PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, AHMEDABAD

State of Gujarat and Union Territories of Dadra, Nagar Haveli and Daman & Diu

(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017) Case of:-Mr. Khatumbara M. Ilyas V/S The New India Assurance Co. Ltd.

Ombudsman: M. Vasantha Krishna Complaint No.: AHD-G-049-1718-0312

Award No. IO/AHD/A/GI/0058/20018-2019

1 Name of the Complainant Mr. Khatumbara M. Ilyas

205, Arshad Residency,Opp. Ambar

Tower,100 ft. Ring Road,

Ahmedabad-380055

2 Policy No:

Type of Policy

Duration of Policy/Policy period

21040034150100008053

Mediclaim Policy 2007

22.03.2017 to 21.03.2018

3 Name of the insured

Name of the policy holder

Mr. Arsh M. Ilyas

Mr. Khatumbara M. Ilyas

4 Name of the insurer The New India Assurance Co. Ltd.

5 Hospitalization Period 06.01.2017 to 07.01.2017

6 Reason of Repudiation As per terms and conditions of the policy

7 Date of receipt of complaint 26.05.2017

8 Nature of complaint Partial Repudiation of claim.

9 Amount of claim Rs.63,884/-

10 Amount Settled Rs.44,984/-

11 Amount of relief sought Rs.18,900/-

12 Complaint registered under Rule No. Rule 13(1)(b) of the I.O. Rules, 2017

13 Date of hearing/place 28.11.2018/Ahmedabad

14 Representation at the hearing:

For the Complainant

For the Insurer

Mr Khatumbara N. Ilyas

Mr Dharmin H. Zaveri,

15 Complainant how disposed AWARD

16. Date of Award / Order 05/02/2019

17. Brief facts of the case:

The Complainant’s son Mr. Arsh was admitted at Adwait ENT Hospital on 06.01.2017 and

discharged on 07.01.2017. He was diagnosed and treated for Adenoid hypertrophy +

tonsillitis. After discharge he submitted a claim for Rs.63,884/- which was settled for

Rs.44,984/-after deduction of Rs.18,900/- towards non payable items. Aggrieved by the

decision of the Company the Complainant has approached the Forum to redress his

grievance for settlement of his claim for balance amount of Rs.18,900/-.

18. Arguments by the Complainant:

The Complainant had stated that the Insurance Company had wrongly deducted Rs.18,900/-

from the claim for treatment of his son Mr. Arsh. He had submitted a letter dated 17.03.2017

from the Adwait Hospital confirming that the coblater the cost of which was disallowed, is not

an instrument but is a disposable blade used for every surgery(tonsillectomy and adenoid)

requiring coblation. It is just like disposable syringe & needle. The Complainant had urged

that after clarification from the hospital, the deduction by the Company was not justified and

therefore the remaining amount of claim of Rs.18,900/- should be paid to him.

19. Arguments by the Respondent:

The representative of the Respondent stated that the treating hospital’s doctor had given

clarification vide his letter dated 17.03.2017 that the coblater was not an instrument but a

disposable blade, which is used for every surgery. Any disposable comes under the category

of non-medical item under Sr. No. 78 of Annexure I – List of Expenses Excluded (Non-

medical), it was not payable as it was part of OT and surgeon charges, hence not paid

separately. He added that the claim was settled as per terms and conditions of the policy.

20. Observations and Conclusions:

The point to be considered in this case was whether the deduction made by the Respondent

was as per the terms and conditions of the policy.

1. The Respondent had deducted Rs.18,900/- towards the coblater charges which

according to them was not reimbursable as per the list Non-Medical items as per

Annexure I of expenses excluded (Non-medical), Sr. No. 78- Surgical Blades.

This item is part of a list of items of hospital services where separate

consumables are not payable but the service is.

2. As per the treating Hospital letter dated 17.03.2017, coblater is not an instrument, but

a disposable blade used for every surgery.

3. Since the treating doctor had confirmed that the Coblater was used under every

surgery, the cost of coblater which is of one time use should be considered as

service and paid as part of OT charges.

AWARD

Taking into account the facts and circumstances of the case and the submissions

made by both the parties, the insurer is directed by the Forum to pay an amount

of Rs. 18,900 to the complainant towards the cost of the coblater which was

earlier disallowed. In addition, interest as per rule 17(7) of the Insurance

Ombudsman Rules, 2017 also becomes payable.

21 The attention of the Complainant and the Insurer is hereby invited to

Rules 17(6) and 17(8) of the Insurance Ombudsman Rules, 2017 as

follows.

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(8) of the said Rules, the award of Insurance Ombudsman shall

be binding on the Insurers.

Dated at Ahmedabad on 5th Feb., 2019

M. Vasantha Krishna

Insurance Ombudsman



(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: M. Vasantha Krishna

Case of Mr. Rajan H. Dhandhukia Vs. The New India Assurance Co. Ltd.

Complaint Ref. No. AHD-G-049-1718-0335 Award No. IO/AHD/A/GI/0059/2018-2019

1 Name& Address of the Complainant Mr. Rajan H. Dhandhukia

24, Shreyas Society , Nr. Divine Life School,

Barrage Road, Vasna, Ahmedabad-380007

2 Policy No:

Type of Policy

Policy period

21230034152800000088

New India Floater Mediclaim

17.12.2015 to 16.12.2016



Mr. Rajan H. Dhandhukia



5 Date of Repudiation Not applicable

6 Reason for Repudiation Not applicable


8 Nature of complaint Partial settlement

9 Amount of claim INR 40569

10 Date of Consent 06.06.2017

11 Date of receipt of SCN 15.06.2017

12 Amount of relief sought INR 20569

13 Complaint registered under Rule No. 13(1) (b) of the IO Rules, 2017

14 Date of hearing/place 28.11.2018 - Ahmedabad


For the Complainant

For the Insurer


Mrs. Payal Shah

16 Complaint how disposed Award

17 Date of Award/Order 05/02/2019

18 Brief facts of the case:

The Complainant was covered under Family Floater Mediclaim policy of The New India

Assurance Co. Ltd. He had taken surgical treatment of right eye cataract on

03.12.2016. His claim for INR 40569/- was settled for INR 20000/- by the insurer. The

complainant made a request to the higher office of the insurer for payment of full claim

which was declined. Aggrieved by this he has approached this Forum.

19 Cause of Complaint:

(A) Complainant’s argument: The complainant submitted that he underwent cataract

surgery of right eye on 03.12.2016. Claim for INR 40569/- for this treatment was

settled for only INR 20000/- after deduction of INR 20569/- by the insurer. The

complainant argued that he had to incur the expenses for the best available

treatment of cataract and the amount was within the sum insured. Hence, his claim

was payable in full. He urged the Forum to help him in getting his genuine claim.

(B) Insurer’s argument: The respondent’s representative submitted that the claim was

settled as per the policy condition No.3.3. According to this condition, liability for

payment of any claim relating to cataract for each eye shall not exceed 10% of the

sum insured or INR 50000/- whichever is less. The complainant was insured for INR

2,00,000/-. The claim was settled for INR 20000/- being 10% of the sum insured as

per the policy condition. He submitted that the settlement was correct.

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

The point to be considered was whether the deduction made under Condition No. 3.3

was correct.

Based on the submission of parties and the material made available to this Forum, the

following points emerged which were pertinent to decide the case:-

1. The policy condition categorically restricted the claim amount for cataract

treatment to 10% of sum insured.

2. The insurer had settled the subject claim for INR 20000/-(10% of sum insured

of INR 2 lacs)

3. The complainant argued during the hearing that the policy document issued to

him did not contain the condition 3.3 based on which his claim was restricted.

Hence same should not be applied to his claim. It is however observed that it is

clearly mentioned in the policy schedule that the policy is subject to terms and

conditions of New India Floater Mediclaim. In case the terms and conditions

were not attached to the policy issued to the complainant, nothing prevented

him from seeking the same from the insurer. Therefore, his argument is not

accepted by the Forum. In view of the foregoing, the settlement of claim by the

insurer is found to be in order by this Forum.

Thus the complaint is not allowed.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by both the parties during the course of hearing, the complaint is not

admitted and no relief is granted to the complainant.

21. If the Award is not acceptable to the Complainant, it would be open for him, to move any

other Forum/Court as he may consider appropriate under the Laws of the Land against the

Respondent Insurer.


M.Vasantha Krishna Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, AHMEDABAD State of Gujarat and Union Territories of Dadra, Nagar Haveli and Daman & Diu

(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017) Case of Mr Bhikhalal C Shah Vs The New India AssuranceCo Ltd

Ombudsman: M.Vasantha Krishna Complaint Ref. AHD-G-049-1718-0415


1 Name & address of the Complainant Mr Bhikhalal C Shah,

C/O Shah & Co. Harikrupa Shopping, B/H City

Gold Cinema, Ashram Road, Ahmedabad

Gujarat-380009

2 Policy No:

Type of Policy

Policy period

21040234162500004247

New Mediclaim 2012

23/11/2016 to 22/11/2017



Mr Bhikhalal C Shah

Kanchanben B Shah

4 Name of the insurer The New India Assurance Co Ltd

5 Date of Partial Settlement 04/04/2017

6 Reason for partial settlement As per PPN Package

7 Date of receipt of complaint 08/06/2017

8 Nature of complaint Partial Settlement

9 Amount of claim Rs. 348103/-

10 Date of Consent 16/06/2017

11 Date of receipt of SCN 20/07/2017

12 Amount of relief sought Rs. 254428/-

13 Complaint registered under Rule No. 13(1)(b) of the I. O. Rules 2017

14 Date of hearing/place 28/11/2018 / Ahmedabad


For the Complainant

For the Insurer

Mr Bhikhalal C Shah

Mrs Sudha R.



18. Brief facts of the case

The complainant was covered under MEDICLAIM POLICY 2012 issued by The New

India Assurance Co Ltd. She was hospitalized for Arthroscopic Surgery (Other than

ACL/Meniscectomy) during the period 23/02/2017 to 25/02/2017. Her claim for Rs

348103/= was settled for Rs 93675/= as per PPN package for single sharing room.

Unsatisfied with the decision of the Respondent, the Insured had approached the

Forum for redressal of her grievance and settlement of the claim.

19. Arguments:

A. Complainant’s argument:

The complainant submitted that the insurance company had settled the claim for

Rs 93675/- as against her total claim of Rs 348103/-. The complainant submitted that

her claim was genuine and requested the Forum to help her in getting her full claim

amount in view of Sum Insured of Rs 5,00,000/- with Cumulative Bonus of Rs

90,000/-.

B. Respondent’s argument:

The insurance company stated that they had applied Reasonable and Customary

Charges clause and restricted the reimbursement to PPN Package rate in

Ahmedabad for Arthroscopic Surgery (other than ACL/Meniscectomy). They have

also deducted the cost of non-medical/non-payable items and disallowed pre/post

hospitalization expenses incurred beyond the applicable time limits.

20. Result of personal hearing with both parties (Observations & Conclusion):

Based on the submission of parties as above and the material made available, the

Forum observes as under:

(1) PPN package rates are part of a contract signed by the insurance company with

the network hospitals. The same cannot be unilaterally imposed on the insured

unless they agree to be treated at a network hospital and the hospital consents to

treat them at the agreed package rate. . The PPN package rates cannot also be

used as benchmark for reasonable and customary charges in all cases and

situations.

(2) In the present case the deductions made by the insurer under various heads and

the reasons for said deductions are as per table below. The Forum’s views on the

said deductions and the amount being additionally allowed by the Forum are also

shown in the table.

(3) The pre hospitalization and post hospitalization charges deductions are in order as the

bills are dated beyond the pre and post limits.

Deductions by Insurer with reason Reason for payment under

award.

Amount

(Rs.)

1. Surgeon’s charges Rs.10800 disallowed

as per PPN package

Wrongly deducted by the

insurer

10800

2. Anesthesia Charges Rs. 16146 disallowed

as per PPN package


insurer

16146

3. (a) Admin Service Charges Rs.32924 not

payable

(b) OT Charges Rs.48620 not payable as

per PPN package

(c) Recovery Charges Rs.550.00 not payable

as per PPN package

(a) Not payable

(b) Wrongly deducted by the

insurer

(c) Wrongly deducted by the

insurer

48620

550

4. Surgical consumables (Implants) Rs.

94600 not payable as per PPN package


insurer – cost of implants is

payable

94600

5. Items listed as Not Payable under PPN

Package.

Expense (Claimed) Deducte

d

(Paid)

Misc.

Charges

400 400 0

Except Misc. charges all other

charges are payable

33837

Nebulisation 260 260 0

Pathology 710 710 0

Room Rent 10000 10000 0

Visiting

Consultation

6900 6900 0

Pharmacy 15967 15967 0

6. Charges beyond pre and post limit.

Total Amounting to Rs 16551.00

The Deduction is in order

because all the bills are dated

beyond the pre/post time limits.

0

Claimed 348103 Total Payable under award 204553

Deducted 254428

Paid 93675

AWARD


made by both the parties during the course of hearing the Respondent is hereby

directed to make an additional payment of Rs 204553/- to the complainant in full and

final settlement of his claim and in addition pay interest as provided under Rule

17(7) of the Insurance Ombudsman Rules, 2017.

21. The attention of the Complainant and the Insurer is hereby invited to

Rules 17(6) and 17(8) of the Insurance Ombudsman Rules, 2017 as follows.

C) 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 compliances of the same to the Ombudsman.

D) According to Rule 17(8) of the said Rules, the award of Insurance

Ombudsman shall be binding on the Insurers.

Dated at Ahmedabad on 5th Feb., 2019.

M. Vasantha Krishna Insurance Ombudsman


(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017) Ombudsman: M. Vasantha Krishna

Case of Mrs. Suhash V Lakhani V/s The New India Assurance Co. Ltd.

Complaint Ref. AHD-G-049-1718-0499 Award No. IO/AHD/A/GI/0061/2018-2019

1 Name & address of the Complainant Mr. Suhash V Lakhani,

C/O Rajesh Vastra Bhandar, Kedareswar Road,

Nr Alankar Super Market, Porbandar-360575

2 Policy No:

Type of Policy

Policy period

211303/34/15/28/00000051

New India Floater Mediclaim

20-Jan-16 TO 19-Jan-17



Mr. Suhash V Lakhani



5 Date of Partial Settlement Not known

6 Reason for partial settlement Waiting Period Clause of the policy

7 Date of receipt of complaint 15-May-17

8 Nature of complaint Partial settlement

9 Amount of claim INR 45000

10 Date of Consent 21/07/2017


12 Amount of relief sought INR 45000

13 Complaint registered under Rule No. Rule 13-(1)-(b) of the I. O. Rules 2017

14 Date of hearing/place 28/11/2018/Ahmedabad


For the Complainant

For the Insurer


Mr Nimesh Gaur,




The complainant was covered under New India Floater Mediclaim policy issued by

The New India Assurance Co. Ltd. He was hospitalized for the treatment of Knee

replacementon12-01-2017 and was discharged on 15-01-2017. His claim for

INR390749/- was settled for INR150000/-.Unsatisfied with the decision of the

respondent, the complainant has approached the Forum for redressal of his

grievance and payment of an additional amount of INR 45000/- towards cumulative

bonus (CB) for which he is eligible.

19 Arguments:

C. Complainant’s argument:

The complainant submitted that he had New India Floater Mediclaim policy issued

by The New India Assurance Co. Ltd. The sum insured under the impugned policy

was INR150000/- In the years 2013 and 2014. It was increased to INR 200000/= in

2015. His claim for INR 390749/- was approved for only INR 150000/- giving the

reason that the enhanced sum assured is not available for the claim as per condition

4.3.2 of the policy. As per the applicable condition, unless the Insured Person has

continuous Coverage in excess of 48 months with the company, the expenses related

to the treatment Joint Replacement due to Degenerative Condition and Age-related

Osteoarthritis and Osteoporosis are not payable. Thus the company has approved

the payment of INR 150000/= by way of cashless approval against the hospital bill of

INR 390000/= approximately. The complainant claims that he is entitled to a further

payment of INR 45000/- on account of CB earned under the policy. He has requested

the Forum to help him in getting the said amount released by the insurer as his claim

is genuine.

D. Respondent’s arguments:

The insurance company stated that they had settled the complainant’s claim as per

condition 4.3.2 of the policy. As per the said condition-“Unless the Insured Person has

continuous Coverage in excess of 48 months with the company, the expenses related

to the treatment Joint Replacement due to Degenerative Condition and Age-related

Osteoarthritis and Osteoporosis are not payable.”

Hence the additional sum insured of INR 1,50,000 due to increase in sum insured to

INR 2,50,000 in 2015 was not available for the payment of subject claim, since the

period of 48 months had not been completed since sum insured was increased

complainant’s claim of INR 3,90,749/- was therefore settled for INR 150000/=being

the sum insured under the policy prior to the said increase.

20. Result of personal hearing with both parties (Observations& Conclusion):

Based on the submission of parties as above and the material made available to this

Forum, the following points emerged which were pertinent to decide the case.

(1) The insured was covered under Individual Mediclaim Policy in year 2013-14 and

2014-15 with sum insured of INR 150000/= with CB of INR 45000/= during both

the years.

(2) The complainant migrated from Individual to Family Floater Policy at the time of

renewal in the year 2015-16 with sum insured of INR 200000/= with no CB.

(3) As per the applicable condition 4.3.2, unless the Insured Person has continuous

Coverage in excess of 48 months with the company, the expenses related to the

treatment Joint Replacement due to Degenerative Condition and Age-related

Osteoarthritis and Osteoporosis are not payable.

(4) Hence the claim was settled forINR150000/= as per the sum insured of the year

2013-14 and the CB was not available after the conversion of the policy to Family

Floater.

(5) The Forum is of the opinion that in case the claim is settled on the basis of sum

insured of an earlier policy, it is equitable that the CB earned thereunder should

also be considered for settlement of the claim.

In view of foregoing, the complaint is admitted.

AWARD


made by both the parties during the course of hearing the Respondent is hereby

directed to make an additional payment of Rs: 45000/- to the complainant in full and

final settlement of the claim and in addition pay interest as per Rule 17(7) of the

Insurance Ombudsman rules, 2017.

21. The attention of the Complainant and the Insurer is hereby invited to the

Rules 17(6) and 17(8) of the Insurance Ombudsman Rules,2017 as follows.

E) 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 compliances of the same to the Ombudsman.

F) According to Rule 17(8) of the said Rules, the award of Insurance

Ombudsman shall be binding on the Insurers.




(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017) OMBUDSMAN: M.VASANTHA KRISHNA

Case of:-Mrs. Damyantiben K. Patel V/S The New India Assurance Co. Ltd. Complaint No.: AHD-G-049-1718-0506


1 Name of the Complainant Mrs. Damyantiben K. Patel

B-9/10, Patel kunj, Umapark Society,

B/d. Umabhavan, Old National Highway No.8,

Ankleshwar-393002

2 Policy No:

Type of Policy


Sum Assured

22060034152500000160

New Mediclaim 2012

06.01.2016 to 05.01.2017

Rs:5,00,000/-



Mrs. Damyantiben K. Patel

Mrs. Damyantiben K. Patel



6 Reason of Repudiation Not applicable


8 Nature of complaint Partial settlement of claim

9 Amount of claim Rs.5,22,969/-

10 Amount Settled Rs.1,48,750/-

11 Amount of relief sought Rs.3,74,219/-




For the Complainant

For the Insurer

Mr. Nishant K. Patel (Son)

Mr. Minesh M. Varma




The Complainant was admitted in Lilavati Hospital, Mumbai on 09.07.2016 for surgery of L4-

L5 stenosis and she was discharged on 17.07.2016. She had submitted a claim of

Rs.5,22,969/- for her treatment, but the Insurance Company had settled the same for

Rs.1,48,750/- citing terms and conditions of the policy. Aggrieved by the decision of the

Insurance Company the Complainant has approached the Forum to resolve her grievance

and order payment of the remaining amount of Rs.3,74,219/-.


The Complainant’s son Mr. Nishant Patel attended the hearing &stated that his mother’s

claim was partially settled for Rs.1,48,750/- after deductions of Rs.3,74,219/- citing terms

and conditions of the policy. He added that Sum Insured was Rs.5,00,000/- and cumulative

bonus(CB) was Rs:52500/- whereas the claim was settled for only Rs.1,48,750/- on

29.03.2017. He informed the Forum that his mother had also made an appeal to the

Regional Office of the Insurance Company, but did not receive any reply. She has urged

upon the Forum to resolve her grievance and direct the insurance company to pay the

remaining amount of Rs.3,74,219/-.


The representative of the respondent stated that for the policy period 2012-13 the sum

insured was Rs.1,25,000/-, the applicable CB was Rs.23,750/-, aggregating to Rs:1,48,750/-

.The sum insured was subsequently enhanced to Rs.5,00,000/- for the policy period 2013-

14. Hence the claim had been paid as per sum insured and CB of policy year 2012-13as per

clause3.1. The Insurer also submitted to the Forum post hearing that the insured had taken

policy in Zone II but the treatment was taken in Zone I and therefore the claim would be paid

only up to 80% of the admissible amount.


The Respondent had approved the claim of the complainant on the basis of policy sum

insured and CB the year 2012-13, citing clause 3.1 of the policy. However, there is nothing

in the said clause to suggest that the current sum insured will not apply to the settlement of

the claim.

It is observed that the complainant had taken treatment for surgery of L4-L5 stenosis (Spinal

Disease) for which there is a waiting period of 24 months as per clause 4.3.1 of the policy.

Similarly, the waiting period for pre-existing diseases is 48 months as per clause 4.1.In the

present case, the complainant held the policy since 2003 and hence the waiting period as

per clause 4.3.1 is not applicable. The disease for which treatment was taken was also not

a pre-existing disease. Hence the waiting period as per clause 4.1 is also not applicable.

The sum insured was enhanced to Rs. 500000 during the policy period 2013-14 and the

treatment was taken in the policy period 2016-17, after more than two years. Therefore, the

waiting period as per clause 5.11 applicable for enhancement of sum insured, does not

impact the subject claim in view of the enhancement having been effected in the year 2013-

14.

The Forum is of the view that the complainant is entitled to indemnity based on the current

sum insured of Rs.500000/- and the CB of Rs.52500/- aggregating to Rs.552500/-.

The respondent had also submitted that the Insured had taken policy from Ahmedabad

under Zone II category but treatment was taken at Mumbai under Zone I. The Insured had

taken treatment in higher zone so, policy Clause No. 3.3 also applied for the claim

settlement. As per clause no. 3.3 the complainant is eligible for 80% of the admissible claim

amount.

In view of the above facts the Complaint is admitted.

AWARD


made by both the parties during the course of personal hearing, the Respondent is

hereby directed to settle the claim of the complainant of Rs. 5,22,969 on the basis of

sum insured of Rs. 5,00,000 and CB of Rs. 52,500 subject to the terms and conditions

of the policy and pay the balance amount. In addition, interest is payable as per Rule

17(7) of the Insurance Ombudsman Rules, 2017.

21. The Insurance Ombudsman Rules, 2017 :

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 (8) of the said Rules, the award of Insurance Ombudsman shall

be binding on the insurers.







Case of:-Mayurkumar R Patel v/s The New India Assurance Co. Ltd.

Complaint Ref. No. : AHD-G-049-1718-0333 Award No. IO/AHD/A/GI/0063/2018-2019

1 Name & Address of

the Complainant

Mr. Mayurkumar Rameshbhai Patel,

23-Bharti Raw House-1,

Link Road, Bharuch.

2 Policy No:

Type of Policy


Sum Insured

22210034162800000038

New India Floater Mediclaim Policy

17.05.2016 to 16.05.2017

Rs:200000/-



Mr. Mayurkumar R Patel

Mr. Mayurkumar R Patel


5 Date of Repudiation 17.06.2017

6 Reason of repudiation Clause 4.3.2 Waiting period

(Enhancement of Sum Insured)



9 Amount of claim Rs. 230875/-

10 Date of partial settlement 17.06.2017

11 Amount of relief sought Rs.125000/-

12 Date of Consent/SCN 09/06/2017/ 23.06.2017

13 Complaint registered under Rule No. 13(1) (b) of IO Rules, 2017.

14 Date of hearing/place 28.11.2018 at Ahmedabad


For the Complainant

For the Insurer

Mr.Mayurkumar R. Patel

Mrs. Anjula N. Barupal

16 Complainant how disposed Award

17 Date of Award 05/02/2019


The Complainant along with his family was insured under New India Floater Mediclaim

Policy issued by the respondent insurer for Sum Insured (SI) of Rs.2,00,000/-. The

complainant had enhanced the Sum Insured from Rs100000/- to Rs 200000/- on

17.05.2013. He was admitted to Welcare Hospital, Vadodara from 26.06.2016 to 30.06.2016

for right hip total replacement surgery. On discharge from the hospital the Complainant had

filed claim for Rs. 230875/-. The respondent had settled the same for Rs.100000/- as per

clause No. 4.3.2 of the policy - Enhancement of Sum Insured. As per the said clause, a

waiting period of 48 months is applicable for any enhancement of sum insured to be

considered for treatment of Osteoporosis and joint replacement due to degenerative

condition.

19. Arguments during the hearing:


The Complainant submitted that he and his family had the Mediclaim policy since the

year 2011. At the time of Policy renewal on 17/05/2013 the Sum Insured was

enhanced from Rs. 100000/- to Rs: 200000/-. However the Respondent had paid his

claim deducting huge amount and treating the S.I. as Rs.100000. He requested the

Forum to order full settlement of the claim.

B. Insurer’s argument:

The representative of the Respondent stated that the Insured had enhanced the Sum

Insured to Rs: 200000/- during the year 2013-2014 and the claim had arisen during

the policy period 2016-17. As per clause No. 4.3.2 of the policy, the reimbursement

for treatment of Osteoporosis was restricted to Sum Insured which was available

before 48 months. Accordingly, Sum Insured of Rs: 100000/- was considered for the

settlement of the claim.

20. Result of hearing with both parties(Observations & Conclusion):

A. The Complainant was covered under New India Floater Mediclaim policy for the

period 17.05.2012 to 16.05.2013 for a sum insured of Rs. 100000 and Sum

Insured was enhanced to Rs. 200000/- on 17.05.2013.

B. The Complainant was treated for osteoarthritis in Right Hip as per Discharge

summary of Welcare Hospital. The treatment was during the 4th policy period

after enhancement of Sum Insured from Rs. 100000 to Rs. 200000.

C. As per note to clause 4.3.2: Unless the Insured Person has continuous coverage

in excess of forty eight months with us, the expenses related to treatment of

(i) Joint replacement due to Degenerative condition, and

(ii) Age-related Osteoarthritis & Osteoporosis are not payable.

D. Before enhancement of sum insured, the sum insured was Rs: 100000. As per

clause 5.11 of the policy, additional sum insured on enhancement of Rs: 100000

shall have a waiting period of 4 years to be considered for treatment of

Osteoporosis. Hence the sum insured of Rs. 100000 being the Sum Insured prior

to enhancement was correctly applied by the respondent insurer in settlement of

the claim.

The compliant is therefore not admitted.

AWARD

In view of the foregoing the decision of the Respondent needs no intervention.

The complaint is not admitted.

21. In case the Award of this Forum is not acceptable to the Complainant, it is open for

him, if he so decides to move any other Forum/Court as he may consider appropriate

under the Laws of the Land against the Respondent Insurer.







Mr. Naresh D. Dantani V/s The New India Assurance Co. Ltd.

Complaint No. AHD-G-049-1718-0502 Award No. IO/AHD/A/GI/0064/2018-2019

1 Name & Address of the Complainant Mr. Naresh D. Dantani,

998, Kajmiya ni chali, Devi Pujak Vas,Opp:

Make well Engineering,Tavdipura, Sahibaug,

Ahmedabad – Gujarat – 380- 004

2 Policy No:

Type of Policy

Policy period

210400/34/16/25/00000390

New Mediclaim 2012 Policy

05/06/2016 To 04/06/2017



Mr. Nareshkumar Dharamdas Dantani

Mr. Nareshkumar Dharamdas Dantani

4 Name of the insurer The New India Assurance Co. Ltd

5 Period of Hospitalization 14/12/2016 to 15/12/2016

6 Reason for repudiation Claim rejected under Clause 4.3.1


8 Nature of complaint Non-settlement of claim

9 Amount of claim Rs. 37,742/-

10 Date of receipt of P.II/III 10/07/2016



13 Complaint registered under Rule No. 13 (1) (b) of The IO Rules, 2017


15 Representation at the hearing at

For the Complainant

For the Insurer

Mr. Naresh D. Dantani

Mr. Dharmin H. Zaveri




The Complainant was insured under New Mediclaim 2012 policy issued by The New India

Assurance Company Ltd. He was hospitalized in Maharshi Surgical Hospital on 14/12/2016

for the treatment of Left Uretic Stone and discharged on 15/12/2016. Since the

complainant’s claim for Rs.37,742/- was rejected under Clause No.4.3.1, he has moved the

Forum for justice.

19. Hearing of the complaint:


The Complainant stated that the Respondent had rejected his claim citing Policy condition

No. 4.3.1. He was not satisfied with the decision of the respondent company to repudiate his

claim. The complainant prayed that his claim should be paid in full.

B. Insurer’s argument:

The representative of the Respondent stated that the complainant had policy since

05/06/2015. He (the complainant) was admitted with complaint of pain in renal area and

diagnosed as left lower uretic stone and operated upon. The surgery was done in the 2nd

year of the policy. So the claim fell under 2 year exclusion clause and was correctly

repudiated under policy condition No. 4.3.1 which reads as:

“Unless the Insured Person has Continuous Coverage in excess of twenty four

months with Us, expenses on treatment of the following illness are not payable –

4.3.1(7) – Stones in Urinary system”.

20. Result of hearing with both parties (Observations & Conclusion):

The point to be considered was whether the insurer was correct in rejecting the claim of the

insured citing policy clause no. 4.3.1.

Based on the submission of parties as above and the material made available to this Forum,

the following points emerged which were pertinent to decide the case:-

1. The Complainant was admitted in Maharshi Surgical Hospital, Ahmedabad for the

period from 14.12.16 to 15.12.16. He was operated for Lt. Ureteric Calculus. The

Complainant had lodged a claim for Rs 37,742/- The respondent had repudiated the

claim.

2. The Respondent had provided the Terms and Conditions of the policy. The policy was

in the 2nd year at the time of the claim/treatment. As per clause No. 4.3.1 of policy, a

waiting period of 2 years was applicable for the said ailment and procedure.

3. The subject Lt. Ureteric Calculus surgery took place within 2 year of the

Commencement of the policy.

4. The Respondent had correctly repudiated the claim.

5. The complainant submitted during the hearing that the policies issued to him did not

have the terms and conditions attached to them and should not be applied to deny his

claim. It is observed that the policy contained a clause that it is subject to the terms and

conditions of New Mediclaim 2012. Even assuming that the terms and conditions were

not attached as alleged by the complainant, nothing prevented him from obtaining the

missing terms and conditions from the insurer. Hence the Forum does not accept his

argument.

6. In view of the foregoing the complaint is not admitted.

AWARD


made by Complainant during the course of hearing the decision of the Respondent

needed no intervention. The complaint is therefore not admitted

21. In case the Order of this Forum is not acceptable to the Complainant, he can move any

appropriate Forum/Court of Law against the Respondent Insurer as he deems fit.


M. Vasantha Krishna

Insurance Ombudsman





Case of:-Mr. Kartik A Shah V/s The New India Assurance Co. Ltd.

Complaint Ref No. : AHD-G-049-1718-0478


1

Name & Address of the

Complainant

Mr. Kartik Ashokbhai Shah

D-2/Kundan Apart, Part-2

Vasna, Ahmedabad

2

Policy No:

Type of Policy

Effective from

Sum Insured

210200/34/15/01/00012253

Mediclaim policy 2007

01/03/2016 to 28/02/2017

Rs.2,00,000/- + Rs.25,000/- (C.B.)



Mrs. Tejal

Mr. Kartik A. Shah


5 Hospitalization period 09/09/2016 to 16/09/2016

6 Reason of partial settlement Under Clause 2.1 of the policy




10 Amount Settled Rs.1,10,051/-


12 Date of receipt of VI-A / SCN 28/11/2018 / 24/08/2017

13 Complaint registered under Rule No. Section 13 (1) (b) of I.O. Rules,2017

14 Date of hearing/place 28/11/2018 / Ahmedabad

15

Representation at the hearing:

For the Complainant

For the Insurer

Mr. Kartik A Shah

Miss Shikha Kashyap




The Complainant’s wife Mrs. Tejal, aged 42 years was diagnosed with congenital

heart disease. She underwent Arterial Septal Defect closure in Apex Heart

Institute, Ahmedabad during the period from09/09/2016 to 16/09/2016. The

Complainant had incurred an expense of Rs.2,10,752/- for the treatment and

preferred a claim under the policy held by him with the respondent insurer. The

respondent settled the claim for Rs.1,10,051/-and disallowed the balance claim

amount of Rs.1,00,701/- citing that the claimant had opted for higher room rent than

eligible and hence proportionate deductions were made as per policy Terms &

Conditions.

19. Cause of Complaint:

Complainant’s argument:

The Complainant submitted that his claim was partially settled without considering

actual facts and figures. He and his family were insured since 17 years without any

claim. His wife was admitted for 4 days in ICCU from 10/09/2016 to 13/09/2016

and for remaining days in a regular room. However the insurance company had

considered only 2 days stay in ICCU and settled his claim on proportionate base,

which was not correct. He had submitted room- wise and date- wise breakup as

well as the package break-up for the procedure ASD/VSD/TOF. His claim was for

Rs.2,10,752/- which was partially settled by Rs.1,10,051/- with a wrong deduction

Rs.1,00,701/-

He had made an appeal to grievance department of the insurer on 26/04/2017 but

still has not received any reply from them. He has requested the Forum to get the

balance amount of claim paid by the insurer.

Insurer’s argument:

The Respondent’s representative submitted that the claimant was eligible for room

rent of Rs.2000/- per day (Rs.4000/- for ICU) as the sum insured was Rs.2,00,000/-.

Insured had availed higher room category of Rs.5500/- per day instead of eligible

Rs.2000/- per day and ICU charges of Rs.6000/- per day instead of Rs.4000/- per

day. Hence, insured was liable for proportionate deductions for other expenses as

per clause 2.1 of the policy Terms & Conditions.

20. Result of hearing with both parties(Observations& Conclusion):

Clause 2.1 of the policy reads as under:

“Our liability for all claims admitted during the period of insurance will be only up to

Sum Insured for which the Insured Person is covered as mentioned in the

Schedule. In respect of those insured persons with cumulative bonus buffer, our

liability for claims admitted under this policy shall not exceed the aggregate of the

sum insured and the cumulative bonus buffer. Subject to this, we will reimburse the

following Reasonable, Customary and Necessary Expenses Admissible as per the

terms and conditions of the policy:

Room, boarding and nursing expenses as provided by the hospital not exceeding

1.00% of the sum insured per day.

Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) expenses not

exceeding 2.00% of the Sum Insured per day.

Reimbursement/payment of Room, boarding and nursing expenses incurred at the

Hospital shall not exceed 1% of the sum insured per day. In case of admission to

intensive care unit or intensive cardiac care unit, reimbursement or payment of such

expenses shall not exceed 2% of the sum insured per day. In case of admission to

a room/ICU/ICCU at rates exceeding the aforesaid limits, the

reimbursement/payment of all other expenses incurred at the hospital, with the

exception of cost of medicines, shall be affected in the same proportion as the

admissible rate per day bears to the actual rate per day of room rent/ICU/ICCU

charges.”

1. The Respondent had submitted an investigation report dated 17/07/2017 of Dr.

S.J. Dumra who had scrutinized the claim file as also visited the hospital and

gave his opinion that the deduction was in order as per policy terms and

conditions.

2. The respondent had also submitted a certificate dated 25/07/2017 of Apex

hospital wherein it was stated the CTOT (Clinical Trials in Organ

Transplantation) charges were same for all categories and it was not connected

with room charge.

3. The complainant had incurred an expense of Rs.2,10,752/-. The surgery was

done under a package of Rs.1,85,000/- (which includes Room charges, OT,

Pathology/Investigation, CTOT charges, Surgeon and Physiotherapist charges).

A break-up was demanded by the respondent which was submitted by the

complainant.

4. As mentioned by the complainant in his representation, he received a discount

of Rs. 5,000 in the room rent/ICU charges with the result that the package cost

came down to Rs. 1,80,000 and the total expenditure to Rs. 2,05,752. Because

of the discount received, per day charges for Room and ICU were reduced to

Rs. 5,500 and Rs. 6,000 respectively against the eligible tariff of Rs. 2,000 and

Rs. 4,000.

5. Deductions made by the Respondent towards non-payable items were found to

be in order and there is no scope to interfere with the same. Reducing other

charges in proportion of the eligible rent/ICU charges to the actual (6000/11500)

as provided in the policy, the amount payable worked out to Rs. 1,09,801. Since

the Respondent has already paid an amount of Rs. 1,10,051, they have no

further liability.

6. In view of the above, the complaint is not admitted.

AWARD

Taking into account the facts & circumstances of the case and the

submissions made by both the parties during the course of hearing the

decision of the Respondent needed no intervention. The complaint is not

admitted.

21. If the award is not acceptable to the complainant, he may approach appropriate

court / forum for redressal of his grievance against the insurer, as he thinks fit.





Case of:-Mr. Gaurav H ChhayaV/s Star Health & Allied Insurance Co. Ltd. Complaint Ref No. : AHD-G-044-1718-0482


1 Name & Address of the

Complainant

Mr. Gaurav H Chhaya,

A-303- Satyam Flats,

Opp: Kirtisagar Flats,

Jodhpur, Ahmedabad-380015

2

Policy No:

Type of Policy

Effective from

Sum Insured

P/171214/01/2016/000819

Mediclassic Insurance Policy

13/06/2015 to 12/06/2016

Rs.2,00,000/- + CB Rs.50,000/-



Ms. Madhavi (Mother)

Mr. Gaurav H Chhaya

4 Name of the insurer Star Health & Allied Insurance Co.Ltd.

5 Period of Hospitalization 19/03/2016

6 Reason for Partial Settlement As per Clause 1.0 of the policy


8 Nature of complaint Non-payment of claim


10 Amount Paid NIL




14 Date of hearing/place 26/11/2018 /Ahmedabad

15


For the Complainant

For the Insurer

Mr. Gaurav H. Chhaya

Mr. Bhavya Shah




The Complainant’s mother Ms. Madhaviben, aged 65 years was insured under Mediclassic

Insurance Policy issued by Star Health & Allied Insurance Company Ltd. She was

hospitalized at Naresh Hospital, Ahmedabad on 19/03/2016 for the surgery of right eye

cataract. Entire Claim of Rs.29,939/- was repudiated by the respondenton the ground that

maximum payable amount for cataract surgery in the policy period was Rs.12,000/- which

was already paid under claim number 358779, in respect of his mother’s left eye cataract

surgery on 09/03/2016.. Dissatisfied with the decision of the respondent, the Insured has

approached the Forum for redressal of his grievance and settlement of the claim.



The complainant stated that he and his family were the holders of the Policy since last 08

years without any claim. His mother had vision problem in right eye and cataract surgery

was performed on 19/03/2016. After the surgery, when he preferred the claim for

Rs.29,939/-, the respondent had rejected the claim on the ground that the maximum amount

of Rs.12,000/- payable per person per policy year for the treatment expenses towards

cataract (for sum insured up to Rs.2 lac) was already paid under claim number 358779 in

respect of left eye cataract surgery of his mother on 09.3.2016..

He added that in the year 2008, the premium for two persons was Rs.10,600/- and in the

year 2016 he had paid Rs.28,010/- as premium for the same two persons. Star health had

increased the premium every year (even though there were no claims at all) but reduced the

cover limit for various ailments without getting specific acceptance of such reduction of limits

from the policyholder at the time of renewal of the policy. Star health had been unfair to

policyholders, especially senior citizens. He requested the Forum to intervene and get his

claim settled.

B. Respondent’s argument:

The representative of the respondent submitted that one claim for cataract surgery of the left

eye performed on 09/03/2016 was already settled on 28/03/2016 as per policy clause 1.0 for

the maximum permissible amount of Rs. 12,000. As per said clause , the company was

liable to pay only Rs.12,000/- per person per policy period for the treatment expenses

towards cataract for sum insured up to Rs.2,00,000/-. Since the present claim was in the

same policy period, noting was payable towards the same. In reply to a question whether

they had provided the terms and conditions to the insured he replied that he did not know.

20. Result of hearing with both parties (Observation & Conclusion):

Based on the submissions made by both the parties and the documents submitted, the

Forum observes as below.

1. The limit of Rs.12,000/- for cataract surgery was clearly mentioned in the policy terms

and conditions and there is no ambiguity about the same.

2. The complainant pointed out that the policy had a no claim bonus (cumulative bonus) of

Rs.50,000 and argued that if the claim exceeded the policy limit, the excess amount

should have been disbursed out of the bonus, which was not done in his case.

However, the Forum is of the opinion that the cumulative bonus can be utilised only

when the sum insured under the policy is not adequate to meet the claim. Moreover,

the manner in which indemnity for cataract surgery has been limited in the policy

precludes utilisation of cumulative bonus as demanded by the complainant. Having

expressed this view, the Forum would also point out that the policy is silent about how

cumulative bonus will be used in settlement of the claim and the insurer is advised to

make an explicit provision in this regard.

3. The complainant also stated that nowhere in Ahmedabad, which is a metro city, one can

get cataract surgery done at the low limit fixed by the insurer. While this is true, it

cannot be a basis for overlooking the specific capping of indemnity for cataract surgery

in the policy.

4. The complainant was continuously insured with the respondent since the year 2008 and

the first policy incepted on 13.06.2018. His main argument is that the respondent

insurer had unilaterally changed the policy limits for various ailments without notice and

without taking the consent of the policyholders. The Forum has looked in to this aspect

and has examined the policy wording for this product over the years. It is observed that

the policy version in 2008 had limited cataract surgery to Rs. 20,000 per eye and Rs.

30,000 in entire policy period and these limits applied irrespective of the sum insured

under the policy. It appears that the policy wording was revised in the year 2013 when

the current limits for cataract surgery linked to the sum insured have been incorporated.

On enquiry with the Head Office of the insurer, it was confirmed by them that

policyholders are notified whenever the product undergoes revision, as stipulated in the

product filing guidelines of the Regulator. However, they were unable to confirm that in

this specific case the customer was notified of the changes. In the absence of such

confirmation, it would be fair to allow the benefit of the pre-revision limits of cataract

surgery to the complainant. Since the applicable annual limit prior to revision was Rs.

30,000 for cataract surgery, and an amount of Rs. 20,000 is already exhausted by

means of the award given by this Forum in complaint no. AHD-G-044-1718-0483, the

insurer should pay an additional amount of Rs. 10,000 in settlement of the present

claim.

5. The complaint is therefore admitted.

AWARD


made by both the parties during the course of hearing, the Forum directs the

respondent insurer to pay an amount of Rs. 10,000 to the complainant in full and

final settlement of the claim. In addition, interest as per rule 17(7) of the

Insurance Ombudsman Rules, 2017 is also payable. The complaint is therefore

partially admitted.

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

provisions of the Insurance Ombudsman Rules, 2017:

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(8) of the Insurance Ombudsman Rules, 2017, the

award of Insurance Ombudsman shall be binding on the Insurers.





Case of:-Mr. Gaurav H ChhayaV/s Star Health & Allied Insurance Co. Ltd. Complaint Ref No. : AHD-G-044-1718-0483



Complainant

Mr. Gaurav H Chhaya,

A-303- Satyam Flats,

Opp: Kirtisagar Flats,

Jodhpur, Ahmedabad-380015

2

Policy No:

Type of Policy

Effective from

Sum Insured

P/171214/01/2016/000819

Mediclassic Insurance Policy

13/06/2015 to 12/06/2016

Rs.2,00,000/- + CB Rs.50,000/-



Ms. Madhavi (Mother)


4 Name of the insurer Star Health & Allied Insurance Co.Ltd.

5 Period of Hospitalization 09/03/2016

6 Reason of Partial Settlement As per Clause 1.0 of the policy




10 Amount Paid Rs.12,000/-





15


For the Complainant

For the Insurer


Mr. Bhavya Shah




The Complainant’s mother Ms. Madhaviben, aged 65 years was insured under Mediclassic

Insurance Policy issued by Star Health & Allied Insurance Company Ltd. She was

hospitalized at Naresh Hospital, Ahmedabad; on 09/03/2016 for surgery of Left eye Cataract.

Against the claim of Rs.29,744/-, the respondent settled Rs.12,000/- and disallowed

Rs.17,744/- citing policy clause 1.0. Dissatisfied with the decision of the respondent, the

complainant has approached the Forum for redressal of his grievance and settlement of the

balance amount of claim for Rs.17,744/-.


C. Complainant’s argument:

The complainant stated that he and his family were the holders of the Policyfor last 8 years

without any claim. His mother had some problem in left eye and cataract surgery was

performed on 09/03/2016. After the surgery, when he preferred the claim for Rs.29,744/-,

the respondent had settled only Rs.12,000/- and deducted Rs.17,744/- stating that a

maximum Rs.12,000/- is payable per person per policy year for the treatment expenses

towards cataract for sum insured up to Rs.2 lac.

He added that in the year 2008, the premium for two persons was Rs.10,600/- and in the

year 2016 he had paid Rs.28,010/- as premium for the same two persons. Star health had

increased the premium every year (even though there were no claims at all) but reduced the

cover limit for various ailments without getting specific acceptance of such reduction of limits

from the policyholder at the time of renewal of the policy. Star health had been unfair to

policyholders, especially senior citizens. He requested the Forum to intervene and get his

balance amount of claim paid.

D. Respondent’s argument:

The representative of the respondent stated that the claim was settled forRs. 12,000/- as per

policy clause 1.0. As per said clause , the Company was liable to pay only Rs.12,000/- per

person per policy period for the treatment expenses towards cataract for sum insured up to

Rs.2,00,000/-. In reply to a questionby the Forum whether they had provided the terms and

conditions to the insured, the representative of the insurer replied that he does not know.

20. Result of hearing with both parties(Observations& Conclusion):

Based on the submissions made by both the parties and the documents submitted, the

Forum observes as below.

6. The limit of Rs.12,000/- for cataract surgery was clearly mentioned in the policy terms

and conditions and there is no ambiguity about the same.

7. The complainant pointed out that the policy had a no claim bonus (cumulative bonus) of

Rs.50,000 and argued that if the claim exceeded the policy limit, the excess amount

should have been disbursed out of the bonus, which was not done in his case.

However, the Forum is of the opinion that the cumulative bonus can be utilised only

when the sum insured under the policy is not adequate to meet the claim. Moreover,

the manner in which indemnity for cataract surgery has been limited in the policy

precludes utilisation of cumulative bonus as demanded by the complainant. Having

expressed this view, the Forum would also point out that the policy is silent about how

cumulative bonus will be used in settlement of the claim and the insurer is advised to

make an explicit provision in this regard.

8. The complainant also stated that nowhere in Ahmedabad, which is a metro city, one can

get cataract surgery done at the low limit fixed by the insurer. While this is true, it

cannot be a basis for overlooking the specific capping of indemnity for cataract surgery

in the policy.

9. The complainant was continuously insured with the respondent since the year 2008 and

the first policy incepted on 13.06.2018. His main argument is that the respondent

insurer had unilaterally changed the policy limits for various ailments without notice and

without taking the consent of the policyholders. The Forum has looked in to this aspect

and has examined the policy wording for this product over the years. It is observed that

the policy version in 2008 had limited cataract surgery to Rs. 20,000 per eye and Rs.

30,000 in entire policy period and these limits applied irrespective of the sum insured

under the policy. It appears that the policy wording was revised in the year 2013 when

the current limits for cataract surgery linked to the sum insured have been incorporated.

On enquiry with the Head Office of the insurer, it was confirmed by them that

policyholders are notified whenever the product undergoes revision, as stipulated in the

product filing guidelines of the Regulator. However, they were unable to confirm that in

this specific case the customer was notified of the changes. In the absence of such

confirmation, it would be fair to allow the benefit of the pre-revision limits of cataract

surgery to the complainant. Since the applicable limit prior to revision was Rs. 20,000

per eye, the insurer should pay an additional amount of Rs. 8,000 in settlement of the

claim.

10. The complaint is therefore admitted.

AWARD


made by both the parties during the course of hearing, the Forum directs the

respondent insurer to pay an additional amount of Rs. 8,000 to the complainant in

full and final settlement of the claim. In addition, interest as per rule 17(7) of the

Insurance Ombudsman Rules, 2017 is also payable. The complaint is therefore

partially admitted.

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


C) 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.

D) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the

award of Insurance Ombudsman shall be binding on the Insurers.


M. Vasantha Krishna

Insurance Ombudsman



(Under Rule No: 16/17 of the Insurance Ombudsman Rules, 2017) Case of:-Mr. Khatumbara M. Ilyas V/S The New India Assurance Co. Ltd.

Ombudsman: M. Vasantha Krishna Complaint No.: AHD-G-049-1718-0312


1 Name of the Complainant Mr. Khatumbara M. Ilyas

205, Arshad Residency,Opp. Ambar

Tower,100 ft. Ring Road,

Ahmedabad-380055

2 Policy No:

Type of Policy


21040034150100008053

Mediclaim Policy 2007

22.03.2017 to 21.03.2018



Mr. Arsh M. Ilyas

Mr. Khatumbara M. Ilyas



6 Reason of Repudiation As per terms and conditions of the policy


8 Nature of complaint Partial Repudiation of claim.


10 Amount Settled Rs.44,984/-





For the Complainant

For the Insurer

Mr Khatumbara N. Ilyas

Mr Dharmin H. Zaveri,




The Complainant’s son Mr. Arsh was admitted at Adwait ENT Hospital on 06.01.2017 and

discharged on 07.01.2017. He was diagnosed and treated for Adenoid hypertrophy +

tonsillitis. After discharge he submitted a claim for Rs.63,884/- which was settled for

Rs.44,984/-after deduction of Rs.18,900/- towards non payable items. Aggrieved by the

decision of the Company the Complainant has approached the Forum to redress his

grievance for settlement of his claim for balance amount of Rs.18,900/-.


The Complainant had stated that the Insurance Company had wrongly deducted Rs.18,900/-

from the claim for treatment of his son Mr. Arsh. He had submitted a letter dated 17.03.2017

from the Adwait Hospital confirming that the coblater the cost of which was disallowed, is not

an instrument but is a disposable blade used for every surgery(tonsillectomy and adenoid)

requiring coblation. It is just like disposable syringe & needle. The Complainant had urged

that after clarification from the hospital, the deduction by the Company was not justified and

therefore the remaining amount of claim of Rs.18,900/- should be paid to him.


The representative of the Respondent stated that the treating hospital’s doctor had given

clarification vide his letter dated 17.03.2017 that the coblater was not an instrument but a

disposable blade, which is used for every surgery. Any disposable comes under the category

of non-medical item under Sr. No. 78 of Annexure I – List of Expenses Excluded (Non-

medical), it was not payable as it was part of OT and surgeon charges, hence not paid

separately. He added that the claim was settled as per terms and conditions of the policy.


The point to be considered in this case was whether the deduction made by the Respondent

was as per the terms and conditions of the policy.

4. The Respondent had deducted Rs.18,900/- towards the coblater charges which

according to them was not reimbursable as per the list Non-Medical items as per

Annexure I of expenses excluded (Non-medical), Sr. No. 78- Surgical Blades.

This item is part of a list of items of hospital services where separate

consumables are not payable but the service is.

5. As per the treating Hospital letter dated 17.03.2017, coblater is not an instrument, but

a disposable blade used for every surgery.

6. Since the treating doctor had confirmed that the Coblater was used under every

surgery, the cost of coblater which is of one time use should be considered as

service and paid as part of OT charges.

AWARD


made by both the parties, the insurer is directed by the Forum to pay an amount

of Rs. 18,900 to the complainant towards the cost of the coblater which was

earlier disallowed. In addition, interest as per rule 17(7) of the Insurance

Ombudsman Rules, 2017 also becomes payable.

22 The attention of the Complainant and the Insurer is hereby invited to

Rules 17(6) and 17(8) of the Insurance Ombudsman Rules, 2017 as

follows.

G) 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


H) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall

be binding on the Insurers.


M. Vasantha Krishna

Insurance Ombudsman

OFFICE OF INSURANCE OMBUDSMAN

MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVI-MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI MILIND KHARAT

CASE OF COMPLAINANT - Ms. Sandra Pereira

V/s.

RESPONDENT : The New India Assurance Co Ltd – Chennai

COMPLAINT REF: No: MUM-G-049-1819- 0007

AWARD No: IO/MUM /A/GI/ /2018-19


Complainant

Ms. SANDRA PEREIRA

Mumbai - 400 101

2 Policy No:

Type of Policy

Duration of Policy/Period

Sum Insured

712500/34/16/21/00000026

GOOD HEALTH MEDICLAIM

01/02/2017 to 31/01/2018

Rs.5,00,000/- + 25% C.B. on Rs.5 lakh

3 Name of Insured


Ms. SANDRA PEREIRA

--do--

4 Name of Insurer The New India Assurance Co Ltd.-Chennai

5 Date of Repudiation 13th May, 2017

6 Reason for Repudiation No active line of treatment.

7 Date of receipt of the complaint 28. 03. 2018

8 Nature of complaint Total Repudiation of Claim


10 Date of Partial Settlement --


12 Complaint registered under Indian

Ombudsman Rules 2017

13 (b)

13 Date of Hearing 25-10-2018 at 3:45 pm

14 Representation at the hearing:-

a) For the complainant NOT Present.

b) For the insurer DrKanak Lashkarkar

15 Complaint how disposed AWARD

16 Date of Award/Order 06.02.2019

Brief Facts of the Case :

Complainant submitted that she was diagnosed with Ca left breast in 2010 and admitted Fortis

Hospital for administration of Zolendronic Acid Injections and Oral Therapy for treatment of Ca left

breast with METS to Skeletal and Brain on various dates since 28.04.2017. She was denied 7 claims

on the grounds of less than 24 hours hospitalization.

Contentions of the Complainant :

The complainant was not present for the hearing, so her written submissions were taken on record.

She submitted that she was diagnosed with Ca left breast in 2010 and underwent lumpectomy

surgery followed by chemotherapy and radiation. She had recurrence in the same breast in 2012

and had mastectomy. Thereafter, in July 2016 she experienced pain in her right leg and started to

limp. An MRI and various tests later showed that the cancer had metastasized to the skeletal and

brain. She immediately started treatment which involved radiation to the brain and femur followed

by IV chemotherapy and Zolendronic Acid Injections, where all her claims were settled. However,

now that she is on an oral chemo protocol, her claims have been repudiated as she is not an

inpatient. She pointed that when she was an inpatient for the Zolendronic Acid Injection, on a

monthly basis, her claims were once again repudiated as it was not chemotherapy but supportive

treatment. She stated that she did not agree with the Insurance Co.’s reasons for repudiating her

claims since her mainstay of treating cancer is chemotherapy and now she has reached a stage

wherein her treatment requires daily oral chemo. She clarified that it is still chemotherapy and the

side effects are the same and the only difference is that she is not required to be an inpatient and

the injections are still part of the current treatment protocol. She reiterated that she is still suffering

from cancer and the only thing that has changed is the treatment protocol. She lamented that at

this point in her treatment when she needed the most support due to the advancement of the

disease; she is being caused great stress which does not help her health condition. Complainant

argued that when the claims for the same treatment were paid earlier, the reason cited by the

Respondent for denial of the subject claims under the policy with same terms and conditions, is not

acceptable. She requested for settlement of the claims.

Contentions of the Respondent:

It was contended on behalf of the Respondent that Ms. Sandra Pereira was a diagnosed case of Ca

Left Breast and underwent treatment with Inj. Zolendronic. The Respondent submitted that on

scrutiny of the OPD papers they observed that Inj Zolendronic Acid (Zomketa/Reclast/Aclasta) is an

IV injection and is used in cancer with metastasis in bones. The same is not a chemotherapy drug, as

it is an immune-modulatory drug and supportive treatment in cancer and the same cannot be

considered under daycare procedure in fact this can be admissible as per-post claim of

chemotherapy treatment. The administered drug is not pharmacologically a chemo drug and hence

will not attract waiver of hospitalization.

Forum’s Observations/Conclusion:

It is noted that Cancer is a multifactorial disease and is one of the leading causes of death

worldwide. The contributing factors include specific genetic background, chronic exposure

to various environmental stresses and improper diet. All these risk factors lead to the

accumulation of molecular changes or mutations in some important proteins in cells which

contributes to the initiation of carcinogenesis. Chemotherapy is an effective treatment against

cancer but undesirable chemotherapy reactions and the development of resistance to drugs

which results in multi-drug resistance are the major obstacles in cancer chemotherapy. So

alternative formulations in practice these days are liposomes, resistance modulation,

hormonal therapy, cytotoxic chemotherapy and gene therapy.

One of the most fundamental changes found in cancer cells is the presence of mutations in the

genes that are responsible for causing cell growth (oncogenes). The defective proteins

produced by these altered genes are prime candidates for targeted therapy. Targeted therapy

is one of the major modalities of medical treatment for cancer. As a form of molecular

medicine, targeted therapy blocks the growth of cancer cells by interfering with specific

targeted molecules needed for carcinogenesis and tumor growth, rather than by simply

interfering with all rapidly dividing cells (e.g. with traditional chemotherapy). Targeted

cancer therapies are expected to be more effective than older forms of treatments and less

harmful to normal cells.

Monoclonal antibodies (MABs) are a specific type of therapy made in a laboratory. They can

be used as targeted therapy to block an abnormal protein in a cancer cell. They can also be

used as an immunotherapy. MABs work by recognising and finding specific proteins on

cancer cells. Each MAB recognises one particular protein. So different MABs have to be

made to target different types of cancer. They work in different ways depending on the

protein they are targeting and some work in more than one way. Inj.Zoledronic acid is a

type of drug called a bisphosphonate used to treat

bone weakness or pain caused by myeloma or cancer that has spread to the bone

Treat high levels of calcium in the blood

Prevent breast cancer spreading to the bones.

