PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE ...

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

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

OMBUDSMAN – NEERJA SHAH

In the matter of: MR. BHARATEESH PATWARI v/s THE NATIONAL INSURANCE CO. LTD

Complaint No: BNG-H-048-1920-0402

Award No: IO(BNG)/A/HI/0284/2019-20

.

The Complaint emanated from the repudiation of maternity claim of wife of the complainant

by Respondent Insurer (RI) under Employee GMC policy vide policy no.

354800/50/18/10000446 from 27.07.2018 till 26.07.2019.

Complainant‟s wife was admitted to Balaji Maternity Home from 28.06.2019 to 04.07.2019

for delivery of baby.

Complainant applied for reimbursement claim to RI, which was objected by RI vide letter dt

21.08.2019 asking for reasons for delay in intimation of claim. His reason for delay in

submission of claim documents was not considered favourably by RI and claim was

repudiated vide e-mail dt 02.09.2019

Aggrieved by decision of RI, he approached this forum for resolution of his grievance. The

complaint is posted for personal hearing on 11.03.2020.

After registration of complaint with this forum, RI settled the claim for Rs 28,267/- vide

UTR No.KKBK200481247529 on 19.02.2020 as per terms and conditions of the policy.

Complainant vide e-mail dt 04.03.2020 confirmed the receipt of the amount and requested

for closure of the complaint.

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

settlement on compromise basis, the complaint is treated as Closed and Disposed off

accordingly.

Dated at Bengaluru on the 04thday of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA




In the matter of: MR. P SATYANARAYANA RAO VS NEW INDIA ASSURANCE CO. LTD


Award No: IO (BNG)/A/HI/0287/2019-20

.

The Complaint emanated from the short settlement of hospitalisation claim by Respondent

Insurer (RI) under LIC GMC policy under policy no. 12070034190400000007 from 01.04.2019

till 31.03.2020.

Complainant was admitted in Jain Institute of Vascular Sciences from 04.11.2019 to 06.11.2019

for diagnosis of Right Index finger soft tissue swelling/Hemangioma.

He applied for reimbursement claim to RI for ₹.81,000/-, which was settled by RI for ₹.69,412/-.

He approached Grievance cell of RI for settlement of balance claim, but his request was not

considered favourably.

Aggrieved by decision of RI, he approached this forum for resolution of his grievance. The

complaint is posted for personal hearing on 24.03.2020.

After mediation of this forum, RI agreed to consider the claim for ₹.9,621/-.

The complainant vide his mail dated 06.03.2020 agreed to settlement offered by RI.

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

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

Compliance of Award:

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

Ombudsman Rules, 2017:

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

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

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

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

compliance of the same to the Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of Shri SHANTARAM D NAYAK V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No: IO/BNG/A/HI/0289/2019-20

The Complaint emanated from repudiation of claim under IBA Mediclaim policy for PNB

employees with Respondent Insurer (RI) vide Policy no. 5001002818P109894215.

The Complainant submitted that his wife was administered 11 Chemotherapy sessions on

various dates at RB Patil Cancer Hospital, Bengaluru. He submitted reimbursement claims

to RI for all 11 sessions.

On scrutiny of medical documents, RI repudiated the claim stating that only chemotherapy

and radiotherapy are payable under the policy. However since patient was administered

injection Herceptin which is an adjuvant chemotherapy, it is beyond the scope of the policy

coverage. Aggrieved by decision of RI, he approached this forum and the complaint was

registered with this forum.

The complaint is posted for personal hearing on 11.03.2020.

After registration of complaint with this forum, RI vide mail dt 06.03.2020 agreed to settle

the claim in full subject to submission of original payment receipt against final hospital bill.

Complainant vide mail dt 09.03.2020 gave his consent for the amount offered by RI. RI is

directed to settle the claim as agreed.

Since, the complaint was resolved amicably, the Complaint is treated as Closed and

Disposed Off accordingly.

Compliance of Award:



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

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

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

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

the Ombudsman.

Dated at Bengaluru on the 09th day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA



In the matter of: MR. RAMESH RAO M V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No: IO/BNG/A/HI/0294/2019-20

1 Name & Address of the Complainant Mr. Ramesh Rao M

MIC-k-Block MF 11/7,

Nandini Layout,

BENGALURU – 560 096

Mobile No. 9986202675

2 Policy No.

Policy period

Type of Policy

5001002818P111211801

01.11.2018 to 31.10.2019

Group health policy - Indian Bank’s Association A/c

Karnataka Bank Ltd.

3 Name of the Insured/ Proposer

Name of the policyholder

Mr. Ramesh Rao M

Self

4 Name of the Respondent Insurer United India Insurance Company Limited

5 Date of Repudiation 08.11.2019

6 Reason for repudiation/rejection Treatment is not listed day care procedure and does

not warrant 24 hours hospitalization

7 Date of receipt of Annexure VI A 07.01.2020

8 Nature of complaint Rejection of claim

9 Amount of claim ₹. 1,40,314/-

10 Date of Partial Settlement NA

11 Amount of relief sought ₹. 1,40,314/-

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

13 Date of hearing/place 11.03.2020 / Bengaluru

14 Representation at the hearing

a) For the Complainant Self

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

15 Complaint how disposed Partially Allowed

16 Date of Award/Order 11.03.2020

17. Brief Facts of the Case

The complaint emanated over rejection of claim by RI. His approach to the Grievance Redressal Officer of

Respondent Insurer (RI) did not yield any positive result and hence, the Complainant approached this

Forum for reimbursement of the same.

18. Cause of complaint:

a. Complainant’s argument:

Complainant along with his wife is insured with RI for sum insured of ₹.9,00,000/-. He underwent cataract

surgery on 06.02.2018. Since then he was under continuous treatment for Age Related Macular

Degeneration (ARMD) and other disorders of eye at Narayana Nethralaya, bengaluru. He submitted all the

claim papers to the TPA/RI from time to time and they have sanctioned some claims. However some claims

were repudiated under the clause that states treatment is not day care procedure and does not warrant 24

hours hospitalization. He represented to the RI; however his claims were not considered favourably and

therefore, he has approached this Forum for settlement of his claims.

b. Insurer’s argument:

The Respondent Insurer in their Self Contained Note (SCN) dated 02.03.2020 submitted that Insured person

IP was covered under above policy for Sum Assured of ₹. 9,00,000/- (Basic + super top up) from 01.11.2018

to 31.10.2019. RI submitted that IP was treated with Right eye intravitrealEylea injection under day care

procedure clause 3.3.

19. Reason for Registration of complaint:

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

registered.

20. The following documents were placed for perusal:

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

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

The dispute is with regard to administration of intravitrealeylea injection and thereby rejection of claim under day care clause. This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing. During the course of personal hearing, complainant submitted that he underwent cataract surgery on 06.02.2018. Since then he was under continuous treatment for Age Related Macular Degeneration (ARMD) and other disorders of eye. RI settled some claims but for claims related to administration of IV eylea injection under Local Anesthesia in a hospital because of technological

advancement was rejected. Details of the claims repudiated by the RI are as follows-

Sr. No.

Claim No.

Patient name DOA/DOD Claimed amount

Claim status

1 854024 Ramesh Rao M

02.05.2019 to 02.05.2019

50354 Denied

2 854024.1 Ramesh Rao M

02.05.2019 to 02.05.2019

8707 Denied


06.05.2019 to 06.05.2019

50846 Denied


27.07.2019 to 27.07.2019

50585 Denied

5 867969.1 Ramesh Rao M

27.07.2019 to 27.07.2019

3269 Denied

6 863205 Usha Rao 26.06.2019 to 26.06.2019

4771 Denied

Representative of RI submitted that in the instant case, and as per policy terms and conditions, this is not a listed day care procedure and does not warrant 24 hospitalization. Hence the claim was repudiated. On perusal of the policy, the relevant terms and condition of the policy are reproduced as – 2.19 HOSPITALISATION Means admission in a Hospital/Nursing Home for a minimum period of 24 In-patient care consecutive hours except for the specified day care procedures/treatments, where such admission could be for a period of less than 24 consecutive hours. For list of these specified day care procedures/treatments, Annexure-1 is given in

which 37 treatments/procedures are given.

2.35 OPD TREATMENT means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient. 3. ADDITIONAL COVERAGES: 3.3 Expenses on Hospitalization for minimum period of a day are admissible. However, this time

limit is not applied to specific treatments and the list of 37 treatments/procedures is given.

This condition will also not apply in case of stay in hospital of less than a day provided – A) The treatment is undertaken under General or Local Anesthesia in a hospital / day care Centre in less than a day because of technological advancement.

3.13 Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field

Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc. are

covered under the scheme. Treatment for all neurological/ macular degenerative disorders shall be

covered under the scheme.

It is noted that IP was under continuous treatment for Age Related Macular Degeneration (ARMD) and received IV injection of Eylea for the right eye under topical anesthesia under day care procedure. The Forum notes that the administration of IV Eylia injection is not an eye surgery. However as per condition 3.13, the treatment for ARMD is covered under the policy. Moreover as per clause 3.3 A,

the treatment was undertaken under Local Anesthesia in a hospital because of technological

advancement. Hence, the decision of RI in repudiating claims of Mr. Ramesh Rao M (mentioned in

Sr. No. 1 to 5 above) is not in order. Hence, Forum directs RI to settle the claims as per terms and

conditions of the policy along with interest.

However, claim no. (Claimed ID) 863205 relating to Ms. Usha Rao, complainant‟s wife, is a case of

pain in right knee. She was treated in Fracture and Orthopaedic Clinic, Bangalore on OPD basis.

The RI repudiated the claim stating OPD treatments are not payable as per policy terms and

conditions and the treatment is also not covered under day care treatment/procedures. The Forum

notes from the additional condition no. 4 of the policy terms and conditions that expenses related to

OPD treatment is not payable. Hence the decision of RI in repudiating the claim (ID 863205) is in

order.

The Complaint is partially allowed.

AWARD

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

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

mentioned at sr. No. 1 to 5 above as per terms and conditions of the policy along with interest @

8.25% (Bank rate of 6.25% + 2%) from the date of filing of the last relevant document by the Insured

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

Interests) Regulations, 2017.

The Complaint is Partially Allowed.

22. Compliance of Award:



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

days of receipt of the award to the Respondent Insurer.

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

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

Ombudsman.

Dated at Bengaluru on the 11th day of March, 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of SRI S V SHIVATHAYA V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No.: IO/(BNG)/A/HI/0297/2019-20

1 Name & Address of the Complainant Mr. S V SHIVATHAYA

Flat No.B-306, NCN Gold,

Flower Garden Road,

Babusapalya, Horamavu Post,

Bengaluru - 560113

Mob - 984404596

E-Mail: [email protected]

2 Policy No.

Type of Policy

Duration of Policy/ Policy Period

50010002818P111270173

Group Health Insurance Policy ( Retirees)

01.11.2018 to 31.10.2019



Indian Banks’ Association a/c. Syndicate Bank

Mr S V Shivathaya

4 Name of the Insurer United India Insurance Company Limited (R I)

5 Date of repudiation 28.01.2020

6 Reason for repudiation NA

7 Date of receipt of Annexure VI-A 24.01.2020

8 Nature of complaint Non sanction of medical bill

9 Amount of claim Rs.10,688/-


11 Amount of relief sought Rs.10,688/-

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

13 Date of hearing/place 20.03.2020/ Bengaluru


a) For the Complainant Absent

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

15 Complaint how disposed Disallowed


17. Brief Facts of the Case:

The complaint emanated from the non settlement of medical bills of complainant by RI. Despite his

repeated representations to RI, the claim was not settled and hence he approached this Forum for

settlement of his claim.

18. Cause of Complaint:

a) Complainant’s arguments:

Complainant submitted that he was covered under IBA – Syndicate Bank Group Health Policy for Retirees.

He underwent Ayurvedic treatment to Ramaiah Indic Speciality Hospital on 20.08.2019 on OPD basis. He

submitted reimbursement claim under the policy on 03.10.2019. He submitted that TPA and RI have

delayed in settlement of his legitimate claim even after submission of all relevant medical bills and inspite

of repeated reminders they are delaying settlement of his claim. Thus he has approached this forum for


b) Respondent Insurer’s Arguments:

RI vide their SCN dated 13.02.2020 submitted that the complainant is covered under Syndicate Bank Group

Health Insurance Policy for Retirees (without domiciliary Treatment Cover). The claim for domiciliary

hospitalisation not covered under the policy as per Condition No.2 which reads

“No Expenses related to domiciliary/OPD treatment is payable”.

The policy covers only hospitalisation expenses and hence the claim falls outside the scope of the coverage

under this policy and is repudiated vide letter dt 28.01.2020.

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):

The dispute is whether the repudiation of the claimed amount by the RI is in order.

Complainant expressed his inability to attend personal hearing. Forum has perused the documentary

evidence available on record and the submissions made by RI during the personal hearing.

Forum notes that the insured has taken Ayurvedic treatment from Ramaiah Indic speciality Hospital

on 20.08.2019, 27.08.2019, 28.08.2019, 30.08.2019 and 11.09.2019 on OPD basis.

Complainant filed reimbursement claim under the policy on 03.10.2019. The claim was not settled

as on date of registration of his complaint with this forum. Thereafter claim was repudiated vide

letter dated 28.01.2020 stating that the claim is for “Domiciliary Hospitalisation” and is not covered

under the policy as per clause 2 of the policy terms and conditions. The policy covers only

hospitalisation expenses and hence the said claim falls outside the scope of the coverage under this

policy.

The policy taken up by the insured is Tailormade Group Mediclaim Policy (without Domiciliary

Treatment Cover), which does not cover expenses incurred on treatment on OPD basis. Clause 1.1 of the policy is relevant to the issue at hand states that

“NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and

definitions contained herein or endorsed, or otherwise expressed here on the Company

undertakes that if during the period stated in the Schedule or during the continuance of this

policy by renewal any insured person shall contract any disease or suffer from any illness

(hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter

called INJURY) and if such disease or injury shall require any such insured Person, upon

the advice of a duly qualified Physician/Medical Specialist/Medical practitioner (hereinafter

called MEDICAL PRACTITIONER) or of a duly qualified Surgeon (hereinafter called

SURGEON) to incur hospitalization/domiciliary hospitalization expenses for

medical/surgical treatment at any Nursing Home/Hospital in India as herein defined

(hereinafter called HOSPITAL) as an inpatient, the Company will pay through TPA to the

Hospital / Nursing Home or Insured the amount of such expenses as are reasonably and

necessarily incurred in respect thereof by or on behalf of such Insured Person but not

exceeding the Sum Insured in aggregate in any one period of insurance stated in the

schedule hereto.”

Furthermore, 2.18 of policy condition defines Inpatient Care as:

“IN PATIENT CARE: In Patient Care means treatment for which the insured person has to

stay in a hospital for more than 24 hours for a covered event.”

Since the complainant did not stay in the hospital and received OPD treatment, the decision of the Respondent Insurer is in accordance with the terms and conditions of policy and found to be in order. The complaint is disallowed.

A W A R D

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

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

the claim by the Respondent Insurer is found to be in order and in consonance with the terms and

conditions of the policy which does not require any interference at the hands of the Ombudsman.

The Complaint is DISALLOWED.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


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


In the matter of Shri B CHANDRASHEKARA V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No.: IO/(BNG)/A/HI/0298/2019-20

1 Name & Address of the Complainant Mr. B CHANDRASHEKHARA

B-202, 2nd Floor,

Mythri Enclave 1st Main,

Saswathipuram,

MYSURU - 570009

Mob - 9611393024

E-Mail: [email protected]

2 Policy No.

Type of Policy


5001002816P109920973

Corporation Bank – IBA

01.10.2016 to 30.09.2017



Indian Banks’ Association a/c. Syndicate Bank

Mrs Nirmala N – Spouse

4 Name of the Insurer United India Insurance Company Limited (RI)

5 Date of repudiation 03.11.2017

6 Reason for repudiation Expenses on obesity treatment and its

complication is excluded under the policy


8 Nature of complaint Repudiation of hospitalisation claim

9 Amount of claim Rs.4,00,000/-


11 Amount of relief sought Rs.4,00,000/-

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

13 Date of hearing/place 20.03.2020/ Bengaluru



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




The complaint emanated from the non settlement of hospitalisation claim of wife of the complainant by RI.

Despite his repeated representations to RI, the claim was not settled and hence he approached this Forum

for settlement of his claim.



Complainant submitted that he was covered alongwith his wife under IBA – Syndicate Bank Group Health

Policy vide policy no 5001002816P109920973 from 01.10.2016 to 30.09.2017. His wife (Insured Person –

hereafter referred to as IP) was hospitalised for treatment of severe COPD with OSA in Dr Tulip’s Obesity &

Diabetic Surgery Centre from 30.07.2017 to 15.08.2017. He submitted reimbursement claim to RI. After

scrutiny of medical documents the claim was denied under condition 4.5 of the policy. Despite his repeated

representation to RI, his plea was not considered favourably. Hence he has approached this forum for

settlement of his claim. He drew attention to newspaper clipping dt 08.11.2018 of Times Of India, reputing

therein the order of Consumer Dispute Redressal Forum, Ahmedabad, wherein in a similar case the forum

had allowed the claim by rejecting the plea of another Insurance Company.


RI vide e-mail dt 12.02.2020 objected to the proposed hearing of the complaint under condition 5.16 of the

policy which reads:

“If the TPA, as per terms and conditions of the policy or the Company shall disclaim liability to the

Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the

date or receipt of the notice of such disclaimer notify the TPA/Company in writing that he does not

accept such disclaimer and intends to recover his claim from the TPA/Company then the claim shall

for all purposes be deemed to have been abandoned and shall not thereafter be recoverable

hereunder.”

Since complainant has failed to approach the forum within 12 months from date of repudiation, the

complaint is liable to be dismissed. RI vide e-mail dt 19.02.2020 also produced the repudiation letter dt

03.11.2017 which was addressed to complainant.



20. The following documents were placed for perusal:-

d. Complaint along with enclosures,

e. Respondent Insurer‟s SCN along with enclosures and

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


The dispute is whether (i) the case was eligible for condoning the delay in respect of complaint

made to this forum; (ii) is the repudiation of the claim by the RI is in order; and (iii) Consumer

Court judgement on weight loss surgery is applicable in this case.

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

both the parties during the personal hearing.

Facts placed on record reveal that the claim was rejected by TPA Mediassist vide e-mail dt

31.10.2017. As per IRDAI Health Regulation 2016, communication regarding claim repudiation

can be done only by Insurance Company. Furthermore, query was raised to complainant to produce

any other communication from RI in respect of his claim. He submitted various letters which were

marked by broker KM Dastur and HO Staff Welfare of the bank where complainant is employed to

RI to consider the claim based on repudiation received by him. On registration of complaint, RI

submitted letter of repudiation dt 03.11.2017 marked to the complainant to this forum. However,

documents available on record show that complainant has been continuously interfacing with IBA

Cell of RI till May 2018 in regards to reconsideration of the claim. RI did not produce any

documentary evidence to substantiate that GRO had communicated rejection of the representation

made by complainant. Thus the forum after taking cognisance of repudiation letter of RI dt

03.11.2017 finds that objection of RI in untenable and extends benefit to complainant for failing to

approach the forum within 12 months of last representation made to RI.

On merits of the case, DS of Dr Tulip‟s Obesity & Diabetes Surgery Centre clearly states that IP

had history of morbid obesity. Patient was obese since childhood and had gradual weight gain over

20 years. OSA was diagnosed since 2 months. During personal hearing complainant admitted that

IP was obese since childhood.

On submission of the complainant that Consumer Court had allowed treatment for weight loss to be

covered under the policy, attention of complainant is drawn to Hon’ble Supreme Court of India judgement

in the case of Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd. &Anr., which states that:

“Before embarking on an examination of the correctness of the grounds of repudiation of the policy,

it would be apposite to examine the nature of a contract of insurance. It is trite that in a contract of

insurance, the rights and obligations are governed by the terms of the said contract. Therefore, the

terms of a contract of insurance law have to be strictly construed and no exception can be made on

the ground of equity.

Thus, it needs little emphasis that in construing the terms of a contract of insurance important, and

it is not open for the court to add, delete or substitute any words. It is also well settled that since

upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the

insured on account of risk covered by the policy, its terms have to be strictly construed to determine

the extent of liability of the insurer. Therefore, the endeavour of the court should always be to

interpret the words in which the contract is expressed by the parties.”

As per condition 4.5 of the policy condition, the following are excluded:

“Convalescence, rest cure, Obesity treatment and its complications including morbid

obesity, treatment relating disorders, Venereal disease, intentional self- injury and use of

intoxication drugs / alcohol.”

In view of Hon‟ble Supreme Court decision quoted above, this forum cannot give benefit to the IP

beyond the specific condition of the policy aforesaid. Decision of the Respondent Insurer is in accordance with the terms and conditions of policy and found to be in order. The complaint is disallowed.

A W A R D

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

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

the claim by the Respondent Insurer is found to be in order and in consonance with the terms and

conditions of the policy which does not require any interference at the hands of the Ombudsman.

The Complaint is Disallowed.


(NEERJA SHAH)

INSURANCE OMBUDSMAN





In the matter of: MR. S. VENKATACHAR V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No: IO(BNG)/A/HI/0300/2019-20

1 Name & Address of the Complainant Mr. S Venkatachar

#37, 1st Cross,

Kodandarama Reddy Layout,

Ramamurth Nagar Main Road,

Behind Uttam Sagar Restaurant,

Bangalore - 560016

Mobile # 9743762547

E-mail: [email protected]

2 Policy No.

Type of Policy

Duration of Policy/Policy Period

5001002818P11214580

Super top up Policy

01.11.2018 to 31.10.2019


Name of the Insured Person

M/s Indian Bank’s Association A/C Dhanlaxmi

Bank

Mr. S Venkatachar


5 Date of Repudiation 11.11.2019

6 Reason for repudiation Post hospitalization expenses are not payable

7 Date of receipt of Annexure VI A 23.01.2020

8 Nature of complaint Repudiation of claim

9 Amount of claim ₹. 55,200/-

10 Date of Partial Settlement Not Applicable

11 Amount of relief sought ₹. 55,200/-

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




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




The complaint arose out of the rejection of the claim on the ground that post hospitalization expenses are

not payable beyond the permissible number of days under clause 1.3 of the policy. The Complainant

represented to Grievance Redressal Officer (GRO) still his claim was not settled. Hence, the Complainant

approached this Forum for settlement of his claim.

18. Cause of complaint:

a. Complainant’s argument:

Complainant along with his wife was insured with RI under Group health policy and super top health policy.

His wife was hospitalised at Sparsh Hospital from 05.06.2019 to 08.06.2019 and underwent bilateral total

knee replacement. It is submitted that as per medical advice from Sparsh Hospital, he had employed a

home nurse for 3 months @ Rs.600/- per day. He applied for reimbursement of his claim; however RI

repudiated his claim stating that home nurse charges are not payable. He then represented his case to the

IBA cell of the RI, however his request was not considered favourably. Hence he approached this form for


b. Respondent Insurer’s argument:

The Respondent Insurer has submitted their Self-Contained Note dated 28.02.2020 and submitted that the

patient was presented to Sparsh Hospital for advance surgeries and was hospitalised from 17.04.2019 to

25.04.2019. The total claimed amount was ₹. 4,37,323/- out of which Rs. 3,00,000/- was settled from the

base policy and remaining ₹. 1,37,323/- was settled from super top up policy. The complainant later

submitted bills for pre and post hospitalization. It is submitted that all these claims were repudiated as the

sum insured under base policy was exhausted and the claims pertaining to pre & post hospitalization are

not covered under super top up policy.

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 requires consideration is whether the repudiation of claim is in accordance with the terms

and conditions of the policy or not.

During the personal hearing on 20.03.2020, representatives of RI was present but the complainant

expressed his inability to attend the hearing vide his email dated 20.03.2020 and submitted that

home care nursing was necessary as the patient has to be in bed rest as per medical advice.

During the course of personal hearing, representative of RI reiterated their earlier submissions and

argued that home nursing care charges and post hospitalization expenses are not payable under the

super top up policy.

It is noted that there were 2 hospitalizations at Sparsh hospital for the insured person, spouse of

complainant. First is from 17.04.2019 to 25.04.2019 for total knee replacement (Left side on

18.04.2019 and right side on 22.04.2019). The total claimed amount was Rs. 4,37,323/- out of

which Rs. 3,00,000/- was settled from the base policy and remaining Rs. 1,37,323/- was settled

from super top up policy.

Second hospitalization was from 05.06.2019 to 08.06.2019 for left knee quadriceps repair under

Spinal Anaesthesia on 06.06.2019. It is noted from the discharge summary that doctor advised

physiotherapy and stated nursing home care is required. It is observed that claim was lodged for Rs.

2,800/- for hospitalization and Rs. 55,200/- towards nursing home care for 3 months.

On perusal of the said terms and conditions, it is noted that condition no. 5.5 covers post hospitalization

upto 90 days. The relevant terms and conditions are reproduced as below:

2.40 POST HOSPITALISATION MEDICAL EXPENSES

Relevant medical expenses incurred immediately 90 days after the Insured person is discharged from the

hospital provided that;

a. Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation

was required; and

b. The In-patient Hospitalisation claim for such Hospitalisation is admissible by us.

2.28 MEDICAL EXPENSESmeans those expenses that an Insured person has necessarily and actually incurred

for medical treatment on account of illness or Accident on the advice of a Medical Practitioner, as long as

these are no more than would have been payable if the Insured Person had not been insured and no more

than other hospitals or doctors in the same locality would have charged for the same medical treatment.

Medical expenses necessarily and actually incurred for medical treatment are defined under 2.29 of the

policy as reproduced below

2.29 MEDICALLY NECESSARY TREATMENTis defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which

5 Is required for the medical management of the illness or injury suffered by the insured;

6 Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity;

7 Must have been prescribed by a Medical Practitioner;

8 Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

It is noted that 4 conditions are noted under 2.29 but are numbered as 5,6,7 and 8. This appears to be a

typographical error in the policy schedule.

It is seen that from documents placed on record that in the discharge summary the consulting doctor has

suggested that nursing home care is required. There is no certificate given by the consulting doctor as to

the necessity of nursing home care to the IP. Condition of the policy requires a prescription from the

medical practitioner and not mere suggestion as the medical expenses should be necessarily required as

laid down under condition no. 2.28 of the policy. In the absence of necessary requirement from the

consulting doctor, the repudiation by the RI is in order. Hence the complaint is disallowed.

AWARD

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

both the parties and the information/documents placed on record, the rejection of claim is found

to be in order and in consonance with the terms and conditions of the policy and does not require

any interference at the hands of Ombudsman.

The Complaint is Disallowed.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


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

OMBUDSMAN - NEERJA SHAH

In the matter of MR. K G MAHARABUSHANAM V/s UNITED INDIA INSURANCE COMPANY LIMITED


Award No.: IO (BNG)/A/HI/0302/2019-20

1 Name & Address of the Complainant MR. K G MAHARABUSHANAM

#17, RajalakshmiSadan, 8th Cross,

B. Channasandra, Kasturi Nagar,

Behind BOSCH Car Service,

BENGALURU – 560043

Mob.No.9448515145

E-mail : [email protected]

2 Policy No.

Type of Policy


5001002818P111276315

Tailormade Group Policy (Retirees)

01.11.2018 to 31.10.2019



Indian Bank’s Association A/c Andhra Bank

Mr. K G Mharabushanam


5 Date of repudiation/Rejection 17.12.2019

6 Reason for repudiation Hospitalisation for diagnostic purposes only


8 Nature of complaint Repudiation of claim

9 Amount of claim Rs. 34,123/-


11 Amount of relief sought Rs. 34,123/-

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





15 Complaint how disposed Allowed



The Complainant emanated from the rejection of claim for treatment on the ground that hospitalisation

was primarily for diagnostic/evaluation purposes and hence, not payable. Despite his taking up the matter

with the Respondent Insurer (RI) against repudiation of his claim, the claim was not settled and hence he

has approached this Forum for rendering him justice.



The Complainant submitted that he was admitted to Fortis Hospital, Bengaluru on 18.09.2019 for severe

chest pain, giddiness and abdominal pain due to urinary problem. He was treated for 3 days and diagnosed

urinary tract infection, type II diabetes mellitus and benign prostrate hyperplasia. He applied for cashless

settlement for hospitalisation bill of ₹. 34,123/- which was rejected by the TPA. He then submitted the

claim to TPA and the same was rejected without reading the Discharge Summary and other medical papers.

The Complainant had taken up the matter with Grievance cell of RI, who also did not respond. Hence, he

has approached this Forum.


The Respondent Insurer submitted their Self-Contained note dated 18.02.2020 admitting coverage,

preferring of claim and their rejection on the ground that the hospitalisation was primarily for

diagnostic/evaluation purposes and it was falling under policy Exclusion 4.7. “Charges 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 of presence of any ailment,

sickness or injury, for which confinement is required at a Hospital/Nursing Home, unless recommended by

the attending doctor.”

Hence, requested for dismissal of Complaint.



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): It is noted that the dispute is with regard to repudiation of the claim for hospitalisation on the ground that the treatment does not require hospitalisation. During the course of personal hearing, the Complainant vehemently submitted that he went to the hospital on for complaints of severe chest pain, giddiness and abdominal pain due to urinary problem. He was admitted as per doctor’s advice only and was examined by the urologist and cardiologist during the treatment.

The Respondent Insurer reiterated their earlier submissions that their rejection on the ground that the hospitalisation was primarily for diagnostic/evaluation purposes and it was falling under policy Exclusion no. 4.7, “Charges 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 of presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home, unless recommended by the attending doctor.” On perusal of the Discharge summary (DS) of Fortis Hospital, it is noted that insured person was admitted for complaints of giddiness on and off, chest pain since 3 to 4 days, complaints of discomfort post urination and history of frequent micturition nocturnal since 1 month. He was diagnosed as Urinary tract infection, Type II diabetes mellitus Hypertension and benign prostrate hyperplasia. It is further noted that he was examined by urologist and cardiologist. During his stay, he was treated with IV fluids, PPI s, antibiotics, analgesics, antimetics and other supportive measures. IP was discharged in stable condition and asked to follow up with treating doctor and urologists after 2 weeks. Furthermore, DS prescribed following medicines at time of discharge: Tablet Zoryl-M2, Aja duo tablet, Inj. H. Mixtard, Cap. Pan-D, Tablet Dolo 650 SOS and old hypertension medications. It is noted from the discharge summary that during the course of treatment, the IP was given Tab. Silofast 8mg and Tab. Silodal which is used for treatment of benign prostrate. Also, Tab. Taxim-O 200mg and Inj. Monocef 1mg was given for treatment of urinary tract infection. In light of above, the forum finds that decision of RI to repudiate claim that there was no active line of treatment is not in order. Therefore, RI is directed to settle the claim subject to terms and condition of the policy. The Complaint is Allowed.

A W A R D

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

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

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

6.25% + 2%) from the date of filing of the last relevant document till the date of payment of the

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

IRDAI vide notification dated 22.06.2017.

The Complaint is ALLOWED.








Ombudsman.

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

(NEERJA SHAH)

INSURANCE OMBUDSMAN




OMBUDSMAN - NEERJA SHAH

In the matter of MR. HARIOM VERMA V/s UNITED INDIA INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant MR. HARI OM VERMA

A-1, 104 Janapriya Greenwood Apartments,

ShomashettyHalli,

Chickkabanavara Post

BENGALURU – 560090

Mob.No. 6379893523

E-mail : [email protected]

2 Policy No.

Type of Policy


5001002818P109894693

Tailormade Group Policy (Retirees)

01.11.2018 to 31.10.2019



Indian Bank’s Association A/c IOB

Mr. HariomVerma


5 Date of repudiation/Rejection NA



8 Nature of complaint Policy servicing related grievances and thereby delay

in settlement of claim

9 Amount of claim Rs.25,465/-


11 Amount of relief sought Rs.25,465/-

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





15 Complaint how disposed Allowed



The Complainant emanated from non-receipt of monthly reimbursement due to non-linking of new bank

account to the policy under which the complainant was insured. Despite his taking up the matter with the

Respondent Insurer (RI) against non-receipt of his claim amount, the claim was not settled and hence he

has approached this Forum for rendering him justice.



The Complainant submitted that he along with his wife was insured with RI under Group health insurance

policy. He is suffering from diabetes and his wife from diabetes and arthritis. Upto November 2018 he had

received all his monthly reimbursement which he had claimed from TPA but from December 2018

onwards, he has not received the same. It is further submitted that he retired in January 2019 and as per

Bank’s policy he has closed his earlier account and opened new account no. 208701000033333with IOB,

Munshipulia Branch, Lucknow for payment of pension and the details along with application and cancelled

cheque were intimated to TPA/RI but still the claim was not credited to his new account. Despite his taking

up the matter with the Respondent Insurer (RI) against non-receipt of his claim amount, the claim was not

settled and hence he has approached this Forum for rendering him justice.


RI has not submitted SCN (Self contained Note).





b. Respondent Insurer’s SCN along with enclosures and



It is noted that the dispute is with regard to non-linking of new bank account details to the policy

under which the complainant was covered/insured.

Complainant vide his email dated 19.03.2020 informed that he received Rs. 13,643/- out of

claimed amount Rs.25,465/- and will receive the balance amount soon.

RI vide their email dated 20.03.2020 submitted that they have credited some of the claims to the

complainant‟s account on 19.03.2020 and assured that balance claims which are in the pipe line

will be credited to his account shortly.

In light of above, Forum directs the RI to settle the balance claims subject to terms and condition

of the policy at the earliest. The Complaint is Allowed.

A W A R D

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

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

to settle the balance claim as per terms and conditions of the policy.

The Complaint is ALLOWED.








Ombudsman.

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

( NEERJA SHAH)

INSURANCE OMBUDSMAN


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

OMBUDSMAN – Smt. NEERJA SHAH

In the matter of Mr.K.V.PASHUPATHY . V/s THE ORIENTAL INSURACE COMPANY LIMITED


Award No. : IO (BNG)/A/HI/0305/2019-20

1 Name & Address of the Complainant Sri K.V.PASHUPATHY,

3/110, Brahmin Street,

Karambakkam ,Porur,

CHENNAI,

TAMIL NADU

Mob.No.9840878753

Mail ID : [email protected]

2 Policy No.

Type of Policy

Duration of policy/Policy period/ PPT

411500/48/2020/627

PNB-Oriental Royal Mediclaim Policy 2017

29.06.2019 to 28.06.2020

3 Name of the Insured

Name of the Policyholder

Self

Smt.K.V.Sunitha

4 Name of the Respondent Insurer The Oriental Insurance Company Limited.

5 Date of repudiation/rejection NA



8 Nature of complaint Non issuance of coverage under health policy

9 Amount of claim NA

10 Date of partial settlement NA

11 Amount of relief sought NA

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

13 Date of hearing/place 24.03.2020 / Bengaluru.


For the Complainant Exemption requested due to Covid 19

For the Respondent Insurer ……….


16 Date of Award/Order: 31.03.2020

17. Brief Facts of the Case:It is case of non inclusion of complainant in the mediclaim policy during the

renewal of policy. In spite of representation with Respondent Insurer (RI), his request was not considered.

Hence, the Complainant has approached this Forum.


a. Complainant’s arguments:The Complainant’s submission was that he has taken Health Insurance policy

wihRI under their PNB-Oriental Royal Mediclaim Insurance Policy, along with wife Mrs.S.V.Sunitya. The

policy was availed through corporate agent Punjab National Bank, Raja Street, T.Nagar, Chennai 600 017.

He approached the Bank for the renewal of policy No.411500/48/2017/690 issued for the period

29.06.2016 to 28.06.2017 since he planned to travel abroad during May 2017 for a duration of 3 months.

During renewal period he was informed by the Bank that since he was crossing the age of 79 years existing

policy cannot be renewed in his name as per policy conditions, but policy will be shifted in spouse name.

He was under the impression that his spouse Smt.S.V.Sunitha will be the policy holder and he will be her

dependent. He paid the renewal premium as per demand made by the Bank accordingly policy was

renewed for the period 2017-18 on 16.05.2017 and policy was delivered to his residence during his stay at

abroad. He failed to check the contents after his return. The policy was renewed for the year 2018-19 and

2019-20 on similar lines.

During May 2019 he was hospitalized for surgery due to fall and fracture of his limb and he came to know

that policy covered his wife only and he was without any coverage. He paid hospitalization charges of

Rs.2,50,000/- out of his moderate savings. The Bank and the R.I acted wrongly in denying coverage under

the existing policy and also without providing alternate policy. He was not provided with any written

communication either of the institution that he was not eligible for the renewal and no alterative was

provided. He represented to R.I vide letter dt.17.08.2019 for which he got reply dt.21.08.2019 assuring

that the matter will be looked into but his grievance was not resolved . Hence approached the forum for

justice to restore insurance coverage under any of the schemes of R.I with continuity benefits.

b. Respondent Insurer’s Arguments: The Respondent Insurer submitted their Self Contained Note dated

03.03.2020 admitting the coverage of the complainant and his spouse Smt.S.V.Sunitha from 29.06.2015

for sum insured of Rs. 3 lakhs and continued renewal upto 28.06.2017. It is submitted that on renewal for

the period 2017-18, since the complainant has surpassed the age of 80 years (DOB 19.08.1936) his name

was deleted from the coverage as per policy conditions No. 3.1 (Entry Age shall be 79 years or early and the

coverage will seize on the day the insured attains the age of 80 years). Further, policy renewed covering

his spouse only till 28.06.2020.

The insured person preferred claim for the hospitalization of complainant who met with an accident on

20.05.2019. The claim falls under the policy period 2018-2019 where in the complainant was not covered

under the policy. Hence the claim was rejected.




Complaint along with enclosures


b. Respondent Insurer‟s SCN along with enclosures and



Personal hearing was not conducted due to COVID 19 and declared complete lockdown in the State.

Forum notes that the dispute is for not providing appropriate health insurance coverage at the time

of renewal of policy.

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

made by both the parties.

Policy Terms and Conditions No.2 deals with Definitions and No.3 deals with OTHER

DEFINITIONS AND INTERPRETTIONS:

RI has relied on other definitions No.3.1 which deals with INSURED PERSON and the same is

reproduced as under:

“Means Person(s) named on the schedule of the policy which includes family comprising of the

proposer, his/her legally wedded spouse, dependent unemployed children (upto two only) between

3( three months) to the age of 26 years. The dependent children may also include unmarried

daughters including divorcee, and widowed daughters provided the maximum number of dependent

children under the entire policy does not exceed two.

Entry Age : The entry age shall be 79 years or early and the coverage will seize on the day the

insured attains the age of 80 years”.

Forum notes that the policy No.411500/48/2017/60 was in force for the period from 29.06.2016 to

28.06.2017 wherein complainant was covered and he attained the age of 80 years during the policy

period as on 19.08.2016 and R.I allowed him to continue his coverage till the expiry of policy

period. Thus R.I violated their own policy conditions.

Forum relies on IRDAI Health Regulations 2016. Regulation No.12 deals with Entry & Exit age &

12(ii) reads as under:-

„Except travel insurance products, personal accident products and Pilot Products referred to in

Regulation 2(i)(l) herein, once a proposal is accepted and a policy is issued which is thereafter

renewed periodically without any break, further renewal shall not be denied on grounds of the age

ofthe insured‟.

Regulation No.13 deals with: Renewal of Health Policies issued by General Insurers and Health Insurers

(not applicable for travel and personal accident policies)

Regulation No.13 (i) reads as under:-

„A health insurance policy shall ordinarily be renewable except on grounds of fraud, moral hazard or

misrepresentation or non-cooperation by the insured, provided the policy is not withdrawn’.

Regulation No.17 deals with Migration of health insurance policy (not applicable for Travel and

Personal Accident policies) & 17(i) reads as under:-

„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 the specific exit age or at the time of withdrawal

of the policy at the option exercised by the said lives by allowing suitable credits for all the previous policy

years, provided the policy has been maintained without a break‟.

Keeping in view the above regulations Forum notes that:

(i) Complainant‟s policy coverage was renewed without any break from the inception of

policy period i.e., 29.06.2015 till the date of dispute for renewal i.e 29.06.2017 being 2nd

renewal.

(ii) Policy was not cancelled as per IRDAI H.I Regulation 13(i).

(iii) R.I violated Regulation No. 17(i) Option to Migrate to a suitable alternative available

health insurance at the end of the specific exit age by not providing opportunity to the

complainant.

However Forum notes that the complainant has erred by not noticing the policy and coverage

details even after receiving the second renewal policy. This error of judgment caused

inconvenience and mental anguish to the complainant. Nonetheless this lapse on the part of the

complainant does not absolve the R.I from not following the Health guidelines aforesaid.

Considering the above R.I is directed to relook and issue alternative available health insurance policy:

(i) With effect from prospective date after collecting appropriate premium to comply Sec.

64VB of Insurance Act

(ii) As per IRDAI H.I Regulations 2016 &(Protection of Policy Holder‟s Interest)

Regulation, 2017

Hence the complainant is Partially Allowed.

A W A R D

Taking into account of the facts and circumstances of the case, R.I is directed to relook and issue

alternative available health insurance policy:

(i) With effect from prospective date after collecting appropriate premium to comply

Sec. 64VB of Insurance Act

(ii) As per IRDAI H.I Regulations 2016 &(Protection of Policy Holder‟s Interest)

Regulation, 2017

Hence, the complaint is Partially Allowed


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

Insurance Ombudsman Rules, 2017:

a. The Complainant shall submit all requirements/Documents required for compliance of award within 15 days of receipt of the award to the Respondent Insurer.

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

Dated at Bangalore on the 31st day of MARCH, 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN




OMBUDSMAN- Smt. NEERJA SHAH

Case of: SRI .YAKAPURKAR SHAMRAO DHARMANNA V/s UNITED INDIA INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant SRI.YAKAPURKAR SHAMRAO DHARMANNA ,

Plot No.37, Udayanagar Colony,

Opp.ChittariSae Mill, New Jewargo Road,

Beside Sonali Flour Mill,

Gulbarga-585 102

Mob.9972021414

Email:[email protected]

2 Policy No.

Type of Policy


5001002818P111251702

Group Health Insurance- State Bank of Hyderabad

(IBA-Retirees)

01.11.2018 TO 31.10.2019



Sri.YAKAPURKAR SHAMRAO DHARMANNA

State Bank of Hyderabad (IBA-Retirees)

4 Name of the Insurer United India Insurance Company Limited

5 Date of repudiation NA



8 Nature of complaint Short settlement

9 Amount of claim ₹. 6,220/-


11 Amount of relief sought ₹.6,220/-

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

13 Date of hearing/place 20.03.2020


a) For the Complainant Absent on request

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




This complaint emanated from the short settlement of Post Hospitalization claim. In spite of contacting

various authorities, his request was not considered. Hence, the Complainant has approached this Forum.



Complaint has submitted post hospitalization bills for Rs.6,220/- followed by primary hospitalization.

Respondent Insurer (R.I) rejected the claim wrongly stating pre & post after 60 days under policy condition

No.1.2.2 read with condition No.1.2. As per policy condition he is entitle for Post hospitalization benefits

for 90 days. His hospitalization period was from 19.06.2019 to 21.06.2019. Calculation of date upto which

medical expenses (Bills) eligible to be considered i.e. 90 days after discharge from 22.06.2019 worksout till

19.09.2019.

His bill for Rs.5520/- (in dispute) is dated 05.09.2019. Medical expenses incurred well within 90 days after

discharge). Bill for Rs.700/- (in dispute) is dated 08.09.2019. R.I violated the relevant policy condition.

Hence he has approached this Forum for settlement of his claim.


The Respondent Insurer submitted vide mail dt.11.03.2020 stating that they reviewed the post

hospitalization bill of the complainant. They observed that complainant was hospitalized on 19.06.2019

and discharged on 21.06.2019. As per policy conditions he is entitle for pre hospitalization medical

expenses for 30 days and post hospitalization for 90 days from the date of discharge i.e.up to 19.09.2019.

The medical bill is dated 05.09.2019 for Rs.5,520/- speaks for purchase of medicine which will be

consumed beyond the post hospitalization period of 90 days.

Accordingly he is entitled for Rs.866/- for use of medicines as per prescription upto 90 days of discharge.

Zandu balm has not been prescribed. Claim of Rs.700/- towards Diabetic check up is an estimate and not

the bill. Hence the same is disallowed. In view of the same requested to dismiss the complaint.


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


(i) Complaint along with enclosures, (ii) Respondent Insurer’s SCN (iii) Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): The present dispute is as to whether the denial of post hospitalization claim by the R.I is in order or

not.

Complainant submitted his inability to travel and appear for personal hearing due to COVID 19.

Hence requested the forum to decide the complaint on merit. R.I reiterated their contentions earlier

made and strongly contended that just by purchasing the medicines within 90 days of post

hospitalization, complainant is not entitled for full reimbursement of Bills. Forum has perused the

documentary evidence available on record and the submissions made by both the parties.

Forum carefully observed the documents and found the :

Under the Definition of Terms and Condition of policy ,Post Hospitalization Expenses are

defined in condition No . 2.40 which is reproduced as under:

„Relevant Medical Expenses incurred immediately 90 days after the insured person is discharged

from the hospital provided that:

(iv) Such Medical expenses are incurred for the same condition for which the Insured

Person‟s Hospitalization was required; and

(v) The In-patient Hospitalization claim for such Hospitalization is admissible by us‟.

Forum observes from the records that the complainant purchased medicines and produced

Pharmacy Bill dated 05.09.2019 for Rs.5520.70 without supporting MedicalPractioner‟s

prescriptions. He has submitted Copy of Estimate No. 61444 dt.08.09.2019 of Mediscan Diagnostic

& Healthcare Pvt. Ltd., is for Rs.700.00 for Basic Diabetic Check up without supporting Medical

Practioner‟s prescriptions and appropriate bill.

Condition No.5 of policy terms deals with Claims Procedure and 5.E deals with details of

Documents to be produced for reimbursement of claims. As per conditionsNo.5.E(x) the claim is to

be supported with all original medicine/pharmacy bills along with the Medical Practioner‟s

prescriptions.

Pharmacy Bill dt. 05.09.2019 for Rs.5520.75 shows that number of medicines purchased are

consumable beyond 90 days of post hospitalization period i.e. 19.09.2019. The claim of Rs.700/-

towards Basic Diabetic check up are without supporting Bill and advice by the Medical

practitioner .

Considering the above facts Forum finds that complainant is entitled only for reimbursement of

medical expenses of post-hospitalization from the date of purchase i.e. 05.09.2019 to 19.09.2019

as dozes prescribed by the Medical practitioner which is relevant to IP‟s hospitalization. With

regard to Basic Diabetic Check up expenses complainant is entitled subject to production of

appropriate bill along with supporting Medical practitioner advice.

Hence, the complaint is Partially Allowed.

A W A R D

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

submissions made by R.I, this Forum directs R.I to relook the claim and settle by collecting necessary documents as per the terms and conditions of policy along with interest @ 6.25% + 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 PARTIALLY ALLOWED.


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


a. The Complainant shall submit all requirements/Documents required for settlement of award within 15 days of receipt of the award to the Respondent Insurer.

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

Dated at Bangalore on the 31stday of MARCH 2020.

(NEERJA SHAH)

INSURANCE OMBUDSMAN


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

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

MrMayankKhandelwal………………….………………………….. Complainant

V/S

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

COMPLAINT NO: BHP-H-051-1920-0231 ORDER NO: IO/BHP/A/HI/0101/2019-2020

Mr MayankKhandelwal (Complainant) has filed acomplaint against United India Insurance

Co. Ltd.(Respondent) alleging partial settlement of mediclaim No.20635792.

Brief facts of the Case -The complainant has stated that he as an employee of Bank of India

was having Medical Policy from respondent company for the period from 01.10.2018 to

30.09.2019. He had submitted a claim No.20635792 on 30.09.2019 for caesarean delivery of

his wife. The respondent had settled his claim after deduction/ rejection of Rs.7,300/- medical

store bill and given the reason that post natal bill cannot be considered. He has reported to

respondent that his wife was discharged on 22.09.2019 i,e Sunday. On Sunday store was

closed so he got the printed bill from the stores on Monday. He further stated that he had a

hand written bill of the store which can be produced by him. Ultrasound bill was rejected

which should also be considered as it requires to get admitted for the same. He has reported

1. Name & Address of the

Complainant

MrMayankKhandelwal

c/o Bank of India, Talibandha Br Raipur C.G

2. Policy No:

Type of Policy

Duration of policy/Policy period

5001002818P109894428

Group Health Insurance Policy

01.10.18 to 30.09.19

3. Name of the insured


Indian Bank’s Association A/C Bank of India

--

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

5. Date of Repudiation/ Rejection 28.11.2019

6. Reason for Repudiation/ Rejection Exclusion of Pre &Post natal expenses as per

clause 3.5 ii

7. Date of receipt of the Complaint 21.01.2020

8. Nature of complaint Partial settlement of mediclaim

9. Amount of Claim --

10. Date of Partial Settlement 28.11.2019

11. Amount of relief sought --

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

13. Date of hearing/place 17.03.2020 at Bhopal

14. Representation at the hearing

For the Complainant Absent

For the insurer MrBadal Jain, Admn Officer

15. Complaint how disposed Dismissed

16. Date of Award/Order 17.03.2020

this complaint to TPA respondent‟s Regional Office but did not get the satisfactory reply.

Hence the complainant approached this forum for redressal of his grievance.

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

No.50010022818P109894428covering their employees with dependant members for the

period from 01.10.2018 to 30.09.2019. The complainant was covered with spouse and

respondent received the claim of spouse for Cesarean section. On review of the claim it was

observed that pre-post natal expenses are not covered unless admitted in the Hospital. So the

post hospitalization claim is repudiated on the basis of policy clause 3.5 {(Special condition

applicable to Maternity Benefit extension (II)}.

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

while respondent have filed SCN with enclosures.

During hearing complainant remained absent and sent letter received on 16.03.2020 about his

absence. I have heard representative of the respondent company at length and perused papers

filed on behalf of the complainant as well as the Insurance Company.

A claim for Rs.71,811/- under above policy was filed by the complainant for the treatment of

LSCS (caesarean delivery) of his wife / insured taken at City Hospital and Research Centre,

Raipur from 17.09.2019 to 22.09.2019 which was settled for Rs.59,400/- and had not paid

medical bill of Rs.2,507/-, Rs.204/- and Rs.7,300/- dated 23.09.2019 as pre and post natal

charges not payable as per policy. Complainant in his complaint, has stated that a bill of

Rs.7,300/- and bill of Ultrasound was rejected and not paid by the respondent. The

representative of the respondent has argued that caesarean delivery treatment was taken from

17.09.2019 to 22.09.2019 and as complainant had filed bill of Rs.7,300/- dated 23.09.2019

and bill of USG dated 24.08.2019 hence, as per policy terms and conditions, pre and post natal

charges are not payable. Bill of Rs.7,300/- is of dated 23.09.2019 and bill of USG is of

24.08.2019 and the insured remained admitted from 17.09.2019 to 22.09.2019. Complainant

has not filed any evidence of hospitalisation on 24.08.2019 and 23.09.2019. Complainant in

his complaint had mentioned that his wife got discharged on 22.09.2019 i.e. on Sunday and as

the store was closed on Sunday he got a printed bill on next working day i.e. Monday. No

evidence to this fact has been filed by the complainant instead filed a cash memo of Raghav

Medical store amounting to Rs.7,306/- which is of 18.08.2019. Bill for Rs.7,306/- dated

18.08.2019 is of no relevance keeping in mind the hospitalisation period. Special conditions

No.II of Clause 3.5 (Maternity expenses benefit extension) states that Pre- natal & post natal

charges in respect of maternity benefit are covered under the policy upto 30 days and 60 days

only, unless the same requires hospitalization. Hence as per above clause, the respondent has

rightly deducted amount of Rs.7,300/- (medical bills) & Rs.900/- (USG) and acted as per

terms and conditions of the policy. Complainant has mentioned in his complaint that as the

claim was not settled in stipulated time limit as per terms and conditions of the policy, the

company is liable to pay penal interest 2% above bank rate. Representative of the respondent

during hearing has argued that on 04.11.2019 complainant was asked to fulfill some

requirements which were complied by the complainant on 15.11.2019. He further argued that

claim was paid on 28.11.2019 without any delay on the part of the respondent. The respondent

has filed query letter dated 04.11.2019 and document filed dated 15.11.2019. Hence there is

no delay on the part of the respondent. In view of above facts and circumstances, respondent

had settled the claim as per terms and conditions of the policy and complaint is liable to be

dismissed.

The complaint filed by Mr MayankKhandelwal stands dismissed herewith.

