + Floater SI of Rs. 3.00 Lakhs. The policy was continuously

renewed thereafter. The present policy was renewed from 30.10.2017 to 29.10.2018. As per the complaint filed,

the complainant‟s wife admitted in Yashoda Hospital, Hyderabad on 16.02.2018 for treatment of Subarachnoid

Hemorrhage. The insurer rejected cashless treatment request on noting that there was non-disclosure of previous

health condition of hypertension since 5 years. The patient was shifted to Care Hospitals, Hyderabad

subsequently and she underwent surgery. Post discharge she passed away. The complainant stated that he had

filed reimbursement claims for payment of hospitalization expenses incurred for the treatment of his wife. The

insurer rejected both the claims alleging that there was non-disclosure of past medical history/conditions. The

complainant stated that he had represented to the insurer stating that his wife‟s hypertension was diagnosed few

months back and submitted few past consultation papers. There was no revision in the decision of the insurer.

Aggrieved, Sri M. Venkatesham filed complaint with this Forum.



The complainant stated that at the time of claim verification, the investigator obtained a declaration from his

son, who was not aware of the exact duration of hypertension history of his mother. He stated that she had it

since 6 months only but it was stated by his son from 5 years due to confusion and disturbed state of mind. The

insurer solely relying upon the same rejected the pre-authorization request which was approved earlier by them

for RS.98,000/- and reimbursement claims. He further stated that he had submitted his wife‟s consultation

papers dated 19.06.2017, 18/08/2017 & 25/09/2017 to confirm that she did not have any hypertension earlier to

her first diagnosis on 25/09/2017. The insurer had not reviewed the claim.


In the Self Contained Note, the insurer submitted that the complainant‟s wife/patient was admitted for treatment

of subarachnoid hemorrhage with hypertension history. The complainant had not disclosed hypertension history

of insured patient at the time of taking the policy or at the time of undergoing medical examination. During

claim verification process the complainant‟s son declared that his mother had HTN since 5 years. The indoor

case papers also confirms the same duration of hypertension history. Since it is a material fact for underwriting

the proposal, the claim of the complainant was repudiated.







c. Rejection letter



Pursuant to the notices issued by this Forum both the parties attended personal hearing at Hyderabad on

27.12.2018. The complainant while reiterating the contents of his complaint stated that on 16.02.2017 during

night hours his wife suddenly had vomiting and had fits and all her limbs were stiffened. Immediately she was

taken to Yasoda Hospital, Hyderabad. The pre-authorization request sent by the hospital was initially approved

by the insurer for Rs.98,000/- and asked for some more information. On furnishing the information they have

cancelled the approval. The hospital, after few days of treatment, stated that surgery needs to be performed and

asked him to deposit the amount. As the treatment cost quoted by the hospital being heavy, he had shifted the

patient to Care Hospitals, Hyderabad. There surgery was performed. Even after surgery she could not be

recovered. As there was no hope of recovery, he got discharged the patient, as he could not bear the treatment

expenses which crossed Rs. 5 Lakhs. After discharge, she passed away within a week. The insurer had not

considered the earlier consultation papers submitted by him which confirmed that she did not have any

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hypertension, prior to its first diagnosis on 25.09.2017. There were no claims preferred by him on the policy till

date except the two claims rejected by the insurer

The representative of the insurer, on the other hand, after hearing to the complainant and on

verification of previous consultation papers submitted by the complainant for review of the decision, agreed to

consider the claim in terms of the policy.

A W A R D The insurer is directed to settle the claim for Rs.4,60,000/- (Rupees Four Lakhs sixty thousand only) towards

full and final settlement of the claim as intimated by them vide their mail. The insurer is also directed to pay the

interest in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017.

The complaint is treated as allowed.


2017: o) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


p) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

q) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE


(Under Rule 16(1)/17 of Insurance Ombudsman Rules, 2017)


Case between: Mr. B. Rajesh Reddy ………………The Complainant

Vs

HDFC ERGO General Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).G .018.1819.0021


1. Name & address of the complainant Mr. B. Rajesh Reddy,

Plot No.12, Nandagiri Hills Society,

Road No.69, Jubilee Hills



Type of Policy


316108000200200300

Health Medicare Classic Insurance Policy

From: 31.03.2017 to 30.03.2018

3. Name of the insured/Policy-holder Mr. B. Rajesh Reddy

4. Name of the insurer HDFC ERGO General Ins. Co. Ltd.




8. Nature of complaint Short settlement of mediclaim


10. Date of Partial Settlement 30.11.2017 - Settled Rs.60,000/-




Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the



of 279



b) For the insurer Mr. Aneesh Bhaskaran, Manager (Legal)




The complainant, Mr. B. Rajesh Reddy took Health Medisure Classic Insurance Policy for himself, spouse and

two daughters, for SI Rs.5.00 Lakhs each, from 31.03.2017 to 30.03.2018 with the Respondent Insurer. As per

the complaint filed, the complainant underwent right eye cataract surgery in M/s Maxi vision Super Specialty Eye

Hospital, Hyderabad on 30.11.2017. After discharge the complainant filed reimbursement claim for Rs.1,50,000/-

and the insurer settled the claim for Rs.60,000/- only. He represented to the insurer to review the claim but in

vain. Aggrieved, Mr. B. Rajesh Reddy filed complaint with this Forum.

18) Cause of Complaint: Short settle of Mediclaim.

c. Complainant’s argument: The complainant submitted that his right eye cataract surgery claim preferred for Rs.1,50,000/- was settled by the

insurer for Rs.60,000/- without taking any consent from for the proposed amount of settlement. He stated that he

had protested for the short settlement of claim and sent several e-mails and made telephone calls. There was no

proper response from the insurer. He represented to the grievance cell of the insurer on 09.03.2018 and there was

no positive review by the insurer. Hence, he pleaded for the intervention of this Forum for settlement of his

claim for the total amount incurred by him.

d. Insurer’s argument: The insurer, in their Self Contained Note, submitted that the complainant made a claim for Rs.1,53,510/- for the

cataract surgery undergone by him at Maxi vision Eye Super Specialty Hospitals, Hyderabad on 30.11.2017.

After scrutiny of the medical documents provided by the complainant, it was noted that the complainant was

advised right eye cataract surgery- phacoemulsification with foldable IOL implantation with femtosecond laser

cataract surgery (victus). The complainant opted for multifocal lens as against the standard monofocal lens being

used in cataract surgery. The discharge summary and all other available documents do not specify any medical

indication or justification warranting use of multifocal lens. Hence, the claim was restricted to Rs.60,000/- as per

the tariff of monofocal lens provided by the hospital. Multifocal lenses are used to correct vision/power (so

patient does not have to wear glasses post surgery, which is mostly for a cosmetic cause) unless the same is

medically warranted. Since no such medical necessity, the restriction of claim for the cost of monofocal lens is

justified. The complainant approached this Forum for illegal enrichment from this respondent.



The claim preferred by the complainant was short settled by the insurer. As the complaint falls under Rule

13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.



b) Discharge summary

c) Doctor certificate


d) Self contained note with its enclosures


Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on

21.12.2018.

The complainant stated that two years back he underwent cataract surgery to his left eye, with multifocal

lens, at the same hospital and the same insurer paid the total claim. He requested time to furnish the details. The

representative of the insurer stated that there was no information about settlement of claim by the company. The

complainant was asked to furnish the details.

The complainant furnished the earlier policy and his claim settlement details to the Forum. On perusal of the

same, the policy was issued by M/s L&T General Insurance Co. and it was merged with the present Respondent

Insurer. The claim preferred for left eye cataract surgery was processed and settled by the Respondent Insurer

without restricting the same to monofocal lens cost rate tariff of the hospital. Since, the complainant proved his

claim against the insurer for similar surgery at the same hospital, the restriction of second eye cataract claim for

monofocal lens rate tariff is not fair. The insurer is directed to process and settle the claim in other terms of the

policy and to pay the difference in amount.

of 279

A W A R D


during the course of the personal hearing, the insurer is directed to pay the difference amount towards full

and final settlement of the claim. The insurer is also directed to pay the interest in terms of Rule 17(7) of

Insurance Ombudsman Rules, 2017 on the difference amount.



2017: r) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


s) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

t) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 31st day of DECEMBER,2018.

(I. SURESH BABU)

OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND

YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. J.B. Chandra Sekhar ……………The Complainant

Vs


Complaint Ref. No. I.O.(HYD).G-048-1819-0006


1. Name & address of the complainant Mr. J.B. Chandra Sekhar,

Plot No.37, Jai Bharat Colony, Lal Bazar,

Trimulgherry, Secunderabad – 500 015.


Type of Policy


551200/50/16/10001755


From 16.03.2017 to 15.03.2018



Mr. J.B. Chandra Sekhar

Mr. J.B. Chandra Sekhar





8. Nature of complaint Short settlement of Mediclaim

9. Amount of Claim Rs. 2,24,274/- & Rs.20,106/-

10. Date of Partial Settlement Settled Rs.1,35,430/- & Rs.10,249/- only

11. Amount of Relief sought Rs.88,844/- + Rs.9857/-



Rules, 2017



13. Date of hearing/place 30.11.2018 & 27.12.2018/ Hyderabad



of 279

b) For the insurer Sri T. B. Rao, Manager





The complainant, Mr. J.B. Chandra Sekhar, took Mediclaim Policy with the insurer in 2006 and continuously

renewed till date. The present National Mediclaim policy was renewed from 16.03.2017 to 15.03.2018 for SI

Rs.3.00 lakhs. As per the complaint filed, he suffered from heart attack and underwent Coronary Angiogram at

KIMS Hospitals, Secunderabad on 04.04.2017. On diagnosis of Coronary Artery Disease – Single vessel he

underwent PTCA Stent on 05.04.2017 and was discharged on 06.04.2017. He incurred Rs.2,24,274/- for the

treatment. As he suffered from vomiting he was again admitted in the hospital on 09.04.2017 and after

stabilization got discharged on 11.04.2017. He incurred Rs.20,105/- for the treatment. He filed reimbursement

claims and the claims were settled for Rs.1,35,430/- & Rs.10,249/- respectively by the TPA/Insurer. He

represented to the insurer to review the settlement but there was no revision in the amounts settled by the insurer.

Aggrieved, Mr. J.B. Chandra Sekhar filed complaint with this Forum.

18) Cause of Complaint: Short settlement of mediclaim.


The complainant submitted that due to sudden heart attack he was admitted and underwent surgical treatment at

KIMS Hospitals, Secunderabad from 04.04.2017 to 06.04.2017. At the time of admission he was told that the

hospital was not a network hospital of National Ins. Co. and so he paid the hospital bill and claimed

reimbursement. He further stated that due to other complications he again admitted in the hospital on

09.04.2017 and got discharged on 11.04.2017 after undergoing treatment. He filed two reimbursement claims

for Rs.2,24,274/- and Rs.20,105/- towards his two hospitalization claims. The insurer settled the claims at

Rs.1,35,430/- and Rs.10,249/- only. On his enquiry he was told that since he had diabetes and hypertension,

four years back sum insured, i.e. 2013-14 Policy sum insured of Rs.1,25,000/- + Cumulative Bonus of

Rs.62,500/- was taken for settlement of the claims. The complainant stated that there was periodical

enhancement in the SI. During 2013-14 year the SI was Rs.1,25,000/- and it was enhanced to Rs. 2.00 Lakhs

during 2014-15 & 2015-16 and it was further enhanced to Rs.3.00 Lakhs from 2016-17 and continued up to

current year of 2017-18. The insurer instead of taking 2017-18 Policy SI taken old SI insured to restrict his

claim. He further submitted that during the course of hospitalization some investigations were carried out by the

doctors and they were disallowed by the insurer alleging that they were not relevant to the diagnosis and

appealed to consider the same as it was not in his hands to say no to any tests and investigations carried out by

the doctors during the hospitalization period. He pleaded for the intervention of this Forum for settlement of his

claim for full amount by the insurer.


In the Self Contained Note, the insurer submitted that the complainant was covered under National Mediclaim

Policy for the period from 16.03.2017 to 15.03.2018 for a SI of Rs.3.00 Lakhs with cumulative bonus of

Rs.85,000/-. Due to chest pain he was hospitalized in KIMS Hospitals, Secunderabad from 04.04.2017 to

06.04.2017 for and the ailment was diagnosed as “ACS-AW ST Elevation MI” thrombolysed with TNK on

04.04.2017. After stabilization CAG was done on 04.04.2017 which revealed single vessel disease and

PTCA/Stent to Ostio Proximal LAD was done on 05.04.2017. The complainant filed reimbursement claim for

Rs.2,24,274/-. The complainant was a known case of diabetes and hypertension and they were pre-existing

ailments. The enhancement in SI if any was not applicable during the first four years of enhancement for any

pre-existing ailments, conditions and its complications. Since CAD was a complication of DM & HTN, four

years back SI, i.e. 2013-14 policy year was taken for settlement of the claim. The complainant underwent

treatment in a PPN Net Work hospital and as per GIPSA norms, the PPN package rates for CAG & PTCA

surgery was taken and main hospitalization claim was paid for Rs.1,35,430/-. For the problem of vomiting, the

complainant was again hospitalized from 09.04.2017 to 11.04.2017 and incurred Rs.201,105/- for the treatment.

The claim was settled for Rs.10,249/- after deduction of non-medical expenses and other expenses not payable

in terms of the policy. Vitamin B-12 test was done and its cost of Rs.2550/- was disallowed as it was not related

to the diagnosis.

The insurer further submitted that KIMS Secunderabad was their net work hospital and insured did not

availed cashless treatment. Though the complainant preferred reimbursement claims, the claims were settled as

per PPN package charges. The hospital charged higher than the PPN package charges to the insured and hence

the difference in the claim had arisen. If the complainant had availed cashless treatment this problem could not

have arisen.

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With the above submissions, the insurer pleaded for dismissal of the complaint as the claims were settled


19) Reason for Registration of Complaint:-

The claims preferred by the complainant were short settled by the insurer. As the complaint falls under Rule 13(b)

of Insurance Ombudsman Rules, 2017, it was registered.



b) Claims working sheets.


d) Discharge summaries

e) Self Contained Note with its enclosures.


Pursuant to the notices given by this Forum both the parties attended personal hearing at Hyderabad on

30.11.2018 & 27.12.2018.

The complainant while reiterating the contents of the complaint stated that after his admission in the

hospital the hospital authorities informed him that it was not a net work hospital of National Ins. Co. and he was

asked to pay the bills. When he enquired with the Agent of the company he too confirmed that it was not a

network hospital. Hence, he availed the treatment and filed reimbursement claims and they were short settled as

explained in his complaint. The representatives of the insurer, on the other hand, stated that KIMS Hospital was

in their net work and as such, though the complainant preferred reimbursement claims, the claims were settled in

terms of GIPSA PPN package charges. Further, the complainant was a k/c/o HTN and DM and there was

enhancement in the SI. The enhanced SI was not considered for the complications arising out of pre-existing

conditions of diabetes and hypertension. The complainant was diagnosed Coronary Artery Disease – single

vessel disease and he underwent CAG and PTCA/Stent. The claims were settled taking four years back policy

SI since the diagnosed ailment was a complication of pre-existing conditions of DM & HTN.

As there was contradiction about the hospital whether it was a net work hospital or not, at the time of

hospitalization of the insured patient/complainant, both the parties were advised to produce evidence to their

respective stand and hearing was adjourned accordingly.

During re-hearing on 21.12.2018, the complainant stated that he had enquired with the hospital and

stated that there was delay in renewal of the MOU with the National TPA by the hospital and hence they asked

him to pay the bill. The representatives of the insurer furnished hospital MOU copies pertaining to the previous

years and could not furnish the current year. They stated that it was renewed after prolonged discussions as the

hospital insisted for revision in the rates for various surgeries and procedures and finally agreed for the old

MOU rates.

The complainant was hospitalized and furnished his TPA ID card for cashless treatment. The hospital

without sending any pre-authorization request to the TPA for approval of cashless treatment straight away

insisted for payment of the bills, probably on the plea that MOU was not renewed with TPA. The complainant

had not raised any dispute on his pre-existing conditions of diabetes and hypertension. The insurer restricted the

reimbursement claim, to the GIPSA PPN package charges without verifying whether there was valid MOU with

the hospital or not on the date of hospitalization of the insured/complainant. As such the insurer is directed to

re-process the claim without applying GIPSA PPN package rate and to allow/pay the balance amount to the

extent of 2013-14 policy sum insured with accrued cumulative bonus as the enhanced sum insured do not

qualify for PEDs. Further, the insurer is also directed to admit the investigations charges disallowed on the

ground that they were not relevant to the diagnosis, as they were done by the doctors to diagnose the ailment by

elimination/ruling out process.

A W A R D Taking into account the facts & circumstances of the case, the documents on record and the submissions made

by both the parties during the course of personal hearing, the insurer is directed to pay difference amount

towards full and final settlement of the claim. The insurer is also directed to pay the interest on difference

amount in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017.


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2017: u) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award


v) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in



the Ombudsman.

w) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I. SURESH BABU)

OMBUDSMAN



OFFICE OF INSURANCE OMBUDSMAN MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE

(Under Rule No. 16/17 of the Insurance Ombudsman Rules, 2017) OMBUDSMAN : MR MILIND KHARAT

CASE OF COMPLAINANT MR BHADRESH M VORA

Vs RESPONDENT : STAR HEALTH & ALLIED INS.CO.LTD.

COMPLAINT REF: NO:MUM-G-044-1819-0113 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Bhadresh M Vora

Mumbai

2

Policy No:

Type of Policy

Duration of Policy/Period

Sum Insured

P/171115/01/2018/007689

Senior Citizens Red Carpet Health Ins.Policy

From 30/10/2017 to 29/10/2018

Rs.10,00,000

3 Name of Insured

Name of the policy holder

Mr Mahendra Vora

Mr Bhadresh M Vora

4 Name of Insurer Star Health & Allied Insurance

Co.Ltd.


6 Reason for repudiation Non disclosure and cancellation of policy

7 Date of receipt of the complaint 17.04.2018

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8 Nature of complaint Total repudiationof claim

9 Amount of claim Rs.59,306.73

10 Date of Partial Settlement -

11 Amount of relief sought Rs.59,306.73

12 Insurance Ombudsman Rules, 2017 13(b)

13 Date of Hearing 01/11/2018 at 03.45 p.m.


a) For the complainant Settled before the hearing

b) For the insurer Settled before the hearing



Brief Facts of the Case :

The complainant‟s father had been hospitalized at Kohinoor Hospital on 25.01.2018 and discharged on

31.01.2018 for the treatment of Ischemic Dilated Cardiomyopathy, Acute on chronic renal failure and diabetes

mellitus. He lodged a claim with the Insurance Company for Rs.59,306.73 which was rejected due to non

disclosure of Chronic Kidney Disease. He submitted that he was the only earning member in the family. Since

he was not agreeable to the repudiation, he approached this Forum seeking relief in the matter.

The Respondent stated in their written statement on scrutiny of medical records, it was observed from the

Investigation Report submitted in response to their query that the Insured‟s serum creatinine value was 3.22

mg/dl; as per the letter dt.25.01.2018 of the above hospital, the patient was diagnosed to have Chronic Kidney

Disease in October 2017. These finding confirmed that the patient had the disease prior to the policy. The

Insured had earlier taken medical insurance policy from The New India Assurance Co Ltd. for the period from

2016 to 2017 and subsequently taken policy from their Co. from 30.10.2017 to 29.10.2018 under portability. At

the time of porting the policy, the Insured had not disclosed the above mentioned medical history/health details

of the Insured person in the proposal form and other documents submitted to them amounted to

misrepresentation/non-disclosure of material facts.

The Forum scheduled a joint hearing of the parties concerned to the dispute on 01.11.2018 at 03.45 p.m.

However, in the meantime, the Forum was informed by the Respondent that they had agreed to settle the claim

to resolve the grievance and reinstate the policy. The complainant agreed for the mutual settlement and

confirmed the same but requested not to reinstate the policy since his father had expired.

In view of the above, the within mentioned complaint of the complainant stands closed at this Forum.

Dated at Mumbai this 6th day of December 2018.

( MILIND KHARAT )

INSURANCE OMBUDSMAN

OFFICE OF INSURANCE OMBUDSMAN

MUMBAI & GOA


(Under Rule No. 16/17 of the Insurance Ombudsman Rules, 2017)

OMBUDSMAN : MR MILIND KHARAT

CASE OF COMPLAINANT - MR ASHISH D VORA

Vs

RESPONDENT : THE ORIENTAL INSURANCE CO LTD

COMPLAINT NO:MUM-G-050-1819-0174

AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant

Mr Ashish D Vora

Mumbai

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2

Policy No:

Type of Policy


Sum Insured

121600/48/2017/2411

Happy Family Floater Policy

From 12/03/2017 to 11/03/2018

Rs.5,00,000/-

3

Name of Insured


Mr Dhirajlal N Vora

Mr Ashish D Vora

4 Name of Insurer The Oriental Insurance Co.Ltd.

5 Date of Repudiation -

6 Reason for repudiation -


8 Nature of complaint Short settlement of claim

9 Amount of claim Rs.1,17,066/- (MCDO 6), Rs.1,14,123/- (MCDO 7)

10 Date of Partial Settlement 19.01.2018 (MCDO 6), 25.05.2018 (MCDO 7)

11 Amount of relief sought Rs.64,089/-


13 Date of Hearing 15.11.2018 at 03.45 p.m.







The complainant‟s mother was hospitalized at Kokilaben Dhirubhai Ambani Hospital from 25.07.2017 to

30.07.2017 for treatment of Atrial Fibrillation with controlled VR moderately severe MR LVEF 55% PASP

67mmHg S/P Pericardiotomy 1982 and moderately severe OAD and advised CAG and NOACs which was not

done since the family was not willing. He claimed for total hospitalization expenses to the tune of Rs.2,31,189/-

against which Rs.1,03,736/-was paid.

The Respondent submitted that the Insured had two policies of The Oriental Insurance Co Ltd. through MCDO

6 and MCDO 7 wherein he claimed for the first total claim of Rs.1,17,066/- with MCDO 6 which was settled

for Rs.52,977/- and the balance claim of Rs.64,089/- was claimed in the second policy. These balance amounts

were actually the non payable items and the capping. Since the claims attracted the Contribution Clause, the

Respondent was liable to pay the excess claim amount and not the non-payable amounts. There was no claim

amount payable by them as per the below calculation independent of two policies.

MCDO 6 MCDO.7

Claimed amount 117066 114123

Non paid 64089 63364

Claim paid 52977 50759

Difference of non submission of bills 2218

As per the above calculations, no claim was payable under the above policy. In fact, there was a recovery of

Rs.50,579/- which was wrongly paid and the Insured was made aware of the same. As per the settlement letters

the claim was repudiated, however, the Respondent discussed the matter with the Insured to settle the matter and

requested him to withdraw the complaint and was communicated to this Forum via email dt.28.05.2018.

The Forum scheduled a joint hearing of the parties concerned to the dispute on 15.11.2018 at 03.45 p.m. The

complainant conveyed in writing on the day of the hearing that he was satisfied with all the clarifications and

withdrew the complaint.

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In view of the above, the within mentioned complaint of the complainant stands closed at this Forum.

Dated at Mumbai this 6th day of December, 2018.

( MILIND KHARAT )

INSURANCE OMBUDSMAN


MUMBAI & GOA


(Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)


CASE OF COMPLAINANT - MR DEEPAK MAKHIJA

Vs

RESPONDENT : STAR HEALTH & ALLIED INSURANCE CO LTD

COMPLAINT REF: NO:MUM-G-044-1819-0355


1 Name & Address of the Complainant Mr Deepak Makhija

Mumbai

2 Policy No:

Type of Policy


Sum Insured

P/171122/01/2017/022478


25.02.2017 to 24.02.2018

Rs. 5,40,000/-

3 Name of Insured

Name of the policy holder Self, Wife, daughter and son

Mr Deepak Makhija

4 Name of Insurer Star Health & Allied Insurance Co.Ltd.

5 Date of cancellation of policy 28.02.2017

6 Reason for cancellation Cheque dishonour


8 Nature of complaint Cancellation of policy

9 Amount of claim -


11 ¤ Amount of relief sought -

12 Complaint registered under Insurance

Ombudsman Rules 2017 Rule 13(c)

13 Date of Hearing 02.01.2019 , 02.45 p.m.


a) For the complainant Mr Deepak Makhija

b) For the insurer Dr Arvind Thakkar



Brief facts of case :

The complainant had taken a policy, the issue date of which was 25.02.2010 and paid premia regularly till Feb

2016. He issued a cheque of Rs.21,212/- for renewal of his policy and the cheque bounced on the date of

presentation. His policy was cancelled on the above grounds.

Contentions of the complainant:

The complainant appeared and deposed before the Forum. He contended that Star Health did not intimate him

of the cancellation of his policy. No communication was sent to him and when he called up the helpline number

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to ask about the exact premium to be paid in February 2018, he was shocked and surprised to know that his

policy had already lapsed one year back. He lamented that he, being a loyal customer, had been paying his

premium since last 7 years in time and he had been given a bonus of Rs.1,60,000/- on this policy. He had not

preferred any claim since 7 years. The cheque he had issued for payment of premium on 21.02.2017 was not

returned to him nor was any intimation given to him that the cheque had bounced. Had he been informed of the

same he would have done the needful immediately since there was a grace period of 90 days. He visited the

Insurance Co.‟s office and demanded proof of intimation of bounced cheque which they failed to give. He

reiterated that his wife and himself have no pre-existing disease and are in good health and neither of them are

engaged in any hazardous occupation. They have been regular customers of Star Health since 2010 and have

paid about Rs.80,000/- premium and just because one fine day his cheque got unintentionally bounced, did he

lose all his rights?

Contentions of the Respondent :

The Respondent contended that due to the dishonor of the premium cheque presented by the Insured under the

within mentioned policy, the captioned policy stood cancelled since inception and hence they were not on

risk/liability whatsoever. The cancellation endorsement relating to the dishonor of cheque and the letter was

already sent to the Insured. Since the policy expired on 25.02.2017, they were unable to consider his request for

renewal of his policy. He was also informed to submit fresh proposal with cheque dishonor charges in cash or

DD for new policy. The Respondent pointed out that the receipt mentions that “the receipt of premium is

subject to realization of cheque” and the policy has a Warranty which reads, “Warranted that in case of

dishonor or premium cheque(s), the Company shall not be liable under the policy and the policy shall be

void abinitio (from inception).”

Forum’s observations/conclusions :

The Forum asked the Respondent to produce any evidence of any letter sent whether by Registered A/D,

ordinary post or courier, informing the complainant about the cheque dishonor and endorsement for cancellation

of policy. The Respondent could not produce any proof to substantiate their stand. The Forum observed that if

the same was initiated during the 90 days grace period, the complainant would have paid the premium and

revived the policy. Since there was no evidence produced, the Forum directed the Respondent to collect the

premium and issue policy on the day he makes the payment with continuity of the earlier benefits with no fresh

waiting periods and CB to continue.

AWARD

Under the facts and circumstances of the case, the Respondent is directed to collect the premium and

issue policy on the date of payment with continuity of the earlier benefits, in favour of the complainant, in

full and final settlement of the complaint. The complaint is accordingly disposed off.

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

Ombudsman Rules, 2017:

a) As per 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.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated: This 2nd day of January, 2018

( MILIND KHARAT )

INSURANCE OMBUDSMAN

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METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of the Insurance Ombudsman Rules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT - Mr Ajit L Thakker

RESPONDENT : United India Insurance Company Ltd. COMPLAINT REF: NO:MUM-G-051-1718-1399 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Ajit L Thakker Mumbai

2 Policy No: Type of Policy Duration of Policy/Period Sum insured

0215002816P109673144 Individual Health Policy - Gold 30.10.2016 to 29.10.2017 Rs.5,00,000/-

3 Name of Insured Name of the policy holder

Mr Ajit L Thakker - do -

4 Name of Insurer United India InsuranceCompany Ltd.





9 Amount of claim Rs.1,39,395/-

10 Date of Partial Settlement 06.09.2017, 13.09.2017 right eye, left eye resp.


12 Complaint registered under Insurance Ombudsman Rules 2017

Rule 13(b)

13 Date of Hearing 31.07.2018, 04.00 p.m.


a) For the complainant Mr Ajit L Thakker

b) For the insurer Ms Leena P Mathkar, AO, Dr Bharti Motling, M/s HealthIndia TPA Services Pvt Ltd.



Brief Facts of the Case : The complainant was admitted to Foresight Eye Centre for surgery of right eye cataract and left eye cataract with Phacoemulsification and foldable IOL Lens Implant on 10.08.2017 and 17.08.2017 respectively. He preferred a claim with the Insurance Co. for Rs.1,39,395/- which was settled for Rs.97,565/-.

Contentions of the Complainant :

The complainant appeared and deposed before the Forum. He submitted that he was insured under the Mediclaim Policy for the past many years and the same was renewed from time to time without break in insurance. He was admitted to Foresight Eye Centre for surgery of right eye cataract and left eye cataract with Phacoemulsification and foldable IOL Lens Implant on 10.08.2017 and 17.08.2017 respectively. He preferred a claim with the Insurance Co. for Rs.1,39,395/- which was settled for Rs.97,565/-.and Rs.41,830/- deducted on account of the Reasonability and customary clause. He contended that the Reasonability Clause is a relative term and the expenses incurred in one hospital cannot be compared to the expenses that may be charged by another hospital. The charges levied by hospitals/surgeons vary considerably depending upon various factors. He pointed out that the hospital charges are based on several factors like availability of qualified and experienced doctors/surgeons and nurses etc. Similarly, doctor’s/surgeon’s fees are also dependent on their

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qualifications, experience and status in their respective fields. He clarified that the best equipped hospitals and highly qualified doctors/surgeons charge higher amounts and it is most unfair and unreasonable to compare charges of normal hospitals to that of highly specialized hospitals. He pointed out that what is reasonable charge for a particular hospital may not be reasonable for another hospital having hi-tech equipments and renowned doctors/surgeons, where their charges would be always higher. He further pointed that as per terms and conditions of the policy, 25% of sum insured for cataract claims are payable. However, his claim is much below the said limit. Hence the settlement was not acceptable to him. He requested for reimbursement of the balance claim amount.

Contentions of the Respondent: The Respondent stated that the complainant admitted to Foresight Eye Centre for surgery of right eye cataract and left eye cataract with Phacoemulsification and foldable IOL Lens Implant on 10.08.2017 and 17.08.2017 respectively. He preferred a claim with the Insurance Co. for Rs.1,39,395/- which was settled for Rs.97,565/-.and Rs.41,830/- deducted. The deductions of Rs.2,440/- was made towards multifocal lens charges, since this lens charges were not justified. They explained the difference between the two type of lens :

Before the development of multifocal/monofocal eye glasses and contact lenses, presbyopia used to be corrected with the so called bifocal eye glass lenses.

Bifocal had two distinct lens powers – one for distance vision and the other for near vision, with the visible line of separation between them.

For the good medium distance vision, which is important for the people working with computers, another so called intermediary zone was added.

With the development of technology, the first to appear were monofocal eye glass lens. Soon after, bifocal and multifocal contact lenses followed. Multifocal lens comprise visual zones with different prescriptive powers blended across the lens. That is why this type of lens is also called a progressive addition lens.

Hence they could not consider the additional progressive treatment part in the insurance policy, only the disease cure part is covered under “mediclaim Insurance”. The operation theatre charges of Rs.2,000/- and surgeon charges fo Rs.16,110/- were disallowed from the claim as these charges of Foresight Eye Centre were on the higher side. Hence they had compared the charges of other hospitals including tertiary care hospitals in metro cities of the same grade for the present surgery and their charges for the same surgery were very much on the lower side. This showed that the charges in this claim was found to exorbitant and hence they deducted the same under Reasonable and customary clause No.3.33 which reads, “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/injury involved.” Forum’s Observations/Conclusion :

On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, multifocal lens was used. The OT charges and surgeon charges compared to other hospitals in the area was found to be on the higher side. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are custodians of public money and have to function with a long term perspective to ensure sustainability of their operations so that at any given point of time they are in a position to meet all liabilities under the policies which are in force. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation and even in the absence of a specific capping in the policy, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. Hence going by the comparative charges produced by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the total payable amount to Rs.20,000/- (Rs.10,000/- per eye). The decision of the Respondent is therefore intervened by the following Order:

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AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.20,000/- for both eyes, in favour of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

c) As per 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.

d) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 23d day of November, 2018.

(MILIND KHARAT) INSURANCE OMBUDSMAN


Mumbai & Goa

Metropolitan Region excluding Navi Mumbai & Thane

((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017) OMBUDSMAN : MR MILIND KHARAT

CASE OF COMPLAINANT -Mr Naresh Chandulal Gandhi

Vs

RESPONDENT : Bajaj Allianz General Insurance Co.Ltd.



1 Name & Address of the Complainant Mr Naresh Chandulal Gandhi

Mumbai

2 Policy No:

Type of Policy


Sum Insured

OG-17-1907-8428-00000174

Global Personal Guard (Individual) Ins Policy

30.06.2016 to 29.06.2017

3 Name of Insured

Name of the policy holder Mr Naresh Chandulal Gandhi

- do -

4 Name of Insurer Bajaj Allianz General Insurance Co.Ltd.


6 Reason for repudiation Pre-existing


8 Nature of complaint Total repudiation of claim

9 Amount of claim TTD for approx.18 weeks


11 Amount of relief sought


Ombudsman Rules 2017 Rule 13(b)

13 Date of Hearing 06.08.2018 , 11.00 a.m.


a) For the complainant Mr Naresh Chandulal Gandhi

b) For the insurer Mr Parveez aAlam, Dr Rashmi Sachdev



Brief facts of case:

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The complainant was admitted to S L Raheja Hospital for left great toe Osteomyelitis on 07.02.2017 and

discharged on 11.02.2017 He submitted the claim to the Insurance Co. which was repudiated on the ground that

the ailment was pre-existing and not disclosed in the proposal form.

Contentions of the complainant :

The complainant appeared and deposed before the Forum. He submitted that he was admitted to S L Raheja

Hospital for left great toe Osteomyelitis on 07.02.2017 and discharged on 11.02.2017 He submitted the claim to

the Insurance Co. which was repudiated on the ground that the ailment was pre-existing and not disclosed in the

proposal form. He stated that he was admitted to hospital for Osteomyelitis of left great toe, primary reason of

complication was, while going to temple near his residence, he was injured on left foot due to hitting on a rock

while walking on road under construction on 04.02.2017. He was under complete bed rest from 07.02.2017 to

14.06.2017 and had to undergo 2 surgeries. He submitted his claim with all the required documents, however

his claim was repudiated stating that “Verification of claim documents reveal aforesaid claimant is a known

case of diabetes mellitus and was hospitalized for Osteomyelitis left great toe and underwent amputation

of the same. We regret to inform you that the claim stands repudiated as the scope of the policy is only

limited to treatment or surgery of any kind unless as a result of accidental bodily injury.” He reiterated

that the surgery would have not taken place if it was not because of accidental damage to his toe. He was not

agreeable to the repudiation and requested for the settlement of his claim.


It was contended on behalf of the Respondent that the Insured was admitted to S L Raheja Hospital for left great

toe Osteomyelitis on 07.02.2017 and discharged on 11.02.2017 He submitted the claim to the Insurance Co.

which was repudiated on the ground that the ailment was pre-existing and not disclosed in the proposal form.

Upon verification of claim documents submitted it was revealed that the Insured was a known case of diabetes

mellitus and was hospitalized for treatment of Osteomyelitis of left great toe and underwent amputation of the

same. The claim was repudiated since the scope of the policy was only limited to treatment or surgery if any

kind, unless as a result of accidental bodily injury. The Respondent further submitted that in the first

consultation papers dt. 07.02.2017 he was admitted on the same day for amputation. The papers mention that he

was suffering from non-healing wound over left great toe with fever with chills with pain and swelling over left

foot since 15 days which is prior to 04.02.2017. The Insured had history of similar complaint; 3 years back as

well on the right little toe. The treating doctor also states that the Insured was treated for right toe (infection)

and not an injury with Osteomyelitis with diabetes and peripheral neuropathy. The Respondent further stated

that they had audio recordings in which the doctor mentions the same but there is no mention of injury or hit by

rock in any of the initial papers, discharge card and the doctor‟s recording. The Respondent, in order to brace

their stand had taken expert opinion who further clarified this stand of repudiation to be correct.

Forum’s Observations/Conclusions :

The Forum observed that insurance is a contract of good faith and the proposal form should be filled by the

Insured in all respects. The Insured was suffering from non-healing wound over left great toe with fever with

chills with pain and swelling over left foot since 15 days which is prior to 04.02.2017. He had history of similar

complaint; 3 years back as well on the right little toe. The treating doctor also states that the Insured was treated

for right toe (infection) and not an injury with Osteomyelitis with diabetes and peripheral neuropathy. The

Respondent further stated that they had audio recordings in which the doctor mentions the same but there is no

mention of injury or hit by rock in any of the initial papers, discharge card and the doctor‟s recording. Thus it is

evident that the complainant‟s ailment was pre-existing and not disclosed in the proposal form which amounts to

non disclosure.The Respondent‟s stand as regards the repudiation of the claim as per the policy terms and

conditions is right. Hence the Forum does not find any valid reason to intervene in the decision of the

Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Naresh Chandulal Gandhi

against the total repudiation of the claim for his hospitalization does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for

him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws

of the land against the Respondent Insurer.

Dated: This 21st day of December, 2018 at Mumbai.

( MILIND KHARAT )

INSURANCE OMBUDSMAN

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OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -Mr Rushikesh Parekh

Vs RESPONDENT : National Insurance Company Ltd.


1 Name & Address of the Complainant Mr Rushikesh Parekh Mumbai


240100501710004343 National Mediclaim Policy 12.08.2017 to 11.08.2018 Rs.3,00,000/- + CB Rs.1,08,750/-


Mr Rushikesh Parekh Mr Rushikesh Parekh

4 Name of Insurer National InsuranceCompany Ltd





9 Amount of claim Rs.84,541/-

10 Date of Partial Settlement



Under Rule 13(b)

13 Date of Hearing 09.08.2018, 11.00 a.m.


a) For the complainant Mr Rushikesh Parekh

b) For the insurer Mr S N Shetty, Medsave Health Insurance TPA Ltd.



Brief Facts of the Case : The complainant was admitted to Doctor Eye Institute Pvt Ltd. for right eye cataract and with Technis One IOL by phacoemulsification undergone on 16.09.2017. He preferred a claim with the Insurance Co. for Rs.84,541/- which was settled for Rs.35,000/- stating the reasonability and customary clause. Contentions of the Complainant :

The complainant appeared and deposed before the Forum. He submitted that was admitted to Doctor Eye Institute Pvt Ltd. for right eye cataract and with Technis One IOL by phacoemulsification undergone on 16.09.2017. He preferred a claim with the Insurance Co. for Rs.84,541/- which was settled for Rs.35,000/- stating the reasonability and customary clause. He lamented that he failed to understand the definition of reasonable cost of treatment. This definition was totally vague and varies from person to person, case to case and disease to disease. In his case it was utmost necessary to do the cataract operation with due diligence and the cost was totally reasonable. He clarified that he did not opt for advanced technology. He further added that the Insurance Co. had tried to us technical terms in case of selection of lenses to hyper the case and

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proved to be exorbitantly high quality lenses He had, in fact, chose the average package of cataract operation and range of lenses. The Insurance Co. has tried to show the lens and technique highly sophisticated whereas the use of Technis ZCB00 Pieceof IOL is Helon 5 lens which had cost him just Rs.7,000/-. This lens is the most commonly used lens by all the doctors and not sophisticated. He stated his wife’s cataract claim for both eyes was done under the same package, by the same doctor and same hospital and was fully settled by the Insurance Co. He mentioned that the Insurance Co was claiming that he had doe the surgery for Refractive Error Correction (4.8) which was totally false, baseless and far from truth. The same is performed for removal of spectacles and is of cosmetic nature. He justified that it was the choice of the patient to choose the hospital and doctor who is easily available in his locality and is reasonable and efficient enough to cure the disease of the patient. Hence the settlement was not acceptable to him. He requested for reimbursement of the balance claim amount. Contentions of the Respondent: The Respondent stated that the complainant was admitted to to Doctor Eye Institute Pvt Ltd. for right eye cataract and with Technis One IOL by phacoemulsification undergone on 16.09.2017. He preferred a claim with the Insurance Co. for Rs.84,541/- which was settled for Rs.35,000/- stating the reasonability and customary clause. They have settled the claim for Rs.35,000/- after invoking the reasonability clause which states, “Reasonable and customary charges mean 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 the illness/injury involved.” The Respondent clarified that in Health Insurance like any other insurance; a common pool is created by collection of premium from many policyholders to pay the claims of a few. This pool is strictly to be utilized for paying the reasonable costs of treatment which is medically necessary to help the insured recover from illness/disease. This pool cannot be generously used for paying claims using advanced technology whose results are often no better than the conventional and less expensive options available unless extensive documents to validate the medical necessity of the advanced technology/procedure are established. The Respondent highlighted the fact that the treatment for cataract was done by use of monofocal lenses only in conventional. They reiterated that the basic purpose of cataract surgery was to restore the vision of the patient which was lost due to the cataract disease. This vision restoration can be done by the conventional surgery using monofocal lenses very effectively. If the insured patient opts for an expensive procedure which is well over the package rate, despite the availability of a standard and effective cataract surgery giving the same outcome, then the additional expenses incurred for this expensive procedure is not reasonable and customary for payment from the insurance policy. In this particular case the Insured had used Technis ZCB00 1 piece acrylic IOL for correction of his refractive error and thus the additional expenses incurred for this procedure is not reasonable and customary. They further added that in the policy there is a specific named exclusion of Refractive Error Correction (4.8) according to which “Surgery for correction of eyesight due to refractive error” is excluded from the scope of the policy. They have compared the charges of other reputed hospitals in the vicinity where it was found that the package rate for the said surgery at Bombay Hospital, Apex Hospital, Kokilaben Dhirubhai Ambani Hospital etc were in the range of Rs.18,000/- to Rs.30,000/-. Thus the restriction of the claim amount to Rs.35,000/- was done in accordance and in keeping with the spirit of the policy . Also it was to be noted that cataract surgery is a planned surgery and not an emergency treatment and the Insured has the option to firsthand contact the Insurance Co. in advance for availing the benefit of cashless treatment in the network hospitals by which such grievances could have been handled more efficiently. Thus the reimbursing the Insured as per the package rate for conventional treatment using monofocal lenses is wholly in conformity with the policy provisions of paying/reimbursing the reasonable cost of cataract treatment. Forum’s Observations/Conclusion: On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, the surgery charges are very much on the higher side even considering the fact that the policy has no capping. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are custodians of public money and have to function with a long term perspective to ensure sustainability of their operations so that at any given point of time they are in a position to meet all liabilities under the policies which are in force. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges”

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Clause of the policy would come into operation and even in the absence of a specific capping in the policy, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. Hence going by the comparative charges produced by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the further payable amount to Rs.20,000/-. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.20,000/-, in favour of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

a) As per 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.


It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 3rd day of December, 2018 at Mumbai.



MUMBAI & GOA


((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)


CASE OF COMPLAINANT -MR VIPUL BANSILAL SHAH

Vs

RESPONDENT : STAR HEALTH & AlLLIED INSURANCE CO LTD



1 Name & Address of the Complainant Mr Vipul Bansilal Shah

Mumbai

2 Policy No:

Type of Policy


Sum Insured

P/171113/01/2017/020810


23.03.2017 to 22.03.2018

Rs.5,00,000/-

3 Name of Insured

Name of the policy holder Ms Pearl V Shah

Mr Vipul Bansilal Shah








11 Amount of relief sought Rs. 23,000/-




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a) For the complainant Mr Vipul Bansilal Shah





The complainant‟s daughter was admitted to VADT Nursing Home from 13.10.2017 to 14.10.2017 for Adeno-

Tonsillar Hypertrophy. He preferred a claim with the Insurance Co. for Rs.1,40,520/- and the same was settled

for Rs.1,15,940/-.


The complainant appeared and deposed before the Forum. He submitted that daughter was admitted to VADT

Nursing Home from 13.10.2017 to 14.10.2017 for Adeno-Tonsillar Hypertrophy. He preferred a claim with the

Insurance Co. for Rs.1,40,520/- and the same was settled for Rs.1,15,940/- deducting Rs.24,580/-. Out of this,

the major deduction of Rs.20,000/- towards Professional Fees/Consultation Charges and Rs.3,000/- towards OT

Charges, under the Reasonable and Necessary Clause was not acceptable to him. He was not agreeable to the

unrealistic deduction since he had paid this amount to the hospital as per their bill. He pointed that nowhere in

the policy there is a mention about the specific/maximum amount payable towards OT charges and

Professional/Consultation charges.


It was contended on behalf of the Respondent that out of the claimed amount of Rs.1,40,520/- the claim was

processed and an amount of Rs.1,15,940/- (Rs.1,02,749/- towards hospitalization expenses + Rs.12,757/-

towards pre hospitalization + Rs.434/- towards post hospitalization expenses) was paid on 16.11.2017. An

amount of Rs.23,000/- was deducted from the Professional Fees and OT charges under the Reasonable and

Customary Clause which reads, “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 the

illness/injury involved.” The expenses of Rs.24,500/- towards OT charges and Rs.98500/- towards Surgeon

Charges was beyond reasonable and necessary as per the prevailing hospital charges in Mumbai. The Bombay

Hospital of the same geographical limit having room rent of Rs.5,500/- for Superior II charges Rs.40,000/- and

Rs.24,500/- (Rs.64,500/-) towards Surgeon Fees for Tonsillectomy and Adenoidectomy respectively and the OT

charge is Rs.17,000/-. Whereas the Dr A B R Desai ENT Clinic having room rent Rs.2,000/- which is lesser

than the Bombay Hospital room rent charges of Rs.98,500/- towards the Surgeon Charges and Rs.24,500/-

towards OT charge. Therefore they had reasonable deducted an amount of Rs.20,000/- and Rs.3,000/- towards

OT charges and Surgeon charges respectively. Thus Rs.1,15,940/- settled towards the above mentioned

hospitalization, was the maximum amount payable as per the terms and conditions of the policy.


The Forum observed that the deduction of Rs.23,000/-which was the complainant‟s main contention, has been

deducted towards Surgeon charges and OT charges on reasonable and customary grounds which is specified

under the terms and conditions of the policy. There is no doubt that an individual has every right to go in for the

best treatment available but the policy would pay only the charges which are necessarily and reasonably

incurred. It has to be borne in mind that Insurance Companies are custodians of public money and have to

function with a long term perspective to ensure sustainability of their operations so that at any given point of

time they are in a position to meet all liabilities under the policies which are in force. As such, whenever it is

observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy

would come into operation and even in the absence of a specific capping in the policy, the Company is within its

right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same

geographical area. Hence going by the comparative charges produced by the Respondent, the Forum is of the

view that the deductions are in order. The Forum, therefore, does not find any valid

reason to intervene in the decision of the Respondent; consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Vipul Bansilal Shah against

the repudiation of the claim for his daughter’s hospitalization does not sustain.

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Dated: This 12th day of December, 2018 at Mumbai.