It is used as a support medication to treat symptoms of cancer such as hypercalcemia (high blood

calcium levels) or to decrease complications (such as fractures or pain) produced by bone metastasis

(spread of cancer to the bone). It is administered as an infusion into the vein (intravenous, IV).

Myeloma or secondary bone cancer may cause the bones to lose calcium, making them weak and

painful. Zoledronic acid reduces the amount of calcium lost from the bones. This can help strengthen

the bones and reduce pain. It can also help to bring blood levels of calcium back to normal.

This Forum has received a number of complaints against non-settlement of claims for such

injections. It is noted that some Companies are paying claims for treatment by way of these

injections even when given in isolation while some other Companies who were also paying

such claims earlier, have now taken a stand that it is admissible only when given as a part of

chemotherapy/radiotherapy or as pre & post hospitalization expenses for related

hospitalization.

The basic ground for denial of these claims is that it is an OPD procedure and hence beyond

the scope of the policy.

On an examination of all the facts/documents produced before the Forum by the Complainant

and the Company, the Forum is of the view that :

As per information collected from various websites, both chemotherapy and targeted

therapy are two effective methods for cancer therapy. Chemotherapy is a type of

cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents) as

part of a standardized chemotherapy regimen. It may be given with a curative intent.

However while Chemotherapy can also kill the normal cells when eliminating the

cancer cells, the normal cells can survive the targeted therapy, when the growth of

cancer cells is limited.

The antibodies used in cancer therapy are engineered to specifically target certain

types of cancer cells. When such antibodies are copied over and over in a lab, the

result is a monoclonal antibody therapy, a treatment consisting of millions of identical

antibodies aimed at the same molecules on tumor cells. As researchers have found

more antigens linked to cancer, they have been able to make MABs against more and

more cancers. Thus, the treatment undergone by the patients seems to be one of

advancement of medical technology in as much as over the past couple of decades,

more than a dozen monoclonal antibodies have been approved by the Food and Drug

Administration to fight cancer, particularly breast, head and neck, lung, liver, bladder,

and melanoma skin cancers, as well as Hodgkin lymphoma.

Insurance Companies are denying the claims stating that this procedure does not

require hospitalization. At the same time it is also noted that it is not an ordinary

injection which can be taken on OPD basis but is given as an intravenous infusion in

a sterile environment by a specialist and requires monitoring of the patient’s

condition for some time thereafter.

The various certificates issued by the medical practitioners indicate that the treatment

is similar to chemotherapy which is paid for by the Companies as a day care

procedure.

It is pertinent to note that basically these injections are a part of cancer treatment.

Targeted therapy is generally preferred by doctors when the cancer does not

respond to other therapies, has spread or is inoperable. Treatment of cancer

patients with antibodies when used alone or in combination with chemotherapy and

radiotherapy, or conjugated to drugs or radioisotopes, prolongs overall survival in

cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced in

treating diseases and Insurers can bring about new products/modify existing products.

It is a sad fact that the mediclaim policies are not updated to keep in pace with such

changes.

The facts that have been brought to the notice of the Forum clearly indicate that this

procedure is an advancement of medical technology where minimum of 24 hours of

hospitalization is not required. . The various certificates issued by the specialists indicate

divided opinion amongst the doctors regarding the procedure being an inpatient or outpatient

one. Besides, the treatment is a prolonged one wherein depending upon the prognosis the

patient has to be administered more number of injections. Though the Forum is able to

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Breast-Cancer-Treatment-Center.aspx?track=breastcancer

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Head-and-Neck-Cancer-Treatment-Center.aspx

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Thoracic-Cancer-Treatment-Center.aspx

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Liver-Cancer.aspx

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Bladder-Cancer.aspx

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Melanoma-Treatment-Center.aspx

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Hodgkin-Lymphoma.aspx

appreciate the case of the complainant in expecting the Insurer to settle the claims in as much

as the treatment being a prolonged one and repetitive in nature but for all the reasons stated

above, it would be reasonable that the complainant bears a part of the expenses. Accordingly,

taking a practical view of the facts of the case, which has been brought to the notice of this

Form, the Forum comes to the conclusion that the cost of the treatment is to be shared equally

between the complainant and the Company.

The Forum is also inclined to advise the Company to take a call on covering the expenses for

the above treatment on appropriate terms and conditions under their mediclaim policy and if

the Company takes a decision to exclude this from the scope of mediclaim policy, appropriate

steps have to be taken by the Company to inform the mediclaim policy holders sufficiently in

advance to avoid proliferation of such complaints in future. Therefore in the facts and

circumstances of the case, the decision of the Company is set aside by the following order.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd. is directed to

settle the claims for 50% of the admissible amount in favour of the complainant, towards full and

final settlement of the complaint.

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

Insurance Ombudsman Rules, 2017:

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

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. It is particularly informed that in case the award is not agreeable to the complainant, it would be

open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider

appropriate under the Laws of the Land against the Respondent Insurer.

Dated: This 6th day of February, 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

OFFICE OF INSURANCE OMBUDSMAN MUMBAI & GOA

METROPOLITAN REGION EXCLUDING NAVI-MUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MRS. KAMINIDEVI BHOIR

V/s. RESPONDENT : The New India Assurance Co Ltd – Mumbai

COMPLAINT REF: No: MUM-G-049-1819- 0018 AWARD No: IO/MUM /A/ GI/ /2018-19 1 Name & Address of the

Complainant

Dr.(Mrs.) Kaminidevi Bhoir

DADAR (East), Mumbai - 400 014 2 Policy No:

Type of Policy

Duration of Policy/Period Sum Insured

142000/34/16/28/00000361 NEW INDIA FLOATER MEDICLAIM

05/07/2016 to 04/07/2017 Rs.5,00,000.

3 Name of Insured


Ms. KADAMBAR BHOIR

Dr.(Mrs.) Kaminidevi Bhoir

4 Name of Insurer The New India Assurance Co Ltd - Mumbai 5 Date of Repudiation 08/06/2017 6 Reason for Repudiation Dental 7 Date of receipt of the complaint 23. 03. 2018 8 Nature of complaint TOTAL REPUDIATION OF CLAIM 9 Amount of claim Rs.1,01,411/- 10 Date of Partial Settlement -- 11 Amount of relief sought Rs.1,01,411/- 12 Complaint registered under Indian


13 (b) 13 Date of Hearing 29th October 2018 at 2:45 pm 14 Representation at the hearing:- a) For the complainant Dr. Kaminidevi Bhoir b) For the insurer Mr. Ashok Nikam and Dr.Shweta Birwatkar-TPA,

MediAssist Ltd. 15 Complaint how disposed AWARD 16 Date of Award/Order

Brief Facts of the Case : The complainant’s daughter was advised hospitalization for complaint of pain in both the temporal regions and accordingly she was admitted to Jaslok Hospital on 05.08.2016 and underwent surgery and discharged on 06.08.2016. She preferred a claim with the Insurance Co. for Rs.1,01,411/- which was repudiated under Clause 4.4.5 of the insurance policy terms and conditions.

Contentions of the complainant: The complainant appeared and deposed before the Ombudsman. She submitted that her daughter was advised hospitalization for complaint of pain in both the temporal regions and accordingly she was admitted to Jaslok Hospital on 05.08.2016 and underwent surgery and discharged on 06.08.2016. She preferred a claim with the Insurance Co. for Rs.1,01,411/- which was repudiated under Clause 4.4.5 of the insurance policy terms and conditions. She stated that the surgery done on her daughter was not a simple dental extraction of the molar. It was done at Jaslok Hospital main

OT by inducing general anesthesia under two days admission. The molars were embedded in the bone and they could not have been removed in a normal dental clinic. They were removed by cutting the bones and diagnosed as ‘deeply impacted maxillary mandibular with sinus closeness 3rd molar”. The surgeon who operated her was not a simple dental surgeon but an expert maxilla-facial surgeon. The molar pain was associated with anterior displacement of the left TM joint having subchondral cystic changes involving the left mandibular condycle which is evident in the MRI taken on 08.11.2016. She reiterated that her daughter is now advised further surgery of TM joint which is still pending since she is appearing for her exams.


It was contended on behalf of the Respondent that the Insured had taken treatment for impacted

maxillary mandibular sinus closeness to 3rd molar and it was evident that no dental treatment is

payable unless arising from an accident as per policy clause 4.4.5 which reads, “Dental treatment or

surgery of any king unless necessitated by accident and requiring hospitalization.”

The Respondent referred to the definition of dental treatment as stated under Ch 1 Reg.2(d) of

Dentists Act 1948 (an Act to regulate the profession of dentistry in India)

Dentistry includes :-

1) The performance of any operation on, and the treatment on any disease, deficiency or lesion

of human teeth or jaws and the performance of radiographic work in connection of human

teeth or jaws or the oral cavity.

2) The giving of any anesthetic in connection with any such operation/treatment.

Forum’s observations :

The Forum observed that the complainant’s daughter had taken treatment for Impacted Maxillary

Mandibular Sinus Closeness to 3rd Molar. The complainant has contended that a specialist had

performed the surgery but the Forum noted that same is not arising out of accident. If the same was

necessitated due to an accident it would be payable. The Respondent has repudiated the claim

under exclusion clause 4.4.5 which clearly states that dental treatment or surgery of any kind unless

due to accident is not payable. The Forum noted that the claim has been rejected in consonance

with the agreed terms of the policy. Hence the Forum does not find any valid reason to intervene in

the decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Dr (Mrs)

Kaminidevi Bhoir against the repudiation by the Respondent of the claim lodged for her daughter’s

hospitalization does not sustain. There is no order for any other relief. The case is disposed of

accordingly.

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

Insurance Ombudsman Rules 2017 :

a) As per Rule 17(6) of the said rules the insurer shall comply with the award within thirty days

of the receipt of the award and intimate compliance of the same to the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the insurers.

Dated at Mumbai this 12th day of February, 2019.

( MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - SHRI MEHUL BAJANIA

V/s.

RESPONDENT : The Oriental Insurance Co. Ltd – Mumbai

COMPLAINT REF: No: MUM-G-050-1819- 0021 AWARD No: IO/MUM /A/ GI/ /2018-19

1 Name & Address of the Complainant Mr. Mehul U. Bajania. Ghatkopar (W), Mumbai - 400 086

2 Policy No: Type of Policy Duration of Policy/Period Sum Insured

131401/48/2018/6005 HAPPY FAMILY FLOATER - 2015 02/12/2017 to 01/12/2018 Rs.3,00,000.

3 Name of Insured Name of the policy holder

Mast: HARSH M. BAJANIA Mr. Mehul U. Bajania

4 Name of Insurer The Oriental Insurance Co Ltd - Mumbai 5 Date of Repudiation 12.03.2017 6 Reason for Repudiation Cosmetic (correction of squint) 7 Date of receipt of the complaint 02.04.2018 8 Nature of complaint Total Repudiation of Claim 9 Amount of claim Rs.52,919/-

10 Date of Partial Settlement -- 11 Amount of relief sought Rs.52,919/- 12 Complaint registered under Indian

Ombudsman Rules 2017 13 (b)

13 Date of Hearing 25.102018 at 02:45 pm 14 Representation at the hearing:-

a) For the complainant Mrs. KINJAL M. BAJANIA ( spouse ) b) For the insurer Mr. RAMA KANT SINGH, BM, Dr Trupti Kurhe,

MDIndia Health Insurance TPA Pvt Ltd. 15 Complaint how disposed Award 16 Date of Award/Order 12TH February,2019

Brief Facts of the Case:

The complainant’s son was admitted to Eye Super Specialities Hospital on 12.01.2017 and

underwent surgery for his eyesight. He lodged a claim for reimbursement of hospital expenses for

Rs.52,919/- which was repudiated by the Insurance Co on grounds of cosmetic surgery not covered.

Contention of the complainant :

The complainant’s wife appeared and deposed before the Forum. She submitted that her son was

admitted to Eye Super Specialities Hospital on 12.01.2017 and underwent surgery for his eyesight.

He lodged a claim for reimbursement of hospital expenses for Rs.52,919/- which was repudiated by

the Insurance Co on grounds of cosmetic surgery not covered. She contended that it is clearly

mentioned in the doctor’s certificate dt.12.01.2017 and 22.03.2017 that this is an acquired squint

and was not present since birth. The doctor has also mentioned that if the surgery was not done it

would have lead to lifelong irreversible visual loss and hence the surgery was justified. She

requested for the settlement of her son’s claim.

Contention of the Respondent:

It was contended on behalf of the Respondent that the Insured was admitted with diagnosis of Left

Non-accomodative Esotropia with Amblyopia which was managed by surgically “both eyes medial

rectus recession 4 mm under general anesthesia. As per the documents it was observed that the

procedure was done for correction of squint. The letter from the treating doctor categorically states

that the procedure performed for the reasons of preventing the permanent loss of vision and

binocularity, but according to the diagnosis it is a type of squint,i.e. it is a congenital anomaly which

is visible externally and refractive error should be greater than+/-7.00 dioptre to consider it as

therapeutic treatment if not it should be considered as cosmetic. Hence the claim was not

admissible as per Exclusion Claus 4.5 which reads, “Circumcision (unless necessary for treatment of

a disease not excluded hereunder or as may be necessitated due to any accident), vaccination

(except as covered under 1.2B(ii), inoculation or change of life or cosmetic or necessitated due to

an accident or as a part of any illness;”

Exclusion clause 4.6 which reads, “Surgery for correction of eyesight, cost of spectacles, contact

lenses, hearing aids etc.” and Exclusion clause 4.8 which reads, “Convalescence, general debility,

“run-down” condition or rest cure, congenital external diseases or defects or anomalies, sterility,

any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-

injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to, and or

use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction

etc. any disease or injury as a result of committing or attempting to commit a breach of law with

criminal intent.”

They reiterated that Left Non-accomodative Esotropia with Amblyopia is a type of squint. Squint can

be congenital or acquired and surgery of squint is considered medically necessary for children up to

10 years of age for vision defect +/-5 dioptre since this surgery can repair the vision impairment up

to the age of 10 year. Beyond 10 years it serves only a cosmetic purpose. In this case refractive

error is +1.00 for right eye and +0.75 for left eye and at the time of surgery age of the child was 11

years.


The Forum, after hearing both the parties, is of the opinion that the refractive error for left eye was

+0.75 and the complainant’s son was 11 years old at the time of surgery. Beyond 10 years the same

serves only as cosmetic and not for repairing vision impairment whereas the surgery of squint is

necessary only upto 10 years of age for vision defect +/-5 dioptre. The letter from the treating

doctor that the surgery is not cosmetic seems to be an afterthought. Therefore, considering these

above facts, the Forum feels that the Respondent’s decision to repudiate the claim is in order. The

Forum, therefore does not find any good ground to intervene with the stand taken by the

Respondent and passes the following Order:

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr

Mehul U. Bajania against the repudiation by the Respondent of the claim lodged for his son’s

hospitalization does not sustain. There is no order for any other relief. The case is disposed of

accordingly.







( MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)


CASE OF COMPLAINANT - MR. SATISHKUMAR VATHRIYAR VS

RESPONDENT : THE ORIENTAL INSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-050-1819-0030 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Satishkumar Vathriyar Mumbai


124500/48/2018/403 Happy Family Floater 2015 Policy 19.04.2017 – 18.04.2018 Rs.6,00,000/-


Mr Satishkumar Vathriyar - do -

4 Name of Insurer The Oriental Insurance Co. Ltd.


6 Reason for repudiation Genetic disorder – clause 4.15

7 Date of receipt of the complaint 08.06.2017

8 Nature of complaint Repudiation of claim


10 Date of Partial Settlement ----


12 Complaint registered under Ombudsman Rules, 2017

Under Rule 13(b)

13 Date of Hearing 26.10.2018 – 02.45 p.m.

14 Representation at the hearing

a) For the complainant Absent

b) For the insurer Mrs Rachana S Ramle, AM, Dr Shweta Gupta, M/s

Raksha Health Insurance TPA Pvt Ltd. 15 Complaint how disposed Award


Brief Facts of the Case: Complainant was admitted to Breach Candy Hospital for treatment of Adult PCD-CRF for renal transplant on 06.02.2017 and Right Nephrectomy-Renal transplant done on 11.02.2017and discharged on 23.02.2017. His mother was the donor and renal transplant was performed in the same hospital. Respondent repudiated both the claim stating that his father had history of PKD which is a genetic disorder not payable as per exclusion clause 4.15 of the policy and under clause 1.8 since the main is not admissible hence the second was also repudiated.

Contentions of the complainant : The complainant could not be present for the hearing hence he submitted a letter stating that he has been advised not to travel to avoid infection and requested to take his written submissions on record. He submitted that he was admitted to Breach Candy Hospital for treatment of Adult PCD-CRF for renal transplant on 06.02.2017 and Right Nephrectomy-Renal transplant done on 11.02.2017and discharged on 23.02.2017. His mother was the donor and renal transplant was performed in the same hospital. Respondent repudiated both the claim stating that his father had history of PKD which is a genetic disorder not payable as per exclusion clause 4.15 of the policy and under clause 1.8 since the main is not admissible hence the second was also repudiated. The claim was denied for Genetic Disorder and since then he had been chasing the Insurer/TPA to provide medical proof to establish this. But they did not respond. He pointed out that only expensive and complex testing of his sample could give indication about this being a genetic disorder and same is not done. His doctors told him that there can be many reasons for kidney failure and in his case it cannot be directly assigned to any genetic condition. As regards his mother’s claim they did not even issue any letter and only orally informed him that the same is not payable. He pointed to the directions given by the High Court and as per their circular directed all insurers to pay claims due to genetic disorders and this finishes the wrong stand taken by the Insurer. Hence he requested for the settlement of his and his mother’s claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that the Insured preferred two claims for himself (recipient) and his mother (donor). While going through the claim documents, it was observed that as per the Discharge Summary, the claimant’s father had history of PKD and the said ailment is hence a genetic disorder which is not payable as per exclusion clause 4.15 of the policy which reads, “Genetic disorders and stem cell implantation/surgery.” His mother’s claim was repudiated under Clause 1.8 which reads, “Medical expenses for in-patient hospitalization for organ donor is covered when the claim of the insured person is admissible under the hospitalization sections of the policy. Since the main claim is not admissible under the scope of the policy, this claim also stands repudiated. Forum’s Observations/Conclusion: In the instant case, complainant was admitted to hospital for treatment of Adult PCD-CRF for renal transplant and his mother has donated her kidney to him. Respondent has repudiated both the claims relying on Exclusion Clauses of the respective policies which exclude coverage of expenses incurred for the treatment of genetic diseases and since the main claim is not admissible, the second claim also stands repudiated. Complainant argued that his was not a genetic disorder and it is rejected without any supporting medico-legal evidence to establish that the claim was due to genetic disorder. He has referred to IRDA’s circular dt.19.03.2018 which directed payment of such claims retrospectively stating that the “Insurance Co.s offering contracts of health insurance are hereby directed that no claim in respect of any existing health insurance policy shall be rejected based on exclusions related to Genetic Disorder.”

As per available information, Polycystic Kidney Disease (PKD) is a genetic disorder

characterized by the growth of numerous cysts in the kidneys. It is the most common

inherited disorder of the kidneys. Symptoms usually develop between the ages of 30 and 40,

but they can begin earlier, even in childhood. The most common symptoms are pain in the

back and the sides and headaches. Other symptoms include liver and pancreatic cysts, urinary

http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm

tract infections, abnormal heart valves, high blood pressure, kidney stones, brain aneurysms,

and diverticulitis. About 90 percent of all cases of polycystic kidney disease (PKD) are

inherited in an autosomal dominant fashion. ADPKD is caused by mutations in the PKD1 and

PKD2 gene. Although there is no cure for ADPKD, treatment can ease symptoms and

prolong life, abnormal gene, which increases the risk to have children with a recessive

genetic disorder.

Thus, it is established that the complainant was treated for a genetic disorder. The policies

issued to the complainant clearly lay down, “No claim will be payable under this Policy for

Genetic disorders”. However, in pursuance to the directions of the Hon’ble High Court of

Delhi, IRDAI vide Circular dt.19.03.2018 directed all Insurance Companies offering

contracts of Health Insurance that no claim in respect of any existing health insurance policy

shall be rejected based on exclusion related to ‘Genetic Disorder’. The Forum was inclined to

allow the subject claim in view of the said circular. However, further, in pursuance of the stay

granted by the Hon’ble Supreme Court of India on the operation of the judgment of the

Hon’ble High court of Delhi, IRDA vide their Circular dated 05.09.2018 has revoked their

earlier Circular dated 19.03.2018. In the light of the same, since the claim has been

repudiated in accordance with the policy terms and conditions the Forum does not find any

valid ground to intervene with the decision of the Respondent and consequently no relief can

be granted to the complainant.

AWARD Under the facts and circumstances of the case, the complaint lodged by Mr Satishkumar Vathriyar against repudiation of the claim for his and his mother’s hospitalization does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 5th day of February, 2019 at Mumbai.

(MILIND KHARAT) INSURANCE OMBUDSMAN

OFFICE OF INSURANCE OMBUDSMAN Mumbai & Goa

Metropolitan Region excluding Navi Mumbai & Thane ((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR PARAS Y SAMPAT

VS RESPONDENT : THE NEW INDIA ASSURANCE CO.LTD.

COMPLAINT REF: NO:MUM-G-049-1819-0083 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Paras Y Sampat Mumbai

2 Policy No: 11140034152500010992

http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm

http://www.nlm.nih.gov/medlineplus/kidneystones.html

http://www.nlm.nih.gov/medlineplus/brainaneurysm.html

http://www.nlm.nih.gov/medlineplus/diverticulosisanddiverticulitis.html

http://ghr.nlm.nih.gov/handbook/illustrations/autodominant

https://ghr.nlm.nih.gov/gene/PKD1

https://ghr.nlm.nih.gov/gene/PKD1

Type of Policy Duration of Policy/Period Sum Insured

Mediclaim 2012 Policy 01.03.2016 to 28.02.2017 & 03.02.2016 to 02.02.2018 Rs.6,00,000/-


Mr Yogesh P Sampat Mrs Anjana Y Sampat

4 Name of Insurer The New India Assurance Co.Ltd.


6 Reason for repudiation Pre-existing disease


8 Nature of complaint Total repudiation of claim


10 Date of Partial Settlement -


12 Complaint registered under Insurance Ombudsman Rules 2017

Rule 13(b)

13 Date of Hearing 31.10.2018 , 03.45 p.m.


a) For the complainant Mr Paras Y Sampat

b) For the insurer Mrs Kiran Salve, Dy Mgr,



Brief facts of case: The complainant’s father had an accidental fall in the bathroom on 21.03.2016 and subsequently suffered a stroke and was paralyzed and admitted to Kokilaben Dhirubhai Ambani Hospital on the same day and discharged on 05.05.2016. He submitted a claim to the Insurance Co. for Rs.7,00,000/- which was repudiated on the ground that hypertension was pre-existing.

Contentions of the complainant :

The complainant appeared and deposed before the Forum. He submitted that his father had an accidental fall in the bathroom on 21.03.2016 and subsequently suffered a stroke and was paralyzed and admitted to Kokilaben Dhirubhai Ambani Hospital on the same day and discharged on 05.05.2016. He submitted a claim to the Insurance Co. for Rs.7,00,000/- which was repudiated on the ground that hypertension was pre-existing. The complainant stated that the policy was in force since 2005 and they claimed only once during the tenure of the policy. His father suffered paralysis due to ‘accidental fall’ and the same was not related to hypertension. The treating doctor has certified the same vide his letter dt.03.05.2016. He pointed out that there were guidelines that stipulate that blood pressure and hypertension cannot be classified as a disease and hence clause 4.1 of the insurance policy is not applicable in this case. At the time of admission of his father to the hospital, they were under severe stress and under the same his brother informed the hospital that his father was taking medicines for hypertension. The Insurance Co. relied on this statement to decline the claim. The treating doctor at the hospital, who is one of the most reputed doctors in the city, has clarified that his father’s injury was attributed to the accidental fall and not hypertension. Hence the rejection of his claim was unwarranted and unfair and requested for the settlement of his claim.

Contentions of the Respondent : It was contended on behalf of the Respondent that on scrutiny of the claim on the basis of the claim documents submitted it was observed that the cause of the ailment for the said admission was Right Gangliocapsular Bleed (Etiology) with hypertension which is pre-existing. As per policy terms and conditions, pre-existing has a waiting period of 4 years. The eligible sum insured of Rs.3,00,000/- for the said ailment had been exhausted in previous claim wherein they have settled the claim for Rs.3,00,000/- against the total claim amount of Rs.3,63,180/- considering sum insured of Rs.3,00,000/-. The enhanced sum insured of Rs.3,00,000/- was not taken into account whilst processing the claim as the coverage enhancement amount has not completed 4 continuous years as the ailment Osteoarthritis has a waiting period of 4 years as per policy terms and conditions Clause 4.1 which reads, “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 with us.” and 5.11 which reads, “ As the sum insured of Rs.3,00,000/- against the above policy has been exhausted, hence they deducted an amount of Rs.63,180/-. The Respondent informed the Forum that in March 2016 they had settled a claim for hip surgery for Rs.3 lacs. They stated that although at time the Insured was also a k/c/o HTN, the fact remains that in the present case there was internal bleed in the brain which was related to HTN and there was no external injury.

Forum’s Observations/Conclusions : The Forum directed the Respondent to seek expert medical opinion to prove that the Right Gangliocapsular Bleed was due to HTN. The Respondent furnished the medical opinion from the Neurologist who opinioned that the CT scan showed acute right cerebral hematoma involving lateral aspect of basal ganglia and adjacent parenchyma with extension of blood into ventricular system, mild subfalcine and uncal herniations. The Neurologist has concluded that the patient had spontaneous bleed due to hypertension leading to weakness, altered sensorium and loss of body control – leading to the fall which is secondary to (due to) bleed and not vice versa. The Forum thus feels that the present admission for the fall was a direct complication of pre-existing HTN which are specifically excluded under the policy and hence the claim was repudiated as per the policy terms and conditions. The Forum thus concludes that the Respondent’s stand as regards the repudiation of the claim as per the policy terms and conditions is in order. Hence the Forum does not find any valid reason to intervene in the decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Paras Y Sampat against the total repudiation of the claim for his father’s hospitalization does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the laws of the land against the Respondent Insurer. Dated: This 11th day of February, 2019 at Mumbai.

( MILIND KHARAT ) INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - Smt. SHARDA PAREKH

V/s.

RESPONDENT : United India Insurance Co. Ltd – Mumbai


AWARD No: IO/MUM /A/ GI/ /2018-19


Complainant

Mrs. Sharda Parekh.

Kandivali (W), Mumbai - 400 067

2 Policy No:

Type of Policy


Sum Insured

0221002817P105172825

INDIVIDUAL MEDICLAIM POLICY

07.07.2017 to 06.07.2018

Rs.3,25,000/- + CB Rs.1,46,250/-

3 Name of Insured


Mrs. Sharda Parekh.

-- do --

4 Name of Insurer UNITED INDIA INSURACE CO.LTD


6 Reason for Repudiation Psychiatric treatment


8 Nature of complaint TOTAL REPUDIATION OF CLAIM






13 (b)

13 Date of Hearing 29.10.2018 at 3:45 pm


a) For the Complainant Mr. Dakshesh C. Parekh (son of complainant)

b) For the Insurer Mrs.VIDISHA V. PARAB, Dr Bharti Motling,

HealthIndia TPA


16 Date of Award/Order 12TH February,2019

Brief facts of the case :

The complainant’s mother was admitted to Atlantis Max Hospital from

05.09.2017 to 07.09.2017 for treatment of abnormal behavior with k/c/o

Parkinson’s Disease. A claim for Rs.32,797/- was preferred with the

Insurance Co. which was repudiated on grounds that the ailment was

related to psychiatric and psychosomatic disorders.


The complainant’s, legal heir, her son appeared and deposed before the

Forum since she expired on 19.01.2018. He submitted that his mother

was admitted to Atlantis Max Hospital from 05.09.2017 to 07.09.2017 for

treatment of abnormal behavior with k/c/o Parkinson’s Disease. A claim

for Rs.32,797/- was preferred with the Insurance Co. which was

repudiated on grounds that the ailment was related to psychiatric and

psychosomatic disorders. He clarified that the treatment for which his

mother was admitted in hospital was for Psychosis-related to

Parkinson’s disease and the treating doctor’s certificates dt.07.11.2017

and 07.12.2017 state that the patient was admitted with Acute Psychosis

which was due to Parkinson’s Disease. He added that the disease can

cause psychosis and he had prescribed medicines for Parkinson’s

Disease related to Psychosis. The complainant’s son requested for the

settlement of his mother’s claim.

Contentions of the Respondent :

It was contended on behalf of the Respondent that the Insured was

admitted with complaints of sudden onset of abnormal behavior, violent

condition and altered sensorium. She was a k/c/o of Parkinson/s Disease

under treatment. During hospitalization, she was treated with tablets.

As per the medical documents, it was observed that she was admitted

with complaints of Acute Psychosis and was treated with antipsychotic

medicines during the hospitalization. The treatment related to

psychiatric and psychosomatic disorders is not payable under the clause

4.9 which reads, Convalescence, general debility, “run down”

condition or rest cure, obesity treatment and its complications

including morbid obesity, congenital external disease or

defects or anomalies, sterility, infertility, venereal diseases,

intentional self-injury/suicide, all psychiatric and psychosomatic

disorders, intentional self injury and use of intoxicating

drugs/alcohol.”

Forum’s Observations :

The Forum observed that the complainant was given Psychiatric

treatment also along with Parkinson’s Disease treatment and the former

is not payable as per policy terms and conditions. The Forum, hence,

taking the above facts into consideration, instructed the Respondent to

pay the admissible claim relating to the Parkinson’s disease treatment

only, deducting the hospitalization expenses for psychiatric treatment to

the complainant. The Respondent’s decision is hence intervened by the

following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is

directed to settle the admissible claim of Rs.23,533/- relating to the

Parkinson’s disease treatment only, deducting the hospitalization

expenses for psychiatric treatment in favor of the complainant, as full

and final settlement of the complaint. There is no order for any other

relief. The case is disposed of accordingly.

The attention of the complainant and the Insurer is hereby invited to the

following provisions of the Insurance Ombudsman Rules 2017 :

a) As per Rule 17(6) of the said rules the insurer shall comply with

the award within thirty days of the receipt of the award and

intimate compliance of the same to the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be

binding on the insurers.


( MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of the Insurance Ombudsman Rules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MS MANJULA L SHAH

VS RESPONDENT : THE ORIENTAL INSURANCE CO LTD


1 Name & Address of the Complainant Ms Manjula L Shah Mumbai

2 Policy No: Type of Policy Duration of Policy/Period Sum insured

121700/48/2017/3104 Mediclaim Insurance Policy (Individual) 02.07.2016 to 01.07.2017 Rs.2,50,000/-


MrLaherchand Shah Ms Manjula L Shah

4 Name of Insurer The Oriental Insurance Company Ltd

5 Date of Repudiation -

6 Reason for repudiation -


8 Nature of complaint Short settlement of claim


10 Date of Partial Settlement 19.07.2017



Under Rule 13 (b)

13 Date of Hearing 16.11.2018, 03.45 p.m.


a) For the complainant Mr Kamal L Shah, son of complainant

b) For the insurer Mrs Chhaya N Pelnekar, AM, Dr Shweta Gupta, M/s Raksha Health Insurance TPA Pvt Ltd.



Brief Facts of the Case : The complainant’s husband was admitted to Sir H N Reliance Foundation Hospital from 08.05.2017

to 13.05.2017 for treatment of IHD, HTN, CCF LV Systolic Dysfunction and Hypothyroidism. She

preferred a claim with the Insurance Co for Rs.54,069/- and the same was settled for Rs.29,025/-

deducting Rs.24,044/-.


The complainant’s son appeared and deposed before the Forum. He submitted that his father was

admitted to Sir H N Reliance Foundation Hospital from 08.05.2017 to 13.05.2017 for treatment of

IHD, HTN, CCF LV Systolic Dysfunction and Hypothyroidism. A claim was lodged with the Insurance

Co for Rs.54,069/- and the same settled for Rs.29,025/- deducting Rs.24,044/-. He pointed out that

out of the deductions, the major deductions was towards room rent of Rs.12,800/- as 4 days stay

was not justified since only Inj.Lasix administered and they paid for only 1 day stay. He explained

that his father’s condition was not stable and his ejection pressure was only 1%. The treating

doctor’s certificate dt.07.06.2017 was furnished stating the need for hospitalization for so many

days. The complainant’s son was not agreeable to the deductions made towards four days room

rent. Hence he requested for the settlement of his father’s balance claim.

Contention of the Respondent :

It was contended on behalf of the Respondent that the Insured claimed for Rs.54,069/- and the

claim settled for Rs.34,085/- deducting room rent Rs.14,000/-. On scrutiny of the documents

submitted for reimbursement, it was observed that the claimant was treated with one dose of Inj

Lasix. Hence the room charges for 1 day only was considered and the remaining 4 days

hospitalization was not justified as during this period only oral medication was given and no other

active line of treatment administered. The other charges viz.doctor charges, investigation charges

and hospital charges were paid as per the entitled room category and non medicals were deducted

since not payable as per terms and conditions of the policy.

Forum’s Observations:

The Forum observed that the deductions made towards non-medical expenses were justified.

However, the major deductions of Rs.12,800/- effected under room rent as 4 days stay not justified

was not acceptable to the Forum. The Forum asked the Respondent to look at the age of the

complainant and consider the stay in hospital as necessary since his condition was also not stable.

Therefore, considering these above facts, it was ordered by this Forum to pay the balance

admissible claim of Rs.8,000/- to the complainant. Hence the Respondent’s decision is intervened by

the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the claim of

Rs.8,000/- in favor of the complainant, as full and final settlement of the complaint. There is no

order for any other relief. The case is disposed of accordingly.







( MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT

CASE OF COMPLAINANT -MR SANJAY N PARIKH

VS

RESPONDENT : THE ORIENTAL INSURANCE CO LTD

COMPLAINT REF: NO:MUM-G-050-1819-0141

AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Sanjay N Parikh

Mumbai

2 Policy No:

Type of Policy


Sum Insured

131300/48/2018/11557

Happy Family Floater-2015 Policy

20.11.2017 to 19.11.2018

Rs.6,00,000/-

3 Name of Insured


Mrs Rama N Parikh

Mr Sanjay N Parikh

4 Name of Insurer The Oriental Insurance Co Ltd.


6 Reason for repudiation Reasonable and customary charges-






12 Complaint registered under Insurance

Ombudsman Rules 2017 Rule 13(b)



a) For the complainant Mr Nareshkumar D Parikh, complainant’s father

b) For the insurer Mrs Rohini S Kumar, Agency Mgr, Dr Trupti Turhe,

M/s Raksha TPA Pvt Ltd. 15 Complaint how disposed Award



The complainant’s mother was admitted to Drushti Eye & Retina Centre & Rajvi Nursing

Home on 04.12.2017 for left eye cataract with IOL implant. He preferred a claim with the

Insurance Co. for Rs.52,852/- and same was settled for Rs.32,000/- on the grounds of the

Reasonability and Customary Clause.


The complainant’s father appeared and deposed before the Forum. He contended that his

wife was admitted to Drushti Eye & Retina Centre & Rajvi Nursing Home on 04.12.2017 for

left eye cataract with IOL implant. He preferred a claim with the Insurance Co. for

Rs.52,852/- and same was settled for Rs.32,000/- on the grounds of the Reasonability and

Customary Clause. He added that they were having Mediclaim Policy with The Oriental

Insurance Co Ltd. since last 20 years and they have been reimbursed a very less amount than

the actual incurred. He requested for the settlement of her balance claim.


It was contended on behalf of the Respondent that the Surgeon Fees Rs.24,700/-, Anesthetic

charges Rs.2,000/- and Micro surgery charges including tests Rs.16,300/- in the geographical

area of Opera House were very much on the higher side. Further the Insured had used

imported foldable lenses costing Rs.3,400/- which are medically not necessary for treatment

(only unifocal lens is admissible). Hence they have settled the claim for Rs.32,000/- under

the Reasonability and Customary Clause 3.41 which reads “the charges for services or

supplies which are the standard charges for the specific provider and consistent with

the prevailing charges in the geographical area for identical or similar services, taking

into account the nature of the illness/injury involved.” They reiterated that the said

charges incurred were on the higher side. They compared the charges with Team The Eye

Associate, Opera House, H N Reliance Hospital, Prathana Samaj and Right Sight Eye Clinic,

Kemps Corner where the cataract package rates are Rs.30,000/-, Rs.31,200/- and Rs.35,000/-

per eye for cataract. In the light of the above, the settlement for Rs.32,000/- was in

consonance with the Reasonability and Customary Clause.

Forum’s observations:

The Forum feels that the surgeon fees and lens charges are very much on the higher side even

considering the fact that there is no restriction in the policy for the same. There is no doubt

that the individual has every right to go in for the best treatment available but the policy

would pay only the charges which are necessarily and reasonably incurred. It has to be borne

in mind that the Insurance Companies are custodians of public money and have to function

with a long term perspective to ensure sustainability of their operations so that at any given

point of time they are in a position to meet all liabilities under the policies which are in force.

As such, whenever it is observed that the charges are unreasonably high, the “Reasonable &

Customary charges” Clause of the policy would come into operation and even in the

absence of a specific capping the policy, the Respondent is within its right to limit the

expenses payable for a particular procedure by comparing the charges prevalent in the same

geographical area.

The Forum questioned the Respondent whether they had ascertained the reasonableness of

the hospital charges and on what basis they thought it to be unreasonable and on the higher

side. The Respondent submitted that they compared the charges of hospitals in the nearby

vicinity and found the charges Drushti Eye & Retina Centre & Rajvi Nursing Home on the

higher side. The Forum felt that the charges at the hospital were not unreasonable. Therefore,

considering this, it was ordered by this Forum to pay the balance admissible claim of

Rs.17,011/- to the complainant. Hence the Respondent’s decision is intervened by the

following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle the

claim of Rs.17,011/-in favor of the complainant, as full and final settlement of the

complaint. There is no order for any other relief. The case is disposed of accordingly.

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

of the Insurance Ombudsman Rules 2017 :





( MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT –MR APURVA ARVIND DOSHI

VS RESPONDENT : MAX BUPA HEALTH INSURANCE CO LTD

COMPLAINT REF: NO : MUM-G-031-1819-0153 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Apurva Arvind Doshi

Mumbai

2 Policy No:

Type of Policy


Sum insured

30447076201702

Family First Gold 1 lac + 30 lacs

28.05.2017 to 27.07.2018

Rs.1,00,000/-

3 Name of Insured

Name of he policy holder

Mrs Riddhi A Doshi

Mr Apurva Arvind Doshi

4 Name of Insurer Max Bupa Health Insurance Co.Ltd.

5 Date of Repudiation 07.02.2018 & 09.02.2018

6 Reason for repudiation Non disclosure


8 Nature of complaint Total repudiation of claims and

cancellation of policy

9 Amount of claim Rs.9,43,813/- (2 claims)/-


11 Amount of relief sought Rs.9,43,813/- (2 claims)/-

12 Complaint registered under

Insurance Ombudsman rules 2017

13(b)

13 Date of Hearing 01.11.2018, 02.45 pm


a) For the complainant Mr Apurva Arvind Doshi

b) For the insurer Ms Shital Patwa




The complainant’s wife was admitted to Sir H N Reliance Foundation Hospital & Research Center for

treatment of Ca tongue from 20.11.2017 to 25.11.2017 and on 21.12.2017 & 05.02.2018. He

preferred a claim with the Insurance Co. for total Rs.9,43,813/- which was rejected on the grounds

of non disclosure.


The complainant appeared and deposed before the Forum. He submitted that his wife was admitted

to Sir H N Reliance Foundation Hospital & Research Center for treatment of Ca tongue from

20.11.2017 to 25.11.2017 and on 21.12.2017 & 05.02.2018. He preferred a claim with the Insurance

Co. for total Rs.9,43,813/- which was rejected on the grounds that as per submitted documents and

investigations carried out, it was found that the Insured was suffering from Rt Anterolateral Tongue

Ulcer Mucosal and excision done on 25.11.2013. Hence there was non disclosure of the same and

the claim stood denied under policy terms and conditions. He pointed out categorically in this

regard, that the treatment now given was irrelevant to the earlier treatment. It had no relevance

with the CA tongue treatment now undergone. He clarified that with regard to the non disclosure

he was informed by the agent that the complete cured ailment need not be disclosed. The agent

was very much aware of the treatment taken in 2013 since the claim was paid by The New India

Assurance Co Ltd. where the policy was insured at that time. Hence repudiation of the claim,

interlinking it with the earlier treatment taken and which is not the case when the Insured is

maintaining normal health and not treated for the same, is not reasonable and justifiable.


It was submitted on behalf of the Respondent that the policyholder submitted a portability and

proposal form to port his policy from The New India Assurance Co Ltd to their insurance policy and

on the basis of the information provided in the Proposal Form, the Proposer was issued the policy,

subject to the policy terms and conditions. The Insurance Co. received a claim form on behalf of the

Insured’s wife for treatment of tongue cancer at Sir H N Reliance Foundation and Research Centre

from 20.11.2017 to 25.11.2017 and for treatment of Malignant Neoplasm at Sir H N Reliance

Foundation Hospital and Research Centre from 12.12.2017 to 26.12.2017. On verification of the

claim for reimbursement of medical expenses it was revealed that the Insured did not disclose that

his wife underwent Anterolateral Tongue Ulcer Mucosal Excision on 25.11.2013 at the time of

porting of the policy. The said claim was denied on the ground of non disclosure. The Respondent

pointed out that the Insured had not only hid the adverse medical history but had also submitted

false no claim declaration. Had this information been disclosed to them, the policy would not have

been issued. Hence as per clause 3 of policy terms and conditions they cancelled the policy too.


The Forum observed that the agent filled the proposal form and the complainant only signed it. It

was also observed that the earlier treatment, i.e. Rt Anterolateral Tongue Ulcer Mucosal and

excision done on 25.11.2013 was not related to the present treatment, i.e.treatment of tongue

cancer. All rights and benefits entitled under the previous policy are passed on to the ported policy

and the Respondent cannot be harsh and deny these rights. The Forum reminded the Respondent

that the complainant was insured with the previous insurer since 2015 without any break and his

policy ported to the new insurer with all benefits. Hence it was not proper for the Respondent to

take a stand that she did not disclose her ailment and thereafter terminate her policy. Moreover, the

ailment for which the Insured was admitted, i.e. Rt Anterolateral Tongue Ulcer was not related

tongue cancer. Therefore, considering this, it was ordered by this Forum to settle the admissible

claim of Rs.9,39,390/- to the complainant. Hence the Respondent’s decision is intervened by the

following Order:

AWARD


Rs.9,39,390/- in favor of the complainant and to reinstate the policy, as full and final settlement of

the complaint. There is no order for any other relief. The case is disposed of accordingly.






Dated at Mumbai this 21st day of February, 2019.

( MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR PRAFUL SHAH

VS RESPONDENT : THE NEW INDIA ASSURANCE CO LTD

COMPLAINT REF: NO: MUM-G-049-1819-0213 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Praful Shah Mumbai


13150034172500000808 New Mediclaim 2012 07.05.2017 to 06.05.2018 Rs.5,00,000/- + CB Rs.1,00,000/-


Mr Praful Shah Mrs Sushila P Shah

4 Name of Insurer The New India Assurance Co Ltd.







11 Amount of relief sought Rs.52,950 /-


Rule 13(b)

13 Date of Hearing 13.11.2018, 02.45 pm.


a) For the complainant Mr Praful Shah

b) For the insurer Mrs S R Parkar,Sr DM, Dr Shweta Gupta, M/s Raksha Health Insurance TPA Pvt Ltd



Brief facts of the case : The complainant was admitted to Brahma Kumaris Global Hospital and Research Centre on

22.12.2017 for treatment of Coronary Heart Disease and discharged on 25.12.2017. He preferred a

claim with the Insurance Co.for Rs.4,24,066/- and same was settled for Rs.3,60,347/- on grounds of

the Reasonability Clause.


The complainant appeared and deposed before the Forum. He contended that he was admitted to

Brahma Kumaris Global Hospital and Research Centre on 22.12.2017 for treatment of Coronary

Heart Disease and discharged on 25.12.2017. He preferred a claim with the Insurance Co.for

Rs.4,24,066/- and same was settled for Rs.3,60,347/- on grounds of the Reasonability Clause stating

that the charges incurred were excess for the said procedure and they had allowed charges as

reasonably and customarily incurred. He clarified that he was admitted in the entitled room as per

the policy terms and conditions and charges were paid as per hospital charges. He requested for the

settlement of his balance claim.


The Respondent submitted that the Insured claimed for Rs.52,950/- towards surgeon charges and

the charges incurred were excess for the said procedure and they allowed charges as reasonably and

customarily incurred. Thus as per the Reasonability and Customary Clause, they allowed maximum

surgeon charges of Rs.1,78,300/- against Rs.2,31,250/- hence excess amount of Rs.52,950/- was

deducted. They reiterated that since Brahma Kumaris Global Hospital and Research Centre does not

have fixed schedule of charges they have applied Customary and Reasonability Clause i.e. the

charges for services or supplies which are the standard charges for the specific provider and

consistent with the prevailing charges in the geographical area for identical or similar services,

taking into account the nature of the illness/injury involved.” They furnished the comparison sheet

wherein the same surgery under same facilities was compared with tertiary care hospitals who are

at par with the said hospital and the maximum was allowed in the abovementioned case. They

clarified that the said charges incurred were on the higher side and they compared the charges with

hospitals like Jaslok Hospital & Research Centre, Bhatia General Hospital and Lilavati Hospital &

Research Centre, hence the maximum payable was Rs.1,78,300/- towards Surgeon Charges.The

other deductions were towards non medical expenses and Rs.2,700/- consultation charges

dt.04.01.2018 and 08.12.2017 since consultation paper was unavailable.


On scrutiny of the documents produced on record and after hearing the depositions of both the

parties, the Forum noted that the Surgeon Charges were on the higher side. There is no doubt that

the individual has every right to go in for the best treatment available but the policy would pay only

the charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance

Companies are custodians of public money and have to function with a long term perspective to

ensure sustainability of their operations so that at any given point of time they are in a position to

meet all liabilities under the policies which are in force. As such, whenever it is observed that the

charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would

come into operation and even in the absence of a specific capping in the policy, the Company is

within its right to limit the expenses payable for a particular procedure by comparing the charges

prevalent in the same geographical area. The Forum, hence, taking the above facts into

consideration, instructed the Respondent to pay the consultation charges of Rs.2,700/- to the

complainant subject to submission of copies of consultation papers to the Respondent. The

Respondent’s decision is hence intervened by the following Order:

AWARD


Rs.2,700/-in favor of the complainant, as full and final settlement of the complaint. There is no








(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT –MR ASHOK P SOLANKI

VS RESPONDENT :THE ORIENTAL INSURANCE CO LTD

COMPLAINT REF: NO : MUM-G-050-1819-0227 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Ashok P Solanki

Mumbai


131101/48/2018/3787 Happy Family Floater-2015 17.10.2017 to 16.10.2018 Rs.6,00,000/-

3 Name of Insured Name of he policy holder

Mr Parth A Solanki Mr Ashok P Solanki

4 Name of Insurer The Oriental Insurance Co.Ltd.




8 Nature of complaint Short settlement of claim-PE




12 Complaint registered under Insurance Ombudsman rules 2017

13(b)



a) For the complainant Mr Ashok P Solanki

b) For the insurer Mrs Anuradha Gopakumar, AO(A), Dr Bharti

Motling, Health India TPa Pvt Ltd. 15 Complaint how disposed Award


Brief Facts of the Case: The complainant’s son was admitted to Maratha Mandir’s Babasaheb Gawde Hospital from

29.01.2018 to 10.02.2018 for treatment of Nephrotic Syndrome with Fluid Overload with

Bilateral Pleural Effusion and Testicular Effusion with AFI. He preferred a claim with the

Insurance Co. for Rs.2,26,465/- and same was settled for Rs.1,37,294/- .


The complainant appeared and deposed before the Forum. He submitted that his son was

admitted to Maratha Mandir’s Babasaheb Gawde Hospital from 29.01.2018 to 10.02.2018 for

treatment of Nephrotic Syndrome with Fluid overload with Bilateral Pleural Effusion and

Testicular Effusion with AFI. He preferred a claim with the Insurance Co. for Rs.2,26,465/-

and same was settled for Rs.1,37,294/-. He submitted that his policy was for SI of Rs.6 lakhs

under Family Floater Policy since the last 2 years and prior to that under Individual

Mediclaim Policy for SI of Rs.1.5 lacs. However, the Insurance Co.has not considered his

current policy sum insured and paid as per his previous sum insured of Rs.1.5 lacs. He was

not agreeable to the deductions and requested for the settlement of his son’s claim.


It was contended on behalf of the Respondent that the Insured is covered under the Happy

Family Floater Policy for SI of Rs.6 lacs since 17.10.2016 and earlier covered under the

Individual Mediclaim Policy for SI of Rs.1.5 lacs. On scrutiny of claim documents

submitted, it was observed from the discharge summary that the Insured was k/c/o

Nephrotic Syndrome which falls under the pre-existing criteria for the enhanced SI of

Rs.4.50 lacs. Hence the claim was settled as per Clause No.4.1 which reads, “All pre-existing

disease (whether treated/untreated, declared or not declared in the proposal form), which

are excluded up to 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. For the

purpose of applying this condition, the date of inception of the first indemnity based

health policy taken shall be considered, provided the renewals have been continuous and

without any break in period, subject to portability condition. The 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”. The other

deductions were effected as per entitled room category, i.e. 1% of SI of Rs.1,50,000/-

(Rs.1,500/- per day) and other deductions for non medicals expenses not payable as per

policy terms and conditions. They added that the K12 Mutation charges of Rs.8,600/- was

disallowed as the investigation was carried out for detecting genetic disorder which is not

admissible as per clause 4.15 which reads, “Genetic disorder and stem cell

implantation/surgery.”

Forum’s observations/conclusions :

The Forum observed that the complainant’s son was a k/c/o of Nephrotic Syndrome which

falls under the pre-existing criteria for the enhanced SI of Rs.4.50 lacs under the Happy

Family Floater Policy which has a waiting period of 48 months. Hence the settlement of the

claim on grounds that the ailment was pre-existing is in order. However the deduction of

K12 Mutation charges which was disallowed on grounds of investigation for detecting

genetic disorder was not justifiable and the Respondent was directed to consider the same.

Therefore, considering these above facts, it was ordered by this Forum to pay the Rs.8,500/-

for the same to the complainant. Hence the Respondent’s decision is intervened by the

following Order:

AWARD


balance claim of Rs.8,500/- in favor of the complainant, as full and final settlement of the


The attention of the complainant and the Insurer is hereby invited to the following

provisions of the Insurance Ombudsman Rules 2017 :

a) As per Rule 17(6) of the said rules the insurer shall comply with the award within

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

Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

insurers.


( MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE



CASE OF COMPLAINANT - MS AMI BHARAT SHAH

VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-049-1819-0280


1 Name & Address of the Complainant Ms Ami Bharat Shah

Mumbai

2 Policy No:

Type of Policy


Sum Insured

712500/34/15/2100000023

Good Health Policy

01/03/2016 – 28/02/2017

Rs.5,00,000/- + 40% CB

3 Name of Insured


Mrs Neela B. Shah

Ms Ami B. Shah




7 Date of receipt of the complaint 16/05/2018

8 Nature of complaint Short Payment (Contribution Clause)




12 Complaint registered under The

Insurance Ombudsman Rules 2017

Rule 13 (b)

13 Date of Hearing 12/12/2018 at 15.45 hrs.


a) For the complainant MsAmi B. Shah

b) For the insurer Dr. Kanak Lashkarkar



Brief facts of the case : The complainant’s mother was admitted to The Eye Super Specialities on 12.01.2017 for right eye

cataract. She preferred a claim with the Insurance Co. under two different policies for Rs.70,000/-

and the same was settled for Rs.24,000/- and Rs.26,000/-.

Contentions of the complainant:

The complainant appeared and deposed before the Forum. She submitted that her mother was

admitted to The Eye Super Specialities on 12.01.2017 for right eye cataract. She preferred a claim

with the Insurance Co. under two different policies for Rs.70,000/- and the same was settled for

Rs.24,000/- and Rs.26,000/-.

She clarified that her mother had undergone left eye cataract surgery on 19.01.2015 where the

claim was lodged for Rs.70,000/- and the same settled for Rs.40,000/- by MD India as per sub-limit

and the other policy was also with The New India Assurance Co Ltd. which was settled for

Rs.24,000/- as per their sub-limit. She added that her mother underwent right eye cataract surgery

on 12.01.2017 and claim lodged with MDIndia and ND Assist under two different New India policies.

MD Assist paid the claim of Rs.24,000/- as per their sub-limit however MD India considered only

Rs.26,000/- as against the sub-limit of Rs.40,000/-. The complainant pointed out that even though

all the parameters were the same, the claim was settled for Rs.64,000/- for the left eye whereas

Rs.50,000/- for right eye. She was not agreeable to the settlement and requested for the settlement

of her mother’s balance claim.


It was contended on behalf of the Respondent that the Insured was covered under the Good Health

Policy with sum insured of Rs.5,00,000/- + 40% CB and claimed for Rs.70,000/- for right eye cataract

surgery. The claim was partially settled under the other policy for Rs.24,000/- as per the cataract

limit. As per Good Health Policy terms and condition, the Co’s liability in respect of payment of any

claim relating to cataract for each eye shall not exceed 20% of the sum insured subject to maximum

of Rs.40,000/- per eye. Hence Rs.26,000/- was settled as per the Contribution Clause No.2.8 and 9

which reads, “Contribution is essentially the right of an Insurer to call upon other Insurers liable to

the same Insured to share the cost of an indemnity claim on a rateable proportion.” and “If the

amount to be claimed exceeds the sum insured under a single policy after considering the

deductibles or co-pay, the Insured person shall have the right to choose Insurers by whom the

claim to be settled. In such cases, the Insurer may settle the claim with Contribution Clause.” For

the balance amount of Rs.46,000/-, the Insured has lodged claim with MD India and out of this

amount, Rs.20,000/- is towards Multifocal Lens which is not payable as per clause 2.37 which reads,

“Reasonable and customary charges means the charges for services which are the standard

charges for the specific provider and consistent with the prevailing charges in the geographical

area for identical or similar services, taking into account the nature of illness/injury involved.”


The Forum noted that Monofocal Lens is settled by the Insurer. It was also observed that the sub

limit, in this case cataract, is applicable per event irrespective of number of policies taken from one

Insurance Co.which means two or more policies taken from that Co. cannot be clubbed for giving

higher benefits. Hence, in all, Rs.50,000/- has been paid for right eye cataract surgery. The

Respondent’s stand as regards the settlement of the claim as per the policy terms and conditions is

in order. Hence the Forum does not find any valid reason to intervene in the decision of the

Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by MsAmi B. Shah against

the short settlement of the claim lodged for her mother’s hospitalization for right eye cataract

surgery does not sustain. There is no order for any other relief. The case is disposed of accordingly.

It is particularly informed that in case the award is not agreeable to the complainant, it would be


appropriate under the laws of the land against the Respondent Insurer.


( MILIND KHARAT )

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - G B BHUMGARA

VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-049-1819-0300


1 Name & Address of the Complainant Mr G B Bhumgara

Mumbai

2 Policy No:

Type of Policy


Sum Insured

11140034162500012738

New Mediclaim 2012

25/03/2017 – 24/03/2018

Rs.3,00,000/- + CB Rs.22,500/-

3 Name of Insured


Mr G B Bhumgara

- do -

4 Name of Insurer The New India Assurance Co. Ltd.

5 Date of Repudiation 30/03/2018

6 Reason for repudiation Hospitalization for diagnostic purpose




10 Date of Partial Settlement Repudiation




13(b)

13 Date of Hearing 14/12/2018 at 02.45 pm



b) For the insurer Ms. Kiran Salve, DM, M/s Raksha Health

Insurance TPA Pvt Ltd



Brief facts of case : The complainant was admitted to B D Petit Parsi General Hospital from 12.12.2017 to 14.12.2017 for

acute abdominal pain and loss of weight (over 12 kilos in two months) as the treating doctor suspected

malignancy of pancreas. He submitted a claim for Rs.54,400/- which was repudiated by the Insurance Co.

on the grounds that during hospitalization only investigations were carried out.


The complainant gave a letter dt Nil, received by us on 14.12.2018 that he was unwell and hospitalized

and expressed his inability to attend the hearing. He conveyed to the Forum to go ahead with the hearing

on the basis of his written submissions.

He submitted that he was admitted to B D Petit Parsi General Hospital from 12.12.2017 to 14.12.2017

for acute abdominal pain, loss of weight (over 12 kilos in two months) as the treating doctor suspected

malignancy of pancreas. He submitted a claim for Rs.54,400/- which was repudiated by the Insurance Co.

on the grounds that during hospitalization only investigations were done. He submitted that before

getting hospitalized, he was under treatment of Dr Lalkaka since the first week of December 2017 who

advised him several blood tests due to loss of weight (approx.15 kilos in 4 months) and abdominal pain.

As there was no improvement, he was advised to consult Dr Jehanbux Chichgar, Physcian at Breach

Candy Hospital who advised him to get admitted to B D Petit Parsi General Hospital as he was also

suspicious. Before admission to hospital he was advised several blood tests and sonography and during

stay in hospital, CT scan done which showed “Bulky Uncinate Process with a Suspicious Hypodensity.”