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

Dated : Mar 17, 2020 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr.D.K. VERMA

Case of Mr. Amit JyotiV/SThe Oriental Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-H-050-1920-0303

1. Name & Address of the Complainant Mr. Amit Jyoti

# 38 Prem Nagar, Ambala,

Haryana- 134003

Mobile No.- 9467758289

2. Policy No:

Type of Policy


124500/48/2019/4291

Group Mediclaim Policy

01-10-2018 To 30-09-2019



Ms. ParulJyoti

M/S Axis Bank Limited

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

5. Date of Repudiation 14/05/2019

6. Reason for repudiation As per clause 5.9 of policy

7. Date of receipt of the Complaint 19-08-2019

8. Nature of complaint Non Payment of Mediclaim

9. Amount of Claim Rs.40407/-

10. Date of Partial Settlement N.A

11. Amount of relief sought Rs.40407/-

12. Complaint registered under

Rule no: Insurance Ombudsman Rules,

2017

Rule 13 (1)(b) – any partial or total repudiation

of claim by an insurer

13. Date of hearing/place 10-02-2020/ Chandigarh


For the Complainant Sh. Amit Jyoti

For the insurer Ms. InduKhurana, Dy. Manager

15 Complaint how disposed Dismissed

16 Date of Award/Order 09/03/2020

17) Brief Facts of the Case:

On 19-08-2019, Mr. Amit Jyoti father of Ms. ParulJyotihad filed a complaint against Oriental

Insurance Company Limited about Non Payment of mediclaim claim in respect of the

hospitalization claim of Ms. RachnaJyoti ,beneficiary covered under group mediclaim policy

number 124500/48/2019/4291 issued to axis bank limited. The claim is with regard to the

hospitalization of MrsRachnaJyoti in Yafe Indoor Clinic from 28.01.2019 to 06.02.2019 for obesity

with Hypertension with Bronchopneumoniawith influenza. The complainant has submitted that the

insurance company is not resolving the health claim no.19104166 and changing goal posts by

giving different reasons of rejection and in the last mail when full payment was made to the

hospital, deposited full documents to the insurance company and if for any reason the hospital is

required to submit some confirmation or documents then this is no reason for rejecting the claim

or assigning the claim as fraud. Further the complaint has sought strict action against the insurance

company for withholding the lawful payment since April, 2019.

On 30-08-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,

Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 06-11-2019.As per SCN, Mrs. RachnaJyoti was

admitted in Yafe Indoor Clinic from 28.01.2019 to 06.02.2019 for obesity with Hypertension with

Bronchopneumonia with influenza treated conservatively. Claim documents were received on

01.03.2019 by the Medi Assist TPA Mumbai. After scrutiny of the documents, claim was moved for

investigation to collect form C and indoor case papers to know the exact treatment given.

According to TPA investigation report, the hospital is non cooperative, indoor case paper records

are incomplete and all indoor case papers are written in same handwriting & treating doctor did

not provide any justification letter regarding the same. Due to non cooperation from hospital and

incomplete documentation the claim was rejected. On insured’s representation against

repudiation, the TPA was again requested to review the claim. The TPA has reverted that according

to investigation report Dr. Aditya Rajan provided IPD records but incomplete like doctor notes

which include daily basis of the patient check up with vital sign, complaints if any, advice treatment

and investigations during hospitalization. Further the investigator had verified all the IPD records

and observed same handwriting in IPD file. The doctor did not provide any justification letter

regarding the same. The insurer submitted that based on the above facts our repudiation stands.

The complainant was sent Annexure VI-A for compliance, which reached this office on 17-09-2019.

18) Cause of Complaint:

a) Complainant’s argument:The insurance company is not responding and changing goal

posts by giving different reasons of rejection of claim.

b) Insurers’ argument:Due to non cooperation and incomplete documentation the claim was

rejected.

19) Reason for Registration of Complaint: -within the scope of the Insurance Ombudsman Rules,

2017.

20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties(Observations & Conclusion):

I have gone through the documents available in the file including the copy of the

complaint ,SCN of the insurer and hospitalization record of the patient ,whose claim for the

hospitalization at Yafe Indoor Clinic from 28/01/2019 to 06/02/2019 for treatment of obesity

with hypertension ,bronchopneumonia with influenza has been denied by the insurance

company. The claim was rejected by the insurer underclause 5.9 of the policy due to

fraud/misrepresentation / concealment, due to non cooperation from hospital and incomplete

documentation. The issue here to be decided is as to whether the denial of claim due to

incomplete IPD papers/non cooperation by the hospital, is justified or not. The complainant

stated that insurance company is not resolving the health claim and changing goal posts by

giving different reasons of rejection of claim in spite of submission of all the documents. As per

insurance company, after receipt and scrutiny of claim documents, the claim was moved for

investigation to collect indoor papers to know the exact treatment given. According to

investigation report of TPA, the hospital provided only incomplete IPD records with regard to

doctor‟s note which include daily basis of patients checkup with vital sign, complaints if any,

advice treatment and investigation during hospitalization. As the hospital was non cooperative

and did not provide any justification as to why hospital records are incomplete and in the same

handwriting, the claim was denied .The insurer could not finalize the admissibility of claim in

the absence of complete IPD records. No insurer / TPA can decide about the admissibility of

claim unless they are provided with the complete indoor record related with the treatment &

investigations done during the hospitalization. In the present case the clarification /justification

sought by the company with regard to incomplete indoor case paper was not provided by the

hospital. Even the investigation conducted by investigator appointed by insurance company to

investigate the claim also confirms the above fact. Certain hospital documents have been

submitted by complainant during personal hearing. On examination of same it is also observed

that the day to day hospital records and progress reports are not provided by complainant and

copy of various investigation reports are unsigned. Hence the denial of the claim is justified

under the given circumstances.The complaint is dismissed being devoid of merits

AWARD

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

parties during the course of personal hearing, no relief is granted to the complainant.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 9th

day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Rohit Gupta V/SReligare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rohit Gupta

S/o Sh. Narinder Gupta, House No.- 838-I,

Block, BRS Nagar, Near Sheetla Mata Mandir,

Ludhiana, Punjab- 141012

Mobile No.- 9316966611

2. Policy No:

Type of Policy


11561922

Group Care Plan

25-01-2019 To 24-01-2020



Mr. Narinder Gupta

Punjab National Bank

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

5. Date of Repudiation 20.04.2019 & 07.05.2019

6. Reason for repudiation Non disclosure of Pre Existing Disease


8. Nature of complaint Denial of Claim

9. Amount of Claim Rs.6.75 lacs


11. Amount of relief sought Rs.3,00,000/-( Sum Insured)



2017



13. Date of hearing/place 10-02-2020 / Chandigarh


For the Complainant Sh. Rohit

For the insurer Dr. Nisha Sharma, Manager Claims

15 Complaint how disposed Award



On 12-07-2019, Mr. Rohit Gupta had filed a complaint against Religare Health Insurance

Co. Ltd. for denial of health insurance claims of his father Sh. Narinder Gupta on the

ground of non disclosure of pre existing ailments whereas the patient did not have any such

medical condition at the time of first insurance i.e January 2018.There seems to be some

kind of miscommunication .The patient history of pre existing conditions as claimed is

recent, definitely post policy inception. Religare officials had themselves certified the

insurance document in Jan.2018 that patient does not have any pre existing condition.

Moreover current diagnoses do not have any relation to pre-existing condition as claimed by

Religare.

Despite sending multiple e-mails to Religare Health Insurance, it has failed to elicit a

response. The complainant has sought the intervention of this office for justice.

On 26-07-2019, the complaint was forwarded to Religare Health Insurance Co. Ltd. Regional Office,

Gurugram, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 26-08-2019.As per the SCN,the insurance company

issued policy no11986639 to complainant’s father along with his mother with effect from

25/01/2018 to 24/01/2019 for sum insured of Rs.3,00,000/- subject to policy terms and conditions.

The policy was further renewed from25/01/2019 to 24/01/2020. During the continuation of the

policy, the complainant approached the company with a cashless request for hospitalization at

Mayo Healthcare Super Specialty Hospitals, Mohali from 19/04/2019 with chief complaint of

headache, vomiting and nausea. That upon careful consideration of the documents submitted by

the insured, the insurance company observed that as per the documents issued by the treating

hospital ,the insured had a history of hypertension since 5 years and diabetes mellitus since 2 years

and concluded that there was Non-Disclosure of Material information on the part of the insured

and accordingly repudiated the cashless claim of the insured vide letter dated 20th April 2019 in

accordance to clause 5.2 i.eNon Disclosure of Material Information as per policy terms and

conditions.

The complainant again applied for the cashless request for hospitalization at Dayanand Medical

college Hospital, Ludhiana from 8th May, 2019 with chief complaint of Melingnant Melanoma. The

Company on careful examination of the documents submitted by the insured observed that there

was Non disclosure of material information and accordingly rejected the cashless request vide

letter dated 7th May and 15th May 2019 in accordance to clause 5.2 i.enon disclosure of material

information as per policy terms and conditions. The fact that complainant’s father had pre-existing

disease of hypertension and diabetes Mellitus since 5 years but no such disclosure was made by

insured at the time of filing the proposal form. The Insured had the opportunity to disclose all the

material information regarding the correct health status at the time of filing of online proposal

form but no such disclosure was made which is best known to insured.



a) Complainant’s argument: The patient does not have any pre existing ailment and the

current diagnoses are not related to it.

b) Insurers’ argument:Complainant‟s father had pre-existing disease of hypertension and

diabetes Mellitus since 5 years but no such disclosure was made by insured at the time of

filing the proposal form.

19) Reason for Registration of Complaint:-within the scope of the Insurance Ombudsman

Rules, 2017.




21) Result of Personal hearing with both parties (Observations & Conclusion):

On perusal of the various documents placed on record including the copy of the complaint,

SCN of the insurer and submission made by both the parties during personal hearing, it has

been observed that the insurance company denied the cashless claim of complainant‟s father

Sh. Narinder Gupta for hospitalization due to headache, vomiting & nausea at Mayo Super

specialty hospital Mohali from 19/04/2019. Again another cashless claim for hospitalization

of complainant‟s father due to malignant at Dayanand Medical College and Hospital from

8th

May, 2019 was also denied by the insurance company. The company denied both the

cashless claims due to the reason that insured had a history of hypertension since 5 years

and diabetes Mellitus since two years and insured had not disclosed these facts while

purchasing policy. The basic issue here to be decided is whether the denial of cashless

claims due to the alleged history of hypertension and diabetes is justified or not, keeping in

view the diagnosis during the two hospitalizations. The insured was first hospitalized on

19/04/2019 with chief complaint of Headache, vomiting & nausea and during his second

hospitalization on 08/05/2019, the treatment was given for Metastatic Malignant Melanoma.

It is amply clear that causes for both the hospitalizations were different and not in any way

can be related or attributed to the patient‟s history of diabetes and hypertension, the denial

of cashless facility by insurance company is not justified on the ground of non disclosure or

pre existing conditions.

As Such the insured is advised to file the reimbursement claim with the insurer for both the

hospitalizations within 15 days from the receipt of copy of the award and insurance

company is directed to consider the claims within 15 days from the date of receipt of

complete claim papers, as per terms and conditions of the policy without taking into account

the ground of non disclosure of hypertension and diabetes.

AWARD


parties during the course of personal hearing, Insurance company is directed to consider the

reimbursement claims of insured as per terms and conditions of the policy.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Manoj Kumar GoyalV/SThe United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Manoj Kumar Goyal

D-8, Silver Heights Apartments,

Near WadalaChowk, Nakodar Road, Jalandhar,

Punjab- 144003

Mobile No.- 9638802107

2. Policy No:

Type of Policy


500100/28/18/P1/09893720

Group health Policy

01-10-2018 To 30-09-2019



Indian Bank’s Association A/c Union Bank

Mr. Manoj Kumar/Mr.Ashok Kumar

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

5. Date of Repudiation 13.03.19 & 04.05.19

6. Reason for repudiation Ailment caused due to alcohol


8. Nature of complaint Repudiation of two claims

9. Amount of Claim Rs. 32221/- + Rs. 8538/-

10. Date of Partial Settlement NA

11. Amount of relief sought Nil



2017





For the Complainant Mr.Manoj Kumar Gotal, Complainant

For the insurer Ms.Mamta Bansal, Dy.Manager




On 20-08-2019, Mr. Manoj Kumar Goyalhad filed a complaint vide which he informed that he and

his family are covered under Group health care taken by Union Bank of India issued by United

India Insurance Co. Ltd. He submitted a hospitalization claim(reimbursement) no. 4005492 and

4205492 A of his father Mr.Ashok Kumar through Paramamount TPA. Both claims have been

repudiated by the company. Claim no. 4205492, for Rs. 32221/-, was related with hospitalization

for dilated cardiomyopathy at Jindal ENT Hospital & Medical research Centre. As per company the

patient was admitted for the ailment which is caused due to alcohol, although none of the report

confirmed that the disease is due to alcohol.

Second Claim no. 4205492A, for Rs. 8538/-, was related with hospitalization for acute

decompensate heart failure with Cardiorenal Syndrome Type-1. As per company, the claimant has

claimed for post hospitalization and the main claim (4205492) is denied under policy clause 4.5

(disease is caused due to use of alcohol). Date of admission in this claim was 04.02.19 while date

of admission in main claim was 10.02.19. As per complainant, claim of post hospitalization cannot

be before date of main claim as such claim has been rejected deliberately without checking the facts

and dates.

On 11-09-2019, the complaint was forwarded to The United India 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 11.02.2020. The complainant was sent Annexure VI-A for

compliance, which reached this office on 19-09-2019.

As per SCN received from insurance company, Mr. Ashok Kumar presented with complaints of

chest pain, dysponea on 10.02.19 at Jindal ENT Hospital & Medical Research centre. Insured was

diagnosed with Dilated Cardiomyopathy. The submitted documents indicate Oral Medicine, IV

Medicines were administrated. Discharge Summary and submitted documents indicate that the

patient was admitted for the ailment which is caused due to alcohol. Claim is denied under clause

no. 4.5 of the policy, which states that any disease caused due to use of intoxication (alcohol) is not

payable. In second claim, patient Mr.Ashok Kumar presented with complaints of Abdominal pain

on 04.02.19 at Gupta Heart and Gen. Care Center. Insured was diagnosed with Acute

Decompensate Heart Failure with cardio renal Syndrome Type 1. The submitted documents

indicate that claimant has claimed for post hospitalization expenses and main claim is denied under

policy clause 4.5, i.e. disease is caused due to use of alcohol.


a) Complainants argument:Company has wrongly repudiated his claims, although earlier

claim paid under same policy.

b) Insurer’s argument:Company has repudiated the claims as per terms and conditions of

the policy.

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman

Rules, 2017.




21) Result of Personal hearing with both parties(Observations & Conclusion)

On perusal of the various documents available in the file including the copy of complaint, SCN,

submissions made by both the parties during personal hearing, it has been observed that father of

Complainant Mr. Ashok Kumar was first admitted in Gupta Heart and General Care Center,

Sadhulshaher from 04.02.19 to 06.02.19 with diagnosed as Acute Decompensated Heart Failure

with Cardirenal Syndrome Type 1. As per company, claim of post hospitalization expenses has

been denied under clause 4.5(disease is caused due to use of alcohol) of the policy under which

main claim is also denied. Mr.Ashok Kumar also hospitalized from 10.02.19 to 11.02.19 in Jindal

ENT Hospital and Medical Research Center, Ganganager with diagnosis of dilated Cariomyopathy.

As per repudiation letter of company, submitted documents indicate that the patient was admitted

for the ailment which is caused due to alcohol. As per policy any disease caused due to use of

intoxication (alcohol) is not payable. Hence claim is being denied under clause 4.5 of the policy.

However, it is seen that in discharge summary of 11.02.19 as well as in OPD slip dt. 18.02.19

submitted by company, treating doctor has marked ? before alcohol which suggest that it could not

definitely be conclude that problem of heart was related with alcohol intake, although the same may

be one of probable cause. Company not provided any concrete evidence of alcohol leading to

present disease either in first or second claim. As per complainant, company has paid his other

claim under same policy, although insurance company could not confirm the same during hearing.

However, treating doctor Dr.Sahil Jindal vide letter dt. 10.05.19 clarified that no reports have

confirmed that dilated cardiomyopathy was due to alcohol. As such company‟s decision of

repudiation of claims is not justified. Keeping in view all this, under both claims about which

complaint is filed, insurance company is directed to pay admissible claims, as per terms and

conditions of the policy within 30days of receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claims as per policy terms and condition

is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement of the

claim.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Ravi BhushanV/SThe United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ravi Bhushan

43, Ravinder Nagar Extn., Near Cheema Chowk,

Mitahpur Road, Jalandhar,

Punjab- 144014

Mobile No.- 8676936686

2. Policy No:

Type of Policy


5001002818P109953495

Group Health Ins. Policy

01.10.2018 to 30.09.2019



Indian Bank Assoc. A/c UCO Bank

Mr. Ravi Bhushan


5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Non settlement of claim

9. Amount of Claim Rs. 34357/-


11. Amount of relief sought Rs. 69214/-



2017





For the Complainant Mr. Ravi Bhushan, Complainant

For the insurer Ms. Mamta Bansal, Dy.Manager

15 Complaint how disposed Partial Award

16 Date of Award/Order 02.03.2020.

17) Brief Facts of the Case: On 26-08-2019, Mr. Ravi Bhushanhad filed a complaint that he undergone ‘ Inguinal Hernia Operation’ on

04032019 at Lajwanti Hospital, Jalandhar City and applied for medical reimbursement claim on 04.04.2019

with all required original papers through UCO Bank, Jalandhar Cantt, where he is serving as manager. On

30.04.19 M/s Heritage Health Insurance TPA raised 3 queries, out of which, one query was to provide the

original money receipt of Rs. 25000/- with pre printed receipt number as provided one is not acceptable.

On request, hospital issued cash receipt on their letter pad and told that they do not use ‘pre printer

receipt’ in their hospital. Said receipt and a certificate issued by hospital submitted to TPA but they raised

same query again. As per complainant, inspite of his various efforts to remove single query, his claim is still

pending at their end.



which was made available to this office on10.02.2019. The complainant was sent Annexure VI-A for

compliance, which reached this office on 03-10-2019.

As per SCN submitted by insurance company, patient Mr.RaviBhushan was admitted for right inguinal

hernia (reducable) in Lajwanti Hospital & Nursing Home, Jalandahr from 04.03.19 to 05.03.19 and

submitted reimbursement claim for Rs. 34357/-. On reviewing the claim documents, TPA found that some

required documents were not provided in the submitted documents by the claimant. So they have asked

for the same issuing query letter. Subsequently on receipt of the compliance from the claimant TPA had

admitted the claim for settlement of Rs. 26985/- making few deductions and settlement was credited to

insured on 17.10.2019. As per details of deductions provided:

a) Rs. 200/- bill- no supporting original prescription (Clause no. 5.E.1(IV) b) Rs. 828/- no GST bifurcation enclosed (clause no. 4.12) c) Rs. 329/- no GST bifurcation enclosed (clause no. 4.12) d) Rs. 592/- no GST bifurcation enclosed (clause no. 4.12) e) Rs. 1801/- no GST bifurcation enclosed (clause no. 4.12) f) Rs. 1912/- no GST bifurcation enclosed (clause no. 4.12) g) Rs. 1600/- - no details enclosed h) Rs. 200/- original report not enclosed.


a) Complainants argument : Insurance Company has paid claim very late and undue deductions

are made under the claim .

b) Insurers’ argument: Claim is settled as per terms and conditions 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


As per discharge summary, Mr. Ravi Bhushan, complainant remains admitted in Lajwanti Hospital and

Nursing Home, Jalandhar City from 04.03.19 to 05.03.19 with chief diagnosis of right Inguinal

Hernia(Reducable). He filed a claim for Rs. 34357/-. At the time of filing the complaint, there was some

dispute regarding pre printed receipt of Rs. 25000/- which is later on resolved. At the time of personal

hearing, complainant admitted that against total bill of Rs. 34357/- he received payment of Rs. 26985/-.

Insurance company provided the details of deductions made in the claim. On perusal of available

documents, it has been observed that deductions of Rs. 200/- has been made for no supporting original

prescription under clause 5.E.I(iv) and Rs. 200/- more is deducted under clause 5.E.I(ix) as original report

not enclosed. Further deductions of Rs.5462/- (828+329+592+1801+1912) is made as no GST bifurcation is

given. As per policy clause no. 4.12 of policy, expenses on purchase of medicines have to be supported by

bills/receipts/cash memos with valid GST no. of the issuer of such bills. As such, deductions are made as

per policy conditions. Besides this, as per insurance company, Rs. 1600/- is deducted as no details provided

for same. As per Complainant, he already submitted the details with insurance company on 22.10.19. He

also provided copy of details of Rs. 1600/- duly counter signed by hospital as an evidence of same. In lieu of

this, besides already paid claim amount, insurance company is directed to pay Rs. 1600/- to the

complainant as per policy terms and conditions towards full and final settlement of the claim within 30

days after the receipt of award copy.

AWARD


parties during the course of personal hearing, insurance company is directed to pay Rs. 1600/- to

the complainant as per terms and condition of policy, towards full and final settlement of the

claim.


Dated at Chandigarh on 2nd

day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Mohd. Islam V/SReligare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Mohd. Islam

H. No.- 539/7, St. No.-1, New Vishnu Puri Shiv

Puri Road, Ludhiana, Punjab- 141007

Mobile No.- 7837649786

2. Policy No:

Type of Policy


11561922

Group Care

25-10-2017 To 24-10-2018



Mr. Mohd. Islam


5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Payment of balance claim amount

9. Amount of Claim Rs.60,000/-





2017

Rule 13 (1)(b) – any partial or total

repudiation of claim by an insurer



For the Complainant Sh. Mohammad Islam

For the insurer Dr. Nisha Sharma, Manager

15 Complaint how disposed Agreement



On 20-08-2019,Mr. Mohd. Islam had filed a complaint against Religare Health Insurance Company

Limited that his claim for the hospitalization at DMC Ludhiana due to bone fracture under policy

no 11561922 from 16/04/2019 to 19/04/2019 has been settled for Rs.8330/- against his total claim

of Rs.60,000/- .The complainant has sought the intervention of this office for payment of balance

claim.


Gurugram, for Para-wise comments and submission of a self-contained note about facts of the

case, which was not received till hearing.

18).The complainant agreed to accept the offer of the insurance company during personal hearing that

they are ready to settle and pay claim amount of Rs.31900/- under policy number 11561922 without

interest and without deduction of any charges, which includes premium of the year 2018-19 & 2019-

20 with policy continuity benefits.

20) Accordingly an agreement was signed between the insurance company and the complainant

on 05/03/2020.

21) The complaint is closed with a condition that the company shall comply with the agreement

and shall send a compliance report to this office within 30 days of receipt of this order for

information and record.


day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Rajinder Singh V/SReligare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajinder Singh

378-R, Model Town, Yamunanagar, Haryana-

135001

Mobile No.- 9034265740

2. Policy No:

Type of Policy


11561922

Group Care

13-12-2018 To 12-12-2019



Mr. Rajinder Singh



6. Reason for repudiation Non disclosure of material facts


8. Nature of complaint Non Payment of Hospitalization Claim

9. Amount of Claim Not mentioned


11. Amount of relief sought Payment of claim



2017





For the Complainant Mr. Rajinder Singh

For the insurer Dr. Nisha Sharma




On19-08-2019, Mr. Rajinder Singh had filed a complaint against the Religare Health Insurance

company for denial of his reimbursement claim of hospitalization due to AC Vertigo,TIA and

stated that they submitted bills to Religare Company (Policy No 13419367) but the company

rejected the claim. In spite of various mails sent to insurer to recheck and do the needful, he did not

get any positive response.Complainant further stated that there is no previous history in medical

documents and is not taking any medicine for hypertension, neither in past nor in present. Religare

Investigator converted simple AC vertigo TIA into hypertension. The insurance company is making

just excuses not to clear the claim for this time not for future also. This is direct cheating with

customer.


Gurugram, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 07-01-2020. As per the SCN, they issued group mediclaim policy

bearing no 11561922 to Mr. Rajinder Singh covering him and his spouse with effect from 13th

December,2018 to 12th December ,2019 for a Sum Insured of Rs.5,00,000/-. During the currency of the

policy, the complainant approached the insurer with reimbursement claim for his hospitalization along

with post hospitalization charges at Gulati Hospital Yamuna Nagar from 23/02/2019 to 27/02/2019. The

complainant was diagnosed with AC Vertigo, TIA. On receipt of the claim form and relevant documents,

insurer came to know that

As per doctor’s Progress notes dated 27/02/2019, the complainant was a known case of Diabetes Mellitus and Hypertension.

As per discharge summary his blood pressure was 166/100 Accordingly the respondent company issued two query letters dated 18/03/2019 to seek

information about exact duration and past history of present illness with 1st consultation paper

and past treatment record of Diabetes Mellitus, Hypertension and pre hospitalization OPD record

of past 1&2 two years and in order to appropriately analyze the claim, also triggered a claim

investigation .On perusal of documents, the insurer came across following facts:

As per the Questionnaire for the insured dated 27/03/2019, the complainant himself

accepted that he has been suffering from hypertension since August,2017 that is much prior

to policy inception and has been receiving treatment from Dr. VimalMiglani and taking

tablet Amlog 5 mg.

As per the treating doctor questionnaire answered by DR. J.K.Gulati dated 27/03/2019. The insured is a known case of Hypertension since August, 2017.

It is clearly established that insured is a Known case of Hypertension since August, 2017 since prior to his

policy commencement date. The same was not disclosed at the time of proposal, Hence the insurer denied

the reimbursement claim vide denial letters dated 29/03/2019 as per clause 5.2 i.e. Non Disclosure of pre

existing ailments i.e. Hypertension at the time of proposal as per policy terms and conditions .Due to

typographical error, incorrect clause (clause 7.7) has been mentioned in denial letter, the correct clause is

5.2.

The declaration made by the complainant on behalf of the insured regarding the following question asked

in the proposal form was as under:

“Has anyone been diagnosed /hospitalized or is currently under investigation for cancer/Diabetes/stroke/heart disease/kidney disease/liver disease/hypertension (Blood Pressure? The complainant answered NO to these questions. Had the correct health status of the proposed life to be insured been disclosed by the complainant at the inception of the policy, then insurer would have issued policy on different terms and conditions. The claim was rightly denied as pee clause 5.2 of the policy terms and conditions. The complainant was sent Annexure VI-A for compliance, which reached this office on 16-09-2019.


a) Complainant’s argument:Complainant stated that the claim has been rejected by insurance

company on flimsy grounds and he requested for payment of his claim.

b) Insurers’ argument:Insurance Company stated that the claim has been rejected as per

terms and conditions of policy.


Rules, 2017.





On perusal of various documents available in file including the copy of complaint filed by

complainant, copy of discharge summary, copy of SCN submitted by insurance company and

also consideration of submissions made by both complainant and insurance company at the

time of personal hearing, it is seen that the claim filed by complainant for his hospitalization at

Gulati hospital, Yamuna Nagar for the period 23.02.2019 to 27.02.2019 with symptoms of AC

vertigo, TIA has been denied by insurance company vide letter dated 29.03.2019 on the ground

of non-disclosure of material facts relating to pre-existing hypertension. The Blood Pressure at

the time of hospitalization was 166/100 which proves that giddiness and vertigo, the present

symptoms were because of high BP. He was managed conservatively & discharged on

improvement.

On perusal of proposal form it is seen that said fact about his pre-existing hypertension was not

disclosed at the time of taking policy. The present cause of hospitalization was within 3 months

of inception of policy on 13.12.2018. The fact about hypertension has also been admitted by

complainant on Questionnaire dated 27.03.2019. In view of above discussion it is abundantly

clear that the complainant having not disclosed the material facts relating to PED and his

hospitalization being because of hypertension only, the repudiation of claim by insurance

company is in order. The case is dismissed.

AWARD


parties during the course of personal hearing, the case is dismissed.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Abhishek Bhardwaj V/SThe Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Abhishek Bhardwaj

S/o Sh. Suresh Kumar Bhardwaj,

Bhardwaj Niwas, Opp.- HPPWD Office, Third

Circle, Chowk Bazar, Solan, Himachal Pradesh-

173212

Mobile No.- 8219493281

2. Policy No:

Type of Policy


510000/48/2019/1719

Group Mediclaim Insurance

06/10/2018 to 05/10/2019



Inox Wind Limited

Abhisekh Bhardwaj



6. Reason for repudiation Not covered under policy on the date of

hospitalization.


8. Nature of complaint Non Payment of mediclaim



11. Amount of relief sought Rs.1,50,000/-



2017





For the Complainant Sh. Abhisekh Bhardwaj

For the insurer Sh. P.K Kalra, Dy. Manager




On 23-09-2019, Mr. Abhiseikh Bhardwaj had filed a complaint against the oriental

insurance company Ltd for rejection of his medicalim. The complainant stated that he was

admitted as full time employee of Inox Wind Limited on 19th

July 2018, being a full time

employee guaranties him a medical insurance cover from the date of joining. The

complainant was admitted in Artemies Hospital Gurugram from 27th

February 2019 to 4th

March 2019 and after discharge went to his town for recovery and returned to office on

29/03/2019 after treatment with the required documents for mediclaim reimbursement. The

complainant then came to know that he was never enrolled in the TPA of the insurance

company with no fault of his as it is the duty of the HR deptt of the company to enroll the

employees at the beginning of tenure. Hence, there was delay in submission of documents

for the reimbursement and the single point of contact person for this, Mr. Shivam Pal told

that the claim has to be submitted within 30 days from the date of discharge. The

complainant submitted all the documents in the Gurugram office of TPA on 17th

of

April,2019 with assurance from Mr. pal that documents shall be submitted and mailed on

10/07/2019 that claim will be processed .But very next date informed that claim was

rejected on the ground that there was delay in submission of documents. On taking up the

grievance in the consumer helpline, the reply provided by the oriental insurance company

for the rejection of claim is that at the time of hospitalization, complainant was not a policy

holder which contradicts the earlier reason provided by Mr. Pal. The TPA card of the

insurance company states that complainant is enrolled for the services from 5th

October

2018 which totally negates the lies made by the insurance company on the consumer

helpline.


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 03/03/2020.

As per SCN, the policy bearing no.510000/48/2019/1719 of group medicalim tailor made insurance

policy schedule was issued in favour of INOX WIND Limited for the period from 06.10.2018 to

05.10.2019. The policy covered Risk- the total number of persons covered under the policy are

3326(1509 employees and 1817 dependents). The insurance under this policy us subject to

conditions, clauses, warranties and endorsements. The clause 6 of the schedule says that –All

additions & deletions of employees covered at pro rata premium subject to no claim reported and

clause 7 of the policy stated that new employees along with their dependents and newly wedded

spouse and new born child will be covered from the date of (joining, marriage and DOB) subject to

monthly declaration and availability of sufficient balance in CD account on effective date. The

insuranceunder this policy is covered subject to strict compliance of the terms, conditions, clauses,

warranties and schedule mentioned under the policy. It is pertinent to mention that the

complainant has been enrolled in the list of insurance coverage on April 2019and he was admitted

in the hospital on 27/02/2019 and discharged on 04/03/2019. During the hospitalization and

treatment period the complainant was not insured or not covered under this policy. The

complainant himself admitted that he is not aware about the insurance coverage and also knows

through his HR deptt. that he is not covered under the insurance policy. There is a grievance if any

has occurred against the HR department only not against the insurer. Hence the company is not

liable to pay the compensation or claim amount.



a) Complainant’s argument: Claim has been denied by the insurer in spite of being

duly covered under the group Mediclaim policy taken by his employer.

b) Insurers’ argument:During the hospitalization and treatment period the complainant

was not insured or not covered under this policy


Rules, 2017.




21) Result of Personal hearing with both parties (Observations & Conclusion): On perusal of

the copy of the complaint, SCN submitted by the insurer, policy copy, policy endorsement schedule

and submission made by both the parties during personal hearings, it observed that mediclaim of

the complainant has been denied by the insurer on the ground that during the hospitalization and

treatment period the complainant was not insured or not covered under this policy. On the other

hand, the complainant stated that he was admitted as a full time employee of the insured Indo

Wind Limited on 19th July, 2018 and being a full time employee guarantees him a medical

insurance cover from the date of joining. His claim for hospitalization in Artemis Hospital,

Gurugram due to typhoid from 27th February, 2019 to 4th March, 2019 has been denied by the

insurer in spite of being duly covered under the group mediclaim policy taken by his employer Inox

Wind Limited. The basic issue before me is to decide whether the complainant was duly covered

under the group mediclaim policy on the date of hospitalization and is the denial of hospitalization

claim of complainant is justified as per policy. The insurer has placed on record the request mail

dated 22/04/2019 received from the insured employer for inclusion of complainant along with

other employees under GMC policy no. 510000/48/2019/1719. Accordingly the insurer issued an

endorsement bearing no 510000/48/2019/1719-007 on 24/04/2019 covering the complainant

along with other employees with effect from 05/03/2019. It is abundantly clear that the patient

was not covered under the group mediclaim policy on the date of hospitalization.. As such, the

decision of insurer about denial of hospitalization claim is in order and does not warrant any

interference. The complaint is dismissed being devoid of merits.

ORDER


parties during the course of personal hearing, no relief is granted to the complainant.

Hence, the complaint is treated as closed


day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mrs. Manjit Kaur V/S The Oriental Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-050-1920-0335

1. Name & Address of the Complainant Mrs. Manjit Kaur

House No.- 291, Sector- 16A,

Chandigarh- 160015

Mobile No.- 9815930243

2. Policy No:

Type of Policy


231102/48/2016/769


01-01-2016 To 31-12-2016



Govt. of Punjab, Deptt of Health &family

welfare.

Mrs. Manjit Kaur



6. Reason for repudiation Delayed submission of papers


8. Nature of complaint Non Payment of Medi claim

9. Amount of Claim Rs.4,07,215/-


11. Amount of relief sought Rs.4,07,215/- (Sum Insured Rs. 3,00,000/-)



2017





For the Complainant Mrs. Manjit Kaur

For the insurer Ms. Renu Garg , Sr.D.M



17) Brief Facts of the Case:On 02-09-2019, Mrs. Manjit Kaur had filed a complaint against the oriental

insurance company limited for non settlement of her knee surgery claim. The complainant submitted that

Punjab Health system Corporation has taken mediclaim policy from the oriental insurance company limited

vide policy no 231102/48/2016/769. The policy is for one year from 01/01/2016 to 31/12/2016. The

complaint submitted that she had taken the treatment at Fortis Hospital Mohali for knee replacement. The

hospital provided the treatment. All the medical bills submitted to TPA but they rejected the claim under

30 days clause. Bills were timely deposited by the complainant in her office but they referred late. Total

amount of claim is Rs.407215/-



which was made available to this office on 04/11/2019. As per the SCN, the insurer submitted that Mrs.

Manjit Kaur is enrolled under Punjab Government Employees and Pensioners health insurance scheme

under MDID-NO-15-09815930243 for the period 01/01/2016 to 31/12/2016 for Sum insured of Rs.3 Lacs

on floater basis as per notification of Punjab state Govt. no. 21/28/12-5HB5/268 dated 20/10/2015.The

policy was issued to the state government covering employees and pensioners for cashless health

insurance scheme for the period 01/01/2016 to 31/12/2016.Under the scheme, employees were enrolled

by their mobile numbers provided in their enrollment form to identify them with their unique identification

number and issue E-card to avail cashless services throughout Punjab/Mohali/Chandigarh in

empanelledhospital under the scheme. Beneficiary never submitted her claim either to insurance company

or TPA. Grievance letter of the beneficiary confirms the same. The scheme was implemented for the period

1st January, 2016 to 31st December, 2016. Since the bills were not submitted within time limitation of the

policy period afterwards beneficiary has to submit the bills to state govt.



a) Complainant’s argument: All the medical bills were taken to TPA office of insurer but

they rejected the claim under 30 days clause.

b) Insurer’s argument: The complainant never submitted her claim either to insurance

company nor TPA. Since the bills were not submitted within time limitation of the policy

period afterwards the beneficiary has to submit bills to state govt.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman

Rules, 2017.





On perusal of various documents placed on record including the copy of the complaint, SCN of

insurer and submission made by both the parties during personal hearing, it is observed that

complaint has been lodged against the oriental insurance company limited for non settlement of

hospitalization claim of complainant due to knee surgery at Fortis Hospital Mohali. According

to complainant, the claim was submitted to TPA but they refused to entertain the case under

reimbursement of PGEPHIS on 04/04/2019. On the contrary, the representative of the insurer

stated that Mrs. Manjit Kaur had never submitted her claim either to the insurance company or

TPA. But admitted that she is enrolled under Punjab Government Employees and Pensioners

health insurance scheme under MDID-NO-15-09815930243 for the period 01/01/2016 to

31/12/2016 for Sum insured of Rs.3 Lacs on floater basis as per notification of Punjab state

Govt. no. 21/28/12-5HB5/268 dated 20/10/2015. It is found that complainant instead of filing

the claim for her hospitalization at Fortis Hospital from 05/10/2016 to12/10/2016 with the

insurer submitted the claim bill to her deptt on 26/11/2016 and was informed by state health

agency Punjab vide letter dated 02/08/2019 that bills pertains to the period of treatment from

05/10/2016 to 12/10/2016.Therefore,the bills for the bills for the treatment for the year 2016 as

per policy terms and conditions the claim has to be submitted to MD India TPA Pvt. Ltd within

30 days i.e late submission from date of discharge. The complainant instead of sending the

original bill with his grievance representation to the insurer enclosed it with the complaint made

to this office copy of which was provided to the insurer. It is established beyond doubt that

complainant had timely filed the reimbursement claim but with the wrong authorities. Since the

treatment taken by the beneficiary falls within the policy period, the insurance company is

directed to settle the reimbursement claim within 30 days as per terms and conditions of the

policy.

AWARD


parties during the course of personal hearing, admissible sum is hereby awarded to be paid by the

Insurer to the Insured, towards full and final settlement of the claim.



day of March, 2020

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. KrishanSofat V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. KrishanSofat

House No.- 111/23, St. No.- 3, Khalsa School

Road, Khanna, Punjab- 141401

Mobile No.- 8427318900

2. Policy No:

Type of Policy


530000/48/2019/146




MalwaGramin Bank

ReetuSofat


5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Short payment of mediclaim


10. Date of Partial Settlement Not mentioned

11. Amount of relief sought Rs50,000/-(Short payment Rs.14714/-)



2017





For the Complainant Sh. KrishanSofat

For the insurer Sh. P.K. Kalra Dy. Manager




On 10-09-2019, Mr. KrishanSofathad filed a complaint against the oriental insurance company

Ltd for the short payment of medicalim. The complainant stated that his wife who is covered

under medicalim policy no 530000/48/2019/146 got operated at R.G stone and Super

Specialty Hospital Ludhiana on 11/03/2019.The cashless treatment was paid by the Raksha

TPA. After getting discharge from hospital, the complainant submitted claim of Rs.28714/- for

pre and post hospitalization on 11/04/2019 along with each and every document and proper

verification by hospital with claim reference no 55651920046606. The claim was passed for

Rs.14714/- and no satisfactory reply was given for short claim payment even after three

months of taking up the matter with them.



which was not received.



a) Complainant’s argument: The insurance company has neither provided him the details

of deductions made from the claim the claim bill nor paid pre hospitalization expenses.

b) Insurer’s argument: The claim has been paid as per terms and conditions of the policy

but can be reconsidered on receipt of details.

19) Reason for Registration of Complaint: Within the scope of the Insurance Ombudsman

Rules, 2017.





On perusal of the copy of the complaint and submission made by both the parties during

personal hearing, it has been observed that complaint is with regard to deduction of Rs.14714/-

made by the insurer from the hospitalization claim bill settled by the insurer. The complainant

alleged that insurer has not provided him the details of deductions made from his claim of

Rs.28714/- and also not paid pre hospitalization and other expenses which otherwise are

payable as per policy terms and conditions. The representative of the insurance company during

the personal hearing agreed to reconsider the deductions made from the claimed bill including

pre hospitalization expenses subject to submission of details. As such, the complainant is

directed to submit the information/ details of bills as required by the insurer within 15 days

from the date of receipt of copy of award and insurer to pay the admissible balance claim

amount as per terms and conditions of the policy within 15 days from the receipt of details.

AWARD


parties during the course of personal hearing, admissible balance claim amount is hereby awarded

to be paid by the Insurer to the Insured, towards full and final settlement of the claim.


Dated at Chandigarh on 23rd

day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Darshan Singh ReehalV/SThe United India Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Darshan Singh Reehal

House No.- 811, Phase-2, Urban Estate, Focal

Point, Ludhiana, Punjab- 141010

Mobile No.- 9464878309

2. Policy No:

Type of Policy


MD-15-0030025331

Group Policy

01.11.16 to 31.10.17



IBA A/c Central Bank of India

Mr. Darshan Singh Reehal





8. Nature of complaint Nonpayment of bill dt.23.03.17 & admission

charges.

9. Amount of Claim Rs. 4045/50


11. Amount of relief sought Rs.2045/50 + Rs.2000=Rs.4045/50 + cost +

interest



2017





For the Complainant Sh.Darshan Singh Reehal, Complainant

For the insurer Ms. Shweta Dhiman, AO

15 Complaint how disposed Partial award

16 Date of Award/Order 17.03.2020.


On 23-09-2019, Mr. Darshan Singh Reehalhad filed a complaint vide which he informed that he is

retired employee of Central Bank of India and had retired on 28.02.2007 and covered under IBA

member banks medical scheme for officers/employees. Under the scheme, he himself and his

spouse insured for sum insured of Rs. 3 lacs, which is being renewed up to date.

Under claim no. 1, complainant had submitted full set of claim for Rs. 2045/50 dt. 23.03.17 for

domiciliary treatment from CMC Hospital, Ludhiana through their Jamalpur Ludhiana Branch,

where he was having his pension account on 25.03.17. The branch had sent the same to R.O.

Ludhiana for onward forwarding to TPA, which was lost in transit. He again sent the full set of

claim duly signed by the treating doctor/hospital through R.O.Ludhiana on 01.06.17 to which TPA

later on replied as „under process‟ in reply of his querry. Complainant again sent the set of claim

(duplicate) on 18.07.17 and also on 23.10.17. But up till now neither the claim has been paid nor

refused with any reason so far.

Under claim no.2, complainant was admitted in Fortis Hospital, Ludhiana on two occasions. In first

case, final bill of Rs. 59436/- were submitted and Rs.4244/90 were deducted in the same. In second

case, Rs. 2650/- is deducted out of final bill of Rs. 28564/08. Deductions included admission

charges of Rs. 1000/- each not sanctioned in the final approval of the hospital. Clause 3.13 of the

policy schedule states that all taxes, surcharges, service charges, registration charges, admission

charges, nursing and administration charges to be payable. But these were not paid by TPA.


Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 11.03.2020. The complainant was sent Annexure VI-A for compliance,

which reached this office on 15-10-2019.

As per SCN received from insurance company, Mr. Darshan Singh Reehal, retiree is covered under

group mediclaim policy of Central Bank of India for the period 01.11.16 to 30.10.17. Complainant

Mr.Reehal had lodged different claims out of which under claim no. MD13289598, for Rs. 2045/-

claim closed as query reply not received for all original documents with original prescription.

Claim no. MD13045513 related to hospitalization from 29.01.17 to 01.02.2017 for Rs. 59346/- was

lodged. The claim is processed and paid for Rs. 51101/- on 09.03.17. Mr. Reehal also submitted an

additional claim for same hospitalization for Rs. 7704/-. The claim is processed and paid for Rs.

3459/- on 18.04.17. Rs.4245/- deducted as paid receipt was not available. Further claim of Fortis

Hospital, Ludhiana for hospitalization from 10.07.17 to 11.07.17 related to fracture of distan

phalanx was lodged. Out of cashless claim for Rs. 26214/-, company processed and paid Rs.

19286/- on 24.08.17. Complainant also submitted an additional claim for same hospitalization for

Rs. 3391/- and Rs. 2392/- is paid out of this on 19.09.17. Rs. 949/- is deducted as no supporting

documents/no bill received by company. Rs.50/- deducted for non medical expenses, which are not

payable.


a) Complainants argument:Company has not settled his claim for Rs.2040/50 for

domiciliary treatment inspite of sending documents again and again. In other claims,

twice admission charges of Rs. 1000/- each is not sanctioned by company which are

otherwise payable as per policy conditions.

b) Insurers’ argument:They have not received original documents of claim from bank

authorities, so unable to process the claim.


Rules, 2017.





On perusal of various documents available in file and submissions made by both complainant

and insurance company during hearing, it is seen that in first claim, Mr. Darshan Singh Reehal,

complainant has submitted original documents to related branch of bank who forwarded the

same to their high office for onward transmission to insurance company. But as per insurance

company, they have not received original claim documents from bank, which are essential for

settlement of claim. There is no documentary evidence on record that original documents were

sent to insurance company by bank, as such company‟s decision of nonpayment of claim is in

order. In other complaint regarding nonpayment of admission charges in claim dt. 29.03.17 and

claim dt. 24.08.17, it is observed that as per clause 3.13 of policy, all taxes, surcharges, service

charges, registration charges, admission charges, nursing and administration charges to be

payable. As such, company has wrongly deducted admission charges of Rs. 1000/- each in two

relevant claims. Therefore, insurance company is directed to pay Rs 2000/- as per terms and

conditions of policy within 30 days from the receipt of award copy.

AWARD


parties during the course of personal hearing, Rs 2000/- 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.



day of March 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Sandeep Singh V/SThe United India Insurance Co. Ltd.


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

Bank of Baroda, Baddi,

Himachal Pradesh- 173208

Mobile No.- 9782228000

2. Policy No:

Type of Policy


500100/28/18/P109892371

Group Health Policy

01.10.18 to 30.09.19



Bank of Baroda

Ms. Amandeep Kaur


5. Date of Repudiation 10.09.2019

6. Reason for repudiation Under clause 3.6


8. Nature of complaint Non payment of claim






2017





For the Complainant Mr.Sandeep Singh

For the insurer Ms.ShwetaDhiman, A.O.



17)Brief Facts of the Case:

On 19-10-2019, Mr. Sandeep Singh had filed a complaint that he had submitted a medical claim

through TPA MD India Pvt. Ltd., which is rejected by company after much delay. Complainant is an

employee of Bank of Baroda and requested for settlement of his claim.

On 30-10-2019, the complaint was forwarded to The United India 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 09.03.2020. The complainant was sent

Annexure VI-A for compliance, which reached this office on 11-11-2019.

As per SCN submitted by insurance company, they issued a group mediclaim policy to Bank of

Baroda Employees Policy for period 01.10.2018 to 30.09.2019. Mr. Sandeep Singh, had submitted

a reimbursement claim for Rs. 13475/- for his dependent spouse Amandeep Kaur for OPD

treatment of pregnancy. On scrutiny of claim documents it is observed that 26 years female was

on treatment for maternity. The treatment is taken on OPD basis. As per policy clause no. 3.5 (ii)

pre-natal and post-natal charges in respect of maternity benefit are covered under the policy upto

30 days and 60 days only, unless the same requires hospitalization. Hence the claim is repudiated

under clause 3.5 (i).


a) Complainants argument :Company has not paid their genuine claim, and denied it on

flimsy grounds.

b) Insurers’ argument:Claim is repudiated as per policy terms and conditions related to

maternity clause.


Rules, 2017.





On perusal of related documents, and after listening submissions made by both parties during

personal hearing, it is observed that insurance company denied claim of Rs. 13475/- related to OPD

treatment of insured Ms. Amandeep Kour. As per insurance company, claim is denied under terms

and conditions of policy which states that pre-natal and post natal charges in respect of maternity

benefit are covered under the policy upto 30 days and 60 days only. Complainant admitted in hearing

that required hospitalization of more than 24 hrs was not performed in this case. It is seen that claim

comes under maternity expenses condition no. 3.5 (ii), which states that pre-natal and post natal

charges in respect of maternity benefit are covered under the policy upto 30 days and 60 days only,

unless the same requires hospitalization. Keeping in view the facts of the case, decision of insurance

company to repudiate the claim, not requires any interference. Hence, the said complaint is hereby

dismissed and no relief is granted.

AWARD


parties during the course of personal hearing, the said complaint is hereby dismissed on merits.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. Hira Lal V/SThe United India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-H-051-1920-0420

1. Name & Address of the Complainant Mr. Hira Lal

C/o House No.- 1141, Sector-8, Hospital Block,

Faridabad, Haryana- 121006

Mobil No.- 9871818171

2. Policy No:

Type of Policy


2221002818P115387653

Group Health Policy

28-02-2019 to 28-02-2020



Mr. Hira Lal



6. Reason for repudiation OPD patient, claim for diagnostic purposes


8. Nature of complaint Repudiation of claim






2017





For the Complainant Mr. Hira Lal, Complainant

For the insurer Ms. Mamta Bansal, Dy. Manager



17) Brief Facts of the Case:On 09-10-2019, Mr. Hira Lal had filed a complaint vide which he informed that

he is 62 yrs senior citizen and had got annual health check up at Asian Hospital Faridabad on 29.03.19 and

was diagnosed with fatty lever, bad cholesterol etc. for which consultant doctor had prescribed some

medicines which he was regularly taking up. He got admitted in Metrol Heart Instiute, Fardiabad on 10th

June 2019 due to severe pain in right shoulder under the senior most Neuro-surgeon Dr. S.Panduranga.

After taking all brief history he suggested for admission so that proper as well as persistent medication

could be done. After 3 days medication and diagnosis/observation as a indoor patient in hospital doctor’s

team was satisfied for discharging him on 13.06.19. The said hospital had submitted a cashless bill for Rs.

36792/- which was not approved by giving the reason that as patient is mainly admitted for investigation

only which may be managed on OPD basis. He had claimed for reimbursement of bill for Rs. 38204/-

(including pre & post expenses) which was not approved by giving the reason, the policy does not cover the

claim. As per complainant, under the circumstances, an annuitant is not responsible anywhere to indulge

himself either to force doctors team for investigation or hospitalization which comes purely under their

jurisdiction. He requested for payment of claim of his mediclaim bill for Rs. 38204/- as he wholly

dependent upon his pension and having a mental retarded dependent daughter of 35 years to look after.

On 28-10-2019, the complaint was forwarded to The United India 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 09.03.2020. The complainant was sent Annexure VI-A for compliance,

which reached this office on 26-11-2019.

As per SCN, the claim is not admissible since the expenses incurred are as an OPD patient and the

hospitalization is for less than 24 hours and which does not qualify for exception mentioned in the policy as

per terms and condition of the policy. Further the claim expenses incurred for diagnostic purpose not

consistent with or incidental to the diagnosis and treatment of positive existence of any ailment is

exclusion under the policy terms and conditions. In view of clause 4.11, the claim is not payable, hence

repudiated.


a) Complainants argument :Complainant requested that insurance company has repudiated

claim on flimsy ground which are not consistent with policy terms and conditions. He

requested for payment of his claim.

b) Insurers’ argument:Insurance Company on other hand reiterated the stand taken in SCN

and requested for dismissal of complaint as repudiation is based on logical grounds as per

terms and conditions of policy.


Rules, 2017.





On perusal of various documents available in file including the copy of complaint,SCN of insurance company and submissions made by the both parties during personal hearing, it is observed that hospitalization claim of Mr.Hira Lal is repudiated by insurance company vide repudiation letter dt. 21.11.19 under which two reasons were given for same. As per this letter, claim expenses incurred for diagnostic purposes not consistent with or incidental to the diagnosis. Regarding same, concerned hospital vide letter dt. 25.06.19 clarified that patient Mr.Hira Lal was admitted in Metro Hospital on 10th June 2019 under neuology department for his acute complaints of pain in right shoulder radiating from cervical region. His admission was quite justified because he had been on OPD treatment from outside for quite some time but was not getting any relief. As per this letter, he was advised to be kept hospitalized so that he could be monitored persistently for any progressive neurological deficit and to be treated with injectable drug régime which is only possible if patient is kept hospitalized. During hospital stay he showed some extended symptoms of vertigo, dizziness and ataxia which eventually prolonged his hospitalization. Further as per repudiation letter,claim expenses incurred are as on OPD patient and hospitalization is for less than 24 hrs. On the contrary, as per discharge summary complainant remain admitted in Metro Heart Institue with Multispecialty, Faridabad from 10.06.19 to 13.06.19, it shows the poor observation on the part of insurance company, reflects the prejudice mindset to reject the claim. As such, repudiation of claim of

complainant by company is not justified. Keeping in view the facts of the case, insurance company is directed to pay admissible claim to insured as per terms and conditions of the policy within 30 days of 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, admissible 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.



day of March, 2020.