( MILIND KHARAT )

INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE


CASE OF COMPLAINANT -MR MAHENDRA L KALANTRI Vs

RESPONDENT : HDFC ERGO GENERAL INSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-018-1718-1599 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the complainant Mr Mahendra L Kalantri Mumbai


2952201319190200000 Health Suraksha Policy – Silver Plan 09.02.2016 to 08.02.2018 Rs.10,00,000/-


Mrs Sujata Kantri Mr Mahendra L Kalantri

4 Name of Insurer HDFC Ergo General Insurance Co. Ltd.


6 Reason for repudiation Non disclosure



9 Amount of claim Rs. 2,50,000/-


11 Amount of relief sought Rs. 2,50,000/-


Rule 13(b)



a) For the complainant Mr Mahendra L Kalantri

b) For the insurer Mr Saahiel Sharrma



Brief Facts of the Case : The complainant’s wife was admitted to Criti Care Hospital on 20.08.2017 for treatment of dengue fever with CVA and shifted to P D Hinduja National Hospital & Medical Research Centre and discharged on 30.08.2017. He preferred a claim with the Insurance Co. for Rs.2,35,472/- but the same was repudiated on the grounds of non disclosure. Contentions of the complainant : The complainant appeared and deposed before the Forum. He submitted that his wife was admitted to Criti Care Hospital on 20.08.2017 for treatment of dengue fever with CVA and shifted to P D Hinduja National

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Hospital & Medical Research Centre and discharged on 30.08.2017. He preferred a claim with the Insurance Co. for Rs.2,35,472/- but the same was repudiated on the grounds of non disclosure. He preferred a claim with the Insurance Co. for Rs.75,168/- but the same was repudiated on the grounds of non disclosure of pre-existing disease-Ventricular Septal Defect and Diabetes prior to the first inception of the policy. . He contended that it was a mistake committed by him when he changed his medical policy from The New India Assurance Co.Ltd. to HDFC Ergo General Insurance Co Ltd. He lamented how the claim could be repudiated for non disclosure when no information was asked and/or no papers/forms were signed. The policy was sold by the lady executive on phone in 2016 and consent given after a number of phone calls made by her. She never asked for any information and when informed that the Insured was already insured with The New India Co Ltd. she suggested that he purchase their policy as it was a good beneficial proposal. No information was asked and no form signed and if no information was asked, how could the claim be repudiated on basis of non disclosure of details. To substantiate this, the treating doctor had given a certificate dt.30.10.2017 stating that the Insured has no past record of diabetes and hypertension as there was never any requirement of check up or tests to be done. This could be verified from the previous insurer, The New India Assurance Co.Ltd. where no claim had been filed. He questioned the Insurance Co.as to what was the relationship between dengue and diabetes/hypertension/ventricular septal defect. He clarified that the hospital discharge Report was clear that the reason for admission was dengue since all the tests including 2D Echo etc were normal including MRI and CT Scan. The complainant pointed out that repudiation of his wife’s claim for dengue treatment was completely against the basic principles of insurance and the rejection was on frivolous and unconnected grounds. Contentions of the Respondent: It was contended on behalf of the Respondent that as per the Transfer Summary of Criti Care Multispeciality Hospital and Research Centre, Mrs Sujata Kalantri was hospitalized on 20.08.2017 with chief complaints of fever since 8 days showing Dengue NSI positive fever associated with petechia in both the lower limbs. However, in view of tremors in the whole body and altered sensorium, she was shifted to P D Hinduja National Hospital & Medical Research Centre for further management on the same day itself and remained there till 30.08.2017. As per the Transfer Summary of Criti Care Hospital, the Insured was found to be a known case of Diabetes Mellitus and Hypertension. After scrutinizing the treatment papers along with Discharge Summary and Transfer Summary submitted for claim reimbursement it was noted that she had not disclosed any pre existing disease of Ventricular Septal Defect and Diabetes prior to the first inception of the policy (February 2016). The same was detected in 1993 and the disclosure of the same would have an impact on the underwriting aspect of the policy in the form of either denial of offer of coverage or at best, restricted the sum insured offered to a lower level with loading of premium. The Respondent stated that insurance contract is a special contract based on the principle of Uberrima Fides, i.e. utmost good faith. In the present case, it was the duty of the Insured to disclose the medical condition to the Insurer at the time of taking the policy. Such suppression of material fact denies the Insured any claim against the Insurer as per the Policy Terms and Conditions. Hence on grounds of non disclosure of material facts the claim was repudiated. Forum’s observations/conclusion: On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum felt that in the instant case, the denial of the claim on grounds of non disclosure is not sustainable since Diabetes Mellitus and Hypertension is in no way related to the ailment of the complainant for which she was hospitalized, i.e.Dengue. The treating doctor’s certificate also confirms the same. Hence the Forum ordered the Respondent to settle the admissible claim of the complainant and make the necessary payment. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay the admissible claim of Rs.2,23,789/-, in favour of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

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It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 10th day of December, 2018 at Mumbai.




OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -Mrs Urmila H Parikh

Vs RESPONDENT : The Oriental Insurance Co Ltd.


1 Name & Address of the Complainant Mrs Urmila H Parikh Mumbai

2 Policy No: Type of Policy Duration of Policy/Period Sum Insured

131101/48/2016/7782 Mediclaim Insurance Policy (Individual) 17.03.2016 to 16.03.2017 Rs.3,00,000/-


Mrs Urmila H Parikh - do -

4 Name of Insurer The Oriental Insurance Co Ltd.







11 Amount of relief sought Rs.89,304 /-


Rule 13(b)



a) For the complainant Mrs Urmila H Parikh

b) For the insurer Ms Anuradha Gopakumar AO(AO), Dr Bharti Motling, Health India TPA Services Pvt Ltd.



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Brief facts of the case : The complainant was admitted to SRV Hospital on 22.08.2016 for Medial Compartment Osteoarthritis Left Knee and discharged 27.08.2016. She preferred a claim with the Insurance Co.for Rs.3,19,368/- out of which an of Rs.2,30,064/- was paid, deducting Rs.89,304/- on grounds of reasonability and customary clause, non medical expenses and proportionate deductions. Contentions of the complainant : The complainant appeared and deposed before the Forum. She contended that she was admitted to SRV Hospital on 22.08.2016 for Medial Compartment Osteoarthritis Left Knee and discharged 27.08.2016. She preferred a claim with the Insurance Co. for Rs.3,19,368/- out of which an of Rs.2,24,064/- was paid and then Rs.6,000/- thereby deducting Rs.83,304/-on grounds of reasonability and customary clause, non medical expenses and proportionate deductions She clarified that the balance Rs. 83,304/- was not paid to her even though it is very much payable to her as per terms and conditions of the policy. She was covered for sum insured of Rs.3,00,000/- and earned cumulative bonus of Rs.1,50,000/- since she was insured for 15 years. She requested for the settlement of her balance claim. Contentions of the Respondent : It was contended on behalf of the Respondent that the Insured was admitted to SRV Hospital on 22.08.2016 for Medial Compartment Osteoarthritis Left Knee and discharged 27.08.2016. She preferred a claim with the Insurance Co. for Rs.3,19,368/- out of which an of Rs.2,24,064/- was paid, deducting Rs.89,304/- on grounds of reasonability and customary clause, non medical expenses and proportionate deductions They, subsequently made a supplementary payment of Rs.6,000/- towards Assistant Surgeon Charges. They explained that medicine charges of Rs.4,823.- were disallowed as item and cost wise details were not available in the claim file. The HGT charges of Rs.100/- were disallowed as reading report was not available. They further added that OT and Assistant surgeon charges of Rs.15,000/- and Rs.4,000/- were disallowed since the charges of SRV Hospital were found to be on the higher side and they compared charges of other hospitals including tertiary care hospitals in metro cities of same grade for present ailment and surgery charges for the same ailment which were very much on the lower side. This showed that the OT charges were found to be exorbitant and hence deducted under the Reasonability and Customary Clause 2.37 which reads, “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 the illness/injury involved.” The Insured opted for room + nursing @ Rs.5,000/- per day for 5 days but as per policy, she was eligible for room charges of Rs.3,000/- per day hence the deduction of Rs.10,000/-. Accordingly they applied proportionate clause and deducted Rs.43,315/- (i.e.40% from all expenses except medicine bills. The non medical expense Rs.11,9661/- was not payable as per clause 4.17, which reads, “All non medical expenses including personal comfort and convenience items or services such as telephone, television, aya/barber or beauty services, diet charges, baby food, cosmetic, napkins, toiletry items etc., guest services and similar incidental expenses or services etc.” and Admission charge Rs.100/- disallowed as per clause 4.25 which reads, “Any kind of service charge/surcharges unless payable by the Government Authority levied by the hospital.” Forum’s observations:

The Forum questioned the Respondent whether they had ascertained the reasonableness of the hospital charges

and on what basis they thought it to be unreasonable and on the higher side. The Respondent submitted that they

compared the charges of hospitals in the nearby vicinity and found the charges at

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SRV Hospital on the higher side. The Forum felt that the charges at the hospital were not unreasonable. Therefore, considering this, it was ordered by this Forum to pay the balance admissible claim to the

complainant. Hence the Respondent‟s decision is intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the claim of Rs13,923/-in favor of the complainant, as full and final settlement of the complaint. There is no order for any other relief. The case is disposed of accordingly.

The attention of the complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules 2017 :

a) As per Rule 17(6) of the said rules 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) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated at Mumbai this 7

th day of November, 2018.

( MILIND KHARAT) INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)

OMBUDSMAN : SHRI MILIND KHARAT

COMPLAINANT - MR. SUSHILA M SANGHVI

VS RESPONDENT : THE ORIENTAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mrs Sushila M Sanghvi

Mumbai

2 Policy No: Type of Policy

Duration of Policy/Period Sum Insured

131102/48/2017/3787 PNB-Oriental Royal Mediclaim Policy

14.08.2016 – 13.08.2017 Rs.5,00,000/-

3 Name of Insured


Mrs Sushila M Sanghvi

4 Name of Insurer The Oriental Insurance Co. Ltd.




8 Nature of complaint Policy matter

9 Amount of claim ----

10 Date of Partial Settlement ----

11 Amount of relief sought ----

12 Complaint registered under Insurance Ombudsman Rules

Under Rule 13(c)

13 Date of Hearing 07.08.2018 – 1.00 p.m.


a) For the complainant Mr. Yogesh Sanghavi

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b) For the insurer Ms. Gayatri S. Patil



Brief Facts of the Case : Complainant was covered under PNB Oriental Royal Mediclaim policy for the period 14.08.2016 – 13.08.2017. Respondent refused to renew his policy w.e.f. 09.10.2017 on the ground that he had completed 79 years of age. Complainant approached this Forum seeking continuity of coverage by renewal of the policy.

Contentions of the Complainant : Complainant contended that she had obtained the policy through Punjab National Bank in the year 2014. She issued a cheque for renewal of the policy falling due on 13.08.2017. However the Respondent refused to renew the policy and returned her premium cheque citing the reason that she had completed 79 years of age. She argued that as per Health Insurance Regulations, 2016, the entry age for Senior citizens was up to 65 years whereas there was no age-limit for exit from the policy; hence the decision of the Respondent was not acceptable to her.

Contentions of the Respondent: Ms. Gayatri Patil submitted that the insured’s policy was due for renewal on 14.08.2017 but the same could not be renewed since she had completed 79 years of age. However the Company has introduced new product from 01.01.2018 known as PNB-ORIENTAL ROYAL MEDICLAIM POLICY-2017 the guidelines for which provide for issuance of policy with entry age upto 79 years and the same can be renewed lifelong. In view of the same, the insured can be issued a fresh policy as per the new product.

Forum’s Observations/Conclusion: After hearing the depositions advanced on behalf of both the parties, Forum is of the view that refusal to renew the policy by the Respondent on the ground that the complainant has completed 79 years of age is in violation of Health Regulations, 2016 issued by the IRDAI and hence cannot be sustained. Their decision is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, The Oriental Insurance Co. Ltd. is directed

to reinstate the policy of the complainant Mrs Sushila M Sanghvi with continuity benefit

by charging the appropriate premium. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 12

th day of December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

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METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)


COMPLAINANT - MR. CHANDRAKANT DEVICHAND SHAH



1 Name & Address of the Complainant Mr Chandrakant Devichand Shah

Mumbai



131102/48/2017/3382 PNB-Oriental Royal Mediclaim Policy

23.07.2016 – 22.07.2017 Rs.5,00,000/-

3 Name of Insured


Mrs Sushila M Sanghvi





8 Nature of complaint Policy matter

9 Amount of claim ----


11 Amount of relief sought ----


Under Rule 13(c)



a) For the complainant Mr Chandrakant Devichand Shah

b) For the insurer Ms. Gayatri S. Patil



Brief Facts of the Case : Complainant was covered under PNB Oriental Royal Mediclaim policy for the period 23.07.2016 – 22.07.2017. Respondent refused to renew his policy w.e.f. 23.07.2017 on the ground that he had completed 79 years of age. Complainant approached this Forum seeking continuity of coverage by renewal of the policy.

Contentions of the Complainant : Complainant contended that he had obtained the policy through Punjab National Bank in the year 2015. He issued a cheque for renewal of the policy falling due on 23.07.2017. However the Respondent refused to renew the policy and returned his premium cheque citing the reason that he had completed 79 years of age. He argued that as per Health Insurance Regulations, 2016, the entry age for Senior citizens was up to 65 years whereas there was no age-limit for exit from the policy; hence the decision of the Respondent was not acceptable to him.

Contentions of the Respondent: Ms. Gayatri Patil submitted that the insured’s policy was due for renewal on 23.07.2017 but the same could not be renewed since he had completed 79 years of age. However the Company has introduced new product from 01.01.2018 known as PNB-ORIENTAL ROYAL MEDICLAIM POLICY-2017 the guidelines for which provide for issuance of policy with entry age upto 79 years and the same can be renewed lifelong. In view of the same, the insured can be issued a fresh policy as per the new product.

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Forum’s Observations/Conclusion: After hearing the depositions advanced on behalf of both the parties, Forum is of the view that refusal to renew the policy by the Respondent on the ground that the complainant has completed 79 years of age is in violation of Health Regulations, 2016 issued by the IRDAI and hence cannot be sustained. Their decision is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, The Oriental Insurance Co. Ltd. is directed

to reinstate the policy of the complainant Mr Chandrakant Devichand Shah with

continuity benefit by charging the appropriate premium. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:




(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. PARAG T PATIL VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-049-1718-1655 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Parag T Patil Mumbai


11060034162700000024 New India Asha Kiran Policy 28.09.2016 – 27.09.2017 Rs.2,00,000/-


Ms Sara P Patil Mr Parag T Patil

4 Name of Insurer The New India Assurance Co. Ltd.


6 Reason for repudiation Genetic disorder – clause 4.4.18





11 Amount of relief sought Rs.3,01,705/-

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12 Complaint registered under Ombudsman Rules, 2017

Under Rule 13(b)



a) For the complainant Mr Parag T Patil

b) For the insurer Mr Dilip G Bhanshe, AO, Dr Anupama Kamble, M/s Raksha Health Insurance TPA Pvt Ltd.



Brief Facts of the Case : Complainant’s daughter was admitted to NeuroGen Brain and Spine Institute for neuororegenerative-neurosurgical treatment from 09.07.2017 to 14.07.2017. Respondent repudiated the claim stating that the patient had complaints of Global Development Delay with Sensory Issues which is a genetic disorder not payable as per exclusion clause 4.4.18 of the policy. Contentions of the Complainant :

Mr. Parag T Patil submitted that his daughter was covered under Asha Kiran Policy with the Respondent since the year 2014. His daughter was diagnosed with no ailment, disease or syndrome. However, since she is prematurely born, she was developing gradually but steadily. Now, she is studying in a normal school, i.e. Balmohan Vidyamandir which is a very good school in vernacular education in Mumbai. He clarified that like every parent, they were somewhat concerned about their daughter and also about her growth. Hence they wanted to give her the best treatment available since they had done a lot of study in child growth/development. She was given neuororegenerative-neurosurgical treatment at NeuroGen Brain and Spine Institute on 10.07.2017 and by God’s grace she is now speaking which was almost lacking. They submitted a claim for Rs.3,01,705/- which was repudiated by the Insurance Co.on the grounds of genetic disorder; hence the reason cited by the Respondent for repudiation of the claim was not acceptable to him.

Contentions of the Respondent: It was contended on behalf of the Respondent that the complainant was covered with them under Asha Kiran Policy since the year 2014 for Rs.2,00,000/-. The Insured was admitted to NeuroGen Brain and Spine Institute for neuororegenerative-neurosurgical treatment from 09.07.2017 to 14.07.2017. On scrutiny of the claim documents, it was observed that the claimant was admitted with complaints of Global Development Delay with Sensory Issues and was treated with neuororegenerative-neurosurgical treatment, Speech Therapy and Psychological Therapy. The said ailment was a genetic disorder which is not payable as per exclusion clause 4.4.18 of the policy which reads, “Genetic disorders and stem cell implantation/surgery.” Hence the claim stood repudiated. Forum’s Observations/Conclusion:

In the instant case, complainant was admitted to hospital with complaints of Global Development Delay with Sensory Issues and treated with neuororegenerative-neurosurgical, Speech Therapy and Psychological Therapy. Respondent has repudiated the claim relying on Exclusion Clauses of the respective policies which exclude coverage of expenses incurred for the treatment of genetic diseases. Complainant argued that his daughter was not suffering from any illness at the inception of his first policy till she was lately diagnosed.

As per available information Global Developmental Delay (GDD) is the general term used to describe a

condition that occurs during the developmental period of a child between birth and 18 years. It is usually defined

by the child being diagnosed with having a lower intellectual functioning than what is perceived as 'normal'.

Studies show that most of the causes of Global Developmental Disability (GDD) develop before birth and in

some cases, GDD develops soon after birth. About 1-3% of children have GDD and many of these children with

GDD also have Intellectual Disability (ID). Like all other developmental delays, there is no single cause of

GDD but there are several factors that increase the risks of GDD and one of the major cause is Genetic

Disorder. Over 40% of the developmental delays including Global Developmental Delay (GDD) are caused by

genetic factors and disorders. Genetic disorders are the problems caused by the errors or changes in a person‟s

genes. Genes are parts of the cells holding the information to tell the body‟s cells how to function. The most

common genetic disorders are Down syndrome and Fragile X syndrome.

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Thus, it is established that the complainant’s daughter was treated for a genetic disorder. The policies issued to the complainant clearly lay down: “No claim will be payable under this Policy for Genetic disorders”. However, in pursuance to the directions of the Hon’ble High Court of Delhi, IRDAI vide Circular dt. 19.03.2018 directed all Insurance Companies offering contracts of Health Insurance that no claim in respect of any existing health insurance policy shall be rejected based on exclusion related to ‘Genetic Disorder’. The Forum was inclined to allow the subject claim in view of the said circular. However, further, in pursuance of the stay granted by the Hon’ble Supreme Court of India on the operation of the judgment of the Hon’ble High court of Delhi, IRDA vide their Circular dt. 05.09.2018 has revoked their earlier Circular dt. 19.03.2018. In the light of the same, since the claim has been repudiated in accordance with the policy terms and conditions the Forum does not find any valid ground to intervene with the decision of the Respondent and consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Parag T Patil against repudiation of the claim for his daughter’s hospitalization does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 5th day of December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017) OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - MR RAMESH KABRA

VS RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.


1 Name & Address of the Complainant Mr Ramesh Kabra Mumbai


13150034152500005290 New Mediclaim 2012 Policy 28.09.2016 to 27.09.2017 Rs.2,00,000/- + C.B. Buffer Rs.15,000/-


Mrs Vidhya R Kabra Mr Ramesh Kabra


5 Date of Repudiation --

6 Reason for repudiation --


8 Nature of complaint Short-settlement of claim





Under Rule 13(b)

13 Date of Hearing 10.08.2018 – 11.00 a.m.


a) For the complainant Mr Ramesh Kabra

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b) For the insurer Mr Shashikant Verma, AO, Dr Anupama Kamble, M/s Raksha TPa Services Pvt Ltd.



Brief Facts of the Case : Complainant’s wife was admitted to Breach Candy Hospital from 04.03.2016 to 07.03.2016 for treatment of umbilical hernia. The total hospital expenses amounted to Rs.1,78,827/- against which the Insurance Co. settled the claim for Rs.91,567/- deducting the balance amount of Rs.89,260/-proportionately based on room rent eligibility. Contentions of the Complainant : The complainant appeared and deposed before the Forum. He stated that his wife was admitted to Breach Candy Hospital from 04.03.2016 to 07.03.2016 for treatment of umbilical hernia. The total hospital expenses amounted to Rs.1,78,827/- against which the Insurance Co. settled the claim for Rs.91,567/- deducting the balance amount of Rs.89,260/-proportionately based on room rent eligibility. He explained that only room charges could be deducted as per the Mediclaim Policy but the proportionate deductions for other charges were totally wrong as Breach Candy Hospital doesn’t increase or decrease charges on room tariff basis. He further pointed out that the hospital has a trust and there is no class based billing system so room charges are payable 1% of sum insured but the other proportionate deductions wee not correct and deducted wrongly. Hence the reason cited by the Company for deductions from the claim amount was not acceptable to him. He requested for settlement of the balance claim amount. Contentions of the Respondent: It was contended on behalf of the Respondent that the Insured was covered for S.I. of Rs.2,00,000/-. The Insured was eligible for room rent of Rs.2,000/- per day being 1% of S.I. however as she occupied a room with rent of Rs.4,250/- the doctor’s fees, investigation charges, visit charges, anesthesia charges, surgeon charges and OT charges were proportionately deducted as per the policy guidelines. They have applied proportionate deduction on all items as per policy clause 3.1 (a) of NIA Mediclaim 2012 policy, “Payment of room, boarding and nursing expenses incurred at the Hospital shall not exceed 1% of the sum insured per day. In case of admission to Intensive Care Unit or Intensive Cardiac Care Unit, reimbursement or payment of such expenses shall not exceed 2% of the sum insured per day. In case of admission to a room/ICU/ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines shall be affected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent/ICUICCU charges.” Hence the other charges were scaled down in proportion to the entitled room category as per Clause 3.1 of the policy. Forum’s Observations/Conclusion: This Forum has in the past heard several cases pertaining to Breach Candy Hospital wherein the said hospital itself has certified that it does not have a class-based rating structure and all other charges are the same across the board irrespective of the category of room occupied. In view of the same while disallowance of room rent in excess of the insured’s eligibility and non-medical expenses being as per policy terms and conditions was in order, there was no justification for reducing other charges in proportion to the entitled room category in the absence of a class-based tariff. Under the circumstances, the Respondent was directed to pay the balance admissible charges deducted from the claim amount on proportionate basis. The decision of the Company is thus intervened by the following Order.

AWARD The Respondent is directed to pay a further amount of Rs.66,892/- in favour of the complainant, in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 13th day of December, 2018 at Mumbai.


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OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT - Mr SIDHRAJ SAMOTA

RESPONDENT : IFFCO-TOKIO General Insurance Co Ltd. COMPLAINT REF: NO:MUM-G-023-1718-1707 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Sidhraj Samota Mumbai


52770990 Swasthya Kavach (Family Health) Policy 10.04.2017 to 09.04.2018 Rs.2,00,000/- + CB Rs.40,000/-


Mrs Chandra Samota - Mr Sidhraj Samota

4 Name of Insurer IFFCO-TOKIO General Insurance Co Ltd.

5 Date of Repudiation NA

6 Reason for repudiation NA

7 Date of receipt of the complaint 26/12/2017

8 Nature of complaint Equipment charges (Non medicals expenses)

9 Amount of claim Rs,2,09,404/-




Rule 13(b)

13 Date of Hearing 20/08/2018 at 01.15 pm


a) For the complainant Dr Hitendra S Samota, complainant’s son

b) For the insurer Dr Jitendra Singh, Mr Karan Bagdai



Brief Facts of the case : The complainant’s wife was admitted to Womens Hospital on 02.05.2017 with diagnosis of prolapsed uterus with cystocele and underwent 3D total laparoscopic hysterectomy + B/L salpingo-oophrectomy with AP repair and discharged on 03.05.2017. He preferred a claim for Rs.2,09,404/- and the same settled for Rs,1,92,827/- deducting Rs.16,577/- towards equipment charges. Contentions of the complainant: The complainant’s son appeared and deposed before the Forum. He submitted that his mother was admitted to Womens Hospital on 02.05.2017 with diagnosis of prolapsed uterus with cystocele and underwent 3D total laparoscopic hysterectomy + B/L salpingo-oophrectomy with AP repair and discharged on 03.05.2017. He preferred a claim for Rs.2,09,404/- and the same settled for Rs,1,92,827/- deducting Rs.16,577/- towards equipment charges. He contended that the claim was partly paid stating that equipment chares are paid in OT charges. He pointed out to a letter submitted by the hospital mentioning that equipment charges are separately charged and not in OT charges. Despite this, the Insurance Co. disallowed the amount. Contentions of the Respondent: It was contended on behalf of the Insurance Company that the Insured submitted a claim for Rs.2,09,404/- wherein she was admitted to Womens Hospital on 02.05.2017 with diagnosis of prolapsed uterus with cystocele and underwent 3D total laparoscopic hysterectomy + B/L salpingo-oophrectomy with AP repair and discharged on 03.05.2017. The claim was settled for Rs,1,92,827/- deducting Rs.16,577/- towards equipment charges and Reinstatement of premium for Rs.9,416/-. Post settlement of the claim, the Insured represented

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regarding the deduction of equipment charges of Rs.11,600/- and submitted a letter from the hospital mentioning that HD/3D camera, light source, hand instruments are mandatory, to which the Respondent reverted on 30.08.2017 mentioning that the claim had been settled well within the scope of the policy as equipment charges are part of OT charges. Since the hospital had already charged Rs.39,600/- on account of OT charges and these charges (HD/3D camera, light source, hand instruments) were part of the OT charges, hence 11,600/- on account of equipment charges had been deducted correctly. The Respondent further reiterated that these charges (HD/3D camera, light source, hand instruments) are purely non medical items; hence the same was also not payable as per IRDA guidelines, “List of Non payable items” (IRDA circular No.IRDA/HLT/CIR/03/T/02/2013, page No.21). They further clarified that IRDA guidelines also stated that equipment charges were excluded from the scope of the hospitalization policy. The list of non payable items had been already submitted to this Forum and as per the submitted list, the equipment charges under the head: “External Durable Devices” are excluded from the ambit of the hospitalization policy. Forum’s Observations/Conclusion: The Forum observed that the hospital had already charged Rs.39,600/- on account of OT charges and these charges (HD/3D camera, light source, hand instruments) were part of the OT charges, hence 11,600/- had been deducted by the Respondent on account of equipment charges. It was agreed by this Forum that these charges (HD/3D camera, light source, hand instruments) were purely non medical items; hence the same not payable as per IRDA guidelines, “List of Non payable items” and the equipment charges under the head: “External Durable Devices” are excluded from the ambit of the hospitalization policy. Hence the Forum does not find any valid reason to intervene with the decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Sidhraj Samota against the short settlement of the claim for his wife’s hospitalization, does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 10th day of December, 2018 at Mumbai.

( MILIND KHARAT ) INSURANCE OMBUDSMAN


MUMBAI & GOA


((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017) OMBUDSMAN : MR MILIND KHARAT

CASE OF COMPLAINANT -MR NEKZAAD VAKIL

Vs

RESPONDENT : ICICI Lombard General Insurance Co.Ltd.



1 Name & Address of the Complainant Mr Nekzaad Vakil

Mumbai

2 Policy No:

Type of Policy


Sum Insured

4128i/iH/86369452/03/000

Health Insurance Policy

15.01.2017 to 14.01.2018

Rs. 10,00,000/-

3 Name of Insured

Name of the policy holder Mrs Zeenia Vakil

Mr Nekzaad Vakil

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4 Name of Insurer ICICI Lombard General Insurance Co.Ltd


6 Reason for repudiation Infertility



9 Amount of claim Rs. 1,51,000/-


11 Amount of relief sought Rs. 1,51,000/-



13 Date of Hearing 20.08.2018 , 11.00 a.m.


a) For the complainant Absent

b) For the insurer Mr Karan Bagdai, Mr Rahul Y Rajurkar




The complainant‟s wife was admitted to Breach Candy Hospital on 22.08.2017 to 23.08.2017 for treatment of

endometrioisis (where the tissue which grows inside the uterus also grows outside) and avgised to undergo

laproscopy with hysteroscopy with polypectonomy for the same. He lodged a claim with the Insurance Co. for

Rs. 1,51,000/-/- which was repudiated stating that the claim was related to fertility or infertility.

Contentions of the complainant :

The complainant remained absent for the hearing so his written submission was taken on record.

He submitted that his wife was admitted to Breach Candy Hospital on 22.08.2017 to 23.08.2017 for treatment of

endometrioisis (where the tissue which grows inside the uterus also grows outside) and advised to undergo

laproscopy with hysteroscopy with polypectonomy for the same. He lodged a claim with the Insurance Co. for

Rs. 1,51,000/-/- which was repudiated stating that the claim was related to fertility or infertility. He stated that

earlier this year, his wife went through an IUI during the testing of which, the doctor diagnosed her with

endometrioisis and advised her to undergo surgery since if unattended could lead to issues like ovarian cysts,

cancer, intestinal and bladder complications, etc. After completing the operation and formalities he submitted

the claim for reimbursement and was shocked to known that the claim was rejected since it was related to

fertility or infertility. He tried to explain through various emails that his wife was diagnosed with cysts which

need to be removed and they were only relating it to infertility since it was first diagnosed when his wife went

for an IUI. His email dt, 05.10.2017 stated that the doctor had mentioned that the cyst was external and not

internal and hence the claim that was linked to infertility was factually incorrect. The Insurance Co mentioned

that in the discharge summary of Breach Candy Hospital under the presenting complaints and medical history it

was mentioned that the patient was with primary infertility k/c/o endometriosis and diagnosed with polyp. He

explained to them that the operation was not for infertility but for polyp and the reason history was mentioned

because the headline clearly asked for medical history of the patient. Even after the doctor‟s note and numerous

explanations with proof that the surgery was not linked to infertility but to remove a polyp/cyst on the outside of

the uterus, the Insurance Co decided to reject the entire claim.


It was contended on behalf of the Respondent that on perusing the discharge summary it was observed that the

Insured was hospitalized in Breach Candy Hospital with presenting complaints of primary infertility, a known

case of endometriosis since 2 years, first cycle of IUI done on 05.08.2017 and was diagnosed with polyp.

During hospitalization, the surgery performed was hysteroscopic polypectomy with endometrial biopsy with

laproscopic left ovarian endometriotic cyst aspiration under GA and was diagnosed with Endocervical Polyp

with left ovarian endometriotic cyst stage III. They clarified that as per the terms and conditions of the policy,

any treatment related to fertility, infertility, sub fertility or assisted conception treatment is not covered as per

Permanent Exclusion 3.4 (xiv), “Any Expense incurred on treatment arising from or tr5aceable to pregnancy

(including voluntary termination of pregnancy, childbirth, miscarriage, abortion or complications or any of

these, including caesarean section) and any fertility, infertility, sub fertility or assisted conception treatment or

sterilization or procedure, birth control procedures and hormone replacement therapy.” However, this exclusion

does not apply to ectopic pregnancy proved by diagnostic means and is certified to be life threatening by

Medical Practitioner. On the basis of the above facts, the Respondent repudiated the said claim on 26.09.2017

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on the ground that any treatment incurred towards hospitalization pertaining to fertility, infertility, sub fertility

or assisted conception treatment are not payable.

Forum’s Observations/Conclusions :

The Forum has observed that complainant was admitted with complaints of primary infertility, a known case of

endometriosis since 2 years. The Respondent sought expert medical opinion and the same confirms that the

treatment undergone by the complainant‟s wife was primarily for infertility and the Forum relied on the same.

The Respondent‟s stand as regards any treatment related to fertility, infertility, sub fertility or assisted

conception treatment not covered under the policy terms and conditions cannot be faulted. Hence the Forum

does not find any valid reason to intervene in the decision of the Respondent, consequently no relief can be

granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by

Mr Nekzaad Vakil against the total repudiation of the claim for his sife’s hospitalization does not sustain.

It is particularly informed that in case the award is no agreeable to the complainant, it would be open for




( MILIND KHARAT )

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR DEEPAK D REDEKAR

Vs RESPONDENT : UNITED INDIA INSURANCE CO LTD


1 Name & Address of the Complainant Mr Deepak D Redekar Mumbai


0217812815P113347541 Individual Family Medicare Policy 07.02.2016 to 06.02.2017 Rs.3,00,000/-


Mrs Rupli Redekar Mr Deepak Redekar

4 Name of Insurer United India Insurance Co.Ltd


6 Reason for repudiation 2 years waiting period for Ureteric Calculus (Kidney stone) on enhanced sum insured.







Under Rule 13(b)

13 Date of Hearing 09.08.2018 at 02.45 pm

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a) For the complainant Mr Deepak Redekar

b) For the insurer Mr Sanjay D Gore, AO, Dr Bharti Motling, M/s HealthIndia Insurance TPA Services Pvt Ltd.



Brief facts of the case :

The complainant’s wife was hospitalized at B K Kidney Centre on 23.12.2016 for treatment of Right Ureteric

Calculus and discharged on 26.12.2016. A claim was lodged for Rs.1,14,322/- and the same was settled by the

Insurance Co.for Rs.74,059/-.

Contentions of the Complainant:

The complainant appeared and deposed before the Forum. He submitted that his wife was hospitalized at B K

Kidney Centre on 23.12.2016 for treatment of Right Ureteric Calculus and discharged on 26.12.2016. A claim

was lodged for Rs.1,14,322/- and the same was settled by the Insurance Co.for Rs.74,059/-.At the time of

admission he called the Insurance Co. and was told that since his policy was for SI of Rs.3 lacs he could opt for

room rent of Rs.3,000/- per day. So accordingly he selected the room rent of Rs.2,800/-. The doctor removed

the stone by laser procedure and again on 12.01.2017 she was admitted for stent removal which was placed at

the time of laser procedure He paid both the hospital bills and applied for reimbursement but the Insurance Co

deducted huge amounts from both the bills while settling the claim, giving various reasons. He contended that

while calculating bed charge the SI of Rs.2 lakhs was considered as the enhanced SI of Rs.1 lakh was not

applicable now as per clause 4.3. He pointed out that Clause 5.14 was applicable where 2 years limit was not at

all mentioned. The enhancement of SI was done in February 2016 and his wife suffered from the ailment in

November 2016. He clarified that as per clause 5.14, as his wife was not suffering from any symptoms at the

time of enhancement, the enhanced SI full amount of 3 lakhs should be considered. He furnished a letter

dt.04.12.2017 from the treating doctor regarding the duration of illness. Hence since the bed charge was not

exceeding 1% of Rs.3 lakhs, the full maount should be paid as well as other charges. The Insurance Co.s stand

that monitor charges and C Arm charges were part of OT and not payable, was accepted by the complainant.

The complainant was not agreeable to the disallowance of Holium Laser charges of Rs.15,000/- on grounds of

advanced medical procedure. He stated that the treatment and the procedure to be carried out to cure the patient

is the sole decision of the treating doctor. He was not agreeable to the short settlement of the claim hence he

approached this Forum with his grievance. He requested for the settlement of his wife’s balance claim.


It was contended on behalf of the Respondent that the Insured was insured with them since 07.02.2014 till

05.02.2016 under Family Floater Mediclaim Policy for a sum insured of Rs.2 lacs. She, later, enhanced the sum

insured to Rs.3 lacs w.e.f.07.02.2016 to 06.02.2017. The Insured was hospitalized from 23.12.2016 to

26.12.2016 at B K Kidney Centre treatment of Right Ureteric Calculus and discharged on 26.12.2016. A claim

was lodged for Rs.1,14,322/- and the same was settled by the Insurance Co.for Rs.74,059/-. As per the policy

details, the Insured was covered for Sum Insured of Rs. 3 lacs and as there was enhancement of Sum Insured of

Rs.1 lac the same was subject to waiting period, hence Sum Insured Rs.2 lacs was applicable under policy

clause 4.3 which reads, “ Unless the Insured has 24 months of continuous coverage, the expenses on

treatment of diseases such as cataract, benign prostatic hyperthrophy, hysterectomy for menorrhagia or

fibromyoma, hernia, hydrocle, congenital internal disease, fistula in anus, piles, sinusitis and related

disorders, gall bladder stone removal, gout and rheumatism, calculus diseases are not payable.” The

deductions of Rs.3,200/- towards room rent was made as per her eligible sum insured of Rs.2 lacs wherein 1%

of Sum Insured Rs.2 lacs, i.e. Rs.2,000/- was paid. The other charges for investigation, OT, surgeon fees,

anesthesia fees and consultant visit fees were proportionately deducted as per the room rent eligibility. The

monitor charges of Rs.1,000/-, Holmium Laser charges of Rs.15,000/- and C Arm charges of Rs.2,000/- were

part of OT charges and they had already paid the eligible OT charges in the claim.

Forum’s Observations/Conclusion :

The Forum maintained that when a 2 years waiting period for calculus is incorporated in the policy where sum

insured is enhanced, it is implied that the same will continue for the subsequent 24 months. If the

hospitalization for the same was after the waiting period then the benefit of doubt would have gone to the

complainant. The aforesaid waiting period of 2 years will complete on 06.02.2019. Therefore the Respondent’s

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settlement of the claim is justified on the above grounds and cannot be faulted. The Forum, therefore, does not find any valid reason to intervene in the decision of the Respondent; consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Deepak Redekar against the repudiation of the claim for his wife’s hospitalization does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 21st day of December, 2018 at Mumbai.




OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MRS DEEPIKA N PANCHAL

Vs RESPONDENT : STAR HEALTH & ALLIED INSURANC CO LTD


1 Name & Address of the Complainant Mrs Deepika Nilesh Panchal Mumbai


P/171135/01/2018/000812 Family Health-Optima Insurance Policy 26.07.2017 to 25.07.2018 Rs.3,00,000/-


Mrs Deepika Nilesh Panchal - do -

4 Name of Insurer Star Health & Allied Insurance Co Ltd.


6 Reason for repudiation Non disclosure


8 Nature of complaint Total repudiation of claim & cancellation of policy.





Rule 13(b)



a) For the complainant Mrs Deepika Nilesh Panchal

b) For the insurer Dr Arvind Thakker



Brief facts of the case :

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The complainant was admitted to Wokhardt Hospitals from 11.09.2017 to 14.09.2017 for treatment of Tenosynovitis Right Wrist. She preferred a claim with the Insurance Co for Rs.1,29,324/-which was rejected on grounds of non disclosure of Rheumotoid Arthritis/Sjogren’s Disease before taking the policy and the policy was terminated with immediate effect. Contentions of the complainant : The complainant appeared and deposed before the Forum. She submitted that she was admitted to Wokhardt Hospitals from 11.09.2017 to 14.09.2017 for treatment of Tenosynovitis Right Wrist. She preferred a claim with the Insurance Co for Rs.1,29,324/-which was rejected on grounds of non disclosure of Rheumotoid Arthritis/Sjogren’s Disease before taking the policy and the policy was terminated with immediate effect. She contended that she had claim for the 3 days hospitalization for severe Atypical Mycobacterium Infection leading to severe pain, swelling and fever. She clarified that he doctor diagnosed Sjogren disease on 16.09.2017 before which there were no active symptoms of the same. Her treating doctor certified the same vide her letter dt.25.11.2017In fact, the hospitalization was due to some other disease and not the one claimed in the Insurance Co.’s letter. She lamented that the accusation by the Insurance Co. that she did not declare the disease at the time of taking policy is inaccurate. Contentions of the Respondent : It was contended on behalf of the Respondent the Insured had insurance cover earlier with The New India Assurance Co.Ltd. for S.I. of Rs.1,50,000/- w.e.f. 26.07.2014 and ported the policy w.e.f 26.07.2017. The Insured reported the claim in the 4

th year of Medical Insurance Policy from inception and it was in the 2

nd

month with Star Health Insurance & Allied Insurance Co.Ltd. She raised a pre-authorization request to avail cashless and on the perusal of the claim documents, it was observed that the condition of the ailment was of a long standing nature but was not disclosed in the proposal form. Since the duration of the ailment could not be ascertained with available claim documents, the cashless authorization was denied and communicated to the Insured. Subsequently she submitted a reimbursement claim and it was observed that as per indoor medical records and the letter dt.;11.10.2017 from the treating doctor that the Insured had overlap syndrome and was now diagnosed with Sjogren’s disease. She underwent investigation and the RA test which was prior to the policy. At the time of porting the policy, the Insured did not disclose the above medical history/health details in the proposal form and other documents which amounts to misrepresentation/non disclosure of material facts. As per the insurance contract, it is the duty of the proposer to disclose all the material facts to the Insurer so that they evaluate the same and decide whether or not to accept the proposal. Hence the policy was cancelled with effect from 21.12.2017 due to non disclosure of PED - Rheumotoid Arthritis/Sjogren’s Disease-overlap syndrome after sending 30 days notice to the Insured and premium was refunded and the same informed to her. Forum’s observations/conclusions : The Forum stated that all rights and benefits entitled under the previous policy are passed on to the ported policy and the Respondent cannot be harsh and deny these rights. The Forum reminded the Responded that the complainant was insured with the previous insurer for 6 years without any break and his policy is ported to the new insurer with all benefits. Hence it was not proper for Star Health & Allied Insurance Co.Ltd.to take a stand that she did not disclose her ailment and thereafter terminate her policy. Moreover, the ailment for which the complainant was admitted, i.e. wrist ailment was not related Sjogren disease. Hence the Respondent’s decision is intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the claim of Rs.1,05,500/- in favor of the complainant, as full and final settlement of the complaint. There is no order for any other relief. The case is disposed of accordingly.



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b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated at Mumbai this day of December, 2018.



METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT –Mr Mahesh Jahalani

Vs RESPONDENT : United India Insurance Co Ltd

COMPLAINT REF: NO : MUM-G-051-1718-1768 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Mahesh Jahalani Mumbai


0212002816P105658642,0212002817P104269562 Individual Health Policy 28.07.2016 to 27.07.2017,23.06.2017 to 22.06.2018 Rs.5,00,000/-

3 Name of Insured Name of he policy holder

Mr Mahesh Jahalani

- do -

4 Name of Insurer United India Insurance Co Ltd








12 Complaint registered under Insurance Ombudsman rules 2017

13(b)

13 Date of Hearing 09.08.2018, 03.45 pm


a) For the complainant Mr Mahesh Jahalani

b) For the insurer Mr Rajiv Chetiwal, AO, Dr Trupti, Ms MDIndia TPA P Ltd.



Brief Facts of the Case: The complainant was admitted to Lilavati hospital for treatment of Ischaemic Heart Disease (PTCA)- Angiography and Angioplasty from 17.07.2017 to 20.07.2017. He lodged two claim for reimbursement of total hospital expenses of Rs.7,38,089/-which was settled for Rs.3,84,252/-deducting Rs.3,50,000/- from the Surgeon Charges.

Contention of the complainant :

The complainant appeared and deposed before the Forum. He submitted that he was admitted to Lilavati hospital for treatment of Ischaemic Heart Disease (PTCA)- Angiography and Angioplasty from 17.07.2017 to 20.07.2017. He lodged two claim for reimbursement of total hospital expenses of Rs.7,38,089/-which was settled for Rs.3,84,252/-deducting Rs.3,50,000/- from the Surgeon Charges. He explained that before admission he enquired with Asian Hospital for the surgery charges of the renowned surgeon, Dr Panda which

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was Rs.10 lacs hence he got admitted at Lilavati Hospital where the charges found were much less. The Insurance Co. did not consider the Surgeon’s Fees of Rs.3,50,000/- stating that “Surgeon charges are already considered in the PTCA package hence expenses related to it deducted.” After receiving the above reply, he wrote to Lilavati Hospital asking them for clarification on the above for which they replied that “As per MOU with your TPA, it is clearly mentioned that if the procedure will be done by Dr Samuel Mathew Kalarical, he will charge extra charges, on and above the package amount.” Accordingly Rs.3,50,000/- charged by Dr Kalarical was on and above the total cost of PTCA package of Rs,1,60,000/0 and is justified and payable. The complainant further contended that the Insurance Co. calculated the payout at 70% considering coronary angioplasty as a major surgery which also was not correct and not justified. He pointed out that Coronary Angioplasty did not fall under the category of major surgeries including cardiac surgery. He clarified that no surgery was done during the procedure of coronary angioplasty hence the claim should be paid for the full amount and not just 70%. The deduction on the above grounds was not acceptable to him. He requested for the settlement of his balance claim.

Contention of the Respondent:

The Respondent submitted that the Insured was admitted to Lilavati hospital for treatment of Ischaemic Heart Disease (PTCA)- Angiography and Angioplasty from 17.07.2017 to 20.07.2017. He lodged two claim for reimbursement of total hospital expenses of Rs.7,38,089/-which was settled for Rs.3,84,252/-deducting Rs.3,50,000/- from the Surgeon Charges. They deducted the Surgeon charges since they were already considered in the PTCA package, hence expenses related to it were deducted. Further, since Coronary Angioplasty being deemed as a major surgery under the Individual Heath Policy coverage 1.2.1(b), Expenses in respect of the following illnesses will be restricted as detailed below:

Hospitalization benefits Limits per surgery restricted to

b. * Major surgeries Actuals expenses incurred or 70% of the SI whichever is less.

*Major surgeries include cardiac surgeries include cardiac surgeries, brain tumour surgeries, pace maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, joint replacement surgery, organ transplant.

Forum’s observations : The Forum observed that there is a PPN agreement between the TPA, the hospital and the Insurance Co. The hospital has charged over and above the agreed PPN rate and the Respondent had paid the complainant as per the pre-decided PPN rate which is right. The complainant had stated that the hospital had conveyed to him that if the procedure is done by Dr Samuel Mathew Kalarical, he will charge extra charges, over and above the package amount to which the Insurance Co./TPA had agreed. However, the complainant did not furnish any such letter/evidence and the same is unacceptable since the package rate is uniform for all without any preferential treatment to a specific doctor. Hence the deduction for the surgeon’s charges on the grounds that it is included in the PTCA package was acceptable. Further, the Forum maintained that the Insurance Co has clearly specified the list of major surgeries and the captioned surgery being a cardiac surgery is a major surgery, hence the capping would apply. Thus, the deductions effected on grounds of 70% capping for major surgeries is in order. Therefore, the Forum does not find any valid reason to intervene in the decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Mahesh Jahalani against the short settlement of the claim for his hospitalization does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 21st day of December, 2018 at Mumbai.


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CASE OF COMPLAINANT -MR TUSHAR S MANIAR Vs

RESPONDENT : THE NEW INDIA ASSURANCE CO LTD COMPLAINT REF: NO:MUM-G-049-1718-1827 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Tushar S Maniar Mumbai


13130034162500005927 New Mediclaim 2012 22.11.2016 to 21.11.2017 Rs.3,00,000/- + CB Rs.88,750/-


Mr Tushar S Maniar - do -

4 Name of Insurer The New India Assurance Co Ltd.

5 Date of Repudiation

6 Reason for repudiation Reasonable and customary charges







Rule 13(b)



a) For the complainant Mr Tushar S Maniar

b) For the insurer Ms Madhuri M Pawar, Admn Officer and Dr Trupti, MDIndia TPA Pvt Ltd.