He added that thereafter, MRI was advised for further definition which revealed – “ No obvious mass

lesion in pancreas but indicated early pancreatitis.” He submitted that he is 76 years old and lost

considerable weight within a few months and had no choice except to obey the doctor’s advice and to get

admitted in hospital. The treating doctor had certified in his letter dt.06.02.2018 that it was mandatory to

get hospitalized for at least 3 days. The complainant was not agreeable to the repudiation, hence

approached this Forum for settlement of his grievance.


It was contended on behalf of the Respondent that after scrutinizing the treatment papers it was noted

that the Insured was admitted for acute abdominal pain. However, during hospitalization, only

investigations were done which could be done on OPD basis. Since policy terms and conditions state

that hospitalization for diagnostic purpose is non payable, hence the said claim was repudiated under

Exclusion Clause No.4.4.11 which states that, “ Charges incurred at Hospital primarily for

diagnostic, x-ray or laboratory examinations or other diagnostic studies not consistent with or

incidental to the diagnosis and treatment of positive existence or presence of any illness or injury

for which confinement is required at a Hospital.” They stated that they have paid the Insured’s claims

for hospitalization for eye treatment and for stroke.


The Forum observed that the treating doctor’s letter dt.06.02.2018 states that the sonography of abdomen

of the patient indicated SOL of Uncinate Process and so he was admitted to hospital for investigations

and treatment. Thus it is evident that the complainant was admitted only for investigation wherein

sonography, CT Scan and MRI was conducted to rule out malignancy. Further the MRI report revealed –

“No obvious mass lesion in pancreas but indicated early pancreatitis.” Hence the Respondent’s stand as

regards the repudiation of the claim as per the policy terms and conditions is in order. Hence the Forum

does not find any valid reason to intervene in the decision of the Respondent, consequently no relief can


AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr G B Bhumgara

against the total repudiation of the claim for his hospitalization does not sustain. There is no


It is particularly informed that in case the award is not agreeable to the complainant, it would be open for

him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate

under the laws of the land against the Respondent Insurer.


( MILIND KHARAT )

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - MR C C BASANTANI

VS

RESPONDENT : NATIONAL INSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-048-1819-0304


1 Name & Address of the Complainant Mr. C.C. Basantani

Mumbai

2 Policy No:

Type of Policy


Sum Insured

24600650160002549

National Mediclaim Policy

30/09/2016 – 29/09/2017

Rs.3,00,000/- + CB Rs.1,15,000/-

3 Name of Insured


Mr C.C. Basantani

------- do -

4 Name of Insurer National Insurance Co Ltd




8 Nature of complaint Short settlement of claim (cataract)






13(b)

13 Date of Hearing 13/12/2018 at 02.45 pm



b) For the insurer Mr Vijay Dighe, AO, M/s E Meditek TPA

Services Ltd.



Brief Facts of the Case : The complainant was admitted to Netra Retina and Laser Centre for left and right eye Phaco cataract surgery with Tecnis Toric Lens Implantation on 21.09.2017 and 28.09.2017. He preferred a claim with the Insurance Co. for total Rs.1,33,552/- which was settled for total Rs. 73,218/- stating the reasonability and customary clause.

Contentions of the Complainant : The complainant could not be present for the hearing and submitted a letter dt.06.12.2018 prior to the hearing, expressed his inability to attend the hearing since he being a senior citizen and requested to go ahead on the basis of his written submissions.

He submitted that was he was admitted to Netra Retina and Laser Centre for left and right eye

Phaco cataract surgery with Tecnis Toric Lens Implantation on 21.09.2017 and 28.09.2017. He

preferred a claim with the Insurance Co. for total Rs.1,33,552/- which was settled for total Rs.

73,218/- stating the reasonability and customary clause. He stated that he was insured with National

Insurance Co Ltd prior to 1990 and till 2017 he had not claimed anything. He further added that one

has to depend only on the advice of the doctors for one’s treatment and the Insurance Co. cannot

dictate terms on where get the treatment done and from which doctor. The settlement was not

acceptable to him and therefore he requested for reimbursement of the balance claim amount.


It was contended on behalf of the Respondent that the Insured lodged two claims for hospitalization

towards LE Phaco and RE Phaco cataract surgery with Tecnis Toric Lens Implantation at Netra Retina

& Laser Centre. The claims were settled for total Rs.73,218/- against the total claimed amount of

Rs.1,33,552/- deducting Rs.60,334/- invoking the reasonability and customary clause No.3.29 which

states, “Reasonable and customary charges mean the charges for services or supplies, which are

the standard charges for the specific provider and consistent with the prevailing charges in the

geographical area for identical or similar services taking into account the nature of the

illness/injury involved.”

The Respondent clarified that in Health Insurance like any other insurance; a common pool is

created by collection of premium from many policyholders to pay the claims of a few. This pool is

strictly to be utilized for paying the reasonable costs of treatment which is medically necessary to

help the insured recover from illness/disease. This pool cannot be generously used for paying claims

using advanced technology whose results are often no better than the conventional and less

expensive options available unless extensive documents to validate the medical necessity of the

advanced technology/procedure are established. The Respondent highlighted the fact that the

treatment for cataract was done by use of monofocal lenses only in conventional. The option of

lenses available in the market for cataract surgery includes Monofocal, Multifocal, Toric, Trifocal

Toric Lens, Accomodating, Aspheric and Intraocular lenses. They highlighted the fact that the

treatment for cataract disease is done by the use of Monofocal Lenses only in conventional

surgeries. The Co/TPA has a package rate agreement with hospitals in some cities for some specified

procedures including cataract. These package rates have been negotiated by the Co/TPA with

different hospitals for policy holders who are subscribers of their Mediclaim Policy by paying

premium and contributing to the common pool from which the cost of treatment is paid for persons

getting hospitalized. They reiterated that the basic purpose of cataract surgery was to restore the

vision of the patient which was lost due to the cataract disease. This vision restoration can be done

by the conventional surgery using Monofocal Lenses very effectively. If the insured patient opts for

an expensive procedure which is well over the package rate, despite the availability of a standard

and effective cataract surgery giving the same outcome, then the additional expenses incurred for

this expensive procedure is not reasonable and customary for payment from the insurance policy.

For non-PPN cases (reimbursement claims from non network hospitals), the claim is settled up to the

extent of expenses of Monofocal Lenses only, used in conventional surgeries to restore the vision of

the patient which was lost due to cataract disease. In this particular case, the Insured had used

Tecnis Toric Aspheric IOL of Abbott. (The clinical results show that the Tecnis Toric Aspheric IOL of

Abbott delivers the sharpest vision, best low light performance and long term sustainability for

patients with astigmatism). Astigmatism is a refractive error meaning it is not an eye disease or eye

health problem, it is simply a problem with how the eye focuses light). This shows that the Insured

in this case had used the lens for correction of his refractive error and thus the additional expenses

incurred for this procedure is not reasonable and customary. They further added that in the policy

there is a specific named exclusion of Refractive Error Correction (4.8) according to which “Surgery

for correction of eyesight due to refractive error” is excluded from the scope of the policy. They

have compared the charges of other reputed hospitals in the vicinity where it was found that the

package rate for the said surgery at Bombay Hospital, Apex Hospital, Kokilaben Dhirubhai Ambani

Hospital etc were in the range of Rs.18,000/- to Rs.30,000/-. Thus the restriction of the claim

amount to Rs.35,000/- for each eye was done in accordance and in keeping with the spirit of the

policy. Also it was to be noted that cataract surgery is a planned surgery and not an emergency

treatment and the Insured has the option to firsthand contact the Insurance Co. in advance for

availing the benefit of cashless treatment in the network hospitals by which such grievances could

have been handled more efficiently. Thus the reimbursing the Insured as per the package rate for

conventional treatment using Monofocal Lenses is wholly in conformity with the policy provisions of

paying/reimbursing the reasonable cost of cataract treatment.



parties, the Forum observed that in the instant case, the surgery charges are very much on the

higher side even considering the fact that the policy has no capping. There is no doubt that the

individual has every right to go in for the best treatment available but the policy would pay only the

charges which are necessarily and reasonably incurred. It has to be borne in mind that Insurance

Companies are custodians of public money and have to function with a long term perspective to

ensure sustainability of their operations so that at any given point of time they are in a position to

meet all liabilities under the policies which are in force. As such, whenever it is observed that the

charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would

come into operation and even in the absence of a specific capping in the policy, the Company is

within its right to limit the expenses payable for a particular procedure by comparing the charges

prevalent in the same geographical area. Hence going by the comparative charges produced by the

Respondent, the Forum is of the view that it would be in the interest of justice to restrict the further

payable amount to Rs.1,20,000/-less already paid, i.e. Rs.73,218/-. The decision of the Respondent is

therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further amount

of Rs.46,782/-, in favour of the complainant, towards full and final settlement of the complaint.



a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the

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

the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.





(MILIND KHARAT)

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - MS. VIDYA PATWARDHAN

VS

RESPONDENT : BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD. COMPLAINT REF: NO:MUM-G-005-1819-0305


1 Name & Address of the Complainant Ms. Vidya Patwardhan

Mumbai

2 Policy No:

Type of Policy


Sum Insured

OG-17-1911-8408-00000027

Silver Health Policy

27/06/2017 – 26/06/2018

Rs.3,00,000/- + CB 25%

3 Name of Insured


Ms. Vidya Patwardhan

- do -

4 Name of Insurer Bajaj Allianz General Insurance Co. Ltd.

5 Date of Repudiation 03/10/2017

6 Reason for repudiation Hospitalization for diagnostic purpose








13(b)

13 Date of Hearing 11/12/2018 @ 15.45 hrs.



b) For the insurer Dr. Rashmi Sachdev




The complainant was admitted to Bhatia Hospital from 08.08.2017 to 23.08.2017 for swelling of leg. She preferred a claim with the Insurance Co. for Rs.1,56,658/- and the same was rejected by them under the pretext that the hospitalization was only for investigation.


The complainant could not be present for the hearing and submitted a letter dt. 30.11.2018 expressing her inability to attend the same since she is on wheel chair and her representative is out of India. Hence the hearing went ahead on the basis of her written submissions. The complainant has submitted that she was was admitted to Bhatia Hospital from

08.08.2017 to 23.08.2017 for swelling of leg. She preferred a claim with the

Insurance Co. for Rs.1,56,658/- and the same was rejected by them under the

pretext that the hospitalization was only for investigation. The denial was not

acceptable to her and hence requested for reimbursement of the claim.


It was contended on behalf of the Respondent that on scrutiny of claim

documents it was observed that the complainant was admitted for diagnosis of

osteoarthritis and sleep apnoea on 08.08.2017 and discharged on 23.08.2017.

During the course of admission she underwent investigations which did not

require hospitalization and was given oral medications, Inj.B12, Vitamin

supplementations and underwent physiotherapy . The claim was hence repudiated

on the grounds of hospitalization primarily for diagnostic and investigation

evaluation without any active medical or surgical management. The Respondent

added that oxygen for dyspnoea and her haemoglobin count was normal for her

age.


The Forum observed that the medical necessity was obvious in view of h/o

dyspnoea on and off since 3 days with restricted movements of both lower limbs

since 15 days, and complaints of difficulty in breathing during sleep suffered by the

complainant. Therefore the hospitalization cannot be said to be totally

unwarranted and solely for diagnostic purpose. Most importantly it was advised by

the doctor. Hence the Forum directed the Respondent to consider the

hospitalization of 5 days and post hospitalization physiotherapy and pay the claim

of Rs.99,318/- in view of the seriousness of the ailment . Hence the Respondent’s

decision does not sustain and is intervened by the following Order :

AWARD

Under the facts and circumstances of the case, the Respondent is directed

to pay the admissible amount of Rs.99,318/-, in favor of the complainant,

towards full and final settlement of the complaint. There is no order for any

other relief. The case is disposed of accordingly.

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

following provisions of the Insurance Ombudsman Rules, 2017:



It is particularly informed that in case the award is not agreeable to the

complainant, it would be open for him/her, if he/she so decides to move any

other Forum/Court as he/she may consider appropriate under the Laws of the

Land against the Respondent Insurer.

Dated: This 1st day of March, 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



(Under Rule No. 16/17 of the Insurance Ombudsman Rules, 2017)

OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT MR RAGHUVEER CHOUDHARY

VS

RESPONDENT : STAR HEALTH & ALLIED INS.CO.LTD.


2

Policy No:

Type of Policy


Sum Insured

P/171100/01/2018/006498

Family Health Optima Insurance Plan

27/11/2017 to 26/11/2018

Rs.5,00,000

3

Name of Insured


Mr Rishi R Choudhary

Mr Raghuveer Choudhary

4 Name of Insurer Star Health & Allied Insurance Co.Ltd.


6 Reason for repudiation Hospitalisation for diagnostic purpose






12 Insurance Ombudsman Rules, 2017 13(b)

13 Date of Hearing 02/01/2019 at 03.45 p.m.


a) For the complainant Settled before the hearing

b) For the insurer Settled before the hearing



Brief Facts of the Case : The complainant’s son had been hospitalized at Kokilaben Dhirubhai Ambani

Hospital on 23.02.2018 and discharged on 26.02.2018 for the treatment of

GERD, Vertigo, Left Vestibular Neuritis and Bilateral mild conductive hearing

loss. He lodged a claim with the Insurance Company for Rs.75,046/- which was

rejected on the grounds of hospitalization for diagnostic purpose only. He

submitted that his son was admitted on the advice of the treating doctor. He

didn’t get cashless facility even though the hospital was in the network but since

his son was critical, he got admitted by paying the deposit. He reiterated that he

didn’t know that the case would be treated as OPD as he had full faith in the

doctor of network hospital as they decide the case as inpatient or outpatient.

Since he was not agreeable to the repudiation, he approached this Forum

seeking relief in the matter.

The Forum scheduled a joint hearing of the parties concerned to the dispute on 02.01.2019 at 03.45 p.m. However, in the meantime, the Forum was informed by the Respondent via email dt.26.12.2018 that they had agreed to settle the claim for Rs.68,529/- to resolve the grievance. The complainant agreed for the mutual settlement and confirmed the same. In view of the above, the within mentioned complaint of the complainant stands closed at this Forum. Dated at Mumbai this 7th day of February 2019. ( MILIND KHARAT ) INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mr. Mihir Kiri

V/s.

RESPONDENT : The New India Assurance Co Ltd




Complainant

Mr. MIHIR KIRI

Mumbai - 400 064

2 Policy No:

Type of Policy


Sum Insured

131500/34/15/01/00005032

MEDICLAIM POLICY 2007 (Hospitalization)

27/10/2015 to 26/10/2016

Rs.1,00,000/-

3 Name of Insured


Mr. Mihir L. Kiri

Mr.Kirit Laxmikant Damjibhai

4 Name of Insurer The New India Assurance Co Ltd

5 Date of Repudiation --

6 Reason for Repudiation --








13 (b)

13 Date of Hearing 12TH September’2018 at 11:00 am


a) For the complainant ABSENT

b) For the insurer Mr.Shashi Kant Verma-AO




The complainant’s father was admitted to Evershine Nursing Home from 12.10.2016 to

14.10.2016 for treatment of New Onset Seizure with Respiratory Tract Infection. He

preferred a claim with the Insurance Co. for Rs.32,244/- and the same was settled for

Rs.20,249/- with deductions under various heads.


The complainant remained absent for the hearing despite serving him the notice in advance

and rescheduling the hearing which was on 14.06.2018 wherein he remained absent. Hence

his written submissions were taken on record. He submitted that his father was admitted to

Evershine Nursing Home from 12.10.2016 to 14.10.2016 for treatment of New Onset Seizure

with Respiratory Tract Infection. He preferred a claim with the Insurance Co. for Rs.32,244/-

and the same was settled for Rs.20,249/- with deductions under various heads. He was not

agreeable to the amount deducted proportionately. He stated that he paid whatever the

doctor charged and necessary for his father’s treatment. The settlement made by the

Insurance Co. was not acceptable to him. He requested for the reimbursement of the balance

claim amount.


The Respondent submitted that Insured was entitled to a room rent of Rs.2,000/. i.e. 2% of

Rs.1,00,000/- for ICU hence payable amount was Rs.4,000/- for 2 days admission , hence

excess amount of Rs.4,400/- was deducted against total amount of Rs.8,400/- as per policy

terms and conditions. Hence the other charges like consultant charges, lab charges, hospital

service charge were scaled down proportionately on the basis of the room rent category as

per Clause 3.1 which reads, “Payment of room, boarding and nursing expenses incurred at

the Hospital shall not exceed 1% of the sum insured per day. In case of admission to

Intensive Care Unit or Intensive Cardiac Care Unit, reimbursement or payment of such

expenses shall not exceed 2% of the sum insured per day. In case of admission to a

room/ICU/ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all

other expenses incurred at the Hospital, with the exception of cost of medicines shall be

affected in the same proportion as the admissible rate per day bears to the actual rate per

day of room rent/ICUICCU charges.” The other deductions were made for non medical

expenses and registration charges which are non payable as per policy.

Forum’s observations: The Forum observes that the complainant was paid room rent as per the eligible sum

insured, i.e.2% of sum insured and all the other charges, viz. doctors charges, investigation

charges paid as per the same entitlement. The deductions made for non medical expenses

and surcharge as per policy terms and conditions were in order. The Forum agrees with the

Respondent’s contention regarding the above deductions. Hence the Forum does not find

any valid reason to intervene with the decision of the Respondent, consequently no relief

can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Mihir L Kiri

against the short settlement of the claim for his father’s hospitalization does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it

would be open for him/her, if he/she so decides to move any other Forum/Court as he/she

may consider appropriate under the laws of the land against the Respondent Insurer.

Dated: This 4th day February, 2019 at Mumbai.

( MILIND KHARAT )

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE ((Under Rule No. 16/17 of Insurance OmbudsmanRules, 2017)


CASE OF COMPLAINANT -MR UDAY GHOSALKAR

VS

RESPONDENT : MAX BUPA HEALTH INSURANCE CO LTD



1 Name & Address of the Complainant Mr Uday Ghosalkar

Mumbai

2 Policy No:

Type of Policy


Sum insured

30437418201601 Heartbeat Family First Gold 5 lacs + 50 lacs

24.06.2015to 23.06.2015

Rs.65,00,000/-

3 Name of Insured

Name of the policy holder Mrs Meenakshi Ghosalkar

Mr Uday Ghosalkar










Ombudsman Rules 2017 Under Rule 13(b)

13 Date of Hearing 23.10.2018 at 03.45 pm


a) For the complainant Mr Uday Ghosalkar

b) For the insurer Ms Shital Patwa




The complainant’s wife was hospitalized at Global Hospital & Research Centre from

19.11.2016 to 01.12.2016 for treatment of Large Cervical Fibroid with Bilateral Hydroureter

and Hydronephrosis and underwent total Laparoscopic Hysterectomy+Bilateral Salpingo-

Oophorectomy+Cystoscopy with Bilateral DJ Stenting and Instillation of Antifungal Agent.

A claim was lodged for Rs. 1,12,222/- which was repudiated arbitrarily by the Insurance Co..

Contentions of the Complainant:

The complainant appeared and deposed before the Forum. He submitted that his wife was

hospitalized at Global Hospital & Research Centre from 19.11.2016 to 01.12.2016 for

treatment of Large Cervical Fibroid with Bilateral Hydroureter and Hydronephrosis and

underwent total Laparoscopic Hysterectomy+Bilateral Salpingo-Oophorectomy+Cystoscopy

with Bilateral DJ Stenting and Instillation of Antifungal Agent. A claim was lodged for

Rs.1,12,222/- which was repudiated arbitrarily by the Insurance Co. He stated that his wife’s

ailment was not pre-existing and the same is also mentioned in the hospital discharge

summary. The doctor advised her to go for surgery on urgent basis. The Insurance Co.’s

repudiation of the claim was not acceptable to the complainant; hence he approached this

Forum for the settlement of his grievance.


It was contended on behalf of the Respondent that on verification of the claim which was

reported for medical expenses, it was found that the claim did not fall under the purview of

the policy for the reason that the Insured had not disclosed the pre-existing medical

conditions at the time of filling the proposal form. They reiterated that it was pertinent to

mention that in the proposal form, the Insured had answered in the negative to all the

important medical questions. During investigation of the claim, it was noted that the Insured

was suffering from complaints of Dysmenorrehal and Menorrhagia and UTI since 2013 and

had taken treatment for the same. In case the Insurance Co. would have been made aware of

the adverse medical conditions of the Insured, they would not have issued the policy or would

have issued the policy applying appropriate exclusions. The said non disclosure directly

affected the underwriting norms of the Insured and the policy was issued under material

concealment. The treating doctor, during investigation, clearly stated that the Insured had

started his treatment on 17.01.2013 for menorrhagia, abdominal colic and white discharge

(prior to policy issuance). In the same statement, the treating doctor stated that the Insured

was admitted on 18.11.2016 with abdominal pain and that the pain related to menorrhagia

due to fibroid. He also mentioned that she had

heavy bleeding problems since 2013. The prescription from Dr R K Kanitkar clearly

mentioned that the Insured underwent a PAP smear and USG which clearly showed she had a

bulky uterus

as on 05.03.2012. There was statement of the Insured wherein she, herself, has declared that

she was having heavy flow during periods since last 20 years and the fact that she was taking

treatment since past 3 years. Hence the claim was repudiated as per Clause 5 which reads,

“Disclosure to Information Norm : The policy shall be void and all premium paid

hereon shall be forfeited to the Company, in the event of misrepresentation, mis-

description or non-disclosure of any material fact.”

Observations/Conclusion of the Forum :

The Forum noted that the complainant’s wife was suffering from complaints of

Dysmenorrehal and Menorrhagia and UTI since 2013 and had taken treatment for the same.

In case the Respondent would have been made aware of the adverse medical conditions of the

Insured, they would not have issued the policy or would have issued the policy applying

appropriate exclusions. The said non disclosure directly affected the underwriting decision of

the Respondent and the policy was issued under material concealment. Therefore the

Respondent’s repudiation of the claim is justified on the above grounds. The Forum,

therefore, does not find any valid reason to intervene in the decision of the Respondent;

consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Uday

Ghosalkar against the repudiation of the claim for his wife’s hospitalization does not

sustain. There is no order for any other relief. The case is dismissed of accordingly.

It is particularly informed that in case the award is not agreeable to the complainant, it would

be open for him/her, if he/she so decides to move any other Forum/Court as he/she may

consider appropriate under the laws of the land against the Respondent Insurer.


( MILIND KHARAT )

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT – MR SANTOSH KUMAR SULTANIA

VS RESPONDENT : UNITED INDIA INSURANCE CO LTD

COMPLAINT NO : MUM-G-051-1819-0218 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the complainant Mr Santosh Kumar Sultania

Mumbai


1207042817P100597423 Individual Health policy 07.04.2017 to 06.04.2018 Rs.3,00,000/-

3 Name of Insured Name of he policy holder

Mrs Manju S Sultania Mr Santosh Kumar Sultania

4 Name of Insurer United India Insurance co.Ltd.








12 Complaint registered under Insurance Ombudsman rules 2017

13(b)



a) For the complainant Mr Santosh Kumar Sultania

b) For the insurer Ms Gitanjali Contractor, Sr BM



Brief Facts of the Case: The complainant’s wife was admitted to Agrawal Eye Hospital for right eye cataract surgery on 01.02.2018. He preferred a claim with the Insurance Co. for total Rs.70,181/- and the same was settled by them for Rs.30,181/- deducting Rs.40,000/-.


The complainant appeared and deposed before the Forum. He submitted that his wife was admitted to

Agrawal Eye Hospital for right eye cataract surgery on 01.02.2018. He preferred a claim with the

Insurance Co. for total Rs.70,181/- and the same was settled by them for Rs.30,181/- deducting

Rs.40,000/-. He contended that his wife, the claimant was covered under Individual Health policy with

sum insured of Rs.3,00,000/- wherein she is entitled to actual expenses or 25% of the sum insured

whichever is less, per eye for her cataract claim. He pointed out that this was her first claim from the

inception of the policy, i.e. from 01.04.2000 hence the settlement was not acceptable to him. He

requested for reimbursement of the balance claim amount.


It was contended on behalf of the Respondent that at the time of claim processing, they have settled the

claim for Rs.30,181/- deducting Rs.40,000/- as per the policy terms and conditions of PPN package. The

Insured underwent Phacoemulsification + IOL implantation under local anesthesia and the GIPSA-PPN

package rates for the referred surgery at prime tertiary care hospitals across Mumbai are Rs.24,000/- for

Jaslok Hospital, Cumballa Hospital, Jupiter Hospital, Fortis Hospital and MGM Hospital. The

Respondent intimated to the hospital to provide cashless facility to the Insured and the Insured was also

informed to avail cashless facility in the same hospital. As per the Customer Information Sheet, Sl.No.5 –

Payment basis-c. In cities where PPN Network is available, cashless will be restricted to PPN

and claim payments as per agreed tariff.” They clarified that Multifocal lens was used, the cost of

which was Rs.30,000/- which is a betterment lens and the same is not payable as per policy terms and

conditions.

Forum’s Observations/Conclusion :

On scrutiny of the documents produced on record and after hearing the depositions of both the parties,

the Forum questioned the Respondent why the Insured was not charged as per PPN rate by the hospital.

The Forum noted that the hospital is under the PPN package and has charged the Insured more than the

agreed rate. Hence the Insured cannot be penalized for the same and the excess charged outside the PPN

package rate to be recovered from the hospital. Multifocal lens is used for correction of eyesight which

leads to betterment which is not payable as per the policy terms and conditions. Hence taking the above

in consideration, the Respondent to consider Unifocal lens charges and pay the balance admissible

expenses of Rs.19,819/- to the complainant. The decision of the Respondent is therefore intervened by

the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further

amount of Rs.19,819/- for right eye cataract surgery, in favour of the complainant, towards full

and final settlement of the complaint.









(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr. Vishnu Nagarsenkar

V/s RESPONDENT : The Oriental Insurance Co. Ltd – Panaji

COMPLAINT REF: No: MUM-G-050-1718- 1243 AWARD No: IO/MUM /A/GI/ /2018-19


Complainant Mr. Vishnu G. Nagarsenkar GOA - 403 001

2 Policy No:


131800/48/2016/1440

Mediclaim Insurance Policy ( Individual ) 29/01/2016 to 28/01/2017 Rs.2,00,000/-


Mrs. NEELA V. NAGARSENKAR M/S COSME FARMA LABORATORIES LTD.

4 Name of Insurer The Oriental Insurance Co Ltd. Panaji, GOA 5 Date of Repudiation 6 Reason for Repudiation No active line of treatment. 7 Date of receipt of the complaint 28th Oct., 2017 by e-mail. 8 Nature of complaint Total Repudiation of Claim 9 Amount of claim Rs.69,343/-

10 Date of Partial Settlement --- 11 Amount of relief sought Rs.69,343/- 12 Complaint registered under Indian


13 (b) 13 Date of Hearing 5TH OCT.’2018 at 10:30 am - PANAJI, GOA 14 Representation at the hearing:-

a) For the complainant Mr. Vishnu Nagarsekar b) For the insurer Mr.S. Arlekar -Div.Incharge; Dr Ralph

Mascarenhas & Mr S.Ghatwal - MDindia Health.

15 Complaint how disposed AWARD 16 Date of Award/Order 06.02.2019

Brief Facts of the Case : The complainant’s wife Ms Neela Nagarsenkar, was admitted to Manipal Hospital, Panaji for Ca Left Breast post operation, post chemotherapy with Bilateral Pleural Effusion on 18.11.2016 and discharged on 19.11.2016. Complainant lodged three claims under the policy for post hospitalization expenses. Respondent repudiated two claims on the ground that the treatment is not covered under Day Care Procedures and could be managed on OPD basis.


The complainant appeared and deposed before the Forum. He submitted that his wife Ms Neela

Nagarsenkar, was admitted to Manipal Hospital, Panaji for Ca Left Breast post operation, post

chemotherapy with Bilateral Pleural Effusion on 18.11.2016 and discharged on 19.11.2016 Complainant

lodged three claims under the policy for post hospitalization expenses and only one claim for

Rs.1,28,007/- was settled for Rs.1,12,215/-. Respondent repudiated the other two post hospitalization

claims on the ground that the treatment is not covered under Day Care Procedures and could be

managed on OPD basis. The complainant furnished a certificate dated 20.01.2017from the treating

Oncologist who stated that the patient was a known case of cancer of left breast operated on 26.01.2007,

after that she received 6 cycles of chemotherapy and then radical radiotherapy. She came November 2016

with skin nodules on left breast and breathlessness and chest x-ray showed pleural effusion and skin

nodule biopsy done showed metastasis in skin nodule. She was advised to take Inj.Faslodex (Fulvestrant)

every 15 days for 3 injections followed by once a month for 6 injections and review. The complainant

requested for settlement of the claims.


It was contended on behalf of the Respondent that the Insured was hospitalized on 18.11.2016 for

breathlessness on and off on exertion since 1 month, post CA Breast Postchemo with Bilateral Pleural

Effusion. They settled the first claim for Rs.1,12,215/- after deducting Rs.15,792/- as per policy

condition and same informed to him. The second claim was submitted on 24.01.2017 for Rs.34,750/-

(post hospitalization) and only Rs.350/- was considered for payment as it was within 60 days and the

other bills were outside the 60 days period.

The treating doctor advised 6+3 number of injections; post chemotherapy vide his certificate

dt.20.01.2017. The same was repudiated since there was no hospitalization of minimum 24 hours, it was

outside the 60 days of main hospitalization and did not fall under day care treatment. The Respondent

stated that more injections were to be administered and the same was awaited, as intimated to them by

the Insured. The claims were rejected as per Exclusion Clause 2.17 of the policy which reads,

“Hospitalization means admission in a hospital for a minimum period of 24 hours inpatient care

consecutive hours except for specified procedures/treatments, where such admission could be

for a period of less than 24 consecutive hours.” This treatment is not a Day Care procedure and is

payable only if part of chemotherapy/radiotherapy or related hospitalization or as pre/post

hospitalization expenses of an admissible claim.

Observations/Conclusion: It is noted that Cancer is a multifactorial disease and is one of the leading causes of death worldwide. The contributing factors include specific genetic background, chronic exposure to various environmental stresses and improper diet. All these risk factors lead to the accumulation of molecular changes or mutations in some important proteins in cells which contributes to the initiation of carcinogenesis. Chemotherapy is an effective treatment against cancer but undesirable chemotherapy reactions and the development of resistance to drugs which results in multi-drug resistance are the major obstacles in cancer chemotherapy. So alternative formulations are in practice these days which are liposomes, resistance modulation, hormonal therapy, cytotoxic chemotherapy and gene therapy. One of the most fundamental changes found in cancer cells is the presence of mutations in the genes that are responsible for causing cell growth (oncogenes). The defective proteins produced by these altered genes are prime candidates for targeted therapy. Targeted therapy is one of the major modalities of medical treatment for cancer. As a form of molecular medicine, targeted therapy blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth, rather than by simply interfering with all rapidly dividing cells (e.g. with traditional chemotherapy). Targeted cancer therapies are expected to be more effective than older forms of treatments and less harmful to normal cells. Monoclonal antibodies (MABs) are a specific type of therapy made in a laboratory. They can be used as targeted therapy to block an abnormal protein in a cancer cell. They can also be used as an immunotherapy. MABs work by recognising and finding specific proteins on cancer cells. Each MAB recognises one particular protein. So different MABs have to be made to target different types of cancer. They work in different ways depending on the protein they are targeting and some work in more than one way. Falsodex is a hormonal drug. It is an estrogen receptor antagonist indicated for the treatment of hormone receptor (HR)-positive metastatic breast cancer in postmenopausal women with disease progression following antiestrogen therapy. Breast cancer cells need the hormone estrogen in order to grow. Fulvestrant works by blocking the effect of estrogen, slowing tumor cell growth. FASLODEX (fulvestrant) injection is administered intramuscular; hence admission to the hospital is not required and is possible on OPD basis. This Forum has received a number of complaints against non-settlement of claims for such injections. It is noted that some Companies are paying claims for treatment by way of these injections even when given in isolation while some other Companies who were also paying such claims earlier, have now taken a stand that it is admissible only when given as a part of chemotherapy/ radiotherapy or as pre & post hospitalization expenses for related hospitalization. The basic ground for denial of these claims is that it is an OPD procedure and hence beyond the scope of the policy. On an examination of all the facts/documents produced before the Forum by the Complainant and the Company, the Forum is of the view that :

As per information collected from various websites, both chemotherapy and targeted therapy are two effective methods for cancer therapy. Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents) as part of a standardized chemotherapy regimen. It may be given with a curative intent. However while Chemotherapy can also kill the normal cells when eliminating the cancer cells, the normal cells can survive the targeted therapy, when the growth of cancer cells is limited.

The antibodies used in cancer therapy are engineered to specifically target certain types of cancer cells. When such antibodies are copied over and over in a lab, the result is a monoclonal antibody therapy, a treatment consisting of millions of identical antibodies aimed at the same molecules on tumor cells. As researchers have found more antigens linked to cancer, they have been able to make MABs against more and more cancers. Thus, the

treatment undergone by the patients seems to be one of advancement of medical technology in as much as over the past couple of decades, more than a dozen monoclonal antibodies have been approved by the Food and Drug Administration to fight cancer, particularly breast, head and neck, lung, liver, bladder, and melanoma skin cancers, as well as Hodgkin lymphoma.

Insurance Companies are denying the claims stating that this procedure does not require hospitalization. At the same time it is also noted that it is not an ordinary injection which can be taken on OPD basis but is given as an intravenous infusion in a sterile environment by a specialist and requires monitoring of the patient’s condition for some time thereafter.

The various certificates issued by the medical practitioners indicate that the treatment is similar to chemotherapy which is paid for by the Companies as a day care procedure.

It is pertinent to note that basically these injections are a part of cancer treatment. Targeted therapy is generally preferred by doctors when the cancer does not respond to other therapies, has spread or is inoperable. Treatment of cancer patients with antibodies when used alone or in combination with chemotherapy and radiotherapy, or conjugated to drugs or radioisotopes, prolongs overall survival in cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced in treating diseases and Insurers can bring about new products/modify existing products. It is a sad fact that the mediclaim policies are not updated to keep in pace with such changes.

The facts that have been brought to the notice of the Forum clearly indicate that this procedure is an advancement of medical technology where minimum of 24 hours of hospitalization is not required. . The various certificates issued by the specialists indicate divided opinion amongst the doctors regarding the procedure being an inpatient or outpatient one. Besides, the treatment is a prolonged one wherein depending upon the prognosis the patient has to be administered more number of injections. Though the Forum is able to appreciate the case of the complainant in expecting the Insurer to settle the claims in as much as the treatment being a prolonged one and repetitive in nature but for all the reasons stated above, it would be reasonable that the complainant bears a part of the expenses. Accordingly, taking a practical view of the facts of the case, which has been brought to the notice of this Form, the Forum comes to the conclusion that the cost of the treatment is to be shared equally between the complainant and the Company.








The Forum is also inclined to advise the Company to take a call on covering the expenses for the above treatment on appropriate terms and conditions under their mediclaim policy and if the Company takes a decision to exclude this from the scope of mediclaim policy, appropriate steps have to be taken by the Company to inform the mediclaim policy holders sufficiently in advance to avoid proliferation of such complaints in future. Therefore in the facts and circumstances of the case, the decision of the Company is set aside by the following order.

AWARD

Under the facts and circumstances of the case, The Oriental Insurance Co. Ltd. is directed to

settle the claims for 50% of the admissible amount in favour of the complainant, towards full and

final settlement of the complaint.



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

d) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.





(MILIND KHARAT)

INSURANCE OMBUDSMAN

.



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT - MR MUKESH G AHUJA

VS RESPONDENT : UNITED INDIA INSURANCE CO LTD

COMPLAINT NO:MUM-G-051-1718-0468 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant

Mr Mukesh G Ahuja

Mumbai

2

Policy No:

Type of Policy


Sum Insured

0221002816P105520858

Individual Health Policy

12/08/2016 to 11/08/2017

Rs.2,25,000/-

3

Name of Insured


Mr Mukesh G Ahuja

do -

4 Name of Insurer United India Insurance Co.Ltd.


6 Reason for repudiation Exclusion Clause No.4.9






12 Insurance Ombudsman Rules, 2017 13(b)

13 Date of Hearing 24/08/2018 at 01.15 p.m.


a) For the complainant Mr Vishal Ahuja, complainant’s son

b) For the insurer Mrs Geeta P Kathe, AM



Brief Facts of the Case : The complainant was admitted to Tata Memorial

Centre from 02.01.2017 to 07.01.2017 for treatment for NODAL RECURRENCE,

CTo N2b Mo, previously treated for Ca Oral cavity and admitted for

Chemotherapy. Patient Reformed smoker and h/o smoking 8-10 Cigarettes per

day since last 30 years. He preferred a claim with the Insurance Co. for

Rs.1,46,904/-and the same was repudiated by the Respondent on the ground

that the ailment was related to chronic smoking history.

Contentions of the Complainant: The complainant’s son appeared and

deposed before the Forum. He contended that his father was admitted to Tata

Memorial Centre from 02.01.2017 to 07.01.2017 for treatment of recurrent

cancer of the oral cavity. He preferred a claim with the Insurance Co. for

Rs.1,46,904/-and the same was repudiated by them on the false assumption

that the ailment was related to chronic smoking history. He submitted that the

claim was denied as per clause No.4.9 which reads, “Convalescence, general

debility; run-down condition or rest cure, obesity treatment and tits

complications including morbid obesity, congenital external disease or

defects or anomalies, treatment relating to all psychiatric and psychosomatic

disorders, infertility, sterility, venereal disease, intentional self-injury and the

use of intoxication drugs/alcohol”. The repudiation mentioned ‘use of

intoxication drugs/alcohol’, i.e. cigarette smoking and the definition of

‘intoxication’ in the English dictionary is ‘to make drunk’. The complainant’s

son clarified that his father stopped smoking in the year 1992 and that

cigarette smoking is not ‘intoxicating’. His father has cancer since the last eight

years and his earlier seven claims had been settled by the Insurance Co. Hence

he requested for the settlement of his claim.

Contentions of the Respondent: The Respondent submitted that on review of

the claim documents it was observed that the Insured had history of smoking

and the current ailment was related to chronic smoking history since 30 years

which was not disclosed. The same is not covered as per Exclusion Clause 4.9

which reads, “Convalescence, general debility; run-down condition or rest

cure, obesity treatment and tits complications including morbid obesity,

congenital external disease or defects or anomalies, treatment relating to all

psychiatric and psychosomatic disorders, infertility, sterility, venereal

disease, intentional self-injury and the use of intoxication drugs/alcohol”.

His earlier claims were erroneously settled since there was no mention of any

smoking habits anywhere in the hospital papers. In the present hospitalization

papers, there is a clear mention of the Insured’s habitual history of smoking 8-

10 cigarettes daily for 30 years, hence the claim stood repudiated.

Forum’s observations/conclusions: The Forum observed that the complainant

had history of smoking 8-10 cigarettes daily for 30 years and the same was not

mentioned in the earlier hospitalization claim documents. It is common

knowledge that smoking has very strong relations with Oral Cancer. Any

treatment taken related to ailments due to smoking is not payable under the

terms and conditions of the policy. Hence the Forum is of the view that the

Respondent’s stand is in order. The Forum, therefore, does not find any good

ground to intervene with the stand taken by the Respondent and passes the

following Order.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr

Mukesh Gopaldas Ahuja against the repudiation of the claim for his

hospitalization does not sustain.



other Forum/Court as he/she may consider appropriate under the laws of the

land against the Respondent Insurer.

Dated: This 25th day of January, 2019 at Mumbai.

( MILIND KHARAT )

INSURANCE MBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR SATYAPAL YADAV

Vs RESPONDENT : ROYAL SUNDARAM ALLIANCE INSURANCE CO

LTD COMPLAINT NO : MUM-G-038-1718-1398 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Satyapal Yadav Mumbai


SY00000017000101, CY00046257000102 Smart Cash Plan 10.12.2016 to 09.12.2017, 28.07.2016 to 27.07.2017 Daily cash benefit Rs.10,000/-, Rs.1,000/-


Mr Satyapal Yadav - do -

4 Name of Insurer Royal Sundaram Alliance Insurance Co.Ltd


6 Reason for repudiation Hospitalisation not warranted, OPD treatment







Rule 13(b)

13 Date of Hearing 31.10.2018 at 02.45 pm


a) For the complainant Mr Satyapal Yadav

b) For the insurer Mr Parshant Arora



Brief facts of case : The complainant was admitted to Sanjeevani Surgical & General Hospital, Malad East for treatment of acute gastroenteritis from 19.01.2017 to 23.01.2017. He submitted a claim for Rs.55,000/- which was repudiated by the Insurance Co. on the grounds of hospitalization not warranted.


The complainant appeared and deposed before the Forum. He submitted that he was admitted to

Sanjeevani Surgical & General Hospital, Malad East for treatment of acute gastroenteritis from

19.01.2017 to 23.01.2017. He submitted a claim for Rs.55,000/- which was repudiated by the

Insurance Co. on the grounds of hospitalization not warranted.

He contended that he claimed under two Cash Benefit Policies which he was holding. He stated

that his main claim was settled by ICIC Lombard General Insurance Co.Ltd. under cashless and

for his hospital cash benefit he claimed from Royal Sundaram Alliance Insurance Co.Ltd. The

same was repudiated on the ground that hospitalization was not required. He questioned the

Insurance Co. that if his illness did not require hospitalization how was his main claim settled.

He was not agreeable to the repudiation and requested for the settlement of the claim.


It was contended on behalf of the Respondent that on receipt of the claim documents and

hospital records, it was clear that the ailment for which the Insured was allegedly admitted did

not require hospitalization and was a clear case wherein treatment had been rendered only on

conservative basis. Further, the papers clearly revealed gross discrepancies. From the same, it

was evident that the hospitalization appeared to have been stage managed for the purpose of

claiming daily cash benefit and hence making unlawful gain from the insurance policy. It was

further submitted that the claim history of the Insured reveals that he has been frequently getting

admitted to hospital for minor ailments for which hospitalization is not required, just to benefit

wrongfully from the daily cash benefit policies. Under the subject policies, previous year, the

Insured had lodged a claim with respect to hospitalization for acute gastroenteritis at Sai Kripa

Hospital from 23.01.2016 to 25.01.2016 which was repudiated. Thereafter he claimed for

hospitalization from 31.03.2016 to 04.04.2016 and the same duly settled for Rs.40,000/-.

However he has repeatedly got admitted for the ailment which does not warrant any

hospitalization and which can be treated on outpatient basis. From the above, it was clear that

the Insured was trying to profit out of the daily benefit insurance by getting admitted for a

number of days and getting a lumpsum amount.


The Forum observed that the claim history of the complainant reveals that he has been

frequently getting admitted to hospital for minor ailments, i.e. gastro enteritis for which

hospitalization is not required. The policy pays only for hospitalization if warranted and if the

doctor thinks it necessary. The same is not within the scope of the policy coverage. The

Respondent’s stand as regards the repudiation of the claim as per the policy terms and

conditions is in order. Hence the Forum does not find any valid reason to intervene in the

decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Satyapal Yadav

against the total repudiation of the claim for his hospitalization does not sustain.





( MILIND KHARAT )

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - SHRI PRATEEK JAIN

V/s.

RESPONDENT : HDFC ERGO General Insurance Co Ltd – Mumbai

COMPLAINT REF: No: MUM-G-018-1718- 1412 AWARD No: IO/MUM /A/ GI/ /2018-19 1 Name & Address of the Complainant Mr. Prateek Jain

Andheri (W), Mumbai - 400 053 2 Policy No:

Type of Policy


316108 000294 280200 Health Medisure Classic Insurance

10/08/2016 to 09/08/2017 Rs.5,00,000. + CB Rs.50,000.

3 Name of Insured


Mr. Prateek Jain

-do-

4 Name of Insurer HDFC ERGO General Ins. Co Ltd - Mumbai 5 Date of Repudiation 30/06/2017 6 Reason for Repudiation Hospitalization for diagnostic purpose 7 Date of receipt of the complaint 23.11.2017 8 Nature of complaint TOTAL REPUDIATION OF CLAIM 9 Amount of claim Rs.43,275/- 10 Date of Partial Settlement -- 11 Amount of relief sought Rs.43,275/- 12 Complaint registered under Indian


13 Date of Hearing 23rd October 2018 at 2:45 pm 14 Representation at the hearing:- a) For the complainant Mr. Prateek Jain b) For the insurer Mr. Milton Kinny, Mr Saahiel Sharma,Dr

Sachin Nevse 15 Complaint how disposed Award 16 Date of Award/Order 08.02.2019


The complainant was hospitalized at SRV Hospital on 31.05.2017 to 01.06.2017 for

palpitation under evaluation. A claim was lodged for Rs.43,275/- which was repudiated

arbitrarily by the Insurance Co.

Contentions of the Complainant:

The complainant appeared and deposed before the Forum. He submitted that he was

hospitalized at SRV Hospital on 31.05.2017 to 01.06.2017 for palpitation under evaluation. A

claim was lodged for Rs.43,275/- which was repudiated arbitrarily by the Insurance Co. He

submitted the treating doctor’s certificate stating that he was admitted for palpitation

perspiration and “ghabrahat” and in view of changes in ECG, he got admitted for further

management and investigation. The doctor further mentioned that the final diagnosis was

vertigo. The Insurance Co.’s repudiation of the claim was not acceptable to the complainant;

hence he approached this Forum for the settlement of his grievance.


It was contended on behalf of the Respondent that on verification of the claim documents it

was observed that the complainant was hospitalized for investigation/evaluation only.

Further as per letter dt.05.06.2017 from the treating doctor, the Insured was diagnosed with

cervical spondylosis and as per letter dt.06.07.2017; the final diagnosis was occurrence of

vertigo. The Respondent pointed out that it was interesting to note that while the discharge

summary dt.01.06.2017 does not refer to any diagnosis and/or treatment given for any

specific illness or disease but the letter dt.05.06.2017 refers to diagnosis of cervical

spondylosis and more surprisingly letter dt.06.07.2017 refers to diagnosis of occurrence of

vertigo. In the light of the above description of true facts based on the documents provided

by the Insured, it primarily appears that post discharge, as an afterthought letters

dt.01.06.2017 and 06.07.2017 were procured in order to receive money from the insurer sans

honest intention. They added that also, it is also the case of the Insurer that diagnosis of

cervical spondylosis and occurrence of vertigo, if at all taken to be true for a moment though

denied in the circumstances described above, does not qualify the Insured to claim under

the policy in the absence of active line of treatment as per Exclusion under Section-D-

25which reads, “Charges incurred primarily for diagnosis, x-ray or laboratory

examinations or other diagnostic studies not consistent with or incidental to the diagnosis

and treatment even if the

same requires confinement at a Hospital/nursing Home.” All other reports were normal,

hence it was concluded that the Insured was admitted for evaluation only.


The Forum observes that the Insured was admitted to the hospital in view of palpitation and

difficulty in breathing which was primarily for diagnostic purpose, however there was no

diagnosis made with reference to any ailment and all reports were normal. The Forum

agrees with the Respondent’s contention that the procedure was done for diagnostic

purpose. Hence the Forum does not find any valid reason to intervene with the decision of

the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by

Mr. Prateek Jain against the repudiation of the claim for his

hospitalization does not sustain.



may consider appropriate under the laws of the land against the Respondent Insurer.

( MILIND KHARAT )

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MR UMAKANT WADKE

VS RESPONDENT : STAR HEALTH & ALLIED INSURANCE CO LTD


1 Name & Address of the Complainant Mr Umakant Wadke Mumbai


P/171113/01/2017/009765 Family Health Optima Insurance Plan 27.09.2016 to 26.09.2017 Rs. 4,00,000/-


Mrs Smita Wadke Mr Umakant Wadke








11 Amount of relief sought Rs. 66,580/-


Rule 13(b)

13 Date of Hearing 24.10.2018 , 03.00 p.m.


a) For the complainant Mr Umakant Wadke

b) For the insurer Dr Arvind Thakkar



Brief facts of case : The complainant’s wife was admitted to MIB Super Speciality Hospital from 26.06.2017 to 29.06.2017 for treatment of right renal calculus. He preferred a claim with the Insurance Co. for

Rs.2,08,796/- and the same was settled for Rs.1,15,169/- on the grounds of the prevailing market rates which are standard charges for the specific provider.

Contentions of the complainant:

The complainant appeared and deposed before the Forum. He contended that his wife was

admitted to MIB Super Speciality Hospital from 26.06.2017 to 29.06.2017 for treatment of right

renal calculus. He preferred a claim with the Insurance Co. for Rs.2,08,796/- and the same was

settled for Rs.1,15,169/- on the grounds of the prevailing market rates which are standard

charges for the specific provider. He contended that he failed to understand that since when, the

rates of all surgeon fees and other hospital charges have been standardized? He pointed out that

each and every hospital and surgeon has different charges. Surgeon fees are based on his

experience and hospital charges on its status. A patient goes to a particular surgeon because

he/she has faith in the surgeon and he/she will not like to be treated by any unknown doctor.

He explained that the total payments were made to the hospital and proper receipt for the same

was obtained. He stated that if the Insurance Co.’s expert panel felt that his doctor charged

more they should have enquired with the said doctor. He further stated that he had paid the

charges as per the hospital norms which should be payable to him by the Insurance Co or they

should prescribe in the clause, the standard rates of each disease. The term just and reasonable is

very vague and the Insurance Co.s rob the gullible public with these terms.


It was contended on behalf of the Respondent that the Insured was insured with The New India

Assurance Co.Ltd. from 27.09.2011 to 26.09.2015 and ported to Star Health & Allied Insurance

Co.Ltd. from 27.09.2015 till 26.09.2018. The policy was issued after endorsing “Treatment of

disease related to Calculus diseases of urinary system” as pre-existing disease as per the proposal

form. The Respondent stated that the Insured claimed in the 3rd year of insurance policy. On

scrutiny of documents, it was observed that as per the discharge summary and other medical

records, the Insured was admitted and treated for right renal calculus and the claim processed

and approved for Rs.1,15,169/- . The reason for deduction was as per the “Reasonable and

customary charges which means the charges for services or supplies which are the

standard charges for the specific provider and consistent with the prevailing charges in

the geographical area for identical or similar services, taking into account the nature of

the illness/injury involved.”

The Respondent clarified and wanted to bring to the notice of the Forum that pre-existing

diseases will be covered after four years of completion of policy. Hence the Insured was eligible

for Rs.1,25,000/- whereas they have paid Rs.1,51,169/- i.e. Rs.26,169/- excess.



parties, the Forum observed that in the instant case, the surgery charges are very much on the

higher side even considering the fact that the policy has no capping. There is no doubt that the

individual has every right to go in for the best treatment available but the policy would pay only

the charges which are necessarily and reasonably incurred. It has to be borne in mind that

Insurance Companies are custodians of public money and have to function with a long term

perspective to ensure sustainability of their operations so that at any given point of time they are

in a position to meet all liabilities under the policies which are in force. As such, whenever it is

observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause

of the policy would come into operation and even in the absence of a specific capping in the

policy, the Company is within its right to limit the expenses payable for a particular procedure by

comparing the charges prevalent in the same geographical area. The Respondent’s stand as

regards the settlement of the claim as per the policy terms and conditions is right. Hence the

Forum does not find any valid reason to intervene in the decision of the Respondent,

consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Umakant

Wadke against the short settlement of the claim lodged for his wife’s hospitalization does

not sustain.





( MILIND KHARAT )

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT -MRS LATA DEEPAK KANSARA

VS

RESPONDENT : THE ORIENTAL INSURANCE CO LTD



1 Name & Address of the Complainant Mrs Lata Deepak Kansara

Mumbai

2 Policy No:

Type of Policy


121300/48/2017/8622

Happy Family Floater-2015 Policy

12.03.2017 to 11.03.2018

Sum Insured Rs.3,00,000/- with 10% co-pay

3 Name of Insured

Name of the policy holder Mrs Lata Deepak Kansara

- do -

4 Name of Insurer The Oriental Insurance Co Ltd.










Rule 13(b)



a) For the complainant Mrs Lata Deepak Kansara

b) For the insurer Mr Kiran D Kharse, AO, Dr Shweta Gupta, M/s Raksha

TPA Pvt Ltd. 15 Complaint how disposed Award


Brief facts of the case : The complainant was admitted to Roshni Eye Clinic on 23.09.2017 for left eye cataract

Phacoemulsification with foldable IOL implant. She preferred a claim with the Insurance Co.

for Rs.52,949/- and same was settled for Rs.24,000/- on the grounds of the Reasonability and

Customary Clause.


The complainant appeared and deposed before the Forum. She contended that she was

admitted to Roshni Eye Clinic on 23.09.2017 for left eye cataract Phacoemulsification with

foldable IOL implant. She preferred a claim with the Insurance Co. for Rs.52,949/- and same

was settled for Rs.24,000/- on the grounds of the Reasonability and Customary Clause. She

pointed out that she was covered under the Mediclaim Policy since last 15 years and there

was no reasonability clause while taking the policy first time. She reiterated that when she

gave intimation about the surgery to the Insurance Co. they did not inform her about any limit

payable for cataract surgery. She was not agreeable to the deductions and requested for the

settlement of her balance claim.


It was contended on behalf of the Respondent that they had compared the charges for the

cataract surgery with other hospitals in the same geographic area in Mumbai in accordance

with the provisions of Clause 3.41 which reads, “the charges for services or supplies which

are the standard charges for the specific provider and consistent with the prevailing

charges in the geographical area for identical or similar services, taking into account the

nature of the illness/injury involved.” Further the Insured had used imported foldable

lenses costing Rs.9,700/- which are medically not necessary for treatment (only unifocal lens

is admissible). Hence they have settled the claim for Rs.24,000/- under the Reasonability and

Customary Clause. They reiterated that the said charges incurred were on the higher side

while comparing the charges with Bombay Hospital & Medical Research Centre, Jaslok

Hospital & Research Centre and S L Raheja Hospital where the cataract package rates are

Rs.25,000/-, Rs.28,000/- and Rs.24,000/-per eye. In the light of the above, the settlement of

Rs.24,000/- was in consonance with the Reasonability and Customary Clause.


The complainant has paid Rs.52,949/- which includes surgeon charges, hospital charges and

lens. The amount paid by the complainant cannot be termed as unreasonable, going by the

charges for cataract in Mumbai.

Therefore, considering this, it was ordered by this Forum to pay the further admissible claim

of Rs.20,000/- to the complainant. Hence the Respondent’s decision is intervened by the

following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to settle

further claim of Rs.20,000/-in favor of the complainant, as full and final settlement of

the complaint. There is no order for any other relief. The case is disposed of

accordingly.

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

of the Insurance Ombudsman Rules 2017 :





( MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : MR MILIND KHARAT CASE OF COMPLAINANT -MRS MASOODA KHAN

VS

RESPONDENT : STAR HEALTH & ALLIED INSURANCE CO LTD




Complainant Mrs Masooda Khan

Mumbai

2 Policy No:

Type of Policy


Sum Insured

P/171114/01/2018/010023

Senior Citizens Red Carpet Insurance

28.11.2017 to 27.11.2018

Rs.2,00,000/-

3 Name of Insured

Name of the policy holder Mrs Masooda Khan

- do -










Insurance Ombudsman Rules 2017 Rule 13(b)



a) For the complainant Mr Shehriyar Khan, complainant’s son

b) For the insurer Dr Arvind Thakkar



Brief facts of case:

The complainant was admitted to Saifee Hospital for treatment of excruciating pain in legs

due to heavy swelling and wounds all over her body due to severe itching from 19.12.2017

and discharged on 22.12.2017. She preferred a claim with the Insurance Co.for Rs.30,188/-

and the same was settled for Rs,17,713/-.


The complainant’s son appeared and deposed before the Forum. He submitted that his mother

was admitted to Saifee Hospital for treatment of excruciating pain in legs due to heavy

swelling and wounds all over her body due to severe itching from 19.12.2017 and discharged

on 22.12.2017. She preferred a claim with the Insurance Co.for Rs.30,188/- and the same

was settled for Rs,17,713/-. He contended that his mother was diagnosed as highly diabetic,

vitamin B12 deficiency and all the tests were advised by the doctor as a routine investigation

for diagnosis of the disease. He further added that during hospitalization, the bills were

forwarded to the Insurance Co for their cashless approval but to their shock and dismay, an

amount of Rs.3,590/- was deducted towards investigations/tests for Vitamin B12, Vitamin D

and HGT on grounds that it was not admissible. Furthermore, 30% was deducted on the

overall bill towards co-payment which neither the Insurance Co. nor their agent had ever

informed the Insured while issuing the policy. The complainant’s son was not agreeable to

the deductions and requested for the settlement of his mother’s balance claim.


It was contended on behalf of the Respondent that the Insured had raised a pre-authorization

request for cashless treatment which was approved for Rs.17,713/- against the final claimed

amount of Rs.30,188/- and communicated to the treating Hospital and also to the Insured.

The deductions were made for expenses on vitamins Rs.3,590/- since not payable as per

Exclusion clause 15 which reads, “Expenses on vitamins and tonics unless forming part of

treatment for injury or disease as certified by the attending physician is not payable.”

The expenses towards non medicals and registration charges, admission charges are not

payable hence deducted. The deduction of Rs.7,592/- was on account of 30% co-pay applied

on the admissible claim as per condition 5 which reads, “This policy is subject to co-

payment of 50% of each and every claim arising out of pre-existing diseases and 30%

of each and every claim for all other claims.”

Forum’s Observations/Conclusions :

The Forum observed that the rights and liabilities of both the Insured and Insurer are strictly

governed by policy of insurance. The Respondent’s stand as regards the deduction of the

claim as per the policy terms and conditions is in order. Hence the Forum does not find any

valid reason to intervene in the decision of the Respondent, consequently no relief can be

granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mrs Masooda

Khan

against the total repudiation of the claim for her father’s hospitalization does not

sustain. There is no order for any other relief. The case is disposed of accordingly.