D.K. VERMA

INSURANCE OMBUDSMAN




Case of Mr. BML Sharma V/SThe New India Assurance Co. Ltd.


1. On 01-11-2019, Mr. BML Sharma had filed a complaint in this office against The New

India Assurance Co. Ltd for not settling the health claim. The required documents were

submitted to the insurance company but the insurance company did not settle the

health claim under policy no. 120700/34/19/04/00000003.

2. This office pursued the case with the insurance company to re-examine the complaint

and they agreed to reconsider the claim.

3. Mr. BML Sharma confirmed telephonically that his complaint has been resolved by

insurance company and he has received payment of his claim and wants to withdraw his

complaint from this forum.

4. In view of the above, no further action is required to be taken by this office and the

complaint is disposed off accordingly.

Dated : 23.03.2020 (Dr. D.K. VERMA)

PLACE: CHANDIGARH INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERY

(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M VASANTHA KRISHNA

Case of Mr B Srinivasan Vs The Oriental Insurance Co. Ltd

COMPLAINT REF: NO: CHN-H-050-1920-0488

Award No: IO/CHN/A/HI/0222/2019-2020

1. Name & Address of the Complainant

Mr B Srinivasan Plot No 139, I Sector, 7th Street, K K Nagar, Chennai 600078

2. Policy No: Type of Policy Duration of policy/Policy period Sum Insured (SI)

411600/48/2019/808 Happy Family Floater 2015 Policy 24/07/2018-23/07/2019 INR 6,00,000

3. Name of the insured Name of the policyholder/Proposer

Mr B Srinivasan Mr B Srinivasan

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

5. Date of Repudiation/short settlement

06/08/2019

6. Reason for Repudiation/short settlement

Pre-existing disease (PED) exclusion

7. Date of receipt of the Complaint 29/11/2019

8. Nature of complaint Non- settlement of claim

9 Date of receipt of consent ( Annexure VIA)

06/01/2020

10 Amount of Claim INR 5,05,985

11

Amount of Monetary Loss (as per Annexure VIA)

Not furnished

12. Amount paid by Insurer if any Nil

13. Amount of Relief sought (as per Annexure VIA)

As per policy eligibility

14.a. Date of request for Self-contained Note (SCN)

18/12/2019

14.b. Date of receipt of SCN 07/01/2020


Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of hearing/place 19/02/2020, Chennai


For the Complainant Mr B Srinivasan

For the insurer Mr S M Hamesh Kumar

18. Complaint how disposed By Award

19. Date of Award/Order 12/03/2020


ComplainantMr B Srinivasan, has availed respondent insurer‟s Happy Family Floater

Policy on 24/07/2017 and has been continuously renewing it and the subject policy period

is 24/07/2018 to 23/07/2019 with sum insured of INR 6 lacs. Hewas admitted in Vijaya

Hospital, Chennai on 04/06/2019 and undergone Coronary angiography on 05/06/2019

followed by Off Pump Coronary Artery Bypass Graft (CABG) surgery on 12/06/2019.

Reimbursement claim of INR 5,05,985 preferred by him for his treatment was repudiated

by insurer on the ground that it was for a complication of the declared pre-existing

Diabetes Mellitus for which the applicable waiting period is 48 months whereas the policy

was in its second year. Aggrieved by the repudiation of the claim, complainant

represented the matter to insurer pointing out that he has been covered earlier by his

employer M/s Areva T & D from 01/07/2013. Since there is no reply from them, he has

approached this Forum for relief.

21)a) Complainant’s submission:

Complainant was working as a Sales and Business Development Officer in Areva T & D

and he, his spouse and dependant parents were covered under Group Medical insurance

Scheme offered by his employer and the available details of policies submitted to insurer

for reconsideration are as under

Policy No Period of Insurance

500300/48/13/41/00000046 01/07/2013-30/06/2014

5003002815P105438184 01/07/2015-30/06/2016

5003002816P106101637 01/07/2016-30/06/2017

Treating doctor G Rangaprasad vide his certificate dated 12/07/2019 confirmed that there

is no history of cardiac ailment in the past and the current condition is an acute one.

Hence claim is payable and Forum‟s intervention is requested for settlement of the same.

b) Insurer’s contention:

Complainant has availed Happy Family Floater Policy covering self, spouse and

dependent child on 23/07/2017 by declaring Diabetes Type II as PED for himself. The

policy has been issued with period of insurance as 24/07/2017-23/07/2018. Complainant

has renewed the policy in time thereafter. On 04/06/2019, during the second policy period,

he was admitted in Vijaya Hospital, Chennai and undergone Coronary angiography and

CABG surgery for treatment of heart disease. As diabetes is a PED as declared by the

complainant and the current treatment for heart disease is a complication of diabetes, the

claim was repudiated by invoking clause 4.1 of the policy which reads as under

“The Company shall not be liable to make any payment under this policy in respect of any

expenses whatsoever incurred by any Insured Person in connection with or in respect of:

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. Pre-

existing Diseases shall be covered only after the Policy has been continuously in force for

48 months.”

The clause further says that this exclusion shall also apply to any complication(s) arising

from Pre existing Diseases. Such complications will be considered as part of the Pre

existing health condition or Disease.

Complainant submitted a certificate dated 12/07/2019 from the treating doctor G

Rangaprasad wherein the doctor has confirmed that the insured patient is diabetic since 4

years and there is no history of cardiac ailment in the past. Hence a second opinion was

obtained from Dr T R Shyamraj of Raksha TPA who has stated that the complainant is a

case of Diabetes Mellitus (DM) for the past 4 years and HBA1C reading of 11.3 confirms

the presence of uncontrolled DM. Present claim is for CABG for treatment of Coronary

Artery Disease (CAD). As per exclusion clause 4.1 of the policy, complications of PEDs

are also excluded. More over treating doctor didn‟t deny the relationship between DM &

CAD. There is only a general mention that CAD is a new disease.

Hence repudiation of the claim under PED exclusion is just and right.

22)Reason for Registration of Complaint: - Rule 13(1)(b)of the Insurance Ombudsman

Rules, 2017, which deals with” Any partial or total repudiation of claims by the life insurer,

General insurer or the health insurer”.

23)The following documents were placed for perusal.

Written Complaint dated 28/11/2019 to the Insurance Ombudsman

Claim repudiation letter of the insurer dated 06/08/2019

Complainant‟s representations dated 06/09/2019 & 18/11/2019 to the Insurer

Insurer‟s response dated 26/11/2019

Consent (Annexure VI A) submitted by the Complainant

Proposal form dated 23/07/2017

Copy of Policy, terms and conditions

Claim form

Self- Contained Note (SCN) of Insurer dated 07/01/2020

Happy Family Floater Policy – 2015 with terms and conditions

Discharge Summary of Vijaya Hospital, Chennai

Treating doctor‟s certificate dated 12/07/2019

Investigation report of the TPA dated 11/07/2019

Opinion of Dr T R Shyamraj vide E mail dated 22/11/2019

24) Result of hearing with both parties (Observations & Conclusion)

1. The issue to be decided is whether CAD for which the complainant has undergone

hospitalization is a complication of already declared PED, DM. If yes, insurer‟s

repudiation is in order since PED exclusion applies to complications of PEDs as

well.

2. Complainant‟s HbA1C level of 11.3 points to uncontrolled DM. He has submitted a

certificate from treating doctor G Rangaprasad who has certified that there is no

history of cardiac ailment in the past but he didn‟t certify that there is no relation

between DM and CAD. Hence Forum concludes that CAD is a complication of DM.

3. Complainant submitted details of previous group insurance policies of his erstwhile

employer under which he was covered. But it is observed that while the last group

policy expired on 30/06/2017, he availed insurance in his individual capacity from

the respondent insurer, only from 24/07/2017 after a gap of 23 days. Hence the

insurance was not continuous. Moreover, there was no porting. The relevant

portion of the policy clause 4.1, relating to relaxation of waiting period reads as

below.

For the purpose of applying this condition, the date of inception of the first

indemnity basedhealth Policy taken shall be considered, provided the renewals

have been continuous andwithout any break in period, subject to portability

condition.

Hence the waiting period for PED cannot be waived based on his previous

coverage.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made during the course of hearing by both the parties, it is established that the

repudiation of the claim by insurer is in order. Hence, the Forum is not inclined to

intervene in the decision of the insurer.

Thus the complaint is Not Allowed.

25) If the decision of the Forum is not acceptable to the Complainant, he is at liberty to

approach any other Forum/Court as per laws of the land against the respondent insurer.

Dated at Chennai on this12th day of March 2020

(M Vasantha Krishna)

INSURANCE OMBUDSMAN FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

PROCEEDINGS BEFORE




Case ofMr S Ramanathan Vs Reliance General Insurance Company Limited

COMPLAINT REF: NO: CHN-H-035-1920- 0508

Award No: I0/CHN/A/GI/0225/2019-2020


Complainant Mr S Ramanathan covered under respondent insurer‟s RGI-BOI

SwasthyaBima policy has preferred a claim of INR 82,000 towards the expenses incurred


Mr S Ramanathan 412 Agraharam, Thiruvisanallur 612105

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

12031928451000048 RGI-BOI SwasthyaBima Policy 01/04/2019-31/03/2020 INR 5,00,000

3. Name of the Insured Name of the Policyholder/Proposer

Mr S Ramanathan Mr S Ramanathan

4. Name of the Insurer Reliance General Insurance Company Limited

5. Date of repudiation/short settlement Repudiation, 20/08/2019

6. Reason for short settlement of claim

Non- disclosure of pre-existing diseases (PED)


8. Nature of Complaint Non-Settlement of claim

9. Date of receipt of Consent (Annexure VI A)

28/01/2020

10. Amount of Claim Not furnished

11. Amount paid by Insurer, if any Nil

12. Amount of Monetary Loss (as per Annexure VI A)

INR 82,000

13. Amount of Relief sought (as per Annexure VI A)

In full

14.a. Date of request for Self-Contained Note (SCN)

27/12/2019



Rule 13(1) (b)of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 19/02/2020, Chennai

17. Representation at the Hearing

For the Complainant Mr S Ramanathan For the Insurer DrHarikrishnan&Ms R Sangeetha



for the cataract surgery he had undergone in respect of both his eyes. Insurer repudiated

the claim on the ground that complainant didn‟t disclose the past history of Hypertension,

Diabetes, Osteoarthritis and Coronary Artery Disease in the proposal at the time of policy

inception on 01/04/2019 and the policy was also cancelled as per Duty of Disclosure

clause 5.12 of the policy. Aggrieved by the repudiation of the claim by insurer,

complainant escalated the matter to Grievance Dept. of the insurer who reiterated the

earlier decision of repudiation. Not satisfied with the response from insurer to his

grievance representation, complainant has approached this Forum for relief.

21(a) Complainant’s submission:

Complainant has been the insured through Bank of India group policy for 20 years. As

proof thereof, policy for the period 2009-10 is furnished to the Forum since that is the

earliest policy the complainant was able to trace. For the current policy year, the service

provider was changed from National Insurance Company to Reliance General Insurance

Company. At the time of switch over, Reliance representative promised that continuity will

be maintained and demanded copies of the last three year policies and the same were

submitted to them. A claim of INR 82,000 was preferred for the cataract surgery

undergone in both the eyes. Initially the insurer sought the cancelled cheque of one

NithyaRamanathan whereas the insured/complainant‟s name is S Ramanathan and when

insurer was asked about the same, it was explained as a back office error. But finally they

repudiated the claim on the ground that the past history of some other pre-existing

diseases (PED) was not furnished at the time of proposal. At the time of availing the policy

with Reliance, neither he was asked to nor he filled in any new proposal form. Hence

claim is payable and Forum‟s intervention is requested for settlement of the same besides

reinstatement of the policy.

21(b) Insurer’s submission:

Complainant‟s claim was for treatment of left eye Pseudo Phakia. On claim verification it

was noticed that the complainant had past history of Hypertension, Diabetes, Osteo

Arthritis and Coronary Artery Disease prior to availing the policy and the same was not

disclosed in the proposal at the time of policy inception on 01/04/2019. Hence the claim

was repudiated and the policy was cancelled as per policy clause 5.1.2. In view of facts

and circumstances mentioned above, Forum is requested to dismiss the complaint.

22) Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with “Any partial or total repudiation of claims by

the life insurer, General insurer or the health insurer”

23) Documents placed before the Forum for perusal. Written Complaint dated 11/12/2019 to the Insurance Ombudsman

Claim repudiation letter of the Insurer dated 20/08/2019

Complainant‟s representation dated 01/11/2019 to the Insurer

Insurer‟s response dated 08/11/2019 to the Complainant


Self-Contained Note (SCN) of insurer dated 12/02/2020

Certificate of Insurance and terms and conditions of Group Policy

Proposal form dated 01/04/2019

Discharge summary of Sri Ramana Eye Centre, Chennai

Insurer‟s E Mail dated 07/09/2019

Treating doctor‟s certificate

Copy of Policy for 2009-10


1. The Forum records its displeasure over the delay in submission of SCN by the

insurer.

2. The claim was repudiated on the ground that there was non-disclosure of pre-

existing disease (PED) such as Hypertension, Diabetes, Osteo Arthritis and

Coronary Artery Disease (CAD) and insurer proved the pre-existing nature of

Diabetes (DM) and CAD by submitting the treating doctor‟s certificate wherein it

has been stated that the insured patient is a case of DM for 20 years and CAD for

2-3 years..

3. Next issue to be decided is whether insurer has proved the non- disclosure of the

PEDs by complainant. Proposal submitted by insurer during hearing was perused

and it is noted that there was no disclosure of any PEDs.

4. Since complainant contended that he has not signed any proposal at the time of

switch over to Reliance, proposal was shown to him and he vehemently denied

having signed the proposal and disowned the signature therein. Forum is also of

the opinion that there is gross variance of the signature in the proposal and in other

documents submitted by him to the Forum including his complaint. Hence Forum

concludes that the copy of the proposal submitted by insurer is not signed by the

complainant. As a consequence, the allegation of non- disclosure of PEDs against

the complainant, insurer‟s repudiation of the claim on the ground of non-disclosure

of PEDs and subsequent cancellation of the policy is also not in order.

5. It is also a moot point whether a proposal was required from the complainant at the

time of renewal of the cover on 01.04.2019, merely because there was change in

the risk carrier (insurer). The complainant established his coverage under the

Group Policy of Bank of India by producing a copy of his policy for the year 2009-10

and the respondent insurers themselves had incorporated the details of his past

coverage (for 3 years from 01/04/2016 to 31/03/2019) in the certificate of insurance

issued to him.

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


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


compliance of the same to the Ombudsman

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant

shall be entitled to such interest at a rate per annum as specified in the regulations,

framed under the Insurance Regulatory and Development Authority of India Act, 1999,

from the date the claim ought to have been settled under the regulations, till the date

of payment of the amount awarded by the Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of

Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on this13th day of March 2020

(M Vasantha Krishna) INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

AWARD

Taking into account the facts & circumstances of the case and the submissions made during the course of hearing, Forum concludes that repudiation of the claim by insurer is not in order and insurer is directed to process and settle the claim of the complainant for INR 82,000 subject to the terms and conditions of the policy along with interest as defined under Rule 17 (7) Insurance Ombudsman Rules, 2017. Insurer is also directed to reinstate the cancelled coverage with continuity benefits.

Thus the complaint is Allowed

PROCEEDINGS BEFORE


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

OMBUDSMAN – Shri M Vasantha Krishna

CASE OF Mr C Vasu Vs The New India Assurance Co. Ltd


Award No: I0/CHN/A/HI/0232/2019-2020


The complainant had covered himself and his family under Good Health Group Mediclaim

Policy ofthe respondent insurer from 01/02/2019 to 31/01/2020 and the sum insured opted


Mr C Vasu No 10, Purushothaman Street, MathiazhaganNagar,Saligramam,Chennai- 600093


71250034182100000021 Good Health Group Mediclaim Policy 01/02/2019 to 31/01/2020 INR 50,000


Mr C Vasu Mr C Vasu

4. Name of the Insurer The New India Assurance Co. Ltd


6. Reason for Repudiation

Dental Treatment- Exclusion Clause 4.4.5


8. Nature of Complaint Repudiation of Claim


02/01/2020

10. Amount of Claim INR 31,000



INR 31,000


INR 31,000

14.a. Date of request for Self- Contained Note (SCN)

19/12/2019



Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 12/02/2020, Chennai

17. Representation at the Hearing

For the Complainant Mr C Vasu

For the Insurer Mr K Kalyanaraman



for himself is INR 50,000. On 03/08/2019 the complainant went to Kala Dental Care and

took treatment for the decayed and impacted tooth and thereafter lodged a claim with the

insurer. The insurer repudiated the claim on the ground that as per the Policy terms,

Dental treatment is not payable unless arising due to an accident and requiring

hospitalization. The complainant escalated the issue to the insurer‟s Grievance

Department who reiterated the earlier decision. Aggrieved by this, the complainant has

approached this Forum seeking justice.

21(a) Complainant’s submission:

The complainant stated that the dental procedure undergone by him was a day care

treatment and requested the Forum to consider his claim as per the policy clause 2.10 for

20% of sum insured.

The complainant added that he meted out the medical expenses out of his hard earned

savings and the denial of claim will put him in financial hardship and under severe stress.

21(b) Insurer’s submission:

The insurer stated in the SCN that the complainant had decayed and impacted tooth,

undergone dental treatment on day care basis and that they repudiated the claim as per

policy exclusion clause 4.4.5 which excludes “All types of dental treatment of any kind

unless necessitated due to accidental injuries and requiring hospitalization for such

procedure to be performed in the operation theatre of a Hospital”.

Since the present treatment of the complainant was not due to any accidental injury and

the patient was not hospitalized for the treatment and the same was taken as day care

treatment, the insurer contended that they were right in repudiating the claim.

22) Reason for Registration of Complaint: - Rule 13(1)(b) of the Insurance Ombudsman

Rules, 2017, which deals with “Any partial or total repudiation of claims by the Life insurer,

General insurer or the health insurer”

23) Documents placed before the Forum for perusal.


Claim form dated 08/08/2019

Claim repudiation recommendation of the TPA(MD India) dated 19/08/2019

Complainant‟s representation dated 09/08/2019 to the TPA


Consent (Annexure VI A) submitted by the Complainant 02/01/2020

Self Contained Note (SCN) of Insurer dated 08/01/2020

Policy copy, terms and conditions

Certificate/Bill dated 03/08/2019 from Kalaa Dental Care


1. The complainant requested in his complaint that his claim may be considered as per

policy clause 2.10 which deals with additional day care treatments with sub limit of 20% of

sum insured.

2. According to the insurer the complainant undertook dental treatment as day care

treatment and it was not due to any accidental injury and also he was not admitted in the

hospital.However while recommending repudiation of claim to insurer, TPA observed that

treatment was taken on out-patient basis.

3. The Forum records its strong disapproval of the failure of the insurer to send a formal

communication of rejection of the claim to the Complainant. The insurer must be aware

that this is a violation of the directions given by IRDAI regarding repudiation of Health

insurance claims.

4. The claim preferred by the complainant clearly falls under policy exclusion 4.4.5 and

hence the repudiation of claim by the insurer is in order. The Forum also notes that

clause 2.10 applies only to specified day care procedures and any other day care

procedure requires prior approval of the TPA and the insurer.

25. If the decision of the Forum is not acceptable to the Complainant, he is at liberty to


AWARD

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

by both the parties during the course of hearing, the Forum is of the view that the

repudiation of the claim by the insurer is in order and does not warrant any intervention

by this Forum.

Thus the complaint is not allowed.

.

Dated at Chennai on this 20th day of March 2020

(Sri M Vasantha Krishna)


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. S R Vellingiri Vs United India Insurance Company Limited

COMPLAINT REF: NO: CHN-H-051-1920-0491 Award No: IO/CHN/A/HI/0235/2019-2020

1. Name & Address of the Complainant Mr. S R Vellingiri 36, V Cross Road, Krishna Colony, Singanallur, Coimbatore – 641 005.


2001002818P111515547 Group Health Insurance Policy – without Domiciliary treatment cover 01.11.2018 to 31.10.2019 INR 3 lakhs


Mr. S R Vellingiri Indian Bank‟s Association A/c Bank of Baroda

4. Name of the Insurer United India Insurance Company Limited


6. Reason for repudiation The procedure is not in the approved list of Day-care procedures


8. Nature of Complaint Repudiation of claim


06.01.2020


11. Amount paid by Insurer, if any NIL


INR 24,453


INR 24,453

14. a. Date of request for Self-Contained Note (SCN)

18.12.2019

14. b. Date of receipt of SCN 12.02.2020

15. Complaint registered under Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 19.02.2020 – Chennai


The complainant, a retired employee of Bank of Baroda is covered along with his spouse

under Tailor made Group Health Insurance Policy issued by the Respondent Insurer (RI)

to the retirees of the Bank. The cover is without domiciliary benefit.

As per Discharge Summary, the complainant was admitted in G Kuppuswamy Naidu

Memorial (GKNM) Hospital, Coimbatore with the complaints of warts in bilateral thigh

since 10 years. He underwent excision with cauterisation of the warty lesions on

26.07.2019 and was discharged on the following day.

The treating doctor has certified that the patient had multiple warts over the medial aspect

of upper thigh which required surgery and was advised admission in the hospital. He has

also stated that the size of the warts was small, only Electro Cautery was used and

biopsy not sent. He has issued one more certificate stating that the patient is a known

case of CAD, HTN and DM and due to co-morbid conditions he was advised admission in

the hospital.

Claim was submitted on 29.07.2019 for INR 24,453 to the RI but the same was

repudiated. The complainant represented to the insurer vide his letter dated 24.10.2019 to

reconsider his claim. Since there was no response from the insurer, he has approached

this Forum vide his letter dated 04.12.2019 for redressal of his grievance.

21 (a) Complainant’s Submission:

The complainant submits that he is a retired bank employee covered by group

health policy issued by the RI.

He underwent surgery and submitted all the papers to the TPA for further process.

They raised some queries and requested for submission of documents.

Post submission of documents, the claim was repudiated by way of SMS.

He has requested the Forum to direct the insurer to settle the claim.

21 (b) Insurer’s Submission:


a) For the Complainant Mr. S R Vellingiri

b) For the Insurer Mr. A B Bhaskaran



The insurer have submitted their SCN vide their letter dated 07.02.2020.

They have stated that the procedure underwent by the complainant is an outpatient

day care procedure which is not part of approved list of day-care procedures as per

the policy.

As per Clause 2.10 Day Care Treatment means the medical treatment and/or

surgical procedure which is – (i) Undertaken under General or Local Anaesthesia in

a hospital/day care centre in less than 24 hours because of technological

advancement and (ii) which would have otherwise required a hospitalisation of

more than 24 hours. Treatment normally taken on an outpatient basis is not

included in the scope of this definition.

As per Clause 2.19 Hospitalisation – Note: Procedures/treatments usually done in

outpatient department are not payable under the policy even if admitted/converted

as an in-patient in the hospital for more than 24 hours.

22. Reason for Registration of Complaint:- Rule 13(1) (b) of the Insurance Ombudsman

Rules, 2017, which reads as “Any partial or total repudiation of claims by the Life Insurer,

General Insurer or the Health Insurer”.

23. Documents placed before the Forum for perusal.

Written Complaint dated 04.12.2019 to the Insurance Ombudsman

Claim repudiation letter of the Insurer dated 23.09.2019

Complainant‟s representation dated 24.10.2019 to the Insurer


Self-Contained Note (SCN) of Insurer dated 07.02.2020


Claim Form

Discharge summary/out-patient record/Bills of G Kuppuswamy Naidu Memorial

Hospital, Coimbatore

Certificates dated 07.09.2019 and 25.09.2019 issued by Dr. A. Sekar

24. Result of hearing with both parties (Observations & Conclusion)

Mr. S R Vellingiri, Complainant, Mr. A B Baskaran, Insurer‟s representative and Dr.

Rachel, Medical Officer of the TPA attended the hearing.

During the hearing the complainant stated that since policy was availed through

bank, all bills and documents were sent through the bank within 4 days of

discharge. He also submits that he was hospitalised for more than 24 hours for the

removal of cyst. He did not receive any repudiation letter but only an SMS rejecting

the claim from the insurer, without assigning any reasons.

The RI contended that cauterisation of wart comes under OPD treatment which is

excluded in the policy. They also argued that it is different from surgery and it is

only removal by burning and no cutting is performed during the procedure.

The RI was advised to submit the repudiation letter to verify the grounds of

repudiation. It is observed that they have repudiated the claim vide their letter dated

23.09.2019 under Policy Condition 2.19 – Hospitalisation and Condition 2.10 – Day

Care Treatment.

As per Discharge Summary, the complainant was admitted on 25.07.2019 at 09.24

a.m. and was discharged on 26.07.2019 at 04.08 p.m. Thus, he was hospitalised

for more than 24 hours.

The treating doctor has issued a Certificate stating that multiple warts were present

over the medial aspect of upper thigh which was painful and the patient needed to

be admitted for surgical removal. He also stated that since the Electro Cautery was

used and the sizes of the wart were small, biopsy was not sent.

Forum notes from clause 3.3 of the Policy that excision of cyst (item no. 9) and

operations/micro surgical operations on the skin (item no.19) are listed day care

procedures and the complainant was hospitalised for more than 24 hours for the

procedure, on the recommendation of the treating doctor, due to co-morbidities

present. Hence, in the opinion of the Forum the claim is admissible as a

hospitalisation claim as well as a day care claim and the insurer was not justified in

invoking clauses 2.10 and 2.19 to reject the same.

AWARD


made by both the parties during the course of hearing, the Forum hereby directs

the respondent insurer to settle the claim of the complainant for INR 24,453

subject to the terms and conditions of the Policy along with interest as provided

under Rule 17(7) of the Insurance Ombudsman Rules, 2017.

Thus the complaint is Allowed.

25. The attention of the Insurer is hereby invited to the following provisions of the


a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer

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

intimate compliance of the same to the Ombudsman.

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as specified in the

regulations, framed under the Insurance Regulatory and Development Authority of

India Act, 1999, from the date the claim ought to have been settled under the

regulations, till the date of payment of the amount awarded by the Ombudsman.



Dated at Chennai on this 23th day of March 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna CASE OF Mr. H Balasubramanian Vs United India Insurance Company Limited

COMPLAINT REF: NO: CHN-H-051-1920-0511 Award No: IO/CHN/A/HI/ 0238/2019-2020


Mr. H Balasubramanian, 1/1, Balasubramaniam Street, Mylapore, Chennai – 600 004.

2.

Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

1202002818P114542267 Tailor Made Group Medi-claim Policy 16.01.2019 to 15.01.2020 INR 3 lakhs


Mr. H Balasubramanian State Bank of India



6. Reason for repudiation Claim does not have OPD (out-patient) coverage




10.01.2020


11. Amount paid by Insurer, if any NIL


INR 41,339


INR 41,339 plus damages for mental agony


30.12.2019



16. Date of Hearing/Place 19.02.2020 - Chennai


a) For the Complainant Mr. H Balasubramanian

b) For the Insurer Mr. A B Bhaskaran




The complainant, an SBI pensioner is covered under Tailor Made Family Floater Group

Mediclaim Insurance Policy issued to retired employees of State Bank of India by the

Respondent Insurer (RI).

As per Discharge Summary, he was admitted in Shekar Eye Hospital, Bangalore on

25.04.2019 with the complaint of blurred vision in Right Eye and was diagnosed as a case

of Right Eye ST BRVO (Branch Retinal Vein Occlusion) with CME (Cystoid Macular

Edema). He underwent Right Eye IntravitrealAccentrix Injection under TA (Topical

Anaesthesia) and was discharged on the same day.

On 29.04.2019 he submitted a reimbursement claim for INR 41,339 to the RI and the

same was repudiated by them vide their letter dated 17.07.2019 on the ground that the

claim does not have OPD coverage. They added that the claim is for Domiciliary

Hospitalization which is not covered under the policy.

The complainant represented to the RI vide his letter dated 18.09.2019 to reconsider his

claim. Since there was no response from them, he has approached this Forum for

redressal of his grievance.


The complainant submits that since advanced treatment was available due to

technological advancements, the entire procedure was done on day care basis.

Post repudiation, he has represented to the insurer and the TPA to reconsider his

claim.

His claim is covered by the policy as Day Care Treatment (clause 2.8) and under

Day Care Benefits (clause 3.19) and as such the insurer is required to settle his

claim of INR 41,339.

He also submits he has taken the policy in his capacity as an individual and

thepresent complaint is with respect to the said policy and the value of the claim

including expenses is less than INR 30 lakhs.


The insurer submitted the SCN vide their letter dated 06.02.2020.

As per policy terms and conditions, the claim does not have OPD coverage. The

claim is for „Domiciliary Hospitalization‟ which is not covered under the policy.

The policy covers only hospitalisation expenses and hence, falls outside the scope

of the coverage under the policy.

The insured has taken domiciliary treatment whereas his policy is not a domiciliary

policy.

Since there is no separate rejection clause in the policy, the claim was rejected

under Policy Condition (2) of Part I, reading as below.

“No expenses related to domiciliary/OPD treatment is payable”.

Hence RI requested the Forum to dismiss the complaint.


Rules, 2017, which deals with “Any partial or total repudiation of claims by the Life Insurer,


23. Documents placed before the Forum for perusal.



Complainant‟s representation dated 18.09.2019



Policy terms and conditions (submitted by the complainant)

Claim form dated 29.04.2019

Discharge summary/Bills of Shekar Eye Hospital, Bengaluru

Opinion dated 19.03.2020 from Prof.Dr. Ganesh, M.D of BRS Hospital


Mr. H Balasubramanian, Complainant and Mr. A B Bhaskaran, Insurer‟s

representative attended the hearing.

There is a delay of one month in submitting the SCN. This Forum records its

displeasure for the late submission and hereby directs the RI to adhere to the

timelines for submission of SCN in future.

It is observed that the claimant had represented to the RI as early as 18.09.2019 to

reconsider his claim and there was no response to the same till the date of hearing.

The Forum records its displeasure over the failure to respond to the customer‟s

grievance. The insurer is advised to strengthen its grievance redressal mechanism

and promptly address the grievances of its customers.

During the hearing the complainant submitted that he was admitted for 2 to 3 hours

and undergone an eye surgery under local anaesthesia. The said treatment should

be considered under Domiciliary Treatment on outpatient basis (clause 3.18) or as

Day Care Treatment (clause 2.8). He also informed the Forum that the treating

doctor emphasized that if this treatment was not done, there would be substantial

effect on his vision.

The insurer failed to provide the policy wording along with the SCN and hence the

Forum relied upon the coverage details submitted by the complainant to draw its

conclusions.

The RI contended that the complainant was administered intravitreal injection and

no surgery was performed. Since the treatment does not meet the technological

advancement criteria as stated in the definition of day-care treatment in clause 2.8,

the claim was repudiated.

Contrary to the assertion of the RI that there is no coverage of domiciliary

treatment, it is observed that clause 3.18 of the policy does cover domiciliary

treatment on outpatient basis, albeit limited to the diseases mentioned therein.

Hence the ground of repudiation, namely “No expenses related to domiciliary/OPD

treatment is payable” is not tenable. Moreover, perusal of the policy wording placed

before the Forum revealed no such exclusion and even if it exists, the same would

be inconsistent with the coverage offered under clause 3.18 and therefore of no

effect or consequence.

The disease/condition for which treatment was taken by the complainant,

namely,ST BRVO with CME is not excluded by the policy.

The Forum obtained opinion whether the procedure undergone is technologically

advanced. This was in the light of insurer‟s contention that while the procedure was

performed under local anaesthesia, it does not meet the criteria of technological

advancement, to satisfy the definition of Day Care Treatment as per clause 2.8 of

the policy. According to Prof. Dr. Ganesh, M.D of BRS Hospital who provided the

opinion, intravitreal injection is the correct procedure for BRVO with CME. It is not

clear from the opinion rendered whether the procedure is advanced or not and

whether in its absence patient would have required hospitalization of more than a

day. It is also observed that treatment normally taken on out-patient (OPD) basis is

not included in the scope of Day Care Treatment.

While it appears that the procedure does not meet the requirements of Day Care

Treatment as per clause 3.8, the Forum examined whether the same is coming

within the purview of Day Care Benefits listed under clause 3.19 of the policy. It is

observed that Eye Surgery is a listed procedure as per item 10 of said clause 3.19

and the definition of Surgery in clause 2.33 of the policy reads as follows.

“Surgery or surgical procedure means manual and /or operative procedure(s)

required for treatment of an illness or injury, correction of deformities and defects,

diagnosis and cure of diseases, relief of suffering or prolongation of life, performed

in a hospital or day care centre by a medical practitioner”.

The above definition of surgery is very broad and does not limit its scope to cutting

operations as is normally understood by the term. It includes manual and/or

operativeprocedures required for treatment of an illness or injury. Hence the

procedure (intravitreal injection in the right eye under local anaesthesia) undergone

in the present case meets the requirement of surgery as per the definition and

therefore is considered as an eye surgery and a listed day care procedure.

AWARD


made by both the parties during the course of hearing, the Forum is of the view

that the repudiation of the claim is notjustified and directs the insurer to settle the

claim of the complainant for INR 41,339 subject to other terms and conditions of

the policy along with interest as provided under Rule 17(7) of the Insurance

Ombudsman Rules, 2017.

Thus the complaint is Allowed.













Dated at Chennai on this 30th day of March 2020.


INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE



OMBUDSMAN– Shri. M. Vasantha Krishna

CASE OF Mr. Sunil FatehchandGada Vs Star Health and Allied Insurance Co. Limited

Complaint REF: No: CHN-H-044-1920-0558


20. Brief facts of the case:

The Complainant, his spouse, children and his dependent parents were covered under the

Group Mediclaim Insurance Policy of Jain International Organisation with the Respondent

Insurer (RI) for a floater Sum Insured of INR 5 lakhs. The period of insurance was

31.03.2018 to 30.03.2019. On 15.02.2019, his father Mr. FatehchandGada met with a

road accident and was admitted in UpasaniSuperspeciality Hospital, Mumbai. Later he

was admitted in Bhatia Hospital, Mumbai for treatment of exacerbation of COPD. The

requests for pre-authorisation to avail cashless treatment and later the claims for

reimbursement submitted to the Insurer were both rejected on the ground that the

treatment was for an ailment which is due to smoking. The Complainant submitted a

representation to the insurer vide letter dated 29.03.2019 for reconsideration of the claim.

The insurer responded on 08.05.2019 expressing their inability to do so. Hence, he has

approached this Forum for relief.

21 a Complainant’s submission:

The Complainant stated that the claims submitted to the insurer for reimbursement of

expenses for treatment undergone at Upasani and Bhatia Hospitals, Mumbai, were

rejected on the ground that the treatment undergone was for an ailment due to

smoking. According to the complainant, the treatment was therefore for a Pre-

Existing Disease (PED) and he contended that the subject policy covers PED. Hence,

he has requested the Forum to direct the Insurer to settle the claim.

21 b. Insurer’s submission:

The Insurer submitted their Self-contained Note (SCN) dated 29.02.2020 stating that

they have reviewed the claims and are now willing to settle both the claims for the

amounts of INR 41,648 (claim no. 661494) and INR 43,276 (claim no. 668846)

respectively. They have submitted the billing sheets showing the details of amounts

offered in claim settlement. Prior to hearing the RI informed the Forum by their mail

dated 07.03.2020 that the amount offered in settlement of the second claim (claim no.

668846) is increased from INR 43,276 to INR 55,050.

22) Reason for Registration of Complaint: - Rule 13(1) (b) of the Insurance Ombudsman

Rules, 2017, which deals with “Any partial or total repudiation of claims by the Life

insurer, General insurer or the health insurer”.

23) Documents placed before the Forum for perusal. Written Complaint to the Ombudsman dated 29.01.2020

Claim Repudiation letters of Insurer dated14.03.2019 and 19.03.2019

Complainant‟s representation to the Insurer dated 29.03.2019 and 04.07.2019

Insurer‟s response to the Complainant vide email dated 08.05.2019 and 16.08.2019



Copy of Policy, terms and conditions


Claim billing sheet dated 29.02.2020

Transfer Summary and final bill of Upasini Super Specialty Hospital

Discharge Summary and final bill of Bhatia Hospital, Mumbai.

24 ) Results of hearing(Observations and Conclusion):

The Complainant, Mr. Sunil FatehchandGada and the Insurer‟s representative

Dr.AsiyaSahima were present for the hearing.

The Forum records its displeasure over the delay in submission of SCN by the

Insurer. The insurer is hereby directed to henceforth submit the SCN on time.

The Insurer informed the Forum their willingness to settle both the claims and

submitted the billing sheets. Upon scrutiny of the same, the following are Forum‟s

observations:

I. Claim no 668846:

- Out of the total claim amount of INR 1,14,838, an amount of INR 59,788

was disallowed in all and the claim settlement offer of the insurer is for

INR 55,050.

- The Policy is subject to Proportionate clause i.e. if the Complainant opts

for a room which is higher than his eligibility (INR 3,000 per day) then all

other expenses except medicines would be paid in proportion of the

eligible room rent to the actual room rent.

- Expense wise details of deductions made are as under:

Sl.

no

Head of

expense

Amount

disallowed

(in INR)

Remarks

1 Room rent

(including

Nursing)

22,000 Eligible room rent per day is only INR

3,000 and INR 5,000 per day for ICU.

Hence proportionate deduction made

2 Professional

fee

9,500 Proportionate deduction

3 Investigation

fee

12,718 No break up; hence only 80%

allowed; Proportionate deduction

also applied

4 Medicines 8,169 Non-medical items like ECG

electrodes, Gloves, Face mask, ECO

bath wipes, mouth wash, sheet, face

mask, intrafix, oxygen tube,

dispensing cup and Insulin syringe

are not payable

5. Ambulance

charges

4,000 Amount claimed – INR 6,500;

payable as per policy – INR 2,500

6 Others 3,401 Admin expenses- Not payable

Total 59,788

II) Claim no 661494:

- Out of the total claim amount of INR 61,195, an amount of INR 19,547 was

disallowed and the claim settlement offer of the insurer is for INR

41,648.

- Expense wise details of deductions made are as under:

-

The settlement offer of the insurer has been verified and found in order by the

Forum.

Sl.

no

Head of

Expense

Amount

disallowed

(in INR)

Remarks

1 Room rent 4,800 Eligible room rent per day is only

INR 5,000 for ICU. Hence

proportionate deduction made

2 Professional

charges

2,860 Proportionate deduction

3 Investigation 2,024 No sputum culture report. Hence,

disallowed. Proportionate deduction

also made

4 Medicines 7,473 Non- medical items like Mask,

Glove, Blade, Under-pad, Ventilator

Kit, Wipes disallowed

5 Others 1,390 Registration charges not payable.

Proportionate deduction made

6 Ambulance 1,000 Ambulance charges claimed –

INR3,500; allowed as per policy INR

2,500

Total 19,547

AWARD

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

by both the parties during the course of hearing, the Forum hereby directs the Insurer

to pay the complainant the amount of INR 96,698 in full and final settlement of the

claim along with interest at applicable rates as provided under Rule 17(7) of the

Insurance Ombudsman Rules, 2017.

Thus, the complaint is allowed.

25. The attention of the complainant and the respondent insurer is drawn to the following

provisions of Rule 17 of the Insurance Ombudsman Rules, 2017.




b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant

shall be entitled to such interest at a rate per annum as specified in the regulations,

framed under the Insurance Regulatory and Development Authority of India Act, 1999,

from the date the claim ought to have been settled under the regulations, till the date

of payment of the amount awarded by the Ombudsman.



Dated at Chennai on thisth 31stday of March 2020

(Sri M Vasantha Krishna) INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE



OMBUDSMAN - SHRI M. VASANTHA KRISHNA

CASE OF Mr. P. Rajesh Vs Apollo Munich Health Insurance Company Ltd




Complainant has availed respondent insurer‟s Easy Health Group Insurance on

09/09/2015 with Indian Overseas Bank (IOB), Portonovo branch as the intermediary


Mr. P Rajesh No. 26, Pappankodi Street, Parangipettai 608502

2. Policy No: Type of Policy Duration of policy/Policy period Sum Insured (SI)

140100/12001/2018/A012588/PE01187832 Easy Health Group Insurance Policy 22/10/2018-21/10/2019 INR 10,00,000

3. Name of the insured Name of the policyholder/proposer

Mr. Rajesh Mr. Rajesh

4. Name of the insurer Apollo Munich Health Insurance

Company Ltd

5. Date of Repudiation/short settlement Not Applicable

6. Reason for repudiation/ short settlement

Not Applicable


8. Nature of complaint Policy was renewed after a break of 44 days in spite of standing instruction to debit the premium amount

9 Date of receipt of consent ( Annexure VIA)

04/02/2020

10 Amount of Claim Not applicable

11

Amount of Monetary Loss (as per Annexure VIA)

Not furnished

12. Amount paid by Insurer if any Not applicable


INR 5,000


14/01/2020

14.b. Date of receipt of SCN Not submitted


Rule 13(1)(f) of the Insurance Ombudsman Rules, 2017



a) For the Complainant Mr. Harsha

b) For the insurer Absent

18. Disposal of Complaint By Award


(corporate agent). Till 2018 policy was renewed by the Bank in time through standing

instruction given to them for auto debiting the premium amount. But in 2018 policy was not

renewed in time and a fresh policy was issued after 44 days, although sufficient balance

was maintained in the bank account. Matter was escalated to the Grievance Department

of the insurer to give continuous effect to the policy. But insurer stated that the new policy

was taken after the grace period and hence continuity benefit could not be granted. Not

satisfied with the decision of the insurer, complainant has approached this Forum for

relief.

21) a) Complainant’s submission:

Complainant is holding a joint bank account with his father Mr H Panmull and mother

MrsRajakumari with IOB, Portonovo branch. On 09/09/2015 IOB had issued respondent

insurer‟s health insurance policy and the policy was renewed continuously by auto

debiting the bank account for the premium. Policy no

140700/12001/2017/A006992/PE006332273 which was due to expire on 08/09/2018 was

not renewed on 09/09/2018 by insurer. Instead a new policy with complainant‟s mother

Mrs. H Panmull as proposer/policyholder was issued on 22/10/2018 after a gap of 44

days. Since the policy was issued as a new policy, continuity benefits are lost. Even after

taking up with the Grievance Department of the insurer along with the proof of having

sufficient balance on the date of renewal, insurer did not provide continuity benefit. The

Bank also took up with their controlling office for correction of the policy to ensure

continuity benefit, on the ground that the customer has been regularly maintaining

balance in the account to cover the premium amount at the time of renewal, but standing

instruction for renewal of the policy was not executed. Thus, it has been proved that there

is a lacuna on the part of insurer. Hence Forum‟s intervention is requested to ensure that

continuity benefit is maintained under the policy, besides endorsing the name of the

complainant as the policyholder , as in the previous policies.

b)Insurer’s contention:

SCN is not submitted by the insurer. IOB Care Department of the insurer vide E Mail

dated 15/12/2019 informed the complainant that the new policy was taken after

completion of grace period and hence continuity benefit cannot be provided and name of

proposer also cannot be changed.

22) Reason for Registration of Complaint: - Rule13 (1) (f) of the Insurance Ombudsman

Rules, 2017, which deals with “policy servicing related grievances against insurers and

their agents and intermediaries.”

23) Documents placed before the Forum.





Easy Health Individual Standard policies for the period 2015-16, 2016-17, 2017-18,

2018-19, 2019-20

Complainant‟s bank account statement for the period from 01/08/2018 to

31/10/2018.

E Mail dated 19/11/2019 ofIOB, Portonovo

24) Result of hearing (Observations & Conclusion):

1. The Forum records its displeasure over non-submission of SCN by the insurer and

their failure to attend the hearing. .

2. E Mail dated 19/11/2019 of the Bank confirms that standing instruction to debit the

premium from bank account for renewal of the policy was not executed.

3. Bank account statement submitted by the complainant reveals that an amount of

INR 21,246.13 was available in the account on 07/09/2018, while the renewal was

due on 08/09/2018.

4. Thus, clearly there was a failure on the part of in the Bank in their capacity as

intermediary to debit the renewal premium and remit the same to the insurer on or

before the due date of 08/09/2018. Although the insurer is not at fault for the

delayed renewal, the relief sought by the complainant, namely continuity benefit

can only be provided by the insurer. As per Regulation 13(iii) of Health Insurance

Regulations of IRDAI, a delay not exceeding 30 days in renewal of the policy is to

be condoned by the insurers for the purpose of providing continuity benefit.

Insurers do condone the delay beyond 30 days too in deserving cases. In the

opinion of the Forum, this is a fit case for condonation since the complainant was

not to blame for the delay in renewal, having given standing instruction for renewal

and having maintained adequate balance in the bank account for executing the

standard instructions.

5. The complainant also demanded that he should be shown as the policyholder in the

renewal policy in the place of his mother. Since the insurer has not participated in

the proceedings and also did not submit the SCN, the reasons for changing the

name of the policyholder from the complainant to his mother is not known.

However, Forum notes that there is no change in the insured persons covered

under the policy, except for the exclusion of Mr. Harsha, son of the complainant,

who attended the hearing on his father‟s behalf. He clarified that his name was

deleted from the policy on his turning a major and he is now covered under a

separate policy. Hence, Forum refrains from giving any direction to the insurer in

this matter and expects them to take a judicious decision depending on the facts of

the case.

6. The demand of the complainant for compensation for mental agony and

harassment is beyond the purview of this Forum.

AWARD


made during the course of hearing, the Forum hereby directs the insurer to provide

continuity benefit under the policy for the period 22/10/2018 to 21/10/2019.


25)The attention of the Insurer is hereby invited to the following provisions of the





b) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of


Dated at Chennai on the 31st day of March, 2020

(M. Vasantha Krishna)


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMIL NADU & PUDUCHERRY (UNDER RULE NO: 16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. S Ramakrishnan Vs United India Insurance Company Limited


1. Name & Address of the Complainant Mr. S Ramakrishnan, Flat 1 C, Block 2, Natwest Aura, Revathipuram Main Road, Urapakkam, Chennai – 603 210.


5001002818P111216812 Tailormade Group Mediclaim Policy (Retirees) - without Domiciliary Treatment cover 01.11.2018 to 31.10.2019 INR 4,00,000


Mr. S Ramakrishnan Indian Bank‟s Association A/c Corporation Bank



6. Reason for repudiation Treatment undergone is primarily for diagnostic and evaluation purpose




20.01.2020

10. Amount of Claim INR 1,31,353



INR 1,31,353


INR 1,31,353


08.01.2020

14. b. Date of receipt of SCN Not received

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



a) For the Complainant Mr. S Ramakrishnan

b) For the Insurer Mr. K P Divyaraj




The complainant is covered under Tailormade Group Mediclaim Policy issued by the

Respondent Insurer (RI) to the retired employees of Corporation Bank.

As per Discharge Summary, the complainant was admitted in Apollo Speciality Hospitals,

Chennai on 12.06.2019 with the chief complaints of extreme fatigue, inability to move

limbs and with excursive (excessive?) sweating. He was diagnosed as a case of Follicular

Non-Hodgkin‟s Lymphoma (NHL) - Stage IV, Grade II, Hypertension (HTN), Coronary

Artery Disease (CAD) and Diabetes Mellitus (DM). He was conservatively treated and

discharged on 16.06.2019.

He submitted a reimbursement claim to the insurer on 20.06.2019 for his treatment and

the same was repudiated as per clause 2.10 of the policy on the ground that the

hospitalisation was primarily for diagnostic evaluation and treatments that are of outpatient

day-care in nature and hence not admissible.

Clause 2.10 of the policy invoked by the insurer reads as under.

“DAY CARE TREATMENT means the medical treatment and/or surgical procedure which

is (i) undertaken under General or Local Anaesthesia in a hospital/day care centre in less

than 24 hours because of technological advancement and (ii) which would have otherwise

required a hospitalisation of more than 24 hours. Treatment normally taken on an

outpatient basis is not included in the scope of this definition”.

The complainant represented to the insurer vide his letter dated 18.10.2019 regarding the

rejection of his claim but did not receive a response. Aggrieved by the non-response, he

has approached this Forum for redressal of his grievance.


The complainant submits that he is taking treatment for follicular NHL, a kind of

cancer from 2015 in Apollo Speciality Hospitals.

He has taken chemotherapy treatment till October 2017.

The treating doctor had advised him to get admitted immediately in the hospital if

there is any serious and sudden illness.

On 12.06.2019 the complainant fainted due to extreme fatigue and he was not able

to move his limbs and there was excessive sweating and he was admitted in an

emergency and treated.

The present hospitalisation is not for the treatment of NHL and he was treated for

dehydration with IV fluids and antacids for two days.

Since he is a heart patient who underwent bypass surgery earlier, the treating

doctor had sought opinion from specialists like Cardio, Neuro and Endocrine

consultants and medical investigations were performed.

He also submits that his claim is not under Clause 2.19 and 2.10 as he was not

treated under day-care.Since he was admitted in an emergency ward under

continuous monitoring, the claim is under clause 2.29 for medically necessary

treatment and under clause 2.14 for emergency care.

The treating doctor has certified that the complainant was admitted on 12.06.2019

with complaints of extreme fatigue and he had near syncope. He was treated for

dehydration and Neuro, Cardio and Endocrine specialists were consulted.


The RI has stated that the complainant was admitted to the hospital as a case of

Follicular NHL and was evaluated for complaints of extreme fatigue and inability to

move limbs and with sweating.

The hospitalisation is primarily for diagnostic evaluations and treatments were of

out-patient (OPD) nature.

Hence, the claim was repudiated invoking Clauses 2.19 and 2.10 of the policy.


Rules, 2017, which deals with”Any partial or total repudiation of claims by the Life Insurer,


23. Documents placed before the Forum.






Discharge summary/Bills of Apollo Speciality Hospital, Chennai

Mail correspondence of the complainant with the Insurer and TPA

Certificate of Dr. Jose M Easow dated 13.09.2019.

24. Result of hearing (Observations & Conclusion)

Mr. S Ramakrishnan, Complainant and Mr. K P Divyaraj, insurer‟s representative

attended the hearing.

The Forum records its displeasure over the non-submission of SCN by the insurer.

Similarly, the lack of response to the representations made by the complainant is a

matter of concern. It is hoped that the insurer will strengthen its customer grievance

redressal mechanism and avoid such lapses in future.

During the hearing the complainant submitted that he underwent chemotherapy for

cancer and subsequently his immunity went down. In the instant case he was

admitted for giddiness with history of heart ailment but the claim was repudiated by

the insurer treating his admission as a day care procedure, though he was

hospitalised for four days.

It is observed that the RI has repudiated the claim by invoking Clause 2.10 which

defines Day Care Treatment whereas the complainant was admitted in the hospital

on an emergency basis and the treating Doctor has issued a certificate to that

extent. The insurer failed to cite any relevant policy exclusion in the letter of

repudiation, although subsequent to the complaint lodged with the Forum, the TPA

seems to have opined that the claim falls under the exclusion note of clause 2.19

which states that “Procedures/treatments usually done in out-patient department

are not payable under the policy even if admitted/converted as an in-patient in the

hospital for more than 24 hours”.

It is observed that the complainant was admitted for emergency care and

considering the co-morbidities such as NHL and CAD, the Forum is of the view that

his hospitalisation was justified. Therefore, repudiation of the claim by the RI under

clause 2.10 of the policy is not in order.

AWARD



the respondent insurer to settle the claim of the complainant for INR 1,31,353
















Dated at Chennai on the 31st day of March, 2020.


INSURANCE OMBUDSMAN



OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. Srinivasan RajagopalVsUnited India Insurance Company Limited


1. Name & Address of the Complainant Mr. Srinivasan Rajagopal, Flat No.3 J- Block, Ceebros Orchid Apartments, 263/33 Velachery Main Road, Velachery, Chennai - 600 042.


0504002818P103444696& 0504002818P103449938 Tailor-made Group Medi-claim - Aarogyadaan Policy& Super Top-up Policy 09.06.2018 to 08.06.2019 Base SI INR 5 lakhs;Top-Up SI INR 15 lakhs


Mrs. DeepaRajagopal Mr. Srinivasan Rajagopal


5. Date of Repudiation / Short Settlement Not applicable

6. Reason for repudiation/ Short settlement Not applicable


8. Nature of Complaint Claim closed due to alleged non-receipt of requisite documents


20.01.2020




INR 2,61,260


INR 2,61,260


09.01.2020


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



a) For the Complainant Mr. Srinivasan Rajagopal

b) For the Insurer Mr. K P Divyaraj




The complainant as an accountholder of Andhra Bank is covered under Tailor-made

Group Mediclaim Policy issued by Respondent Insurer (RI). Apart from himself, he has

also covered his parents since August 2009. The basic Sum Insured (SI) is INR 5 lakhs

and Super Top Up SI is INR 15 lakhs.