Brief facts of the case : The complainant was admitted to Smt S R Mehta & Sir K P Cardiac Institute from 05.05.2017 to 12.05.2017. He preferred a claim with the Insurance Co.for Rs.1,93,324/ which was settled for Rs.1,80,973/- deducting charges of Rs.9,500/- towards surgeon’s fees under the reasonable and customary clause. Contentions of the complainant : The complainant appeared and deposed before the Forum. He submitted that he was admitted to Smt S R Mehta & Sir K P Cardiac Institute from 05.05.2017 to 12.05.2017.. He preferred a claim with the Insurance Co. for Rs.1,93,324/- which was settled for Rs.1,80,973/- deducting charges of Rs.9,500/- towards surgeon’s fees under the reasonable and customary clause. The Insurance Co. informed him that the same was deducted as per Co.’s internal guidelines where OT charges payable is 25% of Surgeon fees hence Rs.9,500/- deducted. He lamented that he was not agreeable to these deductions since nowhere in the policy there was any mention of any cap on OT and Surgeon charges. He, therefore, requested for the settlement of his balance claim. Contentions of the Respondent :

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The Respondent submitted that claim was received for Rs. 1,93,324/ which was settled for Rs. 1,80,973/- deducting charges of Rs.9,500/- towards surgeon’s fees under the reasonable and customary clause where OT charges were payable @ 25% of Surgeon Fees. The Surgeon Fees were Rs.48,000/- and OT charges Rs.21,500/-, hence 25% of Surgeon Fees was Rs.12,000/- hence Rs.9,500/- was deducted from the OT charges. Forum’s observations/conclusions : The Forum asked the Respondent to give an explanation regarding their criteria for reasonableness. The Forum questioned the Respondent whether the internal guidelines regarding the cap on OT charges was incorporated in the policy. The Respondent answered in the negative. The Forum asked the Respondent to be reasonable in deciding reasonableness. Hence this stand of the Respondent was not acceptable. The Forum, therefore, taking the above facts into consideration, instructed the Respondent to pay balance Rs.9,500/- towards OT charges which was found to be reasonable. The Respondent’s decision is hence intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the balance claim of Rs.9,500/- in favor of the complainant, as full and final settlement of the complaint. There is no order for any other relief. The case is disposed of accordingly.



b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated at Mumbai this 21st day of December, 2018.





CASE OF COMPLAINANT - Mr Ashok Malhotra RESPONDENT : The New India Assurance Co Ltd.


1 Name & Address of the Complainant Mr Ashok Malhotra Mumbai


14160034179500000555 New India Mediclaim Policy 03.09.2017 to 02.09.2018 Rs.5,00,000/-


Mr Ashok Malhotra - do -


5 Date of Repudiation NA

6 Reason for repudiation NA

7 Date of receipt of the complaint 12/01/2018

8 Nature of complaint Increase in premium

9 Amount of claim NA

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11 Amount of relief sought Premium charged at age 70, i.e.Rs.26000/- plus tax should be ceased


Rule 13(b)

13 Date of Hearing 10/08/2018 at 03.45 pm


a) For the complainant Mr Ashok Malhotra

b) For the insurer Mr Amit Kumar Pandey, AO



Brief Facts of the case : The complainant’s Mediclaim premium at the age of 72 has been increased from Rs.26,000/- to Rs.35,693/- without any no claim bonus and any additional benefit thus making the total premium after tax to Rs.42,118/-. Contentions of the complainant: The complainant appeared and deposed before the Forum. He submitted that he is a retired person aged 72 years and renewing his Mediclaim insurance policy for more than 25 years and paying premium regularly. Since the last twenty years he had taken only one claim for his cataract operation some ten years ago. He pointed out that as per the Insurance Co.’s brochure, last increase in premium was when one attains 65 years of age but they again increased the premium when he turned 70. The basic premium was Rs.26,000/- less Rs.780/- for no claim bonus plus taxes R s.3,531/- totaling Rs.28,751/-. The next year at age 72, the premium was similar, i.e. Rs.28,809/- but suddenly at age 72 they increased the basic premium of Rs.26,000/- directly to Rs.35,693/- and not given any No Claim Bonus thus making the total after tax premium to Rs.42,118/- without giving any additional benefit or any reason for they have increased nearly 40% making it difficult to pay for a retired person. He lamented that he was paying premium for the last so many years to enjoy the benefit in old age. Now the Insurance Co. has made it difficult by increasing the premium as they know at this age we cannot change the insurance provider as we lose the entire cumulative bonus during the insurance period. He requested for the refund of refund of the increase of Rs.10,473/-. Contentions of the Respondent: It was contended on behalf of the Insurance Company that the Insured renewed the policy, i.e. New India Mediclaim Policy for period 03.09.2017 to 02.09.2018. Last year, the policy was New Mediclaim 2012 and the Co. had discontinued the renewal of New Mediclaim 2012, effective 01.08.2017. The dispute was regarding the premium, which is as per Co.’s guidelines which was intimated in advance to the Insured. He was also intimated about the change in the product and its clauses. They defended their stand. Forum’s Observations/Conclusion: The Forum advised the Respondent to guide the Insured properly about the increase in premium or suggest them to opt for Top-up Policy with bifurcation. The Forum informed the complainant that increases in premiums are duly vetted by the Regulators and approved by them. Hence the Forum does not find any valid reason to intervene with the decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Ashok Malhotra against the increase in premium, does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 7th day of December, 2018 at Mumbai.


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MUMBAI & GOA




CASE OF COMPLAINANT –MR KALIMMULLAH SHARIF

VS

RESPONDENT : UNITED INDIA INSURANCE CO LTD

COMPLAINT REF: NO : MUM-G-051-1718-1845


1 Name & Address of the Complainant Mr Kalimmulah Sharif

Mumbai

2 Policy No:

Type of Policy


Sum insured

1204002817P101202690

Individual Health Policy-Gold Policy

18.04.2017 to 17.04.2018

Rs.5,00,000/-

3 Name of Insured

Name of he policy holder Mr Kalimmulah Sharif

- do - 4 Name of Insurer United India Insurance Co Ltd


6 Reason for repudiation No active line of treatment






12 Complaint registered under Insurance Ombudsman

rules 2017 13(b)

13 Date of Hearing 23.08.2018, 12.00 pm


a) For the complainant Mr Kalimmulah Sharif

b) For the insurer Mr G N Naik, AM, Dr Manjiri Chavan,M/s Heritage

Health Ins. TPA Pvt Ltd




The complainant was admitted to Criticare Multispeciality Hospital on 16.09.2017 for treatment of L4-5-S1

radiculopathy and discharged on 21.09.2017. He preferred a claim with the Insurance Co for Rs. 91,093/- and

the same was repudiated on the grounds the treatment could be managed on OPD basis and there was no active

line of treatment.

Contention of the complainant :

The complainant appeared and deposed before the Forum. He submitted that he was admitted to Criticare

Multispeciality Hospital on 16.09.2017 for treatment of L4-5-S1 radiculopathy and discharged on 21.09.2017.

He preferred a claim with the Insurance Co for Rs. 91,093/- and the same was repudiated on the grounds the

treatment could be managed on OPD basis and there was no active line of treatment. Hence he requested for the

settlement of his present claim. He contended that after taking treatment for swelling and numbness in his left

leg in OPD for 3 months, on advice of his treating doctor, he was hospitalized. He had swelling and he could

not walk without a stick and sleeping on left side was also painful. It was the doctor who prescribed medicines

and advised hospitalization if the complainant did not get relief to prevent paralysis. The complainant added

that at the time of admission they were told that they could avail cashless facility but due to the mistake of the

new doctor who mentioned “no pre consultancy” without checking his file papers, he did not get the cashless

facility. He, subsequently, filed for claim reimbursement. The complainant was not agreeable to the repudiation

of his claim and approached this Forum for the settlement of his claim.

Contention of the Respondent :

The Respondent submitted that the complainant was admitted to Criticare Multispeciality Hospital on

16.09.2017 for treatment of L4-5-S1 radiculopathy and discharged on 21.09.2017. He preferred a claim with the

Insurance Co for Rs. 91,093/- and the same was repudiated on the grounds the treatment could be managed on

OPD basis and there was no active line of treatment. As the treatment protocol adopted in the form of

conservative management did not involve active line of treatment, the same did not justify hospitalization as per

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clause 2.1(b) which reads, “Procedures/treatments usually done on out-patient basis are not payable under

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

care centres.” The Respondent added that only tablets and multi vitamins were given during the entire

hospitalization and MRI of the spine was performed to rule out any abnormality. The basic treatment was for

evaluation only and there were no drastic findings. Hence the claim was repudiated on the basis that

hospitalization for OPD treatment is not covered under the policy.

Forum’s Observations/conclusions :

The Forum observed that the hospitalization was necessary and the same was advised by the treating doctor else

it would lead to paralysis. The complainant was under the doctor‟s treatment since 2 months and only then

hospitalization was advised. The Forum pointed out that the patient had swelling in his left leg and could not

walk without a stick and the same was treated by hospital by tablets. Although there was allegedly no active line

of treatment but the fact remains that there was medically necessary treatment given. Hence the repudiation of

the Respondent on the ground that there was no active line of treatment and could be managed on OPD basis

was not justifiable. The decision of the Respondent is therefore intervened by the following Order:

AWARD Under the facts and circumstances of the case, the Respondent is directed to settle the claim of Rs.70,000/-

in favor of the complainant, as full and final settlement of the complaint. There is no order for any other

relief. The case is disposed of accordingly.

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

Ombudsman Rules 2017 :

c) As per Rule 17(6) of the said rules 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.

d) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers.

Dated at Mumbai this 28th


( MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA


((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)


CASE OF COMPLAINANT -MRS PREETI T SHAH

Vs




1 Name & Address of the Complainant Mrs Preeti T Shah

Mumbai

2 Policy No:

Type of Policy


Sum Insured

P/900000/01/2017/000007

Group Medical Health Insurance Policy

31.03.2017 to 30.03.2018

Rs. 10,00,000/-

3 Name of Insured

Name of the policy holder Mr Lalitkumar Parikh (deceased)

Jain International Organization






9 Amount of claim Rs.1,19,966 /-



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a) For the complainant Mrs Preeti T Shah




Brief facts of case:

The complainant‟s father-in-law was admitted to Bhargav Medical Centre from 18.06.2017 for treatment of

fresh CVA, DM and old CVA and discharged on 22.06.2017 and again from 25.08.2017 to 27.08.2017 for

treatment of Septicaemia with Metabolic Acidosis, DM and old CVA. A claim with the Insurance Co. for Rs.

45,405/- and Rs.59,821/-the same was settled for Rs.25,000/-


The complainant appeared and deposed before the Forum. She submitted that her father-in-law was admitted to

Bhargav Medical Centre from 18.06.2017 for treatment of fresh CVA, DM and old CVA and discharged on

22.06.2017 and again from 25.08.2017 to 27.08.2017 for treatment of Septicaemia with Metabolic Acidosis,

DM and old CVA. A claim with the Insurance Co. for Rs. 45,405/- and Rs.59,821/- was filed and the same was

settled for Rs.25,000/-. She clarified that her father-in-law was admitted in hospital on an emergency basis and

admitted twice and subsequently he expired. She furnished the treating doctor‟s certificate dt.05.07.2017 who

stated that her father-in-law was admitted on an emergency basis with sudden onset of giddiness, headache,

altered speech and vision problem for which CT, MRI Brain was done and treatment given . The total claim

was initially rejected stating that the hospital was not in their network and later on after pursuing the claim; it

was settled for only 20%. She was not agreeable to the deductions and requested for the settlement of 50 % of

the total claimed amount.


The Respondent submitted that the Insured reported two claims for hospitalization in the 3rd

and 5th

year of the

policy. For the first hospitalization from 18.06.2017 to 22.06.2017 and 2nd

hospitalization from 25.08.2017 to

27.08.2017 it was observed that the Insured was admitted in a non network hospital for treatment of CVA which

is a complication of pre-existing HTN and old CVA. As per Clause 2(vii) - Important Conditions, “The

Company is liable to pay the expenses for the

treatment in our network hospitals only” Thus the 1st hospitalization claim was repudiated and again

reviewed and an amount of Rs.12,320/- was paid as per the 80% co-pay (30% towards reimbursement co-pay +

50% towards PED co-pay). An amount of Rs.2,094/- was deducted towards non medical items and Rs.5,143/-

due to non submission of medicine bill dt.03.07.2017. As per Clause 2(i) (a) – Important Conditions, “The

Company is liable to pay the expenses under 50% co-pay on all PED claims irrespective of age……” As

per Clause 2(vii) – Important Conditions, “The Company is liable to pay “Treatment in our network

hospitals only, however in the case of medical emergencies & accidents treatment can be taken in other

hospitals and seek reimbursement. Such claims are subject to additional co-pay of 30% (after adjusting

all the inner limits and co-pay indicated for normal cashless claims)”. Thus they deducted Rs.5,280/-.

Conclusively, an amount of Rs.12,320/- was paid towards the claim deducting Rs.30,117/- which was the

maximum amount payable as per terms and conditions of the policy.

The 2nd hospitalization claim was repudiated and again reviewed and an amount of Rs.13,880/- was paid as per

the 80% co-pay (30% towards reimbursement co-pay + 50% towards PED co-pay). An amount of Rs.6,406/-

was deducted towards non medical items and Rs.815/- due to non submission of urine culture report and lab

charges. As per clause 2 (i) (a) – “The Company is liable to pay expenses under 50 % co-pay on all PED

claim irrespective of age”. Thus they deducted Rs.19,928/-. As per Clause 2(vii) - Important Conditions, “The

Company is liable to pay the expenses for the treatment in our network hospitals only, however in the

case of medical emergencies and accidents, treatment can be taken in other hospitals and seek

reimbursements. Such claims are subject to additional co-pay of 30% (after adjusting all inner limits and

co-pay indicated for normal cashless claims)”. Thus they deducted Rs.5,948/-. Conclusively, an amount of

Rs.13,880/- was paid towards the claim deducting Rs.45,327/- which was the maximum amount payable as per

terms and conditions of the policy.

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The Forum stated that an insurance contract is a legal undertaking and one has to adhere to the contract.

Although the Forum appreciates the concern of the complainant, the insurance broker of JIO is aware of the

contract and acting on behalf of JIO and they have finalized the cover for the complainant and the same should

have been explained to the complainant. The Respondent has properly settled the claim - 50% co-pay for PED

and 30% co-pay for reimbursement. The Forum, therefore, does not find any valid reason to intervene in the

decision of the Respondent; consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mrs Preeti T Shah against the

repudiation of her father-in-law’s claim does not sustain.





( MILIND KHARAT )

INSURANCE OMBUDSMAN OFFICE OF INSURANCE OMBUDSMAN

MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE ((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR AMIT KISHORKUMAR THAKKAR

Vs RESPONDENT : STAR HEALTH & ALLIED INSURANCE CO LTD


1 Name & Address of the Complainant Mr Amit Kishorkumar Thakkar Mumbai


P/171116/01/2017/022394 Star Comprehensive Insurance Policy 06.02.2017 to 05.02.2018 Rs.10,00,000/-


Mst Ayaan Thakkar Mr Amit Kishorkumar Thakkar



6 Reason for repudiation 24 months waiting period for HERNIA







Under Rule 13(b)

13 Date of Hearing 29.08.2018 at 11.00 am


a) For the complainant Mr Amit Kishorkumar Thakkar



16 Date of Award/Order 20.12.2018 Brief facts of the case :

The complainant’s son was hospitalized at Amardeep Multispecialty Children Hospital & Research Centre from

29.07.2017 to 30.07.2017 for treatment of Bilateral Inguinal Hernia and laparoscopy performed. A claim was

lodged for Rs. 79,929/- which was repudiated arbitrarily by the Insurance Co. stating a two years waiting period

for hernia.

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The complainant appeared and deposed before the Forum. He contended that his son, then 13 months old was

noted to have swelling over the abdomen for the past 1 month and this swelling increased gradually and

subsided as initially it was painless and increased in size on straining and reduced at rest. On the 27th

August

2017, it increased in size persistently and was associated with irritability and nausea and his son cried

continuously with pain. The doctor advised ultrasound and on that basis of that report, surgery was suggested

on priority as things would have worsened if not attended within a day or two. He was operated on 29.07.2017

– Laproscopy + Bilateral Inguinal Herniotomies. The complainant clarified that his son had no health problems

and was a healthy baby since birth. The rejection clause applied was not fair since his son was less than two

years. He pointed out that hernia in adults is different from a hernia in a baby which is mostly an emergency. He

requested for the settlement of his son’s claim.


It was contended on behalf of the Respondent that the claim for reimbursement of hospitalization expenses of

the Insured was received for Bilateral Inguinal Herniotomies. The same was scrutinized and it was observed

that the treatment undergone fell under the condition of specific waiting period of 24 months as per Exclusion

Clause 3.a. which reads, “The expenses for treatment of cataract. Degenerative Disc of Vertebral Diseases

and Prolapse of Intervertebral Disc (other than caused by accident), varicose veins and varicose ulcers,

benign prostatic hypertrophy, deviated nasal septum, sinusitis, tonsillitis, nasal polyps, chronic

Supparative Otitis Media and related disorders, hernia, hydrocele, fistula/fissure in ano and

haemorrhoids congenital internal disease/defect (except to the extent provided under Section 2 for

newborn).”

The Respondent clarified that the Insured was a 1 year 2 month old child who underwent treatment for inguinal

hernia in the 6th

month (29.07.2017) of the policy with Star Health & Allied Insurance Co Ltd.. It was further

clarified that the complainant had a Mediclaim Policy with The New India Assurance Co Ltd. w.e.f. 06.02.2014

till 05.02.2017 and his newborn son was included w.e.f. 21.10.2016. In the light of the above facts and

circumstances the claim of the Insured was repudiated.

Observations/Conclusion of the Forum :

The Forum requested the Respondent to check with the policy with the earlier insurer for the waiting period

condition and whether the same applies to new born. The Respondent reverted that the child’s date of birth is

27.06.2016 and was included in the previous year policy period (06.02.2016 to 05.02.2017 with New India) on

21.10.2016 by endorsement. The policy was ported to Star Health on 06.02.2017 (policy period from

06.02.2017 to 05.02.2017). The complainant’s son was admitted on 29.07.2017 for Bilateral Inguinal Hernia

and the claim was rejected on the grounds of 24 month waiting period for the treatment of hernia and congenital

internal disease/defect. On hearing the deposition of both the parties, the Forum maintained that when a 24

months waiting period for hernia is incorporated during the first incepted policy, i.e. 2016 it is implied that the

same will continue for the subsequent 24 months. If the hospitalization for fistula was

after the waiting period then the benefit of doubt would have gone to the complainant. The aforesaid waiting

period of 24 months will complete on 05.02.2018. Therefore the Respondent’s repudiation of the claim is justified on the above grounds. The Forum, therefore, does not find any valid reason to intervene in the decision of the Respondent; consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Amit Kishorkumar Thakkar against the repudiation of the claim for his son’s hospitalization does not sustain. The case is disposed off accordingly. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 20th day of December, 2018 at Mumbai.


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CASE OF COMPLAINANT -Ms Veena Ashok Bhandari Vs

RESPONDENT : The Oriental Insurance Co Ltd. COMPLAINT REF: NO:MUM-G-050-1718-1887 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Ms Veena Ashok Bhandari Mumbai


121200/48/2018/4516 Happy Family Floater 22.08.2017 to 21.08.2018 Rs.5,00,000/-


Ms Veena Ashok Bhandari - do -

4 Name of Insurer The Oriental Insurance Co Ltd.







11 Amount of relief sought Rs.1,70,118 /-


Rule 13(b)



a) For the complainant Mr Ashok Kumar Bhandari, complainant’s husband.

b) For the insurer Ms Hemlata Poojary, Asst Manager, Dr Anupama Kamble, Raksha TPA



Brief facts of the case : The complainant was hospitalized at Saifee Hospital from 23.08.2017 to 26.08.2017 for Acute Myocardial Infarction, primary hypertension and Hypothyroidism. She preferred a claim with the Insurance Co for Rs.5,84,000/- which was settled for Rs.3,73,594/- deducting Rs.1,70,118/- towards surgeon charges. Contentions of the complainant : The complainant’s husband appeared and deposed before the Forum. He submitted that his wife was admitted to Breach Candy in an emergency with complaints of uneasiness on 23.08.2017. Since there was no room available and her condition deteriorated, she was shifted to Saifee Hospital from 23.08.2017 to 26.08.2017 and diagnosed with Inferolateral wall St Segment Elevation Acute Myocardial Infarction, primary hypertension and Hypothyroidism. She underwent coronary angiography with angioplasty. She preferred a claim with the Insurance Co for Rs.5,84,000/- which was settled for Rs.3,73,594/- deducting Rs.1,70,118/- towards surgeon charges on the grounds of the Reasonable and Customary Clause. He clarified that no one could know the charges till the treatment is completed. In an emergency one cannot run to each and every hospital to find out the cheapest and then go ahead with the treatment. Since the treatment was necessary she was compelled to pay whatever was charged. He requested for the settlement of her balance claim. Contentions of the Respondent : It was contended on behalf of the Respondent that the complainant was hospitalized at Saifee Hospital from 23.08.2017 to 26.08.2017 for Acute Myocardial Infarction, primary hypertension and Hypothyroidism. She preferred a claim with the Insurance Co for Rs.5,84,000/- which was settled for Rs.3,87,728/-

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deducting Rs.1,96,272/- out of which Rs.1,70,118/- was towards surgeon charges under the Reasonability and Customary Clause, Lab charges Rs.1,233/- since original report unavailable, non medicals Rs.8,850/- and other charges (registration, administration and miscellaneous charges) as per clause 4.25 . The major deductions towards surgeon charges were made on the basis of the comparative charges with other similar hospitals in the vicinity viz.Kokilaben Dhirubhai Ambani Hospital where the surgeon charges for the same treatment is Rs.1,24,000/0, Bhatia General Hospital Rs.66,000/-, Jaslok Hospital and Research Centre Rs.1,14,800/- and P D Hinduja National Hospital Rs.71,800/-. Since Saifee Hospital where the complainant was admitted does not have fixed schedule of charges they applied the Reasonability and Customary Clause 2.37 which reads, - 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 the illness/injury involved.” The said charges incurred were beyond the reasonable amount in the geographical area for identical services relevant to the illness of the complainant. Thus, on that ground they allowed maximum surgeon charges of Rs.1,24,000/- against Rs.2,94,118/- hence excess amount of Rs. 1,70,118/ - was thereby deducted. Forum’s Observations/Conclusion: On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, the surgery charges are on the higher side even considering the fact that the policy has no capping. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are custodians of public money and have to function with a long term perspective to ensure sustainability of their operations so that at any given point of time they are in a position to meet all liabilities under the policies which are in force. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation and even in the absence of a specific capping in the policy, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. Hence going by the comparative charges produced by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the further payable amount to Rs.35,000/-. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the claim of Rs.35,000/-in favor of the complainant, as full and final settlement of the complaint. There is no order for any other relief. The case is disposed of accordingly.



b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated at Mumbai this 20

th day of December, 2018.

( MILIND KHARAT)

INSURANCE OMBUDSMAN

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OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT - MR MAYUR MEHTA

Vs RESPONDENT : THE NEW INDIA ASSURANCE CO LTD


1 Name & Address of the Complainant Mr Mayur Mehta Mumbai


17040034162500000969 New Mediclaim 2012 15.06.2016 to 14.06.2017 Rs.4,00,000/-


Mrs Avni M Mehta Mr Mayur Mehta

4 Name of Insurer The New India Assurance Co Ltd.







11 Amount of relief sought Rs.42,000 /-

12 Complaint registered under Insurance Ombudsman Rules 2017 Rule 13(b)



a) For the complainant Mr Mayur Mehta

b) For the insurer Mrs Thressia Jacob, Asst Manager, Dr Bharti Motling, M/s Health India Insurance TPA Services Pvt Ltd.



Brief facts of the case: The complainant’s wife was admitted to Dr Trivedi S Total Health Care Pvt Ltd from 19.07.2016 to 20.07.2016 for procedure of 3D Lap Myomectomy with adhesions. He preferred a claim with the Insurance Co. for Rs. 1,27,372/- and same was settled for Rs.82,319/- on the grounds of the Reasonability and customary clause. Contentions of the complainant: The complainant appeared and deposed before the Forum. He submitted that his wife was admitted to Dr Trivedi S Total Health Care Pvt Ltd 19.07.2016 to 20.07.2016 for procedure of 3D Lap Myomectomy with adhesions. He preferred a claim with the Insurance Co. for Rs.1,27,372/- and same was settled for Rs.82,319/- deducting Rs.35,000/- from the surgery charges and Rs.7,000/- from the Anesthetist’s charges on the grounds of the Reasonability and customary clause. The complainant explained that initially his claim was rejected on the grounds that it was a health check up claim which was ridiculous since at the time of intimation he had attached the treating doctor’s letter which stated that it was a Lap Myomectomy surgery. Secondly the deduction from the Anesthetist’s charges was also not correct since it was clearly mentioned in the hospital bill separately s Anesthetist’s charges/Episitomy charges. He was not agreeable to the deductions and requested for the settlement of his wife’s genuine claim. Contentions of the Respondent : It was contended on behalf of the Respondent that the Insured was admitted to Dr Trivedi S Total Health Care Pvt Ltd 19.07.2016 to 20.07.2016 for procedure of 3D Lap Myomectomy with adhesions. A claim was lodged for Rs.1,27,372/- and same was settled for Rs.82,319/- deducting Rs.45,053/-. Out of the total surgery charges of Rs.65,000/- and Anesthetist’s charges of Rs.12,000/- they paid Rs.30,000/- and Rs.5,000/- and deducted Rs.35,000/- and Rs.7,000/- respectively on the grounds of the Reasonability and customary clause. Hence the excess amount was deducted since the same was on the higher side as compared to the charges of the other

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hospitals including tertiary hospitals in metro cities of the same grade for the present surgery charges which were found to be exorbitant and hence deductions made under the Reasonability and customary clause 2.36 which reads, “the charges for services 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 the illness/injury involved.” They further added that only conventional surgery expenses were payable and advanced techniques were not payable. They pointed out that 3D Lap instruments used increases cost of the surgery. They compared the charges with hospitals at Ghatkopar like Zynova Hospital where the room rent is Rs.4,500/- and total surgery charges Rs.71,200/- and Sapna Health Care where the total surgery charges were Rs.70,000/-. Hence considering the above, they have paid Rs.82.319/-. Forum’s observations: On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, the GI surgery and anesthetist’s charges are very much on the higher side even considering the fact that the policy has no capping. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are custodians of public money and have to function with a long term perspective to ensure sustainability of their operations so that at any given point of time they are in a position to meet all liabilities under the policies which are in force. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation and even in the absence of a specific capping in the policy, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. Hence going by the comparative charges produced by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the further total payable amount to Rs.20,000/-towards the surgery and anesthetist’s charges. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the admissible claim of Rs.20,000/-in favor of the complainant, as full and final settlement of the complaint. There is no order for any other relief. The case is disposed of accordingly.



b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers. Dated at Mumbai this 21st day of December, 2018.



METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules 2017)


CASE OF COMPLAINANT - Mr Rikhabchand P. Mehta

VS RESPONDENT : United India Insurance Co.Ltd.

COMPLAINT REF: NO:MUM-G- 051-1718-1980 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Rikhabchand P. Mehta Mumbai

2 Policy No: 1201002814P111701011

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Type of Policy Duration of Policy/Period Sum Insured

Individual Mediclaim Policy 26.03.2015 to 25.03.2016 Rs.500000/-, CB- Rs.100000/-


Mr Rikhabchand P. Mehta Mr Rikhabchand P. Mehta

4 Name of Insurer United India Insurance .Co. Ltd.








12 Complaint registered under Indian Ombudsman Rules 2017

13 (b)

13 Date of Hearing 24.08.2018 at 03.45 pm



b) For the insurer Mr Devendra M Durve, Assistant and Dr Shweta Birwadkar, (M/s Medi Asst.India TPA Pvt Ltd)



Brief Facts of the Case : Mr Rikhabchand P. Mehta is covered under the above policy and was diagnosed as Multiple Myeloma (Blood & Bone) Cancer and taking the treatment at TATA Memorial Hospital since 01-07-2015. He underwent injectible chemotherapy on weekly basis and thereafter for 4 months he developed acute burning in his feet soles and therefore the hospital doctor shifted from injectable chemo therapy to Oral chemo therapy. The Company has honored all his claims for injectable Chemo therapy. He preferred a claim for Rs.12,195/- for hospitalization from 15.01.2016 to 15.01.2016 which was short settled by the Company for Rs.2,710/-deducting Rs.9,485/-. The complainant has submitted in his statement that he was not agreeable with the decision of the Company. Contentions of the complainant: Complainant remained absent. His written submission was taken on record and the hearing continued with the Company. The complainant has submitted in his statement that he was admitted to Tata Memorial Hospital for treatment of Multiple Myeloma and Malignant Plasma Cell Neoplasm on 15.01.2016. He preferred a claim for Rs.12,195/- which was short settled by the Company for Rs.2,710/-deducting Rs.9,485/-. He submitted that this wrongful deduction was due to clubbing two different claims filed on different dates, i.e. claim filed on 23.03.2016 for Rs.12,195/- and another on 26.2.2016 for Rs.41,507/-. It was solely due to the casual approach by the checking/scrutiny official at TPA. Secondly, the date of admission shown as 15.01.2016 is also wrong. The Insurance Co. while deducting Rs.9,485/- say that some bills are older than 60 days which is absolutely wrong. The complainant further submitted that, in fact, no bills were older than 5-7 days. He was not agreeable with the decision of the Company and requested the Forum for settlement of the above balance claim. Contentions of the Respondent: It was contended on behalf of the Respondent that on perusing the claim details, they observed that the amount was reimbursed for the same period of hospitalization at two instances for gross payable of Rs.41,507/- settled on 05.03.2016 and another claim for gross payable amount of Rs.12,195/- settled on 09.04.2016 and deduction made under the same claim payments were Rs.500/- and Rs.9,485/- respectively for reason “Consultation Note not available” and post hospitalization expenses more than 60 days not payable which was properly mentioned in the respective claim settlement advices. The same had been effected as per the policy terms and conditions and deductions correctly made. Forum’sObservations/Conclusion: The Forum observes in this case that the complainant underwent chemotherapy treatment on OPD basis at TATA Memorial Hospital on different dates. The deductions were made for post hospitalization expenses more than 60 days which is not admissible as per the policy terms and conditions. Therefore Company’s settlement of the above claim is sustained. Though the Forum is able to appreciate the concern of the complainant in this regard, it has also to be borne in mind that whenever any dispute arises, it is settled based on the terms & conditions of the policy under which a claim has arisen since these form the very basis of the contract between the parties. Under the circumstances, settlement of the claim by the Respondent being in accordance with the policy terms and conditions, the Forum does not find any valid ground to intervene with the decision of the Respondent in the same matter and pass the following Order.

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AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr.Rikhabchand P.Mehta against the short settlement of the claim lodged for his hospitalization does not sustain. The case is disposed off accordingly. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 13th day of December, 2018 at Mumbai.



MUMBAI & GOA




CASE OF COMPLAINANT -MS SNEHPRABHA AGARWAL

Vs




1 Name & Address of the Complainant Ms Snehprabha Agarwal

Mumbai

2 Policy No:

Type of Policy


Sum Insured

P/171128/01/2018/003010

Senior Citizens Red Carpet Health Insurance Policy

18.09.2017 to 17.09.2018

Rs. 2,00,000/-

3 Name of Insured

Name of the policy holder Ms Snehprabha Agarwal

- do -



6 Reason for repudiation Maximum limit for cataract surgery










a) For the complainant Ms Snehprabha Agarwal





The complainant was admitted to Dr Pai‟s Advanced Eye Care Centre on 05.12.2017 for left eye cataract. She

preferred a claim with the Insurance Co. for Rs.36,643/- and the same was rejected on the grounds the expenses

payable is limited to Rs.15,000/- for cataract during the entire policy period.


The complainant appeared and deposed before the Forum. She contended that she was covered under the Senior

Citizens Red Carpet Policy since the last 5 years. She was admitted to Dr Pai‟s Advanced Eye Care Centre on

05.12.2017 for left eye cataract. She preferred a claim with the Insurance Co. for Rs.36,643/- and the same was

rejected on the grounds that the second claim for left eye could not be given since the Insurance Co. had settled

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her claim for right eye where she was reimbursed Rs.15,000/- as per the limit specified for cataract during the

entire policy period and the same was exhausted. Hence they could not reimburse her for the left eye cataract

expenses. She pointed out that when a patient is suffering from cataract of both eyes; he/she cannot wait for the

surgery of the other eye till next year. She stated that the restrictive condition was deliberately put to deny the

claim for one eye only in one year.


It was contended on behalf of the Respondent that as per the limits incorporated in the policy schedule, the

maximum eligible amount payable for cataract surgery for one or both eyes is Rs.15,000/- only in the entire

policy period for the sum insured of Rs 2 lakhs. The Respondent clarified that they had already reimbursed an

amount of Rs.15,000/- towards hospitalization expenses for treatment of right eye cataract for the admission on

09.11.2017. As the maximum amount had already been settled to the hospital for the above surgery during the

present policy period, no further amount was payable.


The Forum has observed that the Respondent had already reimbursed an amount of Rs.15,000/- towards

hospitalization expenses for treatment of right eye cataract for the admission on 09.11.2017. As the maximum

amount had already been settled for the above surgery during the present policy period, no further amount was

payable for the left eye cataract surgery hospitalization expenses. Hence the Forum concludes that the

Respondent‟s stand is correct. The Forum, therefore, does not find any good ground to intervene with the stand

taken by the Respondent and passes the following Order.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Ms Snehprabha Agarwal against

the repudiation of the claim for her hospitalization does not sustain.




Dated: This 3rd day of January, 2019 at Mumbai.

( MILIND KHARAT )

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT - Mr Jacky M Maru

Vs RESPONDENT : HDFC ErgoGeneral Insurance Co.Ltd.



Mr Jacky M Maru

Mumbai

2

Policy No:

Type of Policy


Sum Insured

2864201877105500000

Health Medisure Classic Insurance From

28/08/2017 to 27/08/2018

Rs.2,00,000/- + CB Rs.1,00,000/-

3 Name of Insured Mr Jacky M Maru

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Name of the policy holder do -

4 Name of Insurer HDFC ErgoGeneral Insurance Co.Ltd.


6 Reason for repudiation Fraud



9 Amount of claim Rs.63,692.62


11 Amount of relief sought Rs.63,692.62


13 Date of Hearing 27/08/2018 at 01.00 p.m.







The complainant was hospitalized at Vinayak Maternity & General Hospital from 14.09.2017 to 21.09.2017 for

treatment of dengue fever with thrombocytopenia. He preferred a claim with the Insurance Co. for

Rs.63,692.62 which was repudiated on the grounds of fake claim.

The complainant contended that he submitted all the papers twice to the Insurlance Co and they have rejected

the same without giving any reason and labelling as fake claim.

The Forum scheduled a joint hearing of the parties concerned to the dispute on 27.08.2018 at 01.00 p.m. However, in the meantime, the Forum was informed by the Respondent that they had agreed to settle the admissible claim for Rs.55,968.71 to the complainant to resolve the grievance and the complainant agreed for the mutual settlement and confirmed the same. In view of the above, the within mentioned complaint of the complainant stands closed at this Forum. Dated at Mumbai this 5th day of November 2018.





CASE OF COMPLAINANT - MR. CHANDRAKANT BHOOT

VS RESPONDENT - NATIONAL INSURANCE CO. LD.


1 Name & Address of the Complainant Mr. Chandrakant Bhoot Mumbai

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2 Policy No:

Type of Policy Duration of Policy/Period

Sum Insured

26100501710000030

National Mediclaim Policy 06.04.2017 – 05.04.2018

Rs.100000/- + C.B. Rs.50,000/-


Mr. Bhavik Bhoot Mr. Chandrakant Bhoot

4 Name of Insurer National Insurance Co. Ltd.

5 Date of Repudiation No letter of repudiation issued

6 Reason for repudiation Correction of eye site - exclusion 4.8






12 Complaint registered under

Ombudsman Rules, 2017

Under Rule 13(b)



a) For the complainant Mr. Bhavik Bhoot - Son

b) For the insurer Mr. Dilip Tawale Rothshield TPA



Brief Facts of the Case : Complaint's son Mr. Bhavik Bhoot underwent both eyes Refractive Lens Exchange (RLC) at Mehta International Eye Institute on 15.07.2017. A claim lodged under the policy for the same was repudiated by the Respondent under Clause 4.8 of the policy which excludes correction of eye sight due to Refractive error from the scope of the policy.

Contentions of the Complainant : Mr. Bhavik stated that he had complaints of blurred vision and frequent headaches for which he consulted a doctor at Bandra and was taking medicines from him since the year 2013. However due to the medication he suffered lot of fluctuation in axis every month. Hence he visited Dr. Cyres Mehta at Mehta International Institute in the year 2017. After examination, the doctor observed very high Myopia and suggested surgery as otherwise there could be permanent loss of vision in both the eyes; hence he went in for the said surgery. Mr. Bhavik argued that the surgery was done not for correction of eyesight but it was necessary for saving of eye sight/vision. He stated that even now he was experiencing a lot of strain and discomfort in the eyes. He requested for settlement of the claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that as per the submitted claim documents, Mr. Bhavik Bhoot aged 27 years, visited Mehta International Eye Institute on 13.07.2017 with c/o dimness of vision for distance and near since 7 years, both eyes strain since 6 months, both eyes halos frequent. He was diagnosed with High Myopia. Myopia is the most common refractive error of the eye. As per clause 4.8 of the policy surgery for correction of eye sight due to refractive error is not payable. Hence the claim was inadmissible under the policy.

Forum’s Observations/Conclusion: On perusal of the documents produced on record, it is observed that the complainant’s son was suffering from High Myopia and was treated for the same. Although it is argued that the surgery was necessary for saving of eye sight, it is ultimately done by correcting the refractive error. Clause 4.8 of the policy specifically excludes surgery for correction of eye sight due to refractive error. It may be noted that whenever any dispute arises it is settled based on the terms and conditions of the policy under which a claim has arisen. This Forum has the inherent limitations in going beyond the provisions of the policy contract and the Forum examines cases in detail to see whether there is any breach of policy provisions while denying a claim and cannot grossly overlook the terms and conditions clearly spelt out in the policy and also approved by the IRDAI. As the decision of the Respondent to repudiate the claim is in accordance with the terms and conditions of the policy, the Forum does not find any valid reason to intervene with the same and consequently no relief can be granted to the complainant.

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AWARD Under the facts and circumstances of the case, the complaint lodged by Mr. Chandrakant Bhoot against National Insurance Co. Ltd. does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 24


(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)


COMPLAINANT - MR. CHANDRAKANT B. DEDHIA

VS

RESPONDENT : BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD.



1 Name & Address of the Complainant Mr. Chandrakant Dedhia

Mumbai

2 Policy No:

Type of Policy


OG-17-1908-8427-00000028

Health Care Supreme Floater Ins. Policy

22.06.2016 - 21.06.2017 Rs.50,00,000/-


Ms. Hansa Chandrakant Dedhia Mr. Chandrakant B. Dedhia

4 Name of Insurer Bajaj Allianz General Insurance Co. Ltd.


6 Reason for repudiation Waiting period – Section 2 - Excl. A2



9 Amount of claim Rs.58,160/- + Rs.30,42,799/-

10 Date of Partial Settlement ---



Ombudsman Rules

Under Rule 13(b)

13 Date of Hearing 04.09.2018 - 12.00 noon


a) For the complainant Mr. Chandrakant Dedhia

b) For the insurer Dr. Rashmi Sachdev Mr. Parveez Alam


16 Date of Award/Order 10.12..2018

Brief Facts of the Case : Complainant‟s wife Ms. Heena C. Dedhia was admitted to Geetanjali Hospital,

Wai on 31.10.2016 following a sudden attack of Pancreatitis and was shifted to Lilavati Hospital on 01.11.2016

for further treatment. She was diagnosed with Acute Pancreatitis with Cholecystitis with cholelithiasis and after

treatment, was discharged from the hospital on 27.12.2016. Respondent repudiated the claims lodged for both

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these hospitalizations stating that the treatment was related to Gall stones which has a Waiting period of 12

months from the inception of the policy as per Section 3 - Exclusion A2 of the policy.

Contentions of the Complainant : Complainant contended that his wife was treated for pancreatitis and

the same was not as a result of gallstone as nowhere in the discharge card it is mentioned so. The reason or the

cause could be something else also like viral infection or for unknown reason, as no reports during treatment are

confirming or conclusive on proximate cause being gall stone. They even submitted to the Respondent a letter

from the treating Surgeon Dr. Hitesh Mehta of Lilavati Hospital and a copy of an article published in Times of

India newspaper dt. 18.03.2017 by renowned Dr. Hemant Thacker who is a Consultant & Cardio Metabolic

Specialist attached to South Mumbai Hospital despite which the Respondent refused to reconsider the claim. He

stated that the decision of the Respondent was not acceptable to them and requested for settlement of the claim.

He added that they were holding another policy with National Insurance Co. Ltd. for S.I. of Rs.10,00,000/-

under which the said Company has settled the claim for Rs.10,33,700/- on 16.10.2017.

Contentions of the Respondent: Dr. Rashmi submitted that the complainant‟s policy covering himself

and his spouse incepted with their Company on 26.07.2016. In October 2016 his wife was hospitalized for the

treatment of Acute pancreatitis with Cholelithiasis with cholecystitis. As per Section 3: Exclusion A2, the policy

does not extend coverage for any expenses incurred for treatment of stones of biliary systems during the first

year from inception of the policy. Hence the claim was repudiated as per policy terms and conditions. She

added that they had referred the matter for expert opinion and as per the said opinion also Ms. Hansa Dedhia‟s

episode of acute necrotizing pancreatitis is attributable to her pre-existing history of cholelithiasis (gall stones).

Forum’s Observations/Conclusion: On perusal of the documents produced on record, it is observed that

the claim in respect of treatment for Acute Pancreatitis with Cholelithiasis with cholecystitis undergone by Ms.

Hansa Dedhia was lodged in the first year since inception of the policy with the Respondent. Acute pancreatitis

is a condition where the pancreas becomes inflamed (swollen) over a short period of time. Most cases of acute

pancreatitis are caused either by alcohol abuse or by gallstones. Other causes may be the use of prescribed

drugs, trauma or surgery to the abdomen or abnormalities of the pancreas or intestine. In rare cases, the disease

may result from infections, such as mumps. In about 15% of cases, the cause is unknown. An acute attack

usually lasts only a few days, unless the ducts are blocked by gallstones. Cholelithiasis refers to the presence of

abnormal concretions (gallstones) in the gallbladder. Cholecystitis is defined as inflammation of the gall bladder

that occurs most commonly after cystic duct obstruction by cholelithiasis. Cholecystitis, choledocholithiasis

and gallstone pancreatitis are the most common complications of cholelithiasis. The complainant‟s wife was

diagnosed with Acute Pancreatitis alongwith Cholelitiasis with Cholecystitis which confirms the presence of

gall stones in the instant case. The certificate issued by her treating surgeon Dr. Hitesh Mehta does not rule out

the cause of Acute Pancreatitis as gall stones in this particular case though he has further stated that it could be

due to any unknown cause. However, in the absence of evidence of any other prevalent cause the Respondent‟s

contention that her episode of acute necrotizing pancreatitis is attributable to her condition of cholelithiasis,

cannot be faulted with since the presence of galls stones is one of the most common causes of acute pancreatitis.

In view of the fact that the policy stipulates a Waiting period of twelve months since inception of the policy for

the treatment of stones of biliary systems, the decision of the Respondent to repudiate the subject claim is found

to be in accordance with the terms and conditions of the policy. The Forum therefore does not find any valid

reason to intervene with the same and consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Chandrakant

B. Dedhia against Bajaj Allianz General Insurance Co. Ltd. does not sustain.


him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws

of the Land against the Respondent Insurer.

Dated: This 10th

day of December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

https://www.verywellhealth.com/what-are-gallstones-1742784

https://www.amboss.com/us/knowledge/Cholelithiasis_and_cholecystitis#xid=V30Ghf&anker=Z7821908c4d368c195af41a8d778901d0

https://www.amboss.com/us/knowledge/Cholelithiasis_and_cholecystitis#xid=V30Ghf&anker=Z29cd27bbe4a228c7ec37c2ffe4bfaefa

https://www.amboss.com/us/knowledge/Fever_and_inflammation#xid=j50_Pg&anker=Z9a9303256b05d642aad8d3c1e2153b5e

https://www.amboss.com/us/knowledge/Gallbladder_and_bile#xid=Q60ukS&anker=Zfcdfb752aaff997c8447f3ded7d7e362


https://www.amboss.com/us/knowledge/Cholelithiasis_and_cholecystitis#xid=V30Ghf&anker=Z29cd27bbe4a228c7ec37c2ffe4bfaefa

https://www.amboss.com/us/knowledge/Cholelithiasis_and_cholecystitis#xid=V30Ghf&anker=Z9dd89c0343aeef155fbe39b0b956d64f

https://www.amboss.com/us/knowledge/Acute_pancreatitis#xid=SS0y_2&anker=Z2832e9c06290306df72198871a5479ee


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MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 OF Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Jeetendra Puri

VS RESPONDENT : Cigna TTK Health Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Jeetendra Puri,

E-401/402 Mountclass II, Yogi Hills,

Mulund West, Mumbai – 400 080

2 Policy No:


Sum Insured

PROCHLR 2900000423

Pro Health Insurance 29.11.2016 TO 28.11.2017

Rs.550000/-


Mr Jeetendra Puri Mr Jeetendra Puri

4 Name of Insurer Cigna TTK Health Insurance Co.Ltd.


6 Reason for repudiation


8 Nature of complaint Non issuance of Policy after payment of

premium

9 Amount of claim


11 Amount of relief sought

12 Complaint registered under Indian Ombudsman Rules 2017

13 (b)

13 Date of Hearing 28.08.2018 at 02.30 Pm


a) For the complainant Settled before hearing

b) For the insurer Settled before hearing



Mr Jeetendra Puri had lodged a complaint for non issuance of policy after payment of requisite

premium amount through online and on renewal he was unable to renew the policy as the policy was not issued.

Aggrieved, he approached this Forum requesting relief in this matter. Records were perused and a

joint hearing of the parties to the dispute was scheduled on 28th August,2018 at 02.30 Pm.

Meanwhile the Company has informed us that they have refunded premium amount of Rs.29870/- to the complainant and the complainant has also agreed and withdrawn his complaint. In view of

pursuant withdrawal of the complaint by the complainant, the complaint stands closed at this Forum. There is no order for any other relief. The case is disposed of accordingly.

Dated at Mumbai, this 10th day of December,2018.


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COMPLAINANT - MR. DILIP V. KHANIVADEKAR

VS RESPONDENT : BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Dilip V. Khanivadekar

Mumbai 400064.



Og-18-1930-8429-00000020 Health Guard (Individual) Policy

08-06.2017 to 07.06.2018 Rs.2,00,000/-

3 Name of Insured


Mast.Chinmay Dilip Khanivadekar

Mr. Dilip V. Khanivadekar



6 Reason for repudiation Waiting period – Clause C-3.



9 Amount of claim 1) Rs.57,000/-





Under Rule 13(b)

13 Date of Hearing 20.08.2018 – 11.15 A.m.


a) For the complainant Mr. Dilip V. Khanivadekar

b) For the insurer Mr. Parveez Alam Dr. Rashmi Sachdev



Brief Facts of the Case : Complainant’s son Mast. Chinmay was admitted to Phonix Hospital, Borivali West,Mumbai from 18.09.2017 to 21.09.2017 for the treatment of Deviated Nasal Septum-Turbinate Reduction. He lodged the total claim of Rs.57,000/-. Respondent repudiated the claim for the said hospitalization stating that there is a Waiting Period of three years for the said treatment as per Clause C3. of the Health Guard policy.

Contentions of the Complainant : Complainant contended that Respondent rejected the claim citing Waiting Period of three years. He argued that he was earlier covered with Max Bupa Insurance Company since 2015 with a continuation period of 2 years and ported his policy to Bajaj Allianz General Insurance Company from 08.06.2017 with continuity benefit extended from 08.06.2015. Since the policy was ported from Max Bupa to Bajaj Allianz and Max Bupa policy does not have waiting period for the said ailment. Hence the repudiation of the claim is not acceptable to him and he requested the Forum for settlement of the above claim.