It is particularly informed that in case the award is not agreeable to the complainant, it would

be open for him/her, if he/she so decides to move any other Forum/Court as he/she may

consider appropriate under the laws of the land against the Respondent Insurer.


( MILIND KHARAT )

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mrs Krishna P. Magdani

V/s. RESPONDENT : The Oriental Insurance Co Ltd


Complainant Mr. Krishna P. Magdani Mumbai

2 Policy No:


131100/48/2017/12693

Oriental Mediclaim Insurance (Individual) 27/10/2016 to 26/10/2017 Rs.5,00,000/-


Mr. PANKAJ MAGDANI MRS. KRISHNA P. MAGDANI

4 Name of Insurer The Oriental Insurance Co Ltd - Mumbai 5 Date of Repudiation -- 6 Reason for Repudiation -- 7 Date of receipt of the complaint 14. 11. 2017 8 Nature of complaint Short settlement of claim 9 Amount of claim Rs.2,34,566/- 10 Date of Partial Settlement 27/06/2017 11 Amount of relief sought Rs.64,912/- 12 Complaint registered under Indian


13 (b)

13 Date of Hearing 11th September’2018 at 1:00 pm 14 Representation at the hearing:- a) For the complainant Mrs. Krishna P Magdani b) For the insurer Mr. Milind Bochgire,AM & Dr. BHARTI -TPA

15 Complaint how disposed Award 16 Date of Award/Order 01.02.2019

Brief Facts of the Case : The complainant was admitted to Lilavati Hospital & Research Centre from 11.05.2017 to 14.05.2017 for treatment of Adenomyosis with Fibroid Uterus. She preferred a claim with the Insurance Co. for Rs.2,34,566/- and the same was settled for Rs.1,43,082/- deducting Rs.91,484/- under the reasonable and

customary clause.


The complainant appeared and deposed before the Forum. She submitted that she was admitted to

Lilavati Hospital & Research Centre from 11.05.2017 to 14.05.2017 for treatment of Adenomyosis with

Fibroid Uterus. She preferred a claim with the Insurance Co. for Rs.2,34,566/- and the same was settled

for Rs.1,43,082/- deducting Rs.91,484/- under the reasonable and customary clause which was totally

unjustified. The deductions were made against room rent. She pointed out that she stayed in room of

Rs.3,500/- as rent whereas as per her eligibility she was entitled to a room rent of Rs.5,000/- hence the

deductions were not acceptable to her. The major deductions were towards doctor visit charges, OT

charges, Surgeon fees, anesthetist charges amounting to Rs.64,912/- under the heading reasonable and

customary and medically necessary charges.


It was submitted on behalf of the Respondent that the hospitalization OT charges, Surgeon charges,

anesthetist charges and doctor visit charges were disallowed as these charges of Lilavati Hospital &

Research Centre were on the higher side. Hence they compared the charges for the present ailment, of

other hospitals including tertiary care hospitals in metro cities and the charges for the same ailment were

very much on the lower side. This shows that the charges in the instant case were found to be exorbitant

and hence the deductions were made as per Condition No.2.37 which reads, “Reasonable and

Customary Charges: means the charges for services or supplies, which are the standard charges

for the specific provider and consistent with the prevailing charges in the geographical area for

identical or similar services, taking into account the nature of the illness/injury involved.”


On scrutiny of the documents produced on record and after hearing the depositions of both the parties,

the Forum observed that in the instant case, the surgery charges are very much on the

higher side even considering the fact that the policy has no capping. There is no doubt that the individual

has every right to go in for the best treatment available but the policy would pay only the charges which

are necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are

custodians of public money and have to function with a long term perspective to ensure sustainability of

their operations so that at any given point of time they are in a position to meet all liabilities under the

policies which are in force. As such, whenever it is observed that the charges are unreasonably high, the

“Reasonable & Customary charges” Clause of the policy would come into operation and even in

the absence of a specific capping in the policy, the Company is within its right to limit the

expenses payable for a particular procedure by comparing the charges prevalent in the same

geographical area.” The Respondent’s stand as regards the settlement of the claim as per the policy

terms and conditions is in order. Hence the Forum does not find any valid reason to intervene in the

decision of the Respondent, consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mrs Krishna P Magdani

against the short settlement of the claim for her hospitalization does not sustain.



under the laws of the land against the Respondent Insurer.

Dated: This 1st day of February, 2019 at Mumbai.

( MILIND KHARAT )

INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVI-MUMBAI & THANE


OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Ms. Aloysia D’Souza

V/s. RESPONDENT : The United India Insurance Co Ltd – Mumbai

COMPLAINT REF: No: MUM-G-051-1718- 2161 AWARD No: IO/MUM /A/GI/ /2018-19

1 Name & Address of the Complainant Ms. ALOYSIA D’SOUZA Mumbai - 400 093


021600/28/16/p1/08887825 INDIVIDUAL HEALTH POLICY 08/10/2016 to 07/10/2017 Rs.1,50,000/- Gold


Ms. ALOYSIA D’SOUZA -do--

4 Name of Insurer The United India Insurance Co Ltd - Mumbai 5 Date of Repudiation 09.11.2017 6 Reason for Repudiation No active line of treatment.

7 Date of receipt of the complaint 13.03.2018 8 Nature of complaint Total Repudiation of Claim 9 Amount of claim Rs.25,000/- 10 Date of Partial Settlement -- 11 Amount of relief sought Rs.25,000/- 12 Complaint registered under Indian


13 Date of Hearing 6th September’2018 at 12:15 pm 14 Representation at the hearing:- a) For the complainant Mrs.Aloysia J. D’Souza b) For the insurer Mr. Alok Verma -AO & Dr. Shweta Gupta – Raksha

TPA 15 Complaint how disposed Award 16 Date of Award/Order 01.02.2019

Brief Facts of the Case : The complainant was admitted to Holy Spirit Hospital from 05.08.2017 to 06.08.2017 for treatment of Accelerated HTN and TIA under evaluation. She preferred a claim with the Insurance Co. for Rs.25,000/- and the same was rejected by them under the pretext that the hospitalization was only for investigation.


The complainant appeared and deposed before the Forum. She submitted that she

was admitted to Holy Spirit Hospital from 05.08.2017 to 06.08.2017 for treatment

of Accelerated HTN and TIA under evaluation. She preferred a claim with the

Insurance Co. for Rs.25,000/- and the same was rejected by them under the

pretext that the hospitalization was only for investigation and that there was no

active line of treatment.

She contended that she had been religiously renewing her policy since inception

from 08.10.1997 (21 years). It was not true that she was hospitalized only for

investigation purpose as confirmed from her treating doctor vide his letter

dt.13.12.2017 who advised her to be admitted in hospital. She clarified that she

had sudden onset of lower lip tingling sensation and heaviness of tongue and

cheek and on examination her BP was 190/100 due to TIA and accelerated HTN.

The denial was not acceptable to her and hence requested for reimbursement of

the claim.


It was contended on behalf of the Respondent that on scrutiny of claim

documents it was observed that only investigations were done in the current

hospitalization and there was no active line of treatment. Hence the claim was

repudiated as per clause 4.11 which reads, “Charges incurred at Hospital or

Nursing Home primarily for diagnosis, x-ray or laboratory examination 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.”

They further submitted that other than oral medication and MRI no other active

treatment was given.


The Forum observed that the medical necessity was obvious in view of sudden

onset of lower lip tingling sensation, heaviness of tongue and high BP suffered by

the complainant which could lead to paralysis and therefore the hospitalization

cannot be said to be totally unwarranted and solely for diagnostic purpose. Most

importantly it was advised by the doctor. Hence the Forum directed the

Respondent to consider the claim in view of the seriousness of the ailment . Hence

the Respondent’s decision does not sustain and is intervened by the following

Order :

AWARD

Under the facts and circumstances of the case, the Respondent is directed

to pay the admissible amount of Rs.19,993/-, in favor of the complainant,

towards full and final settlement of the complaint. There is no order for any


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

following provisions of the Insurance Ombudsman Rules, 2017:





other Forum/Court as he/she may consider appropriate under the Laws of the

Land against the Respondent Insurer.


(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr. CHETAN S. DANI

V/s.

RESPONDENT : United India Insurance Co Ltd – Mumbai


Complainant Mr. CHETAN S. DANI Grant Road, Mumbai - 400 007

2 Policy No:


0221002816P 116056049

Individual Health Policy 04/03/2017 to 03/03/2018 Rs.3,50,000/-


Ms. AYUSHI DANI MR. CHETAN DANI

4 Name of Insurer United India Insurance Co Ltd - Mumbai 5 Date of Repudiation -- 6 Reason for Repudiation -- 7 Date of receipt of the complaint 14. 03. 2018 8 Nature of complaint SHORT SETTLEMENT OF CLAIM 9 Amount of claim Rs.58,767/- 10 Date of Partial Settlement 31/05/2017 11 Amount of relief sought Rs.58,767/- 12 Complaint registered under Indian


13 (b) 13 Date of Hearing 6th September’2018 at 12:00 noon 14 Representation at the hearing:- a) For the complainant Mr. CHETAN DANI b) For the insurer Mrs. VIDISHA V. PARAB

15 Complaint how disposed AWARD 16 Date of Award/Order 5th February,2019


The complainant’s daughter was admitted to Agrawal Clinic Surgical and General Hospital on

16.05.2017 for Laparoscopic Cholecystectomy and discharged on 17.05.2017. He preferred a claim

with the Insurance Co. for Rs.1,05,500/- and the same was settled by them for Rs.46,733/- deducting

Rs.58,767/- stating the reasonability and customary clause.


The complainant appeared and deposed before the Forum. He submitted that his daughter was

admitted to Agrawal Clinic Surgical and General Hospital on 16.05.2017 for Labaroscopic

Cholecystectomy and discharged on 17.05.2017. He preferred a claim with the Insurance Co. for

Rs.1,05,500/- and the same was settled by them for Rs.46,733/- deducting Rs.58,767/- stating the

reasonability and customary clause

He explained that his daughter was first admitted to Bhatia Hospital 13.05.2017 to 16.05.2017 with

complaints of Acute Calculus Cholecystitis. The hospital is nearer to his home but since the estimate

there was given for Rs.2.80 lakhs to Rs.3 lakhs he shifted his daughter to Malad for surgery to cut

down the expenses. Despite this, the Insurance Co made deductions in the claim. He furnished a

certificate dt.15.01.2018 from the treating surgeon stating the clarifications regarding the

Anesthesia charges and Anesthetist’s Fees. He contended that the Surgeon’s Charges at the hospital

are very much reasonable than other hospital in the area performing the same surgery. Hence the

settlement was not acceptable to him and he requested for reimbursement of the balance claim

amount.


It was contended on behalf of the Respondent that on scrutiny of the claim documents it was found

that the Surgeon charges and OT charges were on the higher side. Hence they compared the charges

of other hospitals including tertiary care hospitals in metro cities of the same grade for the present

ailment and surgery charges for the same ailment which were very much on the lower side. This

showed that the consultant charges in the present hospital were exorbitant and hence the same was

deducted under the Reasonable and Customary

Clause 3.33 of the policy which reads, “Reasonable and customary charges mean the charges for

services or supplies, which are the standard charges for the specific provider and consistent with

the prevailing charges in the geographical area for identical or similar services taking into account

the nature of the illness/injury involved.” The other deductions were made for non medical items

as per terms and conditions of the policy.



parties, the Forum observed that in the instant case, the surgery charges are on the higher side even

considering the fact that the policy has no capping. There is no doubt that the individual has every

right to go in for the best treatment available but the policy would pay only the charges which are

necessarily and reasonably incurred. It has to be borne in mind that Insurance Companies are

custodians of public money and have to function with a long term perspective to ensure

sustainability of their operations so that at any given point of time they are in a position to meet all

liabilities under the policies which are in force. As such, whenever it is observed that the charges are

unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into

operation and even in the absence of a specific capping in the policy, the Company is within its right

to limit the expenses payable for a particular procedure by comparing the charges prevalent in the

same geographical area. Hence going by the comparative charges produced by the Respondent, the

Forum is of the view that it would be in the interest of justice to restrict the further payable amount

to Rs.51,250/-. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay a further amount

of Rs.51,250/-, in favour of the complainant, towards full and final settlement of the complaint.









(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr. Arun Janardan Karangutkar

V/s. RESPONDENT : The Oriental Insurance Co Ltd - Mumbai

COMPLAINT REF: No: MUM-G-050-1718- 2209 AWARD No: IO/MUM /A/GI/ /2018-19 1 Name & Address of the Complainant Mr. ARUN JANARDAN KARANGUTKAR

Mumbai - 400 014 2 Policy No:


131102/48/2018/2751

PNB-ORIENTAL ROYAL MEDICLAIM POLICY 14/06/2017 to 01/06/2018 Rs.5,00,000/-


Mr. ARUN JANARDAN KARANGUTKAR --do--

4 Name of Insurer The Oriental Insurance Co Ltd - Mumbai 5 Date of Repudiation 01.09.2017 6 Reason for Repudiation PRE-EXISTING DISEASE 7 Date of receipt of the complaint 20. 03. 2018 8 Nature of complaint Total Repudiation of Claim Amount. 9 Amount of claim Rs.4,05,551/- 10 Date of Partial Settlement -- 11 Amount of relief sought Rs.4,05,551/- 12 Complaint registered under Indian


13 Date of Hearing 6th September’2018 at 2:45 pm 14 Representation at the hearing:- a) For the complainant Mr. Ashwin Arun Karangutkar (SON) b) For the insurer Mrs. Gayatri S. Patil – Astt. (T)


Brief facts of case: The complainant was admitted to Kokilaben Dhirubhai Ambani Hospital & Medicalo Research Institute for treatment of Malignant Neoplasm of Prostrate from 22.o8.2017 to 28.08.2017 .He preferred a claim with the Insurance Co. for Rs.4,05,551/-and the same was repudiated on the ground that the ailment was pre-existing.

Contentions of the complainant : The complainant’s son appeared and deposed before the Forum. He submitted that his father was

admitted to Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute for treatment of

Malignant Neoplasm of Prostrate from 22.08.2017 to 28.08.2017 .He preferred a claim with the

Insurance Co. for Rs.4,05,551/-and the same was repudiated on the ground that the ailment was

pre-existing. He pointed out that according to the Insurance Co. his ailment is a pre-existing disease

because there was a break in policy of 1 year. However, as per his knowledge, he has all the policies

of last three years from the date when he purchased his first policy from 15.05.2015 till 01.06.2018.

He clarified that he submitted his cheque for renewal of policy to Punjab National Bank through

whom he took the policy and they sent the cheque on the same day by courier to the Insurance Co.

who received it on 08.05.2017 but the same was sent on 16.06.2017 and policy issued from

14.06.2017 to 13.06.2018 instead of 15.05.2017 to 14.05.2018 which was totally inappropriate.

Hence there was no break in policy and the claim should be reconsidered favourably. Hence the

rejection of his claim was unwarranted and unfair and he requested for the settlement of his father’s

claim.


It was contended on behalf of the Respondent that on scrutiny of the claim documents it was

observed that the claimant was admitted for Ca Prostrate from 22.08.2017 to 28.08.2017. As the

claimant was a k/c/o carcinoma of prostrate since 18.05.2015, the same is a pre-existing disease

since there is a break in policy of 1 year. Hence the claim was not admissible as per policy clause 4.1.

which reads, “Pre-existing health condition or disease or ailment/injuries: Any

ailment/disease/injuries/health condition which are pre-existing (treated/untreated,

declared/not declared in the proposal form), in case of any of the insured person of the family,

when the cover incepts for the first time, are excluded for such insured person up to 3 years of this

policy being in force continuously. For the purpose of applying this condition, the date of

inception of the first indemnity based health policy taken shall be considered, provided the

renewals have been continuous and without any break in period, subject to the portability

condition. 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.”

Forum’s Observations/Conclusions :

The Forum observed that the complainant has given his cheque in time on 06.05.2017 before the

renewal date. The bank has issued a letter dt. 18.09.2017 wherein they have stated that the cheque

was debited by the Respondent on 16.06.2017 and policy issued erroneously, from 14.06.2017 to

01.06.2018. The policy should have been issued from 15.05.2017 to 14.05.2018, hence there is no

gap in the policy period. Nonetheless, the Forum has pointed out that although the Respondent has

established the continuation benefit of the policy. However since the policy stipulates pre-existing

diseases covered after three years of completion of policy and the complainant was suffering from

carcinoma of prostrate since 18.05.2015 which falls under the 3rd year, the claim will not be

considered as per the pre-existing clause. Therefore, the Respondent’s stand as regards the

repudiation of the claim as per the policy terms and conditions is in order. Hence the Forum does

not find any valid reason to intervene in the decision of the Respondent, consequently no relief can


AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr Arun J Karangutkar

against the total repudiation of the claim lodged for his hospitalization does not sustain.





( MILIND KHARAT )

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - Mr. Tushit V. Amin V/s.

RESPONDENT : The National Insurance Co Ltd – Mumbai




Complainant

Mr. Tushit V. Amin

Mumbai - 400 007

2 Policy No:

Type of Policy


Sum Insured

261300/48/16/8500003549


16/08/2016 to 15/08/2017

Rs.5,00,000/- + CB Rs.2,00,000/-

3 Name of Insured


Mst. Turvasu T. Amin

Mr. TUSHIT V. AMIN

4 Name of Insurer National Insurance Co Ltd


6 Reason for Repudiation --


8 Nature of complaint Short Settlement Of Claim






13 (b)

13 Date of Hearing 11th September’2018 at 12:00 Noon


a) For the complainant Mr. Vikram K Amin, father of complainant

b) For the insurer Ms. Harsha Temkar-DM & Dr. Chavan-M/s Heritage

Health Insurance TPA Pvt Ltd. 15 Complaint how disposed Award

16 Date of Award/Order 5th February, 2019

Brief Facts of the Case:

The complainant’s son underwent a surgical removal of plate from his previously fractured

arm in Jaslok Hospital on 25.05.2017. He preferred a claim with the Insurance Co.for

Rs.1,70,694/- and the same was settled by them for Rs.1,44,070/-.


The complainant’s father appeared and deposed before the Forum. He submitted that his

son preferred a claim with the Insurance Co.for Rs.1,70,694/- for the hospitalization of his

grandson and the same was settled by them for Rs. 1,44,070/-.

He pointed out that a deliberate confusion was created whilst authorizing the estimate and

against the request for ‘A’ class procedure for Rs.1,80,000/-, the authorization was given for

Rs.1,40,000/- for ‘B’ class hospitalization. When this was pointed out, the TPA assured the

complainant that the same would be corrected at the time of discharge and ‘A’ class

authorization would be granted immediately on presenting the bill and he would not be

required to make any payment. However, at time of discharge, even after waiting for hours

this was not sorted out by the TPA and hence the complainant discharged his son after

making payment of Rs.30,338/-. Later the Insurance Co. put forward a new reason for

deduction of Rs.20,670/- towards Assistant Doctor charges, no consultation note and partly

paid, Anesthetist’s visit charges He contended that he was agreeable to the deductions

made for non medical and registration charges but not satisfied with the abovementioned

disallowed amount. He furnished a detailed certificate dt.09.06.2017 from the treating

Orthopedic Surgeon who stated that removal of the plate required care and caution and

hence he required an Assistant and the prerogative to use an Assistant was his and could

not be questioned going by the qualifications and expertise. The complainant requested for

the settlement of the balance claim.


The Respondent submitted that the Insured approached them for cashless medical treatment

and Rs.1,44,840/- was approved. The Insured claimed for Rs. 1,70,694/- and the same was

settled by them for 1,44,070/- deducting Rs.20,670/- towards Assistant Doctor charges, no

consultation note and partly paid Anesthetist’s visit charges. They contended that the

Assistant Doctor charges were not payable and Anesthetist’s visit charges were not justified.


The Forum observed that the complainant had furnished the Orthopedic Surgeon’s

certificate dt.09.06.2017 who stated that removal of the plate required care and caution and

hence he required an assistant. Hence the deductions for Assistant Doctor charges and

Anesthetist visit charges to be considered. Therefore, considering these above facts, it was

ordered by this Forum to pay the balance claim to the complainant. Hence the Respondent’s

decision is intervened by the following Order:

AWARD


balance claim of Rs.20,670/- in favor of the complainant, as full and final settlement of the


The attention of the complainant and the Insurer is hereby invited to the following



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

Ombudsman.


insurers.


( MILIND KHARAT)

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - Mr. Dilip Vasudev Parab

V/s.

RESPONDENT : The Oriental Insurance Co Ltd.




Complainant

Mr. DILIP VASUDEV PARAB

Malad (W ), Mumbai - 400 064

2 Policy No:

Type of Policy


Sum Insured

131102/48/2017/8782

PNB-ORIENTAL ROYAL MEDICLAIM

POLICY

27/01/2017 to 26/01/2018

Rs.5,00,000/-

3 Name of Insured


Mr. DILIP VASUDEV PARAB

--do--

4 Name of Insurer The Oriental Insurance Co Ltd - Mumbai


6 Reason for Repudiation N.A.


8 Nature of complaint Dis-continuation of policy at Renewal date

9 Amount of claim --


11 Amount of relief sought Restoration of cancelled Policy at Renewal



13 (c)

13 Date of Hearing 11th September’2018 at 2:15 pm


a) For the complainant Mr. Dilip Vasudev Parab

b) For the insurer Mrs. Gayatri S. Patil – Astt. (T)

15 Complaint how disposed AWARD


Brief Facts of the Case : Complainant was covered under PNB Oriental Royal Mediclaim policy for the period

26.01.2017 – 25.01.2018. He deposited his renewal cheque in his PNB Branch on 02.01.2017.

His policy was cancelled due to cheque dishonored on account of signature mismatch.

Complainant approached this Forum seeking continuity of coverage by renewal of the

policy.


Complainant contended that he had obtained the policy through Punjab National Bank in

the year 2012. He was covered along with his family under PNB Oriental Royal Mediclaim

policy for the period 26.01.2017 – 25.01.2018. He deposited his renewal cheque in his PNB

Branch on 02.01.2017. His policy was cancelled due to cheque dishonour on account of

signature mismatch.

He submitted that he checked his bank statement several times for debit of his cheque

amount but it did not reflect. Meanwhile he received a policy copy but the amount was not

deducted from his account. Later he received a letter from the Insurance Co. dt. 10.02.2017

stating that the cheque was dishonoured due to signature mis match. He did not receive

any such information from the bank about the cheque. Immediately next working day, he

enquired with the bank and they asked him to pay money by demand draft on the same day

itself, i.e. on 13.02.2017. He filled the forms for the DD on 13.02.2017 but due to tension of

his wife’s illness, he accidently wrote wrong date as 27.02.2017 (post dated). After a few

days, he received a policy copy and his January month’s claim for the reimbursement was

held up due to this new policy. On enquiring about the same at the bank he was informed

that the policy was discontinued. He, then, enquired at the Insurance Co. and they asked

him to get a letter from the bank regarding this. He enquired several times, with PNB Bank

and the Insurance Co. but till date his policy continuation was not approved. Hence,

complainant approached this Forum seeking continuity of coverage by renewal of the

policy.


Ms. Gayatri Patil submitted that, first of all, they deny charge of illegitimate discontinuation

of Policy No.131102/48/2017/8782. They contended that the bank had rightly dishonored

cheque No.073118 dt. 16.01.2017 due to signature mismatch as stated by Mr Dilip Parab in

his statement. Here, they want to highlight and the pertinent point to be noted, that the

drawer of the cheque, Mr Parab had not signed the cheque at all, which shows that he was

not willing to make payment to the Insurance Co., therefore there was no scope to settle the

claim in the absence of 64VB Clause, i.e. nonpayment of consideration. As per the 64VB

Clause of Insurance Act, the policy will be valid subject to realization of cheque, otherwise

the policy will be cancelled from inception/renewal. They reiterated that they had already

paid claim of Rs.4,11,512/- under policies of 2014, 2015 and 2016.


After hearing the depositions advanced on behalf of both the parties, Forum requested the

complainant to submit evidence by way of Bank Statement showing the deduction of

February 2017 premium deducted for policy of 02.03.2017. The complainant submitted the

Bank’s letter dt.11.04.2017 which stated that their account holder (the complainant), issued a

cheque for premium Rs.6,991/- towards renewal of the policy but the cheque was

dishonored by the paying bank with the reason ‘Signature does not match’. Subsequently,

he paid the premium by way of Demand Draft. But a new policy was issued to him and not

a continuation of the old policy which he was holding for about 6 years. They further stated

in their letter that their client wants the same old policy to be continued and doesn’t want to

accept a fresh one which is issued to him. On the basis of this letter, the Insurance Co.

granted continuity and allowed the policy period renewal date w.e.f.27.01.2017 to 26.01.2018

since cheque was dishonored due to technical error. In view of the above facts and

circumstances, the decision of the Respondent is therefore intervened by the following

Order:

AWARD

Under the facts and circumstances of the case, The Oriental Insurance Co. Ltd. is directed

to allow continuity benefits and consider the grace period under the policy of the

complainant Mr Dilip Vasudev Parab.

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


a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply

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



Insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - Shri Joseph Mendonsa V/s.

RESPONDENT : United India Insurance Co Ltd – Mumbai




Complainant

Shri Joseph Mendonsa

Mumbai - 400 069

2 Policy No:

Type of Policy


Sum Insured

120900/28/16/P 11817696

Individual Health Policy

05/12/2016 to 04/12/2017

Rs.4,00,000/-

3 Name of Insured


Shri Audric Joseph Mendonsa (son)

Shri Joseph Mendonsa

4 Name of Insurer United India Insurance Co Ltd - Mumbai

5 Date of Repudiation 2nd January,2018

6 Reason for Repudiation No Active Line of Treatment (Inj.Rituximab)


8 Nature of complaint Total Repudiation Of Claim






13 (b)

13 Date of Hearing 6th September’2018 at 11:45 am


a) For the complainant Shri Joseph Mendonsa

b) For the insurer Ms Rujuta S Sawant, DM, Dr Shruti Patekar, M/s

Vidal TPA Pvt Ltd. 15 Complaint how disposed Award

16 Date of Award/Order 5th February, 2019

Brief Facts of the Case : The complainant’s son was admitted to P D Hinduja National Hospital & Research Centre

from 01.12.2017 for treatment of Lupus Vasculitis Nephritis wherein he was administered Inj

Rituximab and discharged on 03.12.2017. He preferred a claim with the Insurance Co.for

Rs.99,355/- and the same rejected on the ground that the treatment given does not require 24

hours hospitalization and can be taken on day care basis.


The complainant appeared and deposed before the Forum. He submitted that his son was

admitted to P D Hinduja National Hospital & Research Centre from 01.12.2017 for treatment

of Lupus Vasculitis Nephritis wherein he was administered Inj Rituximab and discharged

on 03.12.2017. He preferred a claim with the Insurance Co.for Rs.99,355/- and the same

rejected on the ground that the treatment given does not require 24 hours hospitalization

and can be taken on day care basis.

The complainant pointed out that the same reason for rejection was given last year when his

son was admitted for the same treatment and he had to approach this Forum for justice, for

which he received the award. As always, even this year, the Insurance Co. has given an

unjustified judgment without giving even a single opportunity of being heard, the actual

facts of the were that his son was admitted for 3 days and they had mentioned that day care

was needed. The doctor had mentioned in the prescription that hospitalization was

required but still they rejected the claim on the ground that the same could have been done

on day care basis.


It was contended on behalf of the Respondent that the Insured was a diagnosed case of

Systemic Lupus Erythematosus wherein he was administered Inj Rituximab. The

Respondent submitted that for the mentioned treatment, hospitalization is not warranted

and the same could be taken on OPD basis and does not fall under the approved daycare

list. The claim was denied under clause 1.1, 2.1 & 3.10 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 centre in less than 24 hours because of

technologtical and (ii) which would have otherwise require a hospitalization of more than

24 hours. Treatment normally taken on an out-patient basis is not included in the scope of

this definition.” and “Expenses on hospitalization for minimum period of 24 hours are

admissible. However, this time limit is not applied to specific treatments such as

expenses on hospitalization for minimum of 24 hours are admissible. However, this time

limit is not applied to specific treatments.”

Observations/Conclusion:

It is noted that Systemic Lupus Erythematosus is a multifactorial disease. The

contributing factors include specific genetic background, chronic exposure to various

environmental stresses and improper diet. All these risk factors lead to the

accumulation of molecular changes or mutations in some important proteins in cells

which contributes to the initiation of carcinogenesis. Chemotherapy is an effective

treatment against cancer but undesirable chemotherapy reactions and the

development of resistance to drugs which results in multi-drug resistance are the

major obstacles in cancer chemotherapy. So alternative formulations in practice these

days are liposomes, resistance modulation, hormonal therapy, cytotoxic

chemotherapy and gene therapy.

One of the most fundamental changes found in cancer cells is the presence of

mutations in the genes that are responsible for causing cell growth (oncogenes). The

defective proteins produced by these altered genes are prime candidates for targeted

therapy. Targeted therapy is one of the major modalities of medical treatment for

cancer. As a form of molecular medicine, targeted therapy blocks the growth of

cancer cells by interfering with specific targeted molecules needed for carcinogenesis

and tumor growth, rather than by simply interfering with all rapidly dividing cells

(e.g. with traditional chemotherapy). Targeted cancer therapies are expected to be

more effective than older forms of treatments and less harmful to normal cells.

Monoclonal antibodies (MABs) are a specific type of therapy made in a laboratory.

They can be used as targeted therapy to block an abnormal protein in a cancer cell.

They can also be used as an immunotherapy. MABs work by recognising and

finding specific proteins on cancer cells. Each MAB recognises one particular

protein. So different MABs have to be made to target different types of cancer. They

work in different ways depending on the protein they are targeting and some work

in more than one way. Rituximab is a medication used to treat certain autoimmune

diseases and types of cancer like non-Hodgkin’s lymphoma, chronic lymphocytic

leukemia, rheumatoid arthritis, granulomatosis with polyangitis, idiopathic

thrombocytopenic purpura, pemphigus vulgaris and myasthenia gravis. It is given

by slow injection into a vein. It helps in the elimination of B cells (including the

cancerous ones) from the body allowing a new population of healthy B cells to

develop from lymphoid stem cells.

This Forum has received a number of complaints against non-settlement of claims

for such injections. It is noted that some Companies are paying claims for treatment

by way of these injections even when given in isolation while some other Companies

who were also paying such claims earlier, have now taken a stand that it is

admissible only when given as a part of chemotherapy/ radiotherapy or as pre &

post hospitalization expenses for related hospitalization.

The basic ground for denial of these claims is that it is an OPD procedure and hence

beyond the scope of the policy.

On an examination of all the facts/documents produced before the Forum by the

Complainant and the Company, the Forum is of the view that :

As per information collected from various websites, both chemotherapy and

targeted therapy are two effective methods for cancer therapy.

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer

drugs (chemotherapeutic agents) as part of a standardized chemotherapy

regimen. It may be given with a curative intent. However while

Chemotherapy can also kill the normal cells when eliminating the cancer

cells, the

normal cells can survive the targeted therapy, when the growth of cancer

cells is limited.

The antibodies used in cancer therapy are engineered to specifically target

certain types of cancer cells. When such antibodies are copied over and over

in a lab, the result is a monoclonal antibody therapy, a treatment consisting

of millions of identical antibodies aimed at the same molecules on tumor

cells. As researchers have found more antigens linked to cancer, they have

been able to make MAbs against more and more cancers. Thus,the treatment

undergone by the patients seems to be one of advancement of medical

technology in as much as over the past couple of decades, more than a dozen

monoclonal antibodies have been approved by the Food and Drug

Administration to fight cancer, particularly breast, head and

neck, lung, liver, bladder, and melanoma skin cancers, as well as Hodgkin

lymphoma.

Insurance Companies are denying the claims stating that this procedure does

not require hospitalization. At the same time it is also noted that it is not an

ordinary injection which can be taken on OPD basis but is given as an

intravenous infusion in a sterile environment by a specialist and requires

monitoring of the patient’s condition for some time thereafter.

The various certificates issued by the medical practitioners indicate that the

treatment is similar to chemotherapy which is paid for by the Companies as

a day care procedure.

It is pertinent to note that basically these injections are a part of cancer

treatment. Targeted therapy is generally preferred by doctors when the

cancer does not respond to other therapies, has spread or is inoperable.

Treatment of cancer patients with antibodies when used alone or in

combination with chemotherapy and radiotherapy, or conjugated to drugs or

radioisotopes, prolongs overall survival in cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced

in treating diseases and Insurers can bring about new products/modify

existing products. It is a sad fact that the mediclaim policies are not updated

to keep in pace with such changes.



hospitalization is not required. . The various certificates issued by the specialists

indicate divided opinion amongst the doctors regarding the procedure being an

inpatient or outpatient one. Besides, the treatment is a prolonged one wherein

depending upon the prognosis the patient has to be administered more

number of injections. Though the Forum is able to appreciate the case of the

complainant in expecting the Insurer to settle the claims in as much as the treatment

being a prolonged one and repetitive in nature but for all the reasons stated above, it

would be reasonable that the complainant bears a part of the expenses. Accordingly,

taking a practical view of the facts of the case, which has been brought to the notice

of this Form, the Forum comes to the conclusion that the cost of the treatment is to be

shared equally between the complainant and the Company.

The Forum is also inclined to advise the Company to take a call on covering the

expenses for the above treatment on appropriate terms and conditions under their

mediclaim policy and if the Company takes a decision to exclude this from the scope

of mediclaim policy, appropriate steps










have to be taken by the Company to inform the mediclaim policy holders sufficiently

in advance to avoid proliferation of such complaints in future. Therefore in the facts

and circumstances of the case, the decision of the Company is set aside by the

following order.

AWARD

Under the facts and circumstances of the case, United India Insurance Co. Ltd. is directed

to settle the claims for 50% of the admissible amount in favour of the complainant,

towards full and final settlement of the complaint.



e) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply

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


f) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

Insurers.



may consider appropriate under the Laws of the Land against the Respondent Insurer.


(MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE

(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017)


CASE OF COMPLAINANT - MR. AJAY KISHORE JAIN VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Ajay Kishore Jain,

Mumbai-400052.

2 Policy No: Type of Policy


13150034162500003336 & 13150034152500012000

Mediclain Policy 2012. 06.06.2016 TO 05.06.2017 & 29.03.2016 to 28.03.2017

Rs.5,00,000/- CB Rs.25,000/- & Rs. 8,00,000/- CB Rs.1,95,000/-

3 Name of Insured


Mr. Ajay Kishore Jain

4 Name of Insurer New India Assurance Co. Ltd.

5 Date of Repudiation ---

6 Reason for repudiation ---


8 Nature of complaint Short-settlement of claim


10 Amount of Partial Settlement Rs.7,91,734/-



Insurance Ombudsman rules

Under Rule 13(b)



a) For the complainant Mr. Ajay K.Jain

b) For the insurer Mr. Shashikant Verma, A.O.


16 Date of Award/Order 21-01-2019

Brief Facts of the Case : Complainant Mr. Ajay Kishore Jain was admitted to Lilavati

Hospital from 09.01.2017 to 14.01.2017 and undergone Coronary Angiography (CAG) &

Coronary Angioplasty (PTCA) procedure. Complainant has lodged the claim for

Rs.10,83,912/- under two policies i.e (policy no. 13150034162500003336 & policy no.

13150034152500012000 ). The Company has settled the claim for Rs.5,25,000/- Company

further clarified that the Sum Insured of Rs.5,25,000/- under policy No.

13150034162500003336 issued for the period 06.08.2016 to 05.08.2017 has been fully

exhausted. Subsequently the company has paid Rs.2,62,734/- under another policy No.

13150034152500012000 against balance claim amount of Rs.5,58,912/- and disallowed Rs.

2,96,000/- towards surgeon charges under customary and reasonable expenses.

Contentions of the Complainant : Complainant submitted the total claim for

Rs.10,83,912/- under both the policies. Respondent has settled the claim for Rs. 5,25,000/-

under policy No. 13150034162500003336, i.e.(for sum insured of Rs.5,00,000/- + Rs.

25,000/- cumulative bonus.) Under policy No. 13150034162500003336 he has Claimed for

remaining balance claim amount of Rs. 5,58,912/- . However the Company has paid

Rs. 2,62, 734/- and disallowed Rs.2,96,000/- towards surgeon charges, assistant and stand by

surgeon charges which was not acceptable to him. He requested for settlement of the balance

claim amount of Rs. 2,96,000/- towards surgeon charges.

Contentions of the Respondent: The Forum asked the Company the reasons for short payment of the claim. The Company official Mr.Shashikant Verma , Administrative Officer, submitted that a deduction of Rs.2,96,000/- was made from the claim amount as per Rate List of Lilavati Hospital hence surgeon charges deducted and non medical expenses as per policy terms and conditions Clause 4.4.15 of the policy.

Forum’s Observations/Conclusion: The Forum observed although the surgeon charges appear to be higher that the policy holder has already paid as per hospital bill. Respondent has deducted Rs. 2,96,000/- on the basis of Rate List of Lilavati Hospital. The patient has no control over the charges of surgeon/ hospital and is obliged to pay charges levied in the hospital bill. To resolve the complaint and in the interest of justice the company is directed to pay Rs. 1,48,000/- ( 50% of surgeon charges) towards full and final settlement of the above claim. Hence the following order:

AWARD Under the facts and circumstances of the case, The New India Assurance Co. is directed to pay an additional amount of Rs.1,48,000/- over and above the payment already made by them in favour of the complainant Mr. Ajay K.Jain, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This day of 21st January, 2019 at Mumbai.




OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - MR. ARUN GOENKA

VS RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.



1 Name & Address of the Complainant Mr. Arun Goenka Mumbai



113000/34/15/14/01002126 New India Floater Mediclaim Policy

03.09.2015 – 02.09.2016 Rs.10,00,000/-

3 Name of Insured


Mrs. Sunita Goenka

Mr. Arun Goenka


5 Date of Repudiation

6 Reason for repudiation Exclusion 4.4.11 – Hospitalization only for diagnostic purpose



9 Amount of claim Rs.1,31,899/- + Rs.55,762/- (bal. of

previous claim)



12 Complaint registered under Insurance Ombudsman Rules, 2017

Under Rule 13(b)



a) For the complainant Mr. Kushal Goenka - Son

b) For the insurer Mr. Lakshya Tak, A.O. Mr. Sandeep Kumar Verma, A.O. Dr. Mansi – MD India TPA



Brief Facts of the Case : Complainant’s wife Mrs. Sunita Goenka was admitted to Hiranandani Hospital from 09.12.2015 to 12.12.2015 for the treatment of Complex Communited Humeral head fracture left side following an RTA on 08.12.2015. On 10.02.2016 she was again admitted to Criti Care Hospital for the treatment of sarcoidosis from where she was shifted to Lilavati Hospital on 11.02.2016 and discharged on 14.02.2016. Respondent settled the claim for the former hospitalization after disallowing Rs.55,762/- towards unrelated post hospitalization expenses while the claim for latter hospitalization was rejected on the ground that admission for diagnostic purpose is not payable as per exclusion clause no. 4.4.11 of the policy.

Contentions of the Complainant: Mr. Kushal Goenka, son of the complainant duly authorized

by him appeared and deposed before the Ombudsman. He submitted that on 31.10.2015 his

mother fell down while taking a morning walk in the garden and broke her right shoulder for which

she was admitted to Hiranandani Hospital and was operated upon. The claim for the same was

settled by the Respondent. On 08.12.2015 she suffered multiple injuries and broke her left shoulder

in a road accident. She was again admitted to Hiranandani Hospital and operated upon. This claim

was partly settled by the Respondent. Thereafter she had various complaints, persistent fever,

weakness, cough, backache for which she was investigated and it was found that she had three

fractures in her spine as well. As her complaints persisted and she lost weight drastically doctors

advised further tests including PET scan etc. which were suggestive of cancer/T.B. Though cancer

was ruled out through biopsy, she was diagnosed as suffering from sarcoidosis. Since her condition

was very frail and unstable, doctors advised her to be admitted in a hospital before administering

strong drugs and steroids. On 26.01.2016 they consulted senior gastroenterologist Dr. Samir Parikh

who also advised admission to |Lilavati Hospital. However, they did not hospitalize her immediately

but went in for multiple opinions from different senior doctors including Dr. Farokh Udwadia who

agreed to treat her under his overall advice but suggested that for day to day monitoring she be

treated under a good gastroenterologist who is locally more approachable. Hence they went to Dr.

Sanjeev Khanna who again advised them to hospitalize her immediately. As there was no room

available in Lilavati Hospital, they admitted her to Criti Care hospital on 10.02.2016 and she was

shifted to Lilavati Hospital on the next day and was discharged on 14.02.2016. The claim for this

hospitalization was denied by the Respondent stating that there was no active line of treatment. He

argued that his mother was admitted in accordance with the advice of the doctors treating her. The

patient had multiple complications like heart disease, Diabetes, three fractures in the spine,

Osteoporosis, fresh surgery with implants in both shoulders along with trauma and pain incurred

during the accident. She had lost around 15 kgs in a month. It was thus imperative to keep her

under constant observation so as to monitor the effect of strong drugs administered, her sugar

levels and heart functioning. The treatment involved a team of specialist doctors – Diabetologist,

orthopedic, cardiologist, endocrinologist, Gastroenterologist along with a general physician which

was not possible by keeping her at home and hospitalization was required for constant observation

and guidance of the doctors to enable handling any kind of emergency. Hence the reason cited by

the Respondent for rejection of the claim was not acceptable to them. He requested for settlement

of this claim along with the balance post-hospitalization claim for the previous hospitalization.

Contentions of the Respondent: It was contended on behalf of the Respondent that the claim

for the hospitalization of Mrs. Sunita Goenka at H.L. Hiranandani Hospital in December 2015 for the

treatment of fracture lt. Humerus was settled for the admissible expenses including pre & post

hospitalization expenses barring Rs.55,762/- which were related to Saroidosis and not related to the

ailment for which she was hospitalized. As regards the claim for subsequent hospitalization,

Respondent submitted that the patient was admitted to Criti Care Hospital with c/o fever, gen.

weakness, backache for one month and cough for 10 days. She was diagnosed with Sarcoidosis and

was treated with oral medications post her admission to Lilavati Hospital on 11.02.2016 for further

management. From the submitted documents it was evident that during hospitalization patient

underwent several investigations for evaluation and was treated with oral medications without any

IV medications. Thus the hospitalization was primarily for investigations and evaluation and the line

of treatment administered did not warrant hospitalization. Hence the claim stood repudiated as per

Exclusion Clause no. 4.4.11 of the policy which excludes charges incurred at hospital primarily for

diagnosis, x-ray or laboratory examinations not followed by any active line of treatment.

Observations/Conclusion: On scrutiny of the documents produced on record, it is noted that

Mrs. Sunita Goenka had multiple complications like continuous fever, nausea, insomnia, fluctuating

sugar, weakness following her hospitalizations for fractures resulting from accidental injuries on two

back to back occasions. For her said complaints she consulted various specialist doctors and

underwent series of investigations, which showed abnormal results. Further test revealed lymph

nodes in liver and fear of TB/Cancer. She was finally diagnosed with Sarcoidosis and required

treatment by way of steroids. Considering her frail condition, the treatment had to be administered

under the observation and constant monitoring of specialists; hence she was hospitalized on the

advices of her treating doctors. Under such circumstances, a patient would generally not choose to

take a risk by going against the doctor’s advice as the need for hospitalization is decided by the

doctor. Health Insurance policy enjoins liability upon the Insurance Company to pay expenses for

hospitalization done on the advice of a duly qualified medical practitioner. Therefore the argument

of the Company that admission was primarily for diagnostic purpose not consistent with or

incidental to the diagnosis of positive existence and treatment of any ailment for which confinement

is required at a hospital/nursing home, does not sustain. As regards the claim for balance post-

hospitalization expenses of the previous claim, it is observed that these expenses were in respect of

investigations related to subsequent diagnosis of Sarcoidosis and were not related to the treatment

of humerus fracture for which the patient was basically admitted; hence disallowance of the same is

found to be in order in keeping with policy terms and conditions. However, these expenses can be

considered by the Respondent upto the admissible limit as pre-hospitalization expenses of the claim

for her admission to Lilavati Hospital for the treatment of Sarcoidosis itself. The decision of the

Respondent is therefore intervened by the following Order.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd.

is directed to settle the claim including pre & post hospitalization expenses for

the admissible amount in respect of the hospitalization of Mrs. Sunita Goenka

from 10.02.2016 to 14.02.2016, towards full and final settlement of the

complaint.






(MILIND KHARAT)

INSURANCE OMBUDSMAN





CASE OF COMPLAINANT - MR.ASPI P.BILLIMORIA VS

RESPONDENT : THE ORIENTAL INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Aspi P. Billimoria Mumbai

2 Policy No: Type of Policy Duration of Policy/Period

Sum Insured

131102/48/2017/12022 PNB-Oriental Royal Mediclaim Policy 17-03-2017 to 16-03-2018

Rs.5,00,000/-


Mr. Aspi P.Billimoria



6 Reason for repudiation Exclusion Clause 4.7 – Congenital ailment



9 Amount of claim 1) Rs.2,38,938/-



12 Complaint registered under Insurance Ombudsman rules

Under Rule 13(b)



a) For the complainant Mr. Aspi P. Billimoria

b) For the insurer Mrs. Gayatri S.Patil, A.O.



Brief Facts of the Case : Complainant was admitted to The B.D,Petit Parsee General Hospital from 04.09.2017 to 11.09.2017 for the treatment of Meckels’s Diverticulities which is congenital disease of intestine. Respondent denied the claim for the said hospitalization citing Clause 4.7 of the policy which excludes congenital diseases from the scope of the policy.

Contentions of the Complainant : Complainant stated that he had no symptoms of the

disease till the age of 52 years. Suddenly he had developed pain in lower abdomen due to infection.

He submitted that Meckel’s Diverticulitis is not a congenital disease but it is just an anatomical

variation as certified by his treating Doctor Mr. Mehli Nazir letter dated 27.10.2017. The claim was

lodged for Rs.2,38,938/- along with pre-post hospitalization. Complainant approached this Forum

with a complaint against repudiation of the claim by the Respondent.

Contentions of the Respondent : Mrs.Gayatri Patil, Administrative Officer from The Oriental

Insurance Company stated that the complainant was treated for Meckel’s Diverticulum which is

congenital in nature. As per Clause 4.7, Congenital externaland internal disease,

Anomaly/illness/defects are permanently excluded under the policy. Hence the claim could not be

admitted as per policy terms and conditions.

Forum’s observations/Conclusion: The hospital discharge card mentions diagnosis as

Meckel’s Diverticulum. The treating doctor Dr. Mehili A.Nazir in his certificate dt. 27.10.2017 has

mentioned that the ailment is not congenital in nature but an anatomical variation which can occur

at any point in time. The Respondent has obtained expert opinion of an independent specialist who

also confirmed the condition to be of congenital anomaly and its complications can occur at any

age.Clause 4.7 of the Policy permanently excludes all congenital diseases from the scope of the

policy. Though the Forum is able to appreciate the case of the complainant in expecting the Insurer

to settle the claim in view of the nature of the disease, Health Insurance policy is an annual contract

and whenever any dispute arises it is settled based on the terms and conditions of the policy under

which a claim has arisen. It is to be borne in mind that this Forum has the inherent limitations in

going beyond the provisions of the policy contract and the Forum examines cases in detail to see

whether there is any breach of policy provisions while denying a claim and cannot grossly overlook

the terms and conditions clearly spelt out in the policy and also approved by the IRDAI. Under the

facts and circumstances of the case, repudiation of the claim by the Respondent being in accordance

to the policy terms and conditions, the Forum does not find any valid ground to intervene in the

decision of the Respondent in the matter and hence no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Apsi

P. Billimoria against the Respondent does not sustain and is dismissed.




Dated: This 4th day of January, 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - MR. BIREN SHAH




1 Name & Address of the Complainant Mr. Biren Shah Mumbai



1) 14040034172500000104 New Mediclaim 2012 Policy

16.04.2017 – 15.04.2018 Rs.5,00,000/- + C.B. Rs.43,531/- 2) 14040034172500000100 New Mediclaim 2012 Policy

16.04.2017 – 15.04.2018 Rs.3,00,000/-


Mr. Biren Shah


5 Date of Repudiation Various dates

6 Reason for repudiation OPD Treatment


8 Nature of complaint Total Repudiation of claims

9 Amount of claim Rs.14,77,445/- (12 claims)




Under Rule 13(b)



a) For the complainant Mr. Biren Shah

b) For the insurer Ms. Bhavani Jeyaraman, A.M.



Brief Facts of the Case : Complainant was diagnosed with Ca lt. Buccal Mucosa recurrent HNSCC for which he was administered Inj. Nivolumab at Maniar Oncocare Centre on various dates from 07.07.2017 to 25.01.2018. The claims lodged for the same were repudiated by the Respondent on the ground that there was no hospitalization for a minimum period of 24 hours as required as per Clause no. 2.16.1 of the policy

Contentions of the Complainant : Complainant did not appear for the personal hearing on

the scheduled date despite sending him an advance Notice. His written submissions were taken on

record. In his complaint lodged with the Forum he submitted that he was diagnosed with Ca lt.

Buccal Mucosa for which he underwent wide local excision + bilateral neck dissection + infra

temporal fossa clearance + ALT reconstruction under GA on 02.02.2017. In June 2017 when he went

back to Kochi for a routine check-up, it was discovered through Whole Body PET CT scan and biopsy

that he had developed metastasis in lungs and liver and after testing his EGFR and PDL 1 profile, he

was started on new treatment with injection Nivolumab initially for 6 cycles given every fortnightly

beginning from July 2017 upto September 2017. Respondent however rejected the claims for the

said treatment stating that there was no admission for 24 hours. He argued that the injection newly

introduced in the country, is given through IV under the doctor’s supervision in day care set-up. The

Whole Body PET CT scan done in October 2017 proved that the new line of treatment was successful

to the extent of 80% whereby the metastasis had completely vanished and he was advised to

continue further six cycles to remove the remaining local tumour in the mouth, which started from

November 2017 and ended in January 2018 . The PET CT Scan done thereafter confirmed that the

local aggressive cancer tumour in the mouth had greatly reduced in size and the doctors told him

that another six more cycles would make him completely cancer-free and he can then look forward

to not only a period of remission but also go for his second surgery to give him an artificial jaw to

help him eat and drink normally as currently although he can eat through the mouth very slowly, but

is not able to drink, which he has to do through a peg pipe in the stomach. He stated that this

treatment was the only hope to save his life and requested for settlement of the claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that the

complainant underwent surgery for Ca left buccal mucosa on 02.02.2017 and was advised PET CT

scan and biopsy for further management. Discharge Summary dt. 07.07.2017 of Maniar Oncocare

Centre mentions that patient was diagnosed with recurrent HNSCC (Ca lt. buccal mucosa – 1st degree

stage ypT4b, N2b). During admission the patient was administered Inj. Nivolumab and Inj. Erykine

alongwith ranitidine and paracetamol. Nivolumab, marketed as Opdivo is a medication used to treat

cancer and is a targeted therapy. The policy covers parenteral administration of chemotherapeutic

agents only. Nivolumab being a human IgG4 anti PD1 monoclonal antibody, is not covered and

hence claim is repudiated under policy clause 2.16.1 of the policy. It was further contended that the

insured was covered under policy No. 14040034172500000104 continuously since the year 2000 for

S.I. of Rs.5 lakhs. In the previous policy expiring on 15.04.2017 they have settled 5 claims amounting

to more than Rs.5 lakhs for the treatment of cancer. However, he was diagnosed with Oral cancer in

March 2016 whereas the additional policy for S.I. of Rs.3 lakhs and Top Up Mediclaim policy were

taken effective from 16.04.2016. Hence the claims under policy no. 14040034172500000100 were

repudiated as per clause 4.1 – Exclusion of pre-existing disease until 48 months of continuous

coverage have elapsed from date of inception of his first policy.

Observations/Conclusion: On scrutiny of the documents produced on record, it is

noted that the Respondent has paid the claims of the complainant for the treatment of Ca lt.

Buccal Mucosa under policy no.14040034162500000233 upto the full S.I. of Rs.5 lakhs plus

C.B. The claims under the policy renewed w.e.f. 16.04.2017 were however denied stating

that treatment by way of targeted therapy is not covered under policy clause 2.16.1 of the

policy. Further claims lodged under the additional policy with S.I. of Rs.3 lakhs were

rejected under policy Exclusion clause 4.1 stating that the policy incepted in April 2016 while

the complainant was diagnosed with oral cancer in March 2016. However, the Respondent

could not produce any documentary evidence despite being specifically asked to establish

that the disease was pre-existing to the inception of the additional policy effective from April

2016. Hence this stand of the Respondent for denial of the claims is not sustained. As

regards repudiation of claims under policy clause 2.16.1, it may be stated that Cancer is a

multifactorial disease and is one of the leading causes of death worldwide. Chemotherapy is

an effective treatment against cancer but undesirable chemotherapy reactions and the

development of resistance to drugs which results in multi-drug resistance are the major

obstacles in cancer chemotherapy. So alternative formulations are in practice these days

which are liposomes, resistance modulation, hormonal therapy, cytotoxic chemotherapy and

gene therapy.






protein they are targeting and some work in more than one way. Opdivo (Nivolumab) is a

human monoclonal antibody used to treat patients with unresectable or metastatic melanoma

and disease progression following ipilimumab and, if BRAF V600 mutation positive, a

BRAF inhibitor. It works by helping the immune system to slow or stop the growth of cancer

cells, to treat a certain type of head and neck cancer that keeps coming back or that has

spread to other parts of the body or worsened during or after treatment with other

chemotherapy medications. Hormone therapy is often used after surgery (as adjuvant

therapy) to help reduce the risk of the cancer coming back. Sometimes it is started before

surgery (as neoadjuvant therapy) as well.





chemotherapy/ radiotherapy or as pre & post hospitalization expenses for related

hospitalization. The basic ground for denial of these claims is that it is an OPD procedure and

hence beyond the scope of the policy.


and the Company, the Forum is of the view that :












more antigens linked to cancer, they have been able to make mAbs against more and













procedure.

It is pertinent to note that basically these injections are a part of cancer treatment. Targeted

therapy is generally preferred by doctors when the cancer does not respond to other

therapies, has spread or is inoperable. Treatment of cancer patients with antibodies when used alone or in combination with chemotherapy and radiotherapy, or conjugated to drugs or

radioisotopes, prolongs overall survival in cancer patients.











Forum, the Forum comes to the conclusion that the cost of the treatment is to be shared

equally between the complainant and the Company.

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. Ltd.

is directed to settle the claims in respect of the treatment undergone by Mr.

Biren Shah on various dates from 07.07.2017 to 25.01.2018 for 50% of the

admissible amount, towards full and final settlement of the complaint.



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

h) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.












(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE



CASE OF COMPLAINANT - Jyoti N.Tanna VS

RESPONDENT : The Oriental Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G- 050-1819-0037


1 Name & Address of the Complainant Mrs. Jyoti N.Tanna,

Mumbai



121800/48/2017/14782 Mediclaim Insurance Policy(Individual)

22.03.2017 to 21.03.2018 Rs.200000/-


Mrs. Jyoti N.Tanna Mrs.Jyoti N. Tanna

4 Name of Insurer The Oriental Insurance Co.Ltd.

5 Date of Partial Repudiation

6 Reason for partial repudiation Policy Clause 1.2 A(a)


8 Nature of complaint Partial Repudiation of claim

9 Amount of claim Rs.192048/-

10 Amount of Partial Settlement Rs.39761/-


12 Complaint registered under Indian Ombudsman Rules 2017

13 (b)

13 Date of Hearing 26.10.2018 at 03.00 Pm


a) For the complainant Mrs.Jyoti N.Tanna

b) For the insurer Mrs.Manisha Rajesh Koli, Asst. Manager



Brief Facts of the Case : Mrs.Jyoti N.Tanna was covered under the above policy and she was admitted at Lilavati

Hospital and Research Centre from 30.10.2017 to 01.11.2017 for Peptic Ulcer Disease and lodged total claim of Rs.192048/- out of which the Company has settled for Rs.39761/- and deducted the balance amount of Rs.152287/- on the ground of Policy clause proportionate

to entitled room category. The complainant has represented in his written statement that he is not agreeable with the decision of the Company.

Contentions of the complainant

The complainant submitted during the hearing that she was insured for a sum insured of

Rs.200000/-. She has lodged total claim of Rs.192048/- and the Company has settled the

claim for Rs.39761/- and deducted the balance amount of Rs.152287/-. She stated that she

is agreed for deduction of room rent but disagreed for deduction towards Doctor’s charges,

Consultation charges and Investigation charges. She requested in her statement for

settlement of the balance claim.


The Forum asked the Company the reason for the above deductions. The Company

submitted that complainant is insured for a sum insured of Rs.200000/- and she is eligible

for a room rent of Rs.2000/- per day and she has opted for a higher room rent of

Rs.15000/- per day for three days and therefore they have applied the Policy Clause 2.1 A

(a) (proportionate to entitled room category) and have deducted all other charges in

proportion to the opted room rent.

Observations/Conclusion

The Forum observes in this case that complainant has opted for a higher room rent of

Rs.15000/- per day for three days as against her eligibility of Rs.2000/- per day and the

Company has applied Policy Clause 2.1 A(a) (entitled room category) and deducted all other

charges in proportion to the eligible room rent is sustained.

Though the Forum is able to appreciate the concern of the complainant in this regard, it has

also to be borne in mind that whenever any dispute arises, it is settled based on the terms &

conditions of the policy under which a claim has arisen since these form the very basis of

the contract between the parties. The Forum therefore does not find any valid ground to

intervene with the same and pass the following Order.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mrs Jyoti

N.Tanna against The New India Assurance Company Ltd. does not sustain and is

hereby dismissed.