As per Discharge Summary, on 06.03.2019 the complainant‟s mother Mrs.

DeepaRajagopal was admitted in Apollo First Med Hospitals, Chennai with the complaints

of mass descending p/v for the past 10 years and history of mild white discharge and pain

in the abdomen. She was diagnosed with Third Degree Utero-vesical prolapse

Resolving Acute Appendicitis, underwent Vaginal Hysterectomy with Perineal Floor

repair and Laparoscopic Appendectomy and was discharged on 08.03.2019.

The complainant submitted a reimbursement claim on 27.03.2019 for INR 2,62,260 for his

mother‟s treatment. Since the insured underwent two surgeries at the same time, the

insurer requested the complainant to provide surgery-wise hospital bill with breakup

details. Since the insured did not submit the requested documents even after three

reminders, they closed the claim on the ground of non-cooperation by the insured with an

option to re-open at a later date. He represented to the insurer vide mail dated 27.08.2019

stating that the documents were already submitted on 27.03.2019, but did not receive any

response. Therefore, he has now approached this Forum for redressal of his grievance.


The complainant submits that both the surgeries were carried out simultaneously.

Inspite of handing over all the original bills and reports on 27.03.2019, the TPA was

repeatedly reminding him to submit the original bills.

The TPA insisted for providing breakup charges for both the surgeries separately

but the same was provided in the first submission itself.

He has requested the Forum to do the needful.


The RI has submitted their SCN vide letter dated 21.01.2020.

They have stated that the insured underwent two surgeries at the same time

namely Appendectomy and Hysterectomy.

They had requested the insured to submit the breakup charges for both the

surgeries separately vide their letter dated 16.07.2019.

Subsequently, the TPA had sent three reminders dated 23.07.2019, 30.07.2019

and 06.08.2019 for submission of the requisite documents.

Since they did not receive the documents, the claim was repudiated vide their letter

dated 13.09.2019 as per Clause No.7.10 of the Policy.

Clause 7.10 – Cancellation Clause reads as “The Company may at any time cancel

the Policy on grounds of misrepresentation, fraud, non-disclosure of material fact or

non-cooperation by the insured by sending seven days‟ notice in writing by post to

the insured at his last known address in which case the company shall return to the

insured a proportion of the last premium corresponding to the unexpired period of

insurance if no claim has been paid under the policy. The insured may at any time

cancel this policy and in such event the Company shall allow refund of premium at

company‟s short period rate table given below provided no claim has occurred up

to the date of cancellation”.

However, if the insured submits the required documents, the TPA will be advised to

reopen the claim once again and process the claim within 15 days.

In the circumstances, they requested the Forum to pronounce an awardfavouring

them.


Rules, 2017, which deals with “Any partial or total repudiation of claims by the Life Insurer,




Claim closure letter of the Insurer dated 13.09.2019





Claim Form dated 27.03.2019

Discharge summary/Bills of Apollo First Med Hospitals, Chennai



Complainant Mr. Srinivasan Rajagopal, Mr. Divyaraj, Insurer‟s representative, Dr. S

Gyanesh and Dr. Manjunath Rao, representatives of TPA attended the hearing.

During the hearing the complainant submitted that despite submitting all the

required documents, the claim is yet to be settled by the RI.

It is observed that the RI had been asking for the break-up of charges incurred in

the hospital despite the fact that the samewas very much available in the itemised

invoice of the hospital, so far as Professional Charges are concerned. Since all the

procedures were done together, it may be difficult for the hospital to provide the

break-up for commonly incurred expenditure such as room rent, OT charges, etc.

Although the insurer/TPA did not specify why the break-up for expenditure was

required, it seems to be in view of clause 7.15(4) of the policy, which limits

hospitalisation expenses for Hysterectomy to 20% of the SI, subject to a maximum

of INR 50,000.

The Forum regrets to observe that the claim was closed citing clause no. 7.10 on

account of non-receipt of documents, whereas the said clause is the policy

cancellation clause and has no relevance for closure of the claim.

The Forum is of the view that the closure of the claim by the insurer despite having

received the requisite papers is not justified.During the hearing the RI was directed

to work out the amount payable and submit the claim calculation sheet, which

regretfully, they have failed to provide till now.



AWARD



the respondent insurer to settle the claim of the complainant for INR 2,61,260














Dated at Chennai on the 31stday of March, 2020.


INSURANCE OMBUDSMAN



OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. V Palaniappan Vs United India Insurance Company Limited



Mr. V Palaniappan, B 1, Subikshaa Apartment, Vivek Street, Vanamamalai Nagar, 2nd Main Road, Duraisamy Nagar, Madurai – 625 016.

2.

Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

5001002817P112335108 Group Mediclaim Policy 01.11.2017 to 31.10.2018 INR 4 lakhs


Mrs. P Kasthuri IBA A/c Indian Overseas Bank


5. Date of Repudiation Not applicable

6. Reason for repudiation Not applicable


8. Nature of Complaint Non-settlement of claim


03.02.2020




INR 12,612


INR 12,612


20.01.2020





25 For the Complainant Mr. V Palaniappan

26 For the Insurer Mr. K P Divyaraj




The complainant and his spouse are covered under Tailor Made Group Health Policy

issued to Indian Overseas Bank Retired Employees (Option I) which is without domiciliary

treatment coverage. The policy is live since November 2017.

As per Discharge Summary, the complainant‟s wife Mrs. P L Kasthuri was admitted in

SAAM Hospital, Madurai on 07.03.2018 with complaint of increased frequency of stool

and was diagnosed with Idiopathic Constipation. She underwent colonoscopy, and was

discharged on 09.03.2018.

The complainant submitted a reimbursement claim of INR 12,612 to the insurer through

the Bank on 12.03.2018. The TPA of the insurer claimed to have received the claim

documents only on 19.10.2018 and raised a query on 20.10.2018 to submit all original

documents along with ECS details. They also sought the explanation of the complainant

for the delay in submission of documents with approval from the Nodal Officer. On

26.11.2018 the complainant replied that all the documents were already submitted. Since

the TPA had not received the requested original documents, a query was raised once

again on 27.11.2018 for which the TPA did not receive any reply and the claim was closed

on 28.12.2018. On 08.11.2019, the TPA received the original colonoscopy report and

ECS details and on 04.12.2019 they asked the complainant to submit the originals of

remaining documents to which there was no response. Hence, the claim was once again

closed on 23.12.2019.

The complainant approached the Forum vide his letter dated 06.11.2019, seeking Forum‟s

intervention for settlement of his claim. The Forum directed him to represent the matter to

the insurer and accordingly he appealed to the insurer vide his letters dated18.12.2019

and 30.01.2020 to reconsider his claim. Since he did not receive any reply from the

insurer, the Forum has taken up the complaint for adjudication.


The complainant submits that his wife took treatment for frequent diarrhoea and

the claim bills were submitted to the insurer on 12.03.2018 through IOB NVB

Street Branch, Madurai.

He also submits that the treatment was taken as per treating doctor‟s advice.

He informed the TPA vide his letter dated 07.11.2018 that there was no delay in

submitting the claim as alleged, since all documents were submitted by him on

12.03.2018 through the Bank. On the contrary, there was delay on the part of

TPA in responding to his submission.

There was no response from the insurer until 02.02.2019 when they asked for

additional documents and the same were submitted.

Since his claim is not settled till date despite his representations, he has

requested the Forum to direct the insurer to settle the claim.


The RI have submitted their SCN and have stated that during hospitalization, the

insured was treated conservatively with enema, oral tablets and has undergone

diagnostic procedure of colonoscopy.

She was hospitalized only for diagnostic test which was not followed by any active

line of treatment.The diagnosis and complaint on admission were contradictory.

The treatment administered did not warrant hospitalization. Hence query was

raised by the TPA to submit all original documents including Discharge Summary

with exact diagnosis and line of treatment given in the hospital, since only

photocopies had been submitted earlier. ECS details were also requested.

The RI received a reply from the complainant stating that the documents were

already sent, on 26.11.2018. Since they did not receive the requisite original

documents even after several reminders, the claim was closed.

Since the TPA received the original colonoscopy report and ECS details on

08.11.2019, the claim was re-opened on 04.12.2019 with a request to submit the

remaining original documents. In reply they received the same documents as

before. Therefore, the claim was once again closed on 23.12.2019.

The treating doctor has issued a certificate stating that the patient was admitted for

diarrhoea and was treated for the same, which was received on 24.12.2019. Since

the treatment did not warrant hospitalisation, the claim was closed.

The claim was processed as per Clause 4.7 of the policy which reads as ”Charges

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 of presence of any ailment, sickness

or injury, for which confinement is required at a Hospital/Nursing Home, unless

recommended by the attending doctor”.


Rules, 2017, which reads as ”Any partial or total repudiation of claims by the Life Insurer,




Complainant‟s representations dated 18.12.2019 and 30.01.2020 to the Insurer

Consent (Annexure VI A) submitted by the Complainant dated 30.01.2020




Discharge Summary/Indoor Case Papers (ICP)/Bills of SAAM Hospital, Madurai

Certificate issued by Dr. A S AJegannathan

Certificate of Dr. A. Rengarajan dated 09.03.2018


Referral letterfromDr. A Rengarajan to Dr.Jegannathan dated 15.02.2018

Claim repudiation letter of the insurer undated (post-hearing) 24. Result of hearing (Observations & Conclusion)

Mr. V Palaniappan, Complainant and Mr. Divyaraj, insurer‟s representative

attended the hearing.

During the hearing the complainant submitted that he had submitted all the claim

related documents to the Bank through whom he had availed insuranceon

12.03.2018 itself. But the claim is pending for settlement for the past two years.

The RI submitted that the complainant did not submit the requested original

documents but had repeatedly sent the documents (copies) which were already

submitted earlier. The claim could not be processed due to non-submission of

requisite documents.

There is a delay of one month in submitting the SCN by the insurer. This Forum

records its displeasure over late submission of SCN and advises the insurer to be

prompt in complying with the Forum‟s requirements in future.

Insurer‟s failure to respond to the representations of the complainant is violative of

the guidelines issued by IRDAI for redressal of customer grievances by insurance

companies. Insurer is advised to strictly comply with the guidelines.

During the hearing the insurer were advised to convey their final decision on the

claim before 24.03.2020, in the absence of a categorical communication from them

to the complainanttill then regarding the status of the claim. They have since

repudiated the claim and forwarded to the Forum a copy of their undated letter to

the complainant communicating their decision. It is observed that the claim has

been rejected citing clause no. 4.7 of the policy, on the ground that the treatment

given did not warrant hospitalization.

It is observed from the indoor case papers that the insured was admitted for

evaluation of diarrhoea and had no complaints at the time of hospitalisation. It

appears that even the enema given to her while in hospital was in preparation for

colonoscopy. The discharge summary does not provide details of the treatment

given in hospital and merely mentions „Colonoscopy done‟ against the entry

„Therapeutic Procedures”. Course of treatment in the hospital is stated to be

uneventful. It is observed from the certificate dated 09.03.2018 issued by Dr. A.

Rengarajan who treated the insured initially that she was under his care from

01/02/2018 for Enteritis and was referred to Gastroenterologist for Colonoscopy.

As per his referral letter dated 15.02.2018 to Dr. Jegannathan, Gastroenterologist,

the insured had the history of diarrhoea for six months and her CT abdomen was

normal. The colonoscopy was performed only on 08.03.2018, 3 weeks after the

referral and the results were normal. It is therefore evident that the condition of the

insured did not warrant hospitalisation and she was hospitalised only for

Colonoscopy. Although the complainant claimed in the hearing that his wife had to

be hospitalised due to high blood pressure, diabetes and weakness, the medical

records do not support his contention, nor is there a specific recommendation from

the treating doctor that her condition warranted admission. The certificate issued by

the doctor merely stated that she was admitted for diarrhoea and treated.

Hence insurer is right in concluding that the claim is not admissible under clause

4.7 of the policy which excludes expenditure incurred primarily for diagnostic

purpose.

While the claim is not admissible, the insurer is at fault for delaying and not

communicating their decision to close/reject the claim to the complainant. In the

opinion of the Forum the documents which were already in possession of the

TPA/insurer were sufficient to take a decision regarding the claim and there was no

need to insist on the originals. They also failed to respond to the

reminders/representations made by the complainant regarding delay in settling the

claim.Although there is deficiency of service on the part of the insurer, the Forum is

not in a position to award any compensation or interest for delay, since the claim of

the complainant is inadmissible.



Dated at Chennai on the 31st day of March, 2020.


INSURANCE OMBUDSMAN


AWARD


made by both the parties during the course of hearing, the Forum concludes

that complainant‟s claim is not admissible under the policy.

Thus, the complaint is not allowed.

PROCEEDINGS BEFORE




CASE OF Mr V S Narayanan Vs The New India Assurance Company Ltd




Mr V S Narayanan Flat No. 4, First Floor 13/14, Parameshwari Nagar First Street, Adyar, Chennai 600020

2. Policy No: Type of Policy Duration of policy/Policy period

310300/34/19/04/00000001 Group Mediclaim Policy 11/07/2019-10/07/2020

3. Name of the insured Name of the policyholder/Proposer

Mr V S Narayanan Steel Authority of India Ltd (SAIL)

4. Name of the insurer The New India Assurance Company Ltd


6. Reason for repudiation

Age Related Macular Degeneration (ARMD) exclusion

7. Date of receipt of the Complaint

09/01/2020

8. Nature of complaint Non-settlement of the claim

9. Date of receipt of consent ( Annexure VIA)

06/02/2020


11.

Amount ofMonetary Loss (as per Annexure VIA)

Not furnished

12. Amount paid by Insurer if any Nil


INR 15,091


29/01/2020



Rule no. 13(1)(b) of the Insurance Ombudsman Rules, 2017


17. Representation at the hearing For the Complainant Mr V S Narayanan

For the insurer Mr D Abhishek

18. Disposal of Complaint By Award 19. Date of Award/Order 31/03/2020


ComplainantMr V S Narayanan, is covered under respondent insurer‟s Group Mediclaim

Policy issued to Steel Authority of India Ltd (SAIL) for the period from 11/07/2019 to

10/07/2020. He had undergone Capsulotomy&Iridotomy and thereafter intravitreal

injection of Lucentis under local anesthesia for treatment of Choroidal Neovascular

Membrane (CNM). Claim preferred for the treatment undergone was repudiated by insurer

since intravitreal injection of drugs like Lucentis falls outside the scope of the policy as per

clause 10.12 thereof. Aggrieved by the repudiation of the claim, complainant represented

to the Grievance Department of the insurer for reconsideration of the claim, other than the

cost of Lucentis injection. Since there was no reply from them, he has approached this

Forum for redressal.

21)a) Complainant’s submission:

Complainant submitted that he had undergone Capsulotomy/Iridotomy to clean both his

eyes and thereafter injection Lucentis was administered on intravitreal mode. Initially

exhaustive investigations such as Coherence Tomography scan and Fundus Fluorescein

Angiography scan were done to preserve the vision of right eye as the complainant has

already lost total vision in the left eye. Reimbursement claim preferred was rejected by

insurer on the ground that injection of Lucentis is exclusion as per policy. Out of the total

amount incurred of INR 39846, cost of Lucentis injection is INR 24,755. Since Lucentis is

under policy exclusion, balance amount of INR15,091 is payable and Forum‟s intervention

is requested for settlement of the same.

b) Insurer’s contention:

Complainant consulted Rajan Eye Care for check-up and on thorough investigation by

means of Coherence Tomography Scan & Fluorescein Angiography, the treating doctor

opined that the complainant has lost total vision in left eye due to formation of scar tissue

beneath the retina in full and loss of vision is in the beginning stage in the right eye. This

condition is called Age Related Macular Degeneration (ARMD). Insured was treated by

Capsulotomy/Iridotomy to clean both eyes, seal leaking blood vessels and inhibit their

growth. This was followed by Intravitreal injection of Lucentis to restore normal vision /to

prevent deterioration of vision. As per policy clause 4.4.23 of New India Flexi Floater

Group Mediclaim Policy (IRDAI/HLT/P-H/V.II/340/15-16) and also exclusion 46.0 (xii) of

the SAIL Tender document, treatment ofARMD with injection Avastin /Lucentis /Macugen

is an exclusion. Hence the claim was repudiated.

22)Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance Ombudsman

Rules, 2017, which deals with “Any partial or total repudiation of claims by the life insurer,

General insurer or the health insurer”.

23)The following documents were placed for perusal.


Claim repudiation letter of the Insurer addressed to SAIL



Self-Contained Note (SCN) of the insurer undated

Claim form dated 18/09/2019

Discharge summary of Rajan Eye Care Hospital, Chennai

SAIL Mediclaim Scheme 2019-20 (Tender document)


a) The Forum records its displeasure over delay in submission of SCN by the insurer.

Similarly, the lack of response to the representations made by the complainant is a

matter of concern. It is hoped that the insurer will strengthen its customer

grievance redressal mechanism and avoid such lapses infuture.

b) Claim was repudiated by insurer quoting clause 10.12 of the policy which reads as

under:

Clause

No.

Description

10.12 Treatment for age related Macular Degeneration with

injection Avastin /Lucentis /Macugen

c) Treatment undergone on 20/08/2019 with Intravitreal injection of Avastin falls under

the above exclusion and hence the amount incurred of INR 27,000 is not payable.

d) Complainant incurred INR 11573 on 16/08/2019 for undergoing

Capsulotomy/Iridotomy. Both Capsulotomy&Iridotomy are ophthalmic surgical

procedures.

e) Insurer did not produce the policy wording. However, they submitted a copy of the

tender document issued by SAIL (Request for Quotation – RFQ) for the coverage.

As per clause 42.0 of said document, if ophthalmic surgery is taken in the

hospital/nursing home and the insured is discharged on the same day, the

treatment will be considered to be taken under Hospitalization Benefit.

f) In the opinion of the Forum, it is only the cost of injection of Lucentis which is

excluded by the policy (clause 46.xii of the tender document) and the cost of

Capsulotomy/Iridotomy the complainant had undergone is admissible as

Hospitalization Benefit under clause no. 42 of the tender document.

AWARD


made during the course of hearing by both the parties, Forum concludes that the

repudiation of the claim by insurer is not in order. Insurer is hereby directed to settle

the claim of the complainant for INR 11,573 along with interest as defined under

Rule 17 (7) of Insurance Ombudsman Rules, 2017.

Thus, the complaint is allowed






b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant shall

be entitled to such interest at a rate per annum as specified in the regulations, framed

under the Insurance Regulatory and Development Authority of India Act, 1999, from the

date the claim ought to have been settled under the regulations, till the date of payment of

the amount awarded by the Ombudsman.



Dated at Chennai on the 31st day of March, 2020




OMBUDSMAN - Shri M Vasantha Krishna CASE OF Mr. T S Sridharan Vs United India Insurance Company Limited




Mr. T S Sridharan, No.10/1A, Sri Vidhya Apartments, AlwarthirunagarAnnexe, 2nd Main Road, Chennai 600 087.

2. Policy Nos. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

0411002817P103305667 & 0411002819C063971001 Tailormade Group Health Policy 11.04.2017 to 10.04.2019 & 11.04.2018 to 10.07.2019 INR 4 lakhs


Mrs. Gayathri Devi & Mr. T.S. Sridharan Steel Authority of India Ltd a/c Mr. T S Sridharan


5. Dates of Repudiation Various

6. Reason for repudiation Exclusion 5.8 - Fraudulent claim


8. Nature of Complaint Repudiation of Hospitalisation Claim and 10 nos. domiciliary treatment (OPD) claims


06.02.2020




INR 1,53,890


INR 1,53,890


28.01.2020





a) For the Complainant Mr. T S Sridharan

b) For the Insurer Mr. K P Diviyaraj Dr. ShaheethPeeran



The complainant, is covered under Group Mediclaim Policy issued by Respondent Insurer

(RI) to cover retired employee of Steel Authority of India (SAIL). The complainant and his

spouse are the beneficiaries under the policy for a clubbed Sum Insured (SI) of INR 4

lakhs (INR 2 lakhs each). The scheme is operative for the years 2017-18 and FY 2018-19.

As per Discharge Summary, on 27.07.2017 the complainant‟s wife Mrs. Gayathri Devi was

admitted in Vasuki Hospital, Chennai and was diagnosed with Grade III Osteoarthritis in

both the knees, underwent arthroscopic lavage, debridement treatment and Intra Articular

injection for osteoarthritis and was discharged on 29.07.2017.

The complainant submitted a reimbursement claim for INR 1,42,000 on 11.08.2017 for his

wife‟s treatment. The claim was repudiated citing Condition No.5.8 of the policy and also

as per Clause 46 of the Tender Document issued by SAIL, which are reproduced below.

Condition No.5.8 - The Company shall not be liable to make any payment under this

policy in respect of any claim if such claim be in any manner fraudulent or supported by

any fraudulent means or device whether by the Insured Person or by any other person

acting on his behalf.

Clause 46 of Tender - Misuse of Scheme: Stringent action to be taken against

individuals found to be misusing the system/guilty of any fraudulent activity, viz. debarring

member from Mediclaim membership, blacklisting hospitals, initiating suitable legal action

etc., as deemed fit by SAIL Management.

The complainant had also submitted 10 domiciliary/out-patient treatment (OPD) claims for

himself and his wife which too were repudiated on the ground that there was manipulation

in the documents submitted in the previous hospitalization claim.

The complainant represented to the insurer regarding non-settlement of the hospitalization

claim and the OPD claims through several mails. Aggrieved by the non-response of the

insurer, he has approached this Forum vide his letter dated 30.12.2019 for redressal of his

grievance.


The complainant states that he had submitted eight OPD claims for INR 9,857 on

22.04.2019 and the RI repudiated one claim on 24.05.2019 and the remaining

seven claims on 29.05.2019 under clause no. 5.8 of the policy alleging that there

was manipulation in the submitted documents in respect of the previous

hospitalization claim of the year 2017, The letters of repudiation were addressed

to SAIL and he did not receive any direct communication either from SAIL or from

the RI. Thereby he was deprived of the opportunity of substantiating his claims to

the insurer.

As regards the hospitalization claim submitted on 11.08.2017, the TPA had

informed the complainant after a long delay on 19.06.2018 that the claim has

been rejected under clause no. 46 of the „policy‟ as there is manipulation in the

claim documents. He was also advised that the final decision in the matter will be

taken by the RI. But till date there is no response from the RI.

Earlier, two more OPD treatment claims were submitted on 23.04.2018 for INR

543 and INR 1,490 respectively for which too there was no response from the

TPA. On his representation and follow-up, theyinformed himin the month of May

2019 vide their Grievance ID Nos. 7792074 and 7792095 that the claims were

wrongly closed and will be reprocessed. But there has been no further

communication since then.

He also submits that the RI has not provided any policy copy to him.

He has escalated his grievance at all levels with the RI and since there is no

response, he has approached this Forum to direct the insurer to settle all the

claims.


The complainant and his spouse are covered under Group Mediclaim policy issued

to retired employees of SAIL.

His wife was reportedly admitted in Vasuki Hospital for the treatment of Grade III

Osteoarthritis Right Knee from 27.07.2017 to 29.07.2017.

Claim for INR 1.42 lakhs was lodged by him with the RI on 11.08.2017.

As per MOU with SAIL, any claim beyond INR 1 lakh will be subject to

investigation. Since the above claim is for INR 1.42 lakhs, the RI conducted

investigation of the case.

During the course of investigation by TPA, it was found that the complainant had

lodged the claim fraudulently, dishonestly, criminally and illegally with forged,

fabricated, bogus and false documents in furtherance of his wrongful gain.

The claim was repudiated as per Clause 5.8 of the policy and Clause 46 of the

Tender Document forming part of the policy.

The letter issued by Dr. M C Satish Raja, MBBS, MS Ortho of Vasuki Hospital

stating that the patient named Mrs. Gayathri Devi, 54 years/female has not been

admitted and treated in the hospital at any point of time, evidences the fraudulent

nature of the claim.

As regards the OPD claims, the RI submitted that all the 10 claims have been

rejected since on investigation, the previous claim for insured‟s hospitalization was

found to be fraudulent.


Rules, 2017, which deals with‟Any partial or total repudiation of claims by the Life Insurer,

General Insurer or the Health Insurer‟.



Claim repudiation letter of the Insurer undated and unsigned

Complainant‟s representations dated 15.09.2019and 16.12.2019 to the Insurer


Self-Contained Note (SCN) of Insurer


Claim Form

Discharge summary/Bills of Vasuki Hospital, Chennai


Certificate issued byDr. M C Satish Raja, MBBS, MS Ortho, Vasuki Hospital

Certificate issued by Dr. C.S. Raviprasad, the treating doctor, dated 22.01.2018

Investigation report of the TPA

24. Result of hearing (Observations & Conclusion)

Mr. T S Sridharan, complainant, Mr. K P Divyaraj, insurer‟s representative and Dr.

ShaheethPeeran, representative of TPA attended the hearing.

The insurer submitted a copy of the repudiation letter in respect of the

hospitalization claim post hearing along with the SCN, but the same was found to

be undated and unsigned. It was observed that the claim was repudiated under

clause 5.8 of the policy and clause 46 of the Tender document issued by SAIL in

connection with the policy.

During the hearing, the Forum questioned the RI about Clause 46 of the MOU and

they clarified that the Clause deals with rejection of claims of insured persons with

a history of fraudulent claims.

o However, it is apparent from a reading of the clause reproduced in

paragraph 20 above that the same does not empower the insurer or TPA to

take any action unless deemed fit by the SAIL management. It does not

specifically authorise the insurer to reject a claim on the ground that some

other claim or claims made by the insured was/were found to be fraudulent.

The RI submitted a Certificate from Dr. M C Satish Raja of the treating hospital

stating that the named patient has not been admitted and treated at any point of

time and the records submitted are found to be fake. In response thereto, the

complainant has submitted a certificate from the treating doctor stating that the

patient underwent treatment at the hospital.

Though the complainant has submitted a certificate from the treating doctor, the

hospital and Dr. M C Satish Raja (another doctor working with the same hospital)

havedenied the admission of the insured in the hospital at any point of time and

have clearly mentioned that records submitted are fake.

In addition, the investigator of the TPA who visited the hospital has also confirmed

that the insured was not admitted to the hospital and the case documents are not

available with them. Entries of patient‟s admission and treatment are not found in

the hospital register and system. Hence the investigator concluded that the claim is

fraudulent.

It is not clear in what capacity Dr. M.C. Satish Raja has certified that the insured

was not admitted to the hospital. Without indication of the same, the certificate

issued by him cannot be relied upon, especially when the treating doctor has

certified that the patient was admitted and treated. Nevertheless, in view of the

investigation report of the TPA which too confirms that there was no admission, the

Forum comes to the conclusion that the insurer has rightly rejected the claim under

condition no. 5.8 of the policy. However, the rejection of the claim under clause 46

of the Tender issued by SAIL is not in order, since the clause does not explicitly

authorise the insurer to reject claims. On the contrary, the clause concerns itself

with corrective action to be taken by the management of SAIL, in the event of

misuse of the Scheme.

As regards, the eight OPD (domiciliary treatment) claims rejected by the insurer, it

is observed from the rejection letters that clause 5.8 has been invoked for the

rejection. The clause empowers the insurer to reject any claim which is fraudulent

but the insurer has not established that the claims were fraudulent in nature.

Their submission in the SCN was that the claims were rejected because the

previous hospitalisation was found to be fraudulent. However, clause no. 5.8 does

not permit the insurer to reject a claim on such a ground, nor does clause 46 of the

Tender. Hence, the denial of the eight OPD claims is defective.

The insurer also claimed in the SCN that the other two OPD claims were also

rejected on the same grounds as the eight claims referred to in the previous

paragraph. However, no rejection letters have been placed before the Forum by

the insurer in support of their submission. In any case, rejection of the two claims

on the grounds cited in the SCN is not tenable for the reasons explained above.

The Forum records its displeasure over the submission of SCN by the insurer one

month after the hearing. When the SCN is submitted so late, the very purpose of

seeking the document is defeated. It is expected that the insurer will practise strict

adherence to the timelines for submission of SCN, in future.

This Forum also records its strong displeasure over the inadequate response of the

Insurer/TPA to the complainant‟s representations. They are advised to streamline

their grievance redressal system in tune with the guidelines of the Regulator.

Although the Forum upholds the repudiation of the hospitalization claim, the RI is

directed to send a dated and signed letter of repudiation to the complainant for the

sake of good order.

AWARD


made by both the parties during the course of hearing, the Forum is of the view that

the repudiation of the hospitalisationclaim by the insurer is in order and does not

warrant any intervention by this Forum.

However, the insurer is directed to settle the OPD claims (10 nos.) of the

complainant for an aggregate amount of INR 11,890, subject to the terms and

conditions of the policy along with interest as provided under Rule 17(7) of the

Insurance Ombudsman Rules, 2017.The complaint is disposed of accordingly.



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




intimate compliance of the same to the Ombudsman








Dated at Chennai on the 31stday of March 2020.


INSURANCE 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

Case between: Mr. B MURALIDHAR REDDY………………The Complainant Vs M/s Star Health And Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .11.044.0283/2019-20

Award No.: I.O.(HYD)/A/HI/0180/2019-20

1. Name & address of the complainant Mr.B Muralidhar Reddy

H.No. 5-9-48/1/2/202, Flat #202,

Sree La Casa Apartments, Shaili Garden

Road,

Yapral, Secunderabad : 500 087

(Cell No.88868 -86978)

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

P/131116/01/2020/00----

Mediclassic Insurance Policy

22.07.2019 to 21.07.2020

3. Name of the insured Name of the Policyholder

Mrs. Bhavanam Padmavathi

Mrs. Bhavanam Padmavathi

4. Name of the insurer M/s Star Health And Allied Insurance Company

Limited


6. Reason for repudiation Claim attracts renewal clause No. 8 of policy


8. Nature of complaint Claim pertaining to medical insurance policy

9. Amount of Claim Rs. 6,05,000/-


11. Amount of Relief sought Rs. 300,000/-

12. Complaint registered under 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 18.02.2020 / Hyderabad


a) For the complainant Self

b) For the insurer Sri M Ravi Kumar

15. Complaint how disposed Allowed

16. Date of Order/Award 03.03.2020

17) Brief Facts of the Case: The complainant had purchased an annual health insurance policy for his mother from

respondent on 22.07.2014 and had been renewing the same every year. During the policy period

2017-18, he had enhanced the Sum Insured (SI) under the policy from Rs. 3 Lakhs to Rs. 5 Lakhs.

Subsequently, during the policy period 2019-20, she was admitted to Sunshine Hospitals on

24.07.2019 with chief complaints of headache for the past 2-3 days, and giddiness for the past 10

days. On medical evaluation, she was diagnosed with right frontal convexity Meningioma Grade-1,

hypothyroid, hypertension. She was treated in the hospital up to 21.08.2019 and was billed for an

amount of Rs. 13,95,000/- after allowing concession for an amount of Rs. 26,475/-. When her

claim bills were submitted to respondent, they had processed her claim up to her previous sum

insured only. Not satisfied with the reply given by Grievance department with whom he had

represented his matter, he had therefore filed a complaint against respondent to seek the balance

amount up to the present sum insured with the mediation of this Forum.

18) Cause of Complaint: Partial payment of claim under medical Insurance policy. a) Complainant’s argument:

The complainant had stated that the total amount incurred towards the treatment of his mother was Rs. 14.20 Lakhs whereas; the respondent had paid only Rs. 3.15 Lakhs as against the SI of Rs. 6.05 Lakhs. Despite his repeated attempts to convince the respondent to pay the hospital bills up to his present SI, he could not succeed and therefore he had to pay the differential amount to hospital. When the claim bills were submitted to respondent for reimbursement, he had met with disappointment and after repeatedly following up the matter, he was offered an additional amount of Rs. 60,000/-. The reason given by respondent that his mother had been suffering from the said illness prior to the commencement of first policy was appalling. b) Insurer’s argument: The respondent did not submit their Self Contained Note (SCN) to this forum. However, it was apparent from the correspondence made by respondent with the complainant that the claim submitted by him was reviewed after his request to reconsider his claim, and it was found that the insured was entitled to the claim as per the SI under her previous policy which was Rs. 3 Lakhs and the enhanced portion of her SI was not applicable in the instant hospitalization claim as per condition No. 8 of the insurance policy issued to her. Hence, the maximum amount that she was entitled to was paid after deducting the non- payable items under the policy. 19) Reason for Registration of Complaint: The insurer settled partial amount of claim taking into account Sum insured before enhancement. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer

f. Mail communication of insurer dated 14.02.2020. 21) Result of personal hearing with both the parties: Pursuant to the notices given, both the parties attended the personal hearing on 18.02.2020 at Hyderabad by 11.00AM, and the following are the arguments noted. The complainant himself attended the personal hearing and informed us that his mother had medical insurance policy with the respondent insurer for a sum insured of Rs. 3 lakhs since 2014., and renewing continuously. Subsequently the sum insured had been enhanced up to Rs. 5 lakhs with effect from the year 2017-18 and paid the premium for enhanced SI. He further submitted that the insured person been hospitalized for the ailment of Head ache for the past 3 days and for giddiness of past 10 days at Sunshine Hospitals, Secunderabad on 24.07.2019 and Discharged on 31.08.2019, and incurred an amount of Rs. 13,95,000/- towards hospitalization expenses. Noted that when he lodged the claim with insurers, his claim been settled for Rs. 3,75,000/- taking into account the old S.I of Rs. 3 lakhs during the year of 2016-17. Even he made a representation to the grievance cell of the insurer, he could not get the result in his favor., and lot of correspondence had exchanged with insurer in this connection. Hence he filed the present complaint for reconsideration of his claim taking into account the enhanced sum insured of Rs. 5 lakhs which is continuing from 2017-18 to up to the date of claim. The representative of the insurer attended the hearing and informed us that they have reviewed the claim and agreed to process as per the enhanced sum insured of Rs. 5 Lakhs as intimated to Forum as per their mail dated 14.02.2020. Subsequently the insurers settled the complainant’s claim for Rs. 2,30,000/- as per eligible bills and payment also been made through Demand Draft No: 472729/27.02.2020 of HDFC Bank drawn in favour of complainant, as per the mail of the insurer dated 29.02.2020 along with copy of DD sent therewith., which was also acknowledged by the complainant of over phone.

A W A R D

The complaint is treated as Resolved and closed.

Dated at Hyderabad on the 03 rd day of March, 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

STATES OF A.P., TELANGANA & YANAM (Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)


Case between Mrs.K.Ramachandran Malathi ………………The Complainant Vs M/s Star Health & Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -044-1920-0319

Award No.: I.O.(HYD)/A/HI/ 0181/2019-20 1. Name & address of the complainant Mrs.Ramachandran Malathi,

#11-13-90, Road no 2,

Alakapuri colony, Saroornagar,

Ramakrisnapuram, Hyderabad- 500 035.


Type of Policy


P/131127/01/2020/007055

Mediclassic Insurance Policy Individual

4.11.2019 to 3.11.2020


Mrs.Ramachandran Malathi

Mrs.Ramachandran Malathi

4. Name of the insurer M/s Star Health And Allied Insurance Co. Ltd.




8. Nature of complaint Partial settlement of Mediclaim


10. Date of Partial Settlement Rs.1,55,742/- on 2.1.2020.

11. Amount of Relief sought Rs. 1,02,745/-



13. Date of hearing/place 03.03.2020/Hyderabad


a) For the complainant Spouse Mr.S.Ramachandran

b) For the insurer Mr.M.Ravi Kumar, AGM Dr.Annapurna



17) Brief Facts of the Case: The Complainant was covered under Med classic Insurance Policy (Individual) for a sum insured of Rs.2 Lakhs from 4.11.2013 to 03.11.2014 and renewed thereafter. The current policy period was from 4/11/2019 to 03/11/2020. The complainant aged 67 was admitted on 27/11/2019 at Yashoda Super Specialty Hospital, Hyderabad and got discharged on 29/11/2018 for Right Shoulder Complete Rotator Cuff tear where she underwent Arthroscopic right shoulder rotator cuff repair under GA+ right brachial block on 28.11.2019.Out of the total cost incurred Rs.2,58,487/- she was paid Rs. 1,55,742/-. She requests for the balance payment denied by the respondent. 18) Cause of Complaint: Partial settlement of Mediclaim. a) Complainant’s argument: The Complainant felt, out of the total bill amount of Rs.258487/- paid by her , the respondent approved only Rs.155742/- even though the sum insured limit was Rs.250000/-. She was eligible for the difference amount that was denied on pretext that 1) she availed room rent over and above her eligibility and 2) expenses relating to hospitalization were deducted in proportion to the eligible room rent as per policy terms. She states that she was authorized under cashless authorization letter for single room A/c. She was allotted single room A/c but the cost was Rs.5750 in Block A and Rs.6750/- in Block B. It was not clear in her authorization letter that she was eligible for Rs.4000/- per day room. As a good will gesture she was accommodated in Block B but charged for block A. i.e. 5750/-When she has availed room as per eligibility where does the question of deducting other expenses treating it as over and above her eligible limit in everything.?. She claims for full expenses less 10% co pay but without deductibles based on room rent. b) Insurer’s argument: The insurer in their self contained note sent by mail on 10.02.2020 Mrs.Ramachandran Malathi was covered since 7 years under their policy for Rs.2 Lakh sum insured. She was admitted in Yashoda Hospital on 27/11/2019 to 29.11.2019 for surgery of right shoulder complete rotator cuff tear. She was eligible for 2% of S.I of Rs.2 Lakhs as room rent i.e., 4000/-. The payment details are as under: Total hospitalization claimed: Rs.2,58,487/- Non-payables: Rs. 54,148/- Proportionate deduction: Rs. 31,292/- 10% Co pay : Rs. 17,305/- Total Paid Rs.1,55,742/- by way of NEFT on 2.01.2020. List of non –payables disallowed were: room rent difference for two days Rs.3500, OT charges in proportion to room rent Rs.11687/-, Professional fees in proportion Rs.19022/-, Investigation & diagnostic Rs.583/-, other excluded items like blades, cannula easy fix etc 19287/-, implant charge/needle charges Rs.30052/-. Subsequently, pre and post hospitalization expenses for Rs.29,510/- was submitted and they paid Rs.5759/- as per her eligibility vide NEFT on 13/02/2020 disallowing (Rs.7590/- report bill dated 20.11.2019 not submitted, Rs.400 towards vaporizer not paid, no prescription for bills dated 3/12/2019,17/12/2019,24/12/2019,02/01/2020 and 17/01/2020 for Rs.14971/-, no prescription for bill dated 03.12.2019 for Rs.150/-)

19) Reason for Registration of Complaint:

The insurer partially settled the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary, bills c. Rejection letter d. Correspondence with insurer e. SCN and its enclosures 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 03.03.2020. Both the parties reiterated their grounds for and against the complaint. The spouse of the complainant Mr.S.Ramachandran stated, he has been renewing his policy every year since 7 years without making a claim. He did not receive a copy of the terms and conditions. He never took it seriously until the admission of his wife Smt Malathi Ramachandran K at Yashoda Hospital, Hyderabad on 27/11/2019 for right shoulder rotator cuff tear. As per the cashless authorisarzation letter dated 20.11.2019, it was stated, he was eligible for single room a/c and he took a single room a/c in the hospital. It was only during settlement of his bill, he came to know that his room eligibility was Rs.4000 per day and so their claim was proportionately reduced. He contended that they were eligible for the difference amount that was denied on pretext that 1) she availed room rent over and above her eligibility and 2) expenses relating to hospitalization were deducted in proportion to the eligible room rent as per policy terms. She was allotted single room A/c but the cost was Rs.5750 in Block A and Rs.6750/- in Block B. It was not clear in her authorization letter that she was eligible for Rs.4000/- per day room. As a good will gesture she was accommodated in Block B but charged for block A. i.e. 5750/-.When she has availed room as per eligibility where does the question of deducting other expenses treating it as over and above her eligible limit in everything.? He claims for full expenses less 10% co pay but without deductibles based on room rent upto his maximum sum insured of Rs.2 Lakhs and his cumulative bonus of Rs.50,000/-. The insured reported claim in the 7th year of the policy. Mrs.Rama Chandran Malathi was admitted on 27/11/2019 at Yashoda super speciality hospital, Hyderabad and discharged on 29/11/2019 for diagnosis of right shoulder complete rotator cuff tear. She underwent Arthroscopic right shoulder rotator cuff repair surgery under GA+ right brachial block on 28.11.2019.They had settled the claim for Rs.155752/- plus pre and post hospitalization expense of Rs.5759/- vide NEFT dated 2.1.2020 & 13.02.2020 respectively. The claim was processed taking eligible room rent of 2% of the sum insured subject to a maximum of Rs.5000/-. Therefore 2% of their S.I Rs.2, 00,000/- was Rs.4000/- maximum payable per day. Since the insured availed a higher tariff room of Rs.5750/-, the claim was proportionately deducted as under: Total hospitalization claimed: Rs.2,58,487/- Non-payables: Rs. 54,148/- Proportionate deduction: Rs. 31,292/- 10% Co pay : Rs. 17,305/- Total Paid Rs.1,55,742/- by way of NEFT on 2.01.2020 Total pre and post hospitalization expenses paid: Claimed Rs.29,510/- Paid Rs. 5,759/- by Neft on 13.02.2020 Difference unpaid Rs.23,751/- 7590/- no report for bill dated 20.11.2019 400/- cost of vaporizer 14,971/- cost of soft cloth 150/- no prescription for bill dated 3.12.2019 640/- no prescription for bills dated 3.12.2019,17.12.2019,24.12.2019,2.12020,& 17.1.2020. Since, it was a

seventh year policy, they questioned , why did the insured not approach them if he did not receive the terms and conditions of the policy all these years ?. The complainant said he did not take it seriously, as he never claimed till then. The Forum observed:

From the cashless authorization letter dated 20.11.2019 she was eligible for single room A/C , category and she has availed singe room a/c room. As per Terms & Conditions of the policy contract, her eligibility for Room Rent was based on the sum insured i.e., 2% of Sum Insured upto a maximum of Rs.5000/-. Therefore 2% of her eligible sum insured of Rs.2 Lakhs works out to Rs. 4000/- per day. But the minimum room rent in Yashoda Super Specialty hospital block A single room a/c was 5750/-.She was accommodated in Block B with room rent of Rs.6750/- but charged with Block A room tariff as a goodwill gesture.

There seems to be an Agreed Package rate as seen in the Cashless authorization letter Hospital PPN Package. In which case why was she charged extra on her room rent by Yashoda super specialty hospital?. Though the hospital was aware of PPN package and patient was eligible for Rs.4000/-, they had no reason to charge extra over and above the agreed rates. Because of this the patient had to suffer a financial loss on account of proportionate deductions in all areas except medication which is not acceptable. As the patient was not told, the benefit of doubt goes to the insured.

Her claim for the difference Less 10% co pay is justified based on the cashless authorization letter that mentioned her eligible room category as single room A/c and not Rs.4000/- per day.

The respondent has partially settled her claim for Rs.1,55,742 + of Rs.5,759/- post hospitalization expense ie.,Rs.1,61,501/-, whereas she is eligible upto her maximum sum insured is Rs.2.5 Lakhs( Basic sum insured with cumulative bonus of Rs.50,000/-).

Since the insured availed room rent as per the cashless authorization letter only, her claim may be reworked without making proportionate deduction towards higher room rent charged, for which the insured cannot be held responsible. The balance claim may be settled taking co pay of 10% upto her maximum eligible sum insured including cumulative bonus.

AWARD 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 settle the claim without room rent proportionate deduction upto maximum eligible sum insured plus cumulative bonus deducting 10% towards co pay along with interest. 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.

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 4th day of March, 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN





Case between: Mr. B.Vijayapaul Reddy ………………The Complainant Vs M/s Star Health & Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -044-1920-0324

Award No.: I.O.(HYD)/A/HI/ 0182/2019-20

1. Name & address of the complainant Mr. B.Vijayapaul Reddy,

D.No.1-169, Jagannadha Puram,

Veerlapadu Mandal, Jujjuru,

Vijayawada, Andhra Pradesh- 521 181.


Type of Policy


P/131200/01/2019/007977

Family Health Optima insurance

09.01.2019 to 08.01.2020



Mrs.B.Vijaya Sri

Mr. B.Vijayapaul Reddy



6. Reason for repudiation Non disclosure of PED


8. Nature of complaint Rejection of Mediclaim

17) Brief Facts of the Case: The complainant was covered under Family Health Optima Insurance Plan for himself and

his spouse and two children for a floater sum insured of Rs.5 Lakhs from 09.01.2019 to

08.01.2020. The complainant wife Smt B.Viijaya Sri got admitted in Anu Hospitals, Vijayawada on

07.03.2019 for Renal Calculi (Kidney stone). Her cashless claim was denied as the insured found

from the hospital records that the patient was a known case of Psoriasis since 10 years and was

on steroids and the same was not disclosed during policy inception ie., 09.1.2017 with them. As

per condition no 6 of the policy on mis-representation and non-disclosure of material facts the

claim was denied and policy cancelled. Representation given by the complainant to the

respondent did not yield any favorable result. Hence, a complaint was filed by him in this Forum

against the respondent.

18) Cause of Complaint: Rejection of Mediclaim.

a) Complainant’s argument:

The complainant informed he was insured with the respondent since 09.01.2017 for a

floater sum insured of Rs.5 Lakhs and have been renewing the same continuously since then. All

pre existing health conditions of his family members were revealed in the proposal form. His wife

visited a dermatologist in Archana skin and Kidney care centre, Vijayawada in January 2019 for

skin allergy. On 07.03.2019 she was admitted at Anu Hospital, Vijayawada for treatment of Kidney

stones. In the said hospital records it was written by mistake that she suffered from P Psoriasis

since 10 years and was on steroids. He was surprised how she could be suffering from 10 years

when it was diagnosed only in January 2019. He produced first consultation of her skin allergy

from Archana skin and kidney center. However, it was not considered, his claim was denied and

policy cancelled. He requests the Forum for payment of his claim as well as revival of his policy.

9. Amount of Claim Rs. 64,000/-

10. Date of Partial Settlement ------




13. Date of hearing/place 2020/Hyderabad



b) For the insurer Sri M Ravi Kumar.& Dr Annapurna



b) Insurer’s argument: The insurer submitted his SCN on 25.02.2020. However from the SCN and rejection letter it can be inferred that the insured underwent treatment for right upper ureteric renal calculus on 07.03.2019 at Anu Hospitals, Vijayawada. Although the present admission and treatment was for right upper ureteric renal calculus, it was observed from letter of DR.M.Satheesh of the said hospital while processing cashless request, that Mrs.Vijaya sri was a known case of Psoriasis since 10 years and on steroids which confirms that she had psoriasis prior to date of commencement of first year policy ie, 09.01.2017. Hence, the claim was denied as per condition no 6 of the policy for mis-representation and non disclosure of pre existing disease.

19) Reason for registration of complaint: The claim preferred by the complainant was rejected by the insurer on the ground of non-disclosure of material facts and denied as per policy conditions. As the complaint falls under rule 13.1(b) of Insurance Ombudsman rules 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with conditions. b. Proposal form c. Discharge summary of Hospital d. Claim rejection letter e. Hospital bill f. Doctor certificates. g. Self Contained note by Insurer.

21) Result of personal hearing with both the parties: Pursuant to the notices given, both the parties attended the personal hearing on 03.03.2020 at 11.00 AM in Hyderabad, and noted the following arguments: The complainant himself attended the personal hearing and informed us that he had health insurance policy including his family members for a floater sum insured of Rs. 5 Lakhs since 09.01.2017 and continuously renewing up to 08.01.2020. He submitted that as his wife suffered from pain in right loin region, she was taken to M/s Anu Hospital, Vijayawada and diagnosed the ailment as ‘Right Upper Uretric Calculus’ (Kidney Stone) and admitted on 07.03.2019, and discharged on 12.03.2019 after treatment in stable condition. During hospitalization, cashless authorization was denied and the claim for reimbursement of expenses also been rejected due to the reason that she had the problem of psoriasis since 10 years, said to be not disclosed in proposal form as pre-existing disease, and hence cancelled the policy besides rejecting the claim. Even the complainant referred the matter to the grievance cell of the insurers, he could not get the positive reply from them in his favor. Hence he filed the present complaint for redressal. The representatives of the insurers attended the hearing, and contended as per the points raised in SCN briefly stating that as per the letter of the attending doctor in hospital, they noted

that the insured patient is a known case of psoriasis having suffered since 10 years and was on steroids. They stated that as per their findings, it is presumed that the patient is a known case of Psoriasis which was not declared in proposal form pertaining to the first year of policy issued during 2017, and confirmed their decision of repudiation due to non-disclosure of material facts while issuing the first policy during 2017. On hearing the arguments on both sides, the Forum observed the following: The skin disease of psoriasis as per literature been noted as under:

“Psoriasis is a long-lasting autoimmune disease characterized by patches of abnormal skin. These skin patches are typically red, or purple on some people with darker skin, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete body coverage. Psoriasis is caused, at least in part, by the immune system mistakenly attacking healthy skin cells. If you're sick or battling an infection, your immune system will go into overdrive to fight the infection. This might start another psoriasis flare-up. Strep throat is a common trigger.”

When the insurer raised the query letter to the hospital regarding history of psoriasis, the attending doctor certified that the patient had psoriasis since 1 year (looking like as 10 year & not used plural as ‘years’) and certified to be as a localized type and she was on medication since then. Subsequently, the attending doctor had again certified that the insured patient was taking treatment for psoriasis since 30.01.2019 under a dermatologist, and by mistake they mentioned the psoriasis history as 10 year being actual period is only 1 year. Further, it is also noticed that the respondent insurer was solely relying on the certificate issued by the doctor that the patient was suffering from Psoriasis for the past 10 years. But, the same doctor issued a kind of corrigendum stating that the patient was being treated for Psoriasis for the last one year. The respondent insurer never confronted the doctor in respect of two different versions and failed to ascertain any clarification, nor medical records or any consultation papers to substantiate their argument that the patient was having Psoriasis for the last 10 years. It also unlikely that patient being lady, didn’t consult any doctor if she was having for 10 years.

Hence significance can be given to the first consultation slip at M/s Archana Skin & Kidney Care, Vijayawada dated 30.01.2019 issued by the Dermatologist concerned, which was submitted during hearing by the complainant, supports the recent history of psoriasis for the past 1 week, which is falling very well after the issuance of first policy. The Forum also believes that no prudent man can wait for 10 years having suffered from the symptoms of psoriasis without medication, and it can be safely presumed that it might not be a known case for the insured person before taking the policy during 2017. Under the above circumstances, the Forum feels that the decision of repudiation of claim by the insurer is unjust, and the insurer is directed to process the complainant’s claim as per eligible bills, and advised to restore the policy from the date of cancellation.

AWARD

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

the parties during the course of the personal hearing, the insurer is directed to process the

complainant’s claim as per bills eligible, and advised to restore the policy from the date of

cancellation.

Hence the complaint is Allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance


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.


( I SURESH BABU )

INSURANCE OMBUDSMAN




Ombudsman - Shri I. SURESH BABU IRS

Case between: Mr. M. SWAMY NAIDU………………The Complainant Vs M/s The New India Assurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -049-1920-0294

Award No.: I.O.(HYD)/A/HI/ 0183 /2019-20

Name & address of the complainant Mr. M. Swami Naidu

#6-2-6/6, Mahipala Street,

Amalapuram,Andhra Pradesh State-533 201.

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

12030034180400000011

Group Mediclaim policy

01.09.2018 to 31.08.2019


Mr. M Swamy Naidu

M/s Life Insurance Corporation Of India

4. Name of the insurer M/s The New India Assurance Co. Ltd.

5. Date of Repudiation Not processed

6. Reason for repudiation Request for further documents


8. Nature of complaint Delay in settlement of Mediclaim




12. Complaint registered under Rule No.13 (a) of Ins. Ombudsman Rules, 2017

Rule 13.1 (a) – any delay in settlement of claims by the Life insurer, General Insurer or the Health insurer.

13. Complaint how disposed Allowed (Stastical award)


15 )Brief Facts of the Case:

The complainant, 75 years old and an agent of LIC of India was covered under group health insurance

policy for a period of 1 year. On 08.01.2019, he was admitted in Apollo Hospitals because of onset of acute

slur in his speech associated with weakness of his right upper and lower limbs. CT scan of his brain was

done along with MR angiogram, 2D Echo and carotid Doppler. Tests revealed cardiovascular accident with

right hemiplegic and sub cortical aphasia. He was treated conservatively with anti diabetic medicines, anti

hypertensive medicines, anti-platelets, statins followed by physiotherapy and other supportive measures

before he was discharged in a stable condition on 20.01.2019. He had submitted his claim bills to

respondent in March 2019. The TPA of respondent M/s Mediassist India who had processed the claim on

behalf of respondent had raised certain queries which were promptly attended to. Despite his submission

of all the documents, his claim was not settled till date. Vexed with the delay in settlement of his claim, he

had therefore approached this Forum.