Contentions of the Respondent: Bajaj Allianz General Insurance company was represented by Shri Parveez Alam & Dr.Rashmi Sachdev, they defended the decision of the Insurance Company. The Forum asked the Company the reasons for repudiation of the above claim. The Company submitted that the Mast. Chinmay was hospitalized for the treatment of Deviated Nasal Septum left. The said claim was repudiated as the policy

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does not extend coverage for any expenses incurred for surgery to correct deviated nasal septum during the first 36 months.

Forum’s Observations/Conclusion: On scrutiny of the documents produced on record, it is observed that complainant along with his family members ware covered with Max Bupa Health Insurance till 07.06.2017 and the policy was thereafter ported to the Respondent Company. The request for porting along with Proposal form and premium cheque was submitted by the complainant to the Respondent well in advance. The Forum observes that when the complainant had applied for the continuity benefit while porting to Respondent Insurance Company, he was neither guided for the requirements nor was he informed that his policy is being issued as fresh policy, thus depriving him of his opportunity to at least continue with his earlier insurer. By accepting his proposal, the company has led him to believe that his policy was covered with continuity benefits. When the company intends to accept a proposal as fresh, the same should be conveyed to the proposer expressly so that he is able to take an informed decision. By not doing and invoking the provision only at the time of claim, the company has prejudiced the rights of the complainant nullifying the benefits of the past continuous coverage. In view of the same denial of the claim by treating the policy with Respondent as a fresh and applying fresh Waiting period of 36 months is not justified as the complainant is entitled to continuity benefit up to the extent of Sum Insured held under Max Bupa. The decision of the Respondent to repudiate the claim on the ground stated by them cannot be sustained and is set aside by the following Order:

AWARD

Under the facts and circumstances of the case, Bajaj Allianz General Insurance Company

is directed to pay the admissible claim amount of Rs.57,000/- less non medical expenses

as per policy terms and conditions in favour of the complainant Mr.Dilip V.Khanivadekar, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

e) As per 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.

f) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This day of 24

th December 2018 at Mumbai.





COMPLAINANT - MR. GIRISH SALUNKHE

VS RESPONDENT : MAX BUPA HEALTH CO. LTD.


1 Name & Address of the Complainant Mr. Girish Salunkhe Mumbai


30470100201601 Family First Silver Policy

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Sum Insured

24.10.2016 – 23.10.2017

Rs.25,00,000/-

3 Name of Insured


Mr. Sharad Atmaram Salunkhe

4 Name of Insurer Max Bupa Health Insurance Co. Ltd.





9 Amount of claim 2) Rs.4,50,000/-



12 Complaint registered under Ombudsman Rules

Under Rule 13(b)



a) For the complainant Mr. Girish Salunkhe

b) For the insurer Ms. Shital Patwa



Brief Facts of the Case : Complainant’s father Mr. Sharad Salunkhe was admitted to Wockhardt Hospital on 11.11.2016 with complaints of chest pain and was provisionally diagnosed with IWMI. He was operated with angioplasty; however he unfortunately expired on 12.11.2016 following cardiogenic shock, pulmonary edema. A claim lodged under the policy for the said hospitalization was repudiated by the Respondent on the ground of non-disclosure of history of IHD – Unstable Angina since 20.04.2015 and Diabetes since 4 years which was prior to policy inception date.

Contentions of the Complainant : Complainant stated that his father was working as a driver with

Kandivali Fire Brigade. He was insured with Oriental Insurance Co. since the year 2010 and had also taken a

Super Surplus policy from Star Health w.e.f. January 2015. In October 2015 he was approached by

Respondent‟s agent who convinced him to shift his policy to their Company promising benefits of higher sum

insured for entire family and excellent claims service and also cashless benefit. At that time, his father disclosed

to the agent all his pre-existing ailments of DM, Cataract and angiography undergone by him in April 2015. He

also gave a copy of his Star Health policy which clearly mentioned Diabetes as PED to the agent. However,

while filling up the proposal form, the agent and an employee of the Respondent chose to selectively declare the

information in the proposal form by mentioning only the history of Cataract to ensure sale of policy and his

father being uneducated, trusted them and simply signed the form in Marathi. The policy was accordingly

issued by the Respondent w.e.f. 24.10.2015 and was renewed for the subsequent year. On 11.11.2016 his father

suffered a heart attack while on duty in office following which he was admitted to Wockhardt Hospital. During

the course of treatment, he expired in the hospital on the next day. Respondent denied their request for cashless

approval citing non-disclosure of h/o IHD & DM and they had to run from pillar to post for arranging funds to

pay the hospital bill for claiming the insured‟s body. They then filed a claim for reimbursement of

hospitalization expenses through the agent and followed up with him and Co. official Mr. Soni who initially

washed off their hands saying that they were only into “Sales” and not “Customer service”. The agent later on

confessed to them that he was aware of the fact that Mr. Salunkhe was suffering from diabetes and had

undergone CAG prior to taking the policy but thought that it was not important to declare the said facts in the

proposal form. The agent then advised them to get the insured‟s Death summary changed from the hospital by

deleting record of “diabetes” and also to manage the doctors at Wockhardt Hospital and the records at the

insured‟s work place. Complainant expressed anguish over the treatment meted out to them by the

Respondent‟s agent and officials during the entire process and demanded strict action against the agent for

misguiding the customers and subjecting them to such harassment in their hour of need. He further mentioned

that they ultimately got reimbursement of the hospitalization claim from his father‟s employer.

Contentions of the Respondent: Ms. Shital submitted that Mr. Sharad Salunkhe was issued Family First

Silver Policy effective from 24.10.2015 by their Company on the basis of information provided by him in the

proposal form. In the said proposal form only his history of cataract was mentioned and no other medical

history was provided nor was the same brought to the notice of the Company even after issuance of the policy

without mentioning the PED of DM/IHD. Also it was not a ported policy as the details of previous insurance

were not furnished along with the proposal. On receipt of a request for cashless authorization for Mr. Sharad

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Salunkhe‟s admission to Wockhardt Hospital on 11.11.2016, it was observed that the patient had history of

IHD- Unstable Angina since 20.04.2015 and Diabetes since 4 years. As the said history was pre-existing to the

inception of the policy and was not disclosed while obtaining the policy, cashless facility was denied on the

ground of non-disclosure of material facts as per policy condition. She stated that no reimbursement claim was

lodged with the Company thereafter.

Forum’s Observations/Conclusion: After hearing the depositions of both the parties and analyzing the

documents produced on record, it is observed that the complainant had continuous insurance coverage since the

year 2010. He was misguided by the Respondent‟s agent to shift his policy to their Company without declaring

his PED although his previous policy with Star Health mentioning his PED was shared by him with the agent.

Consequently he lost all his continuity benefits and was also deprived of his genuine claim at the most critical

time, leaving his family members in distress. Fortunately, the hospitalization expenses were later on reimbursed

by his employer. Hence no relief can now be granted as far as the claim amount is concerned. However, the

Forum observes that this is a clear case of mis-sale by the Company‟s agent for which the Respondent should

own up responsibility and refund the premium received by them for both the policy years. The Forum therefore

passes the following Order:

AWARD

Under the facts and circumstances of the case, Max Bupa General Insurance Co. Ltd. is directed to refund an amount of Rs.44,745/- towards premium paid by the insured for two policy periods commencing from 24.10.2015, in full and final settlement of the complaint. There is no order for any other relief. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

g) As per 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.

h) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 14


(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN: SHRI MILIND KHARAT

CASE OF COMPLAINANT – Mr. Girish F Shah

VS RESPONDENT: The Oriental Insurance co. ltd.

COMPLAINT REF: NO: MUM-G-050-1718-1871 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr. Girish F.Shah

604, Ajit Apartment, Sambhav CHS,

Sarvodaya Nagar, Mulund West, Mumbai-400080.

2 Policy No: 131300/48/2017/20885

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Type of Policy


Happy Family Floter Policy 2015 Policy

30.03.2017 to 29.03.2018 Rs.3, 00,000/-

3 Name of Insured


Mrs.Jayshree Girish Shah

Mr.Girish F.Shah







10 Amount of Partial Settlement Rs.24,000/-



Ombudsman rules, 2017

Under Rule 13(b)

13 Date of Hearing 23,08.2018, 1.15 pm


a) For the complainant Mr.Girish F.Shah

b) For the insurer Mrs.Rohini S.Kumar, Agency Manager.



Brief Facts of the Case : Mrs.Jayshree Girish Shah, wife of Complainant hospitalized for Right eye Cataract surgery at The Eye Super Specialities , Ghatkopar Mumbai on 4.08.2017. The Complainant has lodged the claim for Rs.40,431/- on 11.08.2017. The claim was partially settled for Rs.24, 000/- and Rs.16,431/- was disallowed under customary and reasonable expenses.

Contentions of the Complainant: The Forum asked the complainant to brief about the case which the Complainant submitted that he was covered under Happy Family Floater policy since 2000 and as per policy terms and conditions; he is eligible for reimbursement of claim for full amount for cataract operation. Hence the settlement is not acceptable to him. During the hearing he submitted that the earlier cataract claim for Left eye dated 15.07.2016 was settled by the Insurance Company for Rs.33,297/-of the same hospital. During the hearing he requested to the Forum for balance amount of Rs. 16,431/-/- .

Contentions of the Respondent: The Forum asked the Company the reasons for short payment of the claims. The Company official, Mrs. Rohini S,Kumar Agency Manager, submitted that the TPA has

compared the charges of other hospital including tertiary care hospital in metro cities of same grade

for present Cataract surgery and the maximum amount is payable Rs.24, 000/- for each eye. The Respondent agreed for settlement of the balance amount of Rs.9,297/- for Right eye cataract surgery.

Forum’s Observations/Conclusion: On scrutiny of the documanents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, Surgeon fees are on the higher side. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation. Hence going by the comparative charges of earlier cataract surgery charges paid by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the total payable amount to Rs.33,297/-. Hence the balance amount for Rs. 9,297 (33,297 -24,000/-) is to be paid the complainant. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.9,297/- in favor of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

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(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. HEMANT PATEL



1 Name & Address of the Complainant Mr. Hemant Patel

Mumbai



13150034162500007165 New Mediclaim Policy 2012

30.11.2016 – 29.11.2017 Rs.8,00,000/- + C.B. Rs.1,71,500/-

3 Name of Insured


Ms. Heena H. Patel



6 Reason for repudiation Hospitalization less than 24 hours



9 Amount of claim Rs. 58,125/-




Under Rule 13(b)



a) For the complainant Mr. Hemant Patel

b) For the insurer Mr. Shashikant Verma



Brief Facts of the Case : Complainant’s wife Ms. Heena Patel was administered Intravitreal Inj. Accentrix on 17.03.2017 & again on 21.04.2017 at Krishna Eye Centre for the treatment of LE Branch Retinal Vein Occlusion, for which he lodged two separate claims under the policy. Respondent rejected both the claims under Clause 2.16.1 of the policy as hospitalization was for less than 24 hours and the said procedure is also not listed under Clause 2.11 as a Day Care procedure.

Contentions of the Complainant : Complainant contended that his wife had complaints of sudden visual disturbances only in one eye for which she was investigated and was diagnosed with Branch Retinal Vein

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Occlusion in the left eye. As per advice of a Retina Specialist doctor, she was administered Intravitreal Injections Accentrix on 17.03.2017 & 21.04.2017. Respondent rejected the claims for the same stating that admission was for less than 24 hours. He argued that the injection is to be given in the eye under all aseptic conditions in a very sterile atmosphere such as in an O.T. It is a technological advancement and requires medical expertise with safe anesthetic practices and such procedures are done as a day care procedure not requiring 24 hours stay in the hospital. He himself being a physician and ophthalmologists being his colleagues, they helped his wife with personal attention and not charging for medical consultations, Laser treatments and follow-ups which would have definitely cost the treatment much more than what they have claimed for but they being reasonable they kept the cost of the treatment to minimum. He stated that the reason cited by the Respondent for rejection of the claim was not acceptable to them and requested for settlement of both the claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that on scrutiny of the documents it was observed that in both the cases the total period of hospitalization was less than 24 hours and the said procedure is not listed as a day care procedure under the policy. Since the policy terms and conditions state that hospitalization benefits are admissible only if hospitalization is for a minimum period of 24 hours, the claims stood repudiated under Clause nos. 2.16.1 & 2.11 of the policy.

Observations/Conclusion: This Forum has received a number of complaints against non-settlement of claims for such Anti VEGF injections and has made a detailed analysis of all the facts related to the treatment vis-à-vis the Insurance Company’s stand in dealing with these claims which have been elaborated in the Awards issued by the Forum in similar cases heard earlier. During the hearing of these cases the complainants have submitted to the Forum certificates from leading Ophthalmologists mentioning the fact that this procedure is not a surgical intervention but is to be carried out in Operation theatre to maintain a sterile environment. The Insurance Company has also produced certificates from qualified Ophthalmologists stating that injection Lucentis/Avastin is given intravitreal in operation theatre under asceptic precaution and this can be done as an OPD procedure without indoor admission. The facts that have been brought to the notice of the Forum clearly indicate that this procedure is an advancement of medical technology where minimum of 24 hours of hospitalization is not required. Based on the deposition of the complainants, the forum notes that the treatment is a prolonged one wherein depending upon the prognosis the patient has to be administered more number of injections. The various certificates issued by the eye specialists indicate divided opinion amongst the doctors regarding the procedure being an inpatient or outpatient one. Though the Forum is also able to appreciate the case of the complainant in expecting the Insurer to settle the claims in as much as the treatment being a prolonged one and repetitive in nature but for the reasons stated above, it would be reasonable that the complainant bears a part of the expenses. Accordingly, taking a practical view of the facts of the case, which have been brought to the notice of this Form, the Forum has come to the conclusion that the cost of the treatment is to be shared equally between the complainant and the Respondent. The decision of the Respondent is therefore set aside by the following order.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd. is directed to pay 50% of the admissible expenses, in favour of the complainant Mr.

Hemant Patel, as full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 6


(MILIND KHARAT)

INSURANCE OMBUDSMAN

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CASE OF COMPLAINANT - MR. KANTILAL MANEK HARIA

VS RESPONDENT : APOLLO MUNICH HEALTH INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Kantilal Manek Haria

Mumbai



160400/11111/1000387035-02 Easy Health Floater Policy

19.04.2016 to 18.04.2018 Rs. 3,00,000/-

3 Name of Insured


Mr. Kantilal Manek Haria

4 Name of Insurer Apollo Munich Health Insurance Co. Ltd.


6 Reason for repudiation Non-disclosure of material fact








Under Rule 13(b)



a) For the complainant Mr. Kantilal Manek Haria

b) For the insurer Dr. Sunetra Rane



Brief Facts of the Case : Complainant was admitted to Kohinoor Hospital from 21.09.2017 to 25.09.2017 for the treatment of Coronary artery disease. Respondent repudiated the claim for the said hospitalization on the ground that there was non-disclosure on the part of the insured about his history of DM & HTN since 10 years.

Contentions of the Complainant : Complainant submitted that on 21.09.2017 around 9.45 p.m. he was admitted to Kohinoor Hospital following myocardial infarction. On admission he underwent angiography and was shifted to ICU ward around 1.30 p.m. on the next day. At that time the doctor on night duty asked several questions to his son and his son unknowingly told that he had BP and sugar problem since last 10 years instead of 3 years. On the basis of the said incorrect information, his request for cashless approval was denied by the Respondent. After discharge from the hospital, when he lodged a claim for reimbursement, the same was also denied on the ground of non-disclosure of BP and Sugar. He then submitted to the Respondent a letter from his doctor stating the correct duration of DM & HTN as since 3 years and also the test reports done before taking the policy in the year 2013. Despite this, the Respondent maintained their stand of rejection of the claim. He averred that he was detected with DM in 2014 i.e. after one year of taking the policy and the same was not pre-existing to the policy inception. He therefore requested for settlement of the claim. He added that the policy was not renewed by the Respondent after its expiry in April 2018.

Contentions of the Respondent: Dr. Sunetra submitted that the complainant was hospitalized on 22.09.2017 for Anteroseptal myocardial infarction. He was diagnosed with CAD in a k/c/o DM & HTN and underwent PTCA. On scrutiny of the claim documents, it was noted that the insured had h/o DM & HTN since

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10 years and was on medication for the same which fact was not disclosed at the time of taking the policy. Hence the claim was rejected under Section VII(j) of the policy terms and conditions on the ground of non-disclosure and concealment of facts while proposing for insurance. She however stated that the claim has now been reviewed by the Company and they are willing to settle the same for an amount of Rs.3,08,030/-.

Forum’s Observations/Conclusion : Since the Respondent has agreed to settle the claim of the

complainant as per policy terms and conditions, the complaint is closed with the following directions:

AWARD

Under the facts and circumstances of the case, Apollo Munich Health Insurance Co. Ltd. is directed to reinstate the policy and pay the admissible claim amount of Rs.3,08,030/- in

favour of the complainant Mr. Kantilal Manek Haria, in full and final settlement of the complaint.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:




(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN: SHRI MILIND KHARAT CASE OF COMPLAINANT – Mr. Karan Chandiok

VS RESPONDENT: The Oriental Insurance co. ltd.


1 Name & Address of the Complainant Mr. Karan Chandiok, Mumbai-400050


124500/48/2018/2211 Happy Family Floater Policy 30.07.2017 to 29.07.2018 Rs.10, 00,000/-


Mr.Karan Chandiok Mrs. Harvinder Kaur Chandiok

4 Name of Insurer The Orienttal Insurance Co. Ltd.



7 Date of receipt of the complaint 29.012018



10 Amount of Partial Settlement Rs.3,36,050/-


12 Complaint registered under Insurance Ombudsman rules, 2017

Under Rule 13(b)

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13 Date of Hearing 29,08.2018, 11.15 am


a) For the complainant Mr. Karan Chandiok

b) For the insurer Mrs.Akshada Atul Mukne, A.O.



Brief Facts of the Case : Complainant’s mother Mrs. Harvinder Kaur Chandiok 57 years old was admitted to Breach Candy Hospital on 23-08-2017 for the treatment of Postmenopausal Bleeding and operated for Vaginal Hysterectomy on 24-08-2017 and discharge on 26-08-2017.

The Complainant has lodged the claim for Rs.3,91,798/- on 01.09.2017. The claim was partially settled for Rs.3,36,050/- and Rs.55,748/- was disallowed towards surgeon charges under customary and reasonable expenses clause 3.41.

Contentions of the Complainant: The Forum asked the complainant to brief about the case which the Complainant submitted that he and his family were covered under the Happy Family Floater Policy since 2012 for 10, 00,000/- sum insured. During the hearing he submitted that his mother was admitted at Brach Candy Hospital and submitted the claim to Insurance Company. The Insurance Company has disallowed the claim for Rs.55,748/- towards surgeon fees. Hence the settlement is not acceptable to him. He requested to the Forum for balance amount of Rs. 55748/-.

Contentions of the Respondent: The Forum asked the Company the reasons for short

payment of the claims. The Company official, Mrs.Akshada Atul Mukne, Administrative Officer, submitted that the Raksha Health Insurance TPA has compared the charges of other hospital including tertiary care hospital in metro cities of same grade for present surgery and maximum surgeon charges of Rs.1,43,500/- was paid against Rs.1,80,000/- hence excess amount of Rs.36,500/- was deducted along with consultation charges, assistant surgeon charges and non medical expenses. However during the hearing the Respondent agreed for settlement of the balance amount of Rs.38,200/-i.e. (surgeon fees Rs.36500/- & consultation fess Rs.1700/-).

Forum’s Observations/Conclusion: The Respondent has agreed to pay Rs.38,200/- which the Complainant has accepted hence the following Order:

AWARD Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.38,200/- in favor of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 3rd day of January, 2019 at Mumbai.


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MUMBAI & GOA




COMPLAINANT - MR. KARNIK PARIKH

VS RESPONDENT : HDFC ERGO GENERAL INSURANCE CO. LTD.

COMPLAINT REF NO: MUM-G-018-1718-2016 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr. Karnik Parikh Mumbai


2866201775574400000 Health Medisure Super Top Up Policy 22.05-2017 – 21.05.2018-.2018


Mr. Karnik Parikh

4 Name of Insurer HDFC Eargo General Insurance Co. Ltd.


6 Reason for repudiation Exclusion Clause F-1







Under Rule 13(b)

13 Date of Hearing 28.08.2018 – 11.15 A.m.


a) For the complainant Not present as settled before hearing

b) For the insurer Not Present as settled before hearing



Brief Facts of the Case : Complainant was admitted to Breach Candy Hospital,

Mumbai from 18.08.2017 to 24.08.2017 for the treatment of Acute Coronary Syndrome with

gradually raising cardiac enzymes with KGS changes. Respondent repudiated the claim

lodged under the policy for the said hospitalization on the ground that patient is a known case

of Asthma before the first inception of the policy (22-05-2015) and there is history of Asthma

since childhood. Hence, on non disclosure of material facts the claim was repudiated under

section F 1 of policy terms and conditions.

Contentions of the Complainant : Complainant contended that he was admitted to the

Breach Candy hospital for the treatment of coronary artery disease, hypertension and renal

artery stenosis. The company has rejected the claim on the ground of history of Asthma since

childhood and same was not disclosed. Hence the reason cited by the Respondent for

rejection of the claim was not acceptable to them. He requested for settlement of the claim.

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Contentions of the Respondent: The official of HDFC Ergo General Insurance Co. Ltd. was remained absent. They submitted in their statement that the claim is for the hospitalization of Mr. Karnik Parikh at Breach Candy Hospital from 18.08.2017 to 24.08.2017 for the treatment of Acute Coronary Syndrome. The Insurance Company has settled the above claim for Rs.8,54,868/- in favour of the Complainant and requested for withdrawal of the complaint.

Forum’s Observations/Conclusion: Before hearing the Complainant informed the Forum that the claim for Rs.8,54,868/- has been settled by the Insurance Company and has

withdrawn of the complaint. In view of the amicable settlement by the parties, the complaint

stands closed at this Forum. There is no order for any other relief.

Dated: This 2nd

day of January , 2019 at Mumbai.






CASE OF COMPLAINANT - MR. Kunal Sanghvi VS

RESPONDENT : THE ORIENTAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Kunal Sanghvi Mumbai


121300/48/2017/2924 Happy Family Floater Policy 18.07.2016 to 17.07.2017 Rs.10,00,000/-

3 Name of Insured/Patient Name of the policy holder

Mr. Vijay M.Sanghvi Mr. Kunal Vijay Sanghvi


5 Date of Partial Repudiation 28.02.2018, 01.03.2018, 05.03.2018

6 Reason for repudiation Medicines not related to ailment & over charged doses.



9 Amount of total claim Rs.8,42,576/-( for 4 claims)



12 Complaint registered under Insurance Ombudsman rules

Under Rule 13(b)


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a) For the complainant Mr. Kunal Sanghvi

b) For the insurer Mrs.Rajashri N.Korgaonkar, Asst.Manager




Complainant‟s father Shri Vijay M.Sanghvi was admitted to Saifee Hospital, Mumbai from

18.02.2017 to 21.02.2017 for Acute Cardiac Failure, Distolic Ventricular Dysfuction Lower

Respriratory Tract Infection and 07.05.2017 to 10.05.2017for Acute Gastroentertis with

K/C/O DM, HTN, since 1.5 years CKD on medicines.. Total 4 claims were lodged for Rs.

8,42,576/- the Company settled the claim for Rs. 2,79,995/- and deducted Rs.5,62,581/-as

the medical expenses taken are not related to present illness. Pre-post hospitalisation claim

towards medicines and injections purchased were more than the requirements. Hence the

overcharged doses will not be admissible under Policy Clause 3.36. The Complainant

approached this Forum with a complaint against short-settlement by the Respondent of a

claim lodged under the policy.

Contentions of the Complainant : The Forum asked the Complainant to brief the case. Complainant submitted that his father

was admitted at Saifee Hospital and submitted total 4 claims for Rs.8,42,576/-Respondent

reimbursed him only Rs.2,79,995- including pre and post hospitalisation claims which was

not acceptable to him and requested for settlement of the balance claim amount.

Contentions of the Respondent: The Forum asked the Company the reason for partial settlement of the claim to which the Company submitted that a deduction of Rs.5,62,581/- was made from the claim amount as per Clause 3.36 of the policy and gave detailed explanation for the following four claims: 1)Claim No.55621617586346 – Patient admitted from18-02-2017 to 21-02-2017 for diagnosis of acute cardiac failure/Lv dysfunction The patient had brought 120 tablets cudoforte on 21-01-2017 which is recommended for 3 times a day against 84 tablets & the injection victoza was purchased 8 vial of each 2 ml against 1.8 unit per day, whereas inj.tresiba charged for Rs.14800/- is a form of insulin which is paid under lanctus & apdra inj charges for hosptalisation are overcharged doses, hence deducted Rs.56121/-. 2)Claim No.-55621718093623: Patient admitted for complaints of Gastroenteritis, so all medicine related to HTN/CKD/DM are not payable, hence deducted Rs.128154/- 3) Claim No.55621718019214: Patient submitted the claim against pre post claim no. 55621617586346 for same hospitalisaton period and submitted overcharged doses under medication charges aginst tablets and injections i.e. patient purchased 240 cudoforte tablets & 540 renolog tabltes whereas he required only 180 tablets each & injection victoza 26 vial, of 2 ml against 1.8 ml, injection lantus 30 each 3 ml, 70 injection each 3 ml was purchased against recommended 1.8 unit per day. Hence deducted Rs.132716/-. 4)Claim No. 55621718110585:-Complainant submitted the claim for Rs.2,45,590/- for pre post claim of Gastroenteritis. As per policy terms and conditions, in post hospitalization charged to main ailment are admissible. The Company repudiated the claim as all medicine are purchased for HTN/CKD/DM and not related to present illness. Hence the claim not payable under clause 3.36.

Forum’s Observations/Conclusion: The Forum has scrutinized all the documents produced on record. As per policy terms the Respondent is liable to pay reasonable and necessary medical expenses relevant to the treatment. Whenever it is observed that the charges of medicine and injections etc purchased in more quantity against the relevant requirements, the Company is within its right to limit the expenses payable for a particular ailments.

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The decision of the Respondent being in accordance with the policy terms and conditions. The Forum does not find any valid ground to intervene with the decision of the Respondent in the same matter and pass the following Order:

AWARD Under the facts and circumstances of the case, the complaint lodged by Mr. Kunal Sanghvi against The Oriental Insurance Co. Ltd. does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 24th day of December, 2018 at Mumbai.




OMBUDSMAN: SHRI MILIND KHARAT

CASE OF COMPLAINANT – Mr. Laxmichand G. Dharod

VS RESPONDENT: United India Insurance co. ltd.


1 Name & Address of the Complainant Mr. Laxmichand G. Dharod, Mumbai-400064


0204002817P112783815 Individual Health Policy 26.12.2017 to 25.12.2018 Rs.5, 00,000/-


Mr. Laxmichand G. Dharod,

4 Name of Insurer United India Insurance Co. Ltd.





9 Amount of claim Rs.48,210-

10 Amount of Partial Settlement Rs.40,000/-

11 Amount of relief sought Rs.8210/-

12 Complaint registered under Insurance Ombudsman rules, 2017

Under Rule 13(b)

13 Date of Hearing 29,08.2018, 3.00 pm


a) For the complainant Mr. Laxmichand G. Dharod,

b) For the insurer Mrs. Rupali V.Chaubal, A.O.

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Brief Facts of the Case : Mr. Laxmichand G. Dharod Complainant hospitalized for Right eye Cataract surgery at Envision Eye Hospital Mumbai on 08.12.2017. The Complainant has lodged the

claim for Rs.48,210/- on 15.12.2017. The claim was partially settled for Rs.40, 000/- and Rs.8,210/- was disallowed under customary and reasonable expenses.

Contentions of the Complainant: The Forum asked the complainant to brief about the case which the Complainant submitted that he was covered under Gold Mediclaim policy for 5,00,000/- sum insured and as per policy terms and conditions; he is eligible for reimbursement of claim for 25% of sum insured i.e.full amount for cataract operation. Hence the settlement is not acceptable to him. During the hearing he requested to the Forum for balance amount of Rs. 8,210/-.

Contentions of the Respondent: The Forum asked the Company the reasons for short payment of the claims. The Company official, Mrs. Rupali V. Chaubal, Administrative Officer, submitted that the TPA has compared the charges of other hospital including tertiary care hospital in metro cities of same grade for present Cataract surgery and the maximum amount payable is Rs.48, 000/- for each eye. During the hearing the Respondent agreed for settlement of the balance amount of Rs.8,000/- for Right eye cataract surgery.

Forum’s Observations/Conclusion: On scrutiny of the documents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, Surgeon fees and Theater charges are marginally on the higher side. The Respondent has now agreed to pay Rs.8000/- which the Complainant has accepted hence the following Order:

AWARD Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.8,000/- in favor of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 2nd day of January, 2019 at Mumbai.



MUMBAI & GOA


(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017) OMBUDSMAN : SHRI MILIND KHARAT

CASE OF COMPLAINANT - MR. M.B.KAPADIA

VS

RESPONDENT : THE ORIENTAL INSURANCE CO. LTD.

COMPLAINT REF: NO: MUM-G-050-1718-2060


1 Name & Address of the Complainant Mr. M.B.Kapadia Mumbai

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Policy No: Type of Policy Duration of Policy/Period Sum Insured

124700/48/2017/8657 Mediclaim Insurance Policy (Individual ) 18.11.2016 to 17.11.2017 Rs.400000/-


Mr.M.B.Kapadia



6 Reason for repudiation Reasonable and Customary Clause 3.15


8 Nature of complaint Partial Settlement of claim


10 Amount of Partial Settlement Rs. 2,39,257


12 Complaint registered under Insurance Ombudsman Rules, 2017

Under Rule 13(b)

13 Date of Hearing 29.08.2018 – 01.15p.m.


a) For the complainant Mr. M.B.Kapadia

b) For the insurer Mr.Manoj S.Gajbhiye, Asst. Manager



Brief Facts of the Case : Complainant was admitted to Jaslok Hospital from 08.04.2017 to

09.04.2017 for CAG for Cardiac and SOS PTCA. Complainant approached this forum with a

complaint against non settlement by the Respondent of a claim lodged for the said hospitalisation.

Contentions of the Complainant : Complainant submitted that he was admitted to Jaslok

Hospital from 08-04-2017 to 09-04-2017 for his third Angioplasty. The Complainant had submitted

during the hearing that his family members are covered with The Oriental Insurance Company for

more than 10 years. Total claim was lodged for Rs.4,70,646/- along with pre-post hospitalization

claim. The Company settled the claim for Rs.2,39,257/-. An amount of Rs.2,31,389/- was deducted

under reasonable and customary charges as per PPN package. He is not agreeable with the decision

of the Insurance Company and requested for settlement of the balance claim amount.

Contentions of the Respondent: The Forum asked the Company the reasons for short payment

of the claim. The Company official submitted that the Park Mediclaim Insurance TPA has deducted

the charges towards over and above the package charges for Angiography with Angioplasty which is

inclusive of Surgeon fees, Anaesthesia fees under package. Moreover, Cashless facility was available

in Jaslok Hospital, despite that the complainant has gone for reimbursement. Hence, the balance

amount has been disallowed as per PPN package agreed upon with the hospital.

Forum’s Observations/Conclusion: The Forum has scrutinized all the documents produced on

record and observed that complainant has undergone treatment for Angiography with Angioplasty

at Jaslok Hospital. He lodged total claim of Rs.4,70,646/- and the Company has settled it for

Rs.2,39,257/- and disallowed the balance claim amount of Rs.231389/- as per PPN package. Since

the hospital is under PPN, if the patient has been overcharged by the hospital, the Respondent should

seek clarification from the hospital. There is no justification for deductions from the bill amount on

the ground of reasonability. The claim of the complainant has to be settled for the balance amount

towards hospitalisation expenses less non-medical items. The decision of the Respondent is therefore

intervened by the following order.

AWARD Under the facts and circumstances of the case, The Oriental Insurance Company is directed to

pay the admissible claim amount of Rs.231389/-less non medical expenses as per policy terms

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and conditions in favour of the complaint Mr.M.B.Kapadia, towards full and final settlement

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

Insurance Ombudsman Rules, 2017:



Dated: This 3rd

day of January, 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. MISHRIMAL B.SHAH VS

RESPONDENT : MAX BUPA HEALTH INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Mishrimal B.Shsh Mumbai


30512315 Family First Gold & Floater Policy 17.03.2016 to 16.03.2018 Rs. 5,00,000/- & Floater- 15,00,000/-


Mr. Mishrimal B. Shah Mr.Mishrimal B.Shah

4 Name of Insurer Max Bupa Health Insurance Co. Ltd.


6 Reason for repudiation Non-disclosure of material facts



9 Amount of claim 1) Rs.3,21,367/- & Rs.71,816/- Total Rs.3,93,183/- & Prem of Rs. 1,28,972/-




Under Rule 13(b)



a) For the complainant Mr. Mishrimal B. Shah

b) For the insurer Shital Patwa, Mgr. Legal



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Brief Facts of the Case : Complainant was admitted to Breach Candy Hospital Mumbai from 30.10.2016 to 05.11.2016 for the treatment of Acute Subdural Hematoma . He lodged a claim for Rs.3,93,183/- (incl. pre & post hospitalization expenses of Rs. 71,816/-) and refund of premium of Rs.1,28,972/- against the cancellation of the said policy. The claim was repudiated by the Respondent on the ground of non-disclosure of history of Hypertension since 4-5 years, Neck pain problems since last 3-4 years before the inception of the Insurance Policy as the same were not disclosed while taking the policy. Aggrieved with the decision of the Respondent, complainant approached this Forum seeking relief in the matter.

Contentions of the Complainant : The Forum asked the Complainant to brief about the case to which he submitted that he was hospitalized in Breach Candy Hospital on 30-10-2016 for Acute Subdural Hematoma and got discharged on 05-11-2016. Respondent repudiated the claim for the said hospitalization and terminated the policy on the ground of Non-disclosure of hypertension, neck pain. He stated that he never had hypertension or any other medication for any ailment. He submitted that he had under gone pre policy medical and health check-up form Max Bupa Insurance Company and the policy was issued with yearly premium of Rs. 1,28,972/- for himself and his spouse. He stated that there was no question of any non-disclosure on his part and requested for settlement of the claim. He added that the Respondent also cancelled the policy for both his wife and himself which should be reinsteated.

Contentions of the Respondent: The Forum asked the Company the reasons for repudiation of claim to which Ms. Shital Patwa Manager Legal stated that Mr.Mishrimal B. Shah was insured with them since 17.03.2016 along with his spouse. On receipt of the claim documents, it was observed from the complainant had a history of Bilateral Glaucoma since many years and Hypertension/Neck pain since 3 to 5 years. The said history dates back prior to inception of the policy and were not disclosed at the time of proposing for insurance. The claim was repudiated on the ground of Non-Disclosure of material facts/Pre Existing ailment of Hypertension since 4 to 5 years and the policy being a floater policy, was cancelled for both the members.

Forum’s Observations/Conclusion: The Forum observed in this case that the Complainant was admitted to Breach Candy Hospital and lodged the claim for Rs.3,93,183/- along with refund of premium of Rs.1,28,972/-.The Company repudiated the claim on the ground that complainant had a history of Bilateral Glaucoma since many years and Hypertension/Neck pain since 3 to 5 years. As the said history dates back prior to inception of the policy but was not disclosed at the time of proposing for insurance. On scrutiny of the documents produced on record, it is observed from the discharge summary of Breach Candy Hospital that the patient was dignosed for Acute Subdural Hematoma Left posterior frontoparietal and accordingly treatment was given in the hospital. This being not related to alleged pre-existing conditions. Company’s stand of repudiation of the claim on the ground of non disclosure of past history for hypertension and neck pain is not sustainable. The Forum directed company to rework and pay the admissible expenses and reinstate the policy. Accordingly the Company has workout and is agreeable to settle the claim for Rs. 3,70,491/- i.e.(Rs. 318736/- & Rs.52055/-) towards full and final settlement of the claim.

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AWARD

Under the facts and circumstances of the case, Max Bupa Health Insurance Company is directed to pay the admissible claim amount of Rs.3,70,491/- and reinstate the policy. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

i) As per 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.

j) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This day of 2nd January 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA




CASE OF COMPLAINANT - MR. MAHESH DOSHI

VS

RESPONDENT - IFFCO-TOKIO GENERAL INSURANCE CO. LTD.




Mr. Mahesh Doshi, Mumbai

2


52643390 & 52807079 Health Protector Policy 24.06.2016 to 23.06.2017 & 24.06.2017 to

23.06.2018, Rs.400000/-& CB-Rs.2,00,000/-


Mr. Mahesh Doshi Mrs. Jyotsana Mahesh Doshi

4 Name of Insurer IFFCO-TOKIO General Insurance Co. Ltd.

5 Date of Repudiation 20.07.2017 & 08.08.2017

6 Reason for repudiation Registration Number & Duration of hospital



9 Amount of claim Rs.67,300/- & Rs.1,05,600/-


11 Amount of relief sought Rs.67,300/- & Rs.1,05,600/-

12 Complaint registered under Under Rule 13(b)

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b) For the insurer Dr. Satya Vijay Abnave



Brief Facts of the Case : Complaint's wife Mrs.JyotsnaMahesh Doshi was operated for

both eyes for Cataract Surgery at Nagvekar Eye Clinic on 15.06.2017 and 07.07.2017. A

claim were lodged under both the policies for Rs.67300/- and Rs.105600/- respectively and

the same was repudiated by the Respondent under Clause 40 of the policy and the query was

raised by the Respondent for submission of hospital registration certificate establishment

under Clinical Act.

Contentions of the Complainant : Complainant remained absent. Based on his

written submission the hearing continued with the Company. The Complainant has submitted

in his statement that his wife had undergone Trabeculectomy with Ologen Implantation

Surgery and lodged a total claim of Rs.1,72,900/-. The Company repudiated the claim on the

ground that the hospital is not registered as per Bombay Nursing Home Act and the hospital

not fulfil the criteria of day care centre/hospital/nursing home as per policy terms and

conditions under clause 40. He submitted the treating Doctor‟s certificate dated 29th

July

2017 stated that all kinds of Ophthalmic Surgeries require only day‟s admission only and

does not require Nursing Home Registration under Mumbai Nursing Home Act with the

Corporation. Further

Doctor stated that Nagvekar Eye Clinic is registered with Directorate of Health Services

Govt. Of Maharashtra under the registration number BCA-12 and also registered with the

MCGM under Registration No. 760145442. Complainant approached this forum with a

complaint against repudiation of the claim by the Respondent.

Contentions of the Respondent: The Forum asked the Company the reasons for

repudiating the claim to which the Company submitted that due to non submission of

required documents the claim was rejected as per policy clause 40 .

Forum’s Observations/Conclusion: The Forum observed in this case that

Complainant wife underwent cataract surgery with Trabeculectomy with Ologen

Implantation for both eyes at Nagvekar Eye Clinic and lodged the claim for Rs.1,72,900/-.

The Company has repudiated the said claim for non submission of required documents.

Forum observed that on perusal of the documents produced on record, the decision of the

Respondent to repudiate the claim is not justified. The Forum directed the Company to

rework and pay the admissible expenses in favour of the complainant. Accordingly the

company has reworked and is agreeable to settle the claim for Rs.66784/- & Rs.100994/-

totalling to Rs.167778/- for both the eyes towards full and final settlement of the claim. Other

deductions totalling to Rs.5122/- from the claim amount have been made in keeping with the

IRDAI guidelines. Hence the following Order:

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AWARD

The IFFCO-TOKIO General Insurance Company Ltd. is directed to settle the above claim for Rs.1,67,778/- and inform the payment particulars to this Forum. There is no order for any other relief. The case is disposed off accordingly. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the




Dated: This 2nd




MUMBAI & GOA



CASE OF COMPLAINANT - MR. MAHESH DOSHI

VS

RESPONDENT - IFFCO-TOKIO GENERAL INSURANCE CO. LTD. COMPLAINT REF: NO: MUM-G-023-1718-1795



Mr. Mahesh Doshi, Mumbai

2


52643390 & 52807079 Health Protector Policy 24.06.2016 to 23.06.2017 & 24.06.2017 to

23.06.2018, Rs.400000/-& CB-Rs.2,00,000/-


Mr. Mahesh Doshi Mrs. Jyotsana Mahesh Doshi

4 Name of Insurer IFFCO-TOKIO General Insurance Co. Ltd.

5 Date of Repudiation 20.07.2017 & 08.08.2017

6 Reason for repudiation Registration Number & Duration of hospital



9 Amount of claim Rs.67,300/- & Rs.1,05,600/-


11 Amount of relief sought Rs.67,300/- & Rs.1,05,600/-

12 Complaint registered under Under Rule 13(b)

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b) For the insurer Dr. Satya Vijay Abnave



Brief Facts of the Case : Complaint's wife Mrs.JyotsnaMahesh Doshi was operated for

both eyes for Cataract Surgery at Nagvekar Eye Clinic on 15.06.2017 and 07.07.2017. A

claim were lodged under both the policies for Rs.67300/- and Rs.105600/- respectively and

the same was repudiated by the Respondent under Clause 40 of the policy and the query was

raised by the Respondent for submission of hospital registration certificate establishment

under Clinical Act.

Contentions of the Complainant : Complainant remained absent. Based on his written

submission the hearing continued with the Company. The Complainant has submitted in his

statement that his wife had undergone Trabeculectomy with Ologen Implantation Surgery

and lodged a total claim of Rs.1,72,900/-. The Company repudiated the claim on the ground

that the hospital is not registered as per Bombay Nursing Home Act and the hospital not fulfil

the criteria of day care centre/hospital/nursing home as per policy terms and conditions under

clause 40. He submitted the treating Doctor‟s certificate dated 29th

July 2017 stated that all

kinds of Ophthalmic Surgeries require only day‟s admission only and does not require

Nursing Home Registration under Mumbai Nursing Home Act with the Corporation. Further

Doctor stated that Nagvekar Eye Clinic is registered with Directorate of Health Services

Govt. Of Maharashtra under the registration number BCA-12 and also registered with the

MCGM under Registration No. 760145442. Complainant approached this forum with a

complaint against repudiation of the claim by the Respondent.

Contentions of the Respondent: The Forum asked the Company the reasons for

repudiating the claim to which the Company submitted that due to non submission of

required documents the claim was rejected as per policy clause 40 .

Forum’s Observations/Conclusion: The Forum observed in this case that

Complainant wife underwent cataract surgery with Trabeculectomy with Ologen

Implantation for both eyes at Nagvekar Eye Clinic and lodged the claim for Rs.1,72,900/-.

The Company has repudiated the said claim for non submission of required documents.

Forum observed that on perusal of the documents produced on record, the decision of the

Respondent to repudiate the claim is not justified. The Forum directed the Company to

rework and pay the admissible expenses in favour of the complainant. Accordingly the

company has reworked and is agreeable to settle the claim for Rs.66784/- & Rs.100994/-

totalling to Rs.167778/- for both the eyes towards full and final settlement of the claim. Other

deductions totalling to Rs.5122/- from the claim amount have been made in keeping with the

IRDAI guidelines. Hence the following Order:

AWARD

The IFFCO-TOKIO General Insurance Company Ltd. is directed to settle the above claim for Rs.1,67,778/- and inform the payment particulars to this Forum. There is no order for any other relief. The case is disposed off accordingly.

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




Dated: This 2nd




MUMBAI & GOA




CASE OF COMPLAINANT - MR. MANISH RASIKLAL MODY

VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.

COMPLAINT REF: NO: MUM-G-049 -1718-1932


1 Name & Address of the Complainant Mr. Manish Rasiklal Mody, Mumbai.


112800/34/17/28/00000009 New India Floater Mediclaim Policy 04.04.2017 to 03.04.2018 Rs.8,00,000/-


Ms. Khushi Manish Mody Mr. Manish Rasiklal Mody



6 Reason for repudiation


8 Nature of complaint Equipment charges not paid


10 Amount of Partial Settlement Rs.97,852



Under Rule 13(b)

13 Date of Hearing 24.08.2018 – 11.15 am.


a) For the complainant Mr. Manish Rasiklal Mody

b) For the insurer Mr. Sourabh P. Kulkarni, A.O.



Brief Facts of the Case : The Complainant Mr.Manish Mody`s 4 year old daughter Ms. Khushi

Manish Mody was admitted to Speciality Ear Nose Throat Hospital from 23.05.2017 to 24.05.2017

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for Coblation Intracapsular Tonsillectomy with Adenoidectomy Surgery. The Complainant has lodged

the claim for Rs.24,150/- towards special equipment which was used for Coblation procedure

significantly reduced the operation time, intraoperative blood loss and postoperative pain. As per

Doctor`s certificate dated 06.06.2017 stated that the Coblation wand is an essential component for

treatment using the above procedure. The Company has deducted Rs,24,150/- under Reasonable and

Customary charges Clause No.3.39. Complainant approached this forum with a complaint against non

settlement by the Respondent of a claim lodged for the said equipment.

Contentions of the Complainant : He submitted that the Company has deducted the amount of Rs.24,150/- towards special equipment charges under reasonability clause 3.39 which

was not acceptable to them. He requested the Forum for settlement of the above claim which was

disallowed by the Respondent.

Contentions of the Respondent: The Forum asked the Company the reasons for the above

deductions to which the Company submitted that the Coblation procedures involve soft tissue

dissoluation using bipolar radiofrequency energy. As per policy terms and conditions this advanced

technique Company disallowed under reasonably and customary clause 3.39. Further, The Company

submitted that diagnosis and treatment are related to Enlargement Tonsille with Adenoids which was

not payable as per New India Floater Mediclaim policy clause 3.36.

Forum’s Observations/Conclusion : The Forum observed that the Company has settled the

claim as per policy terms and conditions. As per hospital bill, Complainant has already paid the

equipment charges and deducting from the same by the Insurance Company under customary &

reasonably clause is not fully justifiable, and the Company is directed to pay the 50% of balance

amount Rs.12075/-i.e.(Rs.24150 less Rs.12075/-) towards full and final settlement of the above claim.

Hence the following Order:

AWARD Under the facts and circumstances of the case, The New India Assurance Co. is directed to pay

the admissible amount of Rs.12075/- towards 50% of equipment charges, in favour of the

complaint Mr. Manish Rasiklal Mody, in full and final settlement of the complaint.





Dated: This 27th

day of December , 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

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MUMBAI & GOA



CASE OF COMPLAINANT - MR. HETAL S. MERCHANT

VS

RESPONDENT : UNITED INDIA INSURANCE CO. LTD.



1 Name & Address of the Complainant Mr. Hetal S. Merchant, Mumbai.


0203002816P118116382 Individual Health Policy 31.03.2017 to 30.03.2018 Rs.9,00,000/-


Mr. Hetal S.Merchant Mr. Hetal S.Merchant


5 Date of Partial Repudiation 12.09.2017

6 Reason for repudiation Suegeon fees


8 Nature of complaint Short Settlement of claim


10 Amount of Partial Settlement Rs.40,948



Under Rule 13(b)



a) For the complainant Mrs. Madhavi H.Merchant

b) For the insurer Mr.Sushant R. Jagtap,A.O., & Dr.Bharti ,TPA



Brief Facts of the Case : The Complainant Mr. Hetal S Merchant was admitted to Criti Care

Multispeciality Hospital & Research Centre from 23.05.2017 to 24.05.2017 for Perianal Abscess.

The Complainant has lodged the claim for Rs.18,260/- towards surgeon fees which was deducted

under Reasonable and necessary expenses Clause No.3.33.Complainant approached this forum with a

complaint against non settlement by the Respondent of a claim lodged for the said hospitalisation.