Dated at Mumbai, this 8th day of February, 2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules 2017) OMBUDSMAN :

SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Shailesh M Mehta

VS RESPONDENT : Apollo Health Insurance Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Shailesh M Mehta, 102/B New Madhuban, M G Cross Road No 4,

Behind Patel Nagar, Kandivali West, Mumbai – 400 067


Sum Insured

160800/1119/6000014559-05 Optima Restore Policy 30.03.2017 to 29.03.2018

Rs.500000/-


Ms Binita S Mehta (wife) Mr Shailesh M Mehta

4 Name of Insurer Apollo Health Insurance Co.Ltd.


6 Reason for partial repudiation Multifocal lens (cataract surgery)


8 Nature of complaint Partial Repudiation


10 Date of Partial Settlement




13 (b)




b) For the insurer Ms Akanksha Kapur ManagerClaims




Ms Binita S Mehta wife of the complainant insured under the above policy underwent left

eye cataract surgery on 17.07.2017 and right eye cataract surgery on 24.07.2017 both at

Akshar Eye Clinic and lodged claim of Rs.70804/- and Rs.68081/- respectively and the

Company has settled the claim for Rs.49084/- and Rs.47081/-. On scrutiny of claim

documents it was observed that patient was intolerant to spectacles and on request of the

patient, cataract surgery was done with multifocal lens. The Company settled the claim as

per Open tariff of the hospital for cataract surgery related to monofocal lens. The

complainant has represented in his written statement that he is not agreeable with the

decision of the Company.


The complainant remained absent and he has submitted in his written statement that his

wife underwent cataract surgery for both her eyes and total claim of Rs.138885/- was

lodged and the Company has paid only Rs.96165/- and there is no capping for cataract

surgery in the above policy.


The Respondent submitted that insured patient underwent cataract surgery for both her

eyes at Akshar Eye Clinic and lodged total claim of Rs.138885/-. The Company stated that

on scrutiny of claim documents it was observed that treating doctor has certified that patient

was intolerant to spectacles and patient wanted clear vision without spectacles after cataract

surgery and therefore multifocal lens was used at the request of the patient. The

Respondent stated that cataract surgery could have been performed with a monofocal lens

as medically it was not necessary to have multifocal for cataract treatment. Therefore they

have settled the claim for maximum package of monofocal lens. The Forum asked the

Company whether the above policy excludes usage of multifocal lens to which the Company

replied that usage of multifocal lens means it is a cosmetic surgery and their policy excludes

the same.


The Forum observes in this case that the patient underwent cataract surgery for both her

eyes and lodged total claim of Rs.138885/- and the Company has settled the claim for

Rs.96165/-.

It is noted that though there is no specific capping for cataract surgery under the above

policy, this surgery could have been done with monofocal lens as medically it was not

necessary to have multifocal lens and the Company has settled the above claim for

maximum package amount for monofocal lens. Therefore Company’s stand of limiting the

expense upto usage of monofocal lens is sustained.




the contract between the parties. The Forum therefore do not find any good ground to


AWARD

The complaint of Mr Shailesh M Mehta against M/s Apollo Munich Health Insurance Co.Ltd.

in respect of partial repudiation of his wife’s hospitalization claim for the cataract surgery

for both her eyes on 17.07.2017 and 24.07.2017 at Akshar Eye Clinic does not sustain. The

case is disposed of accordingly.




Dated at Mumbai, this 6th day of February,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 15 (1)/16 of Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Jagdishkumar D Jain

VS RESPONDENT : Apollo Munich Health Insurance Co.Ltd.

COMPLAINT REF: NO:MUM-G- 003-1819-0336 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Mr Jagdishkumar D Jain, Saraswatil Steel,

Shop No 2 168/176 Ram Sadan, 2nd Kumbharwadi Sant Sena Maharaj Marg, Girgaon,

Mumbai - 400004



160700/11051/AA00032704-04 Optima Restore Insurance Policy

11.02.2017 to 10.02.2018 Rs.500000/-

3 Name of Insured


Ms Bharti Jagdish Jain (Wife)

Mr Jagdishkumar D Jain

4 Name of Insurer Apollo Munich Health Insurance Co.Ltd.


6 Reason for repudiation Diagnostic Purpose








13 (b)



a) For the complainant Mr Jagdishkumar D Jain

b) For the insurer Mr Subramanain Narayanan Chief Manager




Ms Bharti Jagdish Jain wife of Mr Jagdishkumar D Jain was admitted from 18.09.2017 to

21.09.2017 at Saifee Hospital with complaints of severe left arm pain and neck pain since

four days. The patient was diagnosed with severe muscle spasm, hypertension, acute

cervical muscle spasm. On scrutiny of documents, it was found that patient was admitted

for investigation and evaluation of the ailment and there is no active line of treatment. As

per Discharge Summary patient had history of Lipoma excision five years back which is not

disclosed while taking policy. The Company has repudiated the above claim on the ground

of Policy Clause Section V©(xii)(f) of the policy (Admission primarily for diagnostic and

evaluation purpose only). The complainant has submitted in his written statement that he is

not agreeable with the decision of the Company.


The complainant submitted during the hearing that his wife had complaints of severe left

arm pain and neck pain and they first consulted Spine Surgeon on OPD and on his advice

she was admitted in the hospital for further investigation and management. She underwent

MRI of cervical spine and nerve conduction test and a Neurological opinion was also taken.

However all the reports were normal and she was treated with injections. The complainant

stated that he has submitted a Certificate from the treating doctor to the Insurance

Company.


The Respondent submitted during the hearing that patient was admitted only for

investigation and evaluation of the ailment and there was no active line of treatment. As

per Discharge summary patient had history of Lipoma excision five years back, hypertension

and migraine and they had asked the insured for all past treatment/investigation papers.


The Forum observes in this case that insured patient had first consulted Spine Surgeon on

OPD with complaints of severe left arm pain and neck pain and as the pain did not subside

the doctor advised the patient to get admitted in the hospital for further investigation and

management. The patient was diagnosed with severe muscle spasm, hypertension, acute

cervical muscle spasm. Patient underwent MRI of cervical spine and nerve conduction test

and a Neurological opinion was also taken.

Though all investigation reports were normal, patient was treated with medicines and

injections and no surgical treatment was offered, the fact cannot be ignored that these

investigations were part of treatment and this was necessary at that time for the patient.

Thus Company’s stand of repudiation of above claim on the ground of Policy Clause Section

V©(xii)(f) of the policy (Admission primarily for diagnostic and evaluation purpose only) is

not justifiable and the Company was directed to calculate the admissible claim amount

payable. Accordingly the Company has informed the forum that the admissible claim

amount payable is Rs.48923/-.

AWARD

M/s Apollo Munich Health Insurance Co. Ltd. is directed to settle the above claim

for an amount of Rs.48923/- towards full and final settlement of above claim and

inform the payment particulars to this Forum. There is no order for any other





thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


Dated at Mumbai this 26th day of February ,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Udhavdas Setpal

VS RESPONDENT : Bajaj Allianz General Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Udhavdas Setpal,

304 Pushpagriha Co.op. Soc.Ltd., J/O 16th Road, P D Hinduja Marg,

Bandra West, Mumbai - 400050

2 Policy No:


OG-17-1907-8408-00000091

Health Insurance Policy 27.03.2017 to 26.03.2018 Rs.200000/-


Mr Udhavdas Setpal Mr Udhavdas Setpal

4 Name of Insurer Bajaj Allianz General Insurance Co.Ltd.


6 Reason for repudiation Non renewal of policy on the ground of Non disclosure


8 Nature of complaint Non renewal of Policy

9 Amount of claim


11 Amount of relief sought


13 (b)



a) For the complainant Mr Satish Setpal (Son)

b) For the insurer Dr Rohini Kulur and Mr Parveez Alam




Mr Udhavdas Setpal and Ms Poonam Setpal are insured under the above policy with all

medical tests done and this policy is ported from M/s National Insurance Co.Ltd. where they

were insured for almost forty years. At the time of renewal on 27.03.2018 M/s Bajaj Allianz

denied renewal of Mr Udhavdas Setpal and only renewed policy of his wife Ms Poonam

Sretpal without giving any reason in writing in spite of sending several mails. He was

verbally informed by his agent that they are denying renewal on the ground of Non

disclosure. The complainant has submitted in his written statement that he is not agreeable

with the decision of the Company.


The complainant submitted during the hearing that this policy is ported from M/s National

Insurance Co.Ltd. where he was insured for almost forty years after undergoing all medical

tests. However at the time of renewal on 27.03.2018 the Insurance Company only renewed

his wife’s policy without giving any reason in writing in spite of sending several emails. He

was verbally informed by his agent that they are denying renewal on the ground of Non

disclosure of history of Carcinoma of vocal cord since 2008. The complainant stated that

his intention was not to hide as he had forgotten to mention the same as the disease was

almost ten years back and he is completely cured from it. He also said that he has not

made any claim in his old policy with M/s National Insurance Co.Ltd. and he has not

increased his sum insured also. The complainant requested the forum to continue coverage

in the above policy as cancellation has left him without any cover and he is a senior citizen

and he has been paying his health insurance premium for several years continuously.


The Respondent submitted during the hearing that cashless request from Holy Family

Hospital where insured was admitted on 15.05.2017 with complaints of sudden giddiness,

vomiting. They had rejected this cashless request as insured had history of Carcinoma of

vocal cord since 2008 as per Discharge Summary of the hospital which is prior to porting of

this policy and the same was not disclosed in the Proposal form at the time of portability of

insurance. Therefore they have not renewed his policy on the ground of Non disclosure and

misrepresentation of facts.


The Forum observes in this case that Mr Udhavdas Setpal and Ms Poonam Setpal is insured

under the above policy with all medical tests done and this policy is ported from M/s

National Insurance Co.Ltd. where they were insured for almost forty years. At the time of

renewal on 27.03.2018 the Company only renewed policy of his wife Ms Poonam Setpal

without giving any reason in writing in spite of sending several mails. It is noted that

insured had history of Carcinoma of vocal cord since 2008 as per Discharge Summary of the

hospital during his admission in May,2017 the claim of which was rejected by the Company.

Though there is a non disclosure on the part of the insured with regard to his health history,

the fact that insured being senior citizen is continuously insured with M/s National Insurance

Co.Ltd. for almost forty years and then ported his policy to this Company also cannot be

ignored. Therefore the Forum directed the Company to reinstate the above policy by

insuring Mr Udhavdas Setpal by restoring continuity benefits after collecting appropriate

premium from the insured. The Company has now informed the Forum that they have

reinstated the above policy by insuring Mr Udhavdas Setpal in the renewed policy. There is

no order for any other relief. The case is disposed of accordingly.

AWARD

M/s Bajaj Allianz General Insurance Co.Ltd. is directed to reinstate the above

policy by insuring Mr Udhavdas Setpal by restoring continuity benefits by

collecting appropriate reinstatement premium. There is no order for any other




a) As per Rule 17(6) of the said rules the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.



(MILIND KHARAT)

INSURANCE OMBUDSMAN


MUMBAI & GOA




CASE OF COMPLAINANT - Ms Dhwiti Savani

VS

RESPONDENT : Max Bupa Health Insurance Co.Ltd.

COMPLAINT REF: NO:MUM-G- 031-1819-0281


1 Name & Address of the Complainant Ms Dhwiti Savani,

Savani Transports Pvt.Ltd.,

809-A Broadway Centre,

2nd floor, Dr Ambedkar Road,

Dadar East,

Mumbai – 400 014

2 Policy No:

Type of Policy

Sum Insured


30706747201700

Health Insurance Policy

Rs.3000000/-

29.10.2017 to 28.10.2019

3 Name of Insured


Ms Dhwiti Savani

Ms Dhwiti Savani





8 Nature of complaint Repudiation of claim and policy cancelled




12 Complaint registered under 13 (b)




a) For the complainant Mr Nayant Maneklal Savani (Father)

b) For the insurer Ms Shital Patwa Manager




Ms Dhwiti Savani is insured under the above policy and this policy is ported from M/s Royal

Sundaram Insurance Co.Ltd. where she was insured since four years. She was admitted at

P D Hinduja Hospital from 11.12.2017 to 14.12.2017 for treatment of Deviated Nasal

Septum. On scrutiny of claim documents it was found that the complainant is suffering from

Congenital Bicuspid Aortic Valve Disease (Server AS with Mild AR) and the same was not

disclosed in the Proposal form at the time of portability of insurance. The Company has

repudiated the above claim on the ground of Non disclosure and have also cancelled the

policy on the ground of mis representation of facts. The complainant has represented in her

written statement that she is not agreeable with the decision of the Company.


Mr Nayant Maneklal Savani father of the complainant duly authorized by the complainant

appeared and deposed before the Ombudsman in the joint hearing held with the Company

and he submitted that his daughter was insured with M/s Royal Sundaram for four years and

this policy is a ported policy and the claim was for Deviated Nasal Septum which has nothing

to do with Congenital Bicuspid Aortic Valve Disease. He stated that he has not filled up the

proposal form and the same was filled in by his agent.


The Respondent submitted during the hearing that this policy has been ported from M/s

Royal Sundaram Insurance Co.Ltd. and the insured underwent treatment for Deviated Nasal

Septum. On scrutiny of claim documents it was found that the complainant is suffering from

Congenital Bicuspid Aortic Valve Disease (Server AS with Mild AR) and the same was not

disclosed in the Proposal form at the time of portability of insurance. The Company stated

that though the ailment for which the treatment was taken has got no relation with history

of congenital bicuspid Aortic Valve disease, if the Company would have known this history it

would not have issued the policy to the insured under portability as well. Therefore they

have repudiated the claim under Non disclosure and have also cancelled the policy on the

ground of mis representation of facts.

Observations:

The Forum observes in this case that insured patient is insured under the above policy and

this policy is ported from M/s Royal Sundaram Insurance Co.Ltd. where she was insured

since four years. She was admitted at P D Hinduja Hospital from 11.12.2017 to 14.12.2017

for treatment of Deviated Nasal Septum.

On scrutiny of claim documents it was found that the complainant had history of Congenital

Bicuspid Aortic Valve Disease (Server AS with Mild AR) and the same was not disclosed in

the Proposal form at the time of portability of insurance. The complainant’s contention is

that the Proposal form was filled in by his agent. Though there is non disclosure on the part

of the insured with regard to his health history but the same has got no relevance with the

current claim for which the insured patient underwent treatment (Deviated Nasal Septum).

The Forum notes that as per IRDA guidelines with regard to portability of insurance, the

existing benefits of the policyholder cannot be withdrawn as he was insured with M/s Royal

Sundaram since four years without any break and in the fifth year under the renewed policy

this claim arose within a period of one and half years. Therefore Company’s denial of above

claim on the ground of Non disclosure and subsequent cancellation of policy on the ground

of mis representation of facts is not sustainable and the Company was directed to calculate

the admissible claim amount payable and reinstate the policy excluding the congenital

disorder with continuity benefits. The Company has informed the admissible claim amount

payable as Rs.195641/- after deduction of non payables and the reinstatement premium will

be calculated after receipt of award.

AWARD

M/s Max Bupa Health Insurance Co.Ltd. is directed to settle the above claim for

Rs.195641/- and reinstate the above policy excluding congenital disorder with

continuity benefits subject to collection of appropriate premium towards full and

final settlement of the above claim and inform the payment particulars to this

Forum. There is no order for any other relief. The case is disposed of

accordingly.






insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN


METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules 2017)

OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Parth Dagha

VS RESPONDENT : Star Health and Allied Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Parth Dagha, 1101 Shivalaya Heights Building,

9 Veera Desai Road, Behind Sports Complex, Azad Nagar No 2,

Andheri West, Mumbai - 400053

2 Policy No:

Type of Policy Sum Insured Duration of Policy/Period

P/171127/01/2017/009651

Star Comprehensive Insurance Policy Rs.750000/- 13.01.2017 to 12.01.2018


Mr Tarun Dagha (Father) Mr Parth Dagha

4 Name of Insurer Star Health and Allied Insurance Co.Ltd.


6 Reason for repudiation Exclusion Clause 9 (Alcohol)







13 (b)

13 Date of Hearing 05.09.2018 at 10.30 Am


a) For the complainant Mr Parth Dagha (son)

b) For the insurer Dr A Thakker Manager




Mr Tarun Dagha father of the complainant was admitted at Dr Balabhai Nanavati Hospital on

28.10.2017 and he expired on 02.11.2017 during treatment. On scrutiny of claim

documents it is observed that Patient was diagnosed for Jaundice and is a case of Chronic

Liver Disease (CLD) and Kidney injury. However the onset of ailment could not be

ascertained with the available documents and also cause for CLD was not clear. On perusal

of documents it was observed that insured patient was also admitted from 11.8.2017 to

13.08.2017 and he was having ethanol abuse and he has stopped having alcohol 12 years

back and the current admission Gamma-Glutamyl Transferase (GGT) is 1763 units/ml which

indicates liver injury is secondary to alcohol. The current admission and treatment of the

insured patient was for liver failure which was due to use of alcohol and the patient

developed multi organ failure. The Company has repudiated this claim on the ground of

Exclusion Clause No 9 which reads as “Company is not liable to make any payment in

respect of expense incurred at hospital for treatment of any disease/condition

due to use of alcohol.” The complainant has represented in his written statement that he

is not agreeable with the decision of the Company.


Mr Parth Dagha son of Mr Tarun Dagha appeared and deposed before the Ombudsman in

the joint hearing with the Company and he submitted that his father had stopped taking

alcohol twelve years back and he was absolutely fit and healthy and did not have any effect

of alcohol since last ten years and therefore repudiation of above claim by the Company on

the ground of Policy Exclusion Clause No 9 is not acceptable to him.


The Respondent submitted during the hearing that chronic alcohol consumption leads to

increased activities of GGT in the serum which are associated with an enhancement of GGT

activities in the Liver. These findings suggest that increased GGT activities commonly found

in alcoholic liver disease can be ascribed primarily to hepatic enzyme induction rather than

to liver cell injury, since hepatic GGT activities were increased but not reduced. Therefore

they have repudiated the above claim on the ground of Policy Exclusion Clause No 9. The

Forum asked the Company whether any medical opinion was obtained in this case to which

the Company replied they have taken in house medical opinion.

Observations:

The Forum observes in this case that Mr Tarun Dagga was admitted at Dr Balabhai Nanavati

Hospital on 28.10.2017 and he expired on 02.11.2017 during treatment and the cause of

death was Acute Liver failure and Multi organ failure. The Forum notes that though the

patient had history of ethanol abuse in his earlier admission hospital papers, he had stopped

taking alcohol twelve years back.

To arrive at a fair decision, the Forum obtained independent medical opinion which reads as

“There were no evidence of alcoholic liver disease (the liver was normal in size –

would have been shrunken and nodular in cirrhosis; there were no esophageal

varices – should have been present if there was cirrhosis). Also in August,2017,

three months prior to last admission patient’s HAV (Hepatitis A Antigen) was

positive indicating he had acute viral hepatitis due to Hepatitis A virus. Acute

liver failure is known to occur in Hepatitis A infection, although a small

percentage”.

Based on above, the Company’s stand of denial of above claim on the ground of Exclusion

Clause No 9 (Due to use of Alcohol) is not sustainable and the Company is directed to

calculate the admissible claim amount. Accordingly the Company has calculated the

admissible claim amount payable as Rs.187143/-. Deduction of Rs.66940/- towards

Investigation charges (Reports not available) can be considered for settlement by the

Company (except non payables) subject to submission of relevant reports by the

complainant to the Company. All other deductions are in order.

AWARD

M/s Star Health and Allied Insurance Co.Ltd. is directed to settle the above claim

for an amount of Rs.187143/- and Rs.66940/- (except non payables) subject to

submission of relevant investigation reports towards full and final settlement of

above claim and inform the payment particulars to this Forum. There is no order

for any other relief. The case is disposed of accordingly.





b) As per Rule 17(8)the award of Insurance Ombudsman shall be binding on the

insurers. Dated at Mumbai this 5th day of February,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



(Under Rule No. 16/17 of Insurance Ombudsman Rules 2017) OMBUDSMAN : SHRI MILIND KHARAT

CASE OF COMPLAINANT - Mr Digamber Kolhaji Meshram VS

RESPONDENT : Star Health and Allied General Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G-044-1819-0237 AWARD NO: IO/MUM/A/GI/ /2018-19

1 Name & Address of the Complainant Mr Digamber Kolhaji Meshram, R/O 3, BMC Officers Quarters,

Sardar Nagar No 4, Sion Koliwada, Mumbai – 400 022


P/171114/02/2013/000540 Mediclassic Insurance Policy 03.12.2016 to 26.06.2017 Rs.300000/-


Mr Digamber Kolhaji Meshram Mr Digamber Kolhaji Meshram

4 Name of Insurer Star Health and General Insurance Co.Ltd.


6 Reason for repudiation Non disclosure and Policy cancelled



9 Amount of claim Rs377000/-




13 (b)



a) For the complainant Mr Digamber Kolhaji Meshram,





Mr Digambar K Meshram insured under the above policy with effect from 02.11.2012 was admitted at Fortis Hospitals from 25.04.2017 to 08.05.2017 with complaints of difficulty in

walking, left side weakness since morning and was diagnosed as “Right Basal Ganglia Infarct”. On scrutiny of medical documents it was observed that insured patient is a known case of CVA since 2008, 2011 with residual weakness in the right lower lobe. This was not

disclosed in the Proposal form at the time of inception of insurance which amounts to misrepresentation of material facts and therefore the Company repudiated the above claim on the ground of Non disclosure and cancelled the policy on the ground of

misrepresentation of facts. The complainant has represented in his written statement that he is not agreeable with the decision of the Company.


The complainant submitted during the hearing that he has disclosed his medical history to

his agent before inception of insurance and accordingly his policy was issued with Exclusion

Pre existing disease (Hypertension and its related complications) and was renewed

continuously for four years. He stated that he has also submitted a Certificate from the

treating doctor which says that he had past history of stroke in 2011 and not 2008. Thus

there is no Non disclosure.


The Respondent submitted during the hearing that insured patient was admitted in the

hospital with complaints of difficulty in walking, left side weakness since morning and was

diagnosed as “Right Basal Ganglia Infarct”. On scrutiny of medical documents it was

observed that insured patient is a known case of CVA since 2008, 2011 with residual

weakness in the right lower lobe. This was not disclosed in the Proposal form at the time of

inception of insurance in 2012. These findings confirm that patient had CVA episodes with

residual weakness and now the patient is presented with imbalance while walking with left

sided weakness and diagnosed as Right Basal Gangila infarct. Therefore they have

repudiated the claim on the ground of Non disclosure and have also cancelled the policy and

premium refunded to the insured on the ground of misrepresentation of facts.


The Forum observes in this case that insured patient insured under the above policy with

effect from 02.11.2012 was admitted in the hospital with complaints of difficulty in walking,

left side weakness since morning and was diagnosed as “Right Basal Ganglia Infarct”. It is

noted that patient is a known case of CVA since 2011 with residual weakness in the right

lower lobe and the same is not disclosed in the Proposal form at the time of inception of

insurance. However the insured has disclosed to his agent that he is suffering from

Hypertension and the same is appearing as Policy Exclusion (Hypertension and its related

complications) on the face of the policy since 2012 continuously renewed for four years and

this claim has arisen in the fifth year of insurance. Moreover Hypertension is one of the

major risk factor for the diagnosed disease and the same is disclosed by the insured.

As per IRDA guidelines, Pre existing is defined as “All pre existing diseases 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 in continuously in force for 48 months.”

In this case the pre existing disease is Hypertension and its related complications which is

covered as this claim arose in the fifth year and as regards Non disclosure the insured

patient has declared everything to his agent before inception of insurance and accordingly

Hypertension and its related complications has been excluded for a period of four years from

inception of insurance. Therefore denial of claim under Non disclosure and subsequent

cancellation of policy on the ground of misrepresentation of facts is not sustainable and the

Company is directed to settle the claim for the admissible claim amount after deduction of

non medicals and non payables and also to reinstate the policy by collecting appropriate

premium to the original conditions.

AWARD

M/s Star Health and Allied General Insurance Co.Ltd. is directed to settle the

above claim for the admissible claim amount after deduction of non medicals and

non payables and also to reinstate the policy by collecting appropriate premium

to the original conditions and inform the payment particulars to this Forum.

There is no order for any other relief. The case is disposed of accordingly.





Dated at Mumbai this 21st day of February,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mr Samir D Mehta

V/S RESPONDENT : Star Health & Allied Insurance Co.Ltd.



1 Name & Address of the Complainant Mr Samir D Mehta,

Dosti Acres, Blossom Building, A Wing, 16th floor,

Flat No 1601, Wadala East, Mumbai - 400037



P/171111/01/2017/025364 Medi Classic Insurance Policy

31.03.2017 to 30.03.2018 Rs.3,00,000/-

3 Name of Insured


Mr Samir D Mehta

Mr Samir D Mehta

4 Name of Insurer Star Health and Allied Insurance Co. Ltd.


6 Reason for Partial repudiation Quantum dispute


8 Nature of complaint Short settlement of claim amount.






13 (b)



a) For the complainant Mr Samir D Mehta





Mr Samir D Mehta the insured patient is insured under the above policy since 2008 and he

was admitted at Global Hospital from 14.11.2017 to 15.11.2017 with complaints of pain in

left shoulder since two to three months, complaints of restricted movements and diagnosed

as Left Shoulder Bankart Lesion and he underwent Left shoulder Arthroscopy Bankart repair

and lodged total claim of Rs.273654/- and the Company has settled the claim for

Rs.233537/- and deducted the balance amount of Rs.40117/- detailed as under :

DESCRIPTION AMOUNT DEDUCTED RS.

NON PAYABLES 350

NON MEDICALS 7661

IMPLANT CHARGES (NO INVOICE) HENCE 20%

DEDUCTED

16501

EQUIPMENT CHARGES N P 7055

ADMINISTRATION CHARGES 1350

PRE HOSPITALIZAITON BEYOND 30 DAYS 7200

TOTAL 40117

The complainant has submitted in his written statement that he is not agreeable with the



The complainant submitted during the hearing that he underwent Left shoulder Arthroscopy

Bankart repair and lodged total claim of Rs.273654/- and the Company has settled the claim

for Rs.233537/- and deducted the balance amount of Rs.40117/-. He stated that regarding

Implant Tax Invoice, he has already submitted a letter from the hospital billing department

that the material is purchased in bulk and hence they cannot provide the Tax Invoice and he

requested for settlement of the same.

Contentions of the Company :

The Respondent submitted during the hearing that the insured patient underwent Left

shoulder Arthroscopy Bankart repair and lodged total claim of Rs.273654/- and they have

settled the claim for Rs.233537/- and deducted the balance amount detailed as above. The

Forum asked the Company the reason for deduction of 20% towards Implant charges when

the insured has submitted a written explanation from the hospital.

Observations/Conclusion :

The Forum observes in this case that insured patient is insured under the above policy since

2008 and he was admitted in the hospital with complaints of pain in left shoulder since two

to three months, complaints of restricted movements and diagnosed as Left Shoulder

Bankart Lesion and he underwent Left shoulder Arthroscopy Bankart repair and lodged total

claim of Rs.273654/- and the Company has settled the claim for Rs.233537/- and deducted

the balance amount of Rs.40117/- detailed as above.

The Forum notes that all other deductions are in order except deduction of Rs.16501/-

towards Implant Charges (Tax Invoice not available) when the insured has submitted a

written explanation from the Billing Department of the Hospital that

the material is purchased in bulk and hence the hospital cannot provide the Tax Invoice.

The Company is directed to settle the balance amount of Rs.16501/- deducted towards

Implant Charges.

AWARD

M/s Star Health and Allied Insurance Co. Ltd. is directed to settle the above claim

for balance amount of Rs.16501/- towards full and final settlement of above

claim and inform the payment particulars to this Forum. There is no order for any




a) As per Rule 17(6) of the said rules the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the

Ombudsman.


Dated at Mumbai this 22nd day of February,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Ms Anita S Torvi VS

RESPONDENT : Star Health and Allied Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G-044-1819-0318 AWARD NO: IO/MUM/A/GI/ /2018-19

1 Name & Address of the Complainant Ms Anita S Torvi,

B-27 Room No 002, Ground floor, Sara Choudhary Nagar,

Thakur Complex, Kandivali East, Mumbai - 400101



P/171119/01/2017/009902 Senior Citizens Red Carpet Health Insurance Policy

03.02.2017 to 02.02.2018 Rs.500000/-

3 Name of Insured


Ms Usha S Torvi

Ms Anita S Torvi

4 Name of Insurer Star Health and Allied Insurance Co.Ltd.


6 Reason for repudiation Waiting period of two years








13 (b)



a) For the complainant Ms Anita S Torvi

b) For the insurer Dr A Thakker




Ms Usha S Torvi sister of Ms Anita S Torvi insured under the above policy was admitted at

Sanjeevani Surgical and General Hospital from 09.01.2018 to 16.01.2018 with chief

complaints of nausea, vomiting since three to four days and was diagnosed as UTI with

Calculus Cholecystectis and she underwent Laparoscopic Cholecystectomy and lodged the

claim with the Company. The Company has repudiated the above claim on the ground of

Policy Exclusion Clause No 3(b) which reads as “The Company shall not be liable to

make any payments under this policy in respect of any expenses whatsoever

incurred by the insured person in connection with or in respect of : During the

first two years of continuous operation of this Senior Citizens Red Carpet Health

Insurance Policy any expenses on Gall Bladder and Pancreatic diseases and all

treatments (conservative, interventional, laparoscopic and open) related to

Hepatopancreato – biliary disease including Gall bladder and Pancreatic calculi.

All types of management for kidney and Genito-urinary tract calculi” and this claim

arose in the first year of insurance. The complainant has represented in her written

statement that she is not agreeable with the decision of the Company.


The complainant submitted during the hearing that her sister was admitted to the hospital

with complaints of high blood pressure, high fever, severe stomach pain, Right leg bended

not standing on the floor as a result of fall in bathroom on emergency basis. The doctor first

treated her for the above complaints by giving medicines, traction in right leg etc. Then

sonography was taken and they found stones in Gall Bladder and she was diagnosed as UTI

with Calculus Cholecystectis and she underwent Laparoscopic Cholecystectomy.


The Respondent submitted during the hearing insured patient was admitted in the hospital

with chief complaints of nausea, vomiting since three to four days and was diagnosed as

UTI with Calculus Cholecystectis and she underwent Laparoscopic Cholecystectomy and

lodged the claim with the Company. They have denied the claim on the ground of Policy

Exclusion Clause No 3(b) as this claim arose in the first year of insurance. Further the

insured has submitted a representation for reconsideration of claim. Then their medical

team once again perused and observed that the treating doctor has stated that patient is

admitted for UTI and the patient had joint pain. But there is no mention of joint pain in the

Discharge Summary, claim for joint disease is not payable for first two years as per Policy

Exclusion No 3 of the policy.


The Forum observes in this case that insured patient was admitted in the hospital with chief

complaints of nausea, vomiting since three to four days and was diagnosed as UTI with

Calculus Cholecystectis and underwent Laparoscopic Cholecystectomy. The complainant’s

contention is that her sister was admitted to the hospital on emergency basis with

complaints of high blood pressure, high fever, severe stomach pain, Right leg bended not

standing on the floor as a result of fall in bathroom and the doctor first treated her for the

above complaints by giving medicines, traction in right leg etc. Then sonography was taken

and they found stones in Gall Bladder and she was diagnosed as UTI with Calculus

Cholecystectis and she underwent Laparoscopic Cholecystectomy. The Forum notes that the

diagnosed ailment has a specific waiting period of two years as per Policy Exclusion Clause

No 3 (b) and this claim arose in the first year of policy and thus Company’s stand of denial

of above claim on this ground is sustained.






AWARD

The complaint of Ms Anita S Torvi against M/s Star Health and Allied Insurance Co.Ltd. in

respect of repudiation of her sister’s hospitalization claim at Sanjeevani Surgical and General

Hospital from 09.01.2018 to 16.01.2018 for Laparoscopic Cholecystectomy does not sustain.

The case is disposed of accordingly.





(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mr R S Patel VS

RESPONDENT : National Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G-048-1819-0203 AWARD NO: IO/MUM/A/GI/ /2018-19

1 Name & Address of the Complainant Mr R S Patel, Gunvant Villa, 31, Hatkesh Society, Road No 5 NS,

Juhu Scheme, Vileparle West, Mumbai – 400 056


Sum Insured

260500/48/14/8500002730 National Mediclaim Policy 17.11.2014 to 16.11.2015

Rs.500000/- Plus Rs.200000/- CB


Mr R S Patel Mr R S Patel

4 Name of Insurer National Insurance Co.Ltd.


6 Reason for repudiation As per policy condition (sub limits)


8 Nature of complaint Partial repudiation of claim





13 (b)



a) For the complainant Mr Dilip R Patel (Son)

b) For the insurer Ms Geeta Raghvendra Sr.DM




Mr R S Patel is insured under the above policy and he was diagnosed for Carcinoma of

Prostate and he underwent surgery of Robotic Radical Prostatectomy at Kokilaben D Ambani

Hospital from 03.09.2015 to 09.09.2015 and total claim of Rs.568000/- was lodged and the

Company has settled the claim for Rs.341750/- by cashless and deducted the balance

amount of Rs.226250/- on the ground that Robotic surgery charges are not payable and

Sum Insured available under Section B is exhausted. The complainant has represented in

his written statement that he is not agreeable with the decision of the Company.


The complainant submitted during the hearing that his sum insured is Rs.500000/- plus

cumulative Bonus of Rs.200000/- totaling to Rs.700000/- and and Anesthesia charges of

Rs.52500/- is not cleared though there is sufficient provision under Section 2.3 (i)

“Anesthesia, Blood, OT Charges, etc” which is 50% of the Sum Insured i.e. Rs.350000/-.

The expenses mentioned as Others are Robotic Surgical Appliances Charges of Rs.70000/-

and Surgical Instrument Charges of Rs.90000/- which is not paid.


The Forum asked the Company the reason for the above deductions to which the Company

submitted that they have sub limits under each section and the admissible sum insured is

exhausted and therefore the same was deducted. The Forum asked the Company the

reason for not paying Robotic charges to which the Company replied that the same is

payable up to the extent of standard/conventional treatment expense as per their internal

guidelines. The Forum asked the Company whether patient underwent treatment in network

hospital to which the Company replied Yes.


The Forum observes in this case that insured patient was diagnosed for Carcinoma of

Prostate and he underwent surgery of Robotic Radical Prostatectomy in their network

hospital and total claim of Rs.568000/- was lodged and the Company has settled the claim

for Rs.341750/- by cashless and deducted the balance amount of Rs.226250/- on the

ground that Robotic surgery charges are not payable and Sum Insured under Section B

exhausted.

The Forum notes that as per the above policy’s Operative Clause Coverage is divided into

three Sections 2.1 Room Charges, 2.2 Medical Practitioner’s fees, 2.3 Others. In the end it

is mentioned that Sub limit (as mentioned in 2.1, 2.2 and 2.3) will not apply in case

of Hospitalization in a preferred provider network (PPN).

The Forum had sought clarification from the Company the reason for applying these sub

limits in processing the above claim when the patient has underwent treatment in their

network hospital as per above policy clause. The Company has given a clarification that

Sub limit (as mentioned in 2.1, 2.2 and 2.3) will not apply in case of 1)

Hospitalization in a preferred provider network (PPN) - The said sublimit is not

applicable if the Hospitalization is in a preferred Provider network and

the procedure is a PPN procedure”. However in the policy the wording “and the

procedure is a PPN procedure” is missing. It is further noted that the Company has

neither examined/questioned the hospital authorities the reason for overcharging the patient

when it is their network hospital and if at all any package rates are fixed for the above

ailment and as per policy terms Robotic charges are not excluded. Therefore Company’s

denial of balance amount of Rs.226250/- on the ground that Robotic surgery charges are

not payable and Sum Insured available under Section B is exhausted is not justifiable and

the Company is directed to settle the above claim for balance amount of Rs.226250/-

except non medicals and non payables as per policy norms.

AWARD

M/s National Insurance Co.Ltd. is directed to settle the above claim for balance

amount of Rs.226250/- except non medicals and non payables towards full

and final settlement of above claim and inform the payment particulars to this

Forum. There is no order for any other relief. The case is disposed of accordingly.







(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Rajkumar R Mehta

VS RESPONDENT : National Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Rajkumar R Mehta, 230 Yusuf Meherali Road, Mumbai – 400 033


Sum Insured

260500/50/17/10000471 National Mediclaim Policy 26.05.2017 to 25.05.2018

Rs.350000/- plus Rs.175000/- Cumulative Bonus

3 Name of Insured


Ms Kamlesh V Mehta (wife)

Mr Rajkumar R Mehta



6 Reason for Partial repudiation Quantum (Reasonability)







13 (b)




b) For the insurer Ms Geeta Administrative Officer




Ms Kamlesh Mehta wife of the complainant was admitted at Bhatia Hospital from 23.11.2017

to 26.11.2017 for treatment of Bilateral Osteoarthritis of both knees and Right Knee TKR

and total claim of Rs.301428/- was lodged and the Company has settled Rs.203230/- and

deducted the balance amount on the ground of Reasonable and Customary Clause. The

complainant has represented in his written statement that he is not agreeable with the



The complainant remained absent and he has submitted in his written statement that his

wife underwent Right Knee TKR and treatment for Bilateral Osteoarthritis and total claim of

Rs.301428/- was lodged and the Company has settled Rs.203230/- and deducted the

balance amount on the ground of Reasonable and Customary Clause which is not acceptable

to him.


The Respondent submitted during the hearing that Bhatia Hospital is a non network hospital

and they have compared the rates with other tertiary hospitals like Kokilaben Ambani and

Global Hospital for the same ailment and accordingly they have processed the claim for

Rs.203230/- out of total claim of Rs.301428/- and deducted the balance amount on the

ground of Reasonable and Customary Clause.


The Forum observes in this case that Ms Kamlesh Mehta wife of the complainant was

admitted at Bhatia Hospital for treatment of Bilateral Osteoarthritis of both knees and Right

Knee TKR and total claim of Rs.301428/- was lodged and the Company has settled

Rs.203230/- and deducted the balance amount in comparison with the rates of other tertiary

hospitals like Kokilaben Ambani and Global Hospital for the same ailment on the ground of

Reasonable and Customary Clause.

There is no doubt that an individual has every right to go in for the best treatment available

but the policy would pay only the charges which are necessarily and reasonably incurred. It

has to be borne in mind that Insurance Companies are custodians of public money and have

to function with a long term perspective to ensure sustainability of their operations so that

at any given point of time they are in a position to meet all liabilities under the policies

which are in force.

As such whenever it is observed that the charges are unreasonably high, the “Reasonable

and Customary Charges” Clause of the policy would come into operation, the Company is

within its right to limit the expenses payable for a particular procedure by comparing the

charges prevalent in the same geographical area. However as the hospital is not a Network

hospital, the Forum finds it in order to allow additional amount of Rs.35000/- towards full

and final settlement of above claim.

AWARD

M/s National Insurance Co.Ltd. is directed to settle the above claim for balance

amount of Rs.35000/- towards full and final settlement of above claim and






Ombudsman. b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

insurers.

Dated at Mumbai, this 31st day of January,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Ms Heena Kalpesh Mehta VS

RESPONDENT : The New India Assurance Co.Ltd. COMPLAINT REF: NO:MUM-G- 049-1718-1729


1 Name & Address of the Complainant Ms Heena Kalpesh Mehta, 37, Deepak, 31, Worli Hill Road,

Worli, Mumbai - 400018

2 Policy No:


111900/34/16/25/00006840

New Mediclaim 2012 26.03.2017 to 25.03.2018 Rs.200000/- Plus Bonus Rs.50000/-


Mast Vishwesh K Mehta (Son) Ms Heena Kalpesh Mehta



6 Reason for partial repudiation Policy Clause 3.1 (a)







13 (b)



a) For the complainant Mr Kalpesh Mehta (Husband)

b) For the insurer Mr Suresh M Angre Sr Assistant and Dr Nikita Naik (MD India TPA)




Ms Heena Kalpesh Mehta is insured under the above policy along with her son Mr Vishwesh

K Mehta who was admitted to Lilavati Hospital from 04.08.2017 to 05.08.2017 for treatment

of Right Knee Anterior Cruciate Ligament tear with Medial Meniscus Bucket Handle Tear and

he underwent Right Knee Anterior Cruciate Ligament Reconstruction with Partial Medial

Menisectomy. Total claim of Rs.206987/- was lodged and the Company has settled

Rs.131965/- and have deducted Rs.75022/- on the ground of Policy Clause 3.1(a) to (d)

(proportionate room rent). The complainant has represented in her written statement that

she is not agreeable with the decision of the Company.


The complainant submitted during the hearing that his son is insured for a sum insured of

Rs.200000/- plus cumulative bonus of Rs.50000/- and he was admitted at Lilavati Hospital

for treatment of Right Knee Anterior Cruciate Ligament tear with Medial Meniscus Bucket

Handle Tear and he underwent Right Knee Anterior Cruciate Ligament Reconstruction with

Partial Medial Menisectomy. Total claim of Rs.206987/- was lodged and the Company has

settled Rs.131965/- and have deducted Rs.75022/- on the ground of Policy Clause 3.1(a) to

(d) (proportionate room rent).


The Forum asked the Company the reason for the above deductions. The Company

submitted that patient is insured for a sum insured of Rs.200000/- and he is eligible for a

room rent of Rs.2000/- per day and he has opted for a higher room rent of Rs.3500/- per

day and therefore they have applied the Policy Clause 3.1 (a) (proportionate to entitled

room category) and have deducted all other charges in proportion to the opted room rent.

The Forum asked the Company whether they have examined the room rent tariff of Lilavati

Hospital for room rent of Rs.2000/- to which the Company replied No.


The Forum observes in this case that complainant has opted for a higher room rent of

Rs.3500/- per day against his eligibility of Rs.2000/- per day. The Forum had directed the

Company to recalculate the above claim after examining the room rent tariff of Lilavati

Hospital for room rent of Rs.2000/- per day or one step higher and submit the same to the

Forum. Accordingly the Company has submitted the calculation for room rent of Rs.2700/-

per day, the admissible claim amount works out to Rs.130285/- which is lesser than the

assessed amount of Rs.131965/-.

Thus Company’s stand of deduction of all other charges in proportion to the eligible room

rent as per Policy Clause 3.1(a) to (d) is sustained.






AWARD

The complaint of Ms Heena Kalpesh Mehta against M/s New India Assurance Co.Ltd. in

respect of partial repudiation of her Son’s claim (Mr Vishwesh Mehta) for the hospitalization

expenses incurred from from 04.08.2017 to 05.08.2017 for surgery of Right Knee Anterior

Cruciate Ligament Reconstruction with Partial Medial Menisectomy at Lilavati Hospital does

not sustain. The case is disposed of accordingly.





(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Vishal E Rodrigues

VS RESPONDENT : The New India Assurance Co.Ltd.


1 Name & Address of the Complainant Mr Vishal E Rodrigues,

Sapana Residency A2 G1, Ground Floor, Seraulim, Salcete,

Calva South Goa, Panaji Goa - 403708

2 Policy No:


131400/34/17/28/00000256

New India Floater Mediclaim 22.06.2017 to 21.06.2018 Rs.800000/-


Master Elroy V Rodrigues (Son) Mr Vishal E Rodrigues



6 Reason for repudiation Exclusion Clause 4.4.6.2 Congenital

(Internal & External)


8 Nature of complaint Total repudiation






13 (b)

13 Date of Hearing 05.10.2018 at 10.45 Am (GOA)


a) For the complainant Mr Vishal E Rodrigues

b) For the insurer Administrative Officer and Dr Bharti

(Health India TPA)




Master Elroy V Rodrigues two years old male child of Mr Vishal Rodrigues is insured under

the above policy and he was admitted at Aster Hospital from 02.09.2017 to 03.09.2017 with

presenting complaints of swelling in right inguinal region since March,2017 and he was

diagnosed as Right Inguinal Hernia and he underwent Laproscopic right Inguinal

herniotomy. The Company has repudiated the above claim as the current ailment falls

under congenital external anomaly as per Policy Permanent Exclusion Clause 4.4.6 which

reads as “Any medical expenses incurred for or arising out of expenses on

treatment of Congenital internal and External Disease or Defects or anomalies.

However the exclusion for Congenital External Disease or Defects or anomalies

shall not apply after forty eight months of continuous coverage but such cover

for Congenital External Disease or Defects or anomalies shall be limited to

10% of the average sum insured of the Insured Person in the preceding four

years”. The complainant has represented in his written statement that he is not agreeable

with the decision of the Company.


The complainant submitted during the hearing that his son had swelling in right inguinal

region since March,2017 and then he was diagnosed as Right Inguinal Hernia and as per

advise of the doctor he underwent Laproscopic right Inguinal herniotomy. The complainant

stated that his son did not have this problem since birth and the Company has denied the

claim on the ground of Policy Clause 4.4.6 which is not acceptable to him.


The Respondent submitted that insured patient is two years old baby boy who was admitted

with complaints of swelling over right inguinal region and was diagnosed as Right Inguinal

Hernia and he underwent herniotomy. As this ailment falls under congenital external

anomaly and as per Policy Clause 4.4.6.2 external congenital ailments are not payable and

are payable only after 48 months waiting and this claim arose in the third year of insurance.

The Forum asked the Company whether they have got any evidence for taking this ailment

under Congenital External when the child did not have any complaints of swelling in right

inguinal region since birth to which the Company replied No.


The Forum observes in this case that insured patient is two years old male child of Mr Vishal

Rodrigues who was admitted in the hospital with presenting complaints of swelling in right

inguinal region since March,2017 and he was diagnosed as Right Inguinal Hernia and he

underwent Laproscopic right Inguinal herniotomy. It is noted that the child did not have

any complaints of swelling in right inguinal region since birth and this started in March,2017

and thus this ailment shall not fall under Congenital External and it could be Congenital

internal. This claim arose in the third year of insurance and Congenital Internal Disease or

Defects or anomalies has got a waiting period of 24 months which is completed and

therefore Company’s stand of denial on the ground of Policy Clause 4.4.6 stating that

Congenital External Disease or Defects or anomalies has a waiting period of 48 months of

continuous coverage is not sustainable and the Company was directed to calculate the

admissible claim amount after deducting Non Medicals. Till date we have not received

anything from the Company. The Company is directed to settle the above claim after

deducting non medicals from the claimed amount of Rs.47523/-.

AWARD

M/s New India Assurance Co.Ltd. is directed to settle the above claim after

deducting Non medicals from the claimed amount of Rs.47523/-towards full and

final settlement of above claim and inform the payment particulars to this Forum.

There is no order for any other relief. The case is disposed of accordingly.





Dated at Mumbai this 7th day of February,2019.

(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Bharat J Parekh



1 Name & Address of the Complainant Mr Bharat J Parekh, Inside Mota Mandir,

Bhuleshwar, 3rd Bhoiwada, Mumbai – 400 002


Sum Insured

111700/34/16/25/00003905 New Mediclaim 2012 05.08.2016 to 04.08.2017

Rs.500000/-

3 Name of Insured


Mr Bharat J Parekh

Mr Bharat J Parekh



6 Reason for repudiation Policy Clause 4.4.16 Genetic Disorder


8 Nature of complaint Repudiation






13 (b)



a) For the complainant Mr Bharat J Parekh

b) For the insurer Ms Harinakshi N Karkera Admn.Officer and Dr Mansi Shukla (MD India TPA)




Mr Bharat J Parekh is covered under the above policy and he was admitted at Bombay

Hospital & Medical Research Centre from 06.01.2017 to 08.01.2017 for treatment of

Polycystic Kidney Disease and he underwent A-V Fistula surgery and the final diagnosis is

HTN/ADPKD (Autosomal Dominant Polycystic Kidney Disease) which is a genetic disorder

and the Company has repudiated the claim on the ground of Policy Exclusion Clause 4.4.16

which reads as “Genetic disorders and stem cell implantation/surgery are excluded

from the policy”. The complainant has submitted in his written statement that he is not

agreeable with the decision of the Company.


The complainant submitted during the hearing that he is insured for almost 22 years and he

has submitted a Certificate from his treating doctor which states that he underwent AV

Fistula surgery and he is not agreeable with the decision of the Company with regard to

denial of his claim on the ground of Genetic disorder.


The Respondent submitted during the hearing that insured patient was admitted for

treatment of Polycystic Kidney Disease and he underwent A-V Fistula surgery and they

obtained expert medico legal opinion from their Head Office which states that “PKD is

caused by abnormal genes which produce a specific abnormal protein which has

an adverse effect on tubule development. PKD is a general term for two types,

each having their own pathology and genetic cause Autosomal Dominant

Polycystic Kidney Disease (ADPKD) and Autosomal Recessive Polycystic Kidney

Disease (ARPKD). PKD or PCKD also known as Polycystic Kidney Syndrome

which is a genetic disorder. Arteriovenous fistulas are often surgically created

for use in Hemo-dialysis in people with chronic renal failure resulting from

genetic disorder. An arteriovenous (AV) fistula is an abnormal connection

between an artery and a vein. An arteriovenous fistula surgically created to

make it easier to perform dialysis. If a dialysis needle is inserted into a vein too

many times, the vein may scar and be destroyed.”

Since the surgery has been carried out for providing such access for the treatment of the

various complications arising from genetic disorder which is a standard exclusion under the

policy clause no 4.4.16 and therefore they have repudiated the above claim.


The Forum observes in this case that insured patient was admitted in the hospital for

treatment of Polycystic Kidney Disease and he underwent A-V Fistula surgery and the final

diagnosis is HTN/ADPKD (Autosomal Dominant Polycystic Kidney Disease) which is a genetic

disorder. The policy issued to the complainant clearly lay down “Genetic disorders and

stem cell implantation/surgery are excluded from the policy”. However, in

pursuance of the directions of the Hon’ble High Court of Delhi, IRDAI vide Circular dated

19.03.2018 directed all Insurance Companies offering contracts of Health Insurance that no

claim in respect of any existing health insurance policy shall be rejected based on exclusion

related to ‘Genetic Disorder’. The Forum was inclined to allow the subject claim in view of

said circular.

However further in pursuance of the stay granted by the Hon’ble Supreme Court of India on

the operation of the Judgement of the Hon’ble High Court of Delhi, IRDA vide their Circular

dated 05.09.2018 has revoked their earlier Circular dated 19.03.2018. In the light of the

same, since the claim has been repudiated in accordance with the policy terms and

conditions the Forum does not find any valid ground to intervene with the decision of the

Respondent and consequently no relief can be granted to the complainant.

AWARD

The complaint of Mr Bharat J Parekh against M/s New India Assurance Co.Ltd. in respect of

repudiation of his hospitalization expenses incurred for complaints of Autosomal Dominant

Polycystic Kidney Disease at Bombay Hospital & Medical Research Centre from 06.01.2017

to 08.01.2017 and he underwent A-V Fistula surgery which is a genetic disorder and the

same does not sustain. The case is disposed of accordingly.





(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mr Shankar Sapaliga VS

RESPONDENT : The New India Assurance Co.Ltd. COMPLAINT REF: NO:MUM-G- 049-1819-0162


1 Name & Address of the Complainant Mr Shankar Sapaliga,

601 Palma I, Royal Palms, Aarey Colony, Goregaon East,

Mumbai – 400 065

2 Policy No:

Type of Policy Duration of Policy/Period

111900/34/16/16/00000007 and 111900/34/17/25/00000472

Senior Citizen Mediclaim Policy 29.04.2016 to 28.04.2017

Sum Insured Type of Policy


Rs.150000/- New Mediclaim 2012

29.04.2017 to 28.04.2018 Rs.200000/-

3 Name of Insured


Mrs Mohalatha Sapaliga

Mr Shankar Sapaliga



6 Reason for repudiation


8 Nature of complaint Premium dispute

9 Amount of claim





13 (b)



a) For the complainant Mr Shankar Sapaliga

b) For the insurer Ms Sayali S Bahadkar




Ms Mohalatha Sapaliga is insured under New Mediclaim 2012 Policy in which premium is

increased as per IRDAI approval and converted to New India Mediclaim Policy and this has

been informed by the Company well in advance in the month of February,2018 along with

the premium chart. Mr Shankar Sapaliga is insured under Senior Citizen Mediclaim Policy in

which premium is not changed. The complainant has submitted in his written statement

that the premium for his wife’s renewal policy is almost double compared to last year’s

premium which is not acceptable to him.


The complainant has submitted in his written statement that he and his wife are insured

under the policies of the above Company for almost ten years without break. He has stated

that this year renewal premium for his wife is almost double which is not agreeable to him.

The Forum asked the complainant whether he and his wife are insured under the same

policy to which the complainant replied No and they are covered under two different

policies.


The Company submitted during the hearing that Ms Mohalatha Sapaliga is insured under

New Mediclaim 2012 Policy in which premium is increased with IRDAI approval and

converted to New India Mediclaim Policy and this has been informed by the Company well in

advance in the month of February,2018 along with the premium chart. Mr Shankar Sapaliga

is insured under Senior Citizen Mediclaim Policy in which premium is not changed.


The Forum observes in this case that Ms Mohalatha Sapaliga is insured under New

Mediclaim 2012 Policy in which premium is increased with IRDAI approval and converted to

New India Mediclaim Policy and this has been informed by the Company well in advance in

the month of February,2018 along with the premium chart. Mr Shankar Sapaliga is insured

under Senior Citizen Mediclaim Policy in which premium is not changed. It is noted that the

complainant’s contention about increase in premium for his wife’s renewal policy which is

almost double as compared to last year’s premium.

However it is observed that both the products are different products designed and hence the

premium is also different. The Company reviews the policy after every three years with

regard to cost, claims etc and the premium calculations are submitted to IRDAI which they

will approve or reject the increase in premium. In this case the premium of Mrs Mohalatha

Sapaliga has increased because of migration of New Mediclaim 2012 Policy to New India

Mediclaim Policy and therefore Company’s stand of charging premium (New India Mediclaim

Policy) as per revised premium chart which is approved by IRDAI is sustained.

AWARD

The complaint of Mr Shankar Sapaliga against M/s New India Assurance Co.Ltd.

in respect of charging higher premium for his wife Mrs Mohalatha Sapaliga’s New

Mediclaim Policy at the time of renewal does not sustain. The case is disposed of

accordingly.





(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Gopal Nilesh Subashchandra



1 Name & Address of the Complainant Mr Goyal Nilesh Subashchandra, 12/12 Parth Apartment,

Ganesh Peth Lane, Near Shivaji Park Post Office, Dadar West,

Mumbai – 400 028



131501/34/16/28/00001823 New India Floater Mediclaim

27.02.2017 to 26.02.2018 Rs.500000/-

3 Name of Insured


Master Goyal Vedant (Son)

Mr Goyal Nilesh Subashchandra

4 Name of Insurer M/s New India Assurance Co.Ltd.


6 Reason for repudiation Exclusion Clause 2.15 less than 24 hrs hospitalization







13 (b)



a) For the complainant Mr Goyal Nilesh Subashchandra

b) For the insurer Mr Sudesh R Parab Administrative Officer and Dr Bharti (Health India TPA)




Master Goyal Vedant son of Mr Goyal Nilesh Subashchandra is covered under the above

policy and he was admitted at Shushrusha Citizen Co operative Hospital on 21.12.2017 for

treatment of Multiple CLW (Contused Lacerated Wound) and during hospitalization he was

treated with oral medicines and CLW suturing was done and Investigations were done and

he was discharged on the same day. The Company has repudiated the above claim on the

ground of Policy Clause 2.15 which reads as “Hospitalization means admission as an

Inpatient in a Hospital for a minimum period of 24 consecutive hours except for

the following specified procedures/treatments, where such admission could be

for a period of less than 24 consecutive hours.” The complainant has represented in

his written statement that he is not agreeable with the decision of the Company.


The complainant submitted during the hearing that his son fell down very badly in School on

21.12.2017 and had cut on his lips and as per doctor’s advice he was admitted at

Shushrusha Hospital and he underwent CLW suturing under General Anesthesia on the same

day. After the surgery, the child was not at all co-operative as it was very painful and was

not ready to stay in the hospital. So the treating doctor took a decision to discharge him in

midnight around 1.30 Am.


The Respondent submitted during the hearing that the child got admitted in the hospital

with complaints of multiple CLW and he underwent CLW suturing under General Anesthesia

and was discharged on the same day. The Company stated that CLW suturing is not

payable under day care list and the hospitalization was for less than 24 hours and therefore

they have repudiated the claim on the ground of Policy Clause 2.15.


The Forum observes in this case that patient was a school going boy who fell down in the

School and had cut on his lips and as per advice of the doctor he was admitted in the

hospital and he underwent multiple CLW suturing under General Anesthesia on the same

day. After the surgery, the child was not at all co-operative as it was very painful and was

not ready to stay in the hospital. So the treating doctor took a decision to discharge him in

midnight around 1.30 Am.

The Forum notes that though this procedure is not listed in the day care list of the

Insurance Company, the insured patient is a ten year old school going boy and this was an

accidental injury sustained by him when he fell down in the School which necessitated

multiple CLW suturing under General Anesthesia and as the child was not co operative the

treating doctor had to discharge him in midnight on the same day and therefore Company’s

stand of denial on the ground of Policy Exclusion Clause 2.15 is not justifiable and the

Company was directed to calculate the admissible claim amount payable. Accordingly the

Company has calculated the admissible payable amount as Rs.38608/- after deduction of

Rs.595/- towards non medicals.