16) Cause of Complaint: Delay in settlement of Mediclaim 17) Reason for Registration of Complaint: The claim preferred by the complainant was Delay in settlement of Mediclaim by the insurer. As the complaint fell under Rule 13(a) of Insurance Ombudsman Rules, 2017, it was registered. After registration of complaint by this Forum and on the day of hearing on 06.02.2020 , the insurer further reviewed the claim and processed it and agreed to settle the claim for Rs.1,44,476/-. The Complainant accepted the settlement and informed us over mail on 05/03/2020. The insurer settled the claim on 18/02/2020 by way of NEFT for Rs.1,44,476/- ( One lakh forty four thousand four hundred and seventy six only).

AWARD

The complaint is treated as resolved and closed.


( I SURESH BABU )

INSURANCE OMBUDSMAN





Case between: Mr. RASIQ ALI KHAN………………The Complainant Vs M/s Star Health And Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -044-1920-0278

Award No.: I.O.(HYD)/A/HI/ 0184 /2019-20 1. Name & address of the complainant Mr. Rasiq Ali Khan

# 3-6-188/1, Street #4,

Besides St. Peter’s Government High school,

Hyderguda, Himayathnagar,

Hyderabad,Telengana State -500 029

(Cell No.99511 -40177)


Type of Policy


P/700001/01/2019/045224

Senior Citizens Red Carpet Health Insurance Policy

19.02.2019 to 18.02.2020



Mr. Hussain Ali Khan

Mr. Rasiq Khan

4. Name of the insurer M/s Star Health And Allied Insurance Company Limited


6. Reason for repudiation Non- disclosure of pre- existing disease


8. Nature of complaint Claim pertaining to Medical Insurance






13. Date of hearing/place 03.03.2020 / Hyderabad



b) For the insurer Mr.M.Ravi Kumar, AGM Dr.Annapurna



17) Brief Facts of the Case: The complainant had purchased senior citizens red carpet health insurance policy from respondent to

cover the health of his father who was 75 years old. The effective date of insurance policy was from

19.02.2018. A claim made in the policy period towards his father’s hospitalization was not considered. The

policy was renewed for a further period of 1 year from 19.02.2019. And the claim made in that renewal

policy period was also rejected by respondent on the premise that Chronic Kidney disease (CKD) of his

father for which he had undergone treatment was not disclosed by him at the time of filling in the proposal

form. Aggrieved by this decision, he had approached this Forum.

18) Cause of Complaint: Rejection of claim under medical Insurance policy. a) Complainant’s argument:

The complainant had stated that the respondent was aware of the insured being a CKD patient in the year 2018 when the first claim of his father which was lodged with them was denied then; hence there was no reason for them to send him the renewal letter when the same was meant to be not covered under the policy. Further, he had renewed the policy only after he had received confirmation multiple no. of times from respondent that CKD shall be covered from the 2nd year onwards. He had also referred the rejection of his previous claim pertaining to his father’s CKD treatment which was prior to the renewal of policy as being sufficient proof for respondent to be aware of pre-existing disease at the time of renewal of his father’s policy with them. He had therefore insisted that the claim should be honored by respondent as promised by them which was to pay him 50% of the total bill as co-payment and to reinstate the policy which was cancelled. The complainant had also brought sec 65(B) of Indian Evidence act as educated by his lawyer which says that any electronic act which can be printed on a paper, stored, recorded or copied in optical or magnetic media produced by a computer shall be deemed to be a document. b) Insurer’s argument: The respondent submitted their Self Contained Note (SCN) to this forum on 10.01.2020. The respondent covered Mr.Hussain Ali Khan under senior citizens red carpet policy for a sum insured of Rs.10 Lakhs commencing from 19/02/2018 to 18/02/2019 and later enchanced the sum insured to Rs.15 Lakhs during subsequent renewal. The insured has declared PED of Prostrate and its complications, DM & HTN and their complications during policy inception. When they received cashless request for the first hospitalization in the 3rd month of the policy for Anxiety related issue on 15/05/2018, they had sent a query letter dated 16/05/2018 as they observed from the ICP papers he was a known case of Chronic Disease and Coronary Artery Disease, asking him to submit details of CKD and CAD first diagnosed and its duration, past hospitalization records, past USG abdomen reports along with cardiac documents, past dialysis chart and clarification of any past cardiac surgery done. They did not receive any reply. The cashless approval was denied and the insured never submitted the medical documents for reimbursement of his claim. The policy was renewed in good faith with an enhanced sum insured of Rs.15 Lakhs. After renewal of the policy on 17/04/2019 the father of the complainant was once again admitted in Apollo Hospital, Hyderabad with diagnosis of cardiac arrest. They received cashless request for Rs.1,30,000/-approximately. On scrutiny of ICP papers the insured was a known case of Chronic Kidney Disease for the past 3 years. Since the duration of 3 years falls prior to policy inception, it amounts to non-disclosure of material facts of pre existing disease. To specific questions asked in the proposal form under Medical Declaration at the time of policy inception, “Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/cancer/Renal disorder/Alzheimer’s disease/Parkinson’s disease”- the insured replied in negative which is clearly a Non-disclosure of material fact. As per condition no.9 of the policy “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”. As per condition no 13. Of the policy “the company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact as declared in the proposal form/ at the time of claim or non co.operation of the insured person”. The policy was cancelled w.e.f., 01/06/2019 for non-disclosure of PED Chronic Kidney Disease after sending 30 days notice on cancellation to the insured vide letter dated 22.04.2019 and premium amount of Rs.26,550/- was refunded on 28/05/2019. After denial of cashless claim, the insured did not seek reimbursement of the claim. 19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures 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 03.03.2020. The complainant stated he had insured his father Mr.Hussain Ali Khan, aged 74 years with the respondent under their Senior Citizens Red Carpet Health Insurance policy commencing from 19/02/2018 to 18/02/2019 for a sum insured of Rs.10 lakhs, declaring pre existing diseases as 1) Disease of Prostrate and their complications and 2) Diabetes and Hypertension and their complications. He had not disclosed CKD/CAD of his father inadvertently. His father was admitted in Vasavi Hospital on 15.05.2018 for general weakness and this claim was denied by the insurer on the grounds that the patient is a k/c/o CKD and CAD. His father was admitted for the second time in Apollo Hospital for cardiac arrest on 17/04/2019. His second claim was again rejected for non disclosure of PED. The complainant had stated that the respondent was aware of the insured being a CKD patient in the year 2018 when the first claim of his father which was lodged with them was denied then; hence there was no reason for them to send him the renewal letter when the same was meant not to be covered under the policy. Further, he had renewed the policy only after he had received confirmation multiple no. of times from respondent that CKD shall be covered from the 2nd year onwards. He had also referred the rejection of his previous claim pertaining to his father’s CKD treatment which was prior to the renewal of policy as being sufficient proof for respondent to be aware of pre-existing disease at the time of renewal of his father’s policy with them. He had therefore insisted that the claim should be honored by respondent as promised by them which was to pay him 50% of the total bill as co-payment and to reinstate the policy which was cancelled. The complainant had also brought sec 65(B) of Indian Evidence act as educated by his lawyer which says that any electronic act which can be printed on a paper, stored, recorded or copied in optical or magnetic media produced by a computer shall be deemed to be a document. The respondent covered Mr.Hussain Ali Khan under senior citizens red carpet policy for a sum insured of Rs.10 Lakhs commencing from 19/02/2018 to 18/02/2019 and later enchanced the sum insured to Rs.15 Lakhs during subsequent renewal. The insured has declared PED of Prostrate and its complications, DM & HTN and their complications during policy inception. When they received cashless request for the first hospitalization in the 3rd month of the policy for Anxiety related issue on 15/05/2018, they had sent a query letter dated 16/05/2018 as they observed from the ICP papers he was a known case of Chronic Disease and Coronary Artery Disease, asking him to submit details of CKD and CAD first diagnosed and its

duration, past hospitalization records, past USG abdomen reports along with cardiac documents, past dialysis chart and clarification of any past cardiac surgery done. They did not receive any reply. The cashless approval was denied and the insured never submitted the medical documents for reimbursement of his claim. The policy was renewed in good faith with an enhanced sum insured of Rs.15 Lakhs. After renewal of the policy on 17/04/2019 the father of the complainant was once again admitted in Apollo Hospital, Hyderabad with diagnosis of cardiac arrest. They received cashless request for Rs.1,30,000/-approximately. On scrutiny of ICP papers the insured was a known case of Chronic Kidney Disease for the past 3 years. Since the duration of 3 years falls prior to policy inception, it amounts to non-disclosure of material facts of pre existing disease. To specific questions asked in the proposal form under Medical Declaration at the time of policy inception, “Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/cancer/Renal disorder/Alzheimer’s disease/Parkinson’s disease”- the insured replied in negative which is clearly a Non-disclosure of material fact. As per condition no.9 of the policy “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”. As per condition no 13. Of the policy “the company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact as declared in the proposal form/ at the time of claim or non co.operation of the insured person”. The policy was cancelled w.e.f., 01/06/2019 for non-disclosure of PED Chronic Kidney Disease after sending 30 days notice on cancellation to the insured vide letter dated 22.04.2019 and premium amount of Rs.26,550/- was refunded on 28/05/2019. After denial of cashless claim, the insured did not seek reimbursement of the claim. The forum made the following observations:

At the time of purchasing the policy from the respondent, the complainant had disclosed his father’s pre existing diseases namely DM, HTN, and Prostate disease. Whereas, the ailments namely CKD, CAD, and L AV Fistula were not disclosed.

The policy holder was admitted in the third month of the first policy period commencing from 19.02.2018 to 18.02.2019. On 12/05/2018 he consulted a Nephrologist at Vasavi Hospital where the diagnosis of CKD, Prostatomegaly besides DM and HTN were mentioned. On 15.05.2018 he was admitted to Apollo hospital for Anxiety related issue. As per the doctor’s notes, the father of the complainant was said to be a known case of CKD/CAD. When cashless claim was raised through the hospital for AKI on CKD, the respondent had raised a query related to the onset of CKD. There was no reply either from the hospital or from the insured. Hence, cashless claim was denied but an advice was sent to hospital to inform the insured to come for reimbursement by submitting all the medical records. However, the insured did not approach the insurance company to claim reimbursement.

On perusal of whats up chat transcript where the complainant had a chat with Ms.Mareeswari on 18.07.2018, he had sent the claim papers to her. She had confirmed having submitted the claim twice but was rejected due to CKD. The complainant therefore asked her if the same would be covered after 12 months to which she promptly replied that it would be covered. The reply given by her was on the basis of the policy terms and conditions-waiting period 3(1) (C) where the waiting period is 12 months for pre existing disease. This clause is applicable for PED where the patient is not aware of the ailment and/or where the disease surfaces after the inception of policy. Whereas the complainant did not even once mention that he was seeking clarification for undisclosed PED which he was aware prior to inception of the policy.

The policy was renewed with a higher sum insured from 19.02.2019 to 18.02.2020. On 30.03.2019 and 16.4.2019 he had an informal chat on whatsup with Mr.Avinash. On 17.04.2019 his father was

admitted to Apollo hospital with provisional diagnosis of CKD. On 18.04.2019 he had a chat with Mr.Avinash, wherein he did not mention anything about his father’s hospitalization but only asked a question related to cover of Kidney from 2 nd year onwards and also wanted an assurance that when a claim was made for the same, the insurer should not tell that PED related to Kidney was not disclosed by him. Mr.Avinash has replied that since diabetes was already mentioned there was no need to worry. Whereas Mr.Avinash had only reiterated what Ms.Mareeswari had told him. No where in the chat conversations has Mr Avinash emphatically committed that CKD would be covered even if the policy holder was aware and yet not disclosed at the time of first inception of the policy.

Cashless claim for the second claim was rejected based on the Doctors notes which clearly mention “CKD on medical management since 3 years”. Based on this finding, the insurance company had also cancelled the policy for willful suppression of material facts. The complainant raised a question as to how the second claim could be rejected when the insurance company was aware of CKD during the request made for the first cashless claim and also on the basis of submission of medical records to Ms.Mareeswari. He had also raised a question as to how they had renewed the policy when they felt that the PED of CKD was willfully suppressed. In this regard, the insurer came to know about CKD/CAD but since they were not aware of its onset/duration to term it as pre existing, they have therefore renewed the policy based on utmost good faith. The proof shown by the complainant that he had submitted the previous medical reports pertaining to the first claim during the first policy period to Ms.Mareeswari was not sufficient in itself because she did not confirm as to what all documents were received by her. Hence, the respondent company has confirmed that they were not aware of the onset of CKD which is justified.

The lab test report dated 09.03.2018, 14.03.2018, 08.05.2018 much before the first hospitalization shows high levels of serum creatinine which pertains to functioning of kidneys. The respondent had raised a question as to why the insured had exclusively gone for creatinine tests. The complainant however does not dispute the fact that his father did not suffer from CKD prior to policy inception and had also not produced proof to rebut the ground for denial of his claim except stating that he was misled by the insurance team that it would be covered from the second year onwards.

The complainant has failed in his primary duty to bind by the principles of Contract which specifies the policy holder to Disclose all material facts so that the insurer can take a judicious decision to whether to accept such risks or not in the first place, the insurer had therefore trusted the words of the policy holder as specified in the proposal form and issued a policy and had renewed it thereon.

The policy terms and conditions contain disclosure of pre existing disease norm which when read means that any ailment which the insured is aware of should be declared at the time of purchase of the policy. The waiting period for Pre existing disease of 12 months as mentioned in the policy is with respect to ailments that have already been disclosed or ailments which the insured is not aware of. In the instant case, the complainant was fully aware of pre existing disease of CKD and yet did not disclose the same which therefore amounts to deliberate and willful suppression of material fact. He has also not disclosed other pre existing ailments such as CAD and L AV Fistula. Hence there is no infirmity in the decision taken by the insurer who had repudiated the claim as per policy condition no 9 and subsequently cancelled the policy as per policy condition no 13.

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 complaint devoid of any merit is dismissed.

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

( I SURESH BABU )

INSURANCE OMBUDSMAN



STATES OF A.P., TELANGANA & YANAM



Case between: Mr. D.Venkaiah Chowdary ………………The Complainant

Vs

M/s Star Health & Allied Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).H -044-1920-0323

Award No.: I.O.(HYD)/A/HI/ 0185/2019-20

1. Name & address of the complainant Mr. D.Venkaiah Chowdary,

S/o Late Seetharamaiah,

Door no 12-8-35, Vinjamuri Street,

Agricultural College Road, Bapatla Town,

Guntur District, A.P- 522 101.

Mobile: 9295656595.


Type of Policy


P/700001/01/2019/022257

Family Health Optima insurance

10.09.2018 to 09.09.2019



Mr D.Venkaiah Choudhary

Mr D.Venkaiah Choudhary



6. Reason for repudiation Non disclosure of PED


17) Brief Facts of the Case: The complainant was covered under Family Health Optima Insurance Plan for himself and his

spouse for a floater sum insured of Rs.5 Lakhs from 10.09.2018 to 09.09.2019. On 19.02.2019 he

visited Magna Hospitals, Hyderabad for check up and he was asked by Dr.Santosh to meet a

cardiologist. On 01.03.2019 he went to Sri Lakshmi Super speciality hospital, Guntur where he

underwent ECG, ECO tests, Angiogram. He got his angiogram done at Vista Imaging and Medical

Centre at Hyderabad on 17.04.2019. On 17.04.2019 he got admitted in Star Hopsital, Banjara Hills,

Hyderabad where he underwent treatment for CAG double vessel PTCA stents to LAD and LCX and

got discharged on 24.04.2019.His cashless was denied, he paid the bill in full and submitted

papers for reimbursement. His claim was denied on grounds of non-disclosure of PED, DM+HTN

since 28 years, prostrate and hernia surgery 2017. Representation given by the complainant to the

respondent did not yield any favorable result. Hence, a complaint was filed by him in this Forum

against the respondent.

18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument:

The complainant had submitted that on 19.02.2019 he went to Magna Hospitals,

Hyderabad for check up and he was asked by Dr.Santosh to meet the cardiologist. On 01.03.2019

he went to Sri Lakshmi Super speciality hospital, Guntur where he underwent ECG, ECO tests,

Angiogram. He got his angiogram done at Vista Imaging and Medical Centre at Hyderabad on

17.04.2019. On 17.04.2019 he got admitted in Star Hopsital, Banjara Hills, Hyderabad where he

underwent treatment for CAG Double Vessel disease and got discharged on 24.04.2019.His

cashless was denied, he paid the bill in full and submitted papers for reimbursement. He was

asked to submit three reports which he did on 13.08.2019. From the consultation papers of

Dr.Santosh of Magna Hospital stated he was Diabetic and Hypertensive for the past 28 years

instead of 8 years. He had informed PED of DM and HTN as pre existing at the time of taking







13. Date of hearing/place 03.03.2020/Hyderabad



b) For the insurer Mr M Ravi Kumar & Dr Annapurna



policy. Also he was not aware of his double vessel disease which was stated to be chronic,

longstanding and existed prior to policy inception. He was not told about 48 months waiting

period nor was it mentioned in the policy papers given to him.

b) Insurer’s argument: The insurer submitted their SCN on 25.02.2020. It was noted from SCN that the claim was reported in the 7th month of policy issued., and no previous insurance. It was noted that the insured underwent treatment of coronary artery disease- angina equivalents, fair LV function, CAG double vessel disease (LAD/LCX), successful PTCA stents to LAD and LCX, type 2 diabetes mellitus, hypertension. Again they mentioned in SCN that from consultation papers dated 02.04.2019 of Dr.Santosh submitted during cashless approval request, the insured had DM and HTN for the past 28 years which confirms that he was suffering from the ailment prior to policy inception i.e., 22.04.2019. Also contended that since the insured didn’t disclose the pre-existing disease conditions, waiting periods also not applicable, and non-disclosure amounts to concealment of facts and obtained the policy. His present ailment double vessel disease also confirms it was chronic, longstanding heart ailment existing prior to inception of insurance with them. Hence, the claim was denied as per terms and conditions of their policy.

19) Reason for registration of complaint: The claim preferred by the complainant was rejected by the insurer on the ground of Non declaration of material facts in proposal form as per policy conditions. As the Complaint falls under rule 13.1(b) of Insurance Ombudsman Rules 2017, it was registered. 20) The following copies of documents were placed for perusal.

a. Policy copy with terms and conditions. b. Consultation sheet of Dr R Santosh (Magna Hospitals) c. Discharge summary of M/s Medline Hospitals. d. Certificate issued by M/s CVR Hospital. e. Medical records of M/s Star Hospitals & Discharge summary. f. Proposal form duly filled. g. SCN of Insurer.

21) Result of personal hearing with both the parties: Pursuant to the notices given, both the parties attended the personal hearing on 03.03.2020 at 11 AM in Hyderabad, and following are the arguments noted. The insured himself attended the personal hearing and submitted to us that he had health insurance policy including his spouse with the respondent insurer for a floater sum insured of Rs. 5 Lakhs for the period 10.09.2018 to 09.09.2019. He informed that, as he was suffering from shortness of breath, he had under gone health check up on 19.02.2019 at Magna Hospitals, Hyderabad; and he was advised to contact a Cardiologist. Then he again consulted a doctor in Sri Lakshmi Super Speciality Hospital, Guntur who suggested him to take Angiogram after verification

of reports ECG and ECO. Further he informed that, after undergoing the test of Angiogram at Vista Imaging and Medical Centre, Hyderabad; he was admitted in Star Hospitals, Banjara Hills, Hyderabad on 22.04.2019 and discharged on 24.04.2019 on medical management and in stable condition. He further submitted that his cash less claim which was raised during hospitalization period, and the reimbursement claim lodged with the insurer been denied by the insurer on the ground of pre-existing diseases which were not disclosed in proposal form. Even he represented the same to the grievance cell of insurers for reconsideration; he could not get the positive result in his favor, and hence filed the present complaint for redressal.

On the other side, the representatives of the insurer attended the personal hearing and contended as per the points raised in SCN briefly stating that as per discharge summary of M/s Star Hospitals, it was noted by them that the complainant had been diagnosed to have CAD-Anginal Equivalents, Fair LV Function, Double Vessel Disease (LAD/LCX), Successful Adhoc PTCA, Stents to LAD &LCX and also to have Diabetes and HTN. Further, they stated that the complainant had the history of post Hernia surgery in 2017 prior to issuance of policy, which were not disclosed in proposal form. Hence they submitted that his cashless claim been denied on 24.04.2019, as well as the re-imbursement claim on 09.09.2019 and communicated to him as per their letters. They also stated that, had the complainant disclosed these pre-existing diseases in proposal form, they would not have issued the policy, or would have imposed specific exclusions/waiting periods in the policy. Hence they re-iterated their repudiation decision. On close scrutiny of documents submitted, and the arguments took place during hearing; the forum observed the following:

As per consultation sheet with Dr R.Santosh of M/s Magna Hospital, Hyderabad dated 19.02.2019, it was noted that the complainant is a known case of DM & HTN since 28 years and the medicines of Glykind, Insulin inj, Nurokind, and Telvas 40mg being used since then., and also having the symptoms of burning sensation in foot & palm, which are far before the issuance of current policy i.e. from 10.09.2018. Also, the complainant been diagnosed with Rt.Inguinal Hernia, and Left lower limb Poliomyelitis and also under gone for Right TEP (i.e. Total extra Peritoneal Mesh Hernioplasty) procedure under general anesthesia as per Discharge Summary of M/s Medline Hospital, Guntur dated 06.11.2013 and it was also been noted that he had the history of Hypertension, Diabetes which is a testimony confirming the pre-existence of HTN and DM with the above report of Dr R. Santosh.

Further, as per the certificate issued by Dr.Ch.Visweswara Rao of M/s CVR Hospital, Guntur it was revealed that the complainant had underwent TURP (Trans Urethral Resection of Prostate) for BPH (Benign Prostate Hyperplasia) during 2010 in their hospital. On scrutiny of policy issued by the respondent insurer, it was noted that the pre-existing disease of ‘DM and its complications’ only been recorded, but the relevant questions with regard to other pre-existing ailments such as HTN, TURP surgery, and Inguinal Hernia not been disclosed in proposal form basing on which policy was issued. During the hearing the complainant informed that the proposal is an online one but could not find the relevant questions in proposal. But even then, he would have pointed out to the insurer after receiving the policy, to insert the pre-existing diseases what he had, which he didn’t do, has to be considered as a lapse on his part. The present

ailment of CAD is also an end result of HTN which the complainant had failed to disclose at the time of filling the proposal form.

The very purpose of issuing proposal form by insurers is to elicit all the material information pertaining to the insured on utmost good faith, and enables the insurer to take decision whether to grant coverage of insurance, and if so, with what extra premium for which no opportunity was given to insurers. Under the above circumstances, the Forum feels that it is a clear case of non-disclosure of material facts while issuing the policy as contended by the insurers; and the repudiation decision taken by the insurers is justified and needs no intervention, and the complaint been dismissed with out any merit.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing, the complaint being devoid of any merit and dismissed without any relief.


( I SURESH BABU )

INSURANCE OMBUDSMAN





Case between: Mr. A RAVI TEJA……………The Complainant Vs M/s ICICI Lombard General Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -020-1920-0320

Award No.: I.O.(HYD)/A/HI/ 0186 /2019-20 1. Name & address of the complainant Mr. A Ravi Teja s/o Mr. A Ranga Rao,

T-2, B Block, Sapthagiri Enclave apartments,

Pappula Street, Stone House Pet,

Nellore district,Andhra Pradesh State- 524 002.

(Cell No.87904-73726)


Type of Policy


4128i/HP/138871031/00/000

HP Individual adult

2 Years; 04.11.2017 to 03.11.2019



Mr. Adusumalli Ravi Teja

Mr. Adusumalli Ravi Teja

4. Name of the insurer M/s ICICI Lombard General insurance Co. Ltd.


6. Reason for repudiation Misrepresentation of facts


8. Nature of complaint Partial settlement of Mediclaim


10. Date of Partial Settlement Rs.25,000 paid on 27.02.2020




13. Date of hearing/place 03.03.2020


a) For the complainant Self and father Mr.A.Ranga Rao

b) For the insurer Mr.Amit Tirani, Legal Manager

15. Complaint how disposed Allowed Partly


17) Brief Facts of the Case: The complainant Mr. A. Ravi Teja had insured his health with the respondent company for a period of 2

years for an annual sum insured of Rs. 3 Lakhs. He had also taken a super top up policy for a period of 3

years for an annual sum insured of Rs. 7 Lakhs with a voluntary deductible of Rs. 3 Lakhs. On 01.09.2019,

he was admitted to Vijaya Care Hospital, Nellore with complaints of fever for the past 2 days which was

associated with vomiting and general weakness. Upon his medical evaluation, he was diagnosed with

Dengue fever plus Dengue shock syndrome, and Thrombocytopenia. He was treated in the hospital till

07.09.2019 with platelets and FFP transfusion, IV Fluids, and antibiotics. He had paid an amount of Rs.

1,02,728/- towards his hospitalization, and medicines since the hospital where he was treated was not in

the respondent TPA’s network of hospitals so as to facilitate cashless claim to him. Thereafter, he had

applied for reimbursement of claim. Not only was the claim rejected but the respondent had also issued a

notice of termination of his policy citing misrepresentation of facts by the claimant. His follow-up with

them and also the Grievance department clarifying the situation could not win them over and therefore he

was compelled to approach this Forum with a request to mediate between him and respondent and to

resolve the issue in his favor.

18) Cause of Complaint: Rejection of claim submitted for reimbursement under medical insurance policy. a) Complainant’s argument:

The complainant had stated that while he was admitted in hospital, he had never opted for any separate room for his attendant who in this case was his father. He had opted for a single deluxe room which he had retained till he was discharged from hospital even when he was shifted to ICU in between since the demand for a single deluxe room had made him to do so. During the time he was shifted to ICU, his father had utilized his single deluxe room and therefore the question of his father being allotted a separate room did not arise. Further, when the final bill was about to be prepared, he had requested the hospital to offer him a discount on the bill to which an amount of Rs. 7,600/- was thus reduced and was equivalent to the rent that he had paid towards the single deluxe room; this information was shared with the respondent’s official who had met his father upon his visit to hospital on 02.10.2019. Further, he had obtained the insurance policy after he was solicited by the telesales agent who had assured him of assistance at the time of need but to no avail since the number provided in the policy schedule was neither functioning nor was reachable when there was a need to seek clarification regarding his claim. This being his first claims experience, he was not aware as to the components that he was entitled to claim in the absence of timely assistance. He had therefore requested that the room rent for those days when he was in ICU may be deducted and the balance amount be paid to him. b) Insurer’s argument: The respondent had submitted their self contained note on 02.03.2020. They had issued a health policy for two years commencing from 04.11.2017 to 03.11.2019 and the same was delivered to the insured on 16.11.2017 to the residential address at Nellore by professional couriers vide AWB No.VPL456695859. on 07.09.2019, he was admitted in Vijaya Care Hospital at Nellore with complaints of fever since 2 days prior to admission associated with vomiting and general weakness. Post treatment the insured had filed documents for reimbursement of their claim. The discharge summary showed he was diagnosed with Dengue Fever, Dengue shock syndrome and thrombocytopenia. During investigation of the claim, they obtained two different bills from the hospital authority and the complainant did not clarify the same to them when asked. Hence the claim was repudiated invoking Clause No. 12 of the policy terms and conditions which reads “ the policy shall be null and void and no benefit shall be payable in the event of

untrue or incorrect statements, misrepresentation, mis-description or on non-disclosure in any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or a claim being fraudulent or any fraudulent means or devices being used by the insured or anyone acting on his behalf to obtain any benefit under the policy”. Subsequently, they had once again approached the hospital and obtained the clarification that was intended. The claim was once again reviewed and agreed to settle for Rs.25,000/- as per sub-limits applicable in the policy as per Clause 3.3 Extension HC 15 sub limits on medical expenses/illness/surgeries/Procedures including pre and post hospitalization expenses if any.


The insurer partially settled the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures. 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 03.03.2020. The complainant’s father Sri Ranga Rao said his son was admitted for Dengue Fever in a hospital at Nellore for 7 days from 01/09/2019 to 07/09/2019. The complainant was in the general room for 3 days and in ICU for 4 days whereas in the bill it was shown as 4 days ICU and 6 days in room. Their claim was rejected stating misrepresentation of facts which was not true. Clarification has been given to them. When they approached this forum, the insurers further reviewed their claim and paid Rs.25,000/- vide NEFT on 27.02.2020. Since they had incurred Rs.105086/-, they are not satisfied with the partial settlement .When their sum insured was 3 Lakhs along with a super top up policy for further 7 Lakhs issued by the same respondent, they are at a loss to understand why their claim was partially settled for Rs.25000/- only. The respondent stated that on 07.09.2019, the complainant was admitted at Vijaya Care Hospital in Nellore with complaints of fever since 2 days prior to admission associated with vomiting and general weakness. Post treatment the insured had filed documents for reimbursement of their claim. The discharge summary showed he was diagnosed with Dengue Fever, Dengue shock syndrome and thrombocytopenia. During investigation of the claim, they obtained two different bills from the hospital authority and the complainant did not clarify the same to them when asked. Hence the claim was repudiated invoking Clause No. 12 of the policy terms and conditions which reads “ the policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or on non-disclosure in any material particular in the proposal form, personal statement, declaration and connected documents, or any Material information having been withheld, or a claim being fraudulent or any fraudulent means or devices being used by the insured or anyone acting on his behalf to obtain any benefit under the policy”. Subsequently, they had once again approached the hospital and obtained the clarification that was intended. The claim was once again reviewed and agreed to settle for Rs.25,000/- as per sub-limits applicable in the policy as per Clause 3.3 Extension HC 15 sub limits on medical expenses/illness/surgeries/Procedures including pre and post hospitalization expenses if any. Neft payment was made for Rs.25,000/- on 27.02.2020 towards full and final settlement of the claim.

The Forum observed regarding submission of two bills, base policy and top of policy as Under:

M/s Vijay Care hospital clarified vide their mail dated 21.02.2020 to the respondent that the bills

are not two different bills; one was a consolidated bill and the other contained breakup of the first

bill. When the patient was in ICU the attender of the patient occupied the room hence attenders

room charges were shown as 6 days. That a discount was also given to them towards doctors

charges. A detailed final bill was enclosed to the respondent. Therefore, the question of fraud and

mis-representation does not arise.

The First policy issued for Rs.3 Lakhs covers named major medical illness and procedures and joint

replacement surgery i.e.,1) cancer of specified severity 2) kidney failure requiring dialysis 3) Major

organ/bone marrow transplant 4) all cardiac surgeries 5) multiple sclerosis 6) stroke resulting in

permanent symptoms 7) Permanent paralysis of limbs and 8) All brain related surgeries.

As per extension HC 15: sub-limits on medical expenses/ illness/ surgeries/procedures the

maximum limit of Indemnity under the policy including pre and post hospitalization expenses are

as under:

Sl.no Surgeries/medical procedures Sub-limits Rs.

1 Cataract per eye 20,000

2 Other eye surgeries 35,000

3 ENT 35,000

4 Surgeries for tumors/cysts/nodules/polyp 60,000

5 Stone in urinary system 40,000

6 Hernia related 60,000

7 Appendisectomy 40,000

8 Knee ligament reconstruction surgery 90,000

9 Hysterectomy 60,000

10 Fissures/piles/fistulas 35,000

11 Spine & Vertebrae related 90,000

12 Cellulites/ Abscess 35,000

All medical expenses for any treatment not

involving surgery/medical procedure

25,000

The treatment for dengue fever does not come under the list of 8 no. named major medical illness

and falls under sub-limit HC -15 under medical expenses for any treatment not involving

surgery/medical procedure the payment of Rs.25,000 is justified. The super top up policy for 7

Lakhs comes with a voluntary deductible of 3 Lakhs. Which means claims over and above 3 Lakhs

will only be entertained under super top up policy. Hence, the forum concurs with the decision of

the insurers in settlement of the claim for Rs.25,000/- vide NEFT no. under CMS1411764592 dated

27.02.2020.

A W A R D


parties during the course of the personal hearing and the information/documents placed on

record, the partial settlement of the claim for Rs.25,000/- is justified .

The complaint is Allowed partly


( I SURESH BABU )

INSURANCE OMBUDSMAN





Case between: SRI AASHISH JAIN………………The Complainant Vs M/s The New India Assurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -049-1920-0328


1. Name & address of the complainant Mr. Aashish Jain

Plot #177, Road #3, Trimurti Colony,

Mahendra Hills,Secunderabad

Telengana State- 500 026.

(Cell No. 90004-56761)


Type of Policy


83000034181401007237

Family Floater Mediclaim Policy

25.12.2018 to 24.12.2019



Mr. Aashish Jain

Mr. Aashish Jain



6. Reason for repudiation Claim does not fall within the purview of

policy




10. Date of Partial Settlement -----



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




b) For the insurer Mr.P.Sesha Saikumar, Dy.Mngr

Mr.B.Santosh Kumar




The complainant had purchased an annual medical insurance policy from respondent on 29.12.2015 to

cover the health of his spouse, mother and him and subsequently had included his minor son. During the

policy period 2018-19, he was admitted for a day in Maxi vision eye super specialty hospitals on four

occasions i.e., on 21.01.2019, 21.02.2019, 22.03.2019, and on 20.06.2019 for getting his right eye treated

for Cystoid Macular Edema (CME). On the first three occasions, he was administered Intravitreal Lucentis

Injection under Local Anesthesia and on the final occasion Ozurdex injection under local Anesthesia. He

had filed 4 claims amounting to Rs. 1,19,000/- with respondent. However, prior to his first admission itself,

the TPA of respondent M/s MD India had denied his request to accord cashless claim on the ground that

the said procedure did not warrant 24 hours hospitalization and that it was not listed under the day care

procedure. Dissatisfied with the denial of his claim, he had therefore approached this Forum to render

justice to him.

18) Cause of Complaint: Rejection of cashless and reimbursement of claim amount pertaining to

expenses incurred towards treatment taken in hospital.


The complainant had submitted that he was diagnosed with Branch retinal Vein Occlusion

(BRVO) of his right eye for which he was administered injections under local anesthesia.

However, when he had filed 4 claims for the treatment taken on 4 different occasions, the

respondent had rejected his claim citing clauses 3.10, 3.15.1, and 4.4.23 of the policy as reasons.

His argument was that the said disease of the eye was one of the most common retinal vascular

disorders which occur mostly in people who are above 65 years old and in support of his claim he

had attached a certificate issued by Dr. Muralidhar Rao, a Retina specialist from the hospital

where he got his eye treated. As per the certificate, the treatment was not age related and

therefore the complainant had put forth his argument that the respondent ought to have taken

cognizance of his age which was 48 years before arriving at a decision to reject his claims.

Secondly, he had averred that with the technological advancements made in medical field, many

eye related problems were treated within a few hours which otherwise would have required one

to be hospitalized for days. Further, he had pointed out that the treatment had to be given in

sterile conditions and had to be administered under local anesthesia in an operation theater

under the care of a specialized doctor and therefore could not be treated on an outpatient basis.

Hence, the clause No. 3.29 was highlighted wherein the patient being admitted either as inpatient

or in a day care centre cannot be treated as an outpatient and in his case, the said procedure was

not stated to have been excluded under clause 4 of the policy too.

b) Insurer’s argument:

The respondent has not submitted their self contained note. However, it was obvious from the

letter issued by them to complainant that the cashless claim and later reimbursement claims

could not be entertained because the said procedure did not require 24 hours stay in hospital and

it was not listed under day care procedure too.


The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule

13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

20) The following copies of documents were placed for perusal:

a. Policy copy

b. Discharge summary

c. Rejection letter

d. Correspondence with insurer

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 10.03.2020.

The complainant stated he was diagnosed with Branch retinal Vein Occlusion (BRVO) of his

right eye for which he was administered 4 Lucentis injections under local anesthesia. However,

when he had filed 4 claims for the treatment taken on 4 different occasions, the respondent had

rejected his claim citing clauses 3.10 ( Day Care treatment), 3.15.1(24 Hour hospitalization),

3.15.1 & 4.4.23( ARMD) and 3.15.1 of the policy as reasons. The insured contents that for

administering the injection one does not need to be hospitalization and since he was 48 years old

it cannot be termed as ARMD (Age related Macular Degeneration).

The insurer has not submitted their self contained note. They have rejected the claim under

4.4.23 of their policy which read as “ Treatment for age related macular degeneration ARMD,

Treatments such as rotational field quantum magnetic resonance ( RFQMR), External counter

pulsation (ECP), Enhanced external counter Pulsation (EECP), Hyperbaric Oxygen therapy”

come under 4.4 Permanent exclusion. Since Lucentis injection was used for ARMD related

ailments the claim was rejected.

Branch Retinal Vein Occlusion (BRVO) is a blockage of one or more branches of the central retinal vein, which runs through the optic nerve. Branch Retinal Vein Occlusion symptoms include: Peripheral vision loss. Cystoid Macular Edema or (CME) is a painless disorder which affects the central retina or macula. When this condition is present, multiple cyst-like (Cystoid) areas of fluid appear in the macula and cause retinal swelling or edema.

The forum observed that:

The injection was administed in a hospital with the guidance of a qualified doctor

under local anesthesia. The present treatment does not find place in the specified

list of 22 day care procedure as per the policy. Since the policy was not in tune to

technically advanced procedures the claim was rejected as per Clause No. 3.10-

Day Care Treatment-

“Day care treatment refers to medical treatment, and/ or surgical operation which is

undertaken under General or Local Anesthesia in a hospital/ day care center in less than

24 hours because of technological advancement, and which would have otherwise

required a hospitalization of more than 24 hours.Treatment normally taken on an

outpatient basis is not included in the scope of this definition.

The present treatment does not require 24 hours hospitalization hence rejection of

claim as per Clause No. 3.15.1 “Hospitalization means admission in a hospital for a

minimum period of 24 inpatient care consecutive hours except for specified

procedures/ treatments, where such admission could be for a period of less than 24

consecutive hours” is not applicable.

Rejection of the claim based on Permanent exclusion Clause No. 4.4.23 disallowing of any

expenses incurred or arising out of treatment for Age Related Macular Degeneration (ARMD) is

not applicable in the instant case because the complainant was 48 years old at the time when he

was treated and he cannot be categorized under persons suffering from age related disease. Since

the insured was treated for Vascular disease which is not related to age as certified by the

treating doctor letter dated 4.01.2020 , the Forum directs the insurer to admit and settle all the

four claims towards BRVO treatment , Intravitreal Lucentis injections and Ozurdex injection.

A W A R D


parties during the course of the personal hearing and the information/documents placed on

record, the insurer is directed to admit and settle all the four claims towards BRVO treatment.

The complaint is Allowed.


Rules, 2017:

g) 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.

h) 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.

i) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.


( I SURESH BABU )

INSURANCE OMBUDSMAN




Ombudsman - Shri I. Suresh Babu, IRS

Case between: SRI E JAGAN MOHAN RAO ………………The Complainant Vs

M/s The New India Assurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).H-049-1920-0322


1. Name & address of the complainant Mr. E Jagan Mohan Rao

C-2, Sri Sai Durga Residency,

54-18/2-A, Prasanth Nagar,

Vijayawada,Andhra Pradesh State- 520 008.

(Cell No. 97041-48723)


12070034190400000007

Group Mediclaim Insurance Master Policy

01.04.2019 to 31.03.2020


Mrs. Lalitha Kumari E a/c Mr E Jagan Mohan Rao

M/s Life Insurance Corporation Of India


5. Date of Repudiation -----

6. Reason for repudiation Partial settlement of Mediclaim


8. Nature of complaint Claim pertaining to group medical insurance policy






13. Complaint how disposed Allowed (Statistical Purpose)



The complainant being a pensioner and having retired from M/s Life Insurance Corporation of India was

covered along with his spouse by his employer under the Group Mediclaim Insurance through the policy

taken from respondent company. His wife who was suffering from fever since 12.08.2019 had to be taken

to Ayush Hospitals, Vijayawada on 16.08.2019 because her body temperature soared up to 102.7 degrees

Fahrenheit. She was treated in the hospital before being discharged on 19.08.2019. Out of the total

hospitalization expense and medicines incurred and paid for Rs. 86,441/-, the respondent had settled the

claim partially for an amount of Rs. 53,401/-. Not satisfied with the settlement of claim, the complainant

had given his representation to Grievance department with a request to settle the balance amount after

deducting the non- payable items under the policy. Since there was no response to his representation, he

had therefore approached this Forum to render justice to him.

16) Cause of Complaint: Partial settlement of Mediclaim 17) Reason for Registration of Complaint:-

The claim preferred by the complainant was not settled by the insurer. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

After filing the complaint by the complainant, the insurer further reviewed the complaint and

settled the claim for Rs.18600/- by way of NEFT on 14.02.2020. During the hearing conducted on

10.03.2020 the insured informed over phone of having received the amount from LIC on 19.02.2020. He

requested this Forum to close the complaint.

A W A R D


Dated at Hyderabad on the 10th day of March, 2020

(I.SURESH BABU)

INSURNACE OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND YANAM CITY




Case between: Ms. KANDALA MANASA………………The Complainant Vs M/s Star Health And Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -044-1920-0318

Award No.: I.O.(HYD)/A/HI/ 0189 /2019-20 1. Name & address of the complainant Ms. Kandala Manasa

H.No. 8-6-164/F2/190, FCI Colony, Phase –II,

Vanasthalipuram,Hyderabad -500 070.

(Cell No.96522 -27272)


P/131128/01/2018/015678

Family Health Optima Insurance Plan

11.01.2018 to 30.03.2019


Ms. K. Manasa

Mr. K. Yadi Reddy

4. Name of the insurer M/s Star Health And Allied Insurance Company Limited


6. Reason for repudiation Non disclosure of pre existing disease


8. Nature of complaint Claim pertaining to Medical Insurance

9. Amount of Claim Rs. 2,08,269.76

10. Date of Partial Settlement ----




13. Date of hearing/place 03. 03.2020 & 10.03.2020 / Hyderabad


a) For the complainant Brother Sri K.Prudhvi Reddy

b) For the insurer Sri M.Ravi Kumar, AGM Legal



17) Brief Facts of the Case: The respondent company had issued an annual Medical insurance policy to cover Mr. K Yadi Reddy, his

spouse, and his dependent daughter, for a floater sum insured of Rs. 3 Lakhs on 31.12.2015. During the

policy period 2018-’19, his daughter Ms. K Manasa was admitted to CITI Neuro Centre with features of

Cushing syndrome which she had been suffering from for the past 3-4 years with no other significant

history. She was diagnosed with ACTH secreting pituitary micro adenoma with Cushing’s disease. She was

found to have elevated serum cortisol levels and after undergoing all the relevant medical investigations,

an endo nasal endoscopic transphenoidal excision of tumor that was situated on the left side of her gland

and white in color with well defined plane of cleavage, was done on her. She was discharged on 01.03.2018

in a coherent state. Upon her filing the claim pertaining to amount incurred towards her hospitalization

with respondent, the claim was rejected citing non- disclosure of material facts as the reason and

thereafter her policy was cancelled. Aggrieved by the adverse outcome, she had filed a complaint against

respondent in this Forum.

18) Cause of Complaint: Rejection of claim under medical Insurance policy. a) Complainant’s argument:

The complainant had stated that she was not diagnosed with any of the major illnesses at the time of renewal of her policy. In the year 2016 which was subsequent to the first policy commencement date, she had certain minor symptoms such as missing periods, weight gain, hair fall, and head ache because of which she approached a local homeopath and who had diagnosed her symptoms as Poly Cystic Ovarian syndrome (PCOS); she was treated with homeopathy medicines regularly which gave her temporary relief. Upon the advice of her family doctor, she had consulted an endocrinologist on 27.01.2018 and who upon her medical evaluation had recorded that she could be suffering from Cushing syndrome. Thereafter, she underwent an MRI scan of her pituitary gland and upon consulting another senior Neurosurgeon on 22.02.2018, she was asked to undergo surgery for endoscopic transphenoidal excision of her tumor. When she was admitted for the surgery, a request made for a cashless claim was not accorded by respondent and so her parents had to clear the hospital bills which amounted to Rs. 1,90,000/-. The basis for rejection of her claim given by respondent was that the discharge summary given by hospital mentioned that she had the features of Cushing syndrome for the past 3-4 years to which she had clarified that she never had the occasion to disclose it unless she was aware of the same. Further, she had also submitted that she was not diagnosed with the disease and therefore rejection of her claim on the basis of her symptoms was arbitrary since she was diagnosed with the said syndrome only after she was made to undergo a battery of tests. b) Insurer’s argument: The respondent had mentioned in their self contained note that the insured person had the features of Cushing syndrome prior to commencement of her medical insurance as was evident from the discharge summary of hospital where she was treated. The insured had not disclosed the facts at the time of purchasing the insurance policy as per the information sought in Sl. No. 4(i) of the proposal form and therefore this had amounted to non disclosure of material facts. Previous MRI study with contrast dated 01.08.2012 was proof of same. Hence, the claim was repudiated as per condition No. 6 of policy and the policy was cancelled as per the policy condition No. 12.

19) Reason for Registration of Complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures f. MRI report 2012,2018 and previous medical records 2011-2015 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum the complainant did not attend the hearing scheduled on 03.03.2020. However, the complainant’s brother attended re-hearing on 10.03.2020 at Hyderabad. The complainant’s brother informed his sister Ms.Manasa claim for hospitalization where she underwent surgery on 26.02.2018 for ACTH secreting pituitary micro adenoma with cushings disease. The basis for rejection of her claim given by respondent was that the discharge summary given by hospital mentioned that she had the features of Cushing syndrome for the past 3-4 years to which she had clarified that she never had the occasion to disclose it unless she was aware of the same. Further, she had also submitted that she was not diagnosed with the disease and therefore rejection of her claim on the basis of her symptoms was arbitrary since she was diagnosed with the said syndrome only after she was made to undergo a battery of tests. The insurer Mr.Yadi Reddy took a floater health policy for Rs.3 Lakhs covering himself, spouse and dependent child Ms.Manasa. The first policy commenced from 31.12.2015 to 30.12.2016 and subsequently renewed the same. A claim was reported in the 3 rd year of the policy. An amount of Rs.208269.76 was claimed during reimbursement of medical expenses. To Query rose on 30.03.2018 the insured has submitted the necessary documents on 10.04.2018. Further vide request letter dated 15/09/2018 insured has collected back original medical records, bills, MRI and x-ray films submitted to them. Ms.Manasa was admitted on 26/02/2018 and discharged on 01/03/2018 at Institute of Neuro Sciences Private Limited, Hyderabad whereas per her discharge summary she was diagnosed with ACTH secreting Pituitary Micro Adenoma with Cushing’s disease and underwent Endo Nasal Endoscopic Transphenoidal Excision of the Tumor. It was further observed from the Discharge summary that the patient was having features of Cushing syndrome since 3-4 years, the insured in his letter dated 09.04.2018 also stated she had features of Cushing syndrome since 4 years.MRI report dated 19/02/2018 from Vijaya Diagnostic mentioned in history as “ Clinically Cushing’s syndrome with non suppressible ONDST and LDST. Previous MRI study with contrast dated 01.08.2012 is noted”. Hence, she had features of Cushing syndrome prior to purchase of first policy in 2015 and the same was not disclosed. The present admission and treatment of the insured patient is for pituitary adenoma and Cushing’s syndrome. In the proposal form during inception of the policy, under the column Health History 4(i) the proposer replied in negative as “NO”. Hence the claim was repudiated for non-disclosure of pre existing ailments and communicated to insured vide letter dated 16/04/2018. During the hearing on 10.03.2020, the insured was asked to bring MRI dated 2012 and to submit previous medical consultations if any wherein the doctors advised her for MRI in 2012. The Insured submitted medical records from 26/04/2011 to21.02.2015 along with MRI report dated 01.08.2012. From the above the Forum observed the following:

Claim rejected based on discharge summary dt.26.02.2018 which mentions history of present

illness as”25 years old lady presented with features of Cushing syndrome for 3-4 years. No other significant history”.

MRI report dated 19/02/2018 shows history Hx “clinically Cushing’s syndrome with non suppressible ONDST and LDDST. Previous MRI study with contrast dated 01.08.2012 is noted.

MRI report dated 01/08/2012 shows under impression: Dedicated dynamic contrast MR study of sella and brain is essentially normal for age, no obvious demonstrable microadenomas within the pituitary gland, however, needs correlation with serum prolactin levels.

Consultations and Medical reports dated 26.4.2011 show she was treated for PCOD with medication for regulation of menstrual cycles for 6 months. Subsequent consultations were done on 13.08.2011, 21.06.2012, 07.07.2012, 24.07.2012 when she was advised for MRI Brain and CT Abdomen. Both the scans have not shown any history of Pitutory micro adenoma. She was under regular medication as seen from the consultation papers dated 15.11.2012, 03.05.2013, 28.11.2013,19.07.2014, 21.02.2015 wherein Ms.Manasa’s S.Cortisol leverls were checked, she was given vitamin supplements, tables for weight loss, hair loss prevention tabs along with hormonal tablets to reduce her androgen hormone and regulate her menstrual cycle.

During policy purchase in 31.12.2015, in the proposal for questions on health history (2). Have you consulted/taken treatment/ been admitted for any illness/disease/injury surgery- it has been answered as ‘NO”. To Question no 5(1) Have any of the persons proposed for insurance undergone any medical test ? , 5(2) Prescribed any medication, (i)name the illness for which medicines have been prescribed ,(ii)Details of drugs and medicines prescribed and (iii) Period from which these drugs are taken are all answered as “No”. The complaint was diagnosed with PCOD as seen in 26/04/2011 consultation papers. She has been on medication for regulation of menstrual cycles, weight loss and hair loss problems from 26/04/2011 to 21/02/2015 as per doctors prescriptions. Though she had Cushing’s Syndrome, she was unaware of the same until 2018 when she underwent pituitary micro adenoma E Cushing syndrome, she has failed to disclose information of her medical tests, medication, various treatments from 2011-2015 in the proposal form during first policy purchase in 2015 which amounts to non-disclosure of material facts. As per Contract of insurance, duty of disclosure by proposer is the basis of the contract. In case of health insurance contracts, disclosure of health details are material facts whether to accept insurance or not. The insurance company has therefore been denied of material information on the insured’s health condition in the proposal form that forms the basis of the contract on Utmost Good Faith. Therefore, rejection of claim as per policy condition no 6 and cancellation of policy on grounds of non disclosure of material facts as per condition no12 is justified.

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 complaint devoid of any merit is dismissed without relief.


(I.SURESH BABU)

INSURNACE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017) Ombudsman - Shri I. Suresh Babu

Case between: SRI S SATYANARAYANA ……………The Complainants

Vs M/s United India Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).H.051.1920.0338

Award No. : I.O.(HYD)/A/GI/0190/2019-20

1. Name & address of the complainant Mr. Sunkavalli Satyanarayana

Flat #71, Aruna Co-operative Society,

Road # 3, Jayanagar, KPHB,

Hyderabad-500 072

(Cell No.99480-37630)

2. Policy No. /Collection No. Type of Policy Duration of Policy/Policy period

1502002818P110571082

Individual Health Policy

17.11.2018 to 16.11.2019


Mr. Sunkavalli Satyanarayana

Mr. Sunkavalli Satyanarayana

4. Name of the insurer M/s United India Insurance Co. Ltd.


6. Reason for repudiation Claim falls outside the scope of policy


8. Nature of complaint Claim pertaining to Medical Insurance Policy




12. Complaint registered under 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




b) For the Insurer Dr Sudeep Kumar, Ms Nafeesa Zeenath & Mr Viswanath



17) Brief Facts of the Case: The complainant had purchased an annual medical insurance policy from respondent to cover the

health of his spouse, daughter, and him for a sum insured of Rs. 1 Lakh each. During the renewal

policy period 2018-19, he was stated to have slipped down while walking which had resulted in

fractures to his upper and lower front teeth. He was treated at Expert Dental Case on 14.08.2019

where he underwent an extraction of tooth followed subsequently by root canal treatment and

PFM crowns on 04.10.2019, 10.10.2019, 12.10.2019. He had filed a claim with respondent towards

the treatment expense incurred but the same was denied by them citing reason that the claim

made by him was not covered under policy issued to him. Aggrieved by this decision, he had filed a

complaint in this Forum against them.