Contentions of the Complainant : The complainant was absent and had authorized his wife Mrs. Madhavi Merchant who appeared and deposed before the Ombudsman in joint hearing held with the Company on 24th August 2018. She submitted that the Company has deducted the amount of Rs.18,260/- towards surgeon charges under reasonability clause 3.33 which was not acceptable to them. She requested the Forum for

settlement of the above claim which was disallowed by the Respondent.

Contentions of the Respondent: The Forum asked the Company the reasons for the above

deductions to which the Company submitted that they have allowed maximum surgeon charges of

Rs.20,000/- against Rs.38,260/- and deducted Rs.18,260/- towards surgeon charges and non medical

expenses which are not payable as per policy terms.

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Forum’s Observations/Conclusion : The Forum observed that the policy holder has already

paid the surgeon charges as per hospital bill and deducting from the same under customary &

reasonable clause is not justifiable. Since the hospital is under PPN, if the patient has been

overcharged by the hospital, the Respondent should seek clarification from the hospital. However the

deduction of Rs.18,260/- towards surgeon charges is not sustainable and the Company is directed to

pay Rs.18,260/- towards full and final settlement of the above claim. Hence the following ord

AWARD Under the facts and circumstances of the case, United India Insurance Co. is directed to pay the

admissible amount of Rs.18,260/- towards surgeon charges, in favour of the complaint Mr. Hetal

S. Merchant, in full and final settlement of the complaint.





Dated: This 26th

day of December , 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MRS. NILIMA P. KALELKER

VS RESPONDENT : UNITED INDIA INSURANCE CO. LTD.


1 Name & Address of the Complainant Mrs. Nilima P. Kalelker

Mumbai



Sum Insured

0221002815P103578832 Individual Health Insurance Policy

12.08.2015 – 11.08.2016

Rs.4,25,000/-

3 Name of Insured


Mrs. Nilima P. Kalelker









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Ombudsman Rules

Under Rule 13(b)



a) For the complainant Mrs. Nilima P. Kalelker

b) For the insurer Ms. Vidisha Parab, A.O. Dr. Bharti – Health India TPA



Brief Facts of the Case : Complainant was admitted to Lilavati Hospital from 09.04.2017 to 14.04.2017 for the treatment of Stress Urinary Incontinence + Multiple Uterine Fibroids and underwent Total Lap. Hysterectomy + Bilateral Salpingo Oopherectomy along with TVTO + Adhesolysis. A claim lodged under the policy for Rs.3,12,162/- was settled by the Respondent for Rs.1,13,750/- citing Clause No. 1.2.1 of the policy which lays down a limit of “Actual Expenses or 25% of S.I., whichever is less” for Hysterectomy. Aggrieved by the short-settlement, complainant approached this Forum seeking relief in the matter.

Contentions of the Complainant : Complainant stated that she was admitted to the hospital basically with complaints of Stress Urinary Incontinence and underwent TVTO insertion for the same. Since the doctors observed that she was also having Multiple Uterine Fibroids, it was also decided to perform Hysterectomy + B/L salpingo oopherectomy at the same time. However her basic hospitalization was for the treatment of Urinary Incontinence which was her major problem while Hysterectomy was carried out as a secondary procedure alongwith it. Hence the reason cited by the Respondent for short-settlement of the claim was not acceptable to her. She requested for settlement of the balance claim amount.

Contentions of the Respondent: It was contended on behalf of the Respondent that since the complainant had undergone Hysterectomy along with B/L Oopherectomy which was the main surgery from medical point of view, the claim was settled as per the limit prescribed under the policy for the said surgery viz. maximum 25% of S.I. which works out to Rs.1,06,250/- + post hospitalization expenses of Rs.7,500/-.

Forum’s Observations/Conclusion : After hearing the depositions of both the parties and scrutiny of the documents produced on record, it is observed that the policy stipulates a maximum limit of 25% of S.I. for Hyterectomy. Respondent has accordingly paid the amount for the said surgery as per policy provision. However, the complainant has also undergone surgery for Urinary Incontinence at the same time which has not been considered by the Respondent at all. Respondent was therefore directed to review the claim and inform the admissible amount for the said procedure additionally. Respondent vide e-mail dt. 21.12.2018 informed the Forum that an amount of Rs.98,542/- is payable towards TVTO charges. The decision of the Respondent is therefore intervened by the following Order:

AWARD Under the facts and circumstances of the case, United India Insurance Co. Ltd. is directed to pay a further amount of Rs.98,542/- in favour of the complainant Mrs. Nilima P. Kalelker, in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:



st day of December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279


MUMBAI & GOA




CASE OF COMPLAINANT - MR. NIRMAL KUMAR BARMECHA

VS




1 Name & Address of the Complainant Mr. Nirmal Kumar Barmecha

Mumbai 2 Policy No:

Type of Policy


Sum Insured

11120034142500011435

New Mediclaim 2012 Policy

11.03.2015– 10.03.2016

Rs.300000/- + C.B. Rs.150000/-

3 Name of Insured


Ms. Kanta Barmecha

Mr. Nirmal Kumar Barmecha


5 Date of Repudiation ----

6 Reason for repudiation ----


8 Nature of complaint Short Settlement of claim





Under Rule 13(b)

13 Date of Hearing 12.09.2018 – 2.15 P.M.


a) For the complainant Mr. Manoj Barmecha b) For the insurer Mr. Navneet Verma, A.O.



Brief Facts of the Case : Complainant‟s wife was admitted to Breach Candy Hospital from 17.08.2015 to

29.08.2015 for the treatment of complex Partial Seizure with Severe Hyponatremia with UTI. Complainant

approached this forum with a complaint against short settlement by the Respondent of a claim lodged for the

said hospitalisation.

Contentions of the Complainant : Mr. Manoj Barmecha submitted that the claim for hospitalisation of

Ms. Kanta Barmecha for a total amount of Rs.2,85,320/- was short settled by Rs.40,932/- by the Respondent by

applying proportionate deductions. They even forwarded to the Respondent a letter from Breach Candy Hospital

confirming that it did not have a class based billing system despite which the Respondent refused to reconsider

their decision. He stated that the decision of the Respondent was not acceptable to them and requested for the

settlement of the balance claim amount.

Contentions of the Respondent: It was contended on behalf of the Respondent that Ms. Kanta Barmecha

was eligible for room rent of Rs.3,000/- per day being 1% of S.I. against which she had occupied room with rent

of Rs.3,500/- per day. Therefore, they deducted Rs.6,000/- excess room charges from the claim amount and all

other charges were scaled down in proportion to the entitled room category as per Clause 3.1 of the policy.

Forum’s Observations/Conclusion: This Forum has in the past heard several cases pertaining to Breach

Candy Hospital wherein the said hospital itself has certified that it does not have a class-based rating structure

and all other charges are the same across the board irrespective of the room category. In view of the same while

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disallowance of room rent in excess of the insured‟s eligibility and non-medical expenses being as per policy

terms and conditions was in order, there is no justification for reducing other charges in proportion to the

entitled room category in the absence of a class-based tariff. Respondent was therefore advised to inform the

balance payable amount without applying proportionate deductions. Respondent vide e-mail dt. 18.09.2018

informed the Forum that a further amount of Rs.29,155/- is payable under the main hospitalization claim plus

Rs.1,200/- under post-hospitalization claim. They have further stated that the bills for balance Consultation

charges can be considered on submission of supporting prescriptions for the same.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd. is directed to pay

Rs.30,355/- over and above the amount already paid in favour of the complaint Mr. Nirmal Kumar

Barmecha, in full and final settlement of the complaint and any further admissible amount subject to

submission of supporting documents.

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




Dated: This 6th


(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA




CASE OF COMPLAINANT - MR. NITIN HEMCHAND

VS

RESPONDENT - UNITED INDIA INSURANCE CO. LD.



1 Name & Address of the Complainant Mr. Nitin Hemchand

Mumbai

2

Policy No: Type of Policy


0216002817P109660701 Individual Mediclaim Policy

11.10.2017 - 10.10.2018 ₹200000/-

3 Name of Insured


Mr. Nitin Hemchand



6 Reason for repudiation Hospitalisation < 24 hrs



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9 Amount of claim ₹174706/-


11 Amount of relief sought ₹174706/-

12 Complaint registered under Ombudsman

Rules, 2017

Under Rule 13(b)

13 Date of Hearing 31.10.2018 - 3.15 p.m.


a) For the complainant Mr. Nitin Hemchand

b) For the insurer Ms. Yogita Agashe

Dr. Vrushali - Raksha TPA Pvt Ltd



Brief Facts of the Case : Complainant was admitted to Breach Candy Hospital from 14.1.2018 to 15.1.2018

for the treatment of Phimosis. Respondent repudiated the claim for the said hospitalisation as per clause no. 2 of

the policy stating that there was no hospitalisation for minimum period of 24 hours.

Contentions of the Complainant : Complainant contended that he was initially treated in OPD as there

was no bed available in the hospital. He was admitted as an inpatient at 1.30 pm after the bed became available

and discharged before 12 noon on the next day to avoid charges for the second day. He even submitted to the

Respondent a certificate to that effect from the hospital; however the Respondent refused to reconsider the

claim. He requested for settlement of the claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that as per hospital

papers, the patient was admitted on 14.01.2018 at 1.30 p.m., underwent circumcision for c/o phimosis and was

discharged from the hospital on 15.01.2018 at 11.48 a.m. As per clause no. 2 of the policy, expenses on

hospitalisation for minimum period of 24 hrs are admissible. Hence the claim stood rejected as per policy terms

and conditions.

Forum’s Observations/Conclusion: On scrutiny of the documents produced on record, it is observed that

the complainant approached the EMS of the hospital on 14.01.2018 at 3.00 a.m. with h/o acute urine retention

and not able to pass urine. Since urinary catheter was not able to pass, suprapubic catheter was done and urine

was drained. As stated by the complainant, since there was no bed available, he was sent back and was admitted

as an in-patient at 1.30 p.m. on the same day for further management. Therefore the Respondent‟s stand that 24

hours‟ hospitalization was not completed and hence the claim cannot be admitted, is too technical and cannot be

sustained. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, United India Insurance Co. Ltd. is directed to pay the admissible claim amount of Rs.1,67,954/- in favour of the complainant Mr.

Nitin Hemchand, in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance




Dated: This 31st day of December, 2018 at Mumbai.


of 279


MUMBAI & GOA




COMPLAINANT - MR. PAILESH BAPNA

VS




1 Name & Address of the Complainant Mr. Pailesh Bapna Mumbai

2 Policy No:


Sum Insured

OG-17-1901-8430-0000087

Health Guard Floater Policy 00-00-2017 – 00-00-.2018

3 Name of Insured


Mr.Pailesh B. Bapna

Mast. Moksh P.Bapna



6 Reason for repudiation Exclusion Clause C-7







Under Rule 13(b)



a) For the complainant Not present

b) For the insurer Dr. Rashmi Sachdev

Mr. Parveez Alam



Brief Facts of the Case : Complainant‟s son Mast.Moksh was admitted to Surya Children`s Medicare

pvt.ltd. Hospital, Mumbai from 14.07.2017 to 16.07.2017 for the treatment of Lower Respiratory Tract

Infection. Respondent repudiated the claim lodged under the policy for the said hospitalization on the ground

that as per Exclusion Clause C7 of the policy, expenses on treatment of intermittent abdominal pain and its

complications are not

payable where inpatient care is not warranted and does not require the supervision of qualified nursing staff and

qualified medical practitioner round the clock.

Contentions of the Complainant : Complainant contended that his son was admitted to the Surya

Children‟s hospital with complaints of high fever, cough, and abdominal pain. She was investigated for CBC,

CRP, LFT, RFT, B<C; however the results of all these tests were negative. Hence the reason cited by the

Respondent for rejection of the claim was not acceptable to them. He requested for settlement of the claim.

Contentions of the Respondent: Bajaj Alliancz General Insurance Co. Ltd. was represented by Shri Parveez Alam alongwith Dr. Rashmi Sachdev. They submitted that the claim for the hospitalization of Mat. Moksh at Surya Children’s Medicare Hospital from 14.07.2017 to 16.07.2017 for high fever and pain in lower Abdomen was repudiated by Insurance Company since hospitalization was not justifiable in the instant case. As such, the procedure was possible on OPD basis and did not warrant indoor confinement.

Forum’s Observations/Conclusion: Before hearing the Insurance Company vide letter dated 20.07.2018 received by us on 20.12.2018 informed the Forum that the claim for Rs.33,060/- has been settled

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by the Insurance Company and requested for withdrawal of the complaint. In view of the amicable settlement the parties, the complaint stands closed at this Forum. There is no order for any other relief between.

Dated: This 24th




MUMBAI & GOA




CASE OF COMPLAINANT - MR. PARESH V. KOTHARI

VS




1 Name & Address of the Complainant Mr. Paresh V. Kothari Mumbai



11170034162500003513 New Mediclaim Policy 2012

01.08.2016 - 31.07.2017 Rs.3,00,000/- + C.B. Rs.67,500/-


Mr. Paresh V. Kothari









12 Complaint registered under Ombudsman

Rules, 2017

Under Rule 13(b)



a) For the complainant Mr. Paresh V. Kothari

b) For the insurer Ms. Harinakshi N. Karkera Dr. Mansi Shukla - MDIndia TPA



Brief Facts of the Case : Complainant was admitted to Wockhardt Hospital from 24.06.2017 to 27.06.2017

for Systemic HTN with DM with Dysponea on exertion and underwent CAG followed by Angioplasty.

Complainant approached this Forum with a complaint against short-settlement by the Respondent of the claim

lodged for the said hospitalization.

Contentions of the Complainant : Complainant stated that he was insured with the Respondent since

01.08.2000 for S.I. of Rs.1,50,000/-. In the year 2013, he increased the S.I. to Rs.3,00,000/-. In June 2017 he

was hospitalized and underwent CAG & Angioplasty. Against the claim lodged for an amount of Rs.6,98,367/-

for the said hospitalization, he was reimbursed only Rs.1,36,300/- by the Respondent. He argued that as per

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Clause 4.1 of the policy, a claim for a pre-existing disease is payable on completion of 48 months of continuous

coverage from the date of inception of the first policy whereas his policy had incepted in the year 2000 and

hence he was entitled to claim the full S.I. of Rs.3,00,000/- plus C.B. of Rs.67,500/- even for any PED. He

therefore requested for settlement of the balance claim amount.

Contentions of the Respondent: It was contended on behalf of the Respondent that Mr. Kothari had

enhanced the S.I. from Rs.1,50,000/- to Rs.3,00,000/- w.e.f. 01.08.2013. He is a k/c/o HTN, DM & IHD since

the year 1990. The four years‟ waiting period for PED for the enhanced S.I was completed on 31.07.2017 while

Shri Kothari was hospitalized on 24.06.2017. Hence only the pre-enhanced S.I. of Rs.1,50,000/- could be

considered for settlement of the subject claim. Further, he had occupied a room with rent of Rs.9,500/- against

his eligibility of Rs.1,500/- per day. Hence the other charges were also settled in proportion to the room rent

eligibility of the insured and the claim was settled accordingly.

Forum’s Observations/Conclusion : On perusal of the documents produced on record, it is observed that

the complainant‟s first policy with the Respondent incepted on 01.08.2000 while the S.I. was enhanced from

Rs.1,50,000/- to Rs.3,00,000/- w.e.f. 01.08.2013. The treatment undergone by the complainant during his

hospitalization in June 2016 was related to his pre-existing ailment. As per Clause 4.1 of the policy, no claim is

payable under the policy for treatment of any PED until 48 months of continuous coverage has elapsed from the

date of inception of his first policy with the Company. Further as per Clause 5.11, in respect of any

enhancement of S.I., exclusions 4.1, 4.2 and 4.3 would apply to the additional S.I. from such date. In the instant

case, the enhanced S.I. had not completed the waiting period of four years stipulated for coverage of pre-

existing disease, as on the date of hospitalization. The policy also provides that in case of admission to a room

at rates exceeding the limit of 1% of S.I. per day, the reimbursement of all other expenses incurred at the

hospital, with the exception of cost of medicines, shall be effected in the same proportion as the admissible rate

per day bears to the actual rate per day of Room Rent. Hence the decision of the Respondent to restrict the

claim settlement upto the limit of pre-enhanced S.I. and to the proportion of the corresponding room rent

eligibility is in accordance with the terms and conditions of the policy. Under the circumstances, there is no

valid reason to intervene with the decision of the Respondent in the matter and consequently no relief can be

granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Paresh V.

Kothari against The New India Assurance Co. Ltd., does not sustain. Dated: This 31st day of December, 2018 at Mumbai.





CASE OF COMPLAINANT - MR. PRAVIN KANTILAL JAIN

VS RESPONDENT : RELIGARE HEALTH INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Pravin Kantilal Jain

Mumbai

2 Policy No:

Type of Policy


10158098

Care Floater Policy

22.10.2016 – 21.10.2017 Rs. 5,00,000/-

3 Name of Insured Mr. Pravin Kantilal Jain

of 279


4 Name of Insurer Religare Health Insurance Co. Ltd.


6 Reason for repudiation Hospitalization not justified







Under Rule 13(b)



a) For the complainant Mr. Pravin K. Jain

b) For the insurer Dr. Poonam Bagga



Brief Facts of the Case : Complainant was admitted to Beramji’s Hospital from 16.03.2017 to 25.03.2017 for the treatment of Right Sciatica with Scoliosis. Respondent repudiated the claim for the said hospitalization under policy Exclusion clause 4.3(a) stating that hospitalization was not required and the treatment could have been taken on OPD basis.

Contentions of the Complainant : Complainant submitted that the claim for his admission to Beramji Hospital was rejected by the Respondent stating that hospitalization was not required. He argued that he was suffering from serious back pain and due to the pain he was not able to walk. In fact, he was reluctant to get admitted in the hospital and requested the doctor to advise him some treatment/exercise which he could do at home; but the doctor told him that the treatment was not possible on OPD basis. Hence the reason cited by the Respondent for rejection of the claim was not acceptable to him. He requested for settlement of the claim.

Contentions of the Respondent: Dr. Poonam stated that on scrutiny of the submitted documents, it was observed that the patient was treated with physiotherapy, Accupuncture and Ayurvedic therapy; however no active line of treatment was given during hospitalization. All this treatment could have been given on sessional basis and does not require hospitalization. Thus the treatment was possible on OPD basis and hence the claim was denied as per policy clause 4.3(a).

Observations/Conclusion: On examination of the entire course of treatment, it is noted that the complainant was treated with physiotherapy, Accupuncture alongwith Ayurvedic therapy whereas the hospital is not an Ayurvedic hospital. The Discharge Summary issued by the hospital states that due to the patient’s condition, he could not travel daily to the hospital for OPD treatment and hence was required to be admitted. This gives an impression that the treatment otherwise was possible on OPD basis. Health Insurance Policy basically grants reimbursement of expenses which are reasonably and necessarily incurred on treatment which per se requires hospitalization and not for OPD treatment which is converted into IPD for any other reason. Considering these facts, the Forum does not find any valid reason to intervene with the decision of the Company to repudiate the claim.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Pravin

Kantilal Jain against Religare Health Insurance Co. Ltd. does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 5


(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279




COMPLAINANT - MR. RAVINDRA S.SHEVDE



1 Name & Address of the Complainant Mr. Ravindra S.Shevde Mumbai



Sum Insured

161100/11051/1000272428-05 Individual Health Policy

03.2017 to 03.2018

-----

3 Name of Insured


Mr. Ravindra S. Shevde



6 Reason for repudiation Requirments not submitted


8 Nature of complaint Non settlement of claim


10 Date of Partial Settlement --



Under Rule 13(b)



a) For the complainant Mr. Ravindra S.Shevde

b) For the insurer Dr. Sunetra Dashrath Rane



Brief Facts of the Case : Complainant was admitted to Karuna Hospital Borivali West, Mumbai from 19.08.2017 to 25.08.2017 for the treatment of haemolatic anema and weakness and lodged a claim of Rs.60,285/-.The Company repudiated the claim due to non compliance of the requested documents, the Company repudiated the claim under section VI ii of the policy. Complainant approached this Forum with a complaint against non-settlement by the Respondent of a claim lodged under the policy for the said hospitalization.

Contentions of the Complainant : The Forum asked the Complainant the reason for his grievance. He submitted that he was hospitalized with the complaint of DOF & generalized weakness , haemolatic anema and did all routine investigations and submitted the claim for Rs.60,285/-along with relevant documents to the company. During the hearing the complainant has contended that despite submitting all the required documents to the Company his claim was not settled. He requested for settlement of the claim.

Contentions of the Respondent: The Forum asked the Company the reasons for not settling the claim to which the Dr. Sunetra submitted that due to non submission of requested documents the claim was repudiated under section of VI ii of the policy terms and conditions.

Forum’s Observations/Conclusion:

The Forum observed in this case that the complainant was admitted to Karuna Hospital Borivali Mumbai and lodged the claim for Rs.60,285/- and Company repudiated the claim on the ground for

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non submission of the claim papers. On an analysis of the documents produced on record, it is observed that

the claim lodged by the complainant along with relevant claim papers. Therefore Company‟s stand of

repudiation of the claim on the ground of non submission of requirement documents is not sustainable.

The Forum directed the Company to rework and pay the admissible expenses in favour of the Complainant.

Accordingly the Company has worked out and is agreeable to settle the claim for Rs.60,234/- towards full and

final settlement of the claim. Hence the following Order:

AWARD

Under the facts and circumstances of the case, Apollo Munich Health Insurance Co. Ltd. is directed to pay the admissible claim amount of Rs.60,234/-/- in favour of the complainant Mr. Ravindra S.Shevde in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:







OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MR. RAJKUMAR D. MAURYA

VS RESPONDENT : UNIVERSAL SOMPO GENERAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Rajkumar D. Maurya Mumbai



Sum Insured

2825/55837554/01/000 Complete Healthcare Insurance Policy

11.02.2017 – 10.02.2018

Rs.2,00,000/-

3 Name of Insured


Mr. Rajkumar D. Maurya

4 Name of Insurer Universal Sompo Gen. Insurance Co. Ltd.


6 Reason for repudiation Misrepresentation







Under Rule 13(b)



a) For the complainant Mr. Rajkumar D. Maurya

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b) For the insurer Mr. Priyadarsi Acharya



Brief Facts of the Case : Complainant approached this Forum with a complaint against repudiation by the

Respondent of a claim lodged under the policy for his admission to Prime Speciality Hospital from 30.10.2017

to 05.11.2018 for the treatment of acute severe lower back pain.

Contentions of the Complainant : Complainant contended that on 28.10.2017 he suffered a sudden jerk

while travelling in auto rickshaw following which he developed severe back pain and shooting pain down the

leg. He consulted Dr. Kshitij Shah at Prime Speciality Hospital who prescribed certain medication and advised

an X-ray. As the pain aggravated despite taking medicines and pain killers, he again consulted the doctor on

30.10.2017 and as per his advice got admitted to the hospital. At the hospital, he was treated with Epidural

injection, traction, physiotherapy and medicines and discharged on 05.11.2018. Insurance Company rejected

the claim for the said hospitalization citing certain discrepancies in the claim documents. He stated that the

decision of the Company was not acceptable to him and requested for settlement of the claim.

Contentions of the Respondent: Mr. Acharya submitted that on scrutiny of documents, certain

discrepancies were observed in reference to the statement of the insured and that of treating doctor, treatment

records and medical records which confirmed that claim was prepared with malafide intention to avail undue

benefit of the policy. Hence the claim was repudiated under Clause of Misrepresentation and Misdescription of

the policy. He added that they had even obtained expert medical opinion in the matter according to which the

X-ray submitted by the insured revealed reduced disc spaces signifying that he has degenerative disc disease

which is a chronic disorder and further as per medical documents submitted, the treatment administered to the

patient was an OPD procedure for which hospitalization for 5 days was not justified. Company representative

also produced a set of claim documents submitted by the complainant to Kotak General Insurance Co. for the

same treatment at the same hospital but with different dates of hospitalization.

Observations/Conclusion : On an analysis of the documents produced on record, it is observed that Mr. Rajkumar Maurya was admitted to Prime Speciality Hospital on 30.10.2017 for c/o acute severe low back pain shooting down to right leg with alleged h/o sudden jerk to back while travelling in an auto rickshaw on 28.10.2017. His X-ray revealed L3-4-5 Disc space reduction which indicates degenerative changes and hence there is substance in the Respondent’s contention that the ailment was of chronic nature and not as a result of an accident. Besides, as per hospital papers the patient was treated with only physiotherapy, traction and Epidural injection and therefore the Respondent’s argument that this kind of treatment is possible on OPD basis without the need for confinement to hospital, is also sustainable. Further, the Respondent has also produced copies of another set of claim documents submitted by the complainant to another Insurance Company showing identical complaints due to same kind of accident and the same line of treatment taken in the same hospital but for a different period viz. from 25.11.2017 to 01.12.2017, which raises serious doubts about the genuineness of the claim. Thus prima facie there appear to be certain discrepancies in the claim as pointed out by the Respondent. In view of the said inconsistencies in the claim documents, this Forum does not find any valid ground to intervene with the decision of the Company and the case stands dismissed at this Forum.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Rajkumar D.

Maurya against Universal Sompo General Insurance Company does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 3

rd day of December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279




CASE OF COMPLAINANT - MR. RAVIBHUSHAN R. GUPTA

VS RESPONDENT : HDFC ERGO GENERAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Ravibhushan Ramnath Gupta

Mumbai



316111000141930100 Health Medisure Super Top Up Policy

23.01.2017 – 22.01.2019 Rs.11,00,000/-

3 Name of Insured


Mr. Ravibhushan Ramnath Gupta

4 Name of Insurer HDFC Ergo General Insurance Co. Ltd.


6 Reason for repudiation Non disclosure of material fact







Ombudsman Rules

Under Rule 13(b)



a) For the complainant Mr. Ravibhushan R. Gupta

b) For the insurer Mr. Saahiel Sharma



Brief Facts of the Case : Complainant was admitted to Bombay Hospital from 29.09.2017 o 13.10.2017 for the treatment of Cirrhosis of Liver, Herpes Zoster, Hepatic Encephalopathy, Acute Pancreatitis, Acute Kidney Injury, Diabetes, Hypertension. Respondent rejected the claim for the said hospitalization on the ground of non-disclosure by the insured of the fact that he was suffering from DM & HTN since 15 years.

Contentions of the Complainant : Complainant submitted that his total hospital bill amounted to Rs.6,79,270/-. Out of this Rs.4,25,000/- was reimbursed by United India Insurance Co. Ltd. For the balance amount he lodged a claim under his Top Up policy with the Respondent; however the claim was rejected on the ground that he was suffering from DM & HTN since 2002. Shri Gupta stated that he was holding United India’s policy since the year 2004 and they settled the claim for the full S.I. In 2014 he had taken life insurance policies from Bharti Axa Life Insurance Co. and HDFC Life Insurance Co. after due medical check up. Also the Top Up policy with L & T General Insurance Co. (now HDFC General Insurance Co) was taken in 2015 after medical check up. Even the doctor at Bombay Hospital had issued him a letter certifying that he had fully recovered from the paralysis stroke suffered in 2002 and was not suffering from HTN & DM. Hence the reason cited by the Respondent for repudiation of the claim was not acceptable to him. He requested for settlement of the claim.

Contentions of the Respondent: Mr. Saaheil Sharma contended that as per the claim documents submitted, the patient is a k/c/o DM & HTN since 15 years and has history of CVA in the year 2002. Insured had not disclosed his pre-existing ailments while taking the first policy from them effective from 23.01.2015.

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Thus there was non-disclosure of material facts on the part of the insured and hence the claim stood repudiated under Section F1 of the policy terms and conditions. He pointed out that the certificate issued by Bombay Hospital stating that the patient was having DM & HTN since 1 ½ years was not signed by the concerned doctor. After hearing the depositions of both the parties, in view of the discrepancies pointed out, Respondent was directed to obtain a clarification from the treating doctor at the Hospital on the actual duration of DM & HTN suffered by the complainant, and submit the same to the Forum within 3 days. Respondent thereafter submitted a letter dt. 16.09.2018 obtained from the treating Dr. Ameet Mandot certifying that the history of HTN & DM since 1 ½ years was given by the patient at the time of admission; however as per records of other doctors during hospitalization and on outpatient basis, his history of HTN & DM dates back to 15 years and the discrepancy in the duration of HTN & DM is based on the history given by patient only.

Forum’s Observations/Conclusion: On an analysis of the case, it is observed that the IPD as well as OPD papers of the Hospital mention that Mr. Ravibhushan Gupa is a known case of HTN & DM since 15 yrs. The history narrated before the doctor either by the patient or his/her representative is his or her own statement and hence cannot be totally overlooked. Everybody would like to give exact narration to the doctor so as to enable him to make proper judgement with all the facts put before him so as to enable him to arrive at a correct diagnosis and adopt a proper line of treatment. The complainant claims that the history was recorded wrongly in the hospital records. In that case, if there was any error in the hospital notings, the complainant/his relatives should have got the same rectified immediately. The argument of the complainant that he was having HTN & DM only since 1 ½ years and the certificate issued by the hospital to that effect after denial of the claim by the Respondent appears to be an after-thought and hence cannot be accepted. Also, the treating doctor has later on certified that the letter issued by him rectifying the history of HTN & DM as “since 1 ½ years” was based on the patient’s statement. Hence the same cannot be accepted in evidence. Insurance contracts are governed by the principle of utmost good faith which requires both parties of the insurance contract to deal in good faith and in particular it imparts on the proposer a duty to disclose all material facts which relate to the risk to be covered to enable the insurers to evaluate the risk in its proper perspective. Failure on the part of the complainant to mention these facts to the Insurance Company certainly amounts to non-disclosure/ suppression of material information entitling the Company to deny liability arising under the policy. Under the facts and circumstances of the case, the decision of the Respondent to repudiate the claim on the ground of non-disclosure of material information, cannot be faulted with and the Forum finds no valid ground to intervene with the said decision.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Ravibhushan R. Gupta against HDFC Ergo General Insurance Co. Ltd. does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 7


(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279


MUMBAI & GOA




CASE OF COMPLAINANT - MR. RAM GOPAL MUDALIYAR

VS

RESPONDENT : RELIGARE HEALTH INSURANCE CO. LTD.



1 Name & Address of the Complainant Mr. Ram Gopal Mudaliyar Mumbai


10197711 Care Individual Policy 26.01.2017 to 25.01.2018 Rs. 5,00,000/- + N.C.B. Rs.1,00,000/-


Ms. Shantha Gopal Mudaliyar Mr. Ram Gopal Mudaliyar






9 Amount of claim ?? Rs.3,50,000/-




Under Rule 13(b)



a) For the complainant Mr. Ram Gopal Mudaliyar




Brief Facts of the Case : Complainant‟s mother Ms. Shanta Gopal Mudaliyar was admitted to

Fortis Hospital, Mulund, Mumbai from 24.11.2017 to 30.11.2017 and operated for K43.9 Obstructed

Ventral Hernia. Respondent repudiated the claim for the said hospitalization on the ground that the

insured had history of Spine Surgery undergone 9 years back which was not disclosed to the

Company while obtaining the policy.

Contentions of the Complainant : Complainant submitted that Respondent rejected the claim

lodged under the policy for his mother‟s hospitalization on 24.11..2017 for the treatment of Small

bowel obstruction stating that they had not disclosed the history of Spine surgery undergone by her 9

years back while taking the policy. He submitted that the policy was taken online and he had

disclosed all the information about his mother‟s health to the Company‟s representative at the time.

Besides, the Respondent had paid the earlier claim lodged in June 2017 for the treatment of his

mother for finger injury. Therefore the decision of the Respondent to deny the subject claim and

terminate the policy was not acceptable to him. He requested for settlement of the claim and

reinstatement of the policy.

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Contentions of the Respondent: Dr. Poonam submitted that on scrutiny of the claim

documents submitted by the insured, it was noted that the insured had h/o Spine surgery done 9 years

back which was not disclosed at the time of taking the policy. Hence the claim was rejected on the

ground of non-disclosure of material fact at the time of policy inception and the policy was also

cancelled as per Clause 7.13 of the policy terms and conditions. She added that the claim for the

insured‟s hospitalization in June 2017 for the treatment of Carpal Tunnel Syndrome was settled by the

Company in good faith as the said history of PED was not known to them.

Post-hearing, the Respondent informed the Forum that after denial of cashless claim, the complainant

has not filed any reimbursement claim with them.

Forum’s Observations/Conclusion : On an analysis of the documents produced on record, it is

observed that the subject claim lodged by the complainant was for a treatment which was not in any

way related to his mother‟s pre-existing history of Spine surgery. In view of the same denial of the

claim and cancellation of the policy on the ground stated by the Respondent appears to be too

technical and cannot be sustained. Their decision is therefore set aside by the following Order:

AWARD

Under the facts and circumstances of the case, Religare Health Insurance Co. Ltd. is directed to reinstate the policy and pay the admissible claim amount less non-medical expenses, if any after submission of all the requisite documents/bills in respect of the hospitalization of Ms. Shanta Gopal Mudaliyar, in full and final settlement of the complaint lodged by Mr. Ram Gopal Mudaliyar.






Dated: This 10th




MUMBAI & GOA




COMPLAINANT - MR. SALIM RAFIUDDIN KAZI

VS




1 Name & Address of the Complainant Mr. Salim Rafiuddin Kazi

Mumbai



OG-18-1000-6021-00041051 Mediclaim Insurance Policy

11.11.2017 – 10.11.2018

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Sum Insured Rs.5,00,000/-


Ms. Noorjahan Kazi Mr. Salim Rafiuddin Kazi



6 Reason for repudiation Waiting period – Exclusion Clause C2







Ombudsman Rules

Under Rule 13(b)



a) For the complainant Mr. Salim R. Kazi

b) For the insurer Dr. Rohini Kulur Mr. Parveez Alam



Brief Facts of the Case : Complainant‟s wife Ms. Noorjahan S. Kazi was admitted to Smt. Sushilaben R.

Mehta & Sir Kikabhai Premchand Cardiac Institute, Mumbai from 15.02.2018 to 18.02.2018 for the treatment

of DM, HTN, ?IHD, Anemia. Respondent repudiated the claim lodged under the policy for the said

hospitalization on the ground that as per Exclusion Clause C2 of the policy, expenses on treatment of

Hypertension and Diabetes and its complications are not payable during first 24 months of the policy.

Contentions of the Complainant : Complainant contended that his wife was admitted to the hospital with

complaints of breathlessness. She was investigated for IHD by way of ECG, 2D Echo and CAG; however the

results of all these tests were negative. According to the doctor, her breathing problem was due to low

haemoglobin and heart disease was ruled out. Hence the reason cited by the Respondent for rejection of the

claim was not acceptable to them. He requested for settlement of the claim.

Contentions of the Respondent: Dr. Rohini submitted that the complainant‟s policy covering himself

and his family members incepted with their Company on 11.11.2017. They received a cashless preauthorization

request from the hospital for CAG to be performed on the insured patient on 15.02.2018 with provisional

diagnosis as IHD with h/o HTN & DM. Since the policy stipulates a Waiting period of 24 months from the date

of policy inception for covering expenses related to HTN & DM and their complications, a letter denying

cashless facility was sent to the hospital. Later, on receiving a representation from the insured stating that the

treatment was for an ailment related to low haemoglobin, they called on the insured to submit the supporting

documents; however the same were not received by the Company. Hence the claim could not be reconsidered.

Forum’s Observations/Conclusion: After hearing the depositions advanced by both the parties,

complainant was directed to submit all the necessary documents to the Respondent who in turn were directed to

review the case in the light of the same and inform their final decision in the matter to the Forum within 7 days.

Respondent vide e-mail dt. 31.10.2018 informed the Forum that they have revisited the case and are agreeable to

settle the claim for an amount of Rs.13,271/- after disallowing expenses related to DM & HTN as per policy

condition, in favour of the complainant which amount has been accepted by the complainant vide e-mail dt.

30.10.2018, in full and final settlement of the claim. In view of the amicable settlement between the parties, the

complaint stands closed at this Forum. There is no order for any other relief.

Dated: This 14th



of 279




CASE OF COMPLAINANT - MR. SHAILESH K. SHAH



1 Name & Address of the Complainant Mr. Shailesh K. Shah

Mumbai

2 Policy No:


Sum Insured

14010034162500001781

New Mediclaim Policy 2012 14.06.2016 - 13.06.2017

Rs.8,00,000/- + C.B. Rs.50,000/-


Mr. Shailesh K. Shah



6 Reason for repudiation ARMD Exclusion – Clause 4.4.22



9 Amount of claim Rs. 41,522/-





Under Rule 13(b)



a) For the complainant Mr. Shailesh K. Shah

b) For the insurer Ms. Jayshree Dalvi, A.M. Dr. Suman – Medi Assist TPA



Brief Facts of the Case : Complainant’s wife Ms. Heena Patel was administered Intravitreal Inj. Accentrix on 17.03.2017 & again on 21.04.2017 at Krishna Eye Centre for the treatment of LE Branch Retinal Vein Occlusion, for which he lodged two separate claims under the policy. Respondent rejected both the claims under Clause 2.16.1 of the policy as hospitalization was for less than 24 hours and the said procedure is also not listed under Clause 2.11 as a Day Care procedure.

Contentions of the Complainant : Complainant contended that his wife had complaints of sudden visual disturbances only in one eye for which she was investigated and was diagnosed with Branch Retinal Vein Occlusion in the left eye. As per advice of a Retina Specialist doctor, she was administered Intravitreal Injections Accentrix on 17.03.2017 & 21.04.2017. Respondent rejected the claims for the same stating that admission was for less than 24 hours. He argued that the injection is to be given in the eye under all aseptic conditions in a very sterile atmosphere such as in an O.T. It is a technological advancement and requires medical expertise with safe anesthetic practices and such procedures are done as a day care procedure not requiring 24 hours stay in the hospital. He himself being a physician and ophthalmologists being his colleagues, they helped his wife with personal attention and not charging for medical consultations, Laser treatments and follow-ups which would have definitely cost the treatment much more than what they have claimed for but they being reasonable they kept the cost of the treatment to minimum. He stated that the

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reason cited by the Respondent for repudiation of the claim was not acceptable to them and requested for settlement of the claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that on scrutiny of the documents it was observed that in both the cases the total period of hospitalization was less than 24 hours and the said procedure is not listed as a day care procedure under the policy. Since the policy terms and conditions state that hospitalization benefits are admissible only if hospitalization is for a minimum period of 24 hours, the claims stood repudiated under Clause nos. 2.16.1 & 2.11 of the policy.

Observations/Conclusion: The Forum scrutinized all the documents submitted and observed that although 24 hours hospitalization is not required in such treatments because of advancement of medical technology, the injection is required to be administered in the operation theatre under sterile environment. Also, this treatment is prolonged and repetitive in nature. Therefore, taking a practical, thoughtful and considerate view of the facts, the Forum has decided even in such similar earlier cases that it would be reasonable that the complainant bears a part of the expenses and accordingly concluded that the admissible expenses of such treatment is to be shared equally between the complainant and the Respondent. In view of repeated course of treatment, having already decided vide earlier Awards passed in similar treatment undergone by the complainant, the Respondent is directed to settle the claim for 50% of the admissible expenses incurred. The decision of the Respondent is therefore intervened by the following Order.

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay 50% of

the admissible expenses, in favour of the complainant, as full and final settlement of the complaint.




th day of June, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MR. SHAM D. CHABLANI



1 Name & Address of the Complainant Mr. Sham D. Chablani Mumbai

2 Policy No:


Sum Insured

160100/11120/6000097855-02

Optima Restore Individual Policy 25.04.2016 to 24.04.2018

Rs. 10,00,000/-


Mrs. Kanchan Sham Chablani



6 Reason for repudiation Non-disclosure of material fact








Under Rule 13(b)



a) For the complainant Mr. Sham D. Chablani

b) For the insurer Mr. Subramanian



Brief Facts of the Case : Complainant’s wife was admitted to Wockhardt Hospital on 06.06.2017 and diagnosed with Diabetic Ketoacidosis with Septicemia with Acute Myocardial Infarction in a k/c/o DM & HTN. She expired in the hospital on 08.06.2017. A claim lodged under the policy for the said hospitalization was repudiated by the Respondent on the ground of Non-disclosure of the insured patient’s history of DM since 14 years.

Contentions of the Complainant : Complainant submitted that he along with his wife was insured with United India Insurance Co. Ltd. since the year 2002 and had ported the policy to the Respondent in the year 2013. His wife was detected with Diabetes only since the last 14 months which was erroneously written as “since 14 years” in the hospital records. He submitted a clarification to that effect to the Respondent from the treating doctor; however they refused to reconsider the claim. He further mentioned that his wife was on homeopathic treatment since the year 2007 for c/o loose motions. He stated that this was the first claim lodged for his wife in all these years and the decision of the Respondent was not acceptable to them. He requested for settlement of the claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that complainant along with his wife was covered with them since 25.04.2013. As per claim documents, Mrs. Kanchan Chablani was hospitalized on 06.06.2017 with c/o pain in throat, difficulty in swallowing and fever. She was diagnosed with Diabetic Ketoacidosis with Septicemia with Acute Myocardial Infarction in a k/c/o DM & HTN. She expired in the hospital on 06.06.2017. As per Death Summary, patient had h/o DM since 14 years. Hence the claim was investigated when it was observed that same history was mentioned in the treatment record as well and it was also mentioned that patient was under homeopathic treatment since 2007 which facts were not disclosed to

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the Company while proposing for insurance. Complainant then submitted a certificate stating that the duration of DM was since 14 months and not 14 years. It was contended that the said correction was an after-thought after a query was raised about long-standing DM. Further, Diabetes Ketoacidosis is a complication of long-standing DM; hence h/o DM was a material disclosure which ought to have been made at the time of obtaining the policy. Forum’s Observations/Conclusion : On scrutiny of the documents produced on record, it is observed

that the Respondent rejected the subject claim on the basis of noting in the hospital records of h/o DM since 14

years. However, the said history is disputed by the complainant. He has also produced a certificate from the

treating doctor correcting the history. Respondent on the other hand, could not produce any other documentary

evidence to substantiate h/o long-standing DM. Further, it is noted that Mrs. Chablani was covered with United

India Insurance Co. since the year 2002 and the policy was ported to Respondent in the year 2013. Respondent

also could not produce any previous claims history of the patient. Hence rejection of the claim on the ground

stated by the Respondent is not justified and their decision is set aside by the following Order.

AWARD

Under the facts and circumstances of the case, Apollo Munich Health Insurance Co. Ltd. is

directed to pay the admissible claim amount less non-medical expenses, if any along with simple interest @ 2% p.a. above prevailing bank rate on the said amount from one month

after submission of the final claim documents till the date of actual payment in favour of

the complainant Mr. Sham D. Chablani, in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:







OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MR. SUBHASH MORZARIA



1 Name & Address of the Complainant Mr. Subhash Morzaria

Mumbai



10026116 Care Individual Policy

29.07.2017 - 28.07.2018 Rs.10,00,000/- + N. C.B. Rs.3,00,000/- + NCB-

Super Rs.10,00,000/-


Mr. Subhash Morzaria


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Ombudsman rules

Under Rule 13(b)



a) For the complainant Mr. Subhash Morzaria




Brief Facts of the Case : Complainant was admitted to Breach Candy Hospital from 07.11.2017 to

18.11.2017 and underwent CABG. Complainant approached this Forum with a complaint against short-

settlement by the Respondent of the claim lodged under the policy for the said hospitalization.

Contentions of the Complainant: Complainant stated that the total bill amount for CABG undergone by

him was Rs.29,02,328/- out of which United India Insurance Co. with whom he was holding another policy,

paid him the full S.I. of Rs.5,25,000/-. For the balance Rs.23,77,328/- he lodged a claim with the Respondent

with whom he was holding a policy with S.I. of Rs.23,00,000/- (incl. Bonus) against which he was reimbursed

only Rs.9,94,994/- citing Reasonable & Customary Charges Clause of the policy. He argued that while issuing

the policy he was told that there is no capping on any diseases, operation and room charges and all expenses up

to the limit of S.I. are payable; hence the reasons cited by the Respondent now for deductions from the claim

amount were not acceptable to him. He requested for settlement of the balance claim amount.

Contentions of the Respondent : It was contended on behalf of the Respondent that the complainant had

opted for a room category over and above his entitlement of basic single private room. Hence Room,

Investigation, O.T., Professional and other charges were allowed in proportion to his entitled room category as

per Clause 4.2 (1) of the policy, disallowing a total of Rs.7,82,525/- under all these heads. Also, the O.T. and

Professional charges were found to be on the higher side in as much as Surgeon fees alone constituted

Rs.15,00,000/- out of the total claim for Rs.24,00,000/-. Hence deductions of Rs.6,25,000/- were made under

these heads as per Reasonable & Customary charges clause of the policy. Certain further deductions were made

towards non-medical expenses. Accordingly, the claim was settled for Rs.9,94,994/- as per policy terms and

conditions. She added that the package charges for CABG in Fortis Hospital and Jaslok Hospital were

Rs.3,06,590/- and Rs.6,50,000/- respectively. Thus, it was clear that Breach Candy Hospital has charged in

excess for the subject treatment which is completely unwarranted and uncalled for in comparison to the market

rates for the same treatment.

Forum’s Observations/Conclusion: On hearing the contentions put forth by both the parties and perusal

of the documents produced on record, the Forum independently analyzed the case and is of the view that the

deduction from professional charges of Surgeons and operation charges on the ground of “Reasonability” will

not sustain as the doctor‟s fees will depend on his individual skill, time and complications involved in the

surgery and the patient has no control over it. The insured is adequately covered under the policy. Although the

surgeon charges appear to be on higher side, insured is helpless and had to pay since it was a major surgery and

the patient would not be willing to take any chance with his life. Accordingly he has paid all the charges to the

hospital. In view of the same and in the absence of specific capping under the policy, there is no justification for

such arbitrary deductions from the professional charges and the same have to be allowed. Also, it is observed

that the said hospital does not have a class based billing structure depending on room category and all other

charges are the same across the board. In view of the same deductions from other charges on proportionate

basis as per the complainant‟s room entitlement are also not justified. The disallowance of non-medical

expenses is found to be in order. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, Religare Health Insurance Co. Ltd. is

directed to pay the balance claim amount barring Room charges in excess of insured’s

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eligibility and non-medical expenses in favour of the complainant Mr. Subhash Morzaria,

in full and final settlement of the complaint.




Dated: This day of 10

th December, 2018 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. SURVANA G.AMONKAR



1 Name & Address of the Complainant Mr. Survana G.Amonkar

Mumbai.



14010034162500007300 NIA Mediclaim Policy-2012

11.10.2016 to 10.10.2017 Rs.5,00,000/- & CB Rs.1,50,000/-

3 Name of Insured


Mr. Suvarna G. Amonkar



6 Reason for repudiation DM with Obesity treatment – Excl. Clause No. 4.4.6.1







Ombudsman rules,2017

Under Rule 13(b)



a) For the complainant Miss. Sonali S.Amonkar (Daughter)

b) For the insurer Ms.Jayshree Dalvi AO,& Dr. Suman ,from TPA



Brief Facts of the Case : Complainant was admitted to Hinduja Healthcare Surgical from 22.09.2017 to

24.09.2017 for the treatment of type 2 Diabetes mellitus and Morbid Obesity with Laproscopic Sleeves

Gatrectosmy.

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As per documents submitted it has been observed that the paitent is considered as Obese and the patient treated

for Morbid Obesity. He underwent Sleeve gastrectomy surgical weight loss procedure. Hence the Respondent

repudiated the claim for the same as per Exclusion Clause 4.4.6.1 of the policy which excludes surgery for the

treatment of obesity from the scope of the policy.