AWARD

The New India Assurance Company Ltd. is therefore directed to settle the above

claim for Rs.38608/- and inform the payment particulars to this Forum. There is

no order for any other relief. The case is disposed of accordingly.






insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Ms Rupanjana Amitav Sur VS

RESPONDENT : Oriental Insurance Co.Ltd. COMPLAINT REF: NO: MUM-G-050-1718-0288


1 Name & Address of the Complainant Ms Rupanjana Amitav Sur,

Imperial Heights, 1605-A Best Colony, Behind Oshiwara Bus Depot,

Goregaon West, Mumbai - 400104

2 Policy No:


131100/48/2016/6985

Happy Family Floater Policy 26.08.2015 to 25.08.2016 Rs.1000000/-


Ms Rupanjana Amitav Sur, Ms Rupanjana Amitav Sur

4 Name of Insurer Oriental Insurance Co.Ltd.


6 Reason for repudiation Reasonable and Customary Clause







13 (b)



a) For the complainant Ms Rupanjana Amitav Sur

b) For the insurer Mr Milind M Bochgire Assistant Manager




Ms Rupanjana Sur insured under the above policy underwent 3D Laparoscopic Myomectomy

at Women’s Hospital from 11.01.2016 to 13.01.2016 and lodged total claim of Rs.362450/-

and the Company has settled the claim for Rs.201765/- and deducted the balance amount

of Rs.151000/- on the ground of Reasonable and Customary Clause. The complainant has

represented in her written statement that she is not agreeable with the decision of the

Company.


The complainant submitted during the hearing that she had large fibroids and as advised by

the doctor she underwent 3D Laparoscopic Myomectomy and this surgery was a complicated

one and the duration of surgery was for 67 minutes. She stated that she had lodged total

claim of Rs.362450/- and the Company has settled the claim for Rs.201765/- after deduction

of Rs.151000/- towards Reasonable and Customary Clause which is not acceptable to her.

The Forum asked the complainant whether the claim intimation was given to the Company

before undergoing surgery to which the complainant replied Yes.


The Forum asked the Company the reason for the above deductions to which the Company

submitted that the insured patient underwent 3D Laparoscopic Myomectomy at Women’s

hospital and this procedure comes under Advancement of technology and the policy allows

only conventional method of surgery. The Forum asked the Company whether the policy

specifically excludes this type of Laparoscopic surgery to which the Company replied No.

The Company further stated that the Surgeon, Assistant Surgeon, Anesthesia charges are

very much on the higher side compared to other tertiary hospitals and therefore they have

applied Customary and Reasonable Clause.


The Forum observes in this case that insured patient had large fibroids and as advised by

her doctor she underwent 3D Laparoscopic Myomectomy and this surgery was a complicated

one and the duration of surgery was for 67 minutes. The Forum notes that the Surgeon,

Assistant Surgeon, Anesthesia charges are on the higher side compared to other tertiary

hospitals. However the Company has not produced any documentary evidence to prove the

same.

The Forum observes that the above policy does not specifically exclude advancement of

technology and therefore Company’s stand of denial of balance amount on the ground that

they allow only conventional method of surgery is not justifiable.

There is no doubt that an individual has every right to go in for the best treatment available

but the policy would pay only the charges which are necessarily and reasonably incurred. It

has to be borne in mind that Insurance Companies are custodians of public money and have

to function with a long term perspective to ensure sustainability of their operations so that

at any given point of time they are in a position to meet all liabilities under the policies

which are in force. As such whenever it is observed that the charges are unreasonably high,

the “Reasonable and Customary Charges” Clause of the policy would come into

operation, the Company is within its right to limit the expenses payable for a particular

procedure by comparing the charges prevalent in the same geographical area. However the

Forum finds it in order to allow additional amount of Rs.50000/- towards full and final

settlement of above claim. All other deductions are in order.

AWARD

M/s Oriental Insurance Co.Ltd. is directed to settle the above claim for balance









would be open for him/her, if he/she so decides to move any other Forum/Court as

he/she may consider appropriate under the Laws of the Land against the Respondent

Insurer.


(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - Mr Mayank Patolawala

VS RESPONDENT : Oriental Insurance Co.Ltd.


1 Name & Address of the Complainant Mr Mayank Patolawala, 1-503 Serenity Complex,

Off Link Road, Oshiwara, Andheri West, Mumbai - 400 0102


Sum Insured

121100/48/2017/5384 Individual Mediclaim Policy 20.01.2017 to 19.01.2018

Rs.600000/-


Mr Mayank Patolawala Mr Mayank Patolawala



6 Reason for repudiation OPD Treatment Injection Zolendronic injection (subcutaneous)


8 Nature of complaint Repudiation of claims





Ombudsman Rules, 2017

Under Rule 13(b)



a) For the complainant Mr Mayank Patolawala,

b) For the insurer Mr Rajashri N Korgaonkar Deputy Manager




Mr Mayank Patolawala is diagnosed with Multiple Myeloma (Bone marrow cancer) since 2010 and he has been advised to take Zolendronic Acid Injection by his treating Oncologist on 27.02.2017 and 06.03.2017. The Company has paid earlier two claims for the same

treatment and repudiated the above two claims on the ground that these drugs are not for parenteral chemotherapy and there is no hospitalization. The complainant has represented

in his written statement that he is not agreeable with the decision of the Company. Contentions of the Complainant :

The complainant submitted during the hearing that he is diagnosed with Multiple Myeloma since 2010 and he has been advised to take Zolendronic Acid Injection on 27.02.2017 and

06.03.2017 by his treating Oncologist and he has given a Certificate which states that these injections are administered subcutaneously under supervision of an Oncologist for which hospitalization is not necessary. He further stated that the Company has paid two claims

earlier for the same treatment and repudiated the above two claims on the ground that these drugs are not for parenteral chemotherapy and there is no hospitalization which is not acceptable to him and he requested for settlement of the same.

Contentions of the Respondent: It was contended on behalf of the Respondent that Mr Mayank Patolawala was a diagnosed

case of Multiple Myeloma and he underwent treatment with Inj. Zolendronic Acid. This treatment is not a Day Care procedure and is payable only if part of chemotherapy/radiotherapy or related hospitalization or as pre/post hospitalization expenses

of an admissible claim and the earlier two claims they have paid erroneously. Hence the claims stood repudiated as per terms and conditions of the policy.

Observations/Conclusion: It is noted that Cancer is a multifactorial disease and is one of the leading causes of

death worldwide. The contributing factors include specific genetic background, chronic exposure to various environmental stresses and improper diet. All these risk factors lead to the accumulation of molecular changes or mutations in some

important proteins in cells which contributes to the initiation of carcinogenesis. Chemotherapy is an effective treatment against cancer but undesirable

chemotherapy reactions and the development of resistance to drugs which results in multi-drug resistance are the major obstacles in cancer chemotherapy.

So alternative formulations are in practice these days which are liposomes, resistance modulation, hormonal therapy, cytotoxic chemotherapy and gene therapy. One of the most fundamental changes found in cancer cells is the presence of

mutations in the genes that are responsible for causing cell growth (oncogenes). The defective proteins produced by these altered genes are prime candidates for targeted therapy. Targeted therapy is one of the major modalities of medical

treatment for cancer. As a form of molecular medicine, targeted therapy blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth, rather than by simply interfering with all rapidly

dividing cells (e.g. with traditional chemotherapy). Targeted cancer therapies are expected to be more effective than older forms of treatments and less harmful to normal cells.

Monoclonal antibodies (MABs) are a specific type of therapy made in a laboratory.

They can be used as targeted therapy to block an abnormal protein in a cancer cell.

They can also be used as an immunotherapy. MABs work by recognising and finding specific proteins on cancer cells. Each MAB recognises one particular protein. So

different MABs have to be made to target different types of cancer. They work in different ways depending on the protein they are targeting and some work in more than one way.

Zolendronic Acid Injection: This medication is used to treat high blood calcium levels (hypercalcemia) that may occur with cancer. Zoledronic acid is

also used with cancer chemotherapy to treat bone problems that may occur with multiple myeloma and other types of cancer (such as breast, lung) that have spread

to the bones. This Forum has received a number of complaints against non-settlement of claims

for such injections. It is noted that some Companies are paying claims for treatment by way of these injections even when given in isolation while some other Companies who were also paying such claims earlier, have now taken a stand that it is

admissible only when given as a part of chemotherapy/ radiotherapy or as pre & post hospitalization expenses for related hospitalization. The basic ground for denial of these claims is that it is an OPD procedure and hence beyond the scope of the

policy. On an examination of all the facts/documents produced before the Forum by the


As per information collected from various websites, both chemotherapy and targeted therapy are two effective methods for cancer therapy. Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents) as part of a standardized

chemotherapy regimen. It may be given with a curative intent.

However while Chemotherapy can also kill the normal cells when eliminating the cancer cells, the normal cells can survive the targeted therapy, when the growth of cancer cells is limited.

The antibodies used in cancer therapy are engineered to specifically target certain types of cancer cells. When such antibodies are copied over and over in a lab, the result is a monoclonal antibody therapy, a treatment consisting

of millions of identical antibodies aimed at the same molecules on tumor cells. As researchers have found more antigens linked to cancer, they have been able to make MAbs against more and more cancers. Thus, the treatment

undergone by the patients seems to be one of advancement of medical technology in as much as over the past couple of decades, more than a dozen monoclonal antibodies have been approved by the Food and Drug

Administration to fight cancer, particularly breast, head and neck, lung, liver, bladder, and melanoma skin cancers, as well as Hodgkin lymphoma.

Insurance Companies are denying the claims stating that this procedure does not require hospitalization. At the same time it is also noted that it is not an

ordinary injection which can be taken on OPD basis but is given as an intravenous infusion in a sterile environment by a specialist and

requires monitoring of the patient’s condition for some time thereafter.











It is pertinent to note that basically these injections are a part of cancer treatment. Targeted therapy is generally preferred by doctors when the cancer does not respond to other therapies, has spread or is

inoperable. Treatment of cancer patients with antibodies when used alone or in combination with chemotherapy and radiotherapy, or conjugated to drugs or radioisotopes, prolongs overall survival in cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced in treating diseases and Insurers can bring about new products/modify

existing products. It is a sad fact that the mediclaim policies are not updated to keep in pace with such changes.

The facts that have been brought to the notice of the Forum clearly indicate that this procedure is an advancement of medical technology where minimum of 24 hours of hospitalization is not required. . The various certificates issued by the specialists

indicate divided opinion amongst the doctors regarding the procedure being an inpatient or outpatient one. Besides, the treatment is a prolonged one wherein depending upon the prognosis the patient has to be administered more number of

injections.

Though the Forum is able to appreciate the case of the complainant in expecting the Insurer to settle the claims in as much as the treatment being a prolonged one and

repetitive in nature but for all the reasons stated above, it would be reasonable that the complainant bears a part of the expenses. Accordingly, taking a practical view of the facts of the case, which has been brought to the notice of this Form, the Forum

comes to the conclusion that the cost of the treatment is to be shared equally between the complainant and the Company. Under the facts and circumstances of the case, the decision of the Company is set aside by the following order.

AWARD

M/s Oriental Insurance Co. Ltd. is directed to settle the claims for 50% of the admissible amount in favour of the complainant, towards full and final

settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following


i) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance


j) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

Insurers.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she

may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 4th day of February, 2019 at Mumbai.




OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Anand Hajare



1 Name & Address of the Complainant Mr Anand Hajare, 134, Shrinivas, Dr M B Raut Road,

Shivaji Park, Mumbai – 400 028

2 Policy No:


131102/48/2017/5284

Individual Mediclaim Policy 02.10.2016 to 01.10.2017 Rs.500000/-


Mr Anand R Hazare Mr Anand R Hazare



6 Reason for repudiation Reasonable and Customary Clause







13 (b)



a) For the complainant Mr Anand R Hazare

b) For the insurer Ms Vaishali M Kadam Administrative Officer




Mr Anand R Hajare insured under the above policy was admitted at P D Hinduja Hospital from 16.05.2017 to 18.05.2017 for treatment of Left Medial Meniscus Root Tear and he lodged total claim of Rs.246882/- and the Company has settled the claim for Rs.221771/-

and deducted the balance amount on the ground of Policy Clause Reasonable and Customary Charges and Non payables. The complainant has represented in his written statement that he is not agreeable with the decision of the Company.


The complainant submitted during the hearing that he was admitted in Hinduja hospital for treatment of Left Medial Meniscus Root Tear which is a Network hospital and he lodged total claim of Rs.246882/- and the Company has settled the claim for Rs.221771/- and deducted

the balance amount on the ground of Policy Clause Reasonable and Customary and Non payables. Further he stated that Company has not paid post hospitalization expenses of Rs.7802/- towards purchase of Knee Brace.

Contentions of the Respondent: The Respondent submitted that insured patient underwent treatment of Left Medial

Meniscus Root Tear and he lodged total claim of Rs.246882/- and the Company has settled the claim for Rs.221771/- and deducted the balance amount on the ground of Policy Clause Reasonable and Customary Charges and Non Medicals. The Forum asked the Company

whether the hospital where the patient underwent treatment was a Network hospital to which the Company replied Yes. During the hearing the Company agreed to pay the following amounts detailed as under :

DESCRIPTION AMOUNT RS.

ANESTHESIA CHARGES 3350

ASSISTANT CHARGES 1110

SURGERY CHARGES 9500

DVT CHARGES 1400

BED CHARGES 700

TOTAL 16060

Observations/Conclusion The Forum observes in this case that insured patient underwent treatment of Left Medial

Meniscus Root Tear AT P D Hinduja Hospital which is a Network hospital and he lodged total claim of Rs.246882/- and the Company has settled the claim for Rs.221771/- and deducted the balance amount on the ground of Policy Clause Reasonable and Customary and Non

Medicals. The Forum notes that during the hearing the Company agreed to pay additional amount of Rs.16060/- detailed as above. All other deductions are in order.

AWARD

M/s Oriental Insurance Co.Ltd. is directed to settle the above claim for balance

amount of Rs.16060/- towards full and final settlement of above claim and inform the payment particulars to this Forum. There is no order for any other relief. The case is disposed of accordingly.









MUMBAI & GOA METROPOLITAN REGION EXCLUDING NAVI MUMBAI & THANE


OMBUDSMAN : SHRI MILIND KHARAT COMPLAINANT - Ms Deval Haresh Patel

VS RESPONDENT : United India Insurance Co.Ltd.


1 Name & Address of the Complainant Ms Deval H Patel, Deval Chambers, 2, Nanabhai Lane,

Flora Fountain, Fort, Mumbai – 400 001

2 Policy No:


0221002817P101130184

Individual Health Policy 13.04.2017 to 12.04.2018 Rs.725000/-


Ms Deval H Patel Ms Deval H Patel

4 Name of Insurer United India Insurance Co. Ltd.


6 Reason for repudiation OPD Treatment (Trastuzumab Injection)


8 Nature of complaint Repudiation of claims





Under Rule 13(b)

13 Date of Hearing 09.08.2018 at 11.45 Am


a) For the complainant Ms Deval H Patel

b) For the insurer Ms Geeta Pravin Kathe, Administrative Officer




Ms Deval Patel is diagnosed with Right Breast Cancer in July,2016 and she underwent three surgeries, chemotherapy, the claims of which has been settled by the Company. The insured patient underwent adjuvant therapy (15 to 17 cycles of Injection Trastuzumab) as

advised by her treating Oncologist and the claims were lodged and the Company has repudiated these claims on the ground that no chemotherapy was given alongwith Trastuzumab Injection and are not payable as per terms and conditions of the policy. The complainant has represented in his written statement that he is not agreeable with the

decision of the Company. Contentions of the Complainant :

The complainant submitted during the hearing that she was diagnosed with right breast cancer in July 2016 and she underwent three surgeries, chemotherapy, the claims of which

has been settled by the Company. She stated that she underwent adjuvant therapy (15 to 17 cycles of Injection Trastuzumab) as advised by her treating Oncologist which is used to treat metastatic breast cancer. These claims were repudiated by the Company on the

ground that no chemotherapy was given alongwith Trastuzumab Injection. She requested for settlement of her above claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that Ms Deval Patel is a diagnosed case of Ca

Breast (Right) and she underwent and she underwent three surgeries, chemotherapy, the claims of which has been settled by them. The Respondent stated that patient underwent adjuvant therapy (15 to 17 cycles of Injection Trastuzumab) as advised by her treating

Oncologist. This treatment is not a Day Care procedure and is payable only if part of chemotherapy/radiotherapy or related hospitalization or as pre/post hospitalization expenses of an admissible claim. Hence these claims stood repudiated as per policy terms and

conditions.

Observations/Conclusion:

It is noted that Cancer is a multifactorial disease and is one of the leading causes of death worldwide. The contributing factors include specific genetic background,

chronic exposure to various environmental stresses and improper diet. All these risk factors lead to the accumulation of molecular changes or mutations in some important proteins in cells which contributes to the initiation of carcinogenesis.

Chemotherapy is an effective treatment against cancer but undesirable

chemotherapy reactions and the development of resistance to drugs which results in multi-drug resistance are the major obstacles in cancer chemotherapy.

So alternative formulations are in practice these days which are liposomes, resistance modulation, hormonal therapy, cytotoxic chemotherapy and gene therapy.

One of the most fundamental changes found in cancer cells is the presence of mutations in the genes that are responsible for causing cell growth (oncogenes). The defective proteins produced by these altered genes are prime candidates for

targeted therapy. Targeted therapy is one of the major modalities of medical treatment for cancer. As a form of molecular medicine, targeted therapy blocks the

growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth, rather than by simply interfering with all rapidly dividing cells (e.g. with traditional chemotherapy). Targeted cancer therapies are

expected to be more effective than older forms of treatments and less harmful to normal cells.

Monoclonal antibodies (MABs) are a specific type of therapy made in a laboratory. They can be used as targeted therapy to block an abnormal protein in a cancer cell. They can also be used as an immunotherapy. MABs work by recognising and finding

specific proteins on cancer cells. Each MAB recognises one particular protein. So different MABs have to be made to target different types of cancer. They work in different ways depending on the protein they are targeting and some work in more

than one way. Trastuzumab works by targeting the HER2/neu receptor on cancer cells. The

HER2 gene produces a protein receptor on the cell surface that signals normal cell growth by telling the cell to divide and multiply. Some cancerous breast tissue has too much HER2 (HER2/neu overexpression), triggering the cells to divide and

multiply very rapidly. Trastuzumab attaches to the HER2 receptors to prevent cells from multiplying, preventing further cancer growth and slowing cancer progression.

It may also work by stimulating an immune mechanism. It is generally administered into a vein slowly through a subcutaneous injection. Hormone therapy is often used after surgery (as adjuvant therapy) to help reduce the risk of the cancer coming

back. Sometimes it is started before surgery (as neoadjuvant therapy) as well. This Forum has received a number of complaints against non-settlement of claims

for such injections. It is noted that some Companies are paying claims for treatment by way of these injections even when given in isolation while some other Companies who were also paying such claims earlier, have now taken a stand that it is

admissible only when given as a part of chemotherapy/ radiotherapy or as pre & post hospitalization expenses for related hospitalization. The basic ground for denial of these claims is that it is an OPD procedure and hence beyond the scope of the

policy. On an examination of all the facts/documents produced before the Forum by the


As per information collected from various websites, both chemotherapy and targeted therapy are two effective methods for cancer therapy. Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents) as part of a standardized

chemotherapy regimen. It may be given with a curative intent. However while Chemotherapy can also kill the normal cells when eliminating the cancer cells, the normal cells can survive the targeted therapy, when the

growth of cancer cells is limited.

The antibodies used in cancer therapy are engineered to specifically target certain types of cancer cells. When such antibodies are copied over and over in a lab, the result is a monoclonal antibody therapy, a treatment consisting of millions of identical antibodies aimed at the same molecules on tumor cells.

As researchers have found more antigens linked to cancer, they have been able to make mAbs against more and more cancers. Thus, the treatment undergone by the patients seems to be one of advancement of medical

technology in as much as over the past couple of decades, more than a dozen monoclonal antibodies have been approved by the Food and Drug Administration to fight cancer, particularly breast, head and

neck, lung, liver, bladder, and melanoma skin cancers, as well as Hodgkin lymphoma.

Insurance Companies are denying the claims stating that this procedure does not require hospitalization. At the same time it is also noted that it is not an ordinary injection which can be taken on OPD basis but is given as an

intravenous infusion in a sterile environment by a specialist and requires monitoring of the patient’s condition for some time thereafter.


It is pertinent to note that basically these injections are a part of cancer treatment. Targeted therapy is generally preferred by doctors when the

cancer does not respond to other therapies, has spread or is inoperable. Treatment of cancer patients with antibodies when used alone or in combination with chemotherapy and radiotherapy, or conjugated to

drugs or radioisotopes, prolongs overall survival in cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced in treating diseases and Insurers can bring about new products/modify existing products. It is a sad fact that the mediclaim policies are not updated to keep in pace with such changes.


procedure is an advancement of medical technology where minimum of 24 hours of hospitalization is not required. The various certificates issued by the specialists indicate divided opinion amongst the doctors regarding the procedure being an

inpatient or outpatient one. Besides, the treatment is a prolonged one wherein depending upon the prognosis the patient has to be administered more number of injections. Though the Forum is able to appreciate the case of the complainant in

expecting the Insurer to settle the claims in as much as the treatment being a prolonged one and repetitive in nature but for all the reasons stated above, it would










be reasonable that the complainant bears a part of the expenses. Accordingly, taking a practical view of the facts of the case, which has been brought to the notice of this

Form, the Forum comes to the conclusion that the cost of the treatment is to be shared equally between the complainant and the Company.

The Forum is also inclined to advise the Company to take a call on covering the expenses for the above treatment on appropriate terms and conditions under their mediclaim policy and if the Company takes a decision to exclude this from the scope

of mediclaim policy, appropriate steps have to be taken by the Company to inform the mediclaim policy holders sufficiently in advance to avoid proliferation of such

complaints in future. Therefore in the facts and circumstances of the case, the decision of the Company is set aside by the following order.

AWARD Under the facts and circumstances of the case, The United India Insurance Co. Ltd. is directed to settle all the above claims (Injection Trastuzumab) for 50% of

the admissible amount in favour of the complainant subject to availability of sum insured towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following

provisions of the Insurance Ombudsman Rules, 2017: k) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply

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

of the same to the Ombudsman. l) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

Insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Ms Alka Prakash Shah



1 Name & Address of the Complainant Ms Alka Prakash Shah

3/12 Shanti Sadan Shanti Villa CHS 4, Telli Park,

Andheri East, Mumbai - 400069

2 Policy No: Type of Policy Duration of Policy/Period Sum Insured Policy No: Type of Policy Duration of Policy Sum Insured

1209002816P105221634 Individual Health Policy 29.07.2016 to 28.07.2017 Rs.500000/- 1209002816P104688859 Super Top Up 29.07.2016 to 28.07.2017 Rs.700000/- with threshold of Rs.300000/-


Mr Prakash J Shah (Husband) Ms Alka P Shah



6 Reason for Partial repudiation Sum Insured exhausted







13 (b)



a) For the complainant Ms Alka Prakash Shah

b) For the insurer Mr Sachin Pawar (Vidal TPA)




Ms Alka Praksah Shan and Mr Prakash J Shah are insured under two policies one Individual

Health and another Super Top Up Policy and Mr Prakash J Shah husband of the complainant

was admitted at Kokilaben Dhirubhai Ambani Hospital from 23.06.2017 to 05.12.2017 for

treatment of Acute non Haemorrhagic Right sided Stroke for Crainotomy. Total claim of

Rs.5171846/- was lodged and the Company has settled the claim upto the maximum sum

insured for Rs.350000/- under Individual Health Policy as there is a capping of 75% of the

sum insured (Rs.500000/-) for major diseases and Rs.700000/- under Super Top Up Policy

totaling to Rs.1050000/-. The complainant is claiming the balance amount under his

renewed policies. The Company has denied the balance claim under the renewed policies as

date of admission falls in the previous year policy and the entire sum insured under both the

policies is exhausted. The complainant has represented in his written statement that he is

not agreeable with the decision of the Company.


The complainant submitted during the hearing that her husband is insured under two

policies one Individual Health and another Super Top Up Policy and he was admitted at

Kokilaben Dhirubhai Ambani Hospital from 23.06.2017 to 05.12.2017 for treatment of Acute

non Haemorrhagic Right sided Stroke for Crainotomy. Total claim of Rs.5171846/- was

lodged and the Company has settled the claim upto the maximum sum insured for

Rs.350000/- under Individual Health Policy as it has a capping of 75% of the sum insured

(Rs.500000/-) for major diseases and Rs.700000/- under Super Top Up Policy. The

complainant stated that she is claiming the balance amount under both the renewed policies

which the Insurance Company has denied on the ground that date of admission falls in the

previous year policy period and under the previous year policies the entire sum insured is

exhausted.


The Respondent submitted during the hearing that insured patient was admitted for

treatment of Acute non Haemorrhagic Right Sided Stroke for Crainotomy and they have

settled the claim upto the maximum sum insured under both the policies and the balance

claim amount cannot be considered under the renewed policies, as the date of admission

falls in the last year policy.

Therefore they have repudiated the balance claim under Policy Clause no 4 which reads as

“In no case shall the Company be liable to pay any sum in excess of the Sum

Insured in aggregate of all claims during the period of this Policy.”

The Forum asked the Company the reason for not examining the admissibility of balance

claim amount under Policy Clause: Medical expenses incurred under Two Policy

Periods which reads as “If the claim event falls within two policy periods, the

claims shall be paid taking into consideration the available sum insured in the

two policy periods, including the deductibles for each policy period. Such eligible

claim amount to be payable to the insured shall be reduced to the extent of

premium to be received for the renewal/due date of premium of health insurance

policy, if not received earlier.”


The Forum observes in this case that insured patient is insured under two policies one

Individual Health and another Super Top Up Policy and he was admitted at Kokilaben

Dhirubhai Ambani Hospital from 23.06.2017 to 05.12.2017 and this period of admission falls

under two policy periods for treatment of Acute non Haemorrhagic Right sided Stroke for

Crainotomy. Total claim of Rs.5171846/- was lodged and the Company has settled the claim

upto the maximum sum insured for Rs.350000/- under Individual Health Policy as there is a

capping of 75% of the sum insured (Rs.500000/-) for major diseases and Rs.700000/- under

Super Top Up Policy. The complainant has claimed the balance amount under his renewed

policies. The Forum had directed the Company to examine the admissibility of balance claim

amount under Policy Clause Medical expenses incurred under Two Policy Periods,

under both the above policies. However till date the Forum has not heard anything from

the Insurance Company.

The Forum notes that as per above Policy Clause the balance claim amount is payable under

both the Individual Health and Super Top Up Policy as per policy norms. Therefore

Company’s stand of denial of balance claim amount on the ground of Policy Clause No 4

(Sum insured exhausted) is not sustainable and the Company is directed to settle the

balance admissible claim amounts under both the above policies as per policy terms and

conditions.

AWARD

M/s United India Insurance Co.Ltd. is directed to settle the balance admissible

claim amount under both the above policies as per policy terms and conditions

towards full and final settlement of above claim and inform the payment

particulars to this Forum. There is no order for any other relief. The case is

disposed of accordingly.




Ombudsman. b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the

insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mr Kiran H Modi VS

RESPONDENT : United India Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G-051-1819-0157 AWARD NO: IO/MUM/A/GI/ /2018-19

1 Name & Address of the Complainant Mr Kiran H Modi, 11 Raj Ratna Apartment,

2nd floor, Ba Bhai Ram Mandir Road, Borivali West, Mumbai - 400092


Sum Insured

0207002816P106907085 Individual Health Policy 30.08.2016 to 29.08.2017

Rs.150000/-

3 Name of Insured Mr Kiran H Modi

Name of the policy holder Mr Kiran H Modi



6 Reason for Partial repudiation Sum Insured exhausted







13 (b)



a) For the complainant Ms Shobhana Kiran Modi (Wife)

b) For the insurer Mr Subodh Sawant Administrative Officer




Mr Kiran H Modi is insured under the above policy and has been diagnosed for Pancreatic Cancer since two and half years. He has lodged a claim for his treatment amounting to

Rs.45674/- under the above policy. The Company has repudiated the above claim on the ground that they have already paid his claim for total sum insured of Rs.150000/- under the above policy and the sum insured is exhausted. The complainant has represented in his written statement that he is not agreeable with the decision of the Company.


Ms Shobhana Kiran Modi wife of the complainant duly authorized appeared and deposed before the Honourable Ombudsman in the joint hearing with the Company and she submitted that her husband underwent treatment for Pancreatic Cancer and they had

lodged the claim with the Insurance Company where he is insured for more than 15 years. The Company has denied the claim on the ground that sum insured is exhausted. She stated that they had claimed the deducted amount from the current year policy which the

Company denied. Contentions of the Respondent:

The Respondent submitted during the hearing that patient has submitted the claim for hospitalization expenses during this policy and we have settled the claim maximum upto the

sum insured of Rs.150000/- and the complainant wants to claim the deducted amount from the current year policy under Clause 2.3

Medical expenses incurred under Two Policy Periods : If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles

for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if not received earlier. But the claim does not fall under this clause

as the claim was made for the period from 08/9/2016 to 25/09/2016. The new policy period

is from 30.08.2017 to 29.08.2018 and this claim does not fall between the two policy periods. So we cannot process the claim.


The Forum observes in this case that Mr Kiran H Modi is insured under the above policy and has been diagnosed for Pancreatic Cancer since two and half years. He has lodged a claim

for his treatment amounting to Rs.45674/- under the above policy and during the above policy period the Company has settled the claim maximum upto the sum insured of Rs.150000/-. However the complainant wants to claim the deducted amount from the

current year policy period. Thus Company’s stand of denial of above claim on the ground that they have already paid his claim for total sum insured of Rs.150000/- under the relevant policy and the sum insured having exhausted is sustained.

Though the Forum is able to appreciate the concern of the complainant in this regard, it has also to be borne in mind that whenever any dispute arises, it is settled based on the terms & conditions of the policy under which a claim has arisen since these form the very basis of

the contract between the parties. The Forum therefore do not find any good ground to intervene with the same and pass the following Order.

AWARD

The complaint of Mr Kiran H Modi against M/s United India Insurance Co.Ltd. in respect of

his treatment for Pancreatic Cancer claim amounting to Rs.45674/- does not sustain. The case is disposed of accordingly.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer.


(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - Ms Vasanti N Shetty



1 Name & Address of the Complainant Ms Vasanti N Shetty, B/1401 Sagar Garden CJS Ltd,

LBS Marg, Mumbai - 400080

2 Policy No:


0216002814P112216929/K10002

Individual Mediclaim Policy 11.11.2015 to 10.11.2016 Rs.


Mr Naganna R Shetty (Husband) Ms Vasanti N Shetty



6 Reason for repudiation 4.23 Massages/steam bath/shirodhara

alike ayurvedic treatment







13 (b)



a) For the complainant Mr Naganna R Shetty

b) For the insurer Mr Pravin S Jaiswar Administrative Officer



Brief Facts of the Case : Mr Naganna R Shetty is covered under the above policy and he was admitted at

Vaidyaratnam Nursing Home from 09.11.2016 to 01.12.2016 with complaints of pain on both knees/low back pain radiating to both his legs. He underwent many allopathic treatment but with no results and his family doctor advised him to try with Ayurvedic

treatment the best at Kerala and he took treatment in a Govt. Notified and Ayush Certified Ayurvedic Hospital at Kerala. The Company has repudiated this claim on the ground of Policy Clause 4.23 which reads as “Massages/steam bath/shirodhara like treatments

under Ayurvedic treatment is not covered”. The complainant has represented in her written statement that she is not agreeable with the decision of the Company. Contentions of the complainant

Mr Naganna R Shetty husband of the complainant duly authorized by the complainant appeared and deposed before the Ombudsman in the joint hearing held with the Company

submitted that he underwent ayurvedic treatment for pain on both knees/low back pain radiating to both his legs in Kerala and the Company has repudiated his claim on the ground of Policy Clause 4.23 which is not acceptable to him as the policy does not exclude complete

ayurvedic treatment. He further stated that this Forum has decided his earlier similar claim in his favor by the then Ombudsman.

Contentions of the Respondent: The Respondent submitted that the patient was admitted at Vaidyaratnam Nursing Home for

pain on both knees/low back pain radiating to both legs and underwent ayurvedic treatment. They have repudiated the above claim on the ground of Policy Clause 4.23.

Observations/Conclusion The Forum observes in this case there is an ambiguity in the rejection clause which

mentions massage, steam bath, shirodhara and alike ayurvedic treatment which is specific and hence does not exclude oral medication taken by the complainant. If the clause would have been worded as “All Ayurvedic treatments excluded”, then the decision of the

Respondent could be sustained. Hence the decision of total repudiation of the claim for ayurvedic treatment taken by the complainant is not sustainable.

In view of the said analysis, the Forum is of the view that the benefit of doubt can be given in favor of the complainant and the Insurance Company is directed to pay admissible expenses to the complainant deducting the expenses relating to massage and non medicals.

AWARD

M/s United India Insurance Co.Ltd. is directed to settle the above claim for the admissible expenses after deducting expenses relating to massage and non medicals towards full and final settlement of above claim and inform the

payment particulars to this Forum. There is no order for any other relief. The case is disposed of accordingly.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules 2017 :




(MILIND KHARAT)

INSURANCE OMBUDSMAN



SHRI MILIND KHARAT CASE OF COMPLAINANT - Mr Shailendra Singh



1 Name & Address of the Complainant Mr Shailendra Singh, 5/8 Twinkle Star CHS,

Ghatala Village Road, Chembur, Mumbai – 400 071


Sum Insured

011101/48/17/97/60000043 (Chennai)


Mr Shailendra Singh Mr Shailendra Singh



6 Reason for repudiation Fraudulent







13 (b)



a) For the complainant Mr Shailendra Singh

b) For the insurer Ms Akanksha Sawant Administrative Officer and Dr Sachin Pawar




Mr Shailendra Singh was admitted with complaints of fever and headache since four days at

Dr Das Hospital from 16.09.2017 to 21.09.2017 and he was diagnosed for Dengue fever.

Patient had history of giddiness with fall with CLW (Contused Lacerated Wound) on lip. The

Company has repudiated the claim on the ground that claim documents submitted were

found to be fictitious as per their investigation and the claim is not admissible as per policy

condition 5.7 which reads as “The Company shall not be liable to make any payment

under this policy in respect of any claim if 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”. The complainant has represented in his

written statement that he is not agreeable with the decision of the Company.


The complainant submitted during the hearing that he was admitted with complaints of

fever and headache since four days in the hospital and he was diagnosed for Dengue fever.

He stated that in his blood report platelets count was very low and he was given Platelets

during hospitalization. He also stated that he was admitted in the hospital on 6th floor in a

twin sharing room.


The Respondent submitted during the hearing that there were discrepancies such as the

hospital register was not in sequence. Investigator was appointed and the patient was not

remembering his date of admission/discharge and there was some mismatch in declaration

by the patient with regard to room twin sharing/deluxe. The Company also stated that

hospital has not maintained record of the medicines given to the patient during

hospitalization. Therefore they have repudiated the claim on the ground of Policy condition

5.7.


The Forum observes in this case that patient was admitted in the hospital with complaints of

fever and headache since four days and he was diagnosed for Dengue fever. Patient had

history of giddiness with fall with CLW (Contused Lacerated Wound) on lip. It is noted that

patient’s platelets count were low as per his blood report and he was administered platelets

during hospitalization.

As per Company’s contention during the hearing, though they have observed certain

discrepancies in the records of the hospital with regard to hospital register, list of medicines,

etc, the Company could not produce any documentary evidence to prove the same.

Therefore Company’s stand of denial of above claim on the ground of Policy condition 5.7

(fraudulent) is not sustainable as this claim does not appear to be fraudulent and the

Company was directed to calculate the admissible claim amount payable. Accordingly the

Company has informed the Forum the admissible claim amount payable as Rs.55970/-. All

other deductions are in order.

AWARD

M/s United India Insurance Co.Ltd. is directed to settle the above claim for










(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Ms Kailash Prakash Bhatt VS

RESPONDENT : Aditya Birla Health Insurance Co.Ltd. COMPLAINT REF: NO:MUM-G- 055-1819-0199


1 Name & Address of the Complainant Ms Kailash Prakash Bhatt, 104-A/B Patel Shopping Centre, Chandawarkar Road,

Borivali West, Mumbai - 400092

2 Policy No:


13-17-0002796-00

Health Insurance Policy 11.12.2017 to 10.12.2018 Rs.400000/-


Ms Kailash Prakash Bhatt Ms Kailash Prakash Bhatt

4 Name of Insurer Aditya Birla Health Insurance Co.Ltd.




8 Nature of complaint Mis sale and refund of premium






13 (b)



a) For the complainant Ms Kailash Prakash Bhatt,

b) For the insurer Mr Vikram Jain




Ms Kailash Prakash Bhatt who herself was an Agent of the above Company and the above policy was mis sold to her by their Borivali Branch Manager and their employee had come to her house and demanded 10% extra as loading premium and that time also she had

clarified that she does not want this policy. After issue of policy within the free look period she had requested for cancellation of above policy and refund of premium. Then the Company had written to the insured asking for refund of commission paid to her (Agent) for

Rs.1661.40 by way of cheque in favor of M/s Aditya Birla Health Insurance Co.Ltd. and after that they will be proceeding for cancellation of above policy and refund of premium. The complainant has represented in her written statement that she is not agreeable with the

decision of the Company. Contentions of the complainant The complainant submitted during the hearing that she herself was working as an Insurance Agent with this Company and the above policy was mis sold to her by the Borivali Branch

Manager and their employee had come to her house and demanded 10% extra as loading premium and that time also she had clarified that she does not want this policy. The Forum asked the complainant whether she has returned the earned Agency Commission to which

the complainant replied No. Contentions of the Respondent: The Respondent submitted during the hearing that they have accepted her policy

cancellation request within the free look period of fifteen days and had informed the insured to return the Commission Pay out of Rs.1661.40 by way of cheque or draft as she was the advisor to the above policy to enable them to process the premium refund amount.

Observations/Conclusion The Forum observes in this case that Ms Kailash Prakash Bhatt who herself was an Agent of the above Company and the above policy was mis sold to her by their Borivali Branch

Manager and had demanded 10% extra as loading premium and that time also she had clarified that she does not want this policy. After issue of policy within the free look period she had requested for cancellation of above policy and refund of premium.

Then the Company had written to the insured asking for refund of commission paid to her (Agent) for Rs.1661.40 by way of cheque in favor of M/s Aditya Birla Health Insurance

Co.Ltd. and after that they will be proceeding for cancellation of above policy and refund of premium. However the insured has not returned the Commission amount to the Insurance Company. The Forum directed the Company to settle the above dispute amicably with the

insured and inform the same to the Forum. Accordingly the Insurance Company has informed us by email that they have cancelled the above policy and premium has been refunded to the policyholder after deduction of PPMC (Pre Policy Medical Check up) charges.

AWARD M/s Aditya Birla Health Insurance Co.Ltd. is directed to cancel the above policy and refund the premium after collection of Commission amount of Rs.1661.40

towards full and final settlement of the above complaint and inform the payment particulars to this Forum. There is no order for any other relief. The case is

disposed of accordingly. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules 2017 :




(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - Mrs Damyanti Sharad Ashar VS

RESPONDENT : The New India Assurance Co.Ltd.

COMPLAINT REF: NO:MUM-G- 049-1718-2154 & MUM-G-049-1819-0284 AWARD NO: IO/MUM/A/GI/ /2018-2019

1 Name & Address of the Complainant Ms Damyanti S. Ashar Mumbai

2 Policy No:


111400/34/17/95/00002613

New India Mediclaim Policy From 26.10.2017 to 25.10.2018 Rs.200000/- plus Rs.70000/- CB


Ms Damyanti S Ashar Ms Damyanti S Ashar



6 Reason for partial repudiation Hospitalization less than 24 hours, Injection Accentrix

7 Date of receipt of the complaint 06.03.2018, 16.05.2018 & 16.08.2018


9 Amount of claim Rs.35155/-& Rs.36165/-(bill for 6-02-18 & 9-05-2018)


11 Amount of relief sought Rs.71298/-(Rs.35133/- & Rs.36165/-)



13 (b)

13 Date of Hearing 29.10.2018 at 4 pm &11.01.2019 at 03.00 Pm


a) For the complainant Mr Sharadchandra Anandji Ashar

(Husband)

b) For the insurer Mr.Ashok J.Shirsat Asst. Manager,& Mrs.Kiran P. Salve, A.O.



Brief Facts of the Case : Mrs Damayanti S Ashar is insured under the above policy along with her spouse since year 1998 and she underwent treatment of left eye CNVM (Choroidal Neovascular Membranes)

on 06.02.2018 and 01.05.2018 at Mumbai Retina Centre and was treated with Injection Accentrix and total claim of Rs.71298/- i.e. (Rs.35133/- & Rs.36165/-) was lodged under policy no.111400/34/17/95/00002613 (earlier wrongly registered under policy

no.111400/34/16/25/00007102) and the Company has repudiated these two claims on the ground of Policy Exclusion Clause 2.11 which reads as hospitalization is for less than 24 hours and it is not included in the day care list. The complainant has submitted in her

written statement that she is not agreeable with the decision of the Company as her previous claim was settled by this Forum’s intervention in June,2017.

Contentions of the complainant: The Complainant was absent and had authorized her husband Mr. Sharadchandra Ashar who appeared and deposed before the Ombudsman in joint hearing held with the company

officials on 29.10.2018 at 4 pm &11.01.2019 at 03.00 Pm respectively. He submitted during the hearing that his wife was admitted in the hospital for treatment of left eye CNVM and was treated with injection Accentrix by a competent Retina Specialist at a well equipped

Operation Theatre. For such treatments hospitalization is not required and the patient is saved from unnecessary expenses.

Contentions of the Respondent: The Respondents were represented by Mr. Ashok J. Shirsat Asst. Manager & Mrs.Kiran P. Salve, A.O..The Forum asked the Company the reasons for denying both the claims to which

the Company stated that these hospitalizations were less than 24 hours and this treatment are not listed in their Day care list. Analysis of the case reveals that the treatment of Ms Dmyanti Sharad Ashar consisted of administration of Intravitreal (Antivegf) Accentrix. The

above claim was rejected under Policy Exclusion Clause 2.11 which reads as : “Expenses on Hospitalization are admissible only if hospitalization is for minimum period of 24 hours. However this time limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental

surgery, Lithotripsy (kidney stone removal), D & C are Tonsilectomy, taken in the Hospital/Nursing Home and the insured is discharged on the same day; the treatment will be considered to be taken under Hospital Benefit.”

Observations/Conclusion The facts that have been brought to the notice of the Forum clearly indicate that this

procedure is an advancement of medical technology where minimum of 24 hours of hospitalization is not required. Based on the deposition of the complainants, the forum notes that the treatment is a prolonged one wherein depending upon the prognosis the

patient has to be administered more number of injections.

Looking at the treatment undertaken by the complainant, the Forum finds that the doctors have been administering Lucentis injections, which is costlier than Avastin and the criteria

for choosing Lucentis over Avastin is not clear. The various certificates issued by the eye specialists indicate divided opinion amongst the doctors regarding the procedure being an inpatient or outpatient one.

This Forum has received a number of complaints against non-settlement of claims for ARMD by way of such Anti VEGF injections and has made a detailed analysis of all the facts related

to the treatment vis-à-vis the Company’s stand in dealing with these claims which have been elaborated in the Awards issued by the Forum in similar cases heard earlier. During the hearing of these cases the complainants have submitted to the forum certificates from

leading Ophthalmologists mentioning the fact that this procedure is not a surgical intervention but is to be carried out in Operation theatre to maintain a sterile environment. The Company has also produced certificates from qualified Ophthalmologists and one such

certificate issued by Dr.Nayana Potdar, Associate professor in the department of Ophthalmology – Lokmanya Tilak Municipal General Hospital – Sion reads as follows:- “This is to inform that injection Avastin is given intravitreal for Age related macular degeneration in operation theatre under asceptic precaution and this can be done as an OPD procedure without indoor admission.” One of the Complainants has brought to the notice of the forum that the Govt. of India has approved the import of RANIBIZUMAB (Lucentis injection) vide import

permission letter 6932/06 dated 28.09.2006 by the Company called Novartis India Ltd. We observe that patients are being treated with injection Avastin or Lucentis or Macugen depending as the case may be and these injections are

being purchased through the representatives of “Novartis” and the Company delivers the injection directly to the hospital on receipt of payment from the patients. The Complainants have also informed the forum that the company has

a procedure to give one injection free for purchase of two injections. It is also found that the treatment involves administering 3 injections over a period of 3 to 6 months depending on the prognosis of the patient. It is also observed that

injection Avastin is significantly lower in cost as compared to Lucentis and Macugen and even the same Injection Lucentis is supplied at differential pricing to different customers, the reasons whereof are not known.

Though the Forum is also able to appreciate the case of the complainant in expecting the Insurer to settle the claims in as much as the treatment being a prolonged one and repetitive in nature but for the reasons stated above, it would be reasonable that the

complainant bears a part of the expenses and accordingly, taking a practical view of the facts of the case, which have been brought to the notice of this Forum, the Forum has come to the conclusion that the cost of the treatment is to be shared equally between the

complainant and the Company. In view of repeated course of treatment, having already decided vide earlier Awards issued in similar treatment undergone by the complainant the Respondent is directed to pay the complainant 50% of the admissible expenses incurred.

Hence the Respondent’s decision is intervened by following Order:

AWARD

Under the facts and circumstances of the case, the Respondent is directed to pay the Complainant 50% of the admissible expenses amounting to Rs.35649/-,i.e 50% of (Rs. 35133/-+ Rs.36165/-=Rs.71298/-) in favor of the Complainant, as full and final settlement of above complaint.





insurers.


(MILIND KHARAT)

INSURANCE OMBUDSMAN




COMPLAINANT - MRS.HEMA LAKSHMAN



1 Name & Address of the Complainant Mrs.Hema Lakshman

Mumbai



131300/34/17/95/00000773 New India Mediclaim Policy

18.09.2017 to 17.09.2018 Rs.2,00,000/-


Mrs. Hema Lakshman



6 Reason for repudiation OPD Treatment




10 Amount of Partial Settlement Rs.24,496/-




Under Rule 13(b)



a) For the complainant Mr. Satish Lakshman

b) For the insurer Mrs.Madhuri M.Pawar , A.O.



Brief Facts of the Case : Complainant Mrs.Hema Lakshman, diagnosed with Metastatic Ca Breast was administered Injection Faslodex at P.D.Hinduja National Hospital on 15.10.2017, 31.10.2017, 08.12.2017, 29.12.2017 and 25.01.2018. Complainant lodged the claim for Rs.1,67,248/- under the policy for the same hospitalization expenses. Respondent repudiated the claims on the ground that the treatment is not covered under Day Care Procedures as per policy Clause 2.10.

Contentions of the Complainant : The complainant was absent and had authorized her son Mr.Satish Lakshman who appeared and deposed before the Ombudsman in joint hearing held with the Company. He submitted that his mother aged 85 years is insured with the Respondent since more than last 15 years. She was diagnosed with Ca left breast and as a part of the treatment was advised to take Inj. Faslodex. The Complainant has lodged the claims for the said injections under the above policy and the said claim was denied by the Respondent stating that it was not a Day Care procedure. Complainant argued that when the claims for the same treatment were paid under the previous policy, the reason cited by the Respondent for denial of the subject claims under the policy renewed with same terms and conditions, is not acceptable. She requested in her statement for settlement of the claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that Mrs. Hema Lakshman was a diagnosed case of Ca Breast and underwent treatment with Inj. Faslodex. This treatment is not a Day Care procedure and is payable only if part of chemotherapy/radiotherapy or related hospitalization or as pre/post hospitalization expenses of an admissible claim. Hence the claims stood repudiated as per policy terms and conditions 2.10.

Observations/Conclusion: It is noted that Cancer is a multifactorial disease and is one

of the leading causes of death worldwide. The contributing factors include specific genetic

background, chronic exposure to various environmental stresses and improper diet. All these

risk factors lead to the accumulation of molecular changes or mutations in some important

proteins in cells which contributes to the initiation of carcinogenesis. Chemotherapy is an

effective treatment against cancer but undesirable chemotherapy reactions and the

development of resistance to drugs which results in multi-drug resistance are the major

obstacles in cancer chemotherapy. So alternative formulations are in practice these days

which are liposomes, resistance modulation, hormonal therapy, cytotoxic chemotherapy and

gene therapy.

One of the most fundamental changes found in cancer cells is the presence of mutations in the

genes that are responsible for causing cell growth (oncogenes). The defective proteins

produced by these altered genes are prime candidates for targeted therapy. Targeted therapy

is one of the major modalities of medical treatment for cancer. As a form of molecular

medicine, targeted therapy blocks the growth of cancer cells by interfering with specific

targeted molecules needed for carcinogenesis and tumor growth, rather than by simply

interfering with all rapidly dividing cells (e.g. with traditional chemotherapy). Targeted

cancer therapies are expected to be more effective than older forms of treatments and less

harmful to normal cells.






protein they are targeting and some work in more than one way. Trastuzumab works by

targeting the HER2/neu receptor on cancer cells. The HER2 gene produces a protein receptor

on the cell surface that signals normal cell growth by telling the cell to divide and multiply.

Some cancerous breast tissue has too much HER2 (HER2/neu overexpression), triggering the

cells to divide and multiply very rapidly. Trastuzumab attaches to the HER2 receptors to

prevent cells from multiplying, preventing further cancer growth and slowing cancer

progression. It may also work by stimulating an immune mechanism. It is generally

administered into a vein slowly through a subcutaneous injection. Hormone therapy is often

used after surgery (as adjuvant therapy) to help reduce the risk of the cancer coming back.

Sometimes it is started before surgery (as neoadjuvant therapy) as well.





chemotherapy/ radiotherapy or as pre & post hospitalization expenses for related

hospitalization. The basic ground for denial of these claims is that it is an OPD procedure and

hence beyond the scope of the policy.


and the Company, the Forum is of the view that:












more antigens linked to cancer, they have been able to make mAbs against more and




















procedure.

It is pertinent to note that basically these injections are a part of cancer treatment.

Targeted therapy is generally preferred by doctors when the cancer does not

respond to other therapies, has spread or is inoperable. Treatment of cancer

patients with antibodies when used alone or in combination with chemotherapy and

radiotherapy, or conjugated to drugs or radioisotopes, prolongs overall survival in

cancer patients.

This Forum is of the opinion that lot of new technologies are being introduced in

treating diseases and Insurers can bring about new products/modify existing products.

It is a sad fact that the mediclaim policies are not updated to keep in pace with such

changes.











Form, the Forum comes to the conclusion that the cost of the treatment is to be shared equally

between the complainant and the Company.

The Forum is also inclined to advise the Company to take a call on covering the expenses for

the above treatment on appropriate terms and conditions under their mediclaim policy and if

the Company takes a decision to exclude this from the scope of mediclaim policy, appropriate

steps have to be taken by the Company to inform the mediclaim policy holders sufficiently in

advance to avoid proliferation of such complaints in future. Therefore in the facts and

circumstances of the case, the decision of the Company is set aside by the following order.

AWARD Under the facts and circumstances of the case, The New India Assurance Co. Ltd.

is directed to settle the claims for 50% of the admissible amount in favour of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

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

n) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 4th day of February, 2019 at Mumbai.





COMPLAINANT - MR. JAVERIKUMAR V. JAIN

VS RESPONDENT : UNITED INDIA INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Javerikumar V. Jain Mumbai

2 Policy No:


0207002817P100487943

Individual Health Policy 01.04.2017 – 31.03.2018 Rs.3,25,000/-


Mrs. Shakuntala Jain Mr. Javerikumar V. Jain

4 Name of Insurer United India Insurance Co. Ltd.





9 Amount of claim 1) Rs.1,87,262/-



12 Complaint registered under Ombudsman Rules

Under Rule 13(b)



a) For the complainant Mr. Javerikumar V. Jain

b) For the insurer Mr. Subodh Sawant, A.O. Dr. Mannu Gupta – Medicare TPA



Brief Facts of the Case : Complainant’s wife Mrs. |Shakuntala Shah was operated for right eye cataract on 12.06.2017 and left eye cataract on 14.09.2017 at Bombay City Eye Institute & Research Centre, Mumbai. Complainant approached this Forum with a complaint against short-settlement by the Respondent of the claims lodged for the said hospitalizations.

Contentions of the Complainant : Complainant submitted that against the claims lodged for Rs.92,924/- & Rs.94,338, they were reimbursed only Rs.44,260/- & Rs.38,000/- respectively by the TPA, deducting the balance amount on the ground of Reasonability. He argued that his wife was insured for S.I. of Rs.5,25,000/- (Rs.3,25,000/- + Rs.2,00,000/- under another policy) and the policy lays down a limit of 25% of S.I. for cataract whereas their expenses were less than the stipulated limit. Hence the deductions from the claim amount were not acceptable to them. He requested for settlement of the balance amount under both the claims.

Contentions of the Respondent: It was contended on behalf of the Respondent that Mrs. Shakuntala Jain is insured under the subject policy for S.I. of Rs.3,25,000/-. The claims for cataract surgeries undergone by her in both the eyes were settled as per Reasonable and Customary charges Clause of the policy after comparing the charges of other hospitals for the said procedure.

Forum’s Observations/Conclusion: On perusal of the documents produced on record, it is observed that there is a capping of 25% of S.I. specified under the policy for Cataract surgery. Nevertheless, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation and even in the absence of a specific capping in the policy, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. In the instant case, Respondent has settled the claims by comparing the charges of other hospitals in the vicinity for arriving at customary and reasonable charges. However considering the long standing association of the claimant with the Respondent and the actual amount incurred by her, it is thought proper to allow a further amount of Rs.38,000/- (for both the eyes together) with a view to strike a reasonable balance and resolve the dispute in the matter. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, United India Insurance Co. Ltd. is directed to pay a further amount of Rs.38,000/- (in all) towards claims lodged for cataract surgeries undergone by Mrs. Shakuntala Jain. in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:

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

p) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 21st day of February, 2019 at Mumbai.



MUMBAI & GOA




CASE OF COMPLAINANT - MR. JAYESH SUCHAK

VS

RESPONDENT : THE NEW INDIA ASSURANCE CO. LTD.



1 Name & Address of the Complainant Mr. Jayesh Suchak Mumbai

Policy No: Type of Policy Duration of Policy/Period Sum Insured

131440034162800001093 New India Floater Mediclaim Policy 15.02.2017– 14.02.2018 Rs.800000/-


Mr. Jayesh Suchak


5 Date of Repudiation ----

6 Reason for repudiation ----


8 Nature of complaint Short Settlement of claim





Ombudsman Rules, 2017 Under Rule 13(b)



a) For the complainant Mr. Jayesh Suchak b) For the insurer Ms. Sampada Tare, A.O.



Brief Facts of the Case : Complainant was admitted to Kokilaben Ambani Hospital from

04.03.2017 to 06.03.2017 and underwent Angiography followed by Angioplasty. Complainant

approached this forum with a complaint against short settlement by the Respondent of a claim lodged

for the said hospitalisation.

Contentions of the Complainant : Complainant submitted that the claim for a total amount

of Rs.3,60,346/- for his hospitalization at Ambani Hospital in March 2017 was settled by the TPA for

Rs.2,64,112/- stating that this was the maximum amount payable as per PPN GIPSA Package rate. He argued that he was covered for floater S.I. of Rs.8,00,000/-. There is no such mention in the

policy and hence the reason cited by the Respondent for short-settlement of the claim was not

acceptable to him. He requested for settlement of the full claim amount.

Contentions of the Respondent: It was contended on behalf of the Respondent that

Kokilaben Ambani Hospital is in their GIPSA PPN and hence the claim was settled as per the PPN

Agreed Package Rate for Angiography + Angioplasty applicable for Twin sharing room.

Forum’s Observations/Conclusion: On hearing the depositions of both the parties and

perusal of the documents produced on record, Respondent was asked to seek a clarification from the hospital for not adhering to PPN Agreed Package Rate and inform the Forum within 7 days.

However, the Respondent did not revert in the matter. The Forum therefore analyzed the case and is

of the view that since the hospital is under PPN, if the patient has been overcharged by the hospital, the Respondent should seek clarification/refund of excess amount charged from the hospital and there

is no justification for deductions from the bill amount genuinely paid by the insured on the ground of

reasonability. The claim of the complainant has to be settled for the full hospitalisation expenses less

non-medical items. The decision of the Respondent is therefore intervened by the following order.

AWARD Under the facts and circumstances of the case, The New India Assurance Co. Ltd. is directed to

pay the balance admissible amount of Rs.90,000/-in favour of the complaint Mr. Jayesh Suchak

in full and final settlement of the complaint.






(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. KAVEEN CHHABRIA




1 Name & Address of the Complainant Mr. Kaveen Chhabria Mumbai

Policy No:


112500/34/15/25/00013916

New Mediclaim 2012 Policy 29.03.2018 – 28.03.2017 Rs.4,00,000/- + C.B. Rs.1,20,000/-


Mr. Kaveen Chabria



6 Reason for repudiation Genetic disorder – clause 4.4.16







Under Rule 13(b)

13 Date of Hearing 07.09.2018 – 11.15 a.m.


a) For the complainant Mr. Kaveen Chhabria

b) For the insurer Ms. Nivedita Parulekar, A.O.



Brief Facts of the Case : Complainant was admitted to P.D. Hinduja Hospital on 0.05.2016 for the treatment of Ankylosing Spondylitis. Respondent repudiated the claim on the ground that the ailment is a genetic disorder excluded under Clause 4.4.16 of the policy.

Contentions of the Complainant : Complainant submitted that the claim for the treatment of Ankylosing Spondylitis undergone by him in the year 2016 was paid by the Respondent while the subject claim for the same treatment was rejected by them stating that it is a genetic disorder. He argued that if was a genetic disorder, he would have inherited it from his parents who also happen to be the Company’s clients and in fact do not have a history evidencing the same. He even submitted a certificate from his treating doctor stating that his parents do not have clinical features

of Ankylosing Spondylitis. Despite this, the Respondent maintained their stand of rejection of the claim which was not acceptable to him. He pointed out that courts have ruled in favour of the policy-holders stating that genetic disorders cannot be excluded from the scope of the policy. He requested for settlement of the claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that the patient was diagnosed to have Ankylosing Spondylitis and was admitted for 2nd dose of Inj. Remicade while the 1st dose of injection was already given to him in January, 2016 as mentioned in the discharge card. The claim was referred to a panel of doctors an as per their opinion, the ailment is a genetic disorder. Hence the claim stood repudiated as per Exclusion Clause 4.4.16 of the policy.