18) Cause of Complaint: Rejection of reimbursement of a claim pertaining to Mediclaim insurance policy. a) Complainant’s argument: The complainant had submitted that the dental treatment taken by him was a consequence of an

injury. He had communicated the same to respondent/TPA at regular intervals of time. All the claim

papers insisted upon were submitted to TPA. His contention was that he was not given an

opportunity to support his claim before it was being rejected. Subsequent to the accident, when his

policy was renewed the respondent did not give him no claim bonus which he had been enjoying for

the past 18 years and upon enquiry he was told that the same could not be offered since his present

claim was under process. The TPA whom he had met on 12.11.2019 too had told him that his claim

was kept open. However, his claim was not settled till date.

b) Insurer’s argument: In their self contained note submitted by respondent to this Forum, they had mentioned that the

complainant had chronic periodontitis. The dental treatment taken by him did not arise out of an

accident. As per the exclusion clause 4.8 of the policy, the company shall not be liable to make any

payment under the policy in respect of any expenses whatsoever incurred by any insured person in

connection with or in respect of dental treatment or surgery of any kind unless necessitated by

accident and requiring hospitalization. Hence, the claim was repudiated in accordance with the

policy terms and conditions.

19) Reason for Registration of Complaint:- The claim preferred by the complainant was rejected by the insurer on the ground of exclusion as

per policy terms and conditions.

As the complaint falls under rule 13.1(b) of Insurance Ombudsman rules 2017, it was registered.


a) Policy copy with terms and conditions b) Hosptial treatment records. c) Hospital bills. d) Rejection letter of insurers. e) Review letter and correspondence of complaint. f) Investigation report and hospital certificate. g) Self contained note submitted by insurers.

21) Result of personal hearing with both the parties :

Pursuant to the notices give, both the parties attended the personal hearing on 10.03.2020 at Hyderabad, and following are the arguments noted. The complainant himself attended the hearing and informed us that he had medical insurance policy with respondent insurer for the last 18 years, and continuously renewing up to the period 165.11.2019. It was noted from him that while he was going outside on foot, his leg slipped and he fell down resulting in both upper and lower front teeth getting fractured and taken treatment both for lower front teeth on 14.08.2019 and for upper front teeth on 12.10.2019 at M/s Expert Dental Care Hospital, Chinagantyada, Visakhaptnam at per their consultation sheet dated 14.08.2019. Again noted that when he submitted the claims separately as per claim forms along with hospital records and bills, the same were rejected by the insurers stating the reason that ‘dental treatment is not covered under policy’ as per their letter dated 14.10.2019. The complainant also informed that even he had written for review of his claim to their grievance department of insurer as per letter dated 30.10.2019, no reply has come despite his series of letters, and hence he filed the present complaint for Redressal. The insurer’s representatives attended the hearing and contended as per the points raised in SCN, briefly stating that the complainant’s dental treatment is not admissible as per policy exclusion 4.8, which reads as given below, since the treatment is found to be not arising out of accident and also didn’t require hospitalization. Exclusion 4.8: “The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any injured person in connection with or in respect of Dental treatment or surgery of any kind, unless necessitated by accident and requiring hospitalization”. Hence they reiterated their decision of repudiation as per above exclusion, and submitted that they have communicated the same to the complainant as per their letter dated 14.10.2019. Lot of correspondence been exchanged between the parties for and against the claim. On close scrutiny of documents submitted, and the arguments took place during hearing, the Forum observed the following points: As per consultation sheet dated 14.08.2019, the complainant had gone directly to M/s Expert Dental Care, for treatment of his both upper and lower front teeth which are said to be fractured accidentally while waking due to slippage, and he had been diagnosed with “Ellis Class III fracture along and Chronic generalized Gingivitis with localized periodontitis. The Forum has gone

through the following literature about the medical terminology. Gingivitis is inflammation of the gums (gingival) surrounding the teeth. Gingivitis affects a significant portion of the population and is the most common form of periodontal diseases (diseases of the tissues surrounding the teeth). Chronic gingivitis may lead to receding gums and can be a precursor of Periodontitis. Periodontitis is inflammation of the gums and supporting structures of the teeth. It is one of the most common hum diseases. Periodontitis is caused by certain bacteria (known as periodontal bacteria) and by the local inflammation triggered by those bacteria. Ellis III: These fractures involve the enamel, dentis, and pulp layers. These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink, read or even blood at the center of the tooth. Cross section of Ellis III dental fracture.

From the above literature the Forum noted as per consultation slip dated 14.08.2019, the complainant was already having the disease of Gingivitis, and Periodontitis as on date of consultation, and treated subsequently which was occurred chronically by its nature, but not due to the so called accident. As the complainant intimated the claim to the TPA/insurers by sms on 15.08.2019 that is after lapse of so much after starting treatment on 14.08.2019, the insurers had lost their opportunity to trace the evidences of said accident, and observed that no supporting evidence or illustration of accident been produced by the complainant. Instead, in support of his contention of occurrence of accident, he should have got admitted in any hospital soon after its occurrence rather than consulting a dentist directly. Moreover, as per certificate issued by M/s Expert Dental care, where in it was clearly mentioned that the complainant had taken treatment as Outpatient from 15.08.2019 to 12.10.2019 for the chief complaint of Trauma not arising out of accident, which was also confirmed by the investigator arranged by insurers as per his report dated 11.10.2019. The Forum also observed that there is no rebuttal evidence produced by the complainant contradicting the above certificate. From the above observation the Forum has come to conclusion that the complainant keeping in mind very well that an ordinary dental treatment would be outside the scope of policy, has made it appear to be an accident for the oriented claim without producing proper evidence, and also intentionally failed to give the intimation to TPA on the same day itself, without giving them an opportunity to visit the hospital for cross verification. But, special mention ought to be made in respect of the attitude and behavior of the insurer. In spite of several mails and representations by the insured, no reply leave alone a satisfactory reply was received. The Forum can’t understand as to why the insurers are so indifferent to the complaints of the insured, and why the insured persons are ill-treated when it comes to resolution of grievances. It is noticed that there was gross deficiency of service on the part of insurer and its TPA and blatant violation of principle of natural justice. The conduct of the insurer is highly condemnable, and it doesn’t augur well for insurer, if the apathetic attitude persists. The Forum feels that the insurer will streamline their customer services and render services to customers to their satisfaction in future. Hence under the above circumstances, the subject complainant is dismissed without any merit, as the claim is not tenable as per exclusion 4.8 stated supra, and the Form fells that no

intervention is required in the decision of insurers,

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 complaint is dismissed without any merit.

Dated at HYDERABAD on 11th day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM (Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)


Case between: SRI B V R MURTHY………………The Complainant Vs M/s The United India Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .051.1920.0329

Award No.: I.O.(HYD)/A/GI/ 0 /2019-20

1. Name & address of the complainant Mr. B V R Murthy

D.No. 50-44-8/1/1, Near Suneetha Nursing

Home,

Seethamadhara, Visakhapatnam: 530013

Andhra Pradesh State

(Cell No. 96185-65439)


Type of Policy


5001002818P109894428

Group Mediclaim Tailor-made Policy

01.10.2018 to 30.09.2019



Mrs B. Padmavathi A/c Mr B V R Murthy

M/s Bank Of India Employees Policy

4. Name of the insurer M/s The United India Insurance Co. Ltd.


6. Reason for repudiation Claim rejected under Clause 3.1 of policy










a) For the complainant Absent

b) For the insurer Dr Sudeep Kumar, Ms Nafeesa Zeenath, and Mr Viswanath.



17) Brief Facts of the Case: The complainant being an employee of Bank of India was covered along with his spouse under the

group mediclaim policy issued to his employer by respondent. His wife was admitted to Sunita

Nursing Home, Visakhapatnam on 08.08.2019 with severe headache and vomiting. During her stay

in hospital, she underwent MRI of her brain and spine wherein she was suspected to have

trigeminal neuralgia and migraine and was administered IV fluids and injections Zofer and

Voveron before being discharged on 11.08.2019. He had made a claim for an amount of Rs.

27,277/- which he had paid towards hospitalization and as well as towards pre and post

hospitalization expenses. The respondent’s TPA had denied the claim citing clause No. 3.1 of the

policy terms and conditions. Aggrieved by an unfavorable decision, he had therefore approached

this Forum with a request to intervene in his matter and to enable him to receive the amount

claimed by him from respondent.

18) Cause of Complaint: Rejection of reimbursement of a claim pertaining to mediclaim insurance policy. a) Complainant’s argument:

The complainant had submitted that his wife had been vomiting continuously and had severe headache. He was therefore kept under the observation of Dr. G V Rao, MD and thereafter was treated for hypertension in the hospital. He had submitted a letter from the treating doctor regarding the exact diagnosis when insisted upon by TPA. However, the reason given for rejection of his claim came as an utter surprise to him because the claim that he had made did not come under the definition of domiciliary treatment as his wife was hospitalized for 3 days. Since considerable time had been lost in the ongoing process, he had lost the opportunity to apply for reimbursement to claim from another insurer from whom he had taken a policy.

b) Insurer’s argument: In their self contained note submitted by respondent to this Forum, they had mentioned that the hospitalization was primarily for diagnostic evaluation and the treatment given was outpatient/ day care in nature. MRi of the brain and spine was done on 21/07/2019 which was much prior to hospitalization but as per the discharge summary it was shown as 09.08.2019. Subsequently, she had consulted an ophthalmologist for further evaluation and was diagnosed with macular oedema for which she was treated on outpatient basis. The claim therefore was not admissible as per the policy clause No. 2.19 which reads:” illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment”. Further, the claim did not fall within the purview of Clause No. 2.10 which reads:” Day care treatment means the medical treatment and/ or surgical procedure which is (i) undertaken under General or local Anesthesia in a hospital/ day care center in less than 24 hours because of technological advancement and (ii) which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition”.


The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note of Insurer f. Hospital record. 21) Result of the personal hearing with both the parties:

Pursuant to the notices given to both the parties by this Forum, the representatives of respondent insurer only attended the personal hearing at Hyderabad on 10.03.2020, and the complainant was absent. The representatives of the respondent insurer put-forth the points raised in the Self Contained note which was already submitted, briefly stating that the insured person joined in the hospital primarily for the symptoms of severe headache, with Vomiting, and treated for Migraine and Trigeminal neuralgia, which could be done on Out Patient basis. Also they informed that hospitalization was done for primarily for diagnostic evaluation only and subsequently referred to ophthalmologist for further evaluation and treated as a case of Macular Oedema on OP basis. They brought to the notice of Forum about the definitions in policy, in which circumstances requires hospitalization for Illness, Acute condition, Chronic condition as per clause 2.19 and Day care treatment definition as per clause 2.10. They reiterated that as the present hospitalization didn’t satisfy the above definitions, they confirmed their repudiation decision which was communicated to complainant as per mail dt: 04.12.2020. Mail correspondence been exchanged between the parties for and against the claim. On close scrutiny of documents, and arguments made during the hearing; the Forum observed the following:

The insured person had been hospitalized with the chief complaints of head ache associated with vomiting suspected to be Trigeminal Neuralgia, and Migraine and treated with fluids of medicines for prevention of Nausea, pain relieving, and for Neurological strength, as per discharge summary which could also be treated with tablets on OPD basis. No abnormal readings/findings were noted on physical examination in discharge summary at the time of joining in hospital which necessitates hospitalization, but suspected to be Trigeminal Neuralgia, and Migraine. The Forum has gone through the following medical literature: Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating pain. Migraine is a neurological condition that can cause multiple symptoms. It's frequently characterized by intense, debilitating headaches. Symptoms may include nausea, vomiting, difficulty speaking, numbness or tingling, and sensitivity to light and sound. Migraines often run in families and affect all ages. Zofer 4 MG Injection belongs to the antiemetics drug group which is used to treat nausea as well as vomiting, caused by surgery, chemotherapy and radiation. This medication blocks the chemical serotonin from releasing in your gut and your central nervous system. This medication comes in an IV (intravenous) form that can be injected to your body. Voveran 75 MG Injection is a Non-steroidal anti-inflammatory (NSAID) drug used to treat pain associated with

conditions like Gout, Migraine, Rheumatoid Arthritis, and sprains of muscles and joints and in mild to moderate fever

in some cases.

From the above, it was noted that the suspected complaints of Trigeminal Neuralgia and the Migraine are in chronic, nature which could be treated with tablets on OPD basis and hence didn’t warrant hospitalization. Moreover, the attending doctor had certified that the insured patient been managed with fluids and kept on observation for 3 days and discharged after partial relief., and hence the present hospitalization is falling under the following exclusions of policy: 2.27 : Medically Necessary Treatment is defined as any treatment, tests, medication or stay in hospital or part of stay in hospital which 1) is required for medical management….. 2) ….. 3)……4)…. Again from the hospital record, the insured person took treatment at Visakha Eye Hospital for Blurring of vision which is not related to the present cause of hospitalization. It was also noted that, since the present hospitalization itself is not satisfying the definition as per 2.27 cited above, the pre and post hospitalization expenses incurred by the complainant are also not admissible as per clauses 2.37 & 2.38 ., since these were also not in line with present cause of hospitalization

further.

In the complaint given to Forum, it is observed that the complainant had made a general comment that ‘most of the ailments fall under the list in para No: 3.1’. But, on verification of the particular clause it is noted that specified ailments of 56 numbers have been allowed only under domiciliary treatments in the policy, and the complainant didn’t mention under which ailment the present treatment matches not been mentioned or got certified by the doctor attending. Under the above circumstances, the Forum felt that the complainant’s claim didn’t fall either under domiciliary treatments which are allowed in policy as per clause 3.1, or warrant hospitalization to consider under hospitalization as per policy. Hence the Forum feels that the rejection of the claim by the insurer is justified as per the terms and conditions of policy, and does not see any infirmity in the decision of the insurer and the complaint been dismissed without any merit. The insurer is directed to return the original bills to complainant under acknowledgement after keeping copies of the same as requested by the complainant.

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 complaint been devoid of any merit and Dismissed. The insurer is directed to return the original bills to complainant under acknowledgement after keeping copies of the same as per request of complainant. The complaint is Dismissed.

Dated at Hyderabad on the13 th day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: Mr. K RAMAKRISHNA REDDY……………The Complainant Vs M/s Bajaj Allianz General Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .005.0343/2019-20


1. Name & address of the complainant Mr. K Ramakrishna Reddy

H.No. 8-2-104/A/34, Anuradha Colony,

L B Nagar, Hyderabad. 500 074.

Telengana State- 500 074

(Cell No.99499-49444)


Type of Policy


OG-20-9906-8416-00000028

Health insurance

17.04.2019 to 16.04.2020



Mr. K Ramakrishna Reddy

Mr. K Ramakrishna Reddy

4. Name of the insurer M/s Bajaj Allianz General Insurance Co. Ltd.

5. Date of Repudiation Not mentioned

6. Reason for repudiation Non- disclosure of pre-existing disease


8. Nature of complaint Claim pertaining to medical insurance

9. Amount of Claim Rs. 10, 00,000/-


11. Amount of Relief sought Rs. 10, 00,000/-



Rules, 2017

Rule 13.1 (b) – any partial or total repudiation

of claims by the Life insurer, General Insurer or

the Health insurer




b) For the insurer Mr Ismail, and Sri K.Kiran Kumar



17) Brief Facts of the Case: The complainant Mr K Ramakrishna Reddy had purchased an annual medical insurance

policy on 17.04.2015 from the respondent company and had been renewing the same every year.

On 17.10.2019, he was hospitalized in Yashoda Institute of Liver transplant & Hepatobiliary

diseases hospitals for post Liver Donor Liver transplant (LDLT) treatment; he was a known case of

Hepatitis B Virus (HBV) related Decompensated Liver Disease (DCLD) with Hepatocellular

carcinoma (HCC). He was discharged from hospital on 17.10.2019. His cashless claim was denied

by respondent whereas, New India Insurer from whom he had purchased another policy had

accorded cashless approval for Rs. 630,000/- out of the total hospitalization expense incurred for

Rs. 18, 23,411/- as stated by him. When his claim for reimbursement for an amount of Rs. 10,

00,000/- was submitted to respondent, the same was denied by them on grounds of non-

disclosure of his pre- existing disease at the time of purchase of the insurance policy from them.

18) Cause of Complaint: Rejection of claim submitted for reimbursement under medical insurance policy. a) Complainant’s argument:

The complainant had stated that when he had approached the respondent to accord cashless claim facility, they had denied it citing non-disclosure of his pre-existing condition as the reason. Clarification given by him did not yield positive result. His reimbursement claim made subsequently was also disallowed and the registration of his claim was blocked as communicated to him by respondent. The respondent had also issued him notice regarding the cancellation of his policy. In this regard, he had clarified that in the year 2006, he was admitted to Yashoda Hospitals for Kidney stone removal during which time he was tested positive for Hepatitis B Virus (HBV) in the routine pre surgery evaluation. He had also pleaded that he had completely forgotten about HBV since his attention was mainly towards his kidney stone removal. The allegation of non-disclosure of his pre-existing condition leveled on him was incorrect since he never ever had health issue related to HBV for the past 9 years prior to his purchase of insurance policy in the year 2015 from the respondent and it had been 13 years since its first detection till it came alive in the present hospitalization. Had it been the case that he had been suffering from HBV prior to the issuance of policy or it had been in his remembrance that he was tested positive for HBV; he would have taken treatment for the same but not have neglected it to the extent that it culminated in to his liver being transplanted.

Further, he had pointed out that the waiting period for pre-existing disease as per the policy clause No. 8 was 4 years and since the hospitalization for which he had filed his claim was in the fifth year of the insurance, his claim ought to be paid. The representation given to Grievance department with his clarification was not answered either in the affirmative or otherwise.

b) Insurer’s argument: The respondent had submitted their self contained note on 03.03.2020. it was noted from the SCN that the complainant had obtained the policy from them without disclosing the existence of Hepatitis B Virus in proposal form knowingly, and hence mentioned that the complainant’s claim was denied purely on account of non- disclosure of HBV which was detected in the year 2006 much prior to the issuance of first medical insurance policy by the respondent.i.e. during 2015. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions. b. Discharge summary and Hospital record. c. Rejection letter d. Correspondence with insurer f. Self Contained note of insurer.

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 10.03.2020, and the following arguments noted. The complainant himself attended the personal hearing and informed us that he had health insurance policy covering himself and his spouse since 17.04.2015 and continuously renewing with the respondent insurer upto the current policy valid till 16.04.2020 with floater SI of Rs. 10 lakhs. He submitted that on 17.10.2019 he was hospitalized for liver transplantation in Yashoda Hospitals and got discharged on 03.11.2019 on stable condition with medication as per discharge summary. It was noted from him that his cash less claim been denied on the ground of non-disclosure of material facts in proposal i.e. existing of Hepatitis B since 2006. When he lodged the claim for re-imbursement of hospital bill, it was noted that it was not paid and sent him a mail stating that his claim was blocked, and also received mail that his policy also been cancelled. Not satisfying the decision of insurers he submitted that he filed the present complaint for Redressal. The representatives of insurers attended the personal hearing and contended as per the points raised in the Self Contained Note submitted briefly stating that as the complainant is having Chronic Liver Disease with Hepatocellular Carcinoma he had undergone for liver transplantation surgery and he is already having H/o Hepatitis B virus since 2006 as per case papers., which is a root cause for the present ailment. Also submitted that the complainant had not declared the same in proposal form even though he is well aware about its existence, and obtained the policy.

They again stated, had it been declared, they would not have issued the policy for him on normal lines. Hence reiterated their repudiation decision. On close scrutiny of documents submitted and in the light of arguments took place, the Forum observed the following: As per the discharge summary of the Yashoda hospital, the complainant under gone surgery of LDLT (Living Donor Liver Transplantation) on 18.11.2019 and he was diagnosed with HBV related DCLD with HCC i.e. Hepatitis B Virus related Decomposed Liver Decease with Hepato cellular Carcinoma. Also as per the first consultation sheet at Yashoda hospitals dated 03.08.2019 it was also noted that the complainant is a known case of Chronic Liver Parenchymal disease., and also having Hepatitis B since 2006. When the Forum asked the complaint about existence of Hepatitis B and non disclosure of the same in proposal form, he submitted that in 2006 it was detected through pre-surgery routine checkup when he had undergone for kidney stone removal, and his main concentration was on kidney problem and not on HBV issue. He also said that he did not have any problem since then and even forgotten its existence, and hence confirmed that he had not disclosed the same in proposal form. The Forum has also gone through the medical literature about HBV which is as given below: Hepatitis B Hepatitis is inflammation of the liver. Hepatitis B is hepatitis caused by the hepatitis B virus. Hepatitis B virus spreads through contact with infected blood. Specifically, hepatitis B may spread through:Direct contact with the blood of an infected person, Unprotected sexual activity with an infected person, Needle sharing among intravenous drug users, Sharing razors or other personal items with an infected person, Being pierced or tattooed The hepatitis B virus can cause temporary or long-term (chronic) hepatitis. The initial infection with the virus may not even cause symptoms. People that do develop symptoms following initial infection with the virus have acute hepatitis. Most of them will clear the virus from their liver and blood. But a minority of people will develop a long-term infection. This is called chronic hepatitis. In chronic hepatitis, the symptoms of hepatitis often disappear then come back later. However, about one in ten adults may develop chronic hepatitis. They remain infected by the virus, can develop chronic liver disease, and can pass the virus to other people. People with chronic hepatitis may be free of symptoms for long periods. But symptoms eventually reappear. They may develop symptoms of advanced liver disease, including: Jaundice, Fluid accumulation inside the abdomen, Swelling of the legs, Confusion, Gastrointestinal bleeding. People with hepatitis B who develop cirrhosis are at risk of developing liver cancer. In rare cases, an episode of acute hepatitis B can be unusually severe. It may require hospitalization. A very small number of people with acute infection will develop liver failure. They require a liver transplant to prevent death. People with chronic liver disease that continues to worsen can be considered for a liver transplant. This procedure can be lifesaving. Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer in adults, and is the most common cause of death in people with cirrhosis.

CAN HEPATITIS B GO UNDETECTED FOR MANY YEARS? A chronic hepatitis B infection can go undetected for years – even decades in many cases. The longer a hepatitis B infection is left untreated, the more susceptible you are to developing severe scarring of the liver (cirrhosis) and liver cancer. Decompensated liver disease is also known as decompensated cirrhosis. Cirrhosis is a chronic liver disease that's commonly the result of hepatitis or alcohol use disorder.

From the above, it is noted that the Hepatitis B Virus can cause temporary and Chronic (long term) hepatitis which could be a root cause for the present medical condition of the complainant, finally culminated in his liver being transplanted, and it should have been disclosed in proposal form at the inception of the policy in 2015 as pointed out by the respondent insurer., basing on which the policy been issued, which is a serious lapse on the part of complainant. The very purpose of proposal form issued by the insurer is, to elicit all the material information furnished in utmost good-faith, with respect to the risk for which they are granting insurance coverage, and enable them to evaluate and to take decision whether to grant insurance cover, or to decline, or with how much extra premium to be charged if accepted the risk. It also gives declaration and warranty that all the statements mentioned are true and complete in all respects to be best of the knowledge of proposer. Hence it is the part and parcel, and the bases of Insurance Contract. As far as getting the pre-authorization approval from New India Assurance Company for the same surgery in another policy by the complainant (mentioned in original complaint) the Forum is unaware on what conditions they have authorized, and the complainant would have been disclosed to them while issuing their policy., since the same had not been made available during hearing. Under the above circumstances, the Forum feels that the insurer had rightly repudiated the complainant’s claim and needs no intervention in their decision, and the complaint been dismissed without any merit. However, the insurer is advised to continue the policy with the exclusion of present ailment.

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 complaint is devoid any merit and dismissed. The insurer is advised to restore the policy with the exclusion of present ailment. The complaint is Dismissed.


(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: SRI ANAND KUMAR GOLLA………………The Complainant Vs M/s Star Health and Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .044.1920.0330


1. Name & address of the complainant Mr. Anand Kumar Golla,

20-M/133/NT/502,

Nandini Towers, Matrusri Nagar,

Miyapur, Hyderabad : 500 049

(Cell No. 98665-51183)


Type of Policy


P/131100/01/2019/005081

Star Group Health Insurance

26.02.2019 to 25.02.2020



Mr. Golla Venkata satyanarayana a/c

Mr Anand Kumar G

M/s Guru Gowri Krupa Technologies Pvt. Ltd.

4. Name of the insurer M/s Star Health and Allied Insurance Co. Ltd.


6. Reason for repudiation Midterm inclusion not permissible as per policy

terms


8. Nature of complaint Claim pertaining to group medical insurance






Rules, 2017



the Health insurer




b) For the insurer Mr M. Ravi Kumar



17) Brief Facts of the Case: The respondent had issued an annual group health insurance policy to M/s Guru Gowri Krupa

Technologies Pvt. Ltd. who had placed their offer to pay premium through the intermediary M/s

Futurisk by means of which M/s Guru Gowri Krupa Technologies Pvt. Ltd. employees and their

dependants were covered. However, when the complaint, an employee of the policy holder, had

made a claim in respect of hospitalization expense of his father, the respondent had declined to

settle the claim on the premise that midterm inclusion was not permitted according to terms of

policy. Unhappy with this outcome, the complainant had therefore lodged a complaint against the

respondent in this Forum when his effort to bring the respondent to accept his claim had failed.

18) Cause of Complaint: Rejection of a claim pertaining to mediclaim insurance policy.


The complainant had submitted that the respondent had accept the payment of premium amount of his father Mr Golla Venkata Satyanarayana and had generated an health card with customer ID no. 107515861900203100 along with policy No. P/131100/01/2019/005081 after an endorsement vide No. P/131100/01/2019/005081/006 was passed to this effect. The effective date was 01.05.2019. The premium thus remitted was deducted from his salary every month. On 20.05.2019, his father was admitted to Gleneagles Global hospitals, Hyderabad where he was treated for Cirrhosis of Liver. When he had submitted all the documents related to claim, the respondent had insisted him to submit some more documents to process the claim. Despite the submission of all documents, they had rejected the claim on two grounds for which he had given his justification that his father had been suffering from liver problem more than a year ago for which he was being treated in Yashoda Hospital initially and thereafter in Global hospitals and therefore it was not correct to say that he had included his father to support his hospitalization claim. In support of the first occurrence of the disease, the complainant had stated that he had the reports with him. As regards the ground No. 2 for denial of claim, he had clarified that his parents could not be added from the date of his inception in his organization because of a bug in his company’s internal portal and the same problem continued to remain last year. All the employees in his organization had received e- cards by March end and when he tried to check the same with his employer for his father’s card in the month of April, he came to understand that his father’s data could not be sent at the time of renewal of policy because of the bug in internal portal. His HR team had then sent a request to respondent in the month of May. His argument was that if midterm inclusion was not acceptable to respondent, then the premium ought not to have been accepted in the middle of policy period when an additional request was made to them. Having accepted the same and having allotted a claim no., and request made for submission of further documents, rejection of claim was not proper.

b) Insurer’s argument: The respondent had submitted their self contained note on 09.03.2020. It was noted from the SCN that in the policy covering the parents, the mid terms inclusion of parents names are allowed

in case of new joinees only from the date of their joining, and not the existing employees parents. However for existing employees parents can join during the window time which was allowed upto 30 days from the inception of policy i.e. 26.02.2019. They also submitted that in the instant case, even though the employee is an existing one, his parents names were sent on 11.06.2019 i.e. after the lapse of window time. Hence they confirmed that the claim is out of the scope of policy. 19) Reason for registration of complaint: The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer f. Statements for inclusion of parents names. g. Self contained note of insurer.

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 10.03.2020., and the following arguments were noted. The complainant himself attended the personal hearing and submitted that he is the employee of M/s GGK Technologies P Ltd. since 2014, and his employer purchased a Group Mediclaim policy with the respondent insurer covering all the employees and their families for 12 months effective from 16.02.2019, and also another policy separately covering the dependant parents of all the employees effective from 26.02.2019 to 25.02.2020., by deducting the premium from their monthly payable salary from the employer. Accordingly, he opted his dependent parents to be covered in the later policy, paid the premium and waited upto April, 2019 for the id cards duly issued by the insurer towards confirmation of coverage. Noted that as he didn’t receive the card even then, he followed up continuously with the employer who included their parents name in the ensuing addendum list effective from 16.04.2019 to 14.05.2019 and sent to insurer through the broker M/s Futurisk Insurance Broking Co. P.Ltd.,as per their mail dated 11.06.2019.

He further submitted that unfortunately his father had fallen sick, and undergone major surgery on 21.05.2019 for Liver transplantion at M/s Gleneagles Global Hospitals, Hyderabad; and finally lost him on 10.06.2019 at 1.09 PM while he was in hospital., and incurred huge bill of around Rs. 31.94 lacs. Noted that when he lodged the claim with the insurer along with bills and hospital records for reimbursement of total sum insured for Rs. 3 lacs as per policy, his claim had been rejected by the insurers as per their letter dated 08.10.2019 stating the reason ‘As per policy no midterm inclusion of any employee & dependants are allowed unless he is a new entrant’. Even though he referred the matter for re-consideration of his claim to the grievance department of the insurer, he could not get favourable result; and hence he filed the present complaint for Redressal. The insurer’s representative attended the hearing and contended as per the points

mentioned therein briefly stating that they issued the policy covering the dependent parents of the employees for a floater SI of Rs. 3 lacs per family effective from 26.02.2019 to 25.02.2020 with a provision of addition and deletion of members as long as the employee continues to be in the employees list of the employer along with following condition: “After inception of policy, no midterm inclusion of any employee is allowed unless, he is a new joinee and such inclusion is also subject to payment of additional premium on pro rata basis. For newly joined employees, the insured shall provide the date of joining. Insured will be allowed a window period of 30 days from the policy inception date to review the existing employee list covered under the policy.” They again contested that in the present case, the complaint is neither a new joinee nor intimated their parents names to include in policy within 30 days of window period which was allowed as per above clause. But actually sent the list to them on 11.06.2019 including their parents names in the last of statement under serial numbers 13 & 14 along with premium., which is not in compliance of above clause. Hence they confirmed their repudiation decision as per above clause. As regards the complainant raising a question before this Forum as to how his premium was accepted and endorsement passed to this effect but claim being denied by citing the policy clause, the respondent had categorically told that the policy was issued in the name of his employer and therefore it was the duty of the employer to send the list of additions and deletions by complying with the clause stated supra. The Forum has gone through the documents submitted and in the light of arguments took place during hearing, observed the following: The complainant is continuing as an employee of the employer since 2014 and said to be paying the premium from his salary., and noted from his correspondence with various sources about coverage of his parents, and non-receipt of e-cards. Finally it was noted by him that due to some bug in the company’s internal portal, he didn’t find the names of his parents in the schedule which was attached to the policy commenced on 26.02.2019. Even though, he continuously followed up with various sources; his employer could only include their parents names under serial numbers 13 & 14 in the list effective from 16.04.2019 to 14.05.2019 and the same was sent to insurer only on 11.06.2019 along with premium who passed endorsement on utmost good faith. Since the insurer is getting the list of additions/deletions every month in bulk, they could not verify each and every name as to whether the particular employee is a newly joined/existing, but issued endorsement on utmost good faith as per the advice of the employer, which could be verified only at the time of processing the claim. The employer being the administrator to this group policy issued ought to have communicated immediately to the insurer to include the name of the complainant’s father effective from 26.02.2019 to 25.02.2020. In the instant case, on the above lines Endorsement been issued by the insurer, and at the time of verification, and processing of claim it was found that the complainant is an existing employee (not a newly joined one), and hence his parents could not be covered as per ‘Window clause’ cited supra. It is the sole responsibility of the employer having deducted the premiums from salary to verify the names before sending the same to insurer for inclusion in policy, whether the employee is an existing/newly joined to comply the Clause for inclusion as per policy., which is lapse on their part. Also due to their internal system problem ‘known as bug’ in maintaining the data of dependant parents list should have been sorted out by them as on date of inception of

policy for which the complainant should not have been allowed to run from pillar to post in their organization. It was also the duty of the employer to inform the Respondent insurer about the correct status of the employee i.e. new/existing and should have sought formal approval from the respondent insurer for inclusion of dependent parents names with effect from 26.02.2019, as the employer submitted the list very late. Unfortunately, the employer didn’t do anything in this regard despite being aware of the terms of the policy. The negligence/inept handling of the issue by the employer led to the repudiation of claim of the employee. As the employer is solely and wholly responsible for this monumental blunder, the Forum feels the onus is on the employer to compensate his employee i.e. Mr Ananda Kumar, for his expenses incurred by him towards his father’s treatment. Under the above circumstances, the Forum feels that the insurer has rightly repudiated the claim on their part as per the specific provision of midterm inclusion in the policy, and needs no intervention in their decision of repudiation and dismissed the complaint without merits.

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 complaint is devoid of any merit and Dismissed. The complaint is Dismissed.

Dated at Hyderabad on the13 th day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM



Case between: Mrs. T LEELA……………The Complainant Vs M/s Religare Health Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.HYD-H-037-1920-0339


1. Name & address of the complainant Mrs. T Leela

7-1-31/6/3, Leela Nagar,

S K Road (Near Jain Mandir),

Ameerpet,Hyderabad,Telengana State- 500 016.

(Cell No.96186-22175)


Type of Policy


11301120

Floater Health Insurance

05.07.2019 to 04.07.2020



Mr HariKrishna Tumuluri

Mrs. Tumuluri Leela

4. Name of the insurer M/s Religare Health Insurance Co. Ltd.


6. Reason for repudiation Discrepancy in medical documents and records







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. Complaint how disposed Allowed ( Statistical Purpose)



The complainant had purchased an annual medical insurance policy to cover the health of her spouse and

her on 18.05.2017 for a total sum insured of Rs. 5 Lakhs. In the renewal policy period commencing from

05.07.2019 to 04.07.2020, her husband was admitted to Yashoda Hospitals, Hyderabad on 15.10.2019 with

complaint of acute chest pain associated with sweating, ECG showing upward trend in V2-V6. Coronary

angiogram revealed the presence of a single vessel disease in his Left Anterior Descending (LAD) artery

which accounted for mid 100% thrombotic occlusion; the patient was therefore advised to undergo

primary PTCA plus drug eluting stent to LAD. The result of implant of stent was good and he was

discharged from hospital with medicines on 17.10.2019. However, when a claim was made towards the

hospitalization expense, the respondent had declined to honor the same on account of discrepancies

observed by them related to the patient’s treatment.

16) Cause of Complaint: Non settlement of Mediclaim


The claim preferred by the complainant was non - settlement of Mediclaim by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. After registration of complaint by this Forum and before hearing, the insurer further reviewed the claim and processed it and agreed to settle the claim . The Complainant accepted the settlement. The insurer settled the claim by way of NEFT on 13.03.2020 for Rs.2,61,584/- . Therefore a total amount of Rs.2,61,584/- was paid by NEFT duly informed by way of mail dated 13.03.2020 and 16.03.2020 by the complainant with a request to close the complaint by this Forum. ( Two Lakhs sixty one thousand five hundred and eight four only.)

AWARD



(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: SRI V. SHIVA KUMAR………………The Complainant Vs M/s Star Health and Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.HYD-H-044-1920-0337


1. Name & address of the complainant Mr. V Shiva Kumar

H. No. 2-10-14/17, Flat # 503, Brooklyn Residency, Macha Bollarm, Alwal,

Hyderabad,Telengana State- 500 010.

(Cell No. 99484-39088)


P/131116/01/2019/021098 Family Health Optima Insurance Plan 20.02.2019 to 19.02.2020


Mr Veerabommala Shiva Kumar Mr Veerabommala Shiva Kumar



6. Reason for repudiation Non-submission of documents by insured








13. Date of hearing/place 17 .03.2020



b) For the insurer Mr.M.Ravi Kumar, AGM Legal



17) Brief Facts of the Case: The complainant had purchased an annual medical insurance policy from respondent on 31.12.2016 to

cover the health of his spouse, two dependent children, and his for a basic floater sum insured of Rs.

4,00,000/-. During the policy renewal period 2019-’20, he was admitted to Srikara Hospitals between

03.05.2019 and 13.05.2019 with complaints of pain and swelling over right groin extending from the root

of Pelvis to bottom of scrotum. There was an abscess over the groin region from root of Pelvis to bottom of

Scrotum for which he underwent incision and drainage under spinal anesthesia as per the certificate issued

by Srikara Hospitals dated 27.06.2019. He was treated on 13.05.2019 for hemorrhoids. His request to grant

cashless claim to him could not be accorded by respondent due to want of certain requirements and

thereafter when he had filed his claim papers for reimbursement, it was denied on the same ground. Not

happy with the reason given by respondent, he had therefore approached this Forum to enable him to

receive the amount claimed by him from respondent.



The complainant had submitted that he was not satisfied with the reasons given by respondent for the denial of his claim and his representation made to Grievance department too had not evoked any kind of response and therefore he had requested this Forum to do the necessary. b) Insurer’s argument: The respondent had submitted their Self Contained Note (SCN) on 16.03.2020. The insured was issued Family Health Optima Insurance Policy covering himself, spouse and two dependent children for a floater sum insured of Rs.4 Lakhs on 31.01.2016 and renewed subsequently. It was in the 4 th year of the policy, they received reimbursement claim for Rs.1,42,302/- for admission of Sri V.Shiva Kumar at Srikara Hospital , Secunderabad on 03/05/2019 and discharged on 13/05/2019.From the discharge summary it was noted that the insured was diagnosed with Fistula tract extending from bottom of scrotum to right root of pelvis, D/T Periuretheral Abscess, S/P I & D Fistual tract ectraction and Debridement. They raised a query for want of documents 1) As per ICP h/o similar episode 3 years on and off, hence to submit treatment records and consultation papers 2) a letter from treating doctor regarding probable cause of cellulites groin in this patient for approval of cashless request. The insured did not submit any documents hence cashless approval was denied by them and duly communicated to the insured. Subsequently during submission of reimbursement claim they had raised the following query on 25/05/2019.- 1) since the patient had episodes since 3 years as per case sheet, previous consultation reports and treatments details taken 2) complete set of indoor case papers 3) any past hospitalization for similar episode and treatment taken. The insured did not co operate with them and did not submit the documents. Hence the claim was repudiated as per condition no 3 of the policy which read as “The insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim” and informed vide their letter dated 10/06/2019 to the insured.


The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy & Proposal form. b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosure 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 17.03.2020. The complainant stated he had taken a policy in 2016 and has been renewing the same. He was admitted to Srikara Hospitals between 03.05.2019 and 13.05.2019 with complaints of pain and swelling over right groin .There was an abscess over the groin region for which he underwent incision and drainage under anesthesia as per the certificate issued by Srikara Hospitals dated 27.06.2019. He informed he had consulted a doctor 15 days prior to hospitalization for cellulites who gave him medication and advised him for surgery if the medication was not fruitful. With no relief and in pain at 11 PM at night he admitted himself for surgery. He said, he was a field worker, his work required him to move around in this two wheeler, during summer season due to heat he used to get boils since 2-3 years back. He said he did not consult any doctors nor did he get admitted in any hospital for treatment of the same. Hence, he could not furnish previous consultation/documents as requested by the insurer. To the question asked about Ayurvedic treatment taken, he said he took over the counter medicines from an Ayurvedic Medical Shop for 3 days which gave him temporary relief. A fistula is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces),

such as blood vessels, intestines, or other hollow organs. Fistulas are usually caused by injury or surgery,

but they can also result from an infection or inflammation.Hemorrhoids, also known as piles, are swollen

veins in the lower part of the anus and rectum. When the walls of these vessels are stretched, they become

irritated. Although hemorrhoids can be unpleasant and painful, they are easily treated and very

preventable.

The insurer stated from the Indoor case papers, it was obvious he had a history of similar episode of Fistula on previous occasions too and which used to occur on and off during the past three years. Hence, the complainant was requested to submit the previous medical documents in connection with Fistula but since he did not cooperate with the insurer which was in contravention to the policy condition No. 3, the claim could not be settled and was it was repudiated thereafter. Also conservative Ayurvedic treatment for Hemorrhoids was taken and not disclosed to them in the proposal form during inception of the policy, which amounts to non-disclosure. The Forum observed that the insured suffered from swelling of right scrotum extending to the base of pelvis and the probable cause for cellulites groin could be fistula tract formation, periurethral abscess formation. Periurethral abscess is rare and infectious occur around the periurethral and urethral tissues in men and the treated with abscess drainage. The body's response is inflammation, indicated by pain, redness, heat and swelling. Cellulites, which is a common and sometimes painful bacterial skin infection, most often affects the skin of the lower legs, although the infection can occur anywhere on a person's body

or face. Though, he did have pain during summer season since 3 years, he assumed the cause as heat, he took over the counter drugs for temporary relief and did not suspect it to be severe enough and hence may be treated as non-disclosure of insignificance. As he did not consult any doctor or take treatment for the same, the insured’s inability to submit previous documents is justified. It is only an abscess which occurred due to infection. This happens to everybody and sometimes the abscess can be painful, may require medical assistance to drain the pus after cutting open the abscess. Same thing happened to the complainant, who required medical help and also due to formation and location of the abscess in a very sensitive area. The Forum, directs the insurer to admit and settle the claim.

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 settle the claim along with interest. The complaint is Allowed.


Rules, 2017:

j) 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.

k) 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.

l) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: SRI K VEERA VENKATA APPA RAO………………The Complainant Vs M/s The New India Assurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .049.1920.0336


1. Name & address of the complainant Mr. K Veera Venkata Appa Rao

D.No. 2-159,Vinayaka Temple,

Isukapalli Post, Madhavapuram,

Pithapuram Mandal, East Godavari District

Andhra Pradesh State- 533 450

(Cell No. 94930-65065)


Type of Policy


62040034182800000039

New India Floater Mediclaim

06.11.2018 to 05.11.2019



Mr Katta Veera Venkata Appa Rao @ Veera

Babu

Mr Katta Veera Venkata Appa Rao @ Veera

Babu


5. Date of Repudiation -----

6. Reason for repudiation Claim settled as per the eligible sum insured



9. Amount of Claim Rs. 490,945.58





Rules, 2017



the Health insurer




b) For the insurer Sri G Rama Krishna., Dy Manager



17) Brief Facts of the Case: The complainant had purchased an annual medical insurance policy on 06.11.2012 to

cover the health of his spouse, two children, and his for an individual sum insured of Rs. 1 Lakh

plus Cumulative Bonus (CB) buffer of Rs. 5,000/- till the policy was renewed every year up to

05.11.2016. On 06.11.2016, he had switched over to New India Floater Mediclaim mediclaim

policy for a floater sum insured of Rs. 5 Lakhs which covered the health of all the members

insured earlier. During the policy period 2018-’19, he was admitted to Christian Medical college,

Vellore between 19.10.2019 and 29.10.2019 with presenting complaints of a history of

palpitation on exertion for the past 2 years. He was diagnosed with severe mitral regurgitation for

which he underwent mitral valve replacement under general anesthesia on 24.10.2019. On

submission of his claim bills for reimbursement to respondent for an amount of Rs. 370,945/-, the

respondent had settled it for Rs. 105,000/-. Not satisfied with the partial settlement of his claim,

he had therefore filed a complaint against respondent in this Forum seeking an order to direct the

respondent to pay him the balance amount as claimed by him.

18) Cause of Complaint: Non settlement of a portion of claim amount under medical insurance policy. a) Complainant’s argument:

The complainant had stated that he had acted upon the advice of respondent company’s agent in switching over from New mediclaim policy 2012- where each insured member was covered for a sum insured of Rs. 100,000+ Rs. 5,000/- - to a Floater mediclaim policy (with sum insured at Rs. 5 Lakhs which covered the health of all the insured members). However, when he had filed his claim, the respondent company had declined to settle the entire amount citing the policy condition to restrict the payment to Rs. 105,000/- only. In this regard, he had stated that the agent had assured him that all the original benefits shall be protected from 06.11.2012 in the new product offered to him and that he was eligible for the total cost of surgery. Since, he had paid the hospital bills by taking loan; he was immersed in financial crisis and therefore had requested this Forum to render justice to him. b) Insurer’s argument: In their self contained note submitted to this Forum, the respondent had mentioned that the complainant had migrated from new mediclaim policy 2012 taken on 06.11.2012 with an individual Sum Insured (SI) of Rs. 1 Lakh +CB Rs. 5,000/- to New India Floater mediclaim policy with enhanced SI of Rs. 5 Lakhs on 06.11.2016. He was first diagnosed with Mitral valve prolapsed disease in June 2014 which was prior to migration into new product. Since it was a pre-existing disease, policy condition No. 4.1 was applicable in the instant case which reads:” no claim will be payable under this policy for treatment of any pre-existing condition/ disease, until 48 months of continuous coverage of such insured person have elapsed, from the date of inception of his/ her first policy as mentioned in the schedule”. At the time of his surgery, he was eligible for the claim under the policy period 2014-’15 where the SI was Rs. 1 lakh and CB Rs. 5,000/-. At the same time, the respondent had highlighted Clause No. 5.11 of the policy which reads: “You may seek

enhancement of SI in writing before payment of premium for renewal, which may be granted at our discretion. Before granting such request for enhancement of SI, we have the right to have You examined by a medical practitioner authorized by Us or the TPA. Our consent for enhancement of SI is dependent on the recommendation of the medical practitioner. SI can be enhanced to the next SI band only. Enhancement of SI will not be considered for: (1) insured persons over 65 years of age, (2) insured person who had undergone hospitalization in the preceding two years, (3) insured persons suffering from one or more of the following illnesses/ conditions: (a) Diabetes, (b) Hypertension, (c) Any chronic illness/ ailment, (d) any recurring illness/ ailment, (e) any critical illness”. The migration to the new product was approved with enhanced SI and an endorsement was made in the new product that “pre-existing disease” was not applicable; this was done so on utmost good faith that the individual would not have concealed the presence of any material fact. Hence, in such a scenario, the respondent had gone 48 months back from the present hospitalization claim to the policy period to check the eligibility and as per that policy period, it was observed that the complainant was eligible only for Rs. 105,000/- including CB which was therefore settled on 04.12.2019.


The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal:

a. Policy copy with terms and conditions. b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Hospital records f. Self contained noted by insurer

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 17.03.2020, and the following are the arguments noted. The complainant himself attended the personal hearing and informed us that he had individual health insurance policy as canvassed by the insurer’s agent, covering Rs. 1 lakh each including his family members since 06.11.2012 and renewing continuously. As he was interested to have more sum insured in policy, he migrated to a floater policy as advised by the agent for the sum insured of Rs. 5 lakhs at the time of renewal on 06.11.2015 and renewed the same with the insurer up to 05.11.2019. It was noted from him that as he was suffering from palpitation on exertion, he contacted Christian Medical College Vellore and diagnosed as ‘Mitral valve prolapse; after observation of Angiogram on 07.09.2019, and finally admitted for surgery of Valve replacement on 09.10.2019, and got discharged on 30.10.2019 in stable condition of his health. He further submitted that when he claimed for the entire hospital bill of Rs. 3,70,945/- his claim was short settled for Rs. 1,05,000/- only., and even he represented the same to the grievance dept of insurer, he couldn’t get positive result. Hence he submitted the present complaint for Redressal. The insurer’s representative attended the personal hearing, and contended as per the points raised in their self contained note briefly stating that the complainant had been issued the first policy from 06.11.2012 for a SI of Rs. 1 lakh each along with all his family members valid up to

05.11.2015, and later migrated to the floater SI of Rs. 5 lakhs from 06.11.2015 while renewing. They contended that the present hospitalization of 09.10.2019 for Valve replacement is a pre-existing condition as per consultation with Dr P. Ranga Swamy on 16.06.2014, and also the consultation at Christian Medical College, Vellore on 15.04.2015; and alleged that the complainant knowingly migrated to the floater policy for enhanced sum insured. Since the present ailment had been diagnosed and known to him much after the issuance of 2012 policy, and hospitalized after elapse of 48 months since then; they have settled the complainant’s claim as per existing sum insured of Rs. 1.05 lakh (including cumulative bonus)., and not considered the remaining claim, as the waiting period of 48 months stipulation applies for the enhanced sum insured under floater policy, as per exclusions 4.1, 4.2, 4.3.1 and 4.3.2 under clause 5.11. Hence they reiterated their repudiation decision. On close scrutiny of documents submitted and in the light of above arguments took place during hearing, the Forum observed the following: It is evident that the first policy was issued for a sum insured of Rs. 1 lakh each including his family members which was valid up to 05.11.2015. Later, at the request of the complainant, the insurer issued the Floater policy for a Sum insured of Rs. 5 lakhs effective from 06.11.2015 which was ‘granted at their discretion’ as per clause 5.11 of policy (without undergoing the procedure as mentioned therein) on good faith, basing on the details of proposal form pertaining to policy of 2012, for which the exclusions applies for the enhanced sum insured as per 4.1, 4.2, 4.3.1 and 4.3.2. In this connection fresh proposal would have been obtained by the insurer, to enable the complainant to declare the pre-existing disease identified during 2014, and also on 15.04.2015. In particular, he had also shifted to a floater policy which is a lapse on the part of insurers while issuing the policy during 2015. Because of this lapse on their part, the respondent insurer can’t pin point the complainant about non-disclosure of pre-existing disease for the floater policy issued for enhanced sum insured. Even otherwise, the insurers should have issued the policy with the express condition that “the sum insured been enhanced basing on the health condition of the complainant during 2012 and subsequent ailments which were identified not covered.” However, the Forum feels that the non-issuance of fresh proposal form by the insurers at the time of underwriting alone may not absolve the complainant from the responsibility of observance of utmost good faith on his part, but should have been intimated to the insurer in writing; which he had not done. Again, it was noted during hearing that the complainant had not been given the policy with its terms and conditions by insurer either as on the issuance of policies during 2012 or 2015, and the insured wasn’t aware the conditions of the policy pertaining to the enhanced sum insured. Though the complainant being an agricultural labour and not much educated he could have sought the help of somebody to understand the terms and conditions of the new floater policy, and accordingly he would have exercised his option to continue with the new policy or not. By not issuing and serving the policy terms on the insured, the respondent insurer denied the opportunity to review the terms and conditions of the new floater policy. Added to this, it is learnt that the agent of insurer assured the complainant that he would be entitled to all benefits of the old policy. Thus, the complainant was misinformed by the agent, and the insurer denied him opportunity of reviewing the terms during free look period, by not serving the document i.e. policy containing terms and conditions. The act of the insurer amounts to gross negligence and

deficient service to the insured. To rebut the complainant’s argument, the insurer’s representative couldn’t produce any acknowledgement/evidence having served the policy with terms and conditions to the complainant which is also an another lapse on the part of the respondent insurer.

In view of the above primary underwriting lapses of insurers, the Forum feels that the benefit of doubt would be considered in favor of the complainant, and the insurer is directed to process the complainant’s claim as per bills eligible.

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 process and settle the complainant’s claim as per bills eligible. The complaint is Allowed.


Rules, 2017:

m) 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.

n) 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.

o) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 18 th day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN



STATES OF A.P., TELANGANA & YANAM



Case between: SRI S SANTHI POLIREDDY………………The Complainant

Vs

M/s Star Health and Allied Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).H .044.1920.0348

Award No.: I.O.(HYD)/A/GI/0197/2019-20

1. Name & address of the complainant Mr. S. Santhi Polireddy

D. No. 7-73/2, Near state Bank of India,

Reddy Ramalayam street, Kaza,

Mangalagiri (M), Guntur District.


(Cell No. 99487-16272)


Type of Policy


P/131220/01/2020/000204

Family health Optima Insurance Plan

28.05.2019 to 27.05.2020



Mrs S Rajani

Mr Syamala Santhi Polireddy



6. Reason for repudiation Non disclosure of material facts at the time of taking policy such as Pre-Existing Disease (PED)





11. Amount of Relief sought Restoration of policy





a) For the complainant Not attended

b) For the insurer Sri M Ravi Kumar



17) Brief Facts of the Case: The complainant had purchased an annual medical insurance policy from respondent on

28.05.2018 to cover the health of his spouse, and his for basic floater sum insured of Rs. 5 Lakhs.

He had renewed the policy for a further period of 1 year which was effective from 28.05.2019. His

wife, 47 years old, was admitted to C V R Hospital, Guntur between 24.06.2019 and 26.06.2019

with heart related problem and upon her undergoing Coronary angiogram (CAG), it was diagnosed

that she was having mild Coronary Artery Disease (CAD). She had filed her claim bills with

respondent to claim reimbursement of hospitalization expense incurred but not only was the

claim denied but the respondent had also deleted her name from the insurance policy after

passing an endorsement on 18.01.2020 by citing reason that the insured person had not disclosed

her pre-existing disease which she had before the commencement of the first insurance policy

that was taken from them. Unhappy over the decision taken by respondent, he had filed a

complaint against them in this Forum.