Contentions of the Complainant : The complainant was absent and had authorized his daughter

Miss.Sonali S.Amonkar who appeared and deposed before the Ombudsman in joint hearing held with the

Company. She contended that her father was admitted at Hinduja Healthcare Surgical from 22.09.2017 to

24.09.2017.She submitted that her father was taking the treatment for diabetes since last 10 years and before

surgery his weight was 77 Kg and does not have obesity problems for the age of 50 years. As per Doctor‟s

recommended he had gone for sleeve gastrectomy operation. She submitted that this surgery was done to control

his sugar level ( Diabetes). Respondent‟s decision of denial of the claim stating it to be a complication of morbid

obesity was not acceptable to her. She requested for settlement of the claim.

Contentions of the Respondent : The Company has submitted in their written statement that on

scrutinizing the claim documents submitted by the insured, it was observed that the insured has undergone

Laparoscopic surgery for Sleeving Gastrectomy is a surgical weight loss procedure for reduced of the large

portion of stomach about 15% of its original size. Also uncontrolled Type II DM. Morbid Obesity is the

squeal of Metabolic Syndrome.

As per Exclusion Clause no. 4.4.6.1 of the policy, the Company is not liable to make any payment in respect of

any expenses for treatment of weight control services including surgical procedure for treatment of obesity,

medical treatment of weight control/loss programs. Hence the claim stood repudiated as per policy terms and

conditions.

Forum’s Observations/Conclusion: After hearing the depositions advanced by both the parties and

scrutiny of the documents produced on record it is observed that the complainant was diagnosed with

Uncontrolled Type II, DM with Metabolic Syndrome and underwent laproscopic sleeve gastrectomy Surgery.

Respondent repudiated the claim for the said hospitalization stating that treatment of Obesity is excluded under

the policy and also that Fatty liver, Uncontrolled Type II, DM is the sequelae of morbid obesity. The Forum

observes that being overweight/obese is one of the many risk factors for Metabolic Syndrome.

However it may be noted that whenever any dispute arises it is settled based on the terms and conditions of the

policy under which a claim has arisen. Policy condition specifically excludes coverage of treatment related to

disease caused due to obesity & diabetes mellitus.

Hence the decision of the Respondent to reject the claim being based on policy terms and conditions is found to

be in order and does not call for any intervention by the Forum. Consequently, no relief can be granted to the

complainant. Hence the following Order:

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Suvarna G. Amonkar against The New India Assurance Co. does not sustain.


him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws

of the Land against the Respondent Insurer.

Dated: This 26th


(MILIND KHARAT)

INSURANCE OMBUDSMAN

of 279



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MR.SUSHIL A.SUKHWANI



1 Name & Address of the Complainant Mr.Sushil A.Sukhwani, Mumbai

2 Policy No:


Sum Insured

131102/48/2017/8326

Happy Family Floater Policy 2015 07.01.2017 – 06.01.2018

Rs.10,00,000/-


Mr. Tushar Sushil Sukhwani Mr. Sushil A.Sukhwani










Ombudsman Rules

Under Rule 13(b)

13 Date of Hearing 23.08.2018 – 15.00 pm


a) For the complainant Abesent

b) For the insurer Mrs.Gayatri Swapnil Patil, A.O.



Brief Facts of the Case : Complainant’s son was admitted to Breach Candy Hospital, Mumbai from 17.04.2017 to 19.04.2017 and was diagnosed and treated for Rt. Renal Calculi. Complainant approached this Forum with a complaint against short-settlement by the Respondent of the claim lodged under the policy in respect of the said hospitalization.

Contentions of the Complainant : The Complainant remained absent. Based on his written submission the hearing continued with the Company. The Complainant had submitted in his statement that his family members are covered with The Oriental Insurance Company for more than 14 years. Total claim was RS.3,24,667/- along with pre-post hospitalization claim. The Company settled the claim for Rs.2,09,517/-. An amount of Rs.1,15,150/- was deducted towards Surgeon fees, Anesthesia, Dr. charges, bed charges and medical charges as per GIPSA package. He is not agreeable with the decision of the Insurance Company as the Breach Candy Hospital is not under PPN net work.

Contentions of the Respondent: The Forum asked the Company the reasons for short payment of the claim. The Company official Mrs. Gayatri Patil A.O. submitted that the Health India TPA has deducted the charges towards Surgeon fees, Anesthesia, Dr. Charges, bed charges and medical charges as per GIPSA, PPN package.

Forum’s Observations/Conclusion : The Forum has scrutinized all the documents produced on record and observed that complainant’s son has underwent treatment for Rt. Renal Calculi at Breach Candy Hospital. He lodged total claim of Rs.3,24,667/- and

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the Company has settled it for Rs, 2,09,517/- after deducting charges towards Surgeon fees, Anesthesia, Dr. charges, bed charges and medical charges as per GIPSA package. The Forum observed that the Breach Candy Hospital is not under the GIPSA , PPN network package. The Forum observed in the instant case, Surgeon fees, Anesthesia, Dr. Charges, bed charges and medical charges are marginally on the higher side which compared with other hospital. Whenever it is observed that the charges of particular hospital are unreasonable and Reasonability clause of the policy comes into play. Hence in the interest of the justice further amount for Rs.60,000/- to be paid to the Complainant. The decision of the Respondent is therefore intervened by the following Order:

AWARD Under the facts and circumstances of the case, The Oriental Insurance Co. Ltd. is directed to pay Rs.60,000/- in favor of the Complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:









CASE OF COMPLAINANT - MS. TRUPTI MAROLIA

VS RESPONDENT : STAR HEALTH AND ALLIED INSURANCE CO. LTD.


1 Name & Address of the Complainant Ms. Trupti Marolia Mumbai

2 Policy No:


Sum Insured

P/171129/01/2018/001923

Mediclassic Individual Insurance Policy 17.08.2017 - 16.08.2018

Rs.45,00,000/- + C.B. Rs.50,000/-


Ms. Trupti Girish Marolia

4 Name of Insurer Star Health & Allied Insurance Co. Ltd.


6 Reason for repudiation Obesity treatment – Excl. No. 17






12 Complaint registered under Insurance Under Rule 13(b)

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Ombudsman rules



a) For the complainant Ms. Trupti Marolia

b) For the insurer Dr. Arvind Thakkar, AGM



Brief Facts of the Case : Complainant was admitted to Saifee Hospital from 20.08.2017 to 23.08.2017 for

the treatment of Metabolic Syndrome, Cholelithiasis, Diabetes mellitus, Hypertension and underwent banded

Gastric Bypass + Lap Cholecystectomy. Respondent repudiated the claim for the same as per Exclusion Clause

17 of the policy which excludes surgery for the treatment of obesity from the scope of the policy.

Contentions of the Complainant : Complainant contended that she had complaints of PCOD and

cholelithiasis from the year 2016 and was on medication for the same. However due to morbid obesity she

opted for lap band bypass surgery and also for cholecystectomy which was optional. But the doctor advised her

of the repercussions if she did not undergo the latter surgery and hence she went in for it. Respondent‟s decision

of denial of the claim stating it to be a complication of morbid obesity was not acceptable to her. She requested

for settlement of the claim.

Contentions of the Respondent : Dr. Thakkar submitted that on scrutinizing the claim documents

submitted by the insured, it was observed that the insured has undergone Laproscopic banded Gastric Bypass for

Morbid obesity. Also Cholelithiasis is the sequelae of morbid obesity. As per Exclusion Clause no. 17 of the

policy, the Company is not liable to make any payment in respect of any expenses for treatment of weight

control services including surgical procedure for treatment of obesity, medical treatment of weight control/loss

programs. Hence the claim stood repudiated as per policy terms and conditions. He added that as per certificate

dt. 29.07.2017 issued by Dr. Muffazal Lakdawala, the insured patient was a case of symptomless uncomplicated

gallstones and the surgery has been done prophylactically to avoid the future complications like cholecystitis,

pancreatitis.

On hearing the depositions of both the parties, the complainant was directed to produce within 7 days, a letter

from her treating surgeon clarifying as to whether gall stones was a complication of morbid obesity.

Accordingly, complainant submitted to the Forum a certificate issued by Dr. Lakdawala stating that Gall stones

is independent disease and is not related to obesity. The surgery viz. Lap Cholecystectomy undergone by her

was extremely important as it can stimulate complication like Cholecystitis, Cholangitis, Biliary Pancreatitis,

Gallstones ileus.

Forum’s Observations/Conclusion: After hearing the depositions advanced by both the parties and

scrutiny of the documents produced on record it is observed that the complainant was diagnosed with Metabolic

Syndrome, cholelithiasis, DM & HTN and underwent Banded Gastric Bypass + Lap Cholecystectomy.

Respondent repudiated the claim for the said hospitalization stating that treatment of Obesity is excluded under

the policy and also that Cholelithiasis is the sequelae of morbid obesity. Complainant has submitted a letter

from her treating surgeon stating that Cholelithiasis is not related to obesity and the surgery for the same was

necessary to avoid future complications arising out of it.

The Forum analyzed the case and observes that being overweight/obese is one of the many risk factors for Gall

stones but it cannot be said to be a direct complication of obesity as even non-obese persons can suffer from gall

stones. Besides as per Exclusion Clause 3 (b) of the policy, claims for treatment for hepatobiliary gall bladder

are not payable during the first two years of continuous operation of the policy. The subject claim has been

lodged in the 4th

year of the policy being in continuous force. Had the treatment not been done along with the

treatment for obesity, in all probability the claim for the same would have been considered by the Respondent.

Although the Respondent has further contended that the complainant was asymptomatic for gall bladder stones,

it is a known fact that if a gallstone lodges in a duct and causes a blockage, it might result into serious

complications like cholecystitis, jaundice and bile duct infection, pancreatitis etc. In view of all the above, the

Forum is of the view that although denial of the claim for the treatment of obesity being as per the terms and

conditions of the policy, is in order, the decision of the Respondent to repudiate the entire claim including that

for the treatment of cholelithiasis is not justified. Their decision is therefore intervened by the following Order:

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AWARD

Under the facts and circumstances of the case, Star Health And Allied Insurance Co. Ltd. is directed to pay the admissible claim amount for the treatment of cholelithiasis undergone by Ms. Trupti Marolia, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:





(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017) OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - MR. VINAY GUPTA

VS RESPONDENT : UNITED INDIA INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Vinay Gupta Mumbai


0220002816P117141425 Individual Health Policy 30.03.2017 – 29.03.2018 Rs.5,00,000/-


Mr. Vinay Gupta

4 Name of Insurer United India Insurance Co. Ltd


6 Reason for repudiation OPD Treatment


8 Nature of complaint Total Repudiation of claim


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Under Rule 13(b)



a) For the complainant Mr. Vinay Kumar Gupta

b) For the insurer Mr. Sangeeta Sanjay Surve, A.O. Dr. Bharti – Health India TPA



Brief Facts of the Case : Complainant underwent Lumbar Epidural Block at Lilavati Hospital on 29.08.2017 for the treatment of Bilateral L4-S1 Prolapsed Intervertebral Disc with DDD. Due to relapse, he was again admitted to the same Hospital from 27.11.2017 to 30.11.2017 and was treated conservatively. The claims lodged under the policy for the said treatment were repudiated by the Respondent on the ground that the treatment was possible on OPD basis and did not warrant hospitalization. Aggrieved by the decision of the Respondent, complainant approached this Forum seeking relief in the matter.

Contentions of the Complainant : Complainant stated that as he was suffering from lower back pain from mid July 2017, he consulted Dr. Premik Nagda at Lilavati Hospital and as per his advice underwent Lumbar Epidural Block on 29.08.2017 on Day care basis. In November 2017, the pain resurfaced severely; hence he consulted Spine surgeon Dr. Shekhar Bhojraj who after examining him, advised surgery as the only remedial relief. He was advised to undergo investigations viz. MRI, PET scan, ultrasound etc. for SOS surgery. However, after reviewing the MRI report, he suggested that surgery could be postponed and decided to treat him conservatively with steroid injections and complete bed rest for minimum of 2 weeks followed by physiotherapy. He being a heart patient with history of two heart attacks, was also not keen to go ahead with the spine surgery, knowing fully well the risk involved in it. Respondent however rejected his claims stating that the treatment undergone by him was possible on OPD basis and did not require hospitalization. Complainant argued that he was hospitalized because of intense pain, on the advice of a renowned surgeon for the purpose of surgery which was fortunately avoided due to his cardiac ailment. Hence the reason cited by the Respondent for rejection of the claims was not acceptable to him. He requested for settlement of both the claims.

Contentions of the Respondent: Dr. Bharti submitted that the complainant was admitted to the hospital with complaints of pain in lower back, radiating to right lower limb, paresthesia over right lower limb on lateral aspect, difficulty in walking, sitting, climbing stairs, claudication present after duration of 3 mins. During hospitalization, he received B/L lumbar Transforaminal epidural block at L4-L5, L5-S1 under L.A. + Sedation. The said procedure is done in minor O.T. under aseptic conditions; however is not covered under the list of standard day care procedures and hence the claim stood rejected as per policy terms and conditions. Mr. Gupta was again hospitalized from 27.11.2017 to 30.11.2017 for the same complaints and was treated with oral medication and Injections. During hospitalization, he underwent a series of investigations. Out of the total hospitalization expenses of Rs.1,15,575/-, Rs.7,095/- were towards medicines, Rs.7,000/- towards Doctor charges, Rs.15,500/- towards Room charges and Rs.95,000/- towards investigations all of which were possible on OPD basis after which the decision for surgery/hospitalization could be taken. As there was no active line of treatment justifying the need for hospitalization, the said claim also stood repudiated under the policy and consequently the post-hospitalization claim was also inadmissible.

Observations/Conclusion: On perusal of the documents produced on record, it is observed that during the first hospitalization the patient underwent epidural block procedure which is not listed as a day care procedure under the policy. During the second hospitalization, the complainant was treated with only oral medicines and injections. The said treatment does not justify any

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compelling need for hospitalization and the Forum tends to agree with the Respondent’s contention that there was no justification for hospitalization as the treatment as well as investigations could have been performed on outpatient basis. Mediclaim Policy basically grants reimbursement of expenses which are reasonably and necessarily incurred on treatment which per se requires hospitalization and not for OPD treatment which is converted into IPD for any other reason. Thus, it is found that repudiation of the claim is in accordance with the terms and conditions of the policy. Under the circumstances, there is no valid reason to intervene with the decision of the Respondent in the matter and consequently no relief can be granted to the complainant.

AWARD Under the facts and circumstances of the case, the complaint lodged by Mr. Vinay Gupta against United India Insurance Co. Ltd., does not sustain. It is particularly informed that in case the award is not acceptable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 24th day of December, 2018 at Mumbai.





CASE OF COMPLAINANT - MR. VINOD KOCHU



1 Name & Address of the Complainant Mr. Vinod Kochu Mumbai



Sum Insured

10714641 Care Floater Policy

12.07.2017 to 11.07.2018

Rs. 5,00,000/-

3 Name of Insured


Mr. Vinod Kochu

Ms. Parul Singh










Under Rule 13(b)


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a) For the complainant Mr. Vinod Kochu




Brief Facts of the Case : Complainant was admitted to Aditi Hospital, Mulund, Mumbai from 19.11.2017 to 21.11.2017 for the treatment of Inferior lateral wall Myocardial infarction. He lodged a claim for Rs.3,00,435/- (incl. pre & post hospitalization expenses) under the policy which was repudiated by the Respondent on the ground of non-disclosure of history of Hypertension since 3 years while taking the policy. Aggrieved with the decision of the Respondent, complainant approached this Forum seeking relief in the matter.

Contentions of the Complainant : Complainant stated that on 19.11.2017 midnight he suffered a heart attack and was admitted to Aditi Hospital and was operated for angioplasty. Respondent rejected the claim for the said hospitalization on the basis of Non-disclosure of hypertension. He stated that he never had hypertension or any other disease/condition. Just on one occasion on 01.09.2017, when he visited a doctor because of nausea and checked his BP, it was 126/90, which was nearly normal. Looking at his age, the doctor suggested that he should start taking a couple of medicines and keep his BP normal. This was exactly what he told to the hospital staff in the ICCU on admission, however the history of HTN was incorrectly documented as 3 years instead of 3 months. He stated that there was no question of any non-disclosure on his part and requested for settlement of the claim. He added that the Respondent also cancelled the policy for both his wife and himself on the said ground.

Contentions of the Respondent: Dr. Poonam stated that Ms. Parul Singh was insured with them since 12.07.2016 and her spouse Mr. Vinod Kochu was added in the policy on renewal w.e.f. 12.07.2017. On receipt of the claim documents, it was observed from the Admission History & Assessment Form, Nutritional Assessment Form as well as Discharge Summary of the Hospital that the complainant was duly mentioned to have past history of hypertension since 3 years and was also a smoker. Also, as per the consultation Note dt. 18.11.2017 of Saidhan Hospital the complainant is mentioned to be k/c/o Hypertension/Smoker. As the said history dates back prior to inception of the policy and was not disclosed at the time of proposing for insurance, the claim was rejected as per Clause 7.1 of the policy on the ground of Non-Disclosure of material facts/Pre Existing ailment of Hypertension since 3 years and also the policy being a floater policy, was cancelled for both the members. She added that they had also taken an expert opinion to substantiate the fact that the present ailment of the complainant is directly related to the history of hypertension and habit of smoking of the complainant and as per the said opinion since the patient has h/o hypertension and has been a smoker as well, both these are independent and significant risk factors for ischemic heart disease as jointly they have a synergistic effect. Post hearing, complainant submitted to the Forum a copy of the Consultation Note dt. 01.09.2017 of Dr. Navin S. Shriyan stating “As Newly detected Hypertension” and also a Certificate dt. 05.09.2018 issued by Aditi Hospital stating that Mr. Vinod Kochu was suffering from HTN since 01.09.2017 as per the consultation paper of Dr. Navin Shriyan while the history of HTN since 3 years mentioned in the IPD papers was by mistake.

Forum’s Observations/Conclusion: On an analysis of the case, it is observed that the Discharge Summary and other IPD papers of the Hospital mention that Mr. Vinod Kochu was a known case of HTN since 3 yrs and also had history of Smoking. The history narrated before the doctor either by the patient or his/her representative is his or her own statement and hence cannot be totally overlooked. Everybody would like to give exact narration to the doctor so as to enable him to make proper judgement with all the facts put before him so as to enable him to arrive at a correct diagnosis and adopt a proper line of treatment. The complainant claims that the history was recorded wrongly in the hospital records. In that case, if there was any error in the hospital notings, the complainant/his relatives should have got the same rectified immediately. The argument of the complainant that he was detected with HTN only since 3 months and the certificate issued by the hospital to that effect after denial of the claim by the Respondent appears to be an after-thought and hence cannot be accepted. It is certainly the duty of a proposer to reveal all the important facts about the health status and pre-existing conditions, if any of the person to be insured while proposing for insurance as it is this information furnished in the Proposal Form which forms the basis of the contract of insurance between the Company and the insured person. Insurance contracts are governed by the principle of utmost good faith which requires both parties of the insurance contract to deal in good faith and in particular

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it imparts on the proposer a duty to disclose all material facts which relate to the risk to be covered to enable the insurers to evaluate the risk in its proper perspective. Failure on the part of the complainant to mention these facts to the Insurance Company certainly amounts to non-disclosure/ suppression of material information entitling the Company to deny liability arising under the policy. Under the facts and circumstances of the case, the decision of the Respondent to repudiate the claim on the ground of non-disclosure of material information, cannot be faulted with and the Forum finds no valid ground to intervene with the said decision.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Vinod Kochu

against Religare Health Insurance Co. Ltd. does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 5


(MILIND KHARAT)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –MS. SANDHYA BALIGA

CASE OF: MR MUKESH KUMAR GOEL VS APOLLO MUNICH HEALTH INSURANCE CO. LTD.

AWARD

COMPLAINT REF: NO:NOI-G-003-1718-0341

AWARD NO:

1. Name & Address of the Complainant Mr. Mukesh Kumar Goel,

87, Khajoori Darwaja, Old gur Mandi,

Parikshitgar,

Meerut (U.P.)

2. Policy No:

Type of Policy


S.I.

110100/11051/AA00100373-03

Easy Health Floater

28.6.2014 to 27.6.2015

Rs.3,00,000/-



Mrs. Kavita Goel

Mr. Mukesh Kumar Goel

4. Name of the insurer Apollo Munich Health Insurance Company Ltd.


6. Reason for repudiation

Claim rejected due to Non-compliance of

requirements.


8. Nature of complaint Health claim repudiated


10. Date of Partial Settlement --

11. Amount of relief sought Rs.210000/- + interest as per Annex VI A


Rule no: of IOB rules,2017

13 (1) (b)

13. Date of hearing/place 13.12.2018/Noida


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u) For the Complainant Sh. Mukesh Kumar Goel, Self

v) For the insurer Dr. Mohammad. Danish, A.M.

15 Complaint how disposed Award settled in favour of Complainant


17) Brief Facts of the Case :

The complainant took a Mediclaim Policy No. 110100/11051/AA00100373-03 for the period from 15.07.2017

to 14.07.2018 with sum insured of Rs.5, 00,000/- from Apollo Munich Health Insurance Company Ltd. for

himself and his family. The complainant‟s wife was admitted in Metro Hospital, Noida for the period from

25.8.2017 to 28.8.2017 with complaints of Acyanotic Congenital Heart Disease. The claim was lodged by the

complainant with the company for Rs.2,10,000/-, which was rejected by the company and the policy was also

cancelled on the ground of non disclosure of material facts.


a) Complainants argument : The complainant stated that the insurer had refused for cashless facility as

they had promised at the time of commencement of the policy. The complainant had submitted all the

documents as per their letter dated 25.9.2017, but Insurance Company rejected his claim vide their

letter dated 24.10.2017 and asked some more requirements to reopen the case. He informed the insurer

that all the family members were fit and proper check up was done by insurer. When he pursued hard

for the claim, the insurer arranged further investigation and Mr. Ajay Kumar visited his place and

enquired about the claim. He replied to their queries vide his mail dated 27.11.2017, but the Insurance

Company kept on asking for the same requirements time and again. The claimant has sought relief

from this forum for re-imbursement of his claim.

b) Insurers’ argument: The Insurance Company in its reply dated 10.4.2018 stated that the complainant

had filed cashless request on 23.8.2017 for the complaint of ASD (Atrial Septal Defect). During the

cashless request, they noticed that there was an OPD card of Cardiac and Neuroscience Centre, OPD

dated 2.9.2015, wherein it is mentioned that the patient was a known case of ASD/Hypothyroidism.

Hence the query was raised to provide first consultation and treatment records of the same. The

complainant had filed claim reimbursement for an amount of Rs.2,10,000/- for insured Kavita Goel. On

receipt of the reimbursement claim they again reviewed the claim similar queries were raised as in

previous cashless request. The date of diagnosis of ASD for the first time was 2.9.2015 as per AIIMS

OPD consultation papers. Therefore, it was evident that the complainant had manipulated the facts and

was not co-operating in providing the documents as mentioned in their query letter. On receipt of

requirements the case may be reopened by the Insurance Company.

19) Reason for Registration of Complaint:- Rejection of mediclaim.


a) SCN.

b) Claim details.

c) Mail for rejection of claim and cancellation of policy.

d) Discharge summary.

e) Proposal form.

21) Result of hearing with both parties (Observations & Conclusion) :- Both the parties appeared in the

personal hearing. The Insurance Company stated that the Complainant submitted the Proposal Form on

28.07.2017 and the date of diagnosis of ASD for the first time was 2.9.2015 as per AIIMS OPD

consultation papers. Hence, this was a case of PED. The Complainant had failed to submit the required

documents to the Insurer despite various query Letters dated 23.08.2017, 11.09.2017, 25.09.2017,

03.10.2017, 05.10.2017, 24.10.2017 and Grievance Deptt.‟s mail dated 26.02.2018. Hence, due to non

compliance of the requested documents, they repudiated the claim under section VI ii of the policy. The

Complainant argued that at the time of taking the policy all family members were in good health. After

that at the time of renewal, health of all the family members, being checked up again due to increase of

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Sum Insured and the disease was a recent development. The Insurance Company repudiated the claim on

the ground that the present hospitalization was for management of an ailment which was related to a pre-

existing disease and therefore was not admissible. It was observed that Insurance Company could not

prove that it was a case of PED. A careful scanning of the evidence of the Insurance Company revealed

that except for relying on the clinical summary of AIIMS OPD Consultation papers, they did not produce

even a shred of an evidence to conclusively establish that complainant was taking treatment for his wife‟s

ailment from any hospital in India before taking the mediclaim policy. Mere reference in Discharge

Summary is not sufficient and Insurance Company was required to produce the independent documentary

evidence to prove this fact. The Insurance Company was given time of one week to produce any evidence

to support their plea but Insurance Company had failed to submit the same.

As per case of NCDRC – Satinder Singh Vs. National Insurance Company – The recording of history of

patient in the above stated manner does not become a substantiate piece of evidence and convincing

evidence be brought on record that complainant was aware of pre – existing disease at the time of taking

the policy.

It is found that the Insured must be having pre-existing disease not based on any concrete or specific

evidence. Hence, the decision of the Insurance Company is set aside and claim settled.

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


a. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer

within a period of 15 days from the date of receipt of this Award, a letter of acceptance that the Award is in

full and final settlement of his claim.

b. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of

the acceptance letter of the Complainant and shall intimate the compliance to the Ombudsman.

Place: Noida. SANDHYA BALIGA

Dated: 19.12.2018 INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF MANOJ BHARDWAJ V/S NATIONAL INSURANCE CO. LTD.

COMPLAINT REF: NO. NOI-G-048- 1718 - 0321

AWARD NO:

1. Name & Address of the Complainant Manoj Bhardwarj

Plot No. A-1, S-40/41, Surajpuir, Kasna Road

Greater Noida

AWARD

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

parties during the course of hearing, an award is passed directing the insurance company to pay the

admissible claim amount within 30 days after receipt of required documents under intimation to this

forum.

The complaint is treated as disposed off accordingly.

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2. Policy No:

Type of Policy


461800/48/16/8565000011


7.10.2016 to 6.10.2017



Shanti Devi

Shanti Devi

4. Name of the insurer National Ins. Co. Ltd.


6. Reason for repudiation Incomplete papers


8. Nature of complaint Rejection of Claim





IOB Rules, 2017

13 (1) (b)

13. Date of hearing/place 27.11.2018 and 14.12.2018/ Noida



b) For the insurer Absent

15 Complaint how disposed The case is dismissed by default

16 Date of Award/Order 26.12.2018.

1) Sh. Manoj Bhardwaj (herein after referred to as the complainant) had filed a complaint against the decision

of National Insurance Company Limited(herein after referred to as respondent Insurance Company)

alleging that mediclaim of his mother‟s treatment was wrongly rejected by the insurance company due to

non-receipt of certain requirements.

2) The personal hearing in the case was fixed for 27.11.2018 and 14.12.2018 . The complainant did not attend

the personal hearing on both the dates and none also represented him. The case is dismissed in default

without going into merits of the case.

3) Copies of the order to both the parties.

Place: Noida. (SANDHYA BALIGA)


(WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017


CASE OF RAJAN GUPTA V/S STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED

COMPLAINT REF: NO: NOI-G-044-1819-0154

AWARD NO:

1. Name & Address of the Complainant Sh. Rajan Gupta

5/1, National Road, Laxman Chowk

Dehradun, Uttarakhand - 248001

2. Policy No:

Type of Policy


P/161115/01/2018/009122

Health Plan

19.12.2017 to 18.12.2018



Sm. Madhu Gupta

Sh. Rajan Gupta

4. Name of the insurer Star Health and Allied Insurance Co. Ltd.


6. Reason for repudiation Claim within waiting period of 24 months



9. Amount of Claim 10 Lakhs

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10. Date of Partial Settlement None

11. Amount of relief sought 10 Lakhs


IOB rules

13 (1) (b)

13. Date of hearing/place 20.11.18 and 14.12.18/ Noida


c) For the Complainant Sh.Rajan Gupta,Self

d) For the insurer Sh.Mantosh Kumar,Dy.Manager

15 Complaint how disposed Award in favour of the complainant


17) Brief Facts of the Case :- This complaint is filed by Sh. Rajan Gupta against Star Health & Allied

insurance Company Limited relating to repudiation of claim.

18) Cause of Complaint :-

Complainant’s Argument :- The complainant stated that he had purchased a policy from Star Health & Allied

Insurance Company Limited on 19.12.2016 covering himself and his spouse. His wife developed back pain in

November 2017 following a bout of cough which was sharp shooting, increased with movement and limited

physical activities. In view of persistent pain, MRI of whole spine was done on 19.12.2017 which showed D12

vertebral fracture without retropulsion for which insured underwent vetebroplasty on 21.12.2017 and also

procedure for Multiple Myeloma from Max Hospital, Dehradun. The insured was admitted to BLK SS

Hospital, New Delhi on 11.5.2018 for treatment planned autologous stem cells transplant and was discharged on

30.5.2018. The complainant had submitted all the claim forms to the insurer for reimbursement but the same

was denied by the insurer as per the waiting period clause/ exclusion No. 3 ii (g) of the policy vide letter dated

29-5-2018.

Insurer’s Argument :- The insurer stated that a policy named Family Health Optima Insurance Policy bearing

no. P/161115/01/2018/009122 had been issued covering Mr. Rajan Gupta and Mrs. Madhu Gupta for floater

sum insured of Rs.15 lakhs. The insured was admitted on 11-5-2018 in BLK Memorial Hospital, New Delhi for

diagnosis of Multiple Myeloma and underwent treatment for autologous stem cell transplant. The insured has

undergone the above treatment during the 2nd

year of the policy and same falls within 2 years waiting period of

the policy. Hence the claim payment was repudiated as per waiting period 3 (ii) (g) of the policy terms and

conditions which states that “All types of transplant and related Surgeries are excluded in the first 24 months of

inception of the policy”.

19) Reason for Registration of Complaint: - Non – settlement of claim.

20) The following documents were placed for perusal :-

a) Complaint letter

b) Treatment papers

c) Rejection letter

d) SCN

20) Result of Hearing : – First hearing was held on 14.11.18 in which only the insurance company

was present. None appeared for the complainant. Hence re-hearing was held on 14.12.2018 in

which both the complainant and the Insurance Company appeared. During the hearing, the

insurance company stated that they had settled the claim for Rs.89076/- on 21.11.18. Further, an

amount of Rs.69185/- was pending due to non-submission of prescriptions and test reports. Room

rent and nursing charges of Rs.32000/- had been deducted as per eligibility limit for the Sum

Insured opted.Rs.8050/- and Rs.410/- were deducted as per policy terms and conditions

applicable for non-payable items. The complainant argued that as per his Sum insured of Rs.15

lakhs, he was eligible for room rent of 1% of S.I i.e Rs.15000/- per day but he had availed room

with tariff of only Rs.11500/- but the insurer had approved the room rent of Rs.9000/- per day

only. The insurance company stated that as per policy T&C ,the insured was eligible for Single

Standard AC room for which the tariff was Rs.9000/- as confirmed by the hospital and the same

had been approved by them. They, however agreed to again verify the room tariff with the

hospital. The insurer also assured that on submission of the necessary documents such as

prescriptions and reports for the diagnostic tests carried out, they were willing to reassess the

amount payable. The complainant was advised to collect the required documents from the

hospital and submit the same to the insurer.

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c. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



d. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of


Place: NOIDA SANDHYA BALIGA



PROCEEDINGS BEFORE



OMBUDSMAN – SMT. SANDHYA BALIGA

CASE OF SHIV LAL JAISWAL V/S RELIGARE HEALTH INSURANCE COMPANY


AWARD NO:

1. Name & Address of the Complainant Sh. Shiv Lal Jaiswal

Stellar Jeevan K-1405, Sector 1, Gh-03

Greater Noida West, Gautam Budh Nagar,

Uttar Pradesh-201306

2. Policy No:

Type of Policy


10952019

Health Plan

11-07-2017 to 10-01-2018



Ankita dwivedi

Shiv Lal Jaiswal

4. Name of the insurer Religare Health Insurance Company


6. Reason for repudiation Discrepancy in medical record


8. Nature of complaint Rejection of claim



11. Amount of relief sought Rs.102,564


IOB rules

13 (1) ( b)

13. Date of hearing/place 19.11.18 at Noida


e) For the Complainant Shivlal Jaiswal,Self

f) For the insurer Nisha Sharma,Manager Claims

15 Complaint how disposed Award in favour of Insurance Company


17) Brief Facts of the Case:- This complaint is filed by Sh. Shiv Lal Jaiswal against Religare Health Insurance

Company Limited against rejection of claim by the company.

18) Cause of Complaint:- Rejection of claim

Complainants argument : The complainant stated that he had purchased health insurance policy bearing no.

10952019 covering himself and his spouse Ankita Dwivedi from Religare Heath Insurance Company for the

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

additional amount admissible on submission of the required documents by the complainant.

Hence, the complaint is treated as disposed off.

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period from 11-01-2017 to 10-01-2018 for sum assured of Rs. 5 lakh. On 17-04-2018 his wife was admitted to

VRANDAVAN HOSPITAL, Shahberi,Greater Noida due to head injury, where she was kept in ICU for one

day.On 18-04-2018, she was admitted to Neo Hospital, Noida, where it was found that she had head injury due

to fall at home in the bathroom and was discharged on 21-04-2017 from the hospital. The complainant had

submitted all the relevant claim documents to the insurer but the claim had been repudiated by the insurer on the

ground of discrepancy in medical documents.

Insurers’ argument:- The insurer stated that the complainant The complainant had approached the insurer with

three reimbursement claims with respect to hospitalization of his wife. The first two claims were for

hospitalization in Vrandavan Hospital, Noida on 17-04-2017 and simultaneously in Neo-Hospital on 18-04-

2017. The third claim was for hospitalization in Neo Hospital on 12.05.2017. As per discharge summary dated

18-04-2017 of Vrandavan Hospital , the insured was diagnosed for Head Injury with Ingestion of unknown

substance. It is also mentioned that the insured underwent Gastric Lavage ( stomach cleaning) which shows that

the insured had consumed some toxic substance. However as per the Indoor Case paper of Neo Hospital the

insured is a known case of depression and on antipsychotics ( stopped 2 months back).She was under emotional

distress after her marriage about 4 months back. As per the Medico-Legal Report dated 17.04.17 done at

Vrandavan Hospital and submitted by the complainant the insured is suspected of Head Injury along with

Substance Abuse and history of Depression. Also as per certificate of Neo Hospital dated 19-06-2017, the

insured is taking treatment for depression from BHU until 4 months prior to hospitalization. However the

insured could not produce any consultation paper. In view of the above facts, the claim of the complainant was

rejected on the ground of mis-representation of the facts vide clause 7.1 and clause 4.2 ( 23) of the policy terms

and conditions . The rejection of claim was intimated to the complainant on 04-07-2017.

19) Reason for Registration of Complaint: - Non settlement of claim


a) Complaint letter

b) Rejection letter

c) Policy document

d) SCN

21) Result of Hearing : – Personal hearing was held on 19.11.2018 in which both the complainant and the

Insurance Company appeared and reiterated their submissions. The insurance company argued that due to non-

disclosure of pre-existing disease of depression by the insured the policy was void ab-initio and claim was not

admissible as per policy condition no.6.1 of policy terms and conditions which states

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-

disclosure of any material particulars or any material information having been withheld or if a claim is

fraudulently made or any fraudulent means or devices are used by the policy holder or the insured person or

anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the

premium paid shall be forfeited to the company.

The complainant argued that the hospitalization was for head injury due to fall in the bathroom followed by loss

of consciousness and not due to any psychiatric problem. The insured was only suspected to have ingested some

unknown substance but it was subsequently refuted by the doctors of Vrandavan Hospital and Neo Hospital vide

certificates dated 18.06.17 and 19.06.17 respectively.

The insurance company contended that policy was taken in January 2017 and the incident occurred in April

2017,just 3 months after inception of the policy. The discharge summary and indoor case papers confirm that the

insured was a known case of depression and was on antipsychotics until 2 months prior to hospitalization.

During her stay in the hospital too she was prescribed antipsychotics after consulting a psychiatrist.

Based on the oral submissions and documents exhibited during the hearing I observe that the medical certificate

issued by both the hospitals are on plain paper and much after the hospitalization period. The complainant was

advised to submit affidavit from the treating doctors that the insured had no past history of depression, which the

complainant failed to submit. Hence I find no reason to interfere with the decision of the insurance company to

repudiate the claim on the basis of Non-disclosure of pre-existing disease.

AWARD

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

both the parties during the course of hearing, I find it is a case of non-disclosure of

material facts before the inception of the policy. I see no reason to interfere with the

decision of the insurance company. The complainant is treated as disposed.

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e. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



f. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





PROCEEDINGS BEFORE



OMBUDSMAN – SM. SANDHYA BALIGA

CASE OF SUNIL KUMAR V/S ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY

LIMITED


AWARD NO:

1. Name & Address of the Complainant Sh. Sunil Kumar

C 293-A, Brijdham apartment

Shalimar Garden, Extension 02, Sahibabad

Ghaziabad Uttar Pradesh 201005

2. Policy No:

Type of Policy


HSW0000781000103

Health Plan

From 12-11-2017 to 11-11-2018



Sh. Chhote Lal

Sh.Sunil Kumar

4. Name of the insurer Royal Sundaram General Insurance Company



Treatment for diseases due to tobacco abuse are

excluded under the policy


8. Nature of complaint Non-Settlement of claim





IOB rules

13 (1) (d)



g) For the Complainant Sunil Kumar,Self

h) For the insurer Amit Upadhayay,Asst.Manager



17) Brief Facts of the Case:- This complaint is filed by Sh. Sunil Kumar against Royal Sundaram General

Insurance Company Limited relating to non-settlement of mediclaim of his father Sh. Chhote Lal .

21) Cause of Complaint:- Complainants argument :- The complainant stated that he had purchased Family Health Floater policy from

Royal Sundaram General Insurance company limited for the period from 12.11.2017 to 11.11-.018 for sum

insured of Rs.3,00,000/-. His father Sh. Chhote Lal was hospitalized from 04.12.17 to 08.12.17 at Narender

Mohan Hospital, Mohan Nagar,Ghaziabad for Heart Attack. The complainant had submitted all the required

documents to the insurer for payment of claim but the claim had been rejected by the insurer vide their letter

dated 29.01.2018on the ground that the disease was due to tobacco abuse.

Insurers’ argument:- The insurer stated that the complainant had taken the subject policy for his father,

Chhote Lal for the period of insurance from 12-11-2017 to 11-11-2018. The said policy was running for the 4th

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year since inception when the complainant lodged a claim in respect of hospitalization of his father for extensive

anterior wall myocardial infarction, cardiogenic shock On perusal of discharge summary it was found that

insured was admitted for coronary artery disease- Triple vessel disease. Indoor case records reveal that the

patient had history of smoking and triple vessel disease due to tobacco abuse is specifically not covered under

the policy under Exclusion no.24 of the policy which states that „‟ The company shall not be liable under this

policy for any claim in connection with or in respect of Disease due to tobacco abuse such as Atherosclerosis,

Ischemic heart Disease, Coronary Artery Disease, hemorrhagic stroke, ischemic stroke, Stomach, Kidney,

pancreas and Cervical Cancers. Hence claim was rejected on above grounds.

22) Reason for Registration of Complaint: - Non-settlement of claim


a) Complaint letter

b) Claim Form

c) Rejection letter

d) SCN


Insurance Company appeared and reiterated their submissions. The insurer submitted Consultant‟s notes of the

treating hospital which has clearly mentioned the insured to be a smoker. The insurance company argued that

the patient had history of smoking and triple vessel disease due to tobacco abuse is specifically not covered

under the policy under Exclusion no.24 of the policy .The complainant admitted that his father was a smoker

earlier but had given up smoking long ago.The doctor had been informed accordingly when his father was

admitted for heart problem. I find that the Initial Assessment Form and Consultant‟s notes of Narinder Mohan

Hospital & Heart Centre have clearly mentioned that the insured is a smoker. Hence the insurance company has

rightly repudiated the claim on the basis of Exclusion no.24 of the policy which states that „‟ The company shall

not be liable under the policy for any claim in connection with or in respect of disease due to tobacco abuse such

as Atherosclerosis, Ischemic heart Disease, Coronary Artery Disease, hemorrhagic stroke, ischemic stroke,

Stomach, Kidney, pancreas and Cervical Cancers.”



According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the

insurer within a period of 15 days from the date of receipt of this Award, a letter of acceptance that the

Award is in full and final settlement of his claim.

As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the

receipt of the acceptance letter of the Complainant and shall intimate the compliance 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, I see no reason to interfere with the

decision of the insurance company.

Hence, the complaint is treated as disposed.

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PROCEEDINGS BEFORE



OMBUDSMAN – SMT. SANDHYA BALIGA

CASE OF SH. VAIBHAV GUPTA V/S STAR HEALTH AND ALLIED INSURANCE COMPANY

LTD.


AWARD NO:

1. Name & Address of the Complainant Sh. Vaibhav Gupta

Naya Bazaar, Santpura, Behind Langre Baba

Ka Mandir, Modinagar,

Uttar Pradesh

Pin-201201

2. Policy No:

Type of Policy


P/161212/01/2018/001308

Health Plan

23.05.2017 to 22.05.2018



Sh. Ashok Kumar Gupta

Sh. Ashok Kumar Gupta

4. Name of the insurer Star Health & Allied Insurance Company Ltd.


6. Reason for repudiation Non-disclosure of facts


8. Nature of complaint Cancellation of policy.

9. Amount of Claim


11. Amount of relief sought


IOB rules

13 (1) (b)

13. Date of hearing/place 20.11.2018 and 14.12.2018 / NOIDA



b) For the insurer Mantosh Kumar, Dy.Manager

15 Complaint how disposed Dismissed in default


1) The complaint is filed by Sh. Vaibhav Gupta against Star Health & Allied Insurance Company Ltd. relating

to rejection of claim under policy no.P/ 161212/01/2018/001308 and subsequent cancellation of policy.

2) The personal hearing in the case was fixed for 20.11.2018 and 14.12.2018 . The complainant was absent on

both the dates and none represented him. The case is dismissed in default without going into merits of the case.




(WESTERN U.P& UTTARAKHAND)

PROCEEDINGS BEFORE




CASE OF SH. ANUJ KUMAR V/S STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED


AWARD NO:

1. Name & Address of the Complainant Sh. Anuj Kumar

47/67, Ajanta Colony, Garh Road

Meerut , Uttar Pradesh-250004

2. Policy No:

Type of Policy


P/161132/01/2018/005286

Health Plan

17.1.2018 to 16.1.2019

3. Name of the insured Sh.Anuj Kumar

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Name of the policyholder Sh.Anuj Kumar

4. Name of the insurer Star Health and Allied Insurance Company

Ltd.


6. Reason for repudiation Misrepresentation of material facts


8. Nature of complaint Non –settlement of claim





IOB rules

13 (1) (d)

13. Date of hearing/place 20.11.2018 and 14.12.18/Noida


i) For the Complainant Absent

j) For the insurer Sh.Mantosh Kumar,Dy.Manager

15 Complaint how disposed Dismissed by Default


1) This complaint is filed by Sh. Anuj Kumar against Star Health and Allied Insurance Company limited

relating to non-settlement of claim under Policy No.P/161132/01/2018/005286.

2) The personal hearing in the case was fixed for 20.11.2018 and 14.12.2018 . The complainant was

absent on both the dates and none represented him. The case is dismissed in default without going into

merits of the case.





PROCEEDINGS BEFORE




CASE OF SH. KRISHNADEV MISHRA V/S STAR HEALTH INSURANCE COMPANY


AWARD NO:

1. Name & Address of the Complainant Sh. Krishnadev Mishra

A 601, Engineers Park, Sector Omega1

Greater Noida, U.P.- 201310

2. Policy No:

Type of Policy


P/700002/01/2018/024210

Sr. Citizens Red Carpet Health Ins. Policy

From : 07.07.2017 to 06.07.2018



Yamuna Prasad Mishra

Krishna Dev Mishra

4. Name of the insurer Star Health & Allied Insurance Co. Ltd.


6. Reason for repudiation Pre -existing disease


8. Nature of complaint Rejection of Claim





IOB rules

13 (1) (d)

13. Date of hearing/place 20.11.18 and 14.12.18 / Noida


k) For the Complainant Rakesh Mohan Mishra,Brother

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l) For the insurer Mantosh Kumar,Dy.Manager

15 Complaint how disposed Award in favor of Insurance Company


17) Brief Facts of the Case :- The complaint is filed by Sh. Krishna Dev Mishra against Star Health and Allied

Insurance Company Limited relating to rejection of claim due to non-disclosure of pre-existing disease.

18) Cause of Complaint:-

Complainant’s Argument : The complainant stated that a policy named Senior Citizens Red Carpet Health

Insurance Policy was issued on the life of his father Sh. Yamuna Prasad Mishra by Star Health Insurance for the

period from 07.07.15 to 06.07.18 continuously for three years without any break. No claim was made in the first

two years of the policy. In the third year of policy, his father Sh.Yamuna Prasad Mishra was diagnosed with

Gall bladder stone and was advised for surgery. He was admitted to Sharma Medicare on 12.08.17 and

discharged on 15.08.17.The complainant had submitted the claim documents for reimbursement of medical

expenses to the insurer but the insurer had rejected the claim.

Insurer’s Argument :- The insurer stated that they had issued Senior Citizen Red Carpet policy on the life of

Sh. Yamuna Prasad Mishra and as per policy terms & conditions, no pre-medical check-up was done of the

insured. The insured had submitted claim documents for reimbursement of medical expenses. On going through

the medical records, it was observed from the OP recordsdated10.08.17 that the insured has a pre-existing

condition for 15 years. Although the treatment is for Choleliathisis, the claim was rejected on grounds of non-

disclosure of material facts.”

19) Reason for Registration of Complaint: - Rejection of claim


a) Complaint letter

b) Policy document

c) Claim form

d) Rejection letter

21) Result of Hearing : – Personal hearing was held on 20.11.2018 in which only the insurance company was

present. The complainant did not appear nor did anyone represent him. Hence re-hearing was held on

14.12.18 in which the complainant‟s brother and son of insured Sh. Rakesh Mohan Mishra attended the

hearing. The Insurance Company appeared and reiterated their submissions. The son of the insured argued

that the present hospitalization was for Gall Bladder Stone and unrelated to COPD. The insurer contended

that at the time of taking the policy the onus lies on the insured to disclose all previous health history in the

proposal form. The insured failed to disclose previous history of Chronic Obstructive Pulmonary Disease

(COPD) which was pre-existing at the time of taking the policy for the first time on 07.07.15.This amounts

to non-disclosure of material facts. Hence the claim was rejected on the basis of non-disclosure of material

facts as per Condition No. 9 of the policy T & C and policy of the insured cancelled on the basis of

Condition No.13 of the policy which state that : “The company may cancel the policy on the grounds of

mis-representation, fraud, moral hazard ,non-disclosure of material fact in the proposal form “.

Based on the documents exhibited and oral submissions, it is obvious that there has been non-disclosure of

material facts by the insured, thus making the policy void ab-initio and all benefits under the policy being

forfeited.

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 find no reason to interfere with the decision

of the insurance company.

Hence, the complaint is treated as disposed off.