Forum’s Observations/Conclusion: In the instant case, complainant was treated for Ankylosing Spondylitis. Respondent repudiated the claim relying on Exclusion Clause no. 4.4.16 of the policy which excludes coverage of expenses incurred for the treatment of genetic diseases. Complainant argued that it is not a genetic disorder. The matter was referred for expert medical opinion which confirmed that Ankylosing Spondylitis is a genetic condition with environmental factors influencing. However all those with the gene may not get the disease explaining why parents do not have the disease as certified by treating doctor. It is noted that the policy issued to the complainant clearly lays down: “No claim will be payable under this Policy for Genetic disorders”. The Hon’ble High Court of Delhi had directed IRDAI to have a re-look at the exclusion clause in the insurance contracts to ensure that claims are not rejected on the basis of exclusion relating to genetic disorder. Following the said order, IRDAI vide Circular dt. 19.03.2018 directed all Insurance Companies offering contracts of Health Insurance that no claim in respect of any existing health insurance policy shall be rejected based on exclusion related to ‘Genetic Disorder’. However, in pursuance of the subsequent stay granted by the Hon’ble Supreme Court of India on the operation of the judgement of the Hon’ble High court of Delhi, IRDAI vide their Circular dt. 05.09.2018 has revoked their earlier Circular dt. 19.03.2018. In the light of the same, since the claim has been repudiated in accordance with the policy terms and conditions the Forum does not find any valid ground to intervene with the decision of the Respondent and consequently no relief can be granted to the complainant.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Kaveen Chhabria against The New India Assurance Co. Ltd., does not sustain. It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer. Dated: This 12th day of February, 2019 at Mumbai.



MUMBAI & GOA




CASE OF COMPLAINANT - MRS. NARGIS WADIA

VS

RESPONDENT - THE NEW INDIA ASSURANCE CO. LD. COMPLAINT REF: NO:MUM-G-049-1819-0181



Mrs. Nargis Wadia Mumbai


Sum Insured

142500/34/17/25/0000031 Individual Mediclaim Policy 01.04.2017 – 31.03.2018

Rs.100,000/- + C.B. Buffer Rs.30,000/-


Mrs. Nargis Wadia



6 Reason for repudiation Hospitalisation < 24 hrs

7 Date of receipt of the complaint

02.05.2018







Under Rule 13(b)



a) For the complainant Mrs. Nargis Wadia b) For the insurer Mr. Arghya Banerjee, a.O.

Dr. Suman – Medi Assist TPA



Brief Facts of the Case : Complainant was admitted to Breach Candy Hospital from

31.01.2018 to 01.02.2018 for the treatment of Hypertension/Vertigo. Respondent repudiated

the claim for the said hospitalisation stating that there was no hospitalisation for minimum

period of 24 hours as required as per clause no. 2.11 of the policy.

Contentions of the Complainant : Complainant contended that the claim for her

hospitalization was denied by the Respondent on the ground that her stay in the room fell

short of 24 hours. She stated that she was admitted to the hospital nearly four hours earlier

than the time recorded and was subjected to various investigations, as can be seen from the

time of ECG which was recorded as 14.30. Thereafter other tests like blood, Brain scan

(MRI), etc were carried out in three hours after which she was allotted a room and payment

formalities were done; hence the time of admission was recorded as 4.31 p.m. In view of the

same, the reason cited by the Respondent for denial of the claim was not acceptable to her.

She requested for settlement of the claim.

Contentions of the Respondent: It was contended on behalf of the Respondent that as

per hospital papers, the patient was admitted on 31.01.2018 at 4.31 p.m., was diagnosed with

Hypertension and Vertigo for which she was treated conservatively and was discharged from

the hospital on 01.02.2018 at 12.35 p.m. As per clause no. 2.11 of the policy, expenses on

hospitalisation for minimum period of 24 hrs are admissible whereas in the instant case the

hospital stay was for less than 24 hours. Hence the claim stood rejected as per policy terms

and conditions.

Forum’s Observations/Conclusion: On scrutiny of the documents produced on

record, it is observed that on 31.01.2018 the complainant aged 83 years suffered from an

episode of severe dizziness and perspiration, repeated vomiting, abdominal cramps for which

her GP visited her and noticed her BP to be on higher side. She was given Depin 5 mg stat

and was advised admission to the hospital for further management. At the hospital she

underwent various investigations. Trop T was found to be negative and she was diagnosed as

suffering from Hypertension and Vertigo and treated conservatively for the same. She was

discharged on the next day. Respondent repudiated the claim stating that hospitalization was

for less than 24 hours. Complainant explained that at the hospital as the room was being

prepared, she was first investigated and thereafter given a room and the treatment followed.

It is not the Respondent’s contention that hospitalization was unwarranted neither is the

genuineness of the claim in question. Therefore their stand that 24 hours’ hospitalization was

not completed and hence the claim cannot be admitted, is too technical and cannot be

sustained. The decision of the Respondent is therefore intervened by the following Order:

AWARD

Under the facts and circumstances of the case, The New India Assurance

Co. Ltd. is directed to pay the admissible claim amount less non-medical expenses, if any in favour of the complainant Mrs. Naqrgis Wadia, in full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions

of the Insurance Ombudsman Rules, 2017:

a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the

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





METROPOLITAN REGION EXCLUDING NAVIMUMBAI & THANE (Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017

OMBUDSMAN : SHRI MILIND KHARAT CASE OF COMPLAINANT - MR.OMPRAKASH M.VAHALIA

VS RESPONDENT : NATIONAL INSURANCE CO.LTD.

COMPLAINT REF: NO: MUM-G- 048-1819-0472



Mr.Omprakash M.Vahalia, Mumbai

2 Policy No:

Type of Policy Duration of Policy/Period

240101501610009048

BOI National Swasthya Policy 17.02.2017 to 16.02.2018

3 Name of Insured


Mr. Omprakash M.Vahalia,



6 Reason for repudiation Policy lapsed due to non renewal


8 Nature of complaint Premium not deducted by BOI & policy lapsed

9 Amount of premium refund ---


11 Amount of relief sought ------

12 Complaint registered under RPG rules

13 (b)



a) For the complainant Mr. Omprakash M.Vahalia

b) For the insurer Mr.H.D.Junnarkar, Admn.Officer



Brief Facts of the Case : Mr Omprakash M.Vahalia aged 64 years was issued BOI National Swasthya Bima Policy No:

240101501610009048 for the period from 17.02.2017 to 16.02.2018 for a floater sum insured of Rs. 1 lacs by the Respondent. However the policy lapsed due to nonpayment of renewal premium which was not deducted from complainant’s account by Bank of Baroda. Aggrieved by the same, complainant approached this Forum seeking relief in the matter.

Contentions of the complainant: Mr Omprakash M.Vahalia the Complainant appeared and deposed before the Ombudsman

in the joint hearing with the Company held on 14th February,2019 at 3.00 Pm. During the hearing the complainant submitted that he & his wife were covered under BOI National Swasthya Bima Policy since the year 2009. Bank of India used to debit his account for

renewal premium every year and remit it to National Insurance Company. In the year 2017, due to non reciept of policy he wrote to the Company when he was informed that the policy

renewed for the period 2017-18 has lapsed due to non- payment of renewal premium. The complainant pleaded that he was not at fault as the payment was supposed to be made by the Bank directly to the Insurance Company. He requested for issuance of the policy with

all existing continuity benefits. Contentions of the Respondent:

On behalf of the Respondent it was submitted that the insured was covered under BOI National Swasthya Bima Policy since 17th February, 2009 for a sum insured of Rs.1,00,000/- which was continuously renewed till 16th February, 2017. In the year 2017-2018 i.e. from

(17th February 2017) the policy lapsed for non-payment of renewal premium. Further, as per Clause 5.15 of BOI National Swasthya Bima Policy it is not mandatory on the part of the insurer to send renewal notice to the insured. Respondent further informed that the BOI

National Swasthya Bima Policy has now been discontinued and the policy-holders have been given an option to migrate to any of the Company’s other Mediclaim policies. Observations/Conclusion:

The Forum observed in this case that the insured was covered under BOI National Swasthya Bima Policy since 17th February, 2009 for a sum insured of Rs.1,00,000/- which was continuously renewed till 16th February, 2017. The policy renewed w.e.f. 17.02.2017 lapsed

for nonpayment of renewal premium and the said policy was cancelled. Respondent pleaded that as per Policy Clause 5.15, is not mandatory on the part of the insurer to send renewal notice to the insured. However, it may be noted that if the bank has not paid the premium

due to non-receipt of demand from the Respondent, the complainant cannot be held responsible for the same as remittance of premium was the responsibility of the bank who has been doing it continuously since the year 2009. Hence penalizing the complainant for

lapse on the part of BOI/Insurance Company is not justifiable. Since the said product has now been discontinued, the Forum is of the view that it would be in the interest of justice to renew the policy of the complainant by extending continuity benefit after collection of

appropriate premium as applicable to any of the alternate product as opted by him. The decision of the Respondent is therefore set aside by the following Order:

AWARD

National Insurance Company Ltd. is directed to condone the gap in renewal of

the policy during the year 2017-2018 and issue a fresh policy with all continuity benefits by collecting the new premium as applicable. There is no order for any other relief. The case is disposed off accordingly.

If this Award is not acceptable to the complainant, he is at liberty to approach any other Forum, as he may deem fit for redressal of his grievance.


(MILIND KHARAT)

INSURANCE OMBUDSMAN



OMBUDSMAN: SHRI MILIND KHARAT

CASE OF COMPLAINANT – Mr. Ramesh F. Shah

VS RESPONDENT: The Oriental Insurance co. ltd.


1 Name & Address of the Complainant Mr. Ramesh F. Shah,

Mumbai



121700/48/2017/4725 Mediclaim Insurance Policy(Individual)

03.08.2016 to 02.08.2017 Rs.2, 00,000/-

3 Name of Insured


Mr.Ramesh F. Shah

Mr.Ramesh F.Shah










Insurance Ombudsman rules, 2017

Under Rule 13(b)

13 Date of Hearing 23,10.2018, 4.00 pm


a) For the complainant Mr.Paresh Ramesh Shah

b) For the insurer Mrs.Chhaya N. Pelnekar,A.O.& Dr. Shweta

Gupta, Raksha TPA.



Brief Facts of the Case : Complainant Mr. Ramesh F. Shah, hospitalized for Left eye Cataract surgery at Kokilaben Dhirubhai Ambani Hospital, Mumbai on 30.03.2017. The Complainant has

lodged the claim for Rs.58,420/- on 07.04.2017. The claim was partially settled for Rs.24, 000/- and Rs.34,420/- was disallowed under customary and reasonable expenses. Contentions of the Complainant: The complainant was absent and had authorized his son Mr.Paresh Ramesh Shah who appeared and deposed before Ombudsman in joint hearing held with the Company. He submitted that his father was covered under Mediclaim Insurance Individual Policy since 2003 and as per policy terms and conditions; he is eligible for reimbursement of claim for full

amount for cataract operation. Hence the settlement is not acceptable to him. He requested to the Forum for payment of balance amount of Rs. 34420/- . Contentions of the Respondent: The Forum asked the Company the reasons for short

payment of the claims. The Company official, Mrs.Chhaya N.Pelnekar, A.O., submitted that the TPA has compared the charges of other hospital including tertiary care hospital in metro

cities of same grade for present Cataract surgery and the maximum amount is payable

Rs.24, 000/- for each eye. Hence the Respondent has disallowed the balance claim as per policy terms and conditions. Forum’s Observations/Conclusion: On scrutiny of the documenents produced on record and after hearing the depositions of both the parties, the Forum observed that in the instant case, Surgeon fees and Intraocular Lens are on the higher side. There is no doubt that the individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonably incurred. As such, whenever it is observed that the charges are unreasonably high, the “Reasonable & Customary charges” Clause of the policy would come into operation. Hence going by the comparative charges of earlier cataract surgery charges paid by the Respondent, the Forum is of the view that it would be in the interest of justice to restrict the total payable amount to Rs.50,000/-. Hence the balance amount for Rs.26000/-i.e (Rs.50,000 -24,000/-) is to be paid the complainant. The decision of the Respondent is therefore intervened by the following Order:

AWARD Under the facts and circumstances of the case, the Respondent is directed to pay a further amount of Rs.26000/- in favor of the complainant, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 8th day of February, 2019 at Mumbai.



MUMBAI & GOA




CASE OF COMPLAINANT - MR. RAMESHCHANDRA SHAH

VS

RESPONDENT : NATIONAL INSURANCE CO. LTD.




Mr. Rameshchandra Shah Mumbai

Policy No:


24030048168500003667

National Mediclaim Policy 22.12.2016 – 21.12.2017 Rs.100,000/- + C.B. Rs.50,000/-


Mr. Rameshchandra Shah Mrs. Uma R. Shah

4 Name of Insurer National Insurance Co. Ltd.

5 Date of Repudiation ----

6 Reason for repudiation ----


8 Nature of complaint Short Settlement of claim





Under Rule 13(b)



a) For the complainant Mrs. Minal Shah, Daughter-in-law

b) For the insurer Mrs. Archana Rane, D.M.



Brief Facts of the Case : Complainant was admitted to Dr. Panchamia’s Health Hi-Tech

Orthopaedic And Surgical Hospital from 19.06.2017 to 25.06.2017 for Type III Variants Tronzo

Fracture lt. femur. Complainant approached this forum with a complaint against short settlement by

the Respondent of a claim lodged for the said hospitalisation.

Contentions of the Complainant : Mrs. Minal Shah submitted that her father-in-law Mr.

Ramehschandra Shah was insured with the Respondent since the last 15 years. The claim for a total amount of Rs.1,25,286/- for his hospitalization was settled by the TPA for Rs.45,911/- stating that this

was the maximum amount payable as per PPN GIPSA Package rate. She stated that they were not

aware of any PPN rate nor were they informed about the same by the hospital. She argued that if that was the rate agreed by the hospital and the surgery was possible to be done within that amount, why

did the hospital charge them more and they had no option but to pay the charges as billed by the

hospital. Hence the reason cited by the Respondent for short-settlement of the claim was not acceptable to them. She requested for settlement of the full claim amount.

Contentions of the Respondent: It was contended on behalf of the Respondent that Dr.

Panchamia’s Hospital is in their GIPSA PPN and hence the claim was settled as per the PPN Agreed

Package Rate applicable for the said surgery. On being asked by the Forum whether they had sought any clarification from the hospital for not adhering to PPN Agreed Package Rate, they stated that as

per the statement given by the hospital, the patient did not opt for cashless facility and hence he was

charged as per open tariff.

Forum’s Observations/Conclusion: On hearing the depositions of both the parties and

perusal of the documents produced on record, the Forum is of the view that since the hospital is under

PPN, if the patient has been overcharged by the hospital, the Respondent should seek clarification/refund of excess charged amount from the hospital and there is no justification for

deductions from the bill amount genuinely paid by the insured. The claim of the complainant has to be

settled for the full hospitalisation expenses less non-medical items. The decision of the Respondent is

therefore intervened by the following order.

AWARD Under the facts and circumstances of the case, National Insurance Co. Ltd. is directed to pay the

balance admissible amount (including C-arm, Pulse oxymeter and monitor charges) in respect

of the hospitalization from 19.06.2017 to 25.06.2017 of the complaint Mr. Rameshchandra Shah,

in full and final settlement of the complaint.

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

Ombudsman Rules, 2017:




(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. SANDIP P. REDIJ

VS RESPONDENT : STAR HEALTH AND ALLIED INSURANCE CO. LTD.


1 Name & Address of the Complainant Mr. Sandip P. Redij

Mumbai 2 Policy No:


P/171114/01/2018/016394

Diabetes Safe Insurance Policy 29.03.2018 – 28.03.2019 Rs.10,00,000/-


Mr. Sandip Redij

4 Name of Insurer Star Health & Allied Insurance Co. Ltd.

5 Date of Repudiation 02.01.2018 6 Reason for repudiation Obesity treatment – Excl. No. 12

7 Date of receipt of the complaint 25.05.2018 8 Nature of complaint Repudiation of claim 9 Amount of claim Rs.3,42,202/-

10 Date of Partial Settlement - 11 Amount of relief sought Rs.3,42,202/- 12 Complaint registered under

Insurance Ombudsman rules Under Rule 13(b)

13 Date of Hearing 12.12.2018 – 3.15 p.m. 14 Representation at the hearing

a) For the complainant Mr. Sandip Redij b) For the insurer Dr. Arvind Thakkar, AGM


Brief Facts of the Case : Complainant was admitted to Dr. Shashank Shah’s Laparo-

Obeso Centre Pune from 11.10.17 to 13.10.17 and underwent Laparoscopic Sleeve

Gastrectomy. A claim lodged under the policy for the said hospitalization was repudiated by

the Respondent under Exclusion no 12 of the Policy which excludes the company from any

liability arising out of treatment for obesity.

Contentions of the Complainant : Complainant submitted that he purchased Diabetes

Safe Insurance Policy from Star Health on 29.03.2016 by undergoing all the required pre-

insurance medical tests. He was under the treatment of Dr. Pradeep Talwalkar since 2001 for

Diabetes and was advised to take 30 units of insulin twice a day, despite which his diabetes

was not under control. Considering the possibility of future complications Dr. Talwalkar

advised him to go for Sleeve Gastrectomy. Accordingly he consulted Dr Shashank Shah, an

award winning surgeon from the American Diabetes Association, who also advised him to go

for this surgery for control of diabetes and other related issues. He underwent the surgery on

10.12.17; however Respondent rejected the claim for the same stating that treatment of

obesity is not payable. He argued that he underwent the surgery on the advices of reputed

doctors for control of diabetes and its other related complications and not for obesity. After

the surgery all his diabetes medicines have been stopped totally and his sugar levels are also

within control. Hence the reason cited by the Respondent for rejection of this claim is not

acceptable to him. He requested for settlement of claim.

Contentions of the Respondent : Dr. Thakkar submitted that the complainant had

opted for Diabetes Safe Policy which has four sections - 1. Diabetes and its complications; 2.

Ailments other than diabetes; 3. OPD treatments & 4. Personal Accident. From the discharge

card it is evident that the complainant was treated for Morbid Obesity. Exclusion clause 12 of

the policy specifically excludes the company from any liability to make any payment in

respect of any expenses for treatment of weight control services including surgical procedure

for treatment of obesity, medical treatment for weight control/ loss programs. The said

treatment was not covered under any of the sections of the policy. Hence the claim stood

repudiated as per policy condition.

Forum’s Observations/Conclusion: The Forum analyzed the case and observed that as per

Discharge card and hospital papers, the complainant was overweight/ obese. Though improvement

and resolution of other co-morbidities in obese patients has been observed as a result of weight loss

after bariatric surgery, nevertheless the fact remains that this surgery is an option for people who

cannot lose weight by other means or who suffer from serious health problems related to obesity.

In the present case the complainant argued that he was suffering from uncontrolled Type 2 Diabetes

Mellitus and hence was advised by the doctor to undergo Sleeve Gastrectomy surgery to avoid its

future complications. Even accepting the complainant’s contention that in the instant case the

surgery was not for simple weight loss but was medically needed, the fact remains that it was

primarily the condition of Obesity which necessitated him to undergo the surgery since this surgery

is also not a direct treatment for DM and other problems suffered by the complainant. Most

importantly, the treatment of Obesity and any weight control program is expressly excluded from

the scope of the Policy. It is to be borne in mind that this Forum has the inherent limitations in going

beyond the provisions of the policy contract and the Forum examines cases in detail to see whether

there is any breach of policy provisions while denying a claim and cannot grossly overlook the terms

and conditions clearly spelt out in the policy and also approved by the IRDAI. Under the

circumstances, the decision of the Respondent to repudiate the claim being as per the terms and

conditions of the policy, was found to be in order and does not call for any intervention.

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mr. Sandip R. Redij against

Star Health & Allied Insurance Co. Ltd., does not sustain.





(MILIND KHARAT)

INSURANCE OMBUDSMAN




COMPLAINANT - MRS. SHEELA SATISH SHANBHAG

VS RESPONDENT : UNITED INDIA INSURANCE CO. LTD.

COMPLAINT REF. NO: MUM-G-051-1819-0196


Complainant was covered under Synd Arogya Policy No. 1202002817P102391083 for the period 12.05.2017 to 11.05.2018 for S.I. of Rs.4,00,000/-, issued by the Respondent. She was operated for left eye Cataract at L.V. Prasad Institute, Hyderabad on 03.03.2017 for which she incurred total expenses of Rs.39,000/-. Out of this amount, Rs.26,000/- was settled on cashless basis under IBA Corporate policy held by her. For the balance Rs.13,000/- she lodged a reimbursement claim under Synd Argoya Policy; however the same was not settled by the Respondent despite repeated follow-up. Hence she approached this Forum seeking relief in the matter.

A joint hearing of the parties to the dispute was scheduled to be held on 26.11.2018 at 3.30 p.m. Meanwhile, Respondent informed the Forum that they have settled the claim for the balance amount of Rs.13,000/-. Respondent vide e-mail dt. 02.11.2018 confirmed that he has received the balance claim amount and informed his willingness to withdraw the complaint. In view of the same, the complaint stands closed at this Forum. There is no order for any other relief. The case is disposed of accordingly.

Dated: This 28th day of February,, 2019 at Mumbai.




(Under Rule No. 16/17 of Insurance Ombudsman Rules, 2017) OMBUDSMAN : SHRI MILIND KHARAT

CASE OF COMPLAINANT - MR.SUDHIR P. SHAH

VS

RESPONDENT : NATIONAL INSURANCE CO. LTD. COMPLAINT REF: NO: MUM-G-048-1718-1379


1 Name & Address of the Complainant Mr.Sudhir P. Shah, Mumbai

2 Policy No:


240201501610011929

National Mediclaim Policy 11.01.2017 – 10.01.2018 Rs.5,00,000/-


Mrs. Bharti Sudhir Shah/Sudhir Shah Mr.Bharti Sudhir Shah

4 Name of Insurer National Insurance Co. Ltd.

5 Date of partial Repudiation 19-09-2017

6 Reason for partial repudiation Claim paid under PPN rate






12 Complaint registered under Ombudsman Rules

Under Rule 13(b)

13 Date of Hearing 24.10.2018 – 16.00 pm


a) For the complainant Mr.Sudhir P. Shah

b) For the insurer Absent 15 Complaint how disposed Award


Brief Facts of the Case : Complainant was admitted to Zen Multi Specialty Hospital, Mumbai from 07.06.2017 to 10.06.2017 and operated for K42 multiple Hernia. Complainant approached this Forum with a complaint against short-settlement by the Respondent of the claim lodged under the policy in respect of the said hospitalization. Contentions of the Complainant :

The Forum asked the Complainant the reasons for his grievance. The Complainant had submitted that he and his family members are covered with National Insurance Company for more than 10 years. The Complainant has submitted that the claim for Rs.3,16,095/- along with pre-post hospitalization was lodged under Policy No. 240201501610011930. The Company settled the claim for Rs.89,795/-.

Under policy No. 240201501610011929 he has Claimed for balance amount of Rs.

2,26,300/-. However the Company has disallowed as per GIPSA package which was not

acceptable to him. He requested for settlement of the balance claim amount of Rs. 2,26,300/-

. Contentions of the Respondent: Insurance Company and TPA both remained absent. In the self contained note it is submitted that the claim was settled for Rs.89,795/- under policy no. 240201501610011930 as per GIPSA package. The Complainant approached for balance claim amount of Rs.2,26,300/- under his wife’s policy No. 240201501610011929.The Insurance Company repudiated the claim as per terms and conditions Clause3.23 of the policy. Forum’s Observations/Conclusion : The Forum has scrutinized all the documents produced on record and observed that complainant has undergone treatment for K42 multiple Hernia at Zen Multi Specialty Hospital. He lodged total claim of Rs.3,16,095/- and the Company has settled it for Rs, 89,795/- and disallowed the balance claim amount of Rs.2,26,300/- as per PPN package. Since the hospital is under PPN, network hospital, if the patient has been overcharged by the hospital, the Respondent should seek clarification/refund from the hospital. There is no justification for deductions from the claim amount on the ground of reasonability. The claim of the complainant has to be settled for the balance amount towards hospitalization expenses less non-medical items if any. The decision of the Respondent is therefore intervened by the following order.

AWARD

Under the facts and circumstances of the case, National Insurance Company is directed to pay the admissible claim amount of Rs.2,26,300/-less non medical expenses as per policy terms and conditions in favour of the complaint Mr.Sudhir P.Shah, towards full and final settlement of the complaint. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:


b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated: This 8th day of February, 2019 at Mumbai.





CASE OF COMPLAINANT - Mrs. Vandana Satish Naik



1 Name & Address of the Complainant Mrs. Vandana Satish Naik, Mumbai

2 Policy No:


124500/48/2018/3101

Happy Family Floater-2015 31.08.2017 to 30.08.2018 Rs.500000/-


Mrs. Vandana Satish Naik Mrs. Vandana Satish Naik



6 Reason for partial repudiation As per Policy Clause Reasonable and Customary



9 Amount of claim Rs.1,93,008/-(Rs.99494 & Rs.93514/-)

10 Amount of Partial Settlement Rs.73708/-(Rs.39844/-& Rs.33864/-)



13 (b)



a) For the complainant Mr Satish Naik

b) For the insurer Mrs.Rachana S.Ramle A.O.



Brief Facts of the Case :Mrs.Vandana Satish Naik was covered under the above policy and

she was admitted at Ursekar Laser & Microsurgery Eye Clinic on 07.02.2018 for Left eye cataract surgery and on 14.02.2018 for Right eye cataract surgery in the same hospital and lodged total claim of Rs.1,93,008/-.The Company has settled Rs.39,844/- and Rs.33,864/-

per eye totaling to Rs.73,708/- and deducted the balance amount of RS.1,19,300 on the ground of Reasonable and Customary Clause3.41 & Contribution Clause 5.9. The complainant has represented in his written statement that he is not agreeable with the


Contentions of the complainant:The complainant had authorized her husband Mr. Satish Naik who appeared and deposed before the Ombudsman in joint hearing held with

the Company. He submitted during the hearing that his wife underwent cataract surgery for both her eyes and lodged total claim of Rs.193,008/- and the Company has settled Rs.39844/- & Rs.33864/- per eye totaling to Rs.73708/- and deducted the balance amount

on the ground of Reasonable and Customary Clause and Contribution Clause. He argued that the contribution clause was not applicable for this policy. Hence he was not agreeable with the decision of the company and requested for intervention of the Forum for getting

justice. Contentions of the Respondent:

The Respondent submitted during the hearing that the charges of this hospital were very much on the higher side and they have compared the rates of cataract surgery with hospitals such as Kokilaben D.Ambani Hospital, Fortis Hiranandani Hospital and Jaslok

Hospital where the package rates are Rs.30000/- and Rs.32000/- respectively and they have settled the claim for Rs.39844/- & Rs.33864/-totaling to Rs.73708/-for both eyes and deducted the balance amount on the ground of Reasonable and Customary Clause. Observations/Conclusion:

The Forum observes in this case that the patient underwent cataract surgery for both her eyes at Ursekar Laser & Microsurgery Eye Clinic and lodged total claim of Rs.193008/- and the Company has settled Rs.39844/- & Rs.33864/- totaling to Rs.73708/- for both eyes and

deducted the balance amount on the ground of Reasonable and Customary Clause. The Forum notes that charges of this Hospital are on the higher side as compared to other hospitals like Kokilabe Hospital, Fortis Hospital and Jaslok Hospital. There is no doubt that

an individual has every right to go in for the best treatment available but the policy would pay only the charges which are necessarily and reasonable. As such whenever it is observed that the charges are unreasonably high, the “Reasonable

and Customary Charges” Clause of the policy would come into operation, the Company is within its right to limit the expenses payable for a particular procedure by comparing the charges prevalent in the same geographical area. However the above hospital charges are

on the higher side in comparison to Kokilaben Ambani Hospital and Jaslok Hospital which are network hospitals and the hospital where the patient underwent cataract surgery is a non network hospital and therefore Forum finds it in order. The Forum ordered to pay the

additional amount of Rs.10156/- & Rs.16136/- totaling to Rs.26,292/- for both eyes i.e. (maximum payable Rs.50,000/- per eye less already paid.) All other deductions are in order.

AWARD

M/s Oriental Insurance Co.Ltd. is directed to settle the above claim for additional amount of Rs.26292/- towards full and final settlement of above claims and

inform the payment particulars to this Forum. There is no order for any other relief. The case is disposed of accordingly.




insurers.

c) It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer.


(MILIND KHARAT)

INSURANCE OMBUDSMAN




CASE OF COMPLAINANT - MR. YOGESH D. SAVLA



1 Name & Address of the Complainant Mr. Yogesh D.Savla, Mumbai


Sum Insured

14210034162500002360 New Mediclain 2012 Policy 14.07.2016 to 13.07.2017

Rs.5,00,000/- & CB Rs.1,62,500/-


Mr. Yogesh D.Savla Mrs.Palak Yogesh Savla

4 Name of Insurer New India Assurance Co. Ltd.






10 Amount of Partial Settlement Rs.1,75,053/-


12 Complaint registered under Insurance Ombudsman rules

Under Rule 13(b)

13 Date of Hearing 12.09.2018 – 10.15 a.m.


a) For the complainant Mr. Yogesh D.Savla

b) For the insurer Mrs.Pratibha P.Bolar, A.O.& Dr. Bharti, H.I ,TPA


16 Date of Award/Order 08.02-2019

Brief Facts of the Case : Complainant’s wife Mrs. Palak Yogesh Savla was admitted to

Womens Hospital from 27.05.2017 to 28.05.2017 for surgery of Multiple Fibroid

Uterus. Complainant approached this Forum with a complaint against short-settlement by the

Respondent of a claim lodged under the policy for the said surgery.

Contentions of the Complainant : Complainant submitted that against his total claim

for Rs.3,08,713/-, Respondent reimbursed him only Rs.1,75,053/- which was not acceptable

to him. He stated that he had given advance intimation of hospitalization to the Company

and requested for settlement of the balance claim amount.

Contentions of the Respondent: The Forum asked the Company the reasons for short

payment of the claim. The Company official Mrs.Pratibha P.Bolar Administrative Officer, submitted

that a deduction of Rs.1,33,660/- was made from the claim amount as per Clause 2.36 of the policy

under Reasonable and Customary Charges. After comparing the prevailing charges of other tertiary

care hospitals in metro cities of same grade for present surgery. The charges of other hospitals were

found to be on lower side hence the deductions were made as per policy terms and conditions.

Forum’s Observations/Conclusion: After hearing the depositions of both the parties,

Respondent was advised to review their decision with a view to resolve the dispute in the matter

and inform their final decision to the Forum. Accordingly, Respondent informed the Forum that they

are willing to pay an additional amount of Rs.52,960/- i.e. (50% towards Professional surgeon

charges Rs54,400/-, consultation/visit charges Rs.14320/- and Operation Theatre charges

Rs.37,200/-) towards full and final settlement of the complaint. Hence the following Order:

AWARD

Under the facts and circumstances of the case, The New India Assurance Co. is directed to pay an

additional amount of Rs.52,960/- over and above the payment already made by them in favour of

the complainant Mr. Yogesh D.Savla, towards full and final settlement of the complaint.








Dated: This day of 8th February, 2019 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

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

Case of: MR. MAYANK MAROO V/s STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED Complaint No: BNG-G-044-1819-0323

Award No: IO/(BNG)/A/GI/0370/2018-19

1) The Complainant was covered under the Group Health

Insurance Policy No. P/141130/01/2018/007415 obtained by M/s. Sri Sri Publications Trust

for a Sum Insured of ₹. 1,00,000/-, for the period from 15.02.2018 to 14.02.2019 covering

pre-existing diseases along with waiver of 30 days waiting period, 1/2 year exclusions.

2) Insured Person, Mr. Mayank Maroo (33 years) was admitted to

Sri Sri College of Ayurvedic Science and Research Hospital, Bangalore on 19.06.2018 for

complaints of fever, nausea, loose motions since a day and was diagnosed as Vishama

Jwara/Chardi and was discharged on 21.06.2018.

3) The claim was repudiated by the Respondent Insurer that

allopathic treatment by a non-allopathic doctor.

4) The Complainant represented to the Respondent Insurer along

with a certificate from the Hospital confirming that the doctor who provided the treatment

was a qualified allopathy doctor. However, his claim was not settled.

5) Hence the Complainant approached this Forum for settlement

of the claim.

6) The complaint was taken up for further process and the

complaint was posted for personal hearing on 20.02.2019.

7) Meanwhile, the Respondent Insurer offered to settle the claim for ₹. 5,689/- (including

interest) as against the claim of ₹. 6,057/- and the Complainant consented for the said

settlement.

8) The Respondent Insurer settled the claim and transferred the claim proceeds to the

Complainant’s HDFC Bank Account through NEFT on 15.12.2018.

9) As the Complaint was resolved on Compromise basis, the complaint is Closed and disposed

off accordingly. The personal hearing scheduled for 20.02.2019 stands cancelled.

Dated at Bengaluru on the 4th day of February, 2019

(NEERJA SHAH) INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH Case of: MR. PRASHANTH R KOTIAN V/s STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Complaint No: BNG-G-044-1819-0427 Award No: IO/(BNG)/A/GI/0371/2018-19

1) The Complainant obtained Family Health Optima Insurance

Plan Policy No. P/700001/01/2018/016873 for the period from 20.01.2018 to 19.01.2019

covering himself and his daughter for a floater Sum Insured of ₹. 4,00,000/-, bonus of ₹.

1,05,000/- and Recharge Benefit of Rs. 1,00,000/-. He had continuous insurance since

20.01.2016

2) The Complainant (42 years) was admitted to Columbia Asia

Referral Hospital, Bangalore on 17.02.2018 for complaints of breathing

difficulty/cough/fullness in the legs, Hypertension and Chronic Kidney Disease and was

diagnosed as Acute on Chronic Kidney Disease (CKD) and Hypertension (HTN) was

discharged on 22.02.2018.

3) The claim was repudiated by the Respondent Insurer stating

that the Complainant failed to submit the treatment records along with investigation reports

pertaining to CKD & HTN.

4) The Complainant submitted the Ayurvedic treatment records

along with investigation reports pertaining to CKD & HTN. However, his claim was not

settled.


of the claim.

6) The complaint was taken up for further process.

7) Meanwhile, the Respondent Insurer offered to settle the claim for ₹. 1,10,922/- and

₹.36,924/- as against the claim of ₹. 1,67,037/- and ₹. 41,555/- respectively and the

Complainant consented for the said settlement.

8) The Respondent Insurer settled the claim and transferred the claim proceeds to the

Complainant through NEFT on 31.01.2019.

9) As the Complaint was resolved on Compromise basis, the complaint is Closed and disposed

off accordingly.




PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH In the matter of: MR. G KEMPA GANGAIAH V/s APOLLO MUNICH HEALTH INSURANCE COMPANY LIMITED

Complaint No: BNG-G-003-1819-0362 Award No.: IO/(BNG)/A/GI/0372/2018-19

1 Name & Address of the Complainant Mr. G Kempagangaiah

# 772, 1st Main, 26th Cross

Judicial Layout,

GKVK POST

BENGALURU – 560 065

Mobile # 97415 88993

E-mail: [email protected]

2 Policy /Cert. No.

Type of Policy

120100/12001/2017/A007631/338

Easy Health Group Insurance

Duration of Policy/ Policy Period 23.02.2018 to 22.02.2019

3 Name of the Insured/ Proposer

Name of the policyholder

Mr. Kempa Gangaiah G

4 Name of the Respondent Insurer Apollo Munich Health Insurance Company Limited

5 Date of repudiation/rejection 10.04.2018

6 Reason for repudiation Non-disclosure of Pre-existing Disease

7 Date of receipt of Annexure VI-A 13.11.2018

8 Nature of complaint Rejection of claim and cancellation of the policy

9 Amount of claim ₹. 6,00,000/- (approximately)

10 Date of Partial Settlement NA

11 Amount of relief sought Recovery of medical expenses of ₹. 6,00,000/-

(approximately) and activation of the policy

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

13 Date of hearing/place 07.02.2019 / Bengaluru


a) For the Complainant Mr. Krishna Murthy, Son of the Complainant

b) For the Insurer Dr. Yeshwanth Kumar, Manager

15 Complaint how disposed Partially Allowed


17. Brief Facts of the Case:

The complaint arose out of the repudiation of the claim for non-disclosure of pr-existing disease, senile immature cataract. The Complainant contended with Grievance Redressal Officer (GRO) stating that he disclosed the pre-existing health condition and hence the rejection of claim and cancellation of the policy were unjustified. However neither his claim was settled nor was policy revived. Hence, the Complainant approached this Forum for settlement of his claim and continuation of the policy.

18. Cause of Complaint: a. Complainant’s arguments: The complainant obtained the cited policy covering him for a sum insured of ₹. 5,00,000/-. He took his first policy on 06.09.2017 and renewed continuously. This policy was issued to the Accountholders of Canara Bank.

The Complainant (66 years) underwent Left Eye Phaco+ IOL in Dr. Agarwal’s Health Care Ltd., Bengaluru on 05.03.2018 for his left eye cataract. Cashless and reimbursement claims were denied

by the Respondent Insurer stating that the pre-existing condition of senile immature cataract since 13.02.2017 was not disclosed in the proposal form whilst taking the policy.

The Complainant represented to the GRO seeking settlement of the claim as the pre-existence of cataract was disclosed in the proposal form and sought a copy of the proposal form submitted by him. However, neither the claim was settled nor the proposal form copy was made available to him.

Hence the Complainant approached this Forum for settlement of his claim and continuation of his insurance policy.

b. Respondent Insurer’s Arguments:

The Respondent Insurer in their Self Contained Note (SCN) dated 17.01.2019 whilst admitting the policy coverage submitted that the complainant signed that as per Enrolment Form (EF) the Complainant signed the declaration in Section 4 of the EF which confirmed that all the relevant information was furnished. Further Policy Kit containing all the relevant documents including the Policy terms and conditions were received by the Complainant.

The Patient was admitted to Dr. Agarwal’s Eye Hospital with complaints of diminution of vision in the left eye and was diagnosed as cataract. An investigation was arranged in the said case and as per consultation paper dated 13.02.2017, the patient had cataract which was prior to the policy inception. Non-disclosure of ‘senile immature cataract since 13.02.2017’ in the proposal form amounted to providing incorrect good health declaration and concealment of the facts and hence claim was repudiated by invoking condition 3(t) of the policy. It was further submitted that if it was disclosed in the proposal form, it amounted to pre-existing disease which would be covered after 48 months of continuous insurance. The Complainant was to disclose the material information as per Regulation 4 (8) of IRDA (Protection of Policyholders’ Interests) Regulations, 2017 which he failed to do so.

The Respondent Insurer relied on the decision of National Commission in the order of RP 1208 of 2014 of Canara HSBC Oriental Bank of Commerce Life Insurance Co., Ltd., Vs Lalit Kumar Kothari and the case of Satwant Kaur Sandhu vs The New India Assurance Company Ltd., in the Supreme Court for breach of utmost Good Faith.

The Respondent Insurer submitted that the claim of the Complainant was repudiated in accordance with the documents on record. The Respondent Insurer sought to dismiss the complaint, as the complaint is devoid of merits.

19. Reason for Registration of complaint:-

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

20. The following documents were placed for perusal.

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

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

The issues which require consideration are (1) whether the Complainant was suffering from senile cataract prior to the inception of the policy, (2) whether the denial of claim was in line with the policy terms and conditions and (3) whether the revival and renewal of the policy is to be carried out by the Respondent Insurer in view of the request of the Complainant’s representative. 21.1. During the personal hearing, both the parties reiterated their earlier submissions.

21.2.1. The Forum notes from the ‘Insured Statement Form for Health Insurance Claim’ dated 28.03.2018 submitted by the Complainant that he had cataract since January, 2017 which corroborates with the prescription of Rangalakshmi Netralaya dated 13.02.2017 confirming SIMC.

21.2.2. The Complainant’s representative admitted that he had the said problem from 13.02.2017. He admitted that he disclosed about Diabetes in the proposal form whilst taking the policy.

21.3.1. The waiting period for cataract was 1 year as per exclusion c (i) of the policy and the claim was preferred in the 2nd year thereby it completed the waiting period of 1 year.

21.3.2. The Forum however notes that the complainant had senile cataract prior to taking the first policy on 23.02.2017 which amounted to pre-existing disease.

21.3.3. It is noted from Section 2 (d) of the policy that the pre-existing diseases are covered after 48 months of continuous insurance. In the instant case the claim was preferred in the 2nd year of the policy for the pre-existing disease and the same has not completed the stipulated said waiting period of 48 months. Hence the said claim is not admissible and the rejection of claim is unassailable.

21.4. The Complainant being a Senior Citizen aged 66 years, obtaining a fresh insurance after

cancellation of the policy would be difficult for him. The Forum therefore advises the Respondent

Insurer to revive the cancelled policy from the date of cancellation and to renew the same.

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

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

consonance with the terms and conditions of the policy and does not require any interference at the

hands of the Ombudsman.

The Respondent Insurer is advised to revive the cancelled policy from the date of cancellation and

renew the same.

Hence the complaint is Partially Allowed.

22) Compliance of Award:

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

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

Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the

Ombudsman.

Dated at Bangalore on the day of 7th of February, 2019

(NEERJA SHAH)

INSURANCE OMBUDSMAN



OMBUDSMAN – NEERJA SHAH In the matter of: MR. G KEMPA GANGAIAH V/s APOLLO MUNICH HEALTH INSURANCE COMPANY LIMITED

Complaint No: BNG-G-003-1819-0362

Award No.: IO/(BNG)/A/GI/0372/2018-19

1 Name & Address of the Complainant Mr. G Kempagangaiah

# 772, 1st Main, 26th Cross

Judicial Layout,

GKVK POST


Mobile # 97415 88993


2 Policy /Cert. No.

Type of Policy

Duration of Policy/ Policy Period

120100/12001/2017/A007631/338

Easy Health Group Insurance

23.02.2018 to 22.02.2019



Mr. Kempa Gangaiah G

4 Name of the Respondent Insurer Apollo Munich Health Insurance Company Limited




8 Nature of complaint Rejection of claim and cancellation of the policy

9 Amount of claim ₹. 6,00,000/- (approximately)


11 Amount of relief sought Recovery of medical expenses of ₹. 6,00,000/-

(approximately) and activation of the policy




a) For the Complainant Mr. Krishna Murthy, Son of the Complainant

b) For the Insurer Dr. Yeshwanth Kumar, Manager




The complaint arose out of the repudiation of the claim for non-disclosure of pr-existing disease, senile immature cataract. The Complainant contended with Grievance Redressal Officer (GRO) stating that he disclosed the pre-existing health condition and hence the rejection of claim and cancellation of the policy were unjustified. However neither his claim was settled nor was policy revived. Hence, the Complainant approached this Forum for settlement of his claim and continuation of the policy.

18. Cause of Complaint: a. Complainant’s arguments: The complainant obtained the cited policy covering him for a sum insured of ₹. 5,00,000/-. He took his first policy on 06.09.2017 and renewed continuously. This policy was issued to the Accountholders of Canara Bank.

The Complainant (66 years) underwent Left Eye Phaco+ IOL in Dr. Agarwal’s Health Care Ltd., Bengaluru on 05.03.2018 for his left eye cataract. Cashless and reimbursement claims were denied by the Respondent Insurer stating that the pre-existing condition of senile immature cataract since 13.02.2017 was not disclosed in the proposal form whilst taking the policy.

The Complainant represented to the GRO seeking settlement of the claim as the pre-existence of cataract was disclosed in the proposal form and sought a copy of the proposal form submitted by him. However, neither the claim was settled nor the proposal form copy was made available to him.

Hence the Complainant approached this Forum for settlement of his claim and continuation of his insurance policy.

b. Respondent Insurer’s Arguments:

The Respondent Insurer in their Self Contained Note (SCN) dated 17.01.2019 whilst admitting the policy coverage submitted that the complainant signed that as per Enrolment Form (EF) the Complainant signed the declaration in Section 4 of the EF which confirmed that all the relevant information was furnished. Further Policy Kit containing all the relevant documents including the Policy terms and conditions were received by the Complainant.

The Patient was admitted to Dr. Agarwal’s Eye Hospital with complaints of diminution of vision in the left eye and was diagnosed as cataract. An investigation was arranged in the said case and as per consultation paper dated 13.02.2017, the patient had cataract which was prior to the policy inception. Non-disclosure of ‘senile immature cataract since 13.02.2017’ in the proposal form amounted to providing incorrect good health declaration and concealment of the facts and hence claim was repudiated by invoking condition 3(t) of the policy. It was further submitted that if it was disclosed in the proposal form, it amounted to pre-existing disease which would be covered after 48 months of continuous insurance. The Complainant was to disclose the material information as per Regulation 4 (8) of IRDA (Protection of Policyholders’ Interests) Regulations, 2017 which he failed to do so.

The Respondent Insurer relied on the decision of National Commission in the order of RP 1208 of 2014 of Canara HSBC Oriental Bank of Commerce Life Insurance Co., Ltd., Vs Lalit Kumar Kothari and the case of Satwant Kaur Sandhu vs The New India Assurance Company Ltd., in the Supreme Court for breach of utmost Good Faith.

The Respondent Insurer submitted that the claim of the Complainant was repudiated in accordance with the documents on record. The Respondent Insurer sought to dismiss the complaint, as the complaint is devoid of merits.


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


22. Complaint along with enclosures,

d. Respondent Insurer’s SCN along with enclosures and e. Consent of the Complainant in Annexure VI A & and Respondent Insurer in VII A.


The issues which require consideration are (1) whether the Complainant was suffering from senile cataract prior to the inception of the policy, (2) whether the denial of claim was in line with the policy terms and conditions and (3) whether the revival and renewal of the policy is to be carried out by the Respondent Insurer in view of the request of the Complainant’s representative. 21.1. During the personal hearing, both the parties reiterated their earlier submissions.

21.2.1. The Forum notes from the ‘Insured Statement Form for Health Insurance Claim’ dated 28.03.2018 submitted by the Complainant that he had cataract since January, 2017 which corroborates with the prescription of Rangalakshmi Netralaya dated 13.02.2017 confirming SIMC.

21.2.2. The Complainant’s representative admitted that he had the said problem from 13.02.2017. He admitted that he disclosed about Diabetes in the proposal form whilst taking the policy.

21.3.1. The waiting period for cataract was 1 year as per exclusion c (i) of the policy and the claim was preferred in the 2nd year thereby it completed the waiting period of 1 year.

21.3.2. The Forum however notes that the complainant had senile cataract prior to taking the first policy on 23.02.2017 which amounted to pre-existing disease.

21.3.3. It is noted from Section 2 (d) of the policy that the pre-existing diseases are covered after 48 months of continuous insurance. In the instant case the claim was preferred in the 2nd year of the policy for the pre-existing disease and the same has not completed the stipulated said waiting period of 48 months. Hence the said claim is not admissible and the rejection of claim is unassailable.

21.4. The Complainant being a Senior Citizen aged 66 years, obtaining a fresh insurance after

cancellation of the policy would be difficult for him. The Forum therefore advises the Respondent

Insurer to revive the cancelled policy from the date of cancellation and to renew the same.

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

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

consonance with the terms and conditions of the policy and does not require any interference at the

hands of the Ombudsman.

The Respondent Insurer is advised to revive the cancelled policy from the date of cancellation and

renew the same.

Hence the complaint is Partially Allowed.





Ombudsman.

Dated at Bangalore on the day of 7th of February, 2019

(NEERJA SHAH)

INSURANCE OMBUDSMAN


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

OMBUDSMAN – Mrs NEERJA SHAH In the matter of Shri K SUBASH V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



The complaint emanated for the rejection of claim under Family Health Optima Insurance

Plan policy number P/141130/01/2019/001958

The Complainant’s wife was admitted to Hospital with complaints of irregular cycles and

pain in abdomen. She was diagnosed as ‘Right Ovarian Cyst’. She underwent ‘Laparoscopic

Right Ovarian Cystectomy with Omental and Bowel Adhesiolysis’ and was discharged.

The ground for rejection was that there was break in continuity of insurance for 58 days and

that the ailment started during the said break in period.

Inspite of submitting the required clarifications the RI and their Grievance Cell the claim was

not considered. Aggrieved with the approach of RI, the Complainant approached this

Forum.

The complaint is posted to 27.02.2019 for Personal Hearing.

As there were documents to establish that the patient was under treatment during the

currency of previous policy, this office took up the matter with the RI for reconsideration.

RI vide their mail dated 02.02.2019 have informed that they have reviewed the claim and

are setting as per the terms and conditions of policy.

In view of the mediation of this Forum, the RI vide their mail dated 05.02.2019 have agreed

to settle the claim for ₹.1,24,092/- and have initiated the process of payment.

The Complainant vide his mail dated 12.02.2019 has confirmed receipt of ₹.1,24,092/- and

has informed that he is withdrawing the Complaint.

The complaint was resolved on compromise basis wherein both have agreed for the same and hence, the Complaint is treated as Closed and Disposed off accordingly.

The Forum appreciates the action taken by the RI in resolving the Complaint.

Dated at Bangalore on the 12th day of February, 2019.




OMBUDSMAN - NEERJA SHAH In the matter of SHRI JAGANMOHAN P V/s MAX BUPA HEALTH INSURANCE COMPANY LIMITED

Complaint No: BNG-G-031-1819-0361 Award No. : IO/(BNG)/A/GI/0383/2018-19

1 Name & Address of the Complainant SHRI P. JAGANMOHAN

422, 3rd Cross, Krishna Temple Road

1st Stage, Indiranagar

BENGALURU – 560 038.

Mob.No. 98455 16943

E Mail : [email protected]

2 Policy No.

Type of Policy


30540136201600

Health Companion Variant 2

27.06.2017 to 26.06.2018


Name of the Insured Person

Shri P Jaganmohan

Shri Vidyuth Nair - Son

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


6 Reason for repudiation Non co-operation by hospital for claim verification

7 Date of receipt of the Annexure VI-A 20.11.2019

8 Nature of complaint Repudiation of claim.

9 Amount of claim ₹.1,09,440/-

10 Date of Partial Settlement N.A.

11 Amount of relief sought ₹.1,09,440/- with interest

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



a) For the Complainant Self

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

15 Complaint how disposed Allowed


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

ground that the hospital was non co-operative. His request to Grievance cell was also not

considered. The Complainant having aggrieved with the attitude of the Respondent Insurer (RI) has

approached this Forum.


a) Complainant’s arguments:

The Complainant submitted that he had insured his son with the RI from 27.06.2016 and was

renewed continuously. His son was admitted to Sri Sri Tattva Panchakarma on 14.06.2018 with

complaints of insomnia, acidic bowel, weakness etc., and was discharged on 26.06.2018. He had

preferred a claim for ₹.1,09,440/- and the same was rejected on the hospital was non cooperative.

He states that RI’s representative met the hospital authorities and has verified the details. Inspite of

approaching the GRO of RI, the same was not resolved.

b) Respondent Insurer’s Arguments:

The Respondent Insurer submitted their Self Contained Note dated 29.01.2019 admitting insurance

and preferring of claim and their rejection. It is submitted that the hospital and the insured have not

co-operated at the time of verification/investigation and that hospitalization was not justified and

could have been managed of OPD basis. The claim was repudiated as per clause 3.e (vii) of the

policy.


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


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

21. Result of personal hearing with both the parties (Observations & Conclusions): This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing. After analysing the same, this Forum noted that the dispute is with regard to repudiation of claim on the ground of non co-operation of the Complainant/hospital and whether could have been managed on OPD basis. The Complainant reiterated his contentions and stated that there was co-operation by him and also the hospital. He also stated that the representative of RI had met the operations manager of the hospital and had verified the details. The admission was medically advised and necessary for the treatment. He also submitted that the condition quoted for repudiation is not available in the policy documents sent to him RI reiterated their contention in SCN and submitted that their decision was based on the terms and conditions of policy. Now, they have reviewed and offered settlement of claim for ₹.94,880/-. It was also submitted that the receipt of last document was on 30.06.2018. As the RI has agreed for the settlement of claim for ₹.94,880/- and the same is accepted by the Complainant, the Forum is not going on the merits of the Complaint and directs the RI to settle the same with interest. The Complaint is Allowed.

A W A R D

Taking into account of the facts and circumstances of the case, the documents the oral submissions made by both the parties and the RI’s offer of settlement, the Forum directs the RI to settle the claim as agreed. This Forum directs the Respondent Insurer to settle the claim for ₹.94,880/- as above as per the terms and conditions of policy along with interest @ 6.25% + 2% from the date of receipt of last necessary documents (30.06.2018) to the date of payment of claim, as per regulation 16 (1) (ii) of Protection of Policy holders’ Interests of IRDA Regulations, 2017 issued vide notification dated 22.06.2017. Hence, the complaint is ALLOWED.

22. Compliance of Award:

The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

Dated at Bangalore on the 13th day of February, 2019.

( NEERJA SHAH) INSURANCE OMBUDSMAN



OMBUDSMAN – Mrs NEERJA SHAH In the matter of NOEL THOMAS V/s RELIGARE HEALTH INSURANCE COMPANY LIMITED


Award No. : IO/(BNG)/A/GI/0384/2018-19

1 Name & Address of the Complainant Shri NOEL THOMAS

A-009, Infinite NR Greenwoods

9, Shampur Main Road, R T Nagar


Mob.No. 99168 16168

E Mail ID : [email protected]

2 Policy No.

Type of Policy


11747994

Religare Health Insurance Policy - CARE

11.11.2017 to 10.11.2018



Shri Noel Thomas

Self

4 Name of the Respondent Insurer Religare Health Insurance Company limited


6 Reason for repudiation Non-disclosure of material facs/PED


8 Nature of complaint Repudiation of claim for non-disclosure

9 Amount of claim ₹.45,225/-


11 Amount of relief sought ₹.45,225/-

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




b) For the Respondent Insurer Dr Nisha Sharma, Manager-Claims

15 Complaint how disposed Dismissed



The Complaint emanated from the rejection of claim on the ground of Non-disclosure of material facts prior to inception of policy. Inspite of taking up the complaint with the GRO of the Respondent Insurer (RI), the same was not resolved and hence, the Complainant has approached this Forum.



The Complainant was insured with M/s Star Health Insurance by his previous employer for the past 2 years. As he left the job, he obtained a policy online submitting the required information from the RI from 11.11.2017. The current issue had nothing to do with the previous ailments which had been cured and at the time of taking this policy there was no issue relating to cause for current hospitalisation. He was healthy and not under any critical illness, current hospitalisation was an abrupt case, there was no list of illness to be reported in the online application and claim was reported 10 months after insurance. He was admitted to Vikram Hospital on 13.08.2018 and his request for cashless was rejected on the ground of non disclosure. His claim for reimbursement of ₹.45,225/- was also rejected.

In spite of representation to RI with a clarification letter from the hospital, the same was not considered. Hence, he has approached this Forum.


The Respondent Insurer vide their Self Contained Note dated 13.12.2018 admitted insurance coverage, preferring of request for cashless and their rejection for non-disclosure. They submit that the claim for reimbursement was also rejected for the same reason. It is stated that as per admission history & physical assessment sheet & Emergency room assessment form of Vikram Hospital the Complainant was a known case of CVT 3 years ago and was on medication for 6-8 months. As per certificate of Dr. Rajesh B Iyer dated 13.08.2018, he was having history of CVT (Cerebral venous thrombosis) in October 2014 and was on medication for the same for 6 months. As it was a clear case of non-disclosure, the claim was rejected.

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:

f. Complaint along with enclosures, g. Respondent Insurer’s SCN along with enclosures and h. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A


This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing. On perusal of the Complaint, Forum noted that the dispute is as to whether there was non-disclosure of material facts. The Complainant reiterated his contentions and stated that he had disclosed all the information sought by the RI and that the ailment had been cured and hence, it is not correct to say that there was non-disclosure. He stated that the online proposal was filled up in consultation with the RI’s representative and as the present ailment is independent of the earlier ailments, the same deserves to be considered. The RI reiterated their contentions and submitted that the Complainant had answered in the negative to the specific answers in the proposal and hence claim was repudiated as per clause 7.1 of the policy. As regards the dispute with regard to the declarations made in the proposal, the RI has produced copy of the online proposal and the relevant question and answer given by the Complainant is reproduced below:

1. Has any proposed to be insured been diagnosed with or suffered from/is suffering from or is currently under medication for the following: – Does any insured has PED? Any Neuromuscular (muscles or nervous system) disorder or Psychiatric disorders (including but not limited to Major Neuron Disease, Muscular dystrophies, Epilepsy, Paralysis, Parkinsonism, multiple sclerosis, stroke, mental illness)

As seen from the proposal, the Complainant has declared the said information as ‘No’.

Though the RI contends that the Complainant has answered ‘No’ to the question ‘Has any of the above mentioned person(s) to be insured been diagnosed/hospitalised for any illness/injury during the last 48 months?’ the Forum notes from the proposal that the same is not answered by the Complainant. The relevant conditions/clauses/exclusions are reproduced for the sake of better understanding: Definitions - 1.58 – Pre-existing Disease means any condition, ailment or injury or related condition (s) for which the Insured Person had signs or symptoms, and/or were diagnosed and/or received Medical Advice/treatment within 48 months prior to the first policy issued by the insurer. Exclusions 4.1.(iii) Pre-existing Disease – Claims will not be admissible for any Medical expenses incurred for Hospitalisation in respect of diagnosis/treatment of any Pre-existing Disease until 48 months of continuous coverage has elapsed, since the inception of the first Policy with the Company. Disclosure to Information Norm 7.1 – If any untrue or incorrect statements are made or here has been a misrepresentation, mis description or non-disclosure of any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the Policy holder or the Insured Person or any one acting on his/her behalf, the Company shall have no liability to make payment of any claims and the premium paid shall be forfeited ab initio to the Company. On perusal of the papers, it is noted that the Complainant is not disputing the fact that he underwent treatment in 2014, but contending that the same had been cured, where as RI is contending that the rejection of claim was for non disclosure.