18) Cause of Complaint: Rejection of a claim pertaining to mediclaim insurance policy. a) Complainant’s argument:

The complainant had submitted that the insured member had disclosed that she had high BP and thyroid related problem before taking the insurance policy. Since the issuance of first policy, his spouse had not filed any claim with respondent. However, she had to be admitted to CVR hospital, Guntur since she developed chest pain suddenly. Although the CAG test done on her under the supervision of doctor revealed that she did not have any heart related problem, she continued to have pain and therefore a pulmonologist was consulted at SAKRA World hospital, Bangalore under whose supervision all the related tests were carried out. It was found that she had Interstitial Lung Disease (ILD) and progressive Systemic Sclerosis. Further, she was referred to Rheumatologist who upon conducting some tests found that she had Raynaud’s disease which was diagnosed only in July’19. The reason given by respondent to deny the claim and exclude her name from the policy was not correct according to her because it was diagnosed only after the inception of policy and not before.

b) Insurer’s argument: The respondent had submitted their Self Contained Note (SCN) on 16.03.2020. It was noted from SCN that the respondent’s medical team had reviewed the claim documents and it was found from the consultation notes by Dr. Shweta Singhal, Sakra World hospital, Bangalore that the insured person was suffering from Raynaud’s disease for the past 3-4 years as confirmed by the Rheumatologist which meant that she had this disease prior to the inception date of first insurance policy with them. This fact was not disclosed by her in the proposal form and therefore the company was not liable to pay the claim as per condition Nos. 6 & 12 of insurance policy issued to her which reads, “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 have non-disclosure of material facts and also the policy is liable to be cancelled”. The policy was cancelled by invoking condition No. 15 of policy which reads:”The Company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non disclosure of material fact as declared in

the proposal form and/ or claim form at the time of claim and non-cooperation of the insured by sending the insured 30 days notice by registered letter at the insured person’s last known address”.


The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.


a. Policy copy b. Discharge summary and hospital records c. Rejection letter d. Correspondence with insurer e. Proposal form. f. SCN submitted by insurer.

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum, the complainant remain absent and the representative of the insurer attended the personal hearing at Hyderabad on 17.03.2020 and the following arguments were noted. The insurer’s representative attended the hearing and brought to the notice of Forum as per the points mentioned in SCN briefly stating that they have issued the first policy from 28.05.2018 to 27.05.2019 and renewed upto 27.05.2020. Stated that the complainant lodged the claim during 2nd year of policy for the hospitalization at CVR Hospitals, Guntur for treatment of Chest pain from 24.06.2019 to 26.06.2019 and diagnosed to have unstable Angina with mild CAD. Again they contended that as per the consultation in Sakra Hospital with Dr Swetha Singhal on 15.07.2019, she had the disease of Raynaud’s (Progressive Systemic sclerosis) sysmptoms since 3 to 4 years which was fallen prior to issue of policy i.e. prior to 28.05.2018 and confirmed their repudiation decision on the grounds of non disclosure of facts. Hence reiterated their decision that the complainant’s claim been rejected basing on non disclosure of Raynaud’s in proposal amounts to non disclosure of material facts while issuing the policy.

On close scrutiny of documents submitted in the subject case, it is noted that the insured person had joined in CVR Hospital from 24.06.2019 to 26.06.2019 for chest pain and diagnosed to have Mild CAD, with Unstable Angina and Hypertension and got discharged in stable condition, for which the contributed cause of Hypertension for present ailment had already been declared in proposal form. As per consultation and certification of M/s Sakara Hospitals dated 24.12.2019 the insured person had symptoms of Progressive Systemic Sclerosis, were existing since 3 to 4 years prior to 15.07.2019 on which date she was finally diagnosed to have Raynods disease. Since symptoms are different from final diagnosis, the insured person may not be aware of symptoms which finally culminated to Raynod’s disease, and she would have declared in case if the same were in her notice. It is found that she don’t have any malafide intention to hide any material fact to obtain policy, because, she had sincerely declared the existing disease of Hypertension., and found to be not taken treatment anywhere for the disease of Raynod’s as per records prior to issuance of

policy during 2018. The Forum has gone through the following medical literature: Systemic scleroderma, or systemic sclerosis, is an autoimmune rheumatic disease characterized by excessive production and accumulation of collagen, called fibrosis, in the skin and internal organs and by injuries to small arteries. Collagen is the most abundant protein in the human body, found in the bones, muscles, skin, and tendons. It is the substance that holds the body together. Collagen forms a scaffold to provide strength and structure Raynaud's disease is a rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue. Signs and symptoms of Raynaud's disease include: Cold fingers or toes, color changes in your skin in response to cold or stress, Numb, prickly feeling or stinging pain upon warming or stress relief.

Moreover, It is also observed that the present hospitalization claim lodged with the insurer was related to the heart ailment only, and not for the diagnosed disease of Raynaud’s basing on which claim was repudiated. Hence it was found to be not material for the present claim of the complainant. Again no significance can be given for the certificate obtained at Sakra Hospital dated 24.12.19 stating that the insured person was diagnosed to be suffering from ILD in July 2019 which is much after the issuance of first policy and didn’t affect the admissibility of the present claim of the complainant. Under the above circumstances, the Forum feels that the repudiation decision taken by the insurer is unjust, and advised the insurer to process the complainant’s claim as per bills eligible, and restore the policy from the date of cancellation with the exclusion of ailment for Raynaud’s disease which is a known risk after its diagnosis on 15.07.2019, besides its treatment is also of recurrent nature.

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 settle the claim as per bills eligible and restore the policy till its usual expiry. The complaint is Allowed.


Rules, 2017:

p) 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.

q) 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.

r) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 19 th day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: SRI SUNKARA SRINIVASA RAO………………The Complainant Vs M/s The United India Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H .051.1920.0342


1. Name & address of the complainant Mr. S. Srinivasa Rao

H. No. 5-50/B, Backside Kothapeta Bus Stop,

Kothapeta, Sangam Jagarlamudi PO,

Guntur district,


(Cell No.98486-11513)


0504002818P103444696 Andhra bank Arogyadhan policy


Mr Sunkara Srinivasa Rao M/s Andhra Bank

4. Name of the insurer M/s The United India Insurance Co. Ltd.

5. Date of Repudiation Not mentioned

6. Reason for repudiation Not mentioned











b) For the insurer Sri K Ramesh, Dy Manager., & Dr Pratap



17) Brief Facts of the Case: The complainant had purchased an annual medical insurance policy through Andhra Bank

from respondent that was being issued to Andhra Bank savings bank account holders. He was

admitted to DVC Hospital between 20.02.2019 and 25.02.2019 with history of throat pain for past

2 days and high grade fever, headache, and body pains. His temperature reading was 100 degrees

Fahrenheit at the time of his admission to hospital and he was found to have congested

pharyngeal wall and tonsillar pillars. He was managed conservatively on IV fluids and antibiotics

before he was discharged in a stable condition. He had lodged a claim with respondent on

01.03.2019 for an amount of Rs. 19,023/- which he had paid towards hospitalization expense

incurred by him. Since the TPA of respondent and the respondent did not settle his claim, he had

therefore approached this Forum.

18) Cause of Complaint: Non reimbursement of claim filed under medical insurance policy. a) Complainant’s argument:

The complainant had stated that the TPA of respondent M/s GHPL had replied that they did not receive the claim documents from hospital where he was admitted. Upon enquiring from hospital, he learnt that the same were submitted to the TPA. The TPA enquired from hospital if the claim made was cashless or otherwise and when they were told that it was a cashless claim, they had assured that the claim would be processed. However, on 14.11.2019, they informed that the claim was cancelled since they had received an e- mail from the hospital that the cashless claim request made was withdrawn. There was a technical problem as stated by complainant in his letter addressed to this Forum because of which a request was made by hospital to convert the claim from cashless to reimbursement. Unfortunately, the TPA had later informed him that the claim could not be processed because the request for a cashless claim made by hospital was withdrawn by them. He had pleaded that he had been denied of his claim during an emergency situation.

b) Insurer’s argument: The respondent had submitted their Self Contained Note on 27.02.2020. It was noted from SCN that the complainant admitted in the hospital for Acute Pharyngitis on 20.02.2020, and discharged on 25.02.2019 after treating him conservatively with some antibiotic fluids and medications. During his hospitalization, the TPA received for cashless authorization for which they requested to submit few documents for their necessary action. But the hospital authorities had not yet submitted the required documents even after waiting reasonable time, they closed the file as no claim. Again mentioned in the SCN that the claim was closed as per clause 7.4 of Policy which states as given below: “The insured person shall obtain and furnish to the TPA with all original bills, receipts and other documents, upon which a claim is based and shall also give the TPA/Company such additional information and assistance as the TPA/Company may require in dealing with the claim.” As the hospital is not responding to the queries raised by the TPA, they advised the insured to take up the matter with the Hospital, and agreed to process the claim soon after providing the same by the insurer. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions. b. Discharge summary with hospital records c. Rejection letter d. Correspondence with insurer 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum, both the parties attended the personal hearing at Hyderabad on 17.03.2020, and the following arguments were noted. The complainant himself attended the personal hearing and submitted to us that he had Arogyadaan Medical policy since 2015 from the respondent insurer, and continuously renewing with them up to 08.06.2019. He again informed that as he was suffering from fever, head ache, and throat pain for the last 1 day, he joined in CVR hospital Vadlamudi on 22.02.2019 and got discharged on 25.02.2019 after their treatment conservatively, and on getting stable vitals. He further submitted that his hospitalization bill towards cashless claim not been sanctioned, and the reimbursement claim which was sent through hospital not been settled by TPA/Insurer even after reminding several times. Hence noted that he submitted the subject complaint for Redressal. The representatives of insurers attended the hearing and contended as per the points raised in SCN briefly stating that the required documents such as Original bills, Investigation reports supporting to the diagnosis, Detailed plan of Management with drug administration chart, and the Temperature chart not been received by them to process the complainant’s claim. They insisted to submit the original documents to process the claim and to communicate their decision. Even the complainant shown the courier’s receipt towards of evidence of having sent the originals, they have not acknowledged the documents having received. The Forum allowed time up to 2 days and advised the insurers to go through the copies of hospital records submitted by the complainant, and sought their decision through mail about

settlement of the claim. However, the Forum received the mail dated 18.03.2020 denying the claim of the complaint on the ground that the hospitalization was done only for evaluation purpose, and later diagnosed to be as Acute Pharyngitis, being all vitals are in normal range. Hence they repudiated the claim under policy exclusions 3.2, & 6.11 of policy. On scrutiny of the documents submitted and in the light of arguments, the Forum observed the following points: As per Discharge Summary of DVC Hospitals, the complainant had been admitted with the history of fever since 1 day, throat pain since 2 days with headache and body pains, and also with the history of dry cough. Also noted that the complainant had ‘congested pharyngeal wall and tonsillar pillars’ and diagnosed as “Acute Pharyngitis. Just after admission on 20.02.2019, he had undergone for various tests of Complete Blood count, RFT, Complete Urine Examination, ECG, and X-ray Chest PA view for which the readings of reports were almost in normal range., and all the physical examination reading were also in normal except the temperature was noted to be at 100 F. During the course of hospitalization he was prescribed with antibiotics by way of injections, and oral Tablets to control fever. The Forum has gone through the following medical literature: Acute Pharyngitis: It is an inflammation of the back of the throat, otherwise known as pharynx. The condition generally causes pain and sensation of scratchiness in the region of the throat, as well as difficulty in swallowing. The condition is typically referred to as a sore throat. Acute pharyngitis is generally a self-limited condition with resolution within two weeks. Infected individuals are not however immune to re-infection with most etiologic pathogens.

From the above, the Forum feels that the subject treatment didn’t warrant hospitalization or necessitate hospitalization, could be treated as OP with oral medication besides taking rest at home. Moreover, as informed by the complainant during hearing, that he is the employee of the subject hospital, he could have managed with the employer with oral medications. Hence, the Forum is of the opinion that the subject hospitalization of the complainant is falling under the following exclusions of policy. Clause 3.2 Note 1: Procedures/treatments usually done in outpatient department are not payable even if converted as in-patient in the hospital for more than 24 hours or carried out in day care centre. Clause 6.11: Charges 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 Hospital/Nursing Home.

Under the above circumstances, the Forum feels that the decision taken by the respondent insurer in denying the complainant’s claim is justified, and the no intervention is required. Hence the complaint is devoid of any merit and Dismissed.

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 complaint is devoid of any merit and Dismissed. The complaint is Dismissed.


(I.SURESH BABU)

INSURNACE OMBUDSMAN





Case between: SRI VERA SHEKHER ………………The Complainant Vs

M/s Star Health and Allied Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD) H -044-1920-0331


1. Name & address of the complainant Mr.Vera Shekher

H.No. 1-5-246/5, Plot #7, Road #12,

New Maruthi Nagar, Saroornagar,

Hyderabad,Telengana State- 500 035.

(Cell No. 93930-10100)


Type of Policy


P/131126/01/2020/005334

Family Health Optima Insurance Plan

31.10.2019 to 30.10.2020



Mrs .V. Lavanya

Mr. Vare Shekher



6. Reason for repudiation Non disclosure of material facts at the time of

porting of insurance





11. Amount of Relief sought Rs.61,500/-

12. Complaint registered under Rule No.13 (b) of Ins. Ombudsman Rules, 2017


13. Complaint how disposed Allowed ( Stastical award)



The complainant had renewed his health insurance policy for a further period of 1 year with effect from

31.10.2018 which he had purchased on 31.10.2011 from respondent to cover the health of his spouse, 2

dependent children, and him for a floater sum insured cover of Rs. 2 Lakhs. On 04.11.2019, his wife was

admitted to Asha Hospital with chief complaint of headache followed by difficulty in breathing. She was

diagnosed with Major depressive disorder plus conversion disorder and was therefore initiated on

antipsychotics & antidepressants before being discharged at her request on 09.11.2019 in a partially

improvised state. The claim filed by her with respondent company towards her hospitalization expense was

denied on the premise that her past medical history was not disclosed at the time of porting the policy

from the earlier insurer M/s the Oriental insurance Co. Ltd. Aggrieved by the repudiation of her claim, the

policy holder had filed a complaint against the respondent in this Forum.

16) Cause of Complaint: Non settlement of Mediclaim


The claim preferred by the complainant was non - settlement of Mediclaim by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. After registration of complaint by this Forum and during hearing, the insurer further reviewed the claim and agreed to settle the claim . The Complainant accepted the settlement. The insurer settled the claim by way of NEFT for Rs.54,621/- on 19.03.2020 duly informed by way of mail dated 16.04.2020.

AWARD


Dated at Hyderabad on the 31st day of March, 2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN



(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017) Ombudsman - Shri I. Suresh Babu

Case between: SRI KAILASNATH ANUGONDA………………The Complainant Vs M/s Star Health and Allied Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).H -044-1920-0325


1. Name & address of the complainant Mr. Kailasnath Anugonda Flat # B-2, Padmaja Apartments, Santosh Nagar Colony,Mehdipatnam, Hyderabad,Telengana State- 500 028. (Cell No. 93462-39486)


P/161100/01/2019/011311 Senior Citizens Red Carpet Health Insurance 07.09.2018 to 06.09.2019


Mr. Kailasnath Anugonda Mr. Kailasnath Anugonda

4. Name of the insurer M/s star Health and Allied Insurance Co. Ltd.


6. Reason for repudiation Non- disclosure of pre-existing disease



9. Amount of Claim Cost of medicines - pre & post hospitalization


11. Amount of Relief sought Cost of medicines - pre & post hospitalization






b) For the insurer Mr.M.Ravi Kumar, AGM Legal




The complainant had purchased a Senior citizen red carpet medical insurance policy from respondent in

the year 2017. He was diagnosed with Chronic Kidney Disease (CKD) for which he had undergone

treatment in CARE Hospitals along with other ailments during the 3 rd year of the insurance policy period.

When he had submitted his claim bills comprising of medicine bills post dialysis to respondent, his claim

was rejected on grounds that his CKD was not disclosed at the time of inception of first insurance policy.

Aggrieved by the decision, he had therefore approached this Forum with an appeal to mediate between

him and the respondent and to enable him to receive the amount claimed by him.



The complainant had submitted that he was holding a medical insurance policy purchased from respondent since 07.09.2017 and had paid premium for 3 years in a row. He had declared the pre-existing disease namely Diabetes and Hypertension and the same was mentioned in the policy certificate as “Diabetes and hypertension and their complications”. His claim was that CKD was not established at the time of taking the insurance policy. He had waited for 2 years without lodging any claim and in the 3rd year when he had submitted his medicine bills towards treatment of diabetes and hypertension post dialysis to respondent, they were rejected. His argument was that having disclosed his pre-existing condition of diabetes and hypertension and when the same having been incorporated along with “their complications” in the policy certificate, denial of his claim on grounds of non-disclosure of the associated complication was not justified since one should be aware that CKD was a complication that arose out of Diabetes and Hypertension. At the same time, he had also remarked that he had waited till the waiting period was over and therefore he ought to receive the payment towards his claim. He had also questioned the act of respondent who had refunded him only the 3rd year policy premium when he had paid the same for 3 full terms.

b) Insurer’s argument: The respondent had submitted their self contained note on 16/03/2020. The complainant was issued a Senior Citizens Red Carpet Health Insurance Policy for a sum insured of Rs.2 Lakhs with disclosed PED Diabetes and Hypertension and their complications incorporated in the policy. The first policy was issued from 07/09/2017 to 06.09.2019 and renewed subsequently. The insured reported a claim in the 3rd year of the policy. He was admitted on 15/08/2019 at Care Hospitals, Hyderabad. His claims for medical bills for Rs.14,398/- were rejected as the insured was diagnosed with DM Type 2/ CAD/CKD stage 5. Also the consultation notes dated 01/07/2017 of care hospital submitted in response to their query showed the insured patient was a known case of Chronic Kidney Disease stage 5 and dilated cardiomyopathy with pulmonary edema. The complainant had not disclosed the same in proposal form at the time of inception of policy about his renal disorder which was a declined risk and they would not have issued a policy in the first place to him. Hence, he had violated the policy condition No. 9 which pertained to duty to disclose and in the absence of same the company was not liable to make any payment in respect of any claim. The policy was also liable to be cancelled as per Condition No. 13 which read-“the company may cancel the policy on grounds of misrepresentation, fraud, moral hazard, non- disclosure of material fact as declared in the proposal form and/ or claim form at the time of claim and non- cooperation of the insured by sending the insured 30 days notice . With the above submission, they have requested for dismissal of the complaint. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.


a. Policy copy b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self contained note with enclosures f. previous policy with oriental insurance.

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 17.03.2020. The complainant stated he was covered since three years under the policy. His claim for medical expenses incurred for Rs.14,398/- was rejected, his policy cancelled and premium pertaining to third year alone was refunded back to him. It was an online proposal wherein he was asked questions over phone by telesales broker who filled the information sought. He had declared PED of DM+HTN and their complications during the policy inception. He said his kidney problem was anticipated by the doctors owing to creatinine level of 3 but not confirmed at the time of taking insurance with the respondent. He said cardiac as well as CKD are complications of DM and HTN and therefore he is eligible for the reimbursement of his medical expenses. No pre insurance medical examination was conducted by the insurer on him. He also informed the forum, he was insured since 20 years with Oriental Insurance Company, who has been paying him for CKD related dialysis for a concession in PPN hospitals whereas the medicines are not payable. Moreover the waiting period of 24 months for PED was also met. Hence, he sought for payment of the medication for treatment of DM and HTN and not for ailment of CKD from the respondent. The insurer stated that Renal Disorder was a declined risk under their policy. The insured’s answer to specific questions in the proposal form on Medical declaration: “Have you or any member of your family propose to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer’s disease/Parkinson’s disease, the proposer replied in negative, which was a clear Non-disclosure of material facts. Prior to policy inception the consultation notes dated 01/07/2017 of Care Hospital shows he was a known case of Chronic Kidney Disease Stage 5 and Dilated Cardiomyopathy with pulmonary edema. The same was not disclosed as PED by him. As per condition no 9 of the policy “ if there is any misrepresentation/non-discloure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim”. Also as per condition no 13 of the policy on cancellation “ the company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material facts as declared in the proposal from/ at the time of claim or non-co operation of the insured person”. Hence the policy was cancelled and premium refunded on 21/12/2019. Regarding refund of previous 2 years policy, since the risk was covered throughout the expiry of the I st and 2nd year of policy, the premium towards the same cannot be refunded. The medical expense for current hospitalization was CKD related. The Forum observed that:

The insured was covered with the respondent since 07/09/2017 and renewed subsequently

Prior to policy inception, the consultation paper dated 01/07/2017 from Care Hospital show diagnosis of DM/HTM, CKD Stage 5, CAD and Hypothyroidism.

Admission to Care hospital on 19/07/2017 was for creation of AV Fistula for dialysis access. He was diagnosed with CKD not on MHD (maintenance hemodialysis), DM, HTN, and Hyperthyroidism. AV fistula (arteriovenous fistula): an abnormal connection between an artery and a vein. ... Sometimes, an AV fistula is surgically created for hemodialysis access. Recently, nonsurgical, percutaneous procedures are being used to create AV fistulas for dialysis access

He was again admitted in care on 2/11/2017 for coronary angiogram. Discharge summary show he is known case of Chronic Kidney disease stage V, Left AV Fistula (3 ½ months old), DM type II, HTN, Hypothyroidism and CAD-Mild coronary artery disease.

Letter from treating doctor dated 16/09/2019 confirms the insured was a case of Diabetes mellitus type-2, Hypertension, Hypothyroidism, CAD-mild coronary artery disease and Chronic Kidney Disease stage 5 on thrice weekly maintance Hemodialysis and advised to medication for the above ailments.

Complainant was insured with M/s Oriental insurance company since 2001. He has been claiming for dialysis with them and all his claims were being paid except medication.

The Forum requested for submission of bills pertaining to medication along with copy of one claim settled by M/s Oriental Insurance Company. The insured was asked to send them by mail which was agreed to. Subsequently vide letter dated 18/03/2020 the insured had submitted by hand on 20.03.2020, copies of cashless authorization letter approval of M/s Oriental Insurance company to Care Banjara hospital along with first and latest policy copy.

The insured did not declare any Preexisting diseases in the first policy with Oriental Insurance , policy commencing from 22.02.2001 to 21.02.2002 for a sum insured Rs.3,00,000/-. He has been renewing the same continuously. The latest policy commenced from 22.02.2020 to 21.02.2021 for an enhanced sum insured of Rs.4,50,000/- also shows PED as NIL. Cashless authorization letters dated .25.10.2019, 02.01.2020, 16.1.2020, 21.02.2020 & 05.03.2020 shows payments made by Oriental Insurance Company towards CKD dialysis. From the above, it is clear the insured was aware of his CKD-stage V and did not disclose the same to the respondent while taking a second policy commencing from 07/09/2018 for a sum insured of Rs.2 Lakhs and this amounts to non disclosure of pre-existing diseases. The complainant’s argument that disclosure of DM and HTN and its complications by him automatically covers CKD is not tenable since, the policy covers any complications arising from DM and HTN not known to the insured prior to policy inception. The policy covers only unkown complications of DM and HTN that may arise after purchase of the policy which the insured is unaware . As per Contract of insurance, duty of disclosure by proposer is the basis of the contract. In case of health insurance contracts, disclosure of health details are material facts whether to accept insurance or not. The insurance company has therefore been denied of material information on the insured’s health condition in the proposal form that forms the basis of the contract on Utmost Good Faith. Therefore, rejection of claim as per policy conditions no 9 and cancellation of policy on grounds of non disclosure of material facts as per condition no13 is justified.

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 complaint devoid of any merit is dismissed without cost.

Dated at Hyderabad on the 31st day of March ,2020.

(I.SURESH BABU)

INSURNACE OMBUDSMAN


PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW


Mrs. Sarika Garg…………..……....………………. Complainant

V/S

Star Health & Allied Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-H-044-1920-0105 ORDER NO. IO/LCK/R/HI/0046/2019-20

1. Name & Address of the Complainant Mrs. Sarika Garg,

10/503, Radha Kuti, Allenganj,

Kanpur=208001.

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

P/231121/01/2019/000436

Family Health Optima Insurance Policy

03.06.2018 to 02.06.2019

3. Name of the life insured


Self, and dependent children

Mrs.Sarika Garg

4. Name of the insurer Star Health and Allied Insurance Company Limited

5. Date of Repudiation/Rejection --

6. Reason for repudiation/Rejection --


8. Nature of complaint Partial Repudiation of claim


10. Date of Partial Settlement ---


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

13. Date of hearing/place On 18.03.2020 at 10.15 am at Lucknow


For the Complainant Mr.Sandeep Garg, Husband

For the insurer Mr.C.S. Tandon,

15. Complaint how disposed Recommendation


17. Mrs.Sarika Garg (Complainant) has filed a complaint against Star Health and Allied Insurance Company

Limited (Respondent) challenging the partial repudiation of her medi claim.


18. Brief Facts Of the Case:- The complainant was insured with the respondent under Health Policy for

period 03.06.2018 to 02.06.2019 enjoying 50% NCB. She was admitted in Breach Candy Hospital, Mumbai

on 11.09.2018 for surgery of bulky uterus with multiple uterine fibroids. She was discharged on 16.09.2018.

She submitted a claim to TPA for reimbursement of Rs.722545/-. The TPA settled her claim for Rs.503090/-

and as such there was a short payment of Rs.219455/- but she is asking for Rs.229000/-. The complainant

had lodged a complaint before this forum for unjustified partial settlement of the claim by the respondent.

In their SCN/reply submitted in this office on 30.11.2019, the respondents have submitted that

The insured had stayed in higher category room. Hence a sum of Rs.12000/- was deducted.

Betadine ointment, drainage bag, bandage, gauze, plastic sheet, sponges, gloves, vallylab reliant disp pencil,

pads cautery, pads, apron etc are not payable. Hence Rs.12446/- were deducted from the OT Charges.

A sum of Rs.1 lac was deducted from professional fee as reasonable and customary charges were allowed

taking into account the nature of illness.

As per policy other charges pertaining to cross matching, MRSA screening LR Filter, digital mamo, extra plate

are ot payable. Hence a sum of Rs.10070/- were deducted.

As handwas, handrub, scrub, maternity pad,razor, thermometer, wipes glycerine, shampoo are not payable.

Hene Rs.7249/- deducted from medicine within hospital.

As per other Excluded expenses of the policy charges pertaining to hospital share are not payable. Hence

Rs.69750/- deducted from package charges.

Registration fee and CSSD not payable hence Rs.1039/- were deducted from others.

As per other excluded expenses charges pertaining to blood grouping, extra MRI and contrast in pre-

hospitalization section are not payable. Hence Rs.7200/- was deducted from investigation and diagnostic.

Therefore from claim bill of Rs.722844/-, a sum of Rs.219754/- deducted and Rs.503090/- have been paid to the

insured.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy of policy

document while respondent filed SCN with enclosures.

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

Insurance Company.


21.Undoubtedly insured was assured with the respondent. Insured underwent surgery for fibroid uterus. Surgery was

conducted at Breach Candy Hospital, Mumbai. Bill of Rs.722545/- was submitted. Against the said amount, respondent

paid an amount of Rs.503090/-. For rest of the amount, deductions were made by the respondent which are being

dealt as follows:

Against professional fees (surgeon, anaesthetist, consultant charges etc.)

An amount of Rs.455250/- was claimed against which an amount of Rs.355250/- was paid. Rs.100000/-

was deducted on the ground of reasonable and customary charges. Tariff for the professional charges in

the neighbouring three hospitals in the geographical area for identical services is enclosed with the

additional SCN. Respondents tried to show that on the basis of tariff charges as shown by three hospitals,

the charges of Breach Candy Hospital are on very higher side. Hence deduction was made on the ground

of reasonable and customary charges.

This submission could not be accepted. I am of the opinion that there is no mandatory provision fixed for deduction on

the ground of customary and reasonable charges. Reasonable and customary charges can differ from one hospital to

another and one doctor to another. It depends upon the proficiency and expertise of the doctor as to how much he is

charging. It is nowhere mentioned by the respondent in the SCN that wrong amount is mentioned in the bill. If fee is

charged by the doctor which is included in the hospital bill and paid by the insured then insured is entitled to claim the

fee. Accordingly, deduction of Rs.1,00,000.00 on this ground can not sustain.

Treatment was not done under any package rather hospital charged the fee as per nature of the ailment. No ground

could be shown for deduction of this amount (Rs.69750/- towards hospital share of professional fees). Accordingly, it

has also wrongly been deducted.

An amount of Rs.12000/- as higher category room charges, Rs.12446/- as OT charges, Rs.10070/- as cross matching,

MRSA screening LR filter, digital mamo & extra plate, Rs.7249/- as handwash, band, handrub, scrub, posiflush,

meternity pad, razor, thermmer, intrafix, reshape 60, underpad, decontaman wipes, mini spike, bracelet, glycerine,

shampoo, are deducted which are in accordance with policy terms and conditions.


Accordingly, on the basis of discussions made above, I am of the view that the complaint is liable to be partially

allowed.

Order :

Complaint is partially allowed. Respondents are directed to pay an amount of Rs.1,69,750/- to the complainant within

30 days.

22. Let copy of the award be sent to both the parties.

Dated : March 18, 2020 (Justice Anil Kumar Srivastava)

Place : Lucknow Insurance Ombudsman



Mr. Sushil Kumar Singh…………..……....………………. Complainant

V/S



1. Name & Address of the Complainant Mr. Sushil Kumar Singh,

10, Pawati Nagar, Ganeshpur, Rehmanpur,

Chinhat, Lucknow-227105.

2. Policy No:

Type of Policy


P/231100/01/2019/002836

Family Health Optima Insurance Policy

29.10.2018 to 28.10.2019



Self, wife and dependent daughter

Mr. Sushil Kumar Singh

4. Name of the insurer Star Health and Allied Insurance Company Limited

5. Date of Repudiation/Rejection 27.04.2019

6. Reason for repudiation/Rejection Concealment of material fact


8. Nature of complaint Unjustified Repudiation of claim







For the Complainant Mr. Sushil Kumar Singh

For the insurer Mr.C.S. Tandon



17. Mr. Sushil Kumar Singh (Complainant) has filed a complaint against Star Health and Allied Insurance

Company Limited (Respondent) challenging the repudiation of his wife health claim.


18. Brief Facts Of the Case:- The complainant and his wife were insured with HDFC Ergo General Insurance

Co.Ltd. from 29.10.2015 to 28.10.12017. They switched over to Star Health & Allied Insurance Co.Ltd under

portability and obtained cover for period 29.10.2017 to 28.10.2018 and 29.10.2018 to 28.10.2019. The

complainant’s wife on complaint of pain, consulted Dr. Pooja Dhaon on 27.10.2018 and was diagnosed as

“Suffering from rheumatoid arthritis. Thereafter her treatment was done at Ram Manohar Lohia Institute of

Medical Sciences, Lucknow and a claim of Rs.146919/- was lodged with the insurer. The insurers observed

that at the time of porting insurance cover from HDFC Ergo the insured while filling a new proposal form did

not mention that his wife Mrs. Bandana Singh was suffering from rheumatoid arthritis because Dr. Pooja

Dhaon had mentioned on consultation paper that Mrs. Bandana Singh was suffering from rheumatoid

arthritis for last two years. The claim was repudiated. The claim was repudiated on 27.04.2019 on the

ground of concealment of material fact and insurance policy was cancelled on 08.06.2019. . Aggrieved with

the decision of RIC, the complainant has approached this forum for redressal of his complaint.

In their SCN/reply dated 19.07.2019, the respondents have contended that “utmost good faith” is a cardinal principle of

insurance. While filling proposal form on 01.10.2017, the insured did not close his disease in column 4(f), he did not

disclose that her wife was suffering from rheumatoid arthritis for last 2 years. This was a material fact which was an

important factor for our acceptance of the risk. Hence the claim and the reconsideration were rejected vide letter dated

27.04.2019. Insurance policy was also cancelled on 08.06.2019.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy of policy

document while respondent filed SCN with enclosures.

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

Insurance Company.

21.Complainant was assured with the respondent. Initially he was insured with HDFC Ergo General Insurance

Company. Policy was ported with the respondent on 29.10.2017. A fresh proposal form was submitted wherein no pre-

existing disease was mentioned. Subsequently insured undertook treatment of Rheumatoid Arthritis at Ram Manohar

Lohiya Institute of Medical Sciences, Lucknow. Prior to that she had undertaken treatment of Dr Pooja


Dhaon. It was found that she was patient of rheumatoid arthritis for the last 2 years. Claim was repudiated on this

ground.

Complainant submits that the insured was not suffering from any ailment at the time of porting of policy. Further policy

was also cancelled. Insured was assured with HDFC Ergo General Insurance Company Limited from 29.10.2015. Policy

was ported online. Had insured any malafide intention, she may not have opted for porting of the policy.

In such circumstances, there could not be ground to hold that she was having any intention to defraud the respondent.

Accordingly, although claim was repudiated but her policy should have not been cancelled. Accordingly, complaint is

partially allowed.

Order:

Complaint is partially allowed. Order of repudiation of claim is upheld but respondents are directed to continue the

policy of the insured as per guidelines of IRDA.

22. Let copy of award be given to both the parties.





Mr. Ramesh Chandra Jaiswal…………..……....………………. Complainant

V/S


COMPLAINT NO. LCK-H-049-1920-0009 ORDER NO. IO/LCK/A/HI/0039/2019-20

1. Name & Address of the Complainant Mr. Ramesh Chandra Jaiswal,

Bhandra Rewa Road, Naini,

220 KVA Power House, Allahabad-211008

2. Policy No:

Type of Policy


P/231111/01/2018/003714

Family Health Optima Policy

25.11.2017 to 24.11.2018



Self and spouse

Mr. Ramesh Chandra jaiswal

4. Name of the insurer Star Health & Allied Insurance Company Limited


6. Reason for repudiation/Rejection Disease falls under 48 months Exclusion Clause


8. Nature of complaint Unjustified Repudiation of Claim





13. Date of hearing/place On 18.03.2020 at Lucknow


For the Complainant Mrs. Priya Jaiswal, Daughter

For the insurer Mr. C.S. Tandon

15. Complaint how disposed Award


17. Mr. Ramesh Chandra Jaiswal (Complainant) has filed a complaint against Star Health & Allied

Insurance Company Limited (Respondent) challenging repudiation of his health claim.


18. Brief Facts Of the Case:- The complainant purchased family health optima policy from the respondent

for period 25.11.2017 to 24.11.2018. It was renewal of his first policy. On complaint of some heart related

problem, he was admitted in Heartline Cardiac Care Centre on 17.09.2018 and was discharged on

21.09.2018. Later, he was admitted at Medanta Hospital, Gurgaon on 28.09.2018 and was discharged on

01.10.2018 after under going procedure “PTCA+Stent+RCA(RESOLUTE ONYX) & PLY (Yucon Plus) was done

on 29.09.2018”. After his discharge from the hospital, he filed a reimbursement claim with the respondent

insurance company. The respondents repudiated the claim on 28.02.2019 on the ground of pre-existing

disease and as per waiting period policy clause 3(iii) the company is not liable to make any payment in

respect of expenses for treatment of pre-existing diseases, until 48 months of continuous coverage has

elapsed.

In their SCN/Reply dated 22.05.2019, the respondents have submitted that as per discharge summary of

Heartline Cardiac Centre and Medanta Hosptial, Gurgaon the patient was suffering from CAD, D.M.,

respiratory tract infection, dermatophytosis and dislipidemia which were longstanding diseases. Hence these

diseases were preexisting and for all pre-existing diseases there was a waiting period of 48 months as per

policy clause 3(iii) of the health policy. Therefore repudiation of claim made by the respondents was in

order.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed submitted by the complainant while respondent filed SCN along with enclosures.

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

the insurance company.


21. The complainant was assured with the respondent w.e.f. 25.11.2017 to 24.11.2018. Subsequently policy

was renewed. He developed some heart related problem and admitted in Heartline Cardiac Care Centre,

Allahabad on 17.09.2018 and was discharged on 31.09.2018. Subsequently he was admitted in Medanta

Hospital, Gurgaon on 28.09.2018 and discharged on 01.10.2018 wherein his coronary angiography was

done. Claim was submitted which was repudiated on the following ground :

“we have processed the claim records relating to the above insured-patient seeking reimbursement of

hospitalization expenses for treatment of coronary artery disease – single vessel disease, old myocardial

infarction, LBBB, hypertension, diabetes mellitus, lower respiratory tract infection, derrnatophytosis and

dyslipidmia.”

Repudiation was based on the following diagnosis of Heart Line Cardiac Care Centre, Allahabad :

“As per discharge summary of Heart Line Cardiac Care Centre for the admission on 17.09.2018, the patient is

a follow up case of chronic obstructive airway disease, coronary artery disease, old myocardial infarction,

CCF and respiratory failure but the insured has not submitted the previous follow up records and treatment

records relating to cardiac and respiratory disease inspite of our query.”

Main diagnosis of Heart Line Cardiac Care Centre itself nowhere indicates that the insured was having any

pre-existing disease prior to commencement of the policy. Complainant submits that he was not having any

pre-existing disease prior to the policy which find support from the discharge summary of Heart Line

Cardiac Centre, Allahabad. Accordingly, I am of the view that claim has wrongly been repudiated and

complaint is liable to be allowed.


Order :

Complaint is allowed. Respondents are directed to make the payment of the claim of the claimant within a

period of 30 days .






Sh. Manish Sahu…………..……....………………. Complainant

V/S

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


1. Name & Address of the Complainant Sh. Manish Sahu,

253, Suji Khan Khidkhi, Jhansi City,

Jhansi - 284002

2. Policy No:

Type of Policy


P/161112/01/2018/015640

Family Health Optima Policy

23.01.2018 to 22.01.2018



Mr. Manish Sahu

4. Name of the insurer Star Health & Allied Insurance Co. Limited


6. Reason for repudiation/Rejection EECP Treatment not payable under Policy



9. Amount of Claim Rs.149755.00


11. Amount of relief sought Rs.149755.00

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



For the Complainant Mr. Manish Sahu

For the insurer Mr. C.S. Tandon



17. Mr. Manish Sahu (Complainant) has filed a complaint against Star Health & Allied Insurance Company Limited

(Respondent) challenging repudiation of his health claim.

18. Brief Facts of the Case:- The complainant purchased Family Health Optima Policy for period 23.01.2018 to

22.01.2019. This was his fourth policy. On complain of chest pain, he was admitted in Artemish Hospital. His claim

was paid by the insurer. On advice of his doctor, he further took treatment at Saaol Hospital, New Delhi. After

discharge from hospital, he lodged a reimbursement claim with the insurer which stands repudiated on the ground

that “Enhanced External Counter Pulsation” is not payable. Aggrieved with the decision of the respondent,

complainant had approached this forum.


In their SCN/Reply dated 11.05.209, the respondents submitted that the insured Mr. Manish Sahu was admitted in

SAAOL Heart Centre, New Delhi on 11.05.2018 and discharged on 21.06.2018 where he was diagnosed Coronary

Artery Disease. He was treated under procedure “Enhanced External Counter Pulsation”. The insured submitted a

reimbursement claim on 29.06.2018 for Rs.149755/-.

On scrutiny of the claim documents, it was observed that as per discharge summary of the treating hospital, the

patient underwent Enhanced External Counter Pulsation (EECP) therapy. This procedure falls under policy exclusion

Clause No:17 of the policy which is not payable. In the light of the above, clause the claim was repudiated on

11.07.2018.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly filled/signed

submitted by the complainant while respondent filed SCN along with enclosures.

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

respondent.

21. The complainant was insured with the respondent who underwent a treatment at Saaol Heart Centre, New Delhi

wherein he was treated by Enhanced External Counter Pulsation Therapy. Claim was submitted by him which was

repudiated on the ground that the treatment is covered under Exclusion Clause No:17 of the Policy bond.

Complainant submits that he had undergone the therapy which is very cheaper. It is further submitted that some

other patient got claim in the same therapy under the orders of Insurance Ombudsman of other Zone.

Claim of the complainant is specifically covered under Exclusion No:17 of the Policy bond. Orders of other Insurance

Ombudsman are not binding upon this forum. Accordingly, repudiation has rightly been made by the respondent

which did not require any interference.


Order :

Complaint is dismissed.

22. Let a copy of award be given to both the parties.





Smt. Sarita Singh …………..……....………………. Complainant

V/S

SBI General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO: LCK-H-040-1920-0139 Order No. IO/LCK/A/HI/0026/2019-20

1. Name & Address of the Complainant Smt. Sarita Singh

W/o Rakesh Vill – Terhwa , Post – Terwa

Barabanki (U.P.) - 225305

2. Policy No:

Type of Policy


0000000006128893-02

Group Health Policy

06.02.2019 to 05.02.2020



Self, husband and dependent children

Smt. Sarita Singh

4. Name of the insurer SBI General Insurance Company Limited


6. Reason for repudiation/Rejection Non compliance of the requested documents





11. Amount of relief sought Rs. 99,426/- + Interest




For the Complainant Mrs.Sarita Singh

For the insurer Mr. Sanjeev Tripathi



17. Smt. Sarita Singh (Complainant) has filed a complaint against SBI General Insurance Company Limited

(Respondent) challenging the repudiation of his medical claim.

18. Brief facts of the case: The complainant has stated that she had taken a health insurance policy from

the respondent where she herself, her husband and her son were covered for floater sum insured of Rs.1

lac. . He was admitted on 26.05.2019 in Ram Manohar Lohia Institute Lucknow due

COMPLAINT NO:LCK-H-040-1920-0139 Order No. IO/LCK/A/HI/0026/2019-20

to chest pain and discharged on 28.05.2019.. After that he had filed the claim reimbursement for Rs.

99,426/- with the respondent. He was asked for some documents from the TPA/RIC on 19.06.2019 &

27.06.2019. The documents were submitted on 17.06.2019 & 02.07.2019 to the TPA/RIC and were again

submitted on 17.09.2019 personally at the office of TPA. He could not submit the other documents as the

same were not provided by the hospital. She has further stated that he had no problem of HTN and the

other documents were already submitted by him to the TPA/RIC. Still the claim was not settled and was

repudiated. Aggrieved with the decision of the RIC, the complainant approached this forum.

In their SCN/reply, respondent has stated that the said policy was first issued from 31.01.2017 to

30.01.2018 which was further renewed two times. The aforesaid policy was issued from 06.02.2019 to

05.02.2020. During the aforesaid policy the husband of the insured was hospitalised in Dr. Ram Manohar

Lohia Institute of Medical Sciences from 26.05.2019 to 28.05.2019 for the treatment of Coronary Artery

Disease and underwent surgical management for the same. The claim file of the complainant was assessed

by the TPA to complete the process of evaluation of authenticity of the claim. After going through the

reports and scrutinising all circumstances regarding the subject claim, the TPA observed that few

documents were still pending for completely assessing the claim. Many reminders were also sent to the

policyholder. Despite receipt of the repeated requests and reminders, the insured failed to submit the

aforesaid documents. Therefore, the claim was closed for non submission of requisite documents.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and

copy of policy document while respondent filed SCN with enclosures.


the Insurance Company.


21. Undoubtedly Mrs. Sarita Singh wife of the complainant is covered under Mediclaim Policy of the

respondent. She was admitted at Ram Manohar Lohia Insitute, Luckow on 26.05.2019 for chest pain and

discharged on 28.05.2019. Thereafter she preferred the claim with the respondent which was which was

repudiated.

At the very outset, respondent’s representative submits that the respondent is ready and willing to decide

the claim of the complainant on the basis of available records within a period of 30 days. Accordingly,

complaint is to be disposed off.

Complainant submits that she has already submitted all the documents. She did not have any fresh

documents for submission.

Order :

Complaint is allowed. Respondents are directed to decide the claim of the complainant within a period of

30 days. If the complainant is not satisfied with the decision, complainant is at liberty to move in

accordance with law.






Mr. Kartik Mishra…………..……....………………. Complainant

V/S

SBI General Insurance Co. Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Kartik Mishra,

24, Napier Road Colongy Part-1,

Thakurganj, Lucknow-226003

2. Policy No:

Type of Policy


P0000000008292233


08.02.2017 to 07.12.2018



Self and spouse

Mrs Urmila Mishra



6. Reason for repudiation/Rejection Disease due to use of abuse of any substance



9. Amount of Claim Rs.5,00,000/-


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




For the Complainant Mr. Abhay Kumar Mishra, father




17. Mr. Kartik Misra (Complainant) has filed a complaint against Star Health & Allied Insurance Company

Limited (Respondent) alleging repudiation of his father’s health claim.


18. Brief Facts Of the Case:- The complainant’s mother Mrs Urmila Misra purchased health for her and her husband for

period 25.09.2016 to 24.09.2017. The same could not be renewed timely and was renewed after a break of 2 months 14

day. On complaint of breathlessness, he consulted Rajiv Gandhi Cancer Insitute, Delhi on 11.5.2018 where he was

diagnosed “Non Small Cell Lung Carcinoma”. In a certificate issued by the said institute the treating doctors mentioned

that “the reported history of smoking which might be the likely etiological agent of this ailment”. The insured was

admitted from 25.05.2018 to 02.06.2018, 25.06.2018 to 26.06.2018, 11.06.2018 to 12.06.2018, 01.07.2018 to 04.07.2018

and 23.07.2018 to 24.07.2018 in Rajiv Gandhi Institute and Research Centre. He spent Rs.10-12 lacs on his treatment

whereas his sum insured was Rs.5 lakh only.

In their SCN/Reply dated 05.09.2019, the respondent’s have submitted that the policy was not renewed in time despite

the fact that renewal notice was issued well in time on 22.09.2017. Cashless benefit was denied by the TPA because on

primary scrutiny, it was found that the expenses related to the present ailment were not payable in the first year of

policy as policy inception date was 08.12.2017.

Reimbursment claims were lodged for various admissions in Rajiv Gandhi Cancer Institute and Research Centre. As per

treating doctor’s certificate issued on 05.09.2018 and consultation paper dated 11.05.2018, the patient was a chronic

smoker. The claim was repudiated in the light of the policy Clause No:17 which reads as under :

“Any complication arising out of or ailments requiring treatment due to use of any substance, drug or alcohol and

treatment for de-addition



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

respondent.


21. Date of commencement of the policy was 26.09.2016 which expired after one year. Renewal premium

was paid through State Bank of India on 12.10.2017 although there was a controversy regarding continuity

of the policy keeping in view of the break but the respondent’s representative submits that the insurance

company has condoned the delay. Accordingly, policy shall be treated as continued.

Claim was repudiated on the following grounds:

“As per consultation paper dated 11.05.2018, the insured is a chronic smoker and as per the certificate from

the treating doctor dated 05.09.2018, smoking is the etiological agent of the current ailment. As per policy

clause 17, any complications arising out of or ailment requiring treatment due to use or abuse of any

substance, drug or alcohol and treatment for de-addition is excluded from the scope of policy coverage.

This claim for hospitalization falls beyond purview of policy coverage and hence not payable.”

Claim of the complainant was repudiated on the ground that it is covered under Exclusions Point No:17 of

Group Health Policy which reads as under:

“Any complications arising out of or ailments requiring treatment due to use of abuse of any substance,

drug or alcohol and treatment for de-addiction.”

Complainant submits that he was not a chain smoker. He had left the smoking two years prior to the taking

of the policy. Disease was not consequence of smoking.

Team of doctors of Rajiv Gandhi Cancer Institute and Research Centre, Delhi has issued a certificate dated

05.09.2018 wherein it was certified that the patient had history of smoking which might be the likely

etiological agent of this ailment.


OPD card of Rajiv Gandhi Cancer Institute and Research Centre, Delhi dated 11.05.2018 shows that insured

was having a history of chain smoking to the extent of 100 cigarettes per day for the last 30 years. It is

nowhere informed to the doctors that the insured has left the smoking habit for the last 2 years. Had it been

so it should have been informed to the doctor? It proves that the case of the insured is covered under the

exclusion clause.

Having considered the submissions and after perusal of the records, I am of the view that the repudiation

was rightly made by the respondent which did not require any interference.

Order :







Mr. Amit Agarwal…………..……....………………. Complainant

V/S

SBI General Insurance Co. Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr.Amit Agarwal,

Flat No:DHB 201, Ansal Orchid Green,

Sector-M, Ashiana, LDA Colony, Lucknow-226012.

2. Policy No:

Type of Policy


0000000003599

SBI Group Health Non floater Policy

23.11.2018 to 22.11.2019



Mrs Seema Agarwal



6. Reason for repudiation/Rejection Pre-existing disease is not covered


8. Nature of complaint Non settlement of medical claim



11. Amount of relief sought Not mentioned




For the Complainant Mr. Amit Agarwal




17. Mr. Amit Agarwal (Complainant) has filed a complaint against Star Health & Allied Insurance Company

Limited (Respondent) challenging repudiation of his wife health claim.


18. Brief Facts Of the Case:- The complainant’s wife was insured with the respondent under Group Health

Policy for period 23.11.2018 to 22.11.2019. She was admitted at Ajanta hospital on 30.12.2018 for surgery of

fibroid uterus. Her cashless facility was denied by the TPA. Later her reimbursement claim was also denied on

the ground of pre-existing disease as insured was suffering from white discharge problem for last 6-7 years

and the present ailment is out come of the same. The complainant has submitted that fibroid uterus has no

connection with white discharge problem, but the insurer is not convinced with his submission. Aggrieved

with the decision, the complainant has approached this forum.

In their SCN/Reply dated 23.05.2019, the respondents have submitted that the insured was suffering from

white discharge problem for last 6-7 years and above claim was lodged for cashless authorization at Ajanta

Hospital, Lucknow where she was admitted for treatment of Ovarian Dysfunction. The problem of white

discharge was 6-7 years old while the policy was issued 3 years ago. The patient was admitted with

complaints of irregular bleeding 6 to 8 months. As per consultation paper dated 17.12.2018 patient was

diagnosed as case of white discharge since 6 to 7 years and white discharge is the cause for current ailment

as per details provided. Therefore, the said claim was found to be beyond the scope of health policy as per

policy exclusion No:1.



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

respondent.

21. Undisputedly insured’s wife Smt. Seema Agarwal was covered under the policy. She underwent total

laparoscopic hysterectomy with bilateral salpingectomy with left oophorectomy surgery for treatment of

fibroid uterus at Ajanta Hospital and IVF Centre, Lucknow on 31.12.2018. Thereafter she preferred a claim

with the respondent which was denied on the ground that :


“As per the consultation paper dated 17.12.2018, the insured had complaint of bleeding per vagina since

one month, histopathology report of endometrial biopsy suggestive of hormone induced endometrial

changes and complaint of white discharge per vagina since 6-7 years which is pre-existing in nature and

current ailment is the complication of the same.”

White discharge could not be direct consequence for Fibroid tumour, a certificate to this effect was issued

by the treating doctor on 22.12.2018. Respondents have repudiated the claim merely on this ground.

As per explanation to Section 45(4) of Insurance Act as amended, it has to be proved by the insurer that

such non-disclosure or misstatement was direct cause for the surgery or ailment. In the present case,

insurer could not support the repudiation order which is liable to be quashed.

Order :

Complaint is allowed. Respondents are directed to make the payment of the claim to the complainant within

a period of 30 days.






Mr. Prem Manohar Tiwari …………..……....………………. Complainant

V/S

SBI General Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Prem Manohar Tiwari,

S/o Mr. Bireshwar Dayal Tiwari,474A/7, Brahm Nagar,

Sitapur Road, Lucknow-226001.

2. Policy No:

Type of Policy


00000000008962

Group Health Policy

22.03.2018 to 21.03.2019



Self and his spouse

Mr. Prem Mohan Tiwari



6. Reason for repudiation/Rejection Heart disease not covered under 1st Year Policy


8. Nature of complaint Unjustified Repudiation of claim



11. Amount of relief sought Rs. 218837/- + Interest




For the Complainant Mr. Prem Manohar Tiwari




17. Mr. Prem Manohar Tiwari (Complainant) has filed a complaint against SBI General Insurance Company

Limited (Respondent) challenging the repudiation of his medical claim.


18. Brief facts of the case: The complainant purchased Group Health Insuance Policy from the respondent

for period 22.03.2018 to 21.03.2019. On complaint of some heart related problem, he was admitted in

Divine Heart & Multispecialty Hospital, Lucknow on 24.10.2018 and was discharged on 26.10.2018. A claim

was preferred for Rs.150746/- with the insurer. The procedure done was percutaneous coronary

intervention. The claim was repudiated as expenses incurred for treatment of heart related ailment is not

payable during the first year of policy inception. Again he was admitted in KGMC, Lucknow on 14.11.2018

for treatment and was discharged on 16.11.2018. The second claim was for Rs.68091/-. The complainant

approached Grievance Redressal of the respondent. The Grievance Redressal Committee observed that

the claim was rightly repudiated as heart related treatments are not tenable under first year’s policy. The

GRC sent their denial letter to the insured on 30.03.2019. Aggrieved with the decision of the RIC, the

complainant has approached this forum.