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g. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



h. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





PROCEEDINGS BEFORE




CASE OF SUNITA SHARMA V/S STAR HEALTH AND ALLIED INSURANCE COMPANY

LIMITED


AWARD NO:

1. Name & Address of the Complainant Sunita Sharma

140, Mile Store, Mansi, Delhi Bye Pass Link

Road, Mathura, U.P. Pin-281003

2. Policy No:

Type of Policy


P/ 231123/01/2017/002351

Health Plan

31-3-2017 to 30-3-2018



Sunita Sharma

Sunita Sharma

4. Name of the insurer Star Health and Allied Insurance Co.Ltd.


6. Reason for repudiation Non-submission of Claim Documents


8. Nature of complaint Non – Settlement of claim





IOB rules

13 (1)(b)

13. Date of hearing/place 20.11.18 and 14.12.18 at Noida


m) For the Complainant Sm.Sunita Sharma,Self

n) For the insurer Sh.Mantosh Kumar,Dy.Mgr

15 Complaint how disposed Award in favor of the complainant


17) Brief Facts of the Case :- This complaint is filed by Ms. Sunita Sharma against Star health & Allied

Insurance Company Limited relating to non-settlement of claim.

18) Cause of Complaint :-

Complainant’s Argument : - The complainant stated that she had taken a policy from Star Health and Allied

Insurance Company limited for the period from 31.3.2017 to 30.3.2018 covering self for S.I of Rs.10,00,000/-.

The complainant was admitted at The Bangalore Hospital, Bangalore from 26.6.2017 to 01.7.2017. The

diagnosis was Type 2 Diabetes Mellitus, Hypertension , Chronic Kidney Disease. She further stated that her Pre

Authorization request for cashless treatment was denied on 30.6-.017. The complainant had submitted claim

form and documents for reimbursement of medical expenses but the claim had been denied by the insurer.

Insurers’ argument:- The insurer stated that a policy named Senior Citizens Red carpet Health Insurance

policy had been issued for S.I. of Rs.10,00,000/-. The claim for hospitalization was reported in the 2nd

year of

policy for an amount of Rs.46,128/-.The insured was admitted at The Bangalore Hospital, Bangalore on 26-6-

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2017 and was diagnosed with type 2 Diabetes Mellitus, Hypertension, Chronic Kidney disease . From the Pre

Auth Form, it was observed that the insured was a known case of Diabetes since 20 years, Heart Disease since

10 years and Hypertension since 20 years and was also a known case of CKD. Hence, query was raised vide

letter dated 30.8.2017 the complainant was told to submit documents related to exact duration of CKD and IHD

along with first consultation paper and Discharge Summary/Investigation Reports (ECG and ECHO). The

complainant was told to submit Haemodialysis chart since CKD diagnosed and all past treatment records of

diabetic neuropathy, IBS and hyperparathyroidism. Insurer further stated that despite repeated reminders dated

14.9.2017 and 29.9.2017, the insured has not submitted the required documents. In the absence of above

documents, insurer was unable to further process the claim. Hence, the claim was repudiated on the ground of

non-submission of documents as per Condition No.4 of the policy and same was communicated to the

complainant vide letter dated 13.10.2017.

19) Reason for Registration of Complaint : - Non-settlement of claim.


Complaint letter

Treatment paper

Rejection letter

SCN

21) Result of Hearing : – Personal hearing was held on 20.11.2018 in which both the complainant and

insurance company appeared .The insurance company stated that they were unable to process the claim due

to non-submission of documents related to treatment of pre-existing disease by the insured. The

complainant argued that there was no documentary evidence to claim that the insured had past history of

IHD or CKD.The insurance company was asked to prove that these disease were pre-existing. They sought

time for producing the documents. Hence re-hearing was held on 14.12.18 in which the insurance company

appeared. The complainant and insured did not appear on grounds of old age and ill-health. During the

hearing, the insurance company stated that they had already settled the claim for Rs.16183/- vide NEFT

Transaction No. N248180625669223 dated 05.09.18. Rs.77945/- was deducted as per policy condition of

Co-Pay of 50% for pre-existing diseases and 30% Co-Pay for other illnesses. Break-up of deductions is

given below :

Rs.11462/- for Non-payable items

Rs.48000/- for Hospital Discount

Rs.16183/- for 50% Co-Pay

Rs.2300/- for pre-hospitalization Expenses.

On the basis of documentary and oral submissions, I find that the insurance company has rightly settled the

claim.



i. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



j. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





AWARD

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

the parties during the course of hearing, I observe that the claim has been rightly settled the

claim.

The complaint is therefore dismissed.

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PROCEEDINGS BEFORE


UNDER

(INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –SMT. SANDHYA BALIGA

CASE OF : MRS. SEVA TYAGI VS ICICI LOMBARD GENERAL INSURANCE CO. LTD.

REF: NO:NOI-G-020-1718-0244

AWARD NO:

1. Name & Address of the Complainant Mrs. Sewa Tyagi,

Flat No.201, Supertech Avant Grade,

Plot No.1, Sector 5, Vaishali, Ghaziabad.

2. Policy No:

Type of Policy


4065/ICICILL/96936380/00/000

Secure Mind

29/11/2014 to 28/11/2019



Mr. Vikas Tyagi

Mr. Vikas Tyagi

4. Name of the insurer ICICI Lombard General Insurance Co. Ltd.


6. Reason for repudiation The ailment of the insured falls outside the

purview of the major medical illnesses.


8. Nature of complaint Death Claim repudiation



11. Amount of relief sought 25,00,000/-



13 (1) (b)

13. Date of hearing/place 27.11.2018/Noida


o) For the Complainant Mrs. Seva Tyagi, self.

p) For the insurer Mr. Krashanu Pundir, Legal Manager



17) Brief Facts of the Case: Mr. Vikas Tyagi, husband of the complainant had taken Secure Mind Policy No.

4065/ICICILL/96936380/00/000for the period from 29/11/2014 to 28/11/2019 from ICICI Lombard General

Insurance Co. Ltd. The insured was admitted in Yashoda Super Seciality Hospitals on 19.11.2016 with the

complaints of high grade fever since 10 – 15 days, sweating, chills, profound weakness, decreased appetite,

abdominal pain. Due to breathing difficulty and abdominal pain, he was shifted to ICU on 20.11.2016 and soda

bicarbonate infusion started but his condition deteriorated further. He developed hypotension, so inotropic

support was started. He remained critical on ventilator with high inotropes. He had cardiac arrest at 11.30 a. m.,

CPR done as per ACLS protocol, but patient could not be revived and was declared dead at 12.10 p.m. on

21.11.2016. The company further stated that as per terms and conditions TPA had settled the insured claim for

Rs. 400000/- since the enhanced sum insured of Rs.2 lakhs in Gold Plan would be available after completion of

4 continuous renewals. The claim was lodged by the complainant with the company along with all the relevant

documents but the same was rejected by the company on the ground that there is no evidence of any of the

major medical illness/procedures defined and covered under the policy.

18) Cause of Complaint :

Complainants argument: The complainant stated that her husband had taken home loan of Rs.20,00,000/-

from ICICI Bank for purchasing the flat. The Secure Mind Policy was issued by the ICICI Lombard General

insurance company Ltd. as collateral security. At the time of issuing the policy, it was assured by the company

that everything is covered under the policy and if there is any mis-happening due to any reason, the loan will be

fully secured. The company will make repayment of outstanding home loan amount. She further stated that as

per death summary dated 21/11/2016 of Yashoda Super Specialty Hospitals, the cause of death was multi organ

failure. As per policy, kidney failure and heart attack was covered under the policy. The condition of her

husband deteriorated very fast and he expired before dialysis could start. She stated that the claim of her

husband was wrongly rejected by the company on the false ground before considering multi organs failure. A

certificate of treating doctor of Yashoda Super Speciality Hospitals dated 31.03.2017 was submitted by the

complainant stating that all these diagnosis have led the patient to multi organ failure involving lungs, kidney,

cardiovascular system etc. consequently patient had cardiac arrest and was declared clinically dead as mentioned

in death summary. The complainant has sought relief from this forum for reimbursement of the claim of her

husband.

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Insurers’ argument : The company stated in their SCN that on verification of the Death Certificate of

Yashoda Super Speciality Hospitals dated 21.11.2016, Mr. Vikas Tyagi died due to Acute Viral

Syndrome/Thrombocytopenia/Lower Respiratory Tract Infection/? Acute Respiratory Distress Syndrome

(ARDS)/Sepsis/Shock/ Multi Organ Failure. Thus after further scrutiny and verification of the claim there was

no evidence of any Major Medical illness and procedures as defined and covered under the policy. Hence the

claim falls outside the purview of the major medical illnesses and procedures defined and covered under the

policy.


The ailment falls outside the scope of the policy.


a) Claim details.

b) Doctor Certificate.

c) Policy with T & C.

d) Death Summary.

e) Death Certificate.

f) SCN.

g) Rejection letter.

21) Result of hearing with both parties(Observations & Conclusion) :

Both sides appeared for personal hearing and reiterated their submissions. The complainant stated that her

husband expired in the hospital due to cardiac arrest but the claim of her husband was rejected by the company

on the ground that the disease does not fall under the major medical illness/procedures defined and covered

under the policy. She further stated that as per death summary, the cause of death was multi organ failure and

policy provides coverage against kidney failure and heart attack. The Insurer stated that as per the Death

Summary of Yashoda Super Specialty Hospital, the cause of death of the insured was Acute Viral

Syndrome/Thrombocytopenia/Lower Respiratory Tract Infection/ARDS/Sepsis/Shock/Multi organ failure. The

same cause of death have been mentioned in the death certificate also. Thus it is apparent that death was due to

multi organ failure and not because of any of the critical illness diseases covered under the policy. In view of the

above, the repudiation of claim by the company appears justified.



k. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



l. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of



Dated:10.12.2018. INSURANCE OMBUDSMAN


AWARD

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

the parties during the course of hearing, I do not find any reason to interfere with the decision

of the company.

Hence, the complaint is treated as dismissed.

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PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN UP AND UTTARAKHAND

UNDER RULE NO: 15(1)/16 of

THE REDRESSAL OF PUBLIC GRIEVANCES RULES, 1998)


CASE OF SHREE RAM BIHANI V/S RELIGARE HEALTH INSURACNE CO. LTD.

COMPLAINT REF. NO : NOI-G-037-1819-0152

AWARD NO:

1. Name of the Complainant

Address of the Complainant

Mr. Shree Ram Bihani

D-81, Sector 50, Noida

Gautam Budh Nagar

Noida 201301

Uttar Pradesh

2. Policy No:

Type of Policy


11564877

Health Policy

07.09.2017 to 06.09.2018



Nihal Bihani

Shree Ram Bihani



6. Reason for repudiation Non Disclosure of Pre-existing disease


8. Nature of complaint Rejection of Health Claim





Rule no: of RPG rules

13 1(b)



q) For the Complainant Shri Ram Bihani,Self

r) For the insurer Dr.Nisha Sharma

15 Complaint how disposed Award in favor of Insurance Company


17) Brief Facts of the Case: This complaint is filed by Mr. Shree Ram Bihani against Religare Health

Insurance Company Limited for non-settlement of claim under policy no. 11564877.

18) Cause of Complaint: Non Settlement of Claim

Complainants argument : The complainant stated that he had taken a policy CARE from Religare Health

Insurance Company Limited for the period from 07.09.2017 to 06.09.2018 covering self, his spouse and two

children for S.I of Rs.5,00,000/-. As per statement of complainant, his son was first time detected with cancer

after the inception of the policy. The complainant had submitted claim documents for reimbursement of medical

expenses but the claim had been denied by the insurer on the basis of non-disclosure of pre-existing at the time

of Insurance.

Insurer’s argument: The insurance company vide their SCN dated 21.08.18 stated that during the currency of

the Policy, insurance company received multiple reimbursement claims in regard to admission & treatment of

the complainant‟s son Nihal Bihani at multiple hospitals from 21.09.17 to 02.03.18 for CA Nasopharynx

(Cancer in Head and Neck) which included Radiotherapy and Chemotherapy sessions. On receipt of these

claims insurance company conducted an investigation wherein certain non-disclosures were observed on the part

of the complainant as the insured had history of reduced mouth opening since 6 months prior to the inception of

the policy and had undergone Mastoidectomy for the same. The complainant had the opportunity to declare

insured‟s pre-existing health status while filling the proposal at the time of porting the policy from Cigna TTK

Health Insurance to Religare Health Insurance in the year 2017,but he failed to do so. In the light of the non-

disclosure of pre-existing disease by the complainant, at the time of porting the policy, insurance company

rejected the claim under clause 7.1 and cancelled the policy of the complainant in adherence to the Policy Terms

and Conditions under clause 7.13.

19) Reason for Registration of Complaint: Non-settlement of claim.


a) Complaint letter

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b) Treatment paper

c) Rejection letter

d) SCN

21) Result of hearing with both parties (Observations & Conclusion) :- – Personal hearing was held on

19.11.2018 in which both the complainant and the insurance company appeared and reiterated their

submissions. The insurance company argued that the complainant had not disclosed pre-existing symptoms

of reduced mouth opening of the insured Sh. Nihal Bihani and Mastoidectomy done six months prior to the

current hospitalization. All these were directly related to the present ailment of CA Nasopharynx as

confirmed by Dr.A.R.Deshpande M.S(ENT) and Dr.Rishab Jain M.S(ENT). The policy was thus void ab-

initio and claim was not admissible as per condition no.7.1 of policy terms and conditions which states

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or

non-disclosure of any material particulars or any material information having been withheld or if a claim is


anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and

the premium paid shall be forfeited to the company.

The complainant argued that he had continuous mediclaim policy for 2 years from another insurer. He had

provided information about his son‟s surgery to the agent who had filled up the proposal form of Religare

Health Insurance Company on his behalf but the same was not incorporated in the proposal form.Had the

complainant any intention of concealing any pre-existing disease or claiming for the same he would not

have ported his policy to a different company as his earlier policy was in continuity and he could have

claimed from them without any problem. The complainant was asked to submit evidence in support of his

contention that he had indeed disclosed information about his son‟s illness and surgery to the agent. On

03.12.18, the complainant submitted a visiting card of Mr. Rajesh Kumar Pandey, Agency Manager of

RHIL ,wherein there was mention of some previous policy and Discharge Summary of ENT ,without any

signature. The complainant said that he had been cheated and misled by this agent. A telephonic call was

immediately made to the Agency Manager who denied having ever met the complainant.

Considering the documents exhibited and oral submissions during the hearing and subsequent meeting with

the complainant, I am of the opinion that the insurance company is justified in repudiating the claim due to

non-disclosure of material facts thus violating the principle of Utmost Good Faith as enumerated under

Clause 19(4) of Protection of Policy Holder‟s Interest Regulations ,2017.However the insurance company is

directed to renew the policy of the complainant excluding the son from the scope of the policy.



m. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



n. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of



Dated: 10.12.2018. INSURANCE OMBUDSMAN


AWARD

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

by both the parties during the course of hearing, I agree with the decision of the

insurance company in repudiating the claim. The insurance company is however

directed to renew the policy of the complainant excluding the son from the scope of

the policy.


of 279

PROCEEDINGS BEFORE




CASE OF MANOJ KUMAR JINDAL V/S RELIGARE HEALTH INSURANCE COMPANY LIMITED


AWARD NO:

1. Name & Address of the Complainant Manoj Kumar Jindal

Tibra road, Gali No. 2, Bagh Colony

Modinagar, Ghaziabad Pin-201204

2. Policy No:

Type of Policy


10405975

Health Plan

26-11-2017 to 25-11-2018



Anita Jindal

Manoj Kumar Jindal

4. Name of the insurer Religare Health Insurance Company Limited


6. Reason for repudiation Claim under policy break period


8. Nature of complaint Repudiation of Claim





IOB rules

13 (1) (b)



s) For the Complainant Shubham Jindal,Son

t) For the insurer Dr.Nisha Sharma

15 Complaint how disposed Award in favor of the complainant


23) Brief Facts of the Case:- This complaint is filed by Sh. Manoj Kumar Jindal against Religare Health

Insurance Company Limited for repudiation of medi-claim of his wife Smt. Anita Jindal.

24) Cause of Complaint:- Non settlement of claim.

Complainants argument :- The complainant stated that a health insurance policy bearing no. 10405975 had

been issued covering himself, his spouse and children with effect from 29-09-2015 to 28-09-2016 for sum

assured of Rs.5,00,000/-. The complainant had paid renewal premium through online link on 22-11-

2017.Receipt of premium on 22.11.17 had been confirmed by the customer care of the insurer but the policy was

further renewed from 26-10-2016 to 25-10-2017.The complainant‟s wife was admitted to Fortis Hospital, Noida

on 22-11-2017 for treatment of Acute Stroke- Right MCA scattered Infarct possibly Embolic and was

discharged on 27-11-2017 from the hospital. The complainant had submitted all the relevant claim forms for the

settlement of claim, but the insurer had rejected the claim payment on 05-01-2018 on the ground that policy was

not in force at the time of hospitalization.

Insurer’s argument:- The insurer stated that the complainant had purchased a policy bearing no. 10405975 for

the period from 29.09.2015 to 28.09.2016 for sum assured of Rs.5,00,000/- .The complainant further renewed

the policy from 23.10.2016 to 22.10.2017. The complainant had approached the insurer with a reimbursement

claim with respect to the hospitalization of his spouse , Mrs. Anita Jindal in Fortis Hospital Noida for Acute

Stroke – Right MCA Scattered Infract from 22.11.2017 to 27.11.2017. The complainant had approached the

insurer on 22.11.2017 for renewal of the policy which is after expiry of the due date on 22.10.2017 and expiry

of Grace Period of 30 days on 21.11.2017. The complainant had deposited the renewal premium of Rs.34250/-

through online mode on 22.11.17. The complainant had also submitted “No Claim Declaration Form” on

22.11.2017 and accordingly the policy was renewed from 26.11.2017 to 25.10.2018 with the condition that no

claim will be payable for the break-in –policy period till the new policy is issued. Since the claim was related to

the hospitalization during break-in –period i.e. from 22.11.2017, the claim of the insured was denied by the

insurer vide letter dated 05-01-2018.

25) Reason for Registration of Complaint: - Repudiation of claim


a) Complaint letter

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b) Treatment papers of Fortis hospital

c) Rejection letter

d) SCN


Insurance Company appeared and reiterated their submissions. The insurance company argued that the policy

was due for renewal on 22.10.2017. With a grace period of 30 days for renewal of a lapsed policy, grace period

expired on 21.11.2017, and complainant deposited renewal premium online in the morning of 22.11.2017 for

Rs.34250/-. He also submitted “No Claim” Declaration form in the morning where as the Insured was

hospitalized in the evening at 6.15 PM.The no claim declaration form was accepted and policy was effected

from 26.11.2017.The insurer further argued that in the discharge summary dated 27.11.2017 it is mentioned that

the insured had symptoms on 20.11.2017 similar to the symptoms on 22.11.2017 at the time of hospitalization

i.e. when there was no policy in force. But the same was not declared by the insured in the declaration form.thus

resulting in non-disclosure of symptoms which are material facts for underwriting/renewing a policy.

The insurance company argued that due to non-disclosure of pre-existing symptoms of stroke in the declaration

form by the insured the policy was void ab-initio and claim was not admissible as per Condition No.6.1 of

policy terms and conditions which states

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-

disclosure of any material particulars or any material information having been withheld or if a claim is


anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the

premium paid shall be forfeited to the company.

From the documents exhibited and oral submissions during the hearing, it is observed that the complainant had

paid the renewal premium only one day after expiry of grace period but the insurer had delayed issue of the

policy by 4 days. In view of the above facts the decision of the insurance company is set aside. I find that the

complainant was not aware of the fact that he/she was suffering from stroke symptoms before issue of the

policy. The delay is also condoned. The insurance company is directed to pay the claim as admissible.



o. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



p. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





AWARD

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

both the parties during the course of hearing, the insurance company is directed to

condone the delay in renewal of policy and pay the admissible claim amount to the

insured.


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PROCEEDINGS BEFORE


UNDER INSURANCE OMBUDSMAN RULES, 2017


CASE OF: KAMAL AAGARWAL V/S APOLLO MUNUCH HEALTH INSUANCE CO. LTD


AWARD NO:

1. Name & Address of the Complainant Mr. Kamal Agarwal

F-11, Sec- 39, Noida

U.P. 201301

2. Policy No:

Type of Policy


S.I.

160100/11119/C100000237-03

Optima Restore Insurance Health

04.04.2014 to 03.04.2015

Rs.3,00,000/-



Ms. Meenakshi Agarwal, spouse

Mr. Kamal Agarwal




Admitted on 06.01.2018 for fever, chills,

vomiting and cough. Claim rejected due to Non-

disclosure of material facts. PED Hyponatremia

and addisons, panhypopituitarism








13 (1) (b)

13. Date of hearing/place 13.12.2018 /NOIDA


u) For the Complainant Sh. Kamal Agarwal, Self

v) For the insurer Dr. Mohammad Danish, Asstt. Manager



17) Brief Facts of the Case : Mr. Kamal Agarwal, the complainant had taken “Optima Restore Individual”

Policy No.160100/11119/C100000237-03 for the period 04.04.2014 to 03.04.2015 for basic S.I. of

Rs.3,00,000/-. He had filed cashless request for the treatment of his wife Ms. Meenakshi Agarwal on

06.01.2018 for the complaints of fever, chills, vomiting and cough. His cashless request was rejected by the

Insurance Company on the basis of non-disclosure of material facts. Aggrieved, he requested the insurer

including its GRO to reconsider the claim but failed to get any relief and even cancelled his policy and denied to

reinstate the policy. Thereafter, he preferred a complaint to this office for resolution of his grievance.

18) Cause of Complaint: Rejection of claim and cancellation of policy.

Complainants argument : The complainant stated that his wife Meenakshi contracted a fever on 2nd

January,

2018 and when the fever did not subside she was hospitalized in J.P. hospital on 5th

of Jan 2018 , wherein, it was

diagnosed that she was suffering from a case of salt imbalance. Such salt imbalance had happened to her earlier

also in August 2013. At the time of taking the policy in 2014, he forgot to mention it as salt imbalances were

common occurrence at the time of fever, but the Insurance Company had refused the cashless claim on the

pretext that material facts had been withheld and later on when he submitted the claim for reimbursement, it was

also repudiated with same reason. Furthermore, the Insurance Company had also terminated the policy vide their

letter dated 4.2.2018. He contacted the GRO of insurance Company, but they refused to settle the claim and

terminated the policy. The claimant has sought relief from this forum for re-imbursement of his claim.

Insurers’ argument: The company stated that the complainant had filed cashless request for the treatment of

Complainant‟s wife Mrs. Meenakshi Agarwal for the period from 05.01.2018 to 07.01.2018. When she was

hospitalized for complaints of fever, chills, vomiting and cough. During the cashless request, it was found that

the Patient had history of Hyponatremia and Addisons Disease. It was noted as per Discharge Summary of Max

Healthcare dated 25.09.2013, patient was diagnosed with hyponatremia and Addisons Disease and also as per

the Consultation paper of Dr. Ritesh Gupta (MD AIIMS) dated 01.10.2013, the patient was diagnosed with

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Hypocortisolism and Hyponatremia. Hence, it was clearly evident that the proposer had not disclosed the

material facts at the time of proposal, hence, the claim was repudiated under section VI(ii) of the policy on the

ground of non-disclosure of material fact by the insured.

19) Reason for Registration of Complaint:- The claim was rejected by the company on the ground of Non-

disclosure of material facts and concealment of facts.


a) SCN.

b) Claim details.

c) Rejection Letter of claim and cancellation of policy.


e) Proposal form.

21) Result of hearing with both parties (Observations & Conclusion) : Both the parties appeared in the

personal hearing. The Complainant argued that his wife Meenakshi contracted a fever on 2nd

January,

2018 and when the fever did not subside, he had admitted his wife in J.P. hospital on 5th

of Jan 2018 ,

wherein, it was diagnosed that she was suffering from a case of salt imbalance. Such salt imbalance had

happened to her earlier also in August 2013. At the time of taking the policy in 2014, he forgot to mention it

as salt imbalances were common occurrence at the time of fever. Insurance Company stated that as per

Discharge Summary of Max Healthcare dated 25.09.2013, patient was diagnosed with hyponatremia and

Addisons Disease and also as per the Consultation paper of Dr. Ritesh Gupta (MD AIIMS) dated

01.10.2013, it clearly shows that the patient was suffering from Hypocortisolism and Hyponatremia before

the inception of the policy. It is therefore evident that the proposer had not disclosed the material facts at

the time of taking the policy. The claim was repudiated by the Insurance Company under section VI(ii) of

the policy on the ground of non-disclosure of material fact is justified.



q. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



r. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





AWARD

Taking into account the facts and the submissions made by the insurer during the course of

hearing, I see no reason to interfere with the decision of the Insurance Company in

repudiating the claim.

The complaint is thus dismissed.

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PROCEEDINGS BEFORE


UNDER INSURANCE OMBUDSMAN RULES, 2017


CASE OF VIBHAV CHATURVEDI VS APOLLO MUNICH HEALTH INSUANCE CO. LTD


AWARD NO:

1. Name & Address of the Complainant Mr.Vibhav Chaturvedi

Shop No. 15, Basement, Ellora Complex

Khandari, Agra UP.

2. Policy No:

Type of Policy


111500/1/11051/AA00698955

Medi-claim

16.11.2017 to 15.11.2018



Mr. Vibhav Chaturvedi

Mr. Vibhav Chaturvedi




Treatment ACL Tear. Claim rejected due to

waiting period clause under Section VI C ii of

the policy.


8. Nature of complaint Health claim rejection



11. Amount of relief sought Rs.42644/- + Rs.77939/- as per Annex VI A



13 (1) (b)

13. Date of hearing/place 13.12.2018 /NOIDA


w) For the Complainant Sh. Vibhav Chaturvedi

x) For the insurer Dr. Mohammad Danish, Asstt. Manager

15 Complaint how disposed Award in favour of the Complainant


17) Brief Facts of the Case : Mr. Vibhav Chaturvedi had ported his policy from Star Health and Allied

Insurance Company to Apollo Munich in the November 2017-18. The Complainant was hospitalized for Knee

Surgery in January 2018. He had submitted claim documents to the Insurance Company but they had rejected

his claim on the ground of waiting period clause. Aggrieved, he requested the insurer including its GRO to

reconsider the claim but failed to get any relief. Thereafter, he preferred a complaint to this office for resolution

of her grievance.

18) Cause of Complaint: Rejection of claim

Complainants argument : The complainant stated that he had taken a health insurance policy from Apollo

Munich vide Policy No.111500/1/11051/AA00698955 for the risk covering period 16.11.2017 to 15.11.2018 for

Sum Insured of Rs.5,00,000/- after porting from Star Health and Allied Insurance Company Ltd.. In the month

of January, he had an accident and his right leg and right hand were injured. The Doctor advised X-ray and MRI

and after that the hospital sent a request to Apollo Munich for cashless facility, but TPA rejected his claim and

advised him to file the claim for reimbursement. After that he went to OJAS hospital, where doctor advised him

for knee operation, which was operated on 26.1.2018. The claim for reimbursement with all the documents were

submitted to the insurer, but the same was again rejected by them under section VI C ii of the policy on the

ground of 2 years waiting period clause. Insured read the policy carefully and found that it was not mentioned

anywhere in the policy document that in case of accident, 2 years waiting period is applicable. He also

contacted the GRO of insurance Company, but they refused to settle the claim. The claimant has sought relief

from this forum for re-imbursement of his claim.

Insurers’ argument: The company stated that the complainant ported his policy from Star Health and Allied

Insurance Company limited wherein, he was insured for the period from 16.11.2016 to 15.11.2017 for S.I.

Rs.5,00,000/-. The complainant had filed for cashless request for the treatment of the Complaint at Peoples

Heritage Hospital, Agra on January 19, 2018 to January 22, 2018 for the amount of Rs. 30000/- with complaint

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of acute pain and swelling in right knee and right elbow joint and was diagnosed with soft tissue injury, fracture

head of radius ulna. On reviewing the documents received by the complainant it was found that the treatment of

soft tissue injury knee, fracture head of radius ulna falls under 24 months waiting period clause. Hence, his

cashless request was rejected as per clause VI A (ii) of policy condition stating “As per the available

documents, presenting ailment/procedure for which treatment is sought comes under two years exclusion

list of policy terms and condition i.e. Treatment of ACL TEAR (diagnosis/ailment/procedure) is excluded

from the policy if admitted in 2 years of policy inception date”. Thus reimbursement claims were also

rejected on the basis of the same conditions of the policy. The Insurance Company further submitted that they

had rightly rejected the claim as per terms and conditions of the policy.

19) Reason for Registration of Complaint:- The claim was rejected by the company on the ground of waiting

period clause.


a) SCN.

b) Claim details.



e) Proposal form.

22) Result of hearing with both parties :- Both the parties appeared in the personal hearing. Mr. Vibhav

Chaturvedi stated in favour of his complaint that he had ported his policy from Star Health and Allied

Insurance Company covered under his policy no. P/231115/01/2017/005748 for the period from 16.11.2016

to 15.11.2017 to Apollo Munich and had taken a Policy No.111500/1/11051/AA00698955 for the period

from 16.11.2017 to 15.11.2018. The Complainant was admitted in Peoples Heritage Hospital from

19.01.2018 to 22.01.2018, claimed amount Rs.42644/- which was rejected by the Insurer. Again he was

admitted in Ojas Hospital on 26.01.2018 to 27.01.2018 for knee surgery, claimed amount of Rs.77,939/- but

the same was again rejected by Insurance Company under section VI C ii of the policy on the ground of 2

years waiting period clause. The Complainant produced the Policy which was issued by Royal Sundaram

Alliance Insurance Company Ltd. vide Policy No.AMA0000763000100 for the period 16.11.2015 to

15.11.2016, S.I. of Rs. 5,00,000/- (copy attached) which shows that the policy was running for the third

year from inception. Insurer explained that Insured did not disclose the policy of Royal Sundaram at the

time of inception of the policy with them. Ongoing through the documents exhibited and the oral

submissions, it is observed that the claim falls under the third year of continuous policy coverage. Porting

of policy from one company to another without any break ensures continuity of benefits. Thus, waiting

period of 2 years was completed when the claim was lodged. Hence, the claim of the complainant appears

to have been wrongly rejected by the company.



s. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



t. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of





AWARD

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

parties during the course of hearing, an award is passed directing the insurance company to pay

the admissible claim amount within 30 days after receipt of required documents under intimation

to this forum.

The complaint is treated as disposed off accordingly.

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PROCEEDINGS BEFORE


UNDER INSURANCE OMBUDSMAN RULES, 2017)


CASE OF DHARMENDRA KUMAR VS APOLLO MUNUCH HEALTH INSURANCE CO.

LTD


AWARD NO:

1. Name & Address of the Complainant Mr. Dharmendra Kumar

A-42, Sector Delta Ist,

Greater Noida,

Gautam Budh Nagar, U.P. 201301

2. Policy No:

Type of Policy


S.I.

110103/11001/1000157869-06

Easy Health Floater

10.03.2017 to 09.03.2018

Rs.2,00,000/-



Baby Manvi Singh

Mr. Dharmendra Kumar

4. Name of the insurer Apollo Munich Health Insurance Company

Ltd.



Claim rejected due to Non-disclosure of

material facts.





11. Amount of relief sought Rs.1 LAC as per Annex VI A



13 (1) (b)

13. Date of hearing/place 13.12.2018 / NOIDA


y) For the Complainant Sh. Dharmender Kumar, Self

z) For the insurer Dr. Mohammad Danish, Asstt. Manager



17) Brief Facts of the Case : Mr. Dharmendra Kumar, the complainant had taken a Policy

No.110103/11001//1000157869 commencing from 03.02.2011 to 02.02.2012 was issued for basic S.I.

of Rs.1,00,000/- and was renewed continuously without break for himself and his son Master Bharat.

In the next renewal for the year 2015-16 his daughter Baby Manavi Singh was added. In the next

renewal for the period from 10.03.2017 to 09.03.2018, the Complainant had filed a claim

reimbursement for amount of Rs.65,430/- for his daughter Baby Manavi Singh which was rejected by

the Insurance Company and policy was cancelled on the ground of concealment of material fact.

Aggrieved, he requested the insurer including its GRO to reconsider the claim and reinstatement of

his policy but failed to get any relief. Thereafter, he preferred a complaint to this office for resolution

of her grievance.

18) Cause of Complaint: Rejection of claim and reinstatement of the policy.

a) Complainants argument : The complainant stated that he ported his health insurance policy

from Reliance to Apollo Munich in the year 2011 covering two members and was paying the

premium continuously. During the renewal of the policy in the year 2015-16, he added his newly

born baby Manvi six month after her birth. His daughter was not growing as a normal child,

hence, someone advised him to consult doctor. After consultation, AIIMS doctor advised him for

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heart surgery of his daughter, which was done successfully. He filed the claim for reimbursement

of claim and submitted all the documents required by the Insurance Company. However, they

rejected claim on the ground that his daughter was suffering from Down Syndrome and this was

not disclosed at the time of renewal of the policy in 2015-16. He contacted the GRO of insurance

Company, but they refused to settle the claim and cancelled the policy. He requested the

company that he was not aware of the disease of his daughter, hence he requested them to

continue the policy as earlier with two members only, because total cancellation of policy will

affect the other members also, but his policy reinstatement request was also rejected by the

Company. The claimant has sought relief from this forum for re-imbursement of his claim.

b) Insurers’ argument: The company stated that the complainant ported his policy from Reliance

to Apollo Munich in the year 2011. At the time of renewal from 28.2.2015 to 27.2.2016 insured

Baby Manvi Singh was included in the policy and the policy was issued accordingly. The patient

was admitted in the hospital on 19.4.2017 and discharged on 26.4.2017 at AIIMS. On receipt

of documents the claim was reviewed and found that as per Discharge Summary, the patient

was suffering from Down Syndrome which is a congenital disorder. As per Dr. Lal Path Lab

report dated 18.5.2014 the patient had undergone Chromosome analysis test, wherein the result

showed that the patient was suffering from Down Syndrome. This shows that the Complainant

was aware that his daughter was suffering from Down Syndrome prior to her inclusion in the

policy but he had not disclosed this at the time of adding the insured to the existing policy.

Hence, the claim was repudiated on the ground of non-disclosure of material fact by the insured.

19) Reason for Registration of Complaint:- Rejection of claim and cancellation of policy.


a) SCN.

b) Claim details.



e) Proposal form.

23) Result of hearing with both parties (Observations & Conclusion) : Both the parties appeared

in the personal hearing. The Complainant argued that at the time of birth of his baby, she was a

normal child. After Six months, he added his daughter in the policy. After some time, he noticed

that the growth of his baby was not normal as a result he consulted a doctor. After consultation,

AIIMS doctor advised him for heart surgery of his daughter, which was done successfully.

Insurance Company countered that his daughter was one year old when she was included in the

policy no.110103/11051/1000157869-04 for the period 28.02.2015 to 27.02.2016 and the

Complainant was aware that his daughter was the patient of the disease Down Syndrome. Down

Syndrome is a disease which is generally detected at the time of birth or soon after but the

Complainant did not disclose this material fact intentionally at the time of including his baby in

the policy. The Complainant submitted that at the time of taking the policy, his agent assured him

that every disease is covered under the policy. The Complainant further argued that Down

Syndrome was nowhere mentioned in the exclusions of the policy. Insurance Company replied

that it is not possible to list out names of all excluded genetic diseases in the policy, hence, a

general term was used in the policy exclusion. Insurance Company further stated that Congenital

Disease is not payable as per policy terms and conditions. Although, the claim submitted by the

Complainant was related to the Heart Surgery of his daughter but claim was rejected on the basis

of non disclosure and concealment of material facts under section VII j of policy terms and

conditions. As regards, cancellation of policy in respect of Sh. Dharmender Kumar and Master

Bharat, son of the complainant, insurer stated that since it was a single policy, all other members

were also affected but were willing to restore it for others continuing the same benefits if fresh

application was made. The cancellation of the policy of Sh. Dharmender and his son is to be

restored. Insurer was advised to adjust the balance premium of cancelled policy from 16.05.2017

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to expiry date of the policy in the renewal premium of fresh policy. However, the claim of the

complainant has been rightly rejected by the company as the Congenital Diseases are excluded.

22. The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

u. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to

the insurer within a period of 15 days from the date of receipt of this Award, a letter of acceptance

that the Award is in full and final settlement of his claim.

v. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the

receipt of the acceptance letter of the Complainant and shall intimate the compliance to the

Ombudsman.




PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE

(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO) UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017

OMBUDSMAN–Ms.Neerja Shah CASE OF MR. Mithun P Sarnot v/s Star Health & Allied Ins. Co. Ltd.

COMPLAINT NO: PUN-G-048-1718-0340 Award No IO/PUN/A/GI/ /2018-19

1. Name & Address of the Complainant

MR. Mithun P Sarnot Kothari Bhavan,1-Pune Maharashtra-411042

2. Policy No: Type of Policy:

P/151119/01/2017/0111178 Star Comprehensive Insurance Policy (Ported policy) Policy ported from New India (having insurance for12 years)

3. Policy period: 22-03-2017 to 21-03-2018

4. Sum Insured/IDV Rs10,00,000/-

5. Date of inception of first policy: Of Ported policy: 22/03/2017 -

6. Name & age of the Insured: Name of the Policyholder:

Mrs.Yojana-35 Years. MR. Mithun P Sarnot

7. Name of the Insurer: Star Health & Allied Ins. Co. Ltd 8. Reason for repudiation/Partial

Settlement: Misrepresentation/Non-disclosure of material fact.

9. Date of receipt of the Complaint: 31-08-2017

10. Nature of complaint: Repudiation of claim

11. Amount of Claim: Rs85,000/-

12. Insurance Ombudsman Rule 13(1)(b)

AWARD

Taking into account the facts and the submissions made by the insurer during the course of

hearing, I see no reason to interfere with the decision of the Insurance Company in

repudiating the claim. However, the Insurance Company is directed to restore the policy of

other members giving benefits of continuity subject to fulfillment of requirements.

Hence, the complaint is disposed off.

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(IOR)2017 under which the Complaint was registered:

13. Date of hearing/Place: 14-11-2018 at Pune


aa) For the Complainant: Mr. Mithun Sarnot & his wife Ms. Yojana Sarnot

bb) For the insurer: Dr. Anjali Rathod

15. Complaint how disposed: Award

16. Date of Award:

Brief Facts of the Case: The Complainant along with his family (wife & two daughters) was covered under Star Comprehensive Insurance Policy of the Respondent for the period from 22-

03-2017 to 21-03-2018 for S.I. of Rs10,00,000/-. The 12 years continuously running policy was ported from New India Ass.Co.Ltd. The Complainant’s wife was admitted in ‘NEO HOSPITAL’ Pune from 09-06-2017 to 11-06-2017 for the treatment of Varicose vein (R). The claim was rejected by the Respondent as per condition No 9 of the policy i.e. on the ground of Misrepresentation/non-disclosure of material fact of Pre Existing Disease (PED). Contentions of the Complainant: 1. In December, 2016, she had consulted Dr. Kamerkar of Ruby Hall Clinic as she had some pain in the legs but she was advised that nothing is serious at this stage. However she can consult him again if she feels re-occurrence of pain. 2. In June, 2017, she again felt the pain in the leg & was operated for varicose vein immediately. 3. As the problem was not serious at the time of taking policy, hence the illness was not disclosed at the time of porting. 4. He has contended that the policy was ported from The New India Assurance to Star Health on 22-03-2017. He had continuous policy with the earlier insurer since 12 years with no claim. Had the policy been continued there, the claim would have paid. Contentions of the Respondent: 1. The insured-patient had consulted Dr. Kamerkar of Ruby Hall Clinic in December, 2016 as she had some pain in the legs. 2. The venous doppler report dated 26-12-2016 reveals clearly that the insured-patient’s right sapheao-femoral function is incompetent and reflux is seen on valsalva manocurve. Varicosities in relation to right long saphenous and interior thigh vein. Small varicosities in leg are prior to their policy. 3. The non-disclosure of these facts are revealed from the replies given by the proposer-insured in his proposal form under the ‘Insured person details’, as mentioned below: 1) Undergone any medical test-Replied as ‘No’. 2) Prescribed any medication i. Name of the illness for which medicines have been prescribed- Replied as ‘No’. 3) Been advised for any surgery? If yes, please give details-Replied as ‘No’. 3. The illness of varicosities was not disclosed at the time of porting the policy; hence the claim was rejected on the grounds of non-disclosure. Result of personal hearing with both the parties (Observations & Conclusions): During the personal hearing on 14/11/2018 both the parties reiterated their respective stand.

1. The complainant, during the hearing told that he was guided by his agent while filling the proposal form. The agent Mr. Arun Sarnot, who was also present in the office, was also called for clarification. He could not give satisfactory reply.

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2. It is confirmed from the Respondents that they had tried to obtain the medical history available with the earlier insurer as per the mandatory provisions laid down by IRDAI. However, as no claim was registered there, they did not get the required information.

3. As the complainant was having insurance since 12 years with New India and thereafter with the Respondent, without any claim, except the present claim, establishes the fact that he is not a claims minded person. Moreover, the porting facility is basically introduced for transfer of the credit gained by the insured for pre-existing conditions and time bound exclusions. Keeping this in view, Forum finds that it will be unjustifiable to deny the liability for non- disclosure, at least up to the sum insured, which the insured was having with the earlier insurer. It was therefore, asked to the representative of the insurer to calculate the payable amount under the policy terms and conditions upto the earlier Sum Insured (Rs. 2 lakhs) to enable to award the same.

4. The amount payable as informed by the insurer, is Rs. 75,880/- as against claimed amount of Rs. 83,705/-. Forum is not considering interest part on it as the complainant has also erred in non disclosing of the PED.

5. It was also clarified to the complainant that the Sum Insured for the said PED will remain 2 lacs only, in view of its non disclosure, for which he is convinced.

In view of the above observations, award follows as under: AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 75880/- to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:

17(6) 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. 17(8) The award of Insurance Ombudsman shall be binding on the insurers.

(Neerja Shah)

Insurance Ombudsman, Pune.


(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)


OMBUDSMAN– NEERJA SHAH

CASE OF Mr. Om Prakash Chaturvedi vs. The Oriental Insurance Co.Ltd.

COMPLAINT NO: PUN-G-049-1718-0339

Award No IO/PUN/A/GI/ /2018-19


Om Prakash Chaturvedi, 68 yrs.

Thane


New Mediclaim 2012 17010034162500001866

3. Policy period: 29/07/16 to 28/07/17

4. Sum Insured: Rs. 3,00,000/-

5. Date of inception of first policy: 29/07/2003

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Self

7. Name of the Insurer: The New India Assurance Co.Ltd.

8. Reason for repudiation/Partial Settlement:

His claims for Chemotherapy were initially

settled by the insurer from March 15 to June 16,

but they stopped paying from Oct. 16 onwards.

Inj Zolodonate given for Chemotherapy is not in

the listed day care treatment.

9. Date of receipt of the Complaint: 31/08/2017

10. Nature of complaint: Total repudiation of claim

11. Amount of Claim: Rs. /-

12. Insurance Ombudsman Rule (IOR)2017 under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place: Pune


a) For the Complainant: Could not attend due to his ill health.

b) For the insurer: Dr. Nikhil Parab


16. Date of Award: Brief Facts of the Case:

The complainant is a Senior Citizen, age 70 years, having health insurance with the

Respondent since 29/07/2003. His complaint is for the repudiation of his claims for injection

of Zolodonate, which were initially paid by the Respondent. The claims were rejected on the

grounds that it does not fall under Parenteral chemotherapy, and does not fall under listed

day care treatments. Aggrieved with this, the complainant has approached this Forum for

resolution.


Complainant, vide his mail dt. 06/11/18, showed his inablility to attend the hearing due to

his ill health and requested the Forum to grant the judgement in his favour.

As complained by him, the complainant is suffering from Prostate Cancer. He is taking

chemotherapy treatment from Hinduja Hospital since March 2016. He was reimbursed with

the expenses by the Respondent under his mediclaim policy treated with the injection

Zoldonate, till June 2016. But the Respondent started repudiating his claim from Oct. 2016

onwards stating the reason that the injection Zoldonate does not fall under the listed day

care treatment.

Contentions of the Respondent:

As per their repudiation letter, the chemo treatment by Zoldonate injection does not fall

under listed day care treatment.

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

During the personal hearing on 14/11/2018 both the parties reiterated their respective

stand.

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The representative of Respondent, who is qualified in medical field, contended with the

write ups on the Zodonate injections (contains Zolendronic acid), that this is not a chemo

treatment . The write up reads as:

‘Cancer cells that spread to the bone can secrete substances that can cause cells found in the bone called osteoclasts to dissolve or "eat away" a portion of the bone. These tumors or lesions weaken the bone and can lead to complications. Some of the complications resulting from this bone breakdown are bone pain, fractures and less commonly, hypercalcemia (increased levels of calcium in the blood).

Zoledronic acid is a bisphosphonate. Bisphosphonate medications are used to slow down the osteoclast's effects on the bone. In doing this it can be useful in slowing down or preventing the complications (bone pain, fractures, or high calcium levels) of the bone breakdown.’

Hence, we agree to the contention that this injection is not falling under chemotherapy and it is not listed in day care treatments also. Whereas, the claim of hospitalization dated 10/11/16 mentions that the patient is admitted for next cycle of chemotherapy, is to be considered for payment under day care treatment. The Respondent was therefore asked to calculate the amount payable under this claim and accordingly, he has given the admissible amount under this claim as Rs. 19,296/-.

Award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 19,296/- along with interest at applicable bank rate plus 2% p.a. from 10/01/2016 up to date of payment of this award to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:

17(6) 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. 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 the claim ought to have been settled under the regulations, till the date of payment of the amount awarded by the Ombusman. 17(8) The award of Insurance Ombudsman shall be binding on the insurers.

(Neerja Shah) Insurance Ombudsman, Pune.




OMBUDSMAN–NEERJA SHAH

CASE OF Mr. Ramesh P. Wani V. United India Insurance Co. Ltd




Mr. Ramesh P. Wani, Jalgaon

2. Policy No: Individual Health Policy

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Type of Policy: 2310002816P106764328

3. Policy period: 06/09/16 to 05/09/17

4. Sum Insured: Rs. 5 lacs each



Mrs. Rekha Wani-wife-61 yrs.

7. Name of the Insurer: United India Insurance Co. Ltd.


Total Knee Replacement of both the knees was

taken place. Insurer has settled it considering

one claim only and post operative charges were

also refused.


10. Nature of complaint: Partial repudiation of claim amount

11. Amount of Claim: Rs. 1,64,119/-


13(1)(b)



cc) For the Complainant: Through his daughter Ms. Rupali Narendra

Wani

dd) For the insurer: Mr. K.C. Baviskar, Div.Manager & TPA Dr. Ajay Parandekar

15. Complaint how disposed: Dismissed


Complainant and his wife are having health insurance cover with the Respondent since

06/09/1996. His wife underwent surgery of total knee replacement (TKR)of both the knees,

for which, he had incurred hospital expenses of Rs. 4,60,400/-, out of which Insurer has paid

Rs. 3,32,500/- only, by applying policy clause no. 1.2.1. Aggrieved with this, complainant has

filed this complaint for balance amount of his claim.


His sum insured in the current policy is of Rs. 5 lakhs since 2016 and previously it was Rs.

4,75,000/-. Though the claim falls under PED (Pre existing disease), he should get full

amount of the earlier sum insured i.e. Rs. 4,75,000/-.

Contentions of the Respondent: Initially, they had applied the policy clause of 70% of Sum

Insured (Rs. 4,75,000/-) payable for Knee Replacement and had paid Rs. 3,32,000/-. Again

on receiving the grievance for the less payment, considering the application of this clause

for surgery of two knees separately, as contended by the complainant, paid further amount

of Rs. 1,04,000/-. Hence, no further amount is remained payable.


During the personal hearing on 14/11/2018 both the parties reiterated their respective

stand.

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1. The dispute remained is now of Rs. 24000/- only. The clause applied for the

computation of claim is to be seen first. It says,

‘1.2.1 Expenses in respect of the following specified illnesses will be restricted as detailed

below:

Hospitalisation Benefits LIMITS per surgery RESTRICTED TO

a. Cataract, Hernia,Hysterectomy a. Actual expenses incurred or 25% of the

sum insured whichever is less

b. Major surgeries* b. Actual expenses incurred or 70% of the

Sum Insured whichever is less

• Major surgeries include cardiac surgeries, brain tumour surgeries, pace maker

implantation for sick sinus syndrome, cancer surgeries, hip, knee, joint replacement surgery,

Organ Transplant.

• The above limits specified are applicable per hospitalisation / surgery.’

It is observed that the Respondent had paid Rs. 3,32,000/-, initially, as per the 70% of Sum

Insured of Rs. 4.75.000/- was correct apparently and further payment of Rs. 1,04,000/-, by

considering two separate surgeries of two knees, without the intervention of this Forum is

also a good gesture from the Respondents. But they could not pay balance amount of Rs.

24000/- as the PPN package is of Rs. 4,30,000/- only for this type of surgeries, to which, the

complainant was fully aware of.

To see the authenticity of the contention of the Respondent, the Forum checked the specific

terms in the policy and the declaration form signed and submitted to the hospital, by the

complainant. These are reproduced below:

Insurance Declaration Form submitted to Shalby Hospital:

‘I further declare that I understand that as per Package I and entitled for MB (Implant

/Device/Stent/Special Consumables) but I am willing to use the higher category of

Implant/Devise/Stent/Special Consumables for my treatment and for which I have NO

OBJECTION TO PAY THE DIFFERENCE AMOUNT OF IMPLANT/DEVICE/STENT/SPECIAL

CONSUMABLES OUT OF MY POCKET at the time of admission for the treatment and I

authorized the Hospital Authority to collect the charges from me by way of cash/credit

card/demand draft.’ Policy clause in respect of Network Provider reads as:

‘NETWORK PROVIDER Network Provider means the hospital/nursing home or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility. The list of Network Hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time. Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing.’ Thus, the Forum is fully satisfied with the settlement of the claim by the Respondent and

finds that no lacuna is remained on their part in considering the claim in all respects to give

the full justice to the complainant and finds no room left to consider the complaint.

Award follows:

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AWARD

Under the facts and circumstances of the case, the complaint is dismissed.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:

It is particularly informed that in case the Award when it reaches the Complainant is not agreeable to him/her, it would be open for him/her, if he/she so decides, to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent /Insurer’s decision to reject the claim under the subject policy.

(Neerja Shah)




UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN– Ms. Neerja Shah

CASE OF MR. Rohit D Athwani v/s Star Health & Allied Ins. Co. Ltd.




Mr. Rohit D Athwani

Shagun Chowk,Pimpri-Pune

Maharashtra-411017


P/151118/01/2016/017673 Family Health Optima Insurance Plan

3. Policy period: 01-03-2016 to 28-02-2017

4. Sum Insured Rs10,00,000/-

5. Date of inception of first policy: Of Ported Policy: 01/03/2016 -


Mr. Rohit D Athwani-29 Years.

-Self-

7. Name of the Insurer: Star Health & Allied Ins. Co. Ltd


Misrepresentation/Non-disclosure of material fact.



11. Amount of Claim: Rs.42000/-


13(1)(b)

13. Date of hearing/Place: 14/11/18 at Pune


ee) For the Complainant: Himself

ff) For the insurer: Dr. Anjali Rathod

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16. Date of Award:

Brief Facts of the Case: The Complainant along with his wife was covered under Star

Comprehensive Insurance Policy of the Respondent for the period from01-03-2016 to 28-02-

2017 for S.I. of Rs.10,00,000/-. The policy was ported from ICICI Lombard. The Complainant

was admitted in ‘Aditya Birla Memorial Hospital’ Pune on 24-01-2017 for the treatment of

Acute pancreatitis. The claim was rejected by the Respondent as per condition No 15 of the

policy i.e. on the ground of Misrepresentation/non-disclosure of material facts.


1. In the beginning, he had insurance with Oriental Insurance Co. Ltd. since many years.

2. From 01/03/15, he ported his policy with ICICI Lombard.

3. Then again from 01/03/16, he reported his policy with Star Health and Allied Insurance for SI of Rs. 10 lacs.

4. There is continuous insurance without any break.

5. He had received one claim for Pancreatis from Oriental in the year 2013. Now again in the year 2017 a claim of Pancreatitis was lodged by him with Star Health, which stands rejected by them on the ground that there is nondisclosure of PED (Pre-existing disease). He has contended that while porting of the policy, the agent had told him that all his continuity benefits will remain intact and the PEDs will get covered in new policy also. He had declared his PEDs to the agent, but agent has not mentioned it in the proposal form for his own benefits.

6. He has complaint against the agent also.


They have contended that

The insured patient is a known case of Pancreatitis and was diagnosed before 3 years. He was admitted in Aditya Birla Memorial Hospital from 11/01/13 to 14/01/13 for the said complaints.

The policy was ported from ICICI Lombard GI and as per portability rules of IRDAI, they had confirmed No Claim Status from the web portal provided for this purpose. The complainant had not disclosed about his earlier policies with Oriental.

The complainant had answered as ‘No’ to the query raised in the Proposal Form in the column meant for the insured, which is reproduced as :

‘2. Have you ever consulted /taken treatment/ been admitted for any illness/ disease/Injury/Surgery if yes, details-No’.

The USG report shows Chronic Long Standing Renal and Liver Disease.

They have rejected the claim under the policy condition no. 8 of the policy as reproduced below:

‘the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or

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false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf.’

Result of personal hearing with both the parties (Observations & Conclusions): During the personal hearing on 14/11/2018 both the parties reiterated their respective stand.

1. It is confirmed that the insurer-Respondent have observed the mandatory provisions while porting the insurance. As the complainant had not disclosed about the earlier insurance with OIC, they could not get the claims history, which amounts to non disclosure of material facts.

2. The policy also clearly mentions no cover for Pre-existing diseases. They have rightly waived 30 days and one year waiting period in view of one year old ported policy.

3. The complainant agreed that he was admitted in Aditya Birla Hospital in the year 2013 for the said complaints and the relevant documents are also produced by the Respondent.

4. During the hearing it was specifically questioned to the complainant about the in correct answers given in the proposal form. He replied that he was under the impression that only three years back claims are to be declared. In view of the question specifically asked as ‘have you ever consulted/ taken treatment’, this argument is not acceptable.

5. Thus, the fact of non disclosure and misrepresentation are established beyond doubt. 6. In view of these facts and policy clause, this Forum finds no scope to consider the

complaint in favour of the complainant. The same was conveyed to the complainant during the hearing. Award follows:

AWARD

Under the facts and circumstances, it is observed that the complaint is devoid of merits. Hence, the complaint is dismissed. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:


(Neerja Shah)

INSURANCE OMBUDSMAN, PUNE

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OMBUDSMAN–NEERJA SHAH

CASE OF Mr. Sachin Bhandari Vs. National Insurance Co. Ltd




Mr. Sachin Bhandari, Mira Road, Thane


National Mediclaim No. 380201/48/16/8500000832

3. Policy period: 19/10/16 to 18/10/17

4. Sum Insured: Rs. 50,000/-



Mrs.Rameshwari Bhandari, 59 yrs.-mother

7. Name of the Insurer: National Insurance Co. Ltd.


Claim was denied on the ground that it falls

under PED and has 48 months waiting period,

without considering first policy in group, into

account.


10. Nature of complaint: Total repudiation of claim amount

11. Amount of Claim: Rs. 50,000/-


13(1)(b)



a) For the Complainant: Through his father Mr. Bir Singh Bhandari

b) For the insurer: Mr. Avinash Gaikwad, Manager & TPA Dr. Aakesh Waghe



Complainant, initially, was having insurance in a group health policy insured with the

Respondent since 2012, but thereafter, in the year 2014 they shifted to individual mediclaim

policy, with their Udaipur Div. Office. Hospitalisation claim of his mother, admitted in Sitla

Hospital from 08/03/17 to 12/03/17, was rejected by the Respondent on the ground that

the treatment falls under PED (Pre Existing Disease) and needs 48 months waiting period.

Group policies are not taken into consideration for giving the continuity benefits. Aggrieved

with this, complainant has preferred this complaint.


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Complainant and his parents were covered under group policies, initially for two years, since

18/09/12 and thereafter they shifted to individual mediclaim policy of the same insurer

since 08/10/14 in which earlier policy number of his group policy is mentioned. His

contention is that, it is in continuation of the previous policy since 2012 and with this his

present claim falls under 5th year of the policy. Hence, his claim is very much payable.


They have contended that though the complainant and his parents were covered under a

Tailormade Group Insurance Policy issued by their office only, while getting an individual

policy, he had not requested for portability from group. He had mentioned reply as ‘No’ for

the question of ‘Portability’ in the proposal form. The patient insured was a known case of

Asthmatic bronchitis with hypertension with chronic respiratory failure, complete heart

block, COPD since 30-35 years. Hence the repudiated claim falls under 48 months waiting

period and not payable under policy exclusion 4.1.

They had settled earlier claims as those were acute in nature. Till now, they have paid four

claims amounting to Rs. 23874/-; 15358/-; 39000/- and 11000/-.

They have reiterated that as the complainant-insured had not asked for porting of the policy

in the proposal form and no porting procedure was carried out, hence continuity benefits

cannot be considered.


In this connection, we refer to IRDAI’s clause 17(i) of Health Insurance Regulations 2016,

which states as:

17. Migration of health insurance policy

i) General Insurers and Health Insurers offering health covers specific to age groups such as

maternity covers, children under family floater policies, students etc, shall offer an option to

migrate to a suitable alternative available health insurance policy at the end of specific exit

age at the time of withdrawal of the policy at the option exercised by the said lives by

allowing suitable credits for all the previous years, provided the policy has been maintained

without a break.

It is pertinent to note here that the notification provides that insurer has to offer alternate

cover to the insured by allowing continuity benefits. Portability formalities are not required

here.

By mentioning earlier policy number of group policy in an individual policy of the year 2014-

15 shows its connection with the present policy; otherwise, it is not needed to mention

earlier insurance details. Insurer’s contention that mere mentioning of earlier policy details

do not give right of continuity benefits, is not acceptable as long as the policy is renewed in

time.

In view of this, claim becomes payable. Amount payable under the policy terms and

conditions as confirmed by the Respondent is Rs. 36094/-.

The award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 36094/- along with interest at applicable bank rate plus 2% p.a. from 26/04/17 upto date

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of payment of this award to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:



PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN–NEERJA SHAH

CASE OF Mr. Deepak Chaudhari Vs. The Oriental Insurance Co.Ltd. COMPLAINT NO: PUN-G-050-1718-0362



Mr. Deepak Chaudhari, Thane

2. Policy No:

121100/48/2016/6067 and 121100/48/2017/6918

3. Policy period: 04/02/16 to 03/02/17; 29/03/17 to 28/03/18

4. Sum Insured: 1. Rs. 3,00,000/-

5. Date of inception of first policy: 1. Since many years.


Mr. Janardan Chaudhary, 72 yrs.

7. Name of the Insurer: The Oriental Insurance Co. Ltd.


Complainant had renewed the policy online before due date of its renewal and he had received premium receipt confirmation also from the insurance co. But due to some IT issues, the premium was bounced back in the account of credit card of the complainant to which he was unaware. He got the policy renewed by paying premium separately. Hence gap in the policy happened and the claim occurred during the gap period was denied by the Respondent.


10. Nature of complaint: Total repudiation of claim.

11. Amount of Claim: Rs. 77,500/-


13(1)(b)



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For the Complainant: Through his wife Ms. Aparna Deepak Choudhari

For the insurer: Ms. Rajashri N. Korgaonkar, Deputy Manager


16. Date of Award:

Brief Facts of the Case: Complainant had renewed the policy online on 31/01/17, which was before due date (i.e. on 03/02/17) of its renewal and he had received premium receipt confirmation also from the insurance co. But due to some IT issues, may be, the premium was bounced back, in the account of credit card on 08/02/17. On getting information of this, he got the policy renewed by paying premium separately. Hence gap in the policy was happened and the claim occurred during the gap period was denied by the Respondent. Contentions of the Complainant: His policy renewal was due on 03/02/17, which he renewed online through his credit card on the Respondent’s portal on 31/01/17. He got the status as ‘successes on the portal, screen shot of the same is submitted by him. After a period of 15 days, he enquired about the original policy certificate from the Respondent through his broker. The Respondent also was not in a position to track the payment. Ultimately, the complainant was informed on 27/02/17 that the transactions might have been reversed. Then he enquired with the credit card bankers and he was informed by them that the payment has been reversed by the merchant i.e. The Oriental Insurance Company on 08/02/17 and they do not know the reasons of reversal of payment by the Insurance Co. Mail correspondence done in this respect is placed on record. He was forced by the Respondent to give in writing that he will not claim for the break period. To get the continuity benefits, he had no alternative but to give such letter to get his policy renewed with continuity benefits. His father was hospitalized from 10/02/17 to 13/02/17. The claim for the same was denied by the Respondent. Contentions of the Respondent: The complainant had tried to renew his policy online on 31/01/2017 using his credit card. During online renewal process insured got successful transaction of premium message, however the policy number was nit generated. When the insured enquired with them about the policy document through their brokers, they checked their records and found that the premium amount was not received. The transaction was returned/rejected due to technical error, which was conveyed to the insured though their brokers. Later on when the insured enquired with credit card issuing bank, he came to know that the transaction was reversed on 8/2/17. It was communicated to the insured via email that the delay in renewing the policy has been condoned subject to no entertainment of claim during the intervening period. Vide mail dt. 21/03/17, insured confirmed that he will not claim for the intermittent period. On receiving a fresh cheque on 29/03/17, the policy was released effective 29/03/17 with continuity benefit. As per Health Regulations 2016 issued by IRDAI, ‘the insurer shall provide for a mechanism to condone a delay in renewal upto 30 days from the due date of renewal without deeming such condonation as a break in policy. However, the coverage need not be available for such period.’ In view of the above, the claim in the break period if lodged will not stand payable. However insured will be enjoying all the continued benefits under the policy. They have settled the claim of Mr Janardan Chaudhari (father of insured) under the renewed policy for his hospitalization in May 2017. Result of personal hearing with both the parties (Observations & Conclusions):

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During the personal hearing on 15/11/2018 both the parties reiterated their respective stand.

1. It is pertinent to note here that the complainant had received ‘Successful’ note with the logo and name of Respondent insurer, which was placed on record during hearing also by the complainant. Naturally, one will get assured of having effected with the payment. The Representative of the Respondent was contending that the renewed policy number reflects online, once payment of premium is done. But it is not necessary that the general public is aware of this system of Respondent in respect of online renewals. They have not produced warnings issued in this respect if any are prominently displayed on the screen in case of online payments. They have to make necessary arrangements and precautions in case of online issue of policies in to avoid such situations.

2. The Respondent should have asked him in writing for physical payment of premium, at least when the complainant started asking for the policy document and no renewed policy number was reflected online, forecasting the problem in premium payment, as they should be aware of their online system arrangements and its flaws.

3. Complainant had renewed his policy well within the expiry of the policy. The payment did not effect and it was not conveyed timely by the Respondent by trigerring an email and sms on registered mail ids and mobile number as it is mandatory once any payment successful message had been reflected to the user. To penalize the insured public for the flaws in the online system, is not correct. The Respondent may collect the premium of lapsed period and pay the claim payable within the purview of the policy terms and conditions.

4. In support of our decision, the Forum wants to draw the attention of Respondent to the provision no. 6(ii) given under Insurance Regulatory and Development Authority of India (Outsourcing of Activities by Indian Insurers) Regulations, 2017: ‘6. OUTSOURCING ACTIVITIES SUPPORTING POLICY SERVICING i. Though the policy servicing remains an integral activity for the Insurer who is totally responsible for the services rendered, the activities that support Policyholder servicing are allowed to be outsourced. ii. Where collection of premiums is outsourced by the Insurer, it shall put in place procedures and ensure issuance of premium acknowledgements to the policyholders at the point of collection of premiums through such outsourced Service providers. Provided, Insurers shall remain responsible for the acknowledgements issued and the date and time of such receipt shall be taken into account for considering the underlying benefits of an insurance contract’. Award follows:

AWARD Under the facts and circumstances of the case, the Respondent is directed to settle his claim as per policy terms and conditions by collecting appropriate premium for the lapsed period towards full and final settlement of the complaint.




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CASE OF Mr. Kavade Y.G vs United India Insurance Co. Ltd COMPLAINT NO: PUN-G-051-1718-0360



Mr. Kavade Y.G

Prabhat Road,Lane No15-Pune

Maharashtra-411004


1630002816P102722704 Group Mediclaim Policy

3. Policy period: 02/04/16 to 01/04/17

4. Sum Insured: Rs600,000

5. Date of inception of first policy:

-


Mr. Kavade Y.G-66Years

Bank of Maharashtra



Present treatment can be done on OPD Basis.

9. Date of receipt of the Complaint:

18-09-2017




13(1)(b)



a) For the Complainant: Himself

b) For the insurer: Mohan P. Girme,AM, TPA Dr.Vikas Mane


16. Date of Award:

Brief Facts of the Case: The Complainant was covered under ‘Group Mediclaim Policy’ taken by Bank of Maharashtra from the Respondent for the period from 00-00-2016 to 00-00-2017 for sum insured of Rs6,00,000/-.He was admitted in Ruby Hall Clinic Hospital’ as a case of Ca Prostate on 03-02-2017 for administering injection Zoladex. The claim was rejected under Clause No 3 of the terms & condition of the policy. Contentions of the Complainant:

1. He is a retired officer of Bank of Maharashtra holding mediclaim policy of Rs6lacs since 2014.

2. He was diagnosed for prostate cancer in May 2015 & presently he is under treatment at Radiation Dep’t. in Ruby Hall Clinic, Pune.

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3. In July 2015, he was advised by Dr. Sumit Basu, Chief Radiation Oncologist to undergo a course of eight injection of Zoladex10.8 with an interval of two & half months.

4. He was given six injections under the above prescribed course till Dec, 2016 and all the hospital bills were honored by the TPA of the Respondent.

5. The cashless/Re-imbursement claim of Rs45,190/- for the seventh injection which was due in January, 2017 was rejected by the TPA of the Respondent on the ground that claim for the treatments usually done in OPD are not payable under the policy.


1. The Claim was rejected as per clause No 3 of the terms & condition of the policy which reads as under. “Procedures/treatments usually done in OPD are not payable under the policy even if converted as in-patient in the hospital for more than 24 hours or carried out in Day care Centre’s”. Result of personal hearing with both the parties (Observations & Conclusions): During the personal hearing on 16/11/2018 both the parties reiterated their respective stand. It is observed from the hospital papers that the complainant was admitted in the hospital for injection of Zoldonate. It does not mention as for chemo. The Forum has observed from different write ups on Zodonate and similar injections (contains Zolendronic acid), that this is not a chemo treatment . The write up reads as:

‘Cancer cells that spread to the bone can sec rete substances that can cause cells found in the bone called osteoclasts to dissolve or "eat away" a portion of the bone. These tumors or lesions weaken the bone and can lead to complications. Some of the complications resulting from this bone breakdown are bone pain, fractures and less commonly, hypercalcemia (increased levels of calcium in the blood).

Zoledronic acid is a bisphosphonate. Bisphosphonate medications are used to slow down the osteoclast's effects on the bone. In doing this it can be useful in slowing down or preventing the complications (bone pain, fractures, or high calcium levels) of the bone breakdown.’

Hence, we agree to the contention that this injection is not falling under chemotherapy and it is not listed in day care treatments also. One of the bill No. 91524071 dt. 03/02/17 of Ruby Hall Clinic mentioned about Chemo, hence the Forum asked the Respondent to honor this bill. This amounts to Rs. 9000/-. Award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 9000/- alongwith interest at applicable bank rate plus 2% p.a. as laid down in Regulation 14 of IRDAI (Protection of Policyholders’ Interest) Regulations, 2017 from 10/03/17 up to date of payment of this award to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:

17(6) 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.

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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 the claim ought to have been settled under the regulations, till the date of payment of the amount awarded by the Ombusman. 17(8) The award of Insurance Ombudsman shall be binding on the insurers.




PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (State of Maharashtra excluding Mumbai Metro)

(Under Section 17 of Insurance Ombudsman Rules 2017) OMBUDSMAN: NEERJA SHAH

CASE OF Complainant – Mr. Krupesh Rajesh Ganatra Vs

Respondent: Reliance GeneralInsurance Co. Ltd. COMPLAINT REF: NO: PUN-G-035-1718-0351

Award No. IO/PUN/A/GI/0 /2018-19

1. Name & Address of the Complainant Mr. Krupesh Rajesh Ganatra Thane

2. Policy No: Type of Policy Duration of policy/Policy period

1103262828001759 03/11/16 to 02/11/17

Reliance Health Gain Policy SI:3 lacs

1st Policy inception: 03/11/16

3. Name of the insured Name of the policyholder

Self-32 yrs. Self

4. Name of the insurer Reliance General Insurance Co. Ltd.

5. Date of Repudiation 30/01/17

6. Reason for repudiation Treatment of obesity and its complications are not payable under the policy main clause

no.3.3


8. Nature of complaint Total Repudiation of mediclaim



11. Amount of relief sought Not applicable


12(1)(b)

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13. Date of hearing/place 16/11/18 at Pune


a) For the Complainant Himself

b) For the insurer Mr. Deepak Nair


16 Date of Award/Order

Brief Facts of the Case: The complainantis insured with the Respondent under HealthGain Policy for the period from 03/11/16 to 02/11/17. He underwent surgery of Lap Sleeve Gastroctomy at Wockhartdt Hospital, Mumbai. The claim for the same has been rejected by the Respondent stating the reason that the treatment is obesity related and excluded from the policy. With a contention that the treatment of morbid obesity was done as a life saving treatment, the complainant has approached this Forum for resolution of the dispute.


1.He was suffering from severe breathing difficulties, varicose veins and severe backache apart from morbid obesity. He was getting dying pain. As suggested by his treating doctor, he undergone a bariatric surgery in order to solve the health hazards in future. His claim was rejected by the Respondent giving the reasons that the expenses incurred towards weight management services and treatment are not payable as per their permanent exclusion no. 3.3. 2. In this respect, he has submitted treating doctor’s certificate stating that ‘Krupesh Ganatra, 31 years is 181 kgs with BMI of 69. He is suffering from obesity. He has varicose veins and backache along with restricted mobility and quality of life because of the weight. He becomes breathless on walking small distances. Serious obesity can lead to multiple other health problems and shortened life span. He has been advised to undergo bariatric surgery to loose his extra weight. This is life saving procedure for him and not a cosmetic surgery.’ Contentions of the Respondent: 1.The claim is repudiated under policy exclusion no. 3.3.9, which states as: ‘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.

3.3.9: Weight Management Services and treatment, services and supplies including treatment of obesity (including morbid obesity).’

2.The complainant was not suffering from any disease at the time of undergoing the surgery. The surgery was purely for reducing obesity and not as part of treatment for any disease. Such kind of treatments and surgery are specifically excluded under policy permanent exclusion clause no. 3.3.9.

3. They have contended that the complainant had deliberately concealed his height and weight in the proposal form with dishonest intention. This is evident from the conduct of the complainant that the policy was purchased with an intention to cover the cost of Morbid Obesity.

4. They further objected the certificate issued by the treating doctor. They contended that the doctor has mentioned that the surgery was life saving purpose whereas the document

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fails to show any illness or disease for which the surgery was required. It was purely cosmetic in nature.

5. There is no deficiency in service or unfair trade practice on their part as the repudiation of the claim was done on proper grounds for violation of terms and conditions of the policy.


From the doctor’s certificate, it is evident that the complainant was operated for weight control and morbid obesity to avoid future health issues which may arise. Though it is not a cosmetic surgery, but it is for morbid obesity. Hence, it attracts the policy exclusion no. 3.3.9, that the treatment for obesity or condition arising there from (including morbid obesity) and any other weight control treatments are out scope of the policy.

Even if it is done for controlling varicose veins, backache etc., but these ailments are the conditions arising from morbid obesity, the policy does not cover expenses for such treatments involving weight control programmes.

AWARD

Under the facts and circumstances, it is observed that the claim of the complaint falls beyond the scope of policy cover. Hence, complaint for this cannot be considered. Dismissed. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:


(Neerja Shah)



UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–NEERJA SHAH

CASE OF Mrs. Mugdha Gandhi v/s National Ins. Co. Ltd COMPLAINT NO: PUN-G-048-1718-0343



Mrs. Mugdha Kishore Gandhi

Baner Pashan Link Road-Pashan

Pune- Maharashtra-411021


27200/48/16/8565000066 National Mediclaim Insurance Policy

3. Policy period: 06-06-2016 to 05-06-2017

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4. Sum Insured/IDV Rs5,00,000/-+CB

5. Date of inception of first policy: -


Mrs. Mugdha Gandhi

Mr. Gandhi Kishor Chandmal

7. Name of the Insurer: National Ins. Co. Ltd


Reasonable & customary clause applied


10. Nature of complaint: Partial settlement of claim



13(1)(b)



a) For the Complainant: Mr. Kishore Gandhi & Ms. Mugdha Gandhi

b) For the insurer: Mr. Prashant Hazare, Dy. M.


16. Date of Award:

Brief Facts of the Case: The Complainant along with family was covered under ‘Mediclaim Insurance Policy’ of the Respondent for the period from 06-06-2016 to 05-06-2017 for S.I. of Rs5,00,000/-. The Complainant was admitted in ‘Divya Eye Clinic’ Pune for the cataract surgery of both the eyes. The cataract surgery for left eye was done on 03-02-2017 & for Right eye on 07-02-2017. The claims were settled for an amount of Rs60,000/-( @Rs30,000/-for the cataract of each eye)as against total bill of Rs75,207/- Contentions of the Complainant:

1 No capping limit is prescribed in the policy bond for the cataract surgery.

2. Hence balance payment of Rs15,207/- for each eye cataract, which was deducted while settling the claim should be released by the Respondent.


1. As per reasonable & customary clause, an amount of Rs30,000/-per eye has been considered.

2. The deductions are made under reasonable & customary clause No 3.29 of the policy terms & conditions.

Result of personal hearing with both the parties (Observations & Conclusions): During the personal hearing on 15/11/2018 both the parties reiterated their respective stand. During the deposition, Respondent produced the chart of GIPSA rates and rates of renowned eye specialty hospitals, who are charging maximum of Rs.24000/- for cataract surgery. Still, considering special type of lens, they have paid Rs. 30,000/-. It is also confirmed from the Respondent that there is no capping prescribed on amount for cataract surgery in the policy. There is no proper reasoning for paying Rs. 6000/- only more and not the full amount of expenses. I am of the opinion that the Respondent should consider the full amount of bill

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and pay remaining amount of Rs. 15000/-. No interest is to be considered as the amount already exceeds the tariff suggested by GIPSA. Award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 15,000/- to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:


Dated: This, on November 2018, at Pune


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (State of Maharashtra excluding Mumbai Metro)

(Under Section 17 of Insurance Ombudsman Rules 2017) OMBUDSMAN: NEERJA SHAH

CASE of Mr. Rajesh J. Joshi Vs United India Insurance Co.Ltd. COMPLAINT NO: PUN-G-051-1718-0365

Award No. IO/PUN/A/GI/0 /2018-19


Mr. Rajesh J. Joshi Dombiwali (E)

2. Policy No: Type of Policy Duration of policy/Policy period

120206002816P101450464 02/04/16 to 01/04/17

Syndicate Bank Synd Argya Group Insurance 1st Policy from:16/04/14

3. Name of the insured Name of the policyholder

Mrs. Anjali Joshi-Mother of Complainant

4. Name of the insurer United India Insurance Co.Ltd.

5. Date of Repudiation Not sent by the TPA & also Respondent


Out of two cataract claims, second was settled but first was not. As informed to him orally by TPA, the claim papers were not recd. by them.


8. Nature of complaint Non settlement of claim





12(1)b

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13. Date of hearing/place 15/11/18 at Pune


For the Complainant Mr. Rajesh Joshi & Ms.Anjali Joshi

For the insurer Ms. Swati Hejib, TPA Dr. Amol Pethe


16 Date of Award


Complainant and his mother were covered with the Respondent under Group health insurance Policy provided by their Bankers Syndicate Bank since 16/04/14.His second year policy was upto 15/04/16. He drew a draft from the bankers, by paying cash towards renewal of the policy and handed it over to the bankers on 18/04/16 (after 3 days of expiry of second renewal), against which, he received policy renewed from 02/05/16 to 01/05/17. He had lodged a claim for R eye cataract of his mother, performed on 25/04/16 and a claim for L eye cataract performed on 09/05/16. He received the amount of second claim but for the first claim, he was repeatedly informed by TPA, over phone, to get the policy endorsement covering risk from 18/04/16and ultimately in the month of Feb. 17, he was told that his claim papers are not received by them and to write to the Post Office. Thus, his first claim remained pending. Contention Complainant:

1. As he had handed over the demand draft of renewal premium to the bankers on

18/04/16, his insurance cover should start from 18/04/16.

2. The insurance company has wrongly issued the renewal policy from 02/05/16.

3. The TPA, was giving different reasons initially for non payment of his claim and after

lapse of two months stated that they have not received the claim papers.

Contention of the Respondent:

In the SCN (Self Contained Note), they have contended that the date of renewal of the

policy was on 16/04/16 and they received the Demand Draft dated 18/04/16 on 02/05/16,

hence their renewal period was started from 02/05/16 to 01/05/17. As the cataract

operation done on 25/04/16, was during the break period, was repudiated.

Observations & Conclusion:

1. From the documents submitted before me, establish that the draft was submitted to

the bank on 18/04/2016 and received by the Respondent from bankers on 02/05/16.

2. The ‘Synd Arogya Group Mediclaim Policy’ document submitted on record shows the

clause under ‘Policy period -12 months: Risk to commence from date of banker’s

cheque/DD of the bank’

The statement of cheques/DDs received by the insurer from bankers, submitted

along with SCN, shows the date of DD of Mr. Rajesh Joshi as 18/04/16.

From this, it is clear that the risk of Insurer starts from the date of demand Draft dt.

18/04/16. At the time of first cataract on 25/04/16, policy to be considered as in

force and the insured should get benefits entitled by him under the policy.

3. In support of our decision, the Forum wants to draw the attention of Respondent to

the provision no. 6(ii) given under Insurance Regulatory and Development Authority of

India (Outsourcing of Activities by Indian Insurers) Regulations, 2017:

‘6. OUTSOURCING ACTIVITIES SUPPORTING POLICY SERVICING i. Though the policy servicing remains an integral activity for the Insurer who is totally responsible for the services rendered, the activities that support Policyholder servicing are allowed to be outsourced.

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ii. Where collection of premiums is outsourced by the Insurer, it shall put in place procedures and ensure issuance of premium acknowledgements to the policyholders at the point of collection of premiums through such outsourced Service providers. Provided, Insurers shall remain responsible for the acknowledgements issued and the

date and time of such receipt shall be taken into account for considering the

underlying benefits of an insurance contract’.

4. This claim amount payable is Rs. 25000/-. The complainant is entitled to receive the

claim with interest as the Respondent has kept it unpaid on wrong grounds. He had

submitted the claim papers on 28/04/16.

Award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay

Rs. 25,000/- along with interest at applicable bank rate plus 2% Penal Interest as

laid down in Regulation 14 of IRDAI (Protection of Policyholders’ Interest)

Regulations, 2017 from 28/05/16 (one month from submission of claim

documents) upto date of payment of this award to the complainant towards full

and final settlement of the complaint.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017: 17(6) 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. 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 the claim ought to have been settled under the regulations, till the date of payment of the amount awarded by the Ombudsman. 17(8) The award of Insurance Ombudsman shall be binding on the insurers.


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(UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN–Neerja Shah

CASE OF Mr. K.C Girotra vs United India Insurance Co. Ltd COMPLAINT NO: PUN-G-051-1718-0341



Mr. K.C Girotra Bhosle Nagar-Pune Maharashtra-411037


1619002816P104555576 Individual Health Policy

3. Policy period: 21-07-2016 to 20-07-2017

4. Sum Insured: Rs500,000


11/07/2008


Ms. Manorama Girotra-Wife-Age 65Years Mr. K.C Girotra



OT charges of Rs33,665/-were not paid


31-08-2017

10. Nature of complaint: Partial Repudiation of claim

11. Amount of Claim:


13(1)(b)

13. Date of hearing/Place: 14-11-2018/Pune


gg) For the Complainant: Himself

hh) For the insurer: Mr. Sunil Chitanvis & TPA Dr.


16. Date of Award:

Brief Facts of the Case: The Complainant and his wife, were covered under ‘Individual Health Policy’ of the Respondent for the period from 21-07-2016 to 20-07-2017 for sum insured of Rs5,00,000/-. The Complainant’s wife was admitted in ‘Deenanath Mangeshkar Hospital, Pune’ from 06-03-2017 to 08-03-2017 for the procedure of Right Shoulder Cuff Tear. The Respondent while settling the claim has denied OT charges of Rs33,665/-. The complaint is for this unpaid amount. Contentions of the Complainant: 1. His wife was operated on 07-03-2017 for the procedure of Right Shoulder Cuff Tear.

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2. He had incurred total hospital expenses of Rs1,66,745/-out of which the Respondent has paid Rs1,25,000/-only to the hospital under cashless settlement & OT charges of Rs 33,665/- were not paid. 3. The surgery cannot be performed without these instruments. Contentions of the Respondent: 1. Non-medical charges of Rs 6137/-were disallowed from claim under clause 4.20 of the policy terms & conditions. 2. Separate OT Charges of Rs 28,515/- are not admissible as these are forming part of the Operation theatre charges which were already paid while settling the claim. 3. The Miscellaneous charges of Rs 3,380/- were also disallowed as these are not payable under clause 4.21 of the policy terms & condition. 4. Respondent in their SCN has given the reasons of deduction of amount of Rs. 44,640/- as: These being instrument charges, which were used in Operation Theater(it should be part of and must be included in Operation Theater charges), Customary Reasonable Charges and against those items, which are not to be considered as per IRDAI guidelines and as per policy terms and conditions. Result of personal hearing with both the parties (Observations & Conclusions): During the personal hearing on 14/11/2018 both the parties reiterated their respective stand.

1. Two claims were paid for a total amount of Rs1,25000/-(i.e.Rs1,22,105/-for 1st claim & Rs2,895/-for the second claim).

2. During the hearing, Respondent could not satisfactorily explain the reasons of deductions of Rs. 28515/-, which were used in Operation Theatre. These are the genuine expenses, the complainant has paid to the hospital as charged by them. There is no specific clause of policy to exclude these items. Whereas, the Forum is convinced with the reasons for deduction of amount of Rs. 6137/- and Rs. 3380/- under policy clause 4.21.

3. Forum is therefore of the opinion that the complainant is entitled for the amount of Rs. 28515/- for wrong deduction and interest thereof.

With these observations award follows as under: AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay Rs. 28515/- alongwith interest @8% p.a. from 10/04/17 upto date of payment of this award to the complainant towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:


(Neerja Shah)


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CASE OF Mr. Virendra Kumar Srivastava Vs United India Insurance Co. Ltd. COMPLAINT NO: PUN-G-051-1718-0359



Mr. Virendra Kumar Srivastava

Mira Road, Thane


Tailormade Group Health Policy No. 1202002815P112677548 Group Health Policy issued to SBI

3. Policy period: 16/01/16 to 15/01/17

4. Sum Insured: 15% of SI Rs. 3 lacs for domestic claim



Self, age: 76 yrs.

State Bank of India



His hospitalization claims were rejected in the ground that the hospitalization was for evaluation and diagnostic purpose.


10. Nature of complaint: Total repudiation of claim amount

11. Amount of Claim: Rs. 88346/-


13(1)(b)



ii) For the Complainant: Himself and his daughter Ms. Seema Shrivastava

jj) For the insurer: Dr. Prashant More


16. Date of Award:

Brief Facts of the Case: Complainant is covered under group policy issued by his employer for pensioners. His first claim under domiciliary hospitalization and the second for treatment were rejected by the Respondent on the ground that the hospitalization was for evaluation and diagnostic purpose, not payable under policy exclusion 4.11. Contentions of the Complainant: His first claim was under domiciliary hospitalization for the expenses of Rs. 45300/-incurred on carrying FDG-PET-CT scan alongwith certain medicines and other tests as prescribed by Dr. Udwadia at Breach Candy Hospital. Subsequently. he was admitted in Nanavati Hospital, Mumbai for further treatment and he had filed claim for Rs. 43046/- for the expenses incurred. Both of his claims are rejected by the Respondent.


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As per their contention, patient was admitted to hospital for left sided located pleural effusion. On admission, vitals were stable, investigation were done and oral medications were given. As per policy terms and conditions 1.1 hospitalisation not justified as all the medications given were oral. Hence, as per policy exclusion no. 4.11, expenses incurred primarily for valuation/diagnostic purposes, not followed by active treatment during hospitalization, are not payable.


During the personal hearing on 16/11/2018 both the parties reiterated their respective stand.

1. On perusal of the papers it is observed that he was admitted in different hospitals for exclusively for diagnosis purposes. The details are:

Sr.No. Hospital Period of Hosp. Admitted for:

1 Karuna Hospital 17/06/16 to 25/06/16 Investigations and tests

2 Jaslok Hospital 27/06/16 to 08/07/16 Medicines and tests were prescribed.

3 BreachCandy 30/06/16 OPD, advised for test FDG,PET-CT

4 Bhakti Vedanta 11/07/16 to 13/07/16 Investigations and tests

The Forum finds that the expenses incurred for these hospitalizations are rightly rejected by the Respondent, under the policy exclusion clause no. 4.11 mentioned below. 4.11Charges incurred at hospital or nursing home 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 ailment, sickness or injury for which confinement is required at a hospital / nursing home.’

2. It is observed from the tailor made group policy issued by the Respondent covers domiciliary treatment also, in which, the costs of the medicines can be covered. Accordingly, the respondent is advised to consider the bills of medicines for payment within the balance amount of Sum Insured for domiciliary treatment left under the policy. Award follows:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to consider bills of medicines incurred during the hospitalizations mentioned in the complaint for payment, within the amount of sum insured covered under Domiciliary Hospitalisation, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017:



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UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–Neerja Shah

CASE OF Dr. Sagar Patil v/s Star Health & Allied Ins. Co. Ltd. COMPLAINT NO: PUN-G-044-1718-0367



Dr. Sagar Patil Hatkalangale, Dist. Kolhapur


P/151117/01/2017/003837 Family Health Optima Policy

3. Policy period: 19/10/16 to 18/10/2017

4. Sum Insured/IDV Floater SI Rs. 5,00,000/-


19/10/16 -


Dr. Sagar Patil, 34 yrs. Self

7. Name of the Insurer: Star Health & Allied Ins. Co. Ltd


Non-disclosure of material fact of PED of Reactive Arthritis


31-08-2017

10. Nature of complaint: Repudiation of claim and cancellation of his policy

11. Amount of Claim: Rs. 40921/-


13(1)(b)

13. Date of hearing/Place: 14/11/2018


For the Complainant: Himself

For the insurer: Dr. Anjali Rathod


16. Date of Award:

Brief Facts of the Case: The Complainant along with his family (wife & son) was covered under Star Comprehensive Insurance Policy ‘Family Health Optima Policy’ for the period from 19/10/16 to 02/08/2017 for floater S.I. of Rs 5,00,000/- The Complainant was admitted in ‘Aster Adhar Hospital’, Kolhapur Pune from 21/04/17 to 25/04/17 for the treatment of Young HTN with Hyperhomolystemia. The claim was rejected by the Respondent as per condition No 8 of the policy i.e. on the ground of non-disclosure of material fact of having arthritis prior to inception of the policy. His policy was also cancelled by the Insurer for this reason. Contentions of the Complainant:

1. He was admitted in the hospital for the complaints of headache and poor vision. 2. He denies the fact of non disclosure of having his complaints of arthritis before

getting the first insurance from the Respondent (i.e. before 19/10/16).

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3. He has contended that the consultation paper shown by the Respondent as the proof of his pre-existing ailment, actually is of date 09/03/17, hand written on it, was misunderstood by the insurer as 09/03/15. He produced the treating rheumatologist’s certificate clarifying the date of first consultation as 9/3/17, still the insurer did not pay any attention to his representation and they also cancelled his policy.

Contentions of the Respondent: 1. Complainant has submitted the claim in the 1st year of the policy. 2. Consultation paper dt. 09/03/15 of Aster Adhar Hospital shows that the patient

insured had complaints of Reactive Arthritis, which is prior to policy inception and he had not disclosed it while taking the policy. Complainant, is a doctor and is aware of his health details but has not disclosed the same in the proposal form, at the time of inception of policy from 19/10/16.

3. Although the present admission and treatment of the insured patient is primarily for hypertension, it is observed from prescription dt. 09/03/15 of Aster Adhar Hospital that the insured patent has been on treatment for arthritis and was advised immunosuppressive treatment with Eternacept, which confirms that the patient has arthritis prior to inception of medical insurance policy.

4. Reactive arthritis is an auto immune disease, which is a declined risk as per medical underwriting guidelines. As per the contact of insurance, the insured is expected to declare in the proposal form about details of ailments/sickness-past medical history and the reply for the same helps the insurer to evaluate the material facts and to decide whether to accept the proposal or not.

5. Complainant had submitted his claim for review of their decision along with certificates from the dealing doctor and the concerned hospital stating that the prescription under question was issued on 09/03/17 and not on 09/03/15 which is not acceptable. Hence his reconsideration request was not considered favorably.

6. As per policy condition no. 8, the claim was repudiated for non disclosure of his earlier health ailment of arthritis. Condition no. 8 reads as: ‘The company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf.’


1. The doctor’s certificate dt. 27/04/17, clarifying the date written is 09/03/17 and not 09/03/15, has a foot note stating that ‘this certificate is issued on the request of the applicant for the purpose of office submission. This certificate is not meant for any judicial/execution matter.’ The foot note itself nullifies the effect of his clarification.

2. During the deposition, complainant was repeatedly contending on the ambiguity of date in the prescription, which is a basis of rejection of his claim as proof of having pre-existing ailment. Actually, said prescription dt. 09/03/2015 produced on records reveals that the medicines prescribed therein are applicable for Arthritis, does not show any indication or confusion in date as 09/03/2017. To believe his contention to be true, his consultation records in the hospital on 09/03/17 should be there. At the time of hearing Respondent was asked to visit the hospital again and get the entry in their register of his consulting in the hospital on 09/03/17. As well as to get the clarification from doctor again.

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3. Accordingly the Respondent arranged for hospital visit and the doctor’s visit. They have a report stating as: ‘As instructed by Hon. Ombudsman to verify date of consultation whether it is 9/3/15 or 9/3/17, our representative visited Aster Adhar Hospital, Kolhapur. In system registration is since 5/12/16. No consultation of 9/3/17 or no consultation of 9/3/15 found in the system. When tried to contact the Dr. Nachiket Kulkarni for clarification in date, twice he gave later appointment. When our representative visited third time, he has given written clarification stating date of consultation is 9/3/17 (initially he wrote 9/3/15 and later said 9/3/17) and again mentioned on that letter not to be used for judicial matter. Orally , he confirmed with our investigator that Mr. Sagar Patil is under his treatment since 2015 but not given any written letter for the same and asked to come at later date and will give written statement after consulting with his advocate.’

4. It is observed from the second certificate of Dr. Nachiket Kulkarni, obtained by the representative of the Respondent, shows the date of issue as 24/12/18 (the date which is not yet arrived), which should have been 24/11/18. While clarifying his statements, again he has done the same mistake of overwriting in the date as 9/3/17 to 9/3/15. Here again, he has mentioned that ‘this certificate is issued on the request as for submission of office and not for judicial or execution matter.’

5. By different inconsistencies in the certificate observed as above, the certificates provided by the treating Dr. Nachiket Kulkarni cannot be considered as proof.

6. In view of all these observations, the Forum has came to the conclusion that the treating doctor is not willing to give real /true information in respect of the first consultation of the complainant with him, though orally he is agreeing to the fact that the complainant is under treatment with him since 2015. Under these circumstances, the Forum is not inclined to consider the complaint in favour of the complainant.

AWARD Under the facts and circumstances, it is observed that the complaint is lack of merits. Hence,Dismissed.

(Neerja Shah)




CASE OF Mrs.Zeenath R Balayil vs New India Assurance Co. Ltd COMPLAINT NO: PUN-G-049-1718-0357



Mrs.Zeenath R Balayil Sus Road,Pashan-Pune Maharashtra-411021

2. Policy No: 15040034162500008222

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Type of Policy: New Mediclaim-2012

3. Policy period: 31-03-2017 to 30-03-2018

4. Sum Insured: Rs300,000+CB


30-03-2008


Ms.Zeenath R Balayil-50Years -Self-

7. Name of the Insurer: New India Assurance Co. Ltd.


Treatment given is for diagnostic Purpose


14-09-2017



12. Insurance Ombudsman Rules (IOR)2017 under which the Complaint was registered:

13(1)(b)

13. Date of hearing/Place: 15/11/18 -Pune


a) For the Complainant: Husband Mr. Balayil Muhamed Abdul Razak

b) For the insurer: Ms.Ashwini Chougule


16. Date of Award:

Brief Facts of the Case: The Complainant (Insured) was covered under ‘New Mediclaim-2012 Policy of the Respondent for the period from 31-03-2017 to 30-03-2018 for sum insured of Rs3,00,000/-. She expired during the pendency of this complaint. She was admitted in ‘KEM Hospital’Pune from 24-04-2017 to 25-04-2017 for the Peritoneal Equilibration test for CKD (Chronic Kidney Disease). The claim was rejected on the ground that treatment given is for diagnostic Purpose and is excluded from the policy under clause no.4.4.11. Contentions of the Complainant: The complainant has submitted certificate from treating Dr Valentine Lobo of KEM hospital mentioning that “peritoneal equilibrium test is in accordance with Good practise Guidelines recommended all over the world.” He has further mentioned that “every individual has different peritoneal characteristics and prescription of peritoneal dialysis is based upon the unique report and the test requires minute to minute medical supervision. Hence hospitalization is required.” The complainant has requested the Forum for the reimbursement of hospitalization expenses from the Respondent Company in view of the treating Drs certificate. Contentions of the Respondent: The Respondent has mentioned that as per provisions of Exclusion Clause 4.4.11 of the policy which reads as “Charges incurred at Hospital primarily for diagnosis ,x-ray of chest or laboratory examinations or other diagnostic studies nor 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 hospital” As the exclusion clause is applicable, as per policy conditions they have repudiated the claim. Result of personal hearing with both the parties (Observations & Conclusions):

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During the personal hearing on 15/11/2018 both the parties reiterated their respective stands. Discharge of the patient-insured shows the remarks as stated below: ‘Pt. was admitted for peritoneal equilibration test. Test was performed with 2.5% solution. Procedure was uneventful and pt. is being discharged … ’ It is observed that the hospitalization was purely for diagnosis purpose and as per the policy exclusion clause no. 4.4.11 quoted below, the claim is not payable. ‘4.4.11 Charges incurred at Hospital 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.’ As the confinement of patient in the hospital was not necessary for treatment and it was purely for diagnosis purpose only, the Forum is unable to grant any relief to the complainant. Award follows:

AWARD Under the facts and circumstances, as the claim is not tenable, complaint is devoid of merits. Hence, the complaint is dismissed. Dated at Pune, this on day of November 2018.

(Neerja Shah)


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