In their SCN/reply, respondent have submitted that hypertension and heart related complications are

excluded in the first year of policy. The complainant was admitted in the hospital on 24.10.2018 and the

first policy inception date is 22.03.2018. As per policy Exclusion Clause -3 , the ailment related with heart is

not covered during first year of policy. As such repudiation of claim of the complainant is in order.





21. Undisputedly complainant was insured with the respondent. He suffered for recent anterior wall

myocardial infarction, was admitted firstly in Divine Heart & Multispeciality Hospital, Lucknow and

subsequently in KGMU, Lucknow. He preferred a claim.


The claim was repudiated on the ground that it was covered under Exclusions Clause No: 3 (ix) of the

policy bond which reads as under :

“Exclusions applicable to first year of cover from commencement of the policy, from the following

diseases/illness and its related complications unless an add on cover waiving this exclusion is purchased

by payment of additional premium to us :

“Hypertension, heart disease and related complications”

Accordingly repudiation was made in accordance with the terms and conditions of the policy which did

not require any interference.

Order :







Mr. Narendra Kumar Pandey…………..……....………………. Complainant

V/S

HDFC ERGO General Insurance Co. Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Narendra Kumar Pandey,

F-1, Muskan Apartment, Sector-A,

Aliganj, Lucknow-226024.

2. Policy No:

Type of Policy


2857100373653600000

Health Medisure Classic

28.10.2018 to 27.10.2019



Self and his spouse

Mr Nagendra Kumar Pandey

4. Name of the insurer HDFC ERGO General Insurance Co. Limited


6. Reason for repudiation/Rejection Waiting period of 2 years applicable




10. Date of Partial Settlement --





For the Complainant Mr. Narendra Kumar Pandey

For the insurer Mr. Shiv Prakash Singh



17. Mr. Nagendra Kumar Pandey (Complainant) has filed a complaint against HDFC ERGO General

Insurance Company Limited (Respondent) challenging repudiation of his wife’s mediclaim.


18. Brief Facts Of the Case:- The complainant purchased health insurance policy from the respondent for

first time for period 28.10.2018 to 27.10.2019. His wife developed certain problems related to uterus. They

consulted D. Pallavi Dhawan on 24.01.2019. Her wife went Sir Ganga Ram Hospital, New Delhi for biopsy.

Cashless facility was denied as treating doctor mentioned by mistake that patient had history of fibroid

uterus since 13.02.2018. The doctor later on corrected the year and countersigned on the sheet. It was

further observed that the insured was suffering from hyperthyroid since 10 years, hypertension for 5 years,

skin disease for 8 months and underwent cholecystectoy 10 years back. There was not disclosure of material

facts by the insured. The claim was rejected on 10.04.2019 on the ground of “postmenopausal bleeding was

managed surgically with dilation an curettage which has a waiting period of 02 years under Section D-3 of

the policy”. The claim was repudiated in the light of above policy clause. Aggrieved with the decision of the

respondent, now the complainant had approached this forum.

In their SCN/Reply dated 05.08.2019, the respondents have submitted that the insured has lodged claim on

1st year’s policy where she was diagnosed with history of fibroid uterus since 13.02.2018, hyperthyroid since

10 years, hypertension for 5 years, skin disease for 8 months and she underwent cholecystectomy 10 years

back. These ailments were not disclosed at the time of submission of proposal. As per Policy Section-D-3

“All pre-existing diseases/illness/injury/conditions defined in the policy until 36 months of continuous cover

have elapsed since inception of the first policy with us”.

Hence fibroids, dilatation and curettage for treatment purposes are not covered for first three years.

19. The complainant has filed complaint letter submitted annexure VI A correspondence with respondent

and copy of policy document while respondent filed SCN with enclosures.




21.Undoubtedly, insured was covered under the policy of the respondent. She developed some problem

related to Uterus. Initially she consulted Dr. Pallavi Dhawan at Lucknow. Further she went to Sir Ganga Ram

Hospital, New Delhi wherein diagnosis of fibroid Uterus was confirmed and biopsy was suggested. Biopsy

was conducted wherein malignancy was over ruled. Plan for hysterectomy was made by the doctor if

required but the patient did not opt for the same. Claim was repudiated on the ground that the treatment is

covered under Exclusion Clause No:D.3 of the policy bond. When neither hysteroscopy nor hysterectomy or

any surgery or procedure was conducted then how it should be covered under Clause D.3.

Initially request for cashless facility was refused but the final repudiation letter dated 10.04.2019 was passed

on the ground of provision of Section D.3 of the policy bond. In this case, Point No:D.3 will not cover the

scenario. In the self-contained note, ground of non-disclosure of pre-existing ailment is also taken but as per

Provision of Section 45 of the Insurance Act 1938, insurance company cannot go beyond its repudiation

order.

Accordingly, I am of the view that claim has wrongly been repudiated and complaint is liable to be allowed.

Order :

Complaint is allowed. Respondents are directed to make the payment of claim within 30 days.

22. Let copies of award be given to both the parties.





Mr. Sunil Kumar sharma …………..……....………………. Complainant

V/S

Apollo Munich Health Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO: LCK-H-003-1920-0082 Order No. IO/LCK/A/HI/0029 /2019-20

1. Name & Address of the Complainant Mr. Sunil Kumar Sharma

B-2148, Indira Nagar

Lucknow-226016

2. Policy No:

Type of Policy


180100/11121/AA00670390

Optima Restore Health Policy

22/09/2017 to 21/09/2018



Self, wife and dependent children

Mr. Sunil Kumar Sharma

4. Name of the insurer Apollo Munich Health Insurance Company Limited


6. Reason for repudiation/Rejection Non compliance of the requested documents



9. Amount of Claim ---


11. Amount of relief sought Claim amount & policy continuation




For the Complainant Mr. Sunil Kumar Sharma

For the insurer Mr. Gajendra Singh Chouhan, HDFC Ergo



17. Mr. Sunil Kumar Sharma (Complainant) has filed a complaint against Apollo Munich Health Insurance

Company Limited (Respondent) challenging the repudiation of his medical claim.

18. Brief facts of the case: The complainant has stated that he had taken a health insurance policy from

the respondent on 22.09.2017. He was admitted in S.G.P.G.I Lucknow due to illness and discharged on

15.01.2018. After that he had filed the claim reimbursement for Rs. 3,30,848/- with

COMPLAINT NO: LCK-H-003-1920-0082 Order No. IO/LCK/A/HI/0029 /2019-20

the respondent. Respondent are mailing one query continuously as to when you become Psychiatric

patient? Why are you taking medicine Clonazepam & Flupentixol?. He had further stated that he is not

psychiatric patient. His doctor had denied for giving reason for suggesting the above medicines. He had

requested many times for payment with the respondent but every time it was denied stating some

reasons and making delay in reimbursement. Aggrieved with the delay in settlement of his claim, the

complainant had approached this forum.

In their SCN/reply, respondent has stated that the said policy was issued on the basis of the proposal from

to the policy holder from 22.09.2017 to 21.09.2018. Policy schedule along with all terms and conditions of

the policy were delivered to the policyholder .During the aforesaid policy period a reimbursement claim

for Rs. 3,30,848/- was received on 26.02.2018 for the admission in S.G.P.G.I Lucknow from 24.12.2017 to

15.01.2018 for the treatment of community acquired pneumonia with severe acute respiratory distress. Ist

query related with requirement of documents such as treating doctor certificate for Clonazepam

(antiepileptic drug ) & Flupentixol (Antipsychotic neuroleptic drug) was issued. The said query was not

complied and the claim was repudiated as per section VI (i)(i) of the terms and conditions of the policy.

The respondent had further stated that on further receipt of the documents dated 19.04.2018 it is further

noted that complainant had history of hypertension since 5 years and he was taking Clonazepam &

Flupentixol. To get the clarity on said medical history a query latter dated 09.05.2018 was raised to provide

the documents. The respondent had further sent the reminders dated 23.05.2018, 06.06.2018 &

14.06.2018 for providing the documents. Till date the complainant did not submit the all mandatory

documents Hence, due to non compliance of the requirement as raised for requested documents, the

claim of the complainant could not be approved. Therefore as per T&C of the policy, the claim was

repudiated as per section VI (i) (i).






21. Claim of the complainant was rejected by the respondent on 30.10.2018 on the

following grounds:

1. All investigation, treatment and follow up records pertaining to psychiatric illness since

first diagnosis.

2. Treating doctor’s certificate regarding indication for Clonazepam and Flupentixol.

3 .As per the query letters sent to you, we have observed that requirement raised by us has

not been complied. Hence due to non-compliance of the requested documents, we regret

to inform you that your claim is repudiated under Section Vii of the Policy. Please submit

below documents at earliest to enable us to reopen the claim and decide on admissibility.

Please be informed that any further claim will not be processed until the submission of the

mentioned documents.

4. Please be informed that any further claim will not be processed until the submission of

the mentioned documents.

At the very outset, complainant submits that he has no prescription wherein clonazepam and

flupentixol were prescribed to him. It is further submitted that he was not having these medicines

at the time of admission in Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. At

this stage, respondent representative submits that respondents are ready to reconsider the claim

of the complainant. Accordingly, complaint is liable to be disposed off.

Order:

Complaint is disposed off with a direction to the respondent to reconsider and decide the claim of

the complainant within a period of 30 days. An opportunity of hearing should also be provided to

the complainant. If the complainant is not satisfied with the decision of the respondent insurance

company, he would be at liberty to proceed in accordance with the law.






Mr. Sohan Lal Kesarwani…………..……....………………. Complainant

V/S


COMPLAINT NO. LCK-H-003-1920-0038 ORDER NO. IO/LCK/R/HI/0028/2019-20

1. Name & Address of the Complainant Mr. Sohan Lal Kesarwani,

60-A, Phaphamau, Saraon,

Varanasi Road, Allahabad-211013

2. Policy No:

Type of Policy


180400/11121/AA00293219-01

Optima Restore Floater Policy

21.09.2016 to 20.09.2017



Self , spouse and dependent children

Mr. Sohan Lal Kesarwani



6. Reason for repudiation/Rejection Non submission of required documents


8. Nature of complaint Unjustified Repudiation of three Claims







For the Complainant Mr. Sohan Lal Kesarwani

For the insurer Mr. Gajendra Singh Chouhan



17. Mr. Sohan Lal Kesarwani (Complainant) has filed a complaint against Star Health & Allied Insurance

Company Limited (Respondent) challenging repudiation of his health claim.

COMPLAINT NO. LCK-H-003-1920-0038 ORDER NO. IO/LCK/R/HI/0028 /2019-20

18. Brief Facts Of the Case:- The complainant purchased Optima Restore Floater Policy from the respondent for period

21.09.2015 to 20.09.2016 and got it renewed for further period 21.09.2016 to 20.09.2017. He went Medanta Hospital,

Gurgaon with his friend where his friend was taking treatment. The insured was not feeling well for quite some days

with pain in abdomen. He consulted for his problem at Medanta Hospital, Gurgaon and accordingly underwent some

medical tests. He was diagnosed that he was suffering from Hepato Cellular Carcinoma. He immediately rushed to Tata

Memorial Hospital, Mumbai. He took treatment and submitted three claims as under :

MR CLAIM DOA DOD Diagnosis Claim amount Claim status

5261678 12.10.2016 14.10.2016 Hepato Celluar Carcinoma 68904

Closed on

requirement

526173 17.01.2017 20.01.2017 Hepato Cellular Carcinoma 164360

526178 26.09.2017 28.09.2017 Chronic Liver Disease Pulmonary

Hypertension Hepato Cellular Carcinoma

56190

His claims stand repudiated for non submission of required documents.

In their SCN/Reply dated 25.10.2019, the respondent have submitted that claims of the complainant were rejected for

non submission of mandatory documents in consonance with the Clause No:VI (i)(i) of the policy. They have further

submitted that they are ready to evaluate the claim if the complainant provides all the documents as required in order

to determine the admissibility of the claim.



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

respondent.

21. Claims of the complainant were repudiated differently on different dates on the ground that certain

documents were sought from the complainant but those documents were not provided by the complainant.

COMPLAINT NO. LCK-H-003-1920-0038 ORDER NO. IO/LCK/R/HI/0028 /2019-20

List of the documents have been made part of the repudiation letter. Complainant submits that he

had provided all the original bills including hospital records and pathological reports to the

respondent but receipt of the same was not given to him. He is still ready and prepared to provide

self attested photo copies of all the documents to the respondent alongwith an undertaking for

verification of the documents from the hospital.

In such situation, it would be appropriate that an opportunity should be provided to the

complainant so that he may full fill the requirements of the respondents.

Order :

Complaint is disposed off with a direction that the complainant shall provide self attested copies of

the documents, as required by the responded, within a period of 15 days. Complainant shall also

give an undertaking that the documents can be verified by the respondent from the concerned

hospital. Thereafter, respondent shall verify the documents and dispose off the claim within a

period of 30 days. Respondent shall decide the claim after affording an opportunity of hearing to

the complainant. If the complainant is not satisfied with the decision of the respondent insurance

company, he would be at liberty to proceed in accordance with the law.






Dr. Vipitya Kumar Katiyar…………..……....………………. Complainant

V/S



1. Name & Address of the Complainant Dr. Vipitya Kumar Katiyar,

MIG-19, Surya Vihar Kheora Wanger,

Nawabganj, Kanpur-208002

2. Policy No:

Type of Policy


110103/11121/AA01039023

Optima Restore Floater Policy

06.04.2019 to 05.04.2020

3. Name of the life insured Self , spouse and dependent children

Mr. Vipaty Kumar katiyar




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









For the Complainant Absent

For the insurer Mr. Gajendra Singh Chouhan



17. Mr. Vipitya Kumar Katiyar (Complainant) has filed a complaint against Star Health & Allied Insurance

Company Limited (Respondent) challenging repudiation of his wife health claim.


18. Brief Facts Of the Case:- The complainant ported his health insurance policy from the New India

Assurance Company Limited to Apollo Munich Health Insurance Policy and obtained a policy for period

06.04.2019 to 05.04.2020. On complaint of pain in abdomen the complaint’s wife Mrs. Anju Singh consulted

Dr.Abhimanya Kapoor in Regency Hospital, Kanpur on 20.05.2019. Cashless benefit request for Rs.60000/-

was made by the hospital for cholecystectomy surgical procedure [ gall bladder ]. During processing of

cashless benefit, it was observed that the patient had taken treatment on 29.12.2017 for gall bladder stone.

The insurer repudiated his claim and cancelled his policy ab-initio alleging that there was concealment of

material fact at the time of obtaining insurance cover.

In their SCN/Reply dated 07.08.2019, the respondent have submitted that at the time of porting the cover

from the New India Assurance Company Limited to their company the complainant did not disclose this

pre-existing disease in the proposal form. This non-disclosure of material fact is in violation of the very

fundamentals of the law of contract. Therefore the cashless claim was denied and policy was cancelled ab-

initio for non disclosure of past history of choleithiasis since December 2017.



20. Despite notice complainant is not present. I have heard respondent representative and perused papers

filed on behalf of the complainant as well as respondent.

21. Complaint has been made on the following prayer :

“As per Self Contained Note, complainant has yet not submitted the claim papers before the

respondent rather his prayer for cashless treatment was refused subsequently policy was

cancelled.”


So far as complaint is concerned, it is pre-mature since complainant himself has not submitted any claim

papers with the respondent, he can not make a claim for reimbursement directly before this forum.

Accordingly, complaint is pre-matured.

Order :

Complaint is disposed off with a direction to the complainant to submit his claim in accordance with policy

bond to the respondent within a period of 15 days thereafter respondent shall decide the claim within a

period of 30 days after giving an opportunity of hearing to the complainant.






Mr. S.C. Srivastava…………..……....………………. Complainant

V/S

Religare Health Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-G-037-1819-0136 Order No. IO/LCK/A/GI/0183/2019-20

1. Name & Address of the Complainant Mr. SC Srivastava,

MIG-3/16, Sector-G, Jankipuram,

Lucknow-226021.

2. Policy No:

Type of Policy


10140282

Mediclaim Policy

29.08.2014 to 28.08.2015



Ms. Neelam Srivastava

4. Name of the insurer Religare Health Insurance Company Limited


6. Reason for repudiation/Rejection Dificiency Not replied by the insured


8. Nature of complaint Non settlement of the claim

9. Amount of Claim Rs.360991.00


11. Amount of relief sought Rs.360911.00

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



For the Complainant Mr.S.C. Srivastava

For the insurer Mr. Pratyush Prakash, Manager-Legal



17. Mr.SC Srivastava (Complainant) has filed a complaint against United India Insurance Company

Limited (Respondent) alleging non settlement of mediclaim of Mrs. Neelam Srivastava.

COMPLAINT NO:LCK-G-037-1819-0136 Order No. IO/LCK/A/GI/0183/2019-20

18. Brief Facts Of the Case:- The complainant purchased a health insurance policy for his wife for period

29.08.2017 to 28.08.2018. His wife was admitted in Radius Hospital, Lucknow on 19.03.2018 for her knee

replacement and was discharged on 23.03.2018. He preferred a claim with the insurer for Rs.360991/-

being reimbursement of spent amount. The insurance company, after asking various papers again and

again, repudiated his genuine claim on fabricated grounds. He had therefore, approached this forum with

a request to intervene in the matter for resolving his grievance.

In their SCN/reply, RIC has stated that as per discharge summary of Radius Hospital, the insured is

specified to be suffering from Diabetes, Hypertension and Depression. They asked the insured to submit

first consultation papers regarding Osteoporosis vide their letters dated 25.05.2018, 11.06.2018 and

16.06.2018 but the same was not provided by the insured. Accordingly the company informed the insured

vide letter dated 28.06.2018 that your claim is not payable as per terms and condition listed below :

“Deficiency not replied”

However, respondents have given an offer for settlement of the claim to the insured complainant for

Rs.284640/- vide mail dated 23.01.2020 for full and final settlement. Insured vide his letter dated

27.01.2020 has confirmed that he has accepted the offer of the respondent. Accordingly respondent have

made the payment of his claim for Rs.284640/- as full and final settlement vide NEFT No:

N035201054675865 dated 04.02.2020.



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

as the insurance company.

21. As the complainant’s claim has been settled by the respondent insurance company, there is no need

of any further interference in the matter. The complainant has also confirmed having received his claim

payment. There is nothing on record to rebut the statement.

Accordingly complaint is disposed off as full satisfaction.




PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C. S. PRASAD

CASE OF SH. YASH KUMAR GUPTA VS CHOLA MS GENERAL INS. CO.LTD.

COMPLAINT NO: NOI-G-012-1920-0243

AWARD NO:

1. Name & Address of the Complainant Sh. Yash Kumar Gupta

B-208, Sector-31, Noida

U.P.-201301

Ph. No.09810578288

2. Policy No:

Type of Policy


Sum Insured

2876/00000485/069/00

Group Health Insurance

08.11.2018 to 07.11.2019

Rs.3,00,000/-



Sh. Yash Kumar Gupta

M/s. Dena Bank

4. Name of the insurer Chola MS General Insurance Co. Ltd..


6. Reason for repudiation Repudiation of claim due to PED



9. Amount of Claim N.A.


11. Amount of relief sought Not mentioned in Annex VI A


Rule no: of RPG rules

13 (1) (b)

13. Date of hearing/place 05.03.2020 / Noida


For the Complainant Sh. Yash Kumar Gupta

For the insurer Sh. Jitender Kumar, Sr. Executive Legal

Sh. Manish Batra, Dy. Manager



17. Brief Facts of the Case:- Sh. Yash Kumar Gupta, the Complainant had taken Group Health Policy

(M/s. Dena Bank) Policy No. 2876/00000485/069/00 for the period from 08.11.2018 to 07.11.2019 for

the Sum Insured of Rs.3,00,000/-. The Policyholder was M/s. Dena Bank. The claim for reimbursement

of medical bills was repudiated by the Insurance Company on PED basis. Aggrieved, he requested the

Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred

a complaint to this office for resolution of his grievance.

18. Cause of Complaint:-

a) Complainant’s argument:- Sh. Yash Kumar Gupta, the Complainant stated that he was

suffering from Acidity/gastric problem due to hiatus hernia. For that, he went to Kailash

Hospital, Noida for Endoscopy test on 02.05.2019. During endoscopic test, he felt restlessness

and the doctor took his ECG and suggested for Angiography test. He got admitted and

Angiography test was done. Bypass surgery has been recommended on urgent basis. He got

operated in AIIMS, Delhi. His claim was rejected by the Insurer on the basis that symptoms of

the present ailment were existed and were known to him since 2016 which is not correct.

b) Insurers’ argument:- The Insurance Company stated in their SCN that the complainant was

admitted at Kailash Hospital on 02.05.2019 in emergency with acute chest discomfort during

UGIE with radiation to left arm with sweating. He was diagnosed for CAD –OLD MI AND

TRIPLE VESSEL DISEASE AND SEVERE LV DYSFUNCTION FOR CAG. He got

admitted on 02.05.2019 and discharged on the next day 03.05.2019 and claimed for

R.1,48,445/- for the expenses for treatment.

The complainant had undergone various tests before getting heart surgery at AIIMS Delhi.

As per the insured/complainant declaration, he had gas problems in 2016 and at that time

i.e. on 26.08.2016, an endoscopy was done and was diagnosed as Gastric Problem.

Again, he consulted in Apollo Hospital in OPD and a repeat endoscopy was done and

again on 02.05.2019, an endoscopy was done at Kailash Hospital.

On admitting in Kailash Hospital due to uneasiness was advised for Angiography and

CAG was done on 03.05.2019 and was diagnosed with 90-100% blockage in heart

vessels and was advised for By pass surgery but on request of complaint was discharged

on the same day.

Further took treatment in AIIMS and admitted on 08.05.2019 and CABG done on

10.05.2019 and discharged on 21.05.2019.

A bare perusal of discharge summary/progress notes from AIIMS clearly shows that the patient

underwent CORONAY ANGIOGRAPHY REPORT: ON 21.05.2018; DONE OUTSIDE. Whereby

blockage were duly noted, however complainant knowingly did not place this report neither before the

insurance company nor before the Ombudsman. After having knowledge of the ailment of this disease

on 21.05.2018, the complainant obtained a policy from the Insurer which was effective from

08.11.2018 to 07.11.2019 with an after though of getting expenses from the Insurance Company

without informing the factual position to the insurer.

On perusal of the documents and treatments, it is observed that the signs and symptoms of the disease

and complications were existed prior to inception of the policy i.e. 08.11.2018. The disease was pre

existing and was very well known to complainant which he had deliberately not disclosed to the

Insurer. Therefore, the complaint is liable to be dismissed as per the policy clause 3.2.

A Repudiation letter was sent to the insured that as the disease is pre existing, the claim is inadmissible

as per General Exclusion Clause 3.2 which reads as “No indemnity is available or payable for claims

directly or indirectly caused by, arising out or connected to any Pre existing condition….”.

19) Reason for Registration of Complaint: - Repudiation of Mediclaim


a) Customer complaint

b) Annexure vi and vi (a)

c) Reply of Insurance Company

d) SCN

21) Observations & Conclusion :-

Both the parties appeared for the personal hearing and reiterated their submissions. The Insurance

Company reiterated that the signs and symptoms of the disease and complications existed prior to

inception of the policy i.e. 08.11.2018. The disease was pre existing and was very well known to

complainant which he had deliberately not disclosed to the Insurer. Therefore, the claim was

repudiated as per General Exclusion Clause 3.2 which reads as “No indemnity is available or payable

for claims directly or indirectly caused by, arising out or connected to any Pre existing condition….”.

The complainant argued that current policy was the renewal of his previous policy of the same

Insurance Company. Hence, his disease should not be considered as pre existing. The complainant

submitted copy of previous policy no.2842/00139563/0001/000/00 for the period from 08.11.2017 to

07.11.2018 which was also issued by the same Insurer.

The Insurer stated that they have no knowledge of previous insurance. They also agreed that after the

verification of the previous policy, they will settle the case within a month under intimation to this

office.

I have examined the documents exhibited and oral submissions made by both the parties. I find that the

Insurer has repudiated the claim on the basis of PED before inception of the policy i.e. 08.11.2018

which was incorrect. The inception of the policy was 08.11.2017 instead of 08.11.2018. The Insurance

Company has no valid reason in repudiating the claim under Clause No.3.2. Hence, the Insurance

Company is directed to pay the admissible claim to the complainant.

AWARD

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

by both the parties during the course of hearing, the Insurance Company is directed

to pay the admissible claim to the complainant.

The complaint is treated as disposed off accordingly.

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

of Insurance Ombudsman Rules, 2017:

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


Ombudsman.

Place: Noida. C.S. PRASAD

Dated: 17.03.2020 INSURANCE OMBUDSMAN

(WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S. PRASAD

CASE OF SH. RAJ KUMAR VOHRA V/S UNITED INDIA INSURANCE COMPANY LTD.

COMPLAIN REF. NO.: NOI-H-051-1920-0254

AWARD NO:

1. Name & Address of the Complainant Sh. Raj Kumar Vohra

424, Paschimpuri

Agra, Uttar Pradesh-282007.

Ph. No.09412270081

2. Policy No:

Type of Policy


Sum Insured

500100/48/15/41/00000508


United bank of India (Retirees)

01.11.2015 to 31.10.2016

Rs.4,00,000/-

3. Name of the Insured


Sh. Raj Kumar Vohra

Sh. Raj Kumar Vohra

4. Name of the insurer United India Insurance Company Limited

5. Date of Repudiation --

6. Reason for repudiation --


8. Nature of complaint Partial repudiation of claimed amount



11. Amount of relief sought Rs.15,500/- as per Annex VI A


IOB rules, 2017

13 (1)(b)

13. Date of hearing/place 05.03.2020 / NOIDA


For the Complainant Sh. Raj Kumar Vohra For the insurer Sh. Rajat Gouri, A.O.



17. Brief Facts of the Case:- Sh. Raj Kumar Vohra, the Complainant had taken Group Health Insurance Policy No.

500100/48/15/41/00000508 for the period from 01.11.2015 to 31.10.2016 for the S.I. of Rs.4,00,000/-. The Group

Mediclaim Policy was issued to United bank of India (Retirees) covering their Retired Employees with dependent

members. The Complainant Sh. Raj Kumar Vohra was hospitalized for the disease Choledocholithiasis. The

reimbursement of bills was partially rejected by the Insurance Company. Aggrieved, he requested the Insurer

including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to

this office for resolution of his grievance.


a) Complainant’s argument:- Sh. Raj Kumar Vohra, the Complainant stated that he submitted medical bills

total amount of Rs.32,852/- which included bill of ERCP operation of Rs.15,500/-, as it was duplicate

receipt which was issued by the Synergyplus Hospital, Agra, hence the same was deducted by the Insurance

Company. The complainant contacted to the Hospital Manager and he had issued a letter in regard to

misplaced original receipt. The same was submitted by the complainant to the Insurer alongwith original

coloured report of ERCP operation. But, the insurer did not reimburse the amount of Rs.15,500/-.

b) Insurers’ argument:- The Insurer in their SCN stated that Complainant Sh. Raj Kumar Vohra had lodged

Reimbursement claims for himself. The patient was admitted for CHOLEDOCHOLITHIASIIS in

Synergyplus Hospital on 24/09/2016 and discharged on 25/09/2016.

The Insurance Company had received the reimbursement request of Rs.32,852/- from the claimant and

accordingly the claim was reported vide claim no HH871736071.

On reviewing the claim documents, t h e y found that some required documents were not provided in the

submitted documents by the claimant. So, they had asked for the same issuing query letter.

In compliance to their query, they had received the other reply except original money receipt of

Rs.15,500/-, hence the claim was settled for Rs.15,871/- deducting the following items as per policy and

paid on 10/02/2017 vide UTR No.172A559016Q01064.

Rs.150/- on Bill No.SA=150 dated 25/09/2016 (Consultant) - DIET CHARGESIS NOT

PAYABLE.

Rs.15,500/- on Bill No SA=047 dated 24/09/2016 (Procedures) - DUPLICATE MONEY

RECEIPT IS NOT ACCEPTABLE.

Rs.200/- on Bill No. SA=972 dated 25/09/2016 (Others) - MRD CHARGESIS NOT

PAYABLE.

Rs.300/- on Bill No. SA=19 dated 04/09/2016 (Electrocardiography (E.C.G.) -NO SUPPORTING

DOCTOR ADVICE.

Rs. 50.00 on Bill No SA=350 dated 25/09/2016 (Medicines by Hospital) - NON MEDICAL

ITEMS NOT PAYABLE [SYRINGE]

Rs.8.00 on Bill No SA=612 dated 24/09/2016 (Medicines by Shop) – NON MEDICAL ITEMS

NOT PAYABLE [SYRINGE]

Rs.33.00 on Bill No SA=636 dated 24/09/2016 (Medicines by Shop) - NON MEDICAL


Rs.50.00 on Bill No SA=296 dated 25/09/2016 (Medicines by Shop) - NON MEDICAL


Rs.550.00 on B ill No. SA=511 dated 07/09/2016 (Laboratory) - NO SUPPORTING DOCTOR

ADVICE FOR BLOOD GLU, SERUM AMYLASE & SERUM LIPASE.

Subsequently, they had received the reimbursement request for sub bills of Rs. 4,645/- and out of

which they had paid for Rs.2,145/- on 10/02/2017 vide UTR No.172A559014E11M44 making following

deduction as per terms & conditions of policy.

Rs.500.00 on Bill No.LP=5508 dated 21/10/2016 (Consultant) – MANIPULATION ON

PRESCRIPTIONDATE IS NOT PAYABLE

Rs.2,000.00 on Bill No.LP=0436 dated 24/10/2016 (Endoscopy/Gastroscopy) - NO

SUPPORTING DR. ADVICE NOR REPORT ENCLOSED.

On receipt of representation for part payment from the claimant, they had paid Rs.2,000/- towards

endoscopy charges which was deducted earlier due to non availability of advice. The same had been

paid on 24/02/2017 vide UTR No.172063353M981W33.

Due to non submission of complete query reply in time, the claim has been processed as per available

document received and deducted the claim amount on the basis of Condition clause 5.6.

Condition Clause 5.5: All supporting documents relating to the claim must be filed with the office of the

Bank dealing with the claims or THIRD PARTY ADMINISTRATOR within 30 days from the date of

discharge from the hospital. In case of post-hospitalization, treatment (limited to 90 days), (as mentioned

in para 2.32), all claim documents should be submitted within 30 days after completion of such treatment.

Condition Clause 5.6: The Insured Person shall obtain and furnish to the office o f the Bank dealing with

the claims/THIRD PARTY ADMINISTRATOR with all original bills, r eceipts and other documents upon

which a claim is based and shall also give such additional information and assistance as the Bank through

the THIRD PARTY ADMINISTRATOR/Company may require in dealing with the claim.

T he claim is settled on the basis of available claim document submitted and deduction is v alid as per

policy terms and conditions under Clause 5.5 and 5.6.

19) Reason for Registration of Complaint: - Partial Rejection of Mediclaim





d) SCN

21) Observations and Conclusion :-

Both the parties appeared for personal hearing and reiterated their submissions. The Insurance Company

reiterated that the claim of Rs.15,500/- was not settled because the required documents in original were not

received by the Insurance Company and the Insured was unable to submit the same to the Insurance Company.

The Complainant reiterated that he submitted medical bills total amount of Rs.32,852/- which included bill of

ERCP operation of Rs.15,500/-, as it was duplicate receipt which was issued by the Synergyplus Hospital, Agra,

hence the same was deducted by the Insurance Company. The complainant contacted the Hospital Manager and

he had issued a letter in regard to misplaced original receipt. The same was submitted by the complainant to the

Insurer along with original colored report of ERCP operation. But, the Insurer did not reimburse the amount of

Rs.15,500/-.

The Insurance Company proposed that if the Complainant submits an Indemnity Bond that no claim payment was

received from any other forum and that he will not claim the same claim from any other forum, his claim would

be processed to which the Complainant agreed.

I have examined the documents exhibited and oral submissions made by both the parties. The Complainant is

directed to submit the Indemnity Bond to the Insurance Company that no claim payment was received by him

from any other forum and that he will not claim the same claim from any other forum. The Insurance Company is

directed to pay admissible claim to the Complainant on submission of the Indemnity Bond.

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


a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty

days of the receipt of the award and intimate compliance of the same to the Ombudsman.




PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S. PRASAD

CASE OF SH. MAHESH CHAND VERMA V/S UNITED INDIA INSURANCE COMPANY LTD.

COMPLAIN REF. NO.: NOI-H-051-1920-0253

1. Name & Address of the Complainant Sh. Mahesh Chand Verma

H.No. 126, Prangarhi,

Near Old Bus Stand,

Ghaziabad, Uttar Pradesh-201001.

Ph. No.09899227272/09871007172

2. Policy No:

Type of Policy


Sum Insured

5001002818P113436213 (Basic Policy)

5001002818P113448993 (Super Top Up Policy)


UCO bank (Retirees)

01.11.2018 to 31.10.2019

Rs.3,00,000/- for Main Policy and

Rs.4,00,000/- for Super Top Up policy

3. Name of the Insured


Sh. Mahesh Chand Verma

Sh. Mahesh Chand Verma

4. Name of the insurer United India Insurance Company Limited

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 Complainant is directed to

submit the Indemnity Bond to the Insurance Company that no claim payment was

received from any other Insurance Company and nor would he claim for the same

claim from any other Insurance Company. The Insurance Company is directed to

pay admissible claim to the Complainant on submission of the Indemnity Bond.


5. Date of Repudiation --

6. Reason for repudiation --


8. Nature of complaint Partial repudiation of claimed amount



11. Amount of relief sought Rs.1,42,558/-+Interest due to delay + Penalty as

per Annex VI A


IOB rules, 2017

13 (1)(b)

13. Date of hearing/place 05.03.2020 / NOIDA


For the Complainant Sh. Mahesh Chand Verma

For the insurer Sh. Rajat Gouri, A.O.



17. Brief Facts of the Case:- Sh. Mahesh Chand Verma, the Complainant had taken Group Health Insurance Policy

No.5001002818P113436213 (Basic Policy) and Policy No.5001002818P113448993 (Super Top Up Policy) for the

period from 01.11.2018 to 31.10.2019 for the S.I. of Rs.3,00,000/- and S.I. of Rs.4,00,000/- respectively. The

Group Mediclaim Policy was issued to UCO Bank (Retirees) covering their Retired Employees with dependent

members. The Complainant Sh. Mahesh Chand Verma was hospitalized for the disease Chronic Kidney Disorder

(CKD-V). The reimbursement of bills was partially rejected by the Insurance Company. Aggrieved, he requested

the Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a

complaint to this office for resolution of his grievance.


Complainant’s argument:- Sh. Mahesh Chand Verma, the Complainant stated that he submitted medical bills to the

Insurer. But amount of Rs.1,42,558/- is still pending for reimbursement.

Insurers’ argument:- The Insurer in their SCN stated that they have issued a group Mediclaim policy to U c o Bank

Retiree:5001002818PI13436213 (Base policy) and 5001002818PII3448993 (super top up policy) covering their

Retiree Employees for the period from 01/11/2018 to 31/10/2019.

Mr. Mahesh Chandra Verma (Retired Employee no.- 17025) is included by UCO Bank in the list of insured

persons along with his Spouse for sum insured of Rs.300000/- for main policy and Rs.4,00,000/- for

supertop up policy.

The claims were r e p o r t e d in the name of Mr. Mahesh Chand Verma covered as retired employee under IBA

base policy (for sum insured of Rs.3 lacs) with UCO bank retiree super top up policy(for sum insured of Rs.4

Lacs) for the policy period 2018-19. The sum insured had been exhausted in IBA base policy hence the claims

were reported in UCO Bank retiree super top up policy. The details of claims for which notice has been provided as

under.-

1. Claim No: HH8720017S1, Claimed Amount:- Rs. 14,000/-, Claim type:- Cashless

• They had received the cashless authorization for the above patient from the hospital and

accordingly they had sent the approval of Rs.14,000/-.

2. Claim No.:-HH872001751, Claimed Amount:- Rs.21,163.39, Claim type:- Cashless Reimbursement

• We had received the claim for pre & post expenses for the above mentioned amount and the

claim stand closed with remarks the pre & post expenses are not payable under super top up policy

clause no 2.1(B).

3. Claim No:- HH872002409, Claimed Amount:- Rs. 2,200/-, Claim type:- Cashless

• On receipt of the above request for availing cashless facility, they had sanctioned the cashless of

Rs.2,200/- on behalf of above patient to the hospital as per pre authorization received from the hospital.

4. Claim No:- HH872oo2409, Claimed Amount:-Rs.2634/-, Claim type: Cashless Reimbursement

• They had received the reimbursement request for above mentioned amount from the claimant

and t h e y are unable to reimburse the excess amount Rs.2600/- apart from above cashless approval In

each case in insured's favor (i.e.R s . 4,800/- minus cashless authorization of Rs.2,200/-/-) charged by

hospital Without disclosing in pre authorization form unless they receive proper clarification in

justifying the reason for non-disclosing of exact numbers of dialysis sitting at pre auth stage for

which t h e y had sent email to hospital and copy marked to claimant and also the hospitalization expenses

does not exceed the threshold limit.

5. Claim No:- HH872002658, Claimed Amount- Rs. 2,200/-, Claim type- Cashless

• The above cashless request received from the hospital in respect of the above insured and

accordingly they had sent the mail with approval of Rs.2,200/- to the hospital as per pre

authorization received from the hospital.

6. Claim No.:- HH872002658, Claimed Amount : Rs.5,210/-, Claim type:- Cashless reimbursement


and are unable to reimburse the excess amount Rs.2,600/- apart from above cashless approval in each

case in insured's favor (i.e. R s . 4800/- minus cashless authorization of Rs.2,200/-) charged by

hospital without disclosing in pre authorization form unless they receive proper clarification in justifying

the reason for non-disclosing of exact numbers of dialysis sitting at pre auth stage for which t h e y had

sent email to hospital and copy marked to claimant also the hospitalization expenses does not exceed the

threshold limit.

7. Claim No. HH872003006, Claimed Amount: Rs. 2,200/-, Claim type- Cashless

• They had sanctioned the cashless authorization of Rs.2,200/- to hospital on behalf of above insured

based on the pre authorization received from the hospital.

8. Claim No.:-HH87Z003006, Claimed Amount- Rs.2,793.05, Claim type- Cashless reimbursement

• They had received the reimbursement request for above mentioned amount from the claimant and

are unable to reimburse the excess amount Rs.2,600/- apart from cashless approval in each case in

insured's favor (i.e.R s . 4,800/- minus cashless authorization of Rs.2,200/-) charged by hospital without

disclosing in pre authorization form unless they receive proper clarification in justifying the reason for

non-disclosing of exact numbers of dialysis sitting at pre auth stage for which t h e y had sent email to

hospital and copy marked to claimant and also the hospitalization expenses does not exceed the threshold

limit.

9. Claim No- HH872oo3380, Claimed Amount:- Rs. 2,200/-, Claim-Cashless

• The cashless authorization was received from the hospital for above amount and Rs.2,200/· was

sanctioned accordingly.

10. Claim No:- HH872003380, Claimed Amount:- Rs.2,793/-, Claim type- Cashless reimbursement


and they are unable to reimburse the excess amount Rs.2,600/- apart from cashless approval in each case

in insured's favor (i.e. 4800/· minus cashless authorization of Rs.2,200/-, charged by hospital without


non disclosing of exact numbers of dialysis sitting at pre auth stage for which they had sent email to


limit.

11.Claim No:· HH872004783, Claimed Amount:· Rs.2,200/-, Claim type:- Cashless

• The cashless was sanctioned of Rs.2,200/- as per pre authorization received from the hospital on behalf

of above Insured

12. Claim No.:- HH872004783, Claimed Amount -Rs.2,793/-, Claim type:- Cashless reimbursement

• They had received the reimbursement request for above mentioned amount from the claimant and

they are unable to reimburse the excess amount Rs.2,600/- apart from cashless approval in each case In

insured's favor (i.e. 4800/· minus cashless authorization of Rs.2,200/-, charged by hospital without


non disclosing of exact numbers of dialysis Sitting at pre auth stage for which they had sent email to


limit.

13. Claim No:· HH87Z008907,Claimed Amount:- Rs. 4289/-, Claim type:- Reimbursement

• They had received the reimbursement request for above mentioned amount and the claim now

stand as closed with remarks the hospitalization expenses is less than threshold limit of

Rs.3,00,000/·

14. Claim No:· HH872010081, Claimed Amount:-Rs.5,586/·, Claim type: Reimbursement

• They had received the reimbursement request for above amount. The claim stand closed since

the hospitalization expenses is less than threshold limit of Rs.3,00,000/-

15. Claim No:· HH87Z010516,Claimed Amount: Rs.4,175/-, Claim type: Reimbursement


hospitalization expenses does not exceed the threshold limit of Rs.300000/-

16. Claim No: HH872010708, Claimed Amount:- Rs. 6558./-, Claim type: Reimbursement



17. Claim No: HH872010710, Claimed Amount:- Rs.4,307./-,Claim type: Reimbursement



18. Claim No:- HH872011688, Claimed Amount:- Rs. 218.51, Claim type:- Reimbursement

• They had received the reimbursement request for pre & post expenses and the claim had

been closed since the pre & post expenses is not covered in super top up policy.

19. Claim No:- HH87Z018774, Claimed Amount:-Rs. 28914/-, Claim type:-Reimbursement

• They had received the reimbursement request for pre & post expenses and the claim had

been closed since the pre & post expenses is not covered in super top up policy.

20. The sum insured (3 lac) had been already exhausted In base policy hence the claims were

reported in UCO bank retiree super top up policy. However, as per super top policy condition

Clause 2.1: Any claim under this policy shall be payable by the Company only if

a. It is in respect of Covered Expenses specified in this Policy and

b. The aggregate of covered expenses In respect of hospitalization/s of insured person in

case of Individual policy or all insured persons In case of Family Policy exceeds the

Threshold Level.

c. All limits of reimbursement under any other Health Insurance Policy/Reimbursement Scheme

available to the insured person/s have been exhausted.

21. Thus the claims under Super Top-up policy are payable only of hospitalization (The claims

pertaining to domiciliary /OPO/pre and post hospitalization are not payable).

22. Hence, the non-payment of pre and post hospitalization, claim amount is justified in accordance

with the Terms & Conditions of UCO BANK RETIREES - IBA - SUPERTOP-UP policy".

23. The complainant has also complaint regarding non-receipt of the policy copy. In this regard, in

the IBA policy, the banks take policy for their employees and retirees along with eligible members

where the banks are insured and employees, retirees and their eligible family members are insured

persons. Therefore, they send the policy copies to the respective banks. In case of both these policies

(base policy 5001002818PI13436213 and super top- up policy 500 I 002818P 113448993) with full

terms and conditions were sent to bank.

19) Reason for Registration of Complaint: - Partial Rejection of Mediclaim





d) SCN

21) Observations and Conclusion :-

Both the parties appeared for personal hearing and reiterated their submissions. The Insurance Company admitted

of the complainant having a group Mediclaim policy issued to U C O Bank Retiree: 5001002818PI13436213

(Base policy) and 5001002818PII3448993 (Super top up policy) covering their Retiree Employees for the period

from 01/11/2018 to 31/10/2019. The Insurance Company submitted the details of payments made under the Base

Policy and Super Top Up Policy for the policy period 01/11/2018 to 31/10/2019.

It is observed that the Insurance Company has paid the full Sum Insured of Rs.3,00,000/- during the policy period,

as above under 85 instances of hospitalization from 02.11.2018 to 24.03.2019, mostly, on Cashless basis. After

the exhaustion of sum insured of Base Policy (Rs.3,00,000/-), further claims were treated under Super top up

Policy, wherein, the pre & post expenses are not payable under super top up policy clause no. 2.1(B). It is

further observed that the Insurer during the policy period 01.11.2018 to 31.10.2019, had paid claims of

Rs.96,800/- under 14 instances of hospitalization to the complainant under Super Top Up Policy. However, it is

observed that under claim nos. HH872002409, HH872002658, HH872003006, HH872003380 and

HH872004783, the claims had been denied on the ground “Amount charged was not disclosed in the pre-auth

request by the hospital”. The objection, itself points that it is the fault of the hospital which is a network hospital

of the Insurer. The denial of these claims is unjustified as Sum Insured under Super Top Up Policy is not

exhausted, thus is being set aside.

It is further observed from the SCN that claim nos. HH872008907, HH872010081, HH872010516, HH872010708

and HH872010710 were denied on the ground “the hospitalization expenses is less than threshold limit of

Rs.3,00,000/-”, whereas the claims were lodged under the Super Top Up Policy as the Base Policy had already

exhausted on 24.03.2019. The rejection of these claims is also unjustified and being set aside.

Regarding claim nos. HH872001751 (Amount Rs.21,163/-), HH872011688 (Amount Rs.218.51) and

HH872018774 (Amount Rs.28,914/-), it is observed that these claims were for pre and post hospitalization

expenses which are not payable under the Super Top Up Policy. The rejection of these claims is upheld.

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


a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty

days of the receipt of the award and intimate compliance of the same to the Ombudsman.

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 admissible claims as discussed above to the Complainant.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant MR. BIRESH MALLA BARUAH VS NATIONAL INSURANCE COMPANY LIMITED

COMPLAINT REF NO:: GUW-H-048-1920-0141 Award No

1. Name & Address of the Complainant MR. BIRESH MALLA BARUAH

2. Policy No:

Type of Policy


200802501810000030

MEDICLAIM POLICY

20/09/2018 TO 19/09/2019;S.I.Rs.RS.75000+RS.13750



BIRESH MALLA BARUAH BIRESH MALLA BARUAH

4. Name of the insurer NATIONAL INSURANCE COMPANY LIMITED

5. Date OF OCCURANCE OF LOSS/CLAIM 28/02/2019

6. DETAILS OF LOSS RS.200000/-

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance ombudsman Rule 2017

8.a

8.b

Nature of complaint

Date of receipt of the complain

PARTIALLY SETTLED THE CLAIM

04/02/2020

9. Amount of Claim RS.147947/-

10. Amount of Partial settlement RS.29940/-

11 Amount of relief sought RS.118007/-

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati,

17/03/2020


For the Complainant MR.BIRESH MALLA BARUAH

For the insurer MRS. JULIA T.BASUMATARI

15 Complaint how disposed Through personal Hearing


17) Brief Facts of the Case: The complainant Mr. Biresh Malla Baruah had Group Mediclaim Policy with National insurance

Company limited. Mr. Baruah, the complainant was admitted in Nemcare Hospital, Guwahati on 28/02/2019 & was

discharged on 08/03/2019 with the complaints of known case of Type II Diabetes Mellitus,Hypertension,Hypothyroidism on

regular medication, CAD post Angioplasty. Radical Nephrectomy done under GA on 01/03/2019. The complainant submitted

one claim of Rs.113947/- against which an amount of Rs.29940/-was paid to the insured without citing any reason of

deduction of huge amount of the claim. The complainant has written to us for reconsideration of the claim.

18a) Complainant’s Argument: The complainant is not satisfied with the settlement. The complainant stated that, no letter

from insurance company about amount of settlement was received from insurance company. Only a simple message was

received, that your claim No.200802501 has been approved for Rs. 29940/-. The complainant has written several times

asking details of deduction of the claim amount. But insurance co. never replied to his query.

18 b) Insurers’ Argument: As stated in the SCN the claim was processed under the terms & conditions of the policy. Insurance

co. stated in their SCN that as it is a PED case, They had considered previous SI of Rs.50000/-.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval from

honorable ombudsman13 (1) (b).23

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both the parties (Observations & Conclusion):- Both the parties were called for hearing on 17/03/2020. The complainant was represented by Mr.Biresh Malla Baruah and the insurer was represented by Mrs Julia T Basumatary.

DECISION We have taken in to consideration the facts and circumstances of the case from the documentary as well as

verbal submission made by the claimant and representative of Insurance Co. We have also gone through the

records. Insurance Company stated in their SCN ,as it is a PED case, they had considered previous SI of

Rs.50000/-+ CB RS.5000 in settlement of the claim. But during the course of Hearing insurance co.accepted

that they have committed mistake in settling the claim. After that ,we have reviewed the case once again.

On review, the payable amount has been arrived at Rs.16260/- as shown below:

Particulars Claimed Amount Allowed

Room Charges @ 1% of SIx7

(S.I.50000+CB.5000)=55000

10000 3850

ICU charges @ 2% of SIx1 day 6360 1100

Medical practitioners,surgeon

fees consultant fees @ 25 %

of SI

75060 13750

Anesthesia blood oxygen OT

charges @ 50% of SI

39057 27500

Total 130477 46200

Already paid ---------------------------- 29940

Payable amount ----------------------------- 16260

Under the above circumstances the forum directs the insurance co. to pay the remaining amount of

Rs.16260/- to the insured.

Hence the complaint is treated as closed.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of the award and intimate


Dated at- Guwahati, The 17th Day of March 2020.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Mr. Pramod Kumar Mohanty Vrs. M/S Apollo Munich Health Insurance Co Ltd COMPLAINT REF: NO: BHU-H-003-1920-0091

AWARD NO: IO/BHU/A/GI/ /2019-20


Mr. Pramod Kumar Mohanty Kalinga Lane, Mahatab Road, Cuttack 753012 (9040625141)

2. Policy No: Type of Policy Duration of policy/Policy period

120100/12586/2018/A007873/PE00862655 Group Assurance Health Plan SIV Rs.2.00 lac 16.02.2018 to 15.02.2019 (1st time policy) DoA- 12.03.2018 to 14.03.2018

3. Name of the insured Name of the policyholder

Mr. Pramod Kumar Mohanty Mr. Pramod Kumar Mohanty

4. Name of the insurer Apollo Munich Health Insurance Co Ltd (now changed as:- HDFC Ergo Health Insurance Co Ltd)

5. Date of Repudiation 09.04.2019 Claim falls within 30 days exclusion under the policy 6. Reason for repudiation

7. Dt. of receipt of the Complaint 06.06.2018

8. Nature of complaint Claim for hospitalization expenses


10. Date of Partial Settlement Not applicable


12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 04.03.2020, Bhubaneswar



b) For the insurer Absent

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017


17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant has taken a health insurance policy for the 1st time from Apollo Munich Health Insurance Co Ltd (now the company’s name is changed as:- HDFC Ergo Health Insurance Co Ltd) for the period from 16.02.2018 to 15.02.2019. The complainant was admitted in SCB Medical College Cuttack for diagnosis of CAD- ACS- Acute Anterior Wall Stem…… and was discharged on 14.03.2018. The complainant has submitted Discharge summary of the said treatment. The complainant in his petition has stated that he was also admitted on 19.02.2018 and was discharged on 22.02.2018, but he has not submitted any document in this regard. The insurer declined the claim stating the admission for treatment falls within 30 days of inception of the policy which is an exclusion and therefore the claim is not payable. On not being satisfied with the repudiation of the claim, the complainant preferred an appeal before this forum for redressal.

b. The insurer, in its denial letter dated 09.04.2019 has stated that the submitted claim falls within first 30 days of waiting period clause of the policy. Hence the claim is repudiated under Sec V A I of the policy.

18. a) Complainant’s Argument: - The complainant says that this is covered under the policy hence,

he is entitled for the benefits.

b) Insurer’s Argument: - The insurer in its denial letter dated 09.04.2019 has stated that the submitted claim falls within first 30 days of waiting period clause of the policy. Hence the claim is repudiated under Sec V A I of the policy.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017

20. The following documents are placed in the file.

a. Photocopies of Policy, Copy of Proposal form

b. Photocopies of Hospitalization Bills, Discharge Summary

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone

through all the documents and papers relating the complaint. The Forum records that neither the

complainant nor the insurer appeared for hearing to present their cases. On examination of documents

and policy wordings, it is found that the policy has a 30 days waiting period and treatments within 30

days from the date of inception of the policy are excluded. The policy inception date is 16.02.2018. The

patient was admitted thrice in two different hospitals during the period from 19.02.2018 to 14.03.2018

(i.e. Admission in SCB Medical on 19.02.2018, in Care hospital on 26.02.2018 and in SCB Medical on

12.02.2018). All these dates fall within the 30 days’ waiting period under the policy.

Dated at Bhubaneswar on the 04th day of March, 2020

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

AWARD

The Forum expresses its displeasure for the parties not appearing to present their cases during

the hearing. Taking into account the facts and circumstances of the case and relying on the

documents available in the file, the Forum finds no merit in the case as the claim falls under

exclusion of 30 days’ waiting period. Therefore, the complainant is not entitled to get the

present claim under the policy.

Hence, the complaint stands dismissed.

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