From the available documents and submissions, the Forum is of the opinion that the Complainant being aware of the earlier treatment has failed to disclose the same in the proposal form, which amount to non disclosure of material information. This Forum relies on the Hon’ble Supreme Court of India’s decision in the case of Satwant Kaur Sandhu v/s. The New India Assurance Company Limited IV (2009) CPJ 8 (S.C), wherein the hon’ble court held : “The upshot of the entire discussion is that in a Contract of Insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a "material fact". If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasise that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance”. As the decision of RI is based on medical records and the terms and conditions of policy, this Forum concurs with the decision of the Respondent Insurer. The Complaint is hereby Dismissed.

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

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

the Respondent Insurer in repudiating the claim is in consonance with the terms and conditions of

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

Hence, the Complaint is Dismissed.

Dated at Bengaluru on the 13th day of February, 2019.

( NEERJA SHAH) INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH Case of: MR. BABU KUMAR CHARLES V/s STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Complaint No: BNG-G-044-1819-0308 Award No: IO/(BNG)/A/GI/0389/2018-19

1) The Complainant obtained Senior Citizens Red Carpet Health

Insurance Policy No. P/141115/01/2017/012755 for the period from 28.02.2017 to

27.02.2018 covering his father for a floater Sum Insured of ₹. 5,00,000/-. He had continuous

insurance since 28.02.2015.

2) The insured person, Mr. Charles E S (75 years) was admitted to

Bhagwan Mahaveer Jain Hospital, Bangalore on 23.01.2018 for complaints of altered

sensorium since 3 days and diagnosed as ICH-Left temporoparietal bleed, Ischemic Heart

Disease and Hypertension. He was discharged on 29.01.2018.

3) The claim was repudiated by the Respondent Insurer and policy

was cancelled stating that the Complainant was a known case of Hypertension and Ischemic

Heart Disease (ICH) since 4 years which was prior to obtaining the first policy but the same

was not disclosed whilst obtaining the first policy.

4) The Complainant represented to GRO of the Respondent

Insurer stating that his father was hale and healthy and did not undergo any treatment for

heart. His father had normal BP levels till he took the first policy and the hypertension was

contracted after commencement of the first policy. However, his claim was not settled.


of the claim and revival of the cancelled policy.

6) The complaint was taken up for further process and the same

was posted for personal hearing on 20.02.2019.

7) Meanwhile, the Respondent Insurer settled the claims for ₹. 13,353/-, ₹. 2,972/, ₹. 3,787/-

and ₹. 6,581/- on 27.06.2018, 14.08.2018, 01.01.2019 and 07.01.2019. Though the

Complainant accepted for the claim settlement, he did not withdraw the complaint and

insisted for revival of the cancelled policy.

8) Subsequently the Respondent Insurer agreed to revive the cancelled policy and to provide

continuous insurance. Thereafter the Complainant withdrew his complaint.

9) The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17

(6) of the Insurance Ombudsman Rules, 2017, whereunder the Respondent Insurer shall

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


10) As the Complaint was resolved on Compromise basis with the intervention of this Forum, the

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

scheduled for 20.02.2019 stands cancelled.


(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA


OMBUDSMAN –NEERJA SHAH In the matter of: MR SUNIL KUMAR V V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. V Sunil Kumar

G-04, Sadashiv Residency

Shivalaya Road, Sadashivnagar

BELGAUM – 590 001

Mobile # 97315 22994

E-mail ID : [email protected]

2 Policy Number

Type of Policy


P/141213/01/2018/002389


15.02.2018 to 14.02.2019



Dr Sunil Kumar Venkatesh Reddy

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

5 Date of repudiation 06.09.2018



8 Nature of complaint Rejection of claim

9 Amount of claim ₹.6,68,390/- + expenses for further treatment


11 Amount of relief sought ₹.6,68,390/- + future chemotherapy + ₹.5,00,000/-





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




The claim was rejected on the ground that it was a pre-existing disease which was not disclosed and

the same would be covered after completion of waiting period of 48 months of continuous

insurance. The Complainant represented to Grievance Redressal Officer (GRO) of the Respondent

Insurer that he was actively discharging his duties and did not have any pre-existing ailment.

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

his claim.



The Complainant along with his wife and son were covered under the cited policy for a basic floater

Sum Insured of Rs, 15,00,000/- with a Recharge Benefit of Rs. 1,50,000/-.

The Complainant is a doctor. He was working with Narayana Hrudayalaya till September 2017 and

had corporate insurance till he was with the said hospital. As his family moved to Belagavi, he joined

Lakeview Heart & Super Speciality Hospital, Belgaum and obtained the cited policy. As per

Discharge Summary of Lakeview Hospital, Belagavi, he was admitted to on 13.07.2018 for

complaints of fever with GCTC around 01.30 AM and had history of ? conjunctivitis since 3 days –

tongue bite + and was diagnosed as ‘Frontal Lobe Glioma’ and convulsions with GCTC and was


He was admitted to Apollo hospitals, Sheshadripuram, Bengaluru and as per the Discharge Summary,

he had complaints of history of headache and history of one episode of GTCS (generalized tonic-

clonic seizure) 2 days back and was diagnosed as ‘Left Frontal Glioma’ KPS score – 90. He underwent

Left frontal craniotomy and excision of mass under GA with neuronavigation fluorescein and intra

operative neuronmonitiring guidance under GA and was discharged on 21.07.2018. His request for

cashless and also reimbursement was rejected.

Aggrieved with the rejection of the claim, the Complainant approached GRO of Respondent Insurer

stating that he was discharging his professional functions and did his European Diploma in

Anaesthesia & Critical care in Sweden during 13.05.2018 to 23.05.2018 and had he known about the

pre-existing condition he would not dared to move out of the country. He further added that he did

not have any symptoms and signs of glioma till it appeared as an episode of convulsions on

13.07.2018 whereas the policy was obtained on 15.02.2018 and sought for settlement of the claim.

He further submitted a certificate dated 12.09.2018 by Lakeview Hospital where he was working

stating he was independently attending to OTs, ICU and high risk cases and he did not have any signs

and symptoms of Neurological illness before the said episode and GTCS. However his claim was not

settled. Hence, he approached this Forum for settlement of his claim.


The Respondent Insurer in their Self Contained Note (SCN) dated 25.01.2019 whilst admitting insurance coverage submitted that the claims were rejected on the grounds of on completion waiting periods 3 (iii) for pre-existing Diseases. After reporting of the complaint with this Forum the claims were reviewed again by their medical team and offered to settle the claims for Rs. 17,245/- (Claim No. 233512/2019) and Rs. 2,44,761/- (Claim No. 191280/2019), preferring of claim and their rejection on the ground of waiting period 3 (iii) - PED. Hence, RI has requested us to mediate and absolve them from the complaint made.


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

registered.


i. Complaint along with enclosures, j. Respondent Insurer’s SCN along with enclosures and k. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A


The issues which require consideration are (1) whether the claim settlement offered is in tune with the policy terms conditions, (2) whether to consider the rejection of 2 radiotherapy/chemotherapy claims along with this complaint and (3) whether imposition of additional conditions during the currency of the policy and at the time of renewal is valid.

21.1. Since the Respondent Insurer offered to settle the claims, the Forum has not gone into the

merits of the complaint.

21.2. The Respondent Insurer submitted that they are agreeable to settle the claims as stated in SCN for ₹.17,245/- as against Rs. 17,345/- and ₹.2,44,761/- as against Rs. 2,87,696/- . The Respondent Insurer confirmed that the amount offered for claim settlement is as per the terms and conditions of the policy and the same is accepted by the Complainant. The Complainant did not prove consent for the same.

21.3. The Complainant represented that in one of the claims amount was reduced for non-

submission of prescription. The Complainant submitted that the prescription was submitted to the

Respondent Insurer subsequently. He also produced the copy of the same. The representative of

the Respondent Insure assured the complainant that the claim would settled considering the said

prescription

21.4. As regards the contention of the Complainant about non-settlement of chemotherapy claims, the Representatives of the Respondent Insurer assured that the said claims which were rejected subsequent to said offer of settlement of claims and the same would be settled without further delay, upon receipt of the consent from the Complainant. In the light of this Award, the Respondent Insurer is advised to initiate payment of the said offered claims including the disallowed amount for non-submission of prescription. 21.5. It is noted that the Respondent Insurer incorporated ‘All Neurological diseases and its complications’ as Pre-Existing Diseases. Having settled the claim treating that the insured person was not suffering from the present illness and also neurological disorders, the Respondent Insurer is not justified in incorporating the above as pre-existing. The Complainant submitted that the said rider was found in the renewed policy also. The Respondent Insurer is directed to withdraw the said rider/exclusion from the previous policy and also from the renewed policy immediately and not to incorporate the same in the subsequent policies also. 21.6. The Complainant submitted that he should be awarded damages for the mental tension and stress and for the financial crunch which resulted in him buying cheap medicines. It was explained to him that the Forum has no authority to award damages as per Rule No. 17 (i) of Insurance Ombudsman Rules, 2017. Further the complainant is informed that he is entitled for interest which is within the purview of said Ombudsman Rules and the same is awarded.

A W A R D

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

Respondent Insurer agreeing for settlement, the directs the Respondent Insurer to settle the

claims as agreed along with interest @ 8.25% (Bank rate of 6.25% + 2% penalty) from 30 days

from the date of filing of the last relevant document by the Insured till the date of payment of the

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

The Respondent Insurer is directed to withdraw the said rider/exclusion of neurological disorders from the previous policy and also from the renewed policy immediately and not to incorporate the same in the subsequent policies also. The complaint is Allowed.

24) Compliance of Award: The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the

Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the


Ombudsman.

Dated at Bangalore on the 21st day of February, 2019




OMBUDSMAN –NEERJA SHAH In the matter of: MR SUNIL KUMAR V V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. V Sunil Kumar

G-04, Sadashiv Residency

Shivalaya Road, Sadashivnagar

BELGAUM – 590 001

Mobile # 97315 22994


2 Policy Number P/141213/01/2018/002389

Type of Policy



15.02.2018 to 14.02.2019



Dr Sunil Kumar Venkatesh Reddy






9 Amount of claim ₹.6,68,390/- + expenses for further treatment


11 Amount of relief sought ₹.6,68,390/- + future chemotherapy + ₹.5,00,000/-









The claim was rejected on the ground that it was a pre-existing disease which was not disclosed and

the same would be covered after completion of waiting period of 48 months of continuous

insurance. The Complainant represented to Grievance Redressal Officer (GRO) of the Respondent

Insurer that he was actively discharging his duties and did not have any pre-existing ailment.

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

his claim.



The Complainant along with his wife and son were covered under the cited policy for a basic floater

Sum Insured of Rs, 15,00,000/- with a Recharge Benefit of Rs. 1,50,000/-.

The Complainant is a doctor. He was working with Narayana Hrudayalaya till September 2017 and

had corporate insurance till he was with the said hospital. As his family moved to Belagavi, he joined

Lakeview Heart & Super Speciality Hospital, Belgaum and obtained the cited policy. As per

Discharge Summary of Lakeview Hospital, Belagavi, he was admitted to on 13.07.2018 for

complaints of fever with GCTC around 01.30 AM and had history of ? conjunctivitis since 3 days –

tongue bite + and was diagnosed as ‘Frontal Lobe Glioma’ and convulsions with GCTC and was


He was admitted to Apollo hospitals, Sheshadripuram, Bengaluru and as per the Discharge Summary,

he had complaints of history of headache and history of one episode of GTCS (generalized tonic-

clonic seizure) 2 days back and was diagnosed as ‘Left Frontal Glioma’ KPS score – 90. He underwent

Left frontal craniotomy and excision of mass under GA with neuronavigation fluorescein and intra

operative neuronmonitiring guidance under GA and was discharged on 21.07.2018. His request for

cashless and also reimbursement was rejected.

Aggrieved with the rejection of the claim, the Complainant approached GRO of Respondent Insurer

stating that he was discharging his professional functions and did his European Diploma in

Anaesthesia & Critical care in Sweden during 13.05.2018 to 23.05.2018 and had he known about the

pre-existing condition he would not dared to move out of the country. He further added that he did

not have any symptoms and signs of glioma till it appeared as an episode of convulsions on

13.07.2018 whereas the policy was obtained on 15.02.2018 and sought for settlement of the claim.

He further submitted a certificate dated 12.09.2018 by Lakeview Hospital where he was working

stating he was independently attending to OTs, ICU and high risk cases and he did not have any signs

and symptoms of Neurological illness before the said episode and GTCS. However his claim was not

settled. Hence, he approached this Forum for settlement of his claim.


The Respondent Insurer in their Self Contained Note (SCN) dated 25.01.2019 whilst admitting insurance coverage submitted that the claims were rejected on the grounds of on completion waiting periods 3 (iii) for pre-existing Diseases. After reporting of the complaint with this Forum the claims were reviewed again by their medical team and offered to settle the claims for Rs. 17,245/- (Claim No. 233512/2019) and Rs. 2,44,761/- (Claim No. 191280/2019), preferring of claim and their rejection on the ground of waiting period 3 (iii) - PED. Hence, RI has requested us to mediate and absolve them from the complaint made.



registered.


l. Complaint along with enclosures, m. Respondent Insurer’s SCN along with enclosures and n. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A


The issues which require consideration are (1) whether the claim settlement offered is in tune with the policy terms conditions, (2) whether to consider the rejection of 2 radiotherapy/chemotherapy claims along with this complaint and (3) whether imposition of additional conditions during the currency of the policy and at the time of renewal is valid.

21.1. Since the Respondent Insurer offered to settle the claims, the Forum has not gone into the

merits of the complaint.

21.2. The Respondent Insurer submitted that they are agreeable to settle the claims as stated in SCN for ₹.17,245/- as against Rs. 17,345/- and ₹.2,44,761/- as against Rs. 2,87,696/- . The Respondent Insurer confirmed that the amount offered for claim settlement is as per the terms and conditions of the policy and the same is accepted by the Complainant. The Complainant did not prove consent for the same.

21.3. The Complainant represented that in one of the claims amount was reduced for non-

submission of prescription. The Complainant submitted that the prescription was submitted to the

Respondent Insurer subsequently. He also produced the copy of the same. The representative of

the Respondent Insure assured the complainant that the claim would settled considering the said

prescription

21.4. As regards the contention of the Complainant about non-settlement of chemotherapy claims, the Representatives of the Respondent Insurer assured that the said claims which were rejected subsequent to said offer of settlement of claims and the same would be settled without further delay, upon receipt of the consent from the Complainant. In the light of this Award, the Respondent Insurer is advised to initiate payment of the said offered claims including the disallowed amount for non-submission of prescription. 21.5. It is noted that the Respondent Insurer incorporated ‘All Neurological diseases and its complications’ as Pre-Existing Diseases. Having settled the claim treating that the insured person was not suffering from the present illness and also neurological disorders, the Respondent Insurer is not justified in incorporating the above as pre-existing. The Complainant submitted that the said rider was found in the renewed policy also. The Respondent Insurer is directed to withdraw the said rider/exclusion from the previous policy and also from the renewed policy immediately and not to incorporate the same in the subsequent policies also. 21.6. The Complainant submitted that he should be awarded damages for the mental tension and stress and for the financial crunch which resulted in him buying cheap medicines. It was explained to him that the Forum has no authority to award damages as per Rule No. 17 (i) of Insurance Ombudsman Rules, 2017. Further the complainant is informed that he is entitled for interest which is within the purview of said Ombudsman Rules and the same is awarded.

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

Respondent Insurer agreeing for settlement, the directs the Respondent Insurer to settle the

claims as agreed along with interest @ 8.25% (Bank rate of 6.25% + 2% penalty) from 30 days

from the date of filing of the last relevant document by the Insured till the date of payment of the

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

The Respondent Insurer is directed to withdraw the said rider/exclusion of neurological disorders from the previous policy and also from the renewed policy immediately and not to incorporate the same in the subsequent policies also. The complaint is Allowed.

25) Compliance of Award: The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the

Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the


Ombudsman.





OMBUDSMAN –NEERJA SHAH In the matter of: MR T K SRIDHARAN V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. T K Sridharan

# 316, Komarala Brigade Residency

Uttarahalli Road


Mobile # 93428 65662


2 Policy Number

Type of Policy


P/700001/01/2019/008045 & 8048

Senior Citizens Red Carpet Health Insurance Policy

17.06.2018 to 16.06.2019



Shri T K Sridharan & Smt Revathi Sridharan

Shri T K Sridharan & Smt Revathi Sridharan



6 Reason for repudiation Not Applicable


8 Nature of complaint Change of policy terms at the time of renewal

9 Amount of claim Nil


11 Amount of relief sought Issuance of policy without co-pay clause

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





15 Complaint how disposed Disallowed



The complaint emanated from the alleged imposition of additional conditions at the time of renewal

of policy. The Complainant represented to Grievance Redressal Officer (GRO) stating that whilst

porting neither the said condition was informed to him nor policy terms and conditions were

provided to him along with the policy schedule. However his grievance was not redressed and

hence the Complainant approached this Forum.



The Complainant obtained the cited policy covering himself and his wife separately in two individual

policies. He ported to the present insurer from M/s Royal Sundaram General Insurance Company

with whom he had continuous policies from 2006 to 2017. As Royal Sundaram was not continuing

their policies, he ported the cited individual policies from 17.06.2017 for both of them. He received

the policies which clearly stated that the terms were attached to the same but policy schedule alone

was received without the terms and conditions.

The Complainant renewed the same policies in 2018 and surprisingly found the co-pay clause

printed on the face of the policies whereas the same were not mentioned in the previous policies.

He wrote to the Respondent Insurer questioning how a new clause of co-pay could be introduced in

the renewed policies. He further contended that the details of this condition were not informed to

him whilst taking the first ported policy.

This discrepancy was referred to the GRO as well as IGMS of IRDA but the issue was not resolved.

Hence, the Complainant has approached this Forum for deletion of co-pay clause from his and his

wife’s policy.


The Respondent Insurer in their Self Contained Note (SCN) dated 20.11.2018 admitted that the Complainant and his wife ported to them and obtained Senior Citizens Red Carpet Insurance through telesales. Renewal of the same was done in 2018 through telesales.

It was submitted that the Senior Citizen Policy is offered at the entry age of 60 - 74 years and renewed till life time.

Condition no. 5 of policy deals with co-payment and reads as – ‘Condition 5. Co-Payment: This policy is subject to co-payment of 50% of each and every claim arising out of Pre-existing Diseases and 30% of each and every claim for all other claims’. When the complaint was raised on 19.06.2018, the reply was given on the same day. Subsequent queries were also responded vide their e-mails dated 20.06.2018 and 29.06.2018 The policies issued to the Complainant were with the terms and conditions and as per Condition no. 5, dealt with Co-pay.

Hence, Respondent Insurer requested to absolve them from the complaint made.


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

complaint was registered.


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

21. Result of personal hearing with both the parties (Observations & Conclusions): The issues which require consideration are (1) whether the contention of the complainant that the policy schedule alone was sent without the terms and conditions of the policy is correct, (2) whether the complainant has questioned the Insurance Company for not sending the terms and conditions along with the policy schedule. (3) whether the Complainant availed the free look period option of reporting the discrepancies with the Respondent Insurer when the same were not matching with the proposal submitted/information furnished in the telephonic enquiry and (4) whether complainant is eligible for continuation of the policies without co-pay clause.

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

21.2. During the Personal Hearing the Complainant reiterated that he took the policies through

telesales and the Representatives of Respondent Insurer did not inform him about the applicability

of the condition of co-pay at any point of time and in particular at the time of porting. He received

schedule of the Policy alone without terms and conditions.

21.3. The Representative of the Respondent Insurer submitted that when the policy was generated through telesales, policy schedule along with relevant terms and conditions along with a copy of proposal form were mailed to the registered e-mail id of the Complainant and hard copies thereof were sent by post. Policy schedule would be invariably sent along with terms and conditions with a copy of proposal form. 21.4.1. The Forum asked the Respondent Insurer for (1) Audio conversation of both the parties at the proposal stage, (2) covering letter for having sent the schedule of the policy along with terms and conditions and (3) copy of postal receipt showing the date and weight of the envelope in grams (to ascertain whether the terms and conditions were also despatched in the envelope). But the Respondent Insurer could not submit sl. no. 1 & 3. Non-production of audio recording is in clear violation of Guidelines on Distance Marketing of Insurance Products dated 05.04.2011. Copy of the postal receipt would have helped the Respondent Insurer to establish that they had indeed dispatched the terms and conditions along with the schedule to the Complainant. 21.4.2. As regards sl. no. 2, the Forum finds that on the reverse of the policy schedule received by the Complainant it is clearly mentioned that ‘Further, the policy is subject to the condition of ‘free look period. As per this condition, a free look period of 15 days from the date of receipt of the policy is available to you to review the terms and conditions of the policy. In case you are not satisfied with the terms and conditions, you may seek cancellation of the policy and in such an event, we shall allow refund of premium paid after adjusting the cost of pre-acceptance medical screening, if any,...’. 21.4.3. The Forum notes that this was an opportunity given to the Complaint to get the copy of the terms and conditions of the policy if not received by him earlier. 21.4.4. The covering letter also advised to visit their website: www.starhealth.in for product details. 21.4.5. It is verified from the aforesaid site that the details of co-payment are shown on the policy. (link - www.starhealth.in/sites/default/files/policy-clauses/Senior-Citizens-Red-Carpet-Health-InsurancePolicy.pdf). Forum finds that the Complainant did not ask the Respondent Insurer for a copy of terms and conditions which were purported to be sent along with the policy schedule. He also did not visit the site to ascertain the details of the policy terms and conditions. 21.5. The Respondent Insurer submitted that in the event of telesales, the policy copies would be sent to the registered e-mail id. The Complainant confirmed that he received the policy first on his e-mail and hard copies later. The aspect of receiving the policy schedule along with the terms and conditions over e-mail for the policy years 2017-18 has not been confirmed by the Complainant. 21.7.1. Though it is not appearing on the face of the schedule, the policy issued was subject to conditions, clauses, warranties, exclusions etc. It is noted from condition no. 5 of the previous policy that co-pay clause was indeed part of the conditions of the policy. 21.7.2. Forum notes that every Insurer files terms and conditions of the policy before obtaining the approval from the regulator IRDAI and co-pay clause is part of such conditions. It is further noted from the schedule of 2017-18 it had ‘Unique Identification No. IRDA/NL-HL T/SJAO/P-H/V/V.II/172/14-15’ which indicates the approval for the product obtained from the Regulator, Insurance Regulatory and Development Authority of India (IRDAI). The same number is appearing on the schedule of the policy for 2018-19. Hence it cannot be accepted that the previous policy did not contain co-pay clause.

http://www.starhealth.in/

http://www.starhealth.in/sites/default/files/policy-clauses/Senior-Citizens-Red-Carpet-Health-InsurancePolicy.pdf

http://www.starhealth.in/sites/default/files/policy-clauses/Senior-Citizens-Red-Carpet-Health-InsurancePolicy.pdf

21.7.3. The Forum notes that this is not the case where the co-pay clause was introduced in the policy after the first renewal. The said co-pay was part of the approval obtained from IRDAI and could have been in existence since 2014-15 as the approval number indicated 2014-15. 21.8.1. During the course of personal hearing, the Complainant submitted that – (1) The Senior Citizens are given priority by The Government of India but the Star Health on the contrary introduced co-pay in the Senior Citizen policy which hurts the Senior Citizens. (2) In his earlier policies with Royal Sundaram had no such co-pay. If he was aware of such co-pay condition at the time of porting, he would have continued with Royal Sundaram only. (3) Discretion of portability vests with the Insurance Company issuing the ported policy which he questioned. 21.8.2. The Forum notes that – (1) As afore discussed, Star Health obtained approval for the product for marketing the same. The Regulator IRDAI is established by Government of India has provided the approval for the same which is unquestionable. (2) When he took the first policy with Royal Sundaram, he was aged about 59 and when he ported to the present insurer he was aged 70 years and the present insurer would have issued the policy as per the approval obtained for their product and as per their underwriting guidelines. The option still rests with the Complainant to port to any other company of his choice. During the personal hearing he has informed that with a notice of one month his previous insurer informed him that they would not be able to provide the renewal. The portability should be made 45 days before the expiry of the policy. In the instant case the present insurer would have waived the time line of 45 days and issued the policy. (3) The Insurance Company accepting the proposal through porting may decide based on the data received from the existing company and also the proposal form whether it is fit case for porting or otherwise based on their underwriting guidelines. As already informed the said guidelines of Health Regulation viz., Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016 are issued by IRDAI considering the aspirations of the general public and also the requirements of Insurance Companies. 21.9. Under the circumstances the Forum expresses its inability to provide any relief to the Complainant. 21.10. As regards specific request of the Complainant for alternatives available to him if he does not get desired relief from this Forum, it is to inform that the Complainant may approach Consumer Forum or civil court for redressal.

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, Forum directs

the Respondent Insurer to ensure that audio recording is preserved as laid down (21.4.1 refers),

also to send the terms and conditions of the policy along with Policy schedule and to maintain

proper records for having done so.

Hence, the Complaint is Dismissed.





OMBUDSMAN – NEERJA SHAH In the matter of: MRS. GEETHA PUTHANE v/s RELIGARE HEALTH INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mrs. Geetha Puthane

W/o Mr. Krishna Puthane

TMAES Polytechnic

Bellary Road

HOSPET – 583 201

Bellary Dt.

Mobile # 94496 44167


2 Policy No.

Type of Policy


10568097

Care

02.03.2017 to 01.03.2018

3 Name of the Insured/Proposer


Mr. Krishna Puthane

Mrs. Geeta K Puthane

4 Name of the Respondent Insurer Religare Health Insurance Company Limited


6 Reason for repudiation Tobacco use for 10 years – Permanent exclusion



9 Amount of claim ₹. 5,19,541/-

10 Date of Partial Settlement Not Applicable

11 Amount of relief sought ₹. 5,19,541/-

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




b) For the Respondent Insurer Dr. Nisha Sharma, Manager - Claims



17. Brief Facts of the Case: - The complaint arose out of repudiation of claim for treatment of tongue cancer of Complainant’s wife on the ground that the present complaint out of use of tobacco which was permanent exclusion of the policy. He represented to Grievance Redressal Officer (GRO) along with a certificate from a treating doctor stating that the present ailment was attributable to the sharp teeth. However his claim was not settled. Hence he approached this Forum for settlement of his claim. 18. Cause of Complaint: - a) Complainants argument:

The husband of the Complainant, Mr. Krishna Puthane obtained the cited policy covering himself,

the insured patient, Mrs. Geeta K Puthane and their son for a floater Sum Insured of Rs. 5,00,000/-.

He took his first policy on 02.03.2016 and renewed continuously.

As per Discharge Summary of HCG Hospital, Banaglore, Mrs. Geetha K Pthane (43 years), the Insured

Person was admitted on 06.03.2018 with complaint of pain in left side of tongue since last 3 months

and ulcer in the left side of tongue since last 20 days. It was diagnosed as Carcinoma Tongue,

cT2N1M0 and underwent Partial Glossectomy + Left MRNO + Free FLAP and she discharged on

15.03.2018.

The claim was not registered by Respondent Insurer as per their letter dated 25.04.2018 stating that

the present ailment (Malignant neoplasm of other and unspecified parts of tongue) fell under

permanent exclusion - condition caused by substance abuse - tobacco. The reimbursement claim

was rejected vide their letter dated 26.04.2018.

The Complainant represented to GRO vide his letter dated 19.05.2018 along with a certificate of Dr.

Dr. Vishal U S Rao stating that the subject ailment was attributable to sharp teeth. However his

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

as he incurred huge expenses for the treatment of his wife.


The Respondent Insurer in their Self Contained Note (SCN) dated 18.01.2019 whilst admitting the

insurance coverage, submitted that reimbursement claim was preferred for Rs. 5,86,057/- (including

pre & post hospitalisation expenses). It was submitted that as per History & Physical Examination

sheet prepared by HCG Hospital and under the head ‘Social History’, the insured patient had the

habit of checking ‘Areca Nut’ since 10 years. It was further submitted that any illness attributable to

consumption or substance abuse was permanently excluded as per 4.2.23 reading as “4.2 Permanent

Exclusions ‘Any claim in respect of any insured person for, arising out of or directly or indirectly due to

any of the following shall not be admissible unless expressly stated to the contract elsewhere in the

Policy terms and conditions. 23. Act of self-destruction or self-inflicted injury, attempted suicide or

suicide while sane or insane or illness or injury attributable to consumption, use, misuse or abuse of

intoxicating drugs and alcohol or hallucinogens”.

The Respondent Insurer obtained an independent opinion from Dr. Sachin Almel, MD, DM (Medical

Oncology), Mumbai who opined vide his letter dated 27.12.2018 that Chronic areca nut chewing is

an accepted and recognised independent risk factor for oral cancer. They also obtained another

opinion from Dr. C H Asrani, DNB (Family Medicine), MBBS, Mumbai who described Areca Nut as -

‘Areca Nut is the seed of the fruit of the oriental palm, Areca catechu. It is the basic ingredient of a

variety of widely used chewed products. This slices of the nut, either natural or processed, may be

mixed with a variety of substances including slaked lime (calcium hydroxide) and spices such

cardamom, coconut and saffron. Most significantly they may be mixed with tobacco products or

wrapped in the leaf of the piper betel plant. Hence the more common name was ‘betel nut’. Areca

nut is used by an estimated 200-400 million people mainly IndoAsians and Chinese. He concluded

that chewing Areca Nut for 10 years is an accepted and recognized independent risk factor for oral

cancer.

The Respondent Insurer submitted they sought etiology of the complainant’s ailment of CA tongue

from Dr. U S Vishal Rao vide their letter dated 05.01.2019, whose certificate was submitted by the

Complainant. But he failed to respond to the said letter.

The Respondent Insurer relied on Supreme Court’s decision in ECGC vs. M/s. Garg Sons Internal

wherein it was decided that the terms of the contract have to be construed strictly without altering

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

It was prayed for the dismissal of the complaint as the claim denial was as per the terms and

conditions of the policy.

19. Reason for Registration of Complaint: -

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

20. The following documents were placed for perusal: - a. Complaint along with enclosures,

b. SCN of the Respondent Insurer along with enclosures along with the enclosures and c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.

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

The issues which require consideration are (1) whether the insured patient had the habit of chewing Areca Nut for the past 10 years, as per History & Physical Examination sheet prepared by HCG Hospital, (2) whether the certificate issued by Dr. Vishal U S Rao can be considered and (3) whether the proposal form contained a question about consuming of Areca Nut and whether the Complainant disclosed the same.

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

21.2. The Complainant reiterated that Dr. Vishal U S Rao vide his certificate dated 15.05.2018 confirmed that sharp teeth contributed for the tongue cancer and hence the stand of the Respondent Insurer is unsustainable.

21.2.1. The Forum notes from the said certificate that the doctor stated that the patient had not given any history of tobacco use, when enquired about the personal habits. Therefore his opinion that sharp teeth could have contributed for said tongue cancer is prejudiced.

21.3.1. It is noted from History & Physical Examination – Adult Form that the patient had the habit of consuming ‘Areca Nut’ since 10 years.

21.3.2. The Respondent Insurer sought etiology from the Dr. Rao vide their letter dated 05.01.2019. It is submitted by the Respondent Insurer that the said doctor did not respond to their letter. Doctor in the cited letter stated that the patient did not give any history of tobacco use. In the light of the above the Forum does not take cognizance of the said doctor’s certificate on which the Complainant relies.

21.4.1. The Respondent Insurer obtained an independent opinion from Dr. Sachin Almel, MD, DM

(Medical Oncology), Mumbai who opined vide his letter dated 27.12.2018 that Chronic areca nut

chewing is an accepted and recognised independent risk factor for oral cancer.

21.4.2. Another opinion from Dr. C H Asrani, DNB (Family Medicine), MBBS, Mumbai was also

obtained who concluded that chewing Areca Nut for 10 years is an accepted and recognized

independent risk factor for oral cancer.

31.4.3. The Forum notes from the web that the following factors contribute/which may raise chances of getting tongue cancer:

Tobacco use Alcohol use Jagged teeth Not taking care of your teeth and gums.

Tobacco use is stated to be one of the reasons for contracting tongue cancer. In the light of the opinions of the 2 doctors as explained supra in 21.4.1 & 2, it is opined that tongue cancer in the instant case could have been due to Arecanut use.

21.5. The Forum notes from public domain that ‘Consumption of areca nut has many harmful effects on health and is carcinogenic to humans. Various compounds present in the nut, including arecoline (the primary psychoactive ingredient which is similar to nicotine), contribute to histologic changes in the oral mucosa. It is known to be a major risk factor for cancers (squamous cell carcinoma) of the mouth and esophagus’.

21.6. Discharge Summary also did not confirm about the sharp teeth causing injury to tongue and the habit of consuming Arecanut for the past 10 years.

21.7. The Respondent Insurer rejected the claim vide their letter dated 25.04.2018 stating the reason of denial as ‘Permanent Exclusion: Condition caused by substance abuse – Tobacco. The issue which arises now is to ascertain independently whether ‘Areca Nut’ could be considered as Tobacco. The Forum notes that neither the literature provided by the Respondent Insurer nor collected by this Forum confirm that Arecanut is the same as tobacco. Therefore the contention of the Respondent Insurer about permanent exclusion of usage of tobacco does not apply to the usage of Arecanut.

21.8. It is verified from the proposal form that there was a question about habits, in particular usage of tobacco but not Arecanut. Therefore the question of non-disclosure would not arise.

21.9. It was vehemently contended by the Representative of the Respondent Insurer that they were not

liable to admit the claim as the claim was not admissible as per 4.2.23 reading as “4.2 Permanent

Exclusions ‘Any claim in respect of any insured person for, arising out of or directly or indirectly due to

any of the following shall not be admissible unless expressly stated to the contract elsewhere in the

Policy terms and conditions. 23. Act of self-destruction or self-inflicted injury, attempted suicide or

suicide while sane or insane or illness or injury attributable to consumption, use, misuse or abuse of

intoxicating drugs and alcohol or hallucinogens”.

21.9.1. The relevant portion of the above exclusion is ‘illness or injury attributable to consumption, use, misuse or abuse of intoxicating drugs and alcohol or hallucinogens’.

21.9.2. As regards ‘drug’, it is noted from wikipedia that drug is – ‘In pharmacology, a drug is a chemical substance of known structure, other than a nutrient of an essential dietary ingredient, which, when administered to a living organism, produces a biological effect’. 21.9.3. Another definition of drug from web that states that ‘A drug is any substance (with the exception of food and water) which, when taken into the body, alters the body's function either physically and/or psychologically. Drugs may be legal (e.g. alcohol, caffeine and tobacco) or illegal (e.g. cannabis, ecstasy, cocaine and heroin)’

In the light of the above, ‘Arecanut’ is not to be considered as a drug.

21.9.4. It is noted from web that ‘Alcohol’ is provided as ‘It is classed as a depressant, meaning that it slows down vital functions—resulting in slurred speech, unsteady movement, disturbed perceptions and an inability to react quickly’.

In the light of the above, ‘Arecanut’ is not to be considered as an Alcohol.

21.9.5. As regards hallucinogen, it is noted from web that ‘when under the influence of either type of drug, people often report rapid, intense emotional swings and seeing images, hearing sounds, and feeling sensations that seem real but are not. Psilocybin mushrooms, LSD, and Salvia divinorum are commonly used hallucinogenic and dissociative compounds.

21.9.6. As regards intoxication it is noted from web that ‘an abnormal state that is essentially poisoning carbon monoxide intoxication, the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs drank to the point of intoxication cocaine intoxication.

21.9.7. In the light of the above, ‘Arecanut’ is not to be considered as hallucinogen and intoxicatin.

21.10. It is noted from the web that the Areanut is a stimulant but not intoxicant. It increases alertness, energy, an attention and boosts mood. On the other hand, an intoxicant produces conditions of diminished mental and physical ability, hyper excitability or stupefaction. Arecanut is neither an intoxicant nor a drug. It is neither alcohol nor drug nor hallucinogen and thus it does not fall within the exclusion clause 4.2.23 of the policy.

21.11. In the light of the above, the Forum extends the benefit to the Complainant.

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

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

terms and conditions of the policy.

The Complaint is Allowed.





Ombudsman.




PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - NEERJA SHAH In the matter of: MRS SUSHEELA DEVI V/s MAX BUPA HEALTH INSURANCE COMPANY LIMITED

Complaint No: BNG-G-031-1819-0314 Award No : IO/(BNG)/A/GI/0388/2018-19

1 Name & Address of the Complainant Mrs. Susheela Devi

W/o Mr. Moolchand Porwar

“Sundar Kunj”, 90/1,12th C Main

KSSIDC Industrial Estate

6th Block, Rajaji Nagar


Mobile # 93429 05155/95915 16269


2 Policy No.

Type of Policy


30529635201600

Family Silver 1 Lac + 15 Lacs

19.05.2016 to 18.05.2017



Mr. Moolchand Porwad

Mrs. Susheela Devi

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


6 Reason for repudiation Non-disclosure of Pre-existing Diseases


8 Nature of complaint Rejection of claim and cancellation of policy




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



a) For the Complainant Mr. Moolchand Porwar, Husband

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




The Complainant emanated from the rejection of medi-claim on the ground of non-disclosure of pre-

existing diseases. She represented to Grievance Redressal Officer (GRO) that she disclosed her

health condition to the marketing person. However he did not fill the same in the said proposal

form. Further her claim was not considered and policy was cancelled. Hence the Complainant

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



The Complainant obtained the cited policy covering himself and his wife for an Individual Sum

Insured of Rs. 1,00,000/- and floater Sum Insured of Rs. 15,00,000/-. He took the present policy

with this Insurer starting with the present policy. Earlier he had insurance from M/s. Bajaj Allianz for

the past 11 years i.e., 2006.

As per the Discharge Summary of Apollo Hospitals, Bangalore, the Complainant (62 years) was

admitted with complaints of pain in both knees, dull aching pain, non-radiating, restricted

movements, aggravates on walking and relieves on rest and was diagnosed as Osteoarthritis both

knees and underwent Total left knee replacement on 11.04.2017 and total right knee replacement

on 13.04.2017 under SA and was discharged in a stable condition on 18.04.2017.

Another claim for Rs. 47,706/- was submitted on 23.05.2017 and the same was also repudiated on

the same grounds.

The reimbursement claim was rejected by the Respondent Insurer vide their e-mail dated

12.04.2017 on the grounds of non-disclosure of Bilateral pedal edema since 2 years and

Hypertension since 10 years. The Complainant represented to GRO stating that (1) Previous health

condition was disclosed to the doctor who visited to their house to take samples of blood and urine

and ECG was done on the patient. (2) The Complainant disclosed Hypertension (HTN) to the person

who canvassed the policy. He filled the proposal form improperly without recording our disclosures

and took our signature on the policy. It was his mistake of not filling up the proposal form properly.

(3) Pedal edema was not because of any abnormality of body but it was due to continuous sitting

and frequent travelling. There was no malafide intention in not disclosing the same. (4) The present

complaint had no nexus with Pedal edema and HTN. (5) It was the mistake of the employee of the

Respondent Insurer who did not fill up the proposal form without furnishing the information despite

the details were disclosed to him. There was no fault on the part of the complainant. (6) She failed

to get the continuity benefits though she had continuous insurance since 2006.

However her claim was not settled and the policy was cancelled. Hence the Complainant

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


The Respondent Insurer in their Self Contained Note (SCN) dated 10.12.2018 whilst admitting

insurance coverage submitted that pre-authorisation request for the hospitalisation in St. Martha’s

Hospital, Bangalore for Rs. 28,000/- in respect of policyholder for treatment of Right Foot Celluitis

from 03.04.2017 till 07.04.2017, which was denied. An investigation was arranged which revealed

that the insured was already suffering from Pedal Edema since 2 years and Hypertension since 10

years. It was pertinent to mention that in the Proposal Forum under Section 6 ‘Medical History’, a

series of questions were asked which were replied as ‘No’ and during MER thereby depriving the

underwriter to take a clear assessment of the risk to be undertaken.

The policy was cancelled for non-disclosure of health of the insured by invoking clause 3 without

refund of premium. The claim of the Complainant was rejected on the grounds of termination of

policy. The policy shall be void and all premium paid herein shall be forfeited to the Company by

virtue of ‘Disclosure to Information Norm’, Def. 14.

It was further submitted that the policyholder filed similar complaint with this Forum under

Complaint No. BNG-G-031-1718-935 and the same was dismissed.

It was submitted that the claims were rightfully repudiated and the policy cancellation was

inconsonance with the terms and conditions of the policy.



registered.




The issues which arise for consideration are (1) whether the policy was ported to become eligible for porting benefits, (2) whether denial of claim on the ground of claim lodged on cancelled policy is in order, (3) whether the complainant established that the information about pre-existing condition was informed to the sales person of the policy, (4) whether the complainant is entitled for policy benefits based on the merits of the policy and (5) whether the policy revival request could be considered. .

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

21.2. It is noted that Complainant and her husband were insured with Bajaj Allianz since 31.10.2006 and renewed continuously 12.11.2016. During the year 2016, the Complainant’s husband, Mr. Moolchand Porwar obtained the cited policy on 19.05.2016 covering himself and the complainant by submitting a proposal form. The present policy was not a ported policy. Hence the credit of the previous insurance policies was not passed on to the complainant in the present policy. Further, the present policy was obtained during the currency of the policy of Bajaj Allianz which jeopardised the extension of benefits of the previous policy.

21.3. The husband of the Complainant is the policyholder of the cited policy. He filed a complaint with this Forum under Complaint No. BNG-G-031-1718-935 for rejection of claim for non-disclosure of pre-existing disease in the proposal form whilst obtaining the cited policy and cancellation of the policy. This Forum passed an Award No. IO/(BNG)/A/GI/0221/2018-19 by dismissing the complaint by upholding the contention of Respondent Insurer in rejection of the claim for non-disclosure of material fact and also did not interfere with the cancellation of the policy.

21.4.1. The Respondent Insurer rejected the subject claim on the ground that the policy was cancelled by the time the claim was preferred. It is noted that the policy was cancelled vide the e-mail dated 12.04.2017. The Respondent Insurer submitted that the policy was cancelled invoking clause 3 – ‘Cancellation by Us’ which stated that ‘Without prejudice to the above, We may terminate this Policy during the Policy Period by sending 30 days prior notice to Your address shown in the Schedule of Insurance without refund of premium if......’ and was ending with ‘For avoidance of doubt, it is clarified that no claim shall be admitted and/or paid by Us during the notice period’. It was further contended by the Respondent Insurer that since the claim was preferred during the cancellation period, they were not liable to pay the claim as per the cited clause which was invoked for cancellation of the policy. Accordingly the claim was denied.

21.4.2. Though the cancellation clause disentitled the policyholder to prefer claim during the notice of cancellation, the Forum notes that the very basic purpose of providing a waiting period is defeated if the claims arising/filed during the said cancellation period were inadmissible.

21.4.3. In the instant case, Forum notes that at the time of cancellation of the policy, the complainant was undergoing treatment. Though the Complainant was discharged on 18.04.2017, admission into the hospital was on 10.04.2017 which was prior to issuance of cancellation of the policy. The cause of action arose prior to the date of cancellation and claim was preferred during the cancellation notice period i.e., 12.05.2017. Therefore the Forum opines that the claim was admissible as the cause of action arose prior to commencement of the policy cancellation notice.

21.5.1. The issue that arises for consideration now is whether the claim is admissible on its merits. It is noted from the Discharge Summary of Apollo Hospitals, it was stated as ‘Yes – on medication’ against History of Diabetes Mellitus and History of Hypertension. Against Past/Present/Family History, it was mentioned that ‘H/O – OLD CVA NO DEFICITS’.

21.5.2. It is noted from the proposal form submitted at the time of obtaining the present insurance that against questions (1) Within the last 2 years, have you consulted a doctor or a healthcare professional? (2) Within the last 7 years, have you been to a hospital for an operation and/or an investigation (eg. scan, x-ray, biopsy or blood tests? (3) Do you take tablets, medicines or drugs on a regular basis? (4) Winthin the last 3 months have you experienced any health problems or medical conditions which you/proposed insured person have/has not seen a doctor?, it was mentioned as ‘No’.

21.5.3. It is noted from the ‘Discharge Medication’ in the Discharge Summary that medication was given for HTN with heart complications, Blood Thinner, Diabetes and the duration was given as ‘to continue’ which implies that they were used earlier and needed to be continued regularly as the end date was not given except for one tablet which had end date. The Representative of Complainant has confirmed that the insured patient was taking treatment for DM & HTN. However this aspect of pre-existence of above diseases/disorders and CVA was not disclosed in the proposal form which amounted to non-disclosure of material information. Therefore the claim becomes inadmissible as per terms and condition no.1 of the policy.

21.6.1. The diagnosis of the subject hospitalisation is ‘Osteoarthritis both knees’, as per Discharge Summary which is in the nature of Degenerative nature. As per exclusion 4 (c), the Company shall not be liable for ‘Degenerative disorders of knee/hip’ within 24 months of persons aged above 60 years at the commencement of the policy. The age of the insured person as per Discharge Summary is 62 years, 1 month and 4 days. As the claim occurred within 11 months of commencement of the policy, her age at the commencement of the policy would have been 61 years +. Therefore the above exclusion is applicable and she is not entitled for the said claim. It is noticed from the policy, the age of the insured patient was stated as 59 years which should have been 61+.

21.6.2. The Complainant also failed to provide any cohesive proof that the details of pre-existing condition of both the insured persons was informed to the sales executives at the time of obtaining the policy. 21.6.3. In the light of the above, the Complainant is not entitled for settlement of claim under the policy issued. 21.7. The Forum expresses its displeasure over the unprofessional approach of the executive of the Respondent Insurer in providing the subject insurance coverage without ensuring the continuation of the credits of earlier insurance of about 11 years. It is noted that during the currency of policy of Bajaj (13.11.2015 to 12.11.2016), this insurance policy was issued (19.05.2016 to 18.05.2017) without following the porting norms as laid down under Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016. 21.8.1. The Complainant’s Representative vehemently sought for revival of the policy as he was not able to get fresh insurance from other Insurers at his age. In view of the unprofessional approach of the executive of the Respondent Insurer, the Forum is inclined to extend the benefit of having the continuous insurance by the Complainant and her spouse. 21.8.2. In the light of the above, since the Complainant had continuous insurance since 2006 and are senior citizens, the Forum advises the Respondent Insurer to provide revival of the cancelled policy and renewal thereof subject to their underwriting guidelines. The Forum also expresses that the Complainant has to comply with advices/underwriting guidelines of the Respondent Insurer for revival of policy and continuity of uninterrupted insurance.

A W A R D Taking into account of the facts and circumstances of the case, the documents the oral submissions made by both the parties, the rejection of the claim is found to be in consonance with the terms and conditions of the Policy and it does not warrant any interference at the hands of the Ombudsman. Revival of cancelled policy and renewal thereof shall be as per 21.8.2 above. Hence, the complaint is partially allowed.

22. Compliance of Award:

The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

Dated at Bangalore on the 15th day of February, 2019



PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF

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

OMBUDSMAN – NEERJA SHAH In the matter of: MR. KESAV KUMAR V/s NATIONAL INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mr. Keshav Kumar

F2, No. 60, Kapilla Apartment

6th Main, 7th Cross

Venkatappa Layout

Sanjaynagar

BENGALURU - 560 094

Mobile # 8970554029


2 Policy No.

Type of Policy


261000501710001437

Parivar Mediclaim

23.11.2017 to 22.11.2018



Mr. Keshav Kumar

Mrs. Puja Maheshwari

4 Name of the Respondent Insurer National Insurance Company Limited

5 Date of Repudiation/Rejection 13.03.2018

6 Reason for repudiation Non-completion of waiting period for maternity

7 Date of receipt of the Annexure VI A 01.06.2018

8 Nature of complaint Rejection of maternity

9 Amount of claim ₹. 53,384/-

10 Date of (Partial) Settlement Not Applicable

11 Amount of relief sought ₹. 75,000/- (inclusive of interest, trauma and

compensation)

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

13 Date of hearing/place 20.02.2019/ Bengaluru



b) For the Respondent Insurer Mr. J Udaya Kumar, Dy. Manager




The complaint emanated from the repudiation of the claim on the ground that the waiting period for

maternity was not completed. The Complainant represented to Grievance Redressal Officer (GRO)

stating that the prior to porting, the broker who finalised the business confirmed that waiting period

stipulation was 24 months for maternity. However, his claim was not considered. Hence, the

Complainant approached this Forum for settlement of claim.


a) Complainant’s Arguments:

The Complainant obtained the cited policy covering himself and his wife for a floater Sum Insured of

₹.4,00,000/-.

Insured person, Mrs. Puja Maheshwari was admitted to Rajmahal Vilas Hospital, Bengaluru on

30.01.2018 with complaints of 36 weeks of amenorrhoea with non-reactive NST with PIH. A male

baby was extracted through LSCS. Since the said hospital was not under network hospitals, cashless

was not sought. Reimbursement claim was rejected by the Respondent Insurer stating that she had

not completed the requisite 3 years continuous policy period.

The Complainant represented stating that he was the insured person in the corporate policy taken

by his employer since December 2012. He got married in December, 2015 and got his wife included

in the corporate policy in January, 2016. Upon his resignation he was relieved from the organisation

on 10.12.2017. However he took the cited policy on 23.11.2017 prior to quitting the organisation.

Whilst obtaining the cited policy, it was confirmed by the JLT Insurance Broker, who finalised the

said policy that the policy had a waiting period of 12 months and hence his claim was admissible.

However the Respondent Insurer did not consider the claim stating that the waiting period of 3 years

for maternity was not completed. Hence the Complainant approached this Forum for settlement of

his claim.

b) Insurer’s Arguments:

The Respondent Insurer in their Self Contained Note (SCN) dated 04.06.2018 whilst confirming the

coverage submitted that Mrs. Puja Maheswari wife of the complainant was included in the group

policy of Kotak Mahindra Bank in January, 2016 and obtained the cited policy covering her besides

him since 23.11.2017.

The Respondent Insurer submitted that as per maternity clause 2.1.11 that the maternity claims

were payable provided the policy in force continuously for three years from the inception or from

the date of inclusion of such insured person, whichever is later. As she did not complete the waiting

period of 3 years at the time of delivery, her claim was not admissible. It was further submitted that

the Respondent Insurer was not party to the communication sent by the broker that the claim was

payable with 2 years waiting period. Since the Complainant chose National Parivar Mediclaim policy,

the claim was not payable as per the cited condition.


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

registered.


d. Complaint along with enclosures, e. Respondent Insurer’s SCN along with the enclosures and f. Consent of the Complainant in Annexure VI A & Respondent Insurer in VII A.

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

The issues which require consideration are (1) whether the benefits were extended as per the rules of portability and (2) whether the complainant completed the waiting period for maternity as per the portability rules and (3) whether the broker confirmed the waiting period for maternity benefits as 12 months for maternity cover.

21.1. Personal hearing scheduled for 31.12.2018 was rescheduled for today, in view of the request of the Complainant. 21.2. During the personal hearing, both the parties reiterated their earlier submissions.

21.3.1. It is noted from the correspondence of the broker with the complainant that the Respondent Insurer granted portability facility. 21.3.2. Under Note 2 of Schedule I appended to Regulation 17 of lRADAI (Health Insurance) Regulations, 2016 the individual member covered under a group health insurance policy is permitted to migrate from group policy to an individual policy of the same insurer. Accordingly the Complainant migrated to individual policy from the group policy on his resignation. Such individuals who port to an individual policy shall be given credit based on the number of years of continuous insurance cover, irrespective of whether the previous policy had any pre-existing disease exclusion/time bound exclusions. 21.4. The Forum notes that the insured person, Mrs. Puja Maheswari was covered in the corporate policy from January, 2016 till 22.11.2017 and from 23.11.2017 till the date of delivery i.e., 30.01.2018 in the subject policy. Thus she was continuously covered in the corporate policy and individual policy for 22+ months. As the exact dates of corporate policy were not provided, the month of January, 2016 was considered as full month. 21.5.1. Maternity clause 2.1.11 of the policy reads as “The Company shall pay to the hospital or reimburse the insured the medical expenses, incurred as an in-patient, for delivery or termination upto the first two deliveries or terminations of pregnancy during the lifetime of the insured or his spouse, if covered by the Policy, provided the Policy has been continuously in force for thirty six from

the inception of the Policy or from the date of inclusion of the insured by the Policy, whichever is later”. 21.5.2. The insured person was covered under the previous policy for 1 year 10 months+. After porting to the present policy, the claim occurred. Since the waiting period of 36 months has not been completed including the waiting period gained under the portability, the Complainant is not entitled for maternity benefits. 21.6. It is noted that the Broker clearly explained the provisions of migration and also sent the terms and conditions of the policy vide their mail dated 13.10.2017. The Complainant sought specific clarifications from the said broker vide his e-mail dated 13.10.2017 seeking inter-alia clarification whether the waiting period of 3 years can be waived considering the fact he did not raise any claim for the past 5 years in his previous group insurance policy. 21.7.1. The Complainant has vehemently submitted that that the broker confirmed that maternity benefits were payable after completion of 12 months and he produced e-mail dated 16.10.2017 of the broken in support of his contention. 21.7.2. On the other hand the Representative of the Respondent Insurer submitted that broker is not authorised to modify the terms and conditions of the policy. In view of the evidence produced it is clear that the Broker has overstepped his authority for which the Complainant cannot be made to forgo his claim. 21.8. The Insured person (Mrs. Puja Maheswari) was covered in the corporate policy in January, 2016 and ported to this policy in the month of November, 2017. Hence she completed continuous insurance of 22+ months which satisfies the criteria of waiting period of 12 months for maternity. 21.9. Under the circumstances, the Forum extends benefit to the Complainant. 21.10. The Respondent Insurer may recover the said loss from Broker for negligence/overstepping of their authority if they deem fit.

A W A R D Based on the above facts and circumstances of the case and the documents are available on the

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

the claim of maternity as per the terms and conditions of the policy.






Ombudsman.

Dated at Bengaluru on the 21st day of February, 2019




OMBUDSMAN – NEERJA SHAH In the matter of: MR. K K RAMASWAMY V/s THE NATIONAL INSURANCE COMPANY

LIMITED Complaint No: BNG-G-048-1819-0367


1 Name & Address of the Complainant Mr. K K Ramaswamy

# A-8 – 1502, Elite Promenade

J P Nagar 7th Phase

BANGALORE – 560 078

Mobile # 99721 33987


2 Policy Number

Type of Policy


606008501810000023

Parivar Mediclaim

22.05.2018 to 21.05.2019



Mr. K K Ramaswamy

Mrs. Vasantha Ramaswamy

4 Name of the Respondent Insurer The National Insurance Company Limited

5 Date of repudiation

6 Reason for repudiation Inpatient treatment less than 24 hours


8 Nature of complaint Rejection of claims as the period of hospitalisation

was less than 24 hours


10 Date of Partial Settlement Not Applicable

11 Amount of relief sought ₹.1,00,000/- + interest

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




b) For the Respondent Insurer Absent




The complaint emanated from the repudiation of the claim on the ground that adjuvant

chemotherapy was not covered under the policy. The Complainant represented to Grievance

Redressal Officer (GRO) stating that the stipulation of minimum 24 hours hospitalisation was not

applicable for administration of adjuvant chemotherapy drug as chemotherapy was covered under

the Day Care Procedures. However, his claim was not considered. Hence, the Complainant

approached this Forum for settlement of claim.



The Complainant obtained the cited policy covering himself and his wife for a floater Sum Insured of

₹.3.50,000/-.

Insured person, Mrs. Vasantha Ramaswamy was detected with breast cancer and was advised to

undergo surgery followed by chemo and radiation as per protocol. The patient received external

beam radiotherapy to the right breast to a dose of 45 Gy/25 fractions by 3DCRT technique with 6, 15

MV photons treated over 5 weeks from 25.04.2018 to 30.05.2018. The Respondent Insurer settled

the surgery claim but rejected the chemotherapy and radiation claims stating that adjuvant

chemotherapy/radiotherapy did not fall under the Day Care procedures of the Policy and the

inpatient treatment did not qualify for the hospitalisation as per 3.7 of the policy.

The Complainant represented to GRO stating that 24 hours hospitalisation was not required for

chemotherapy and radiotherapy and hence his claims were to be settled.

However, his claims were not settled even after approaching the GRO. Hence, he approached this

Forum for settlement of his claim.


The Respondent Insurer did not submit the Self Contained Note (SCN)



registered.


g. Complaint along with enclosures, h. Respondent Insurer’s SCN along with enclosures and

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


The issues which require consideration are (1) whether chemotherapy was covered under Day Care procedures and (2) whether Adjuvant chemotherapy/radiotherapy is different from chemotherapy in the policy.

21.1. The representative of Respondent Insurer did not appear for the personal hearing and the complainant reiterated their earlier submissions.

21.2. It is noted from web that “Adjuvant (meaning “in addition to”) chemotherapy/radiotherapy refers to medicines administered after surgery for the treatment of breast cancer. Adjuvant chemotherapy/radiotherapy is designed to prevent recurrence of the disease, particularly distant recurrence”.

21.3. It is noted from 3.14 (i) of the policy that “Hospitalisation means admission in a hospital as an in-patient for a minimum period of 24 (twenty four) consecutive hours. However, this time limit is not applicable to amongst other .......... chemotherapy, radiotherapy”. Thus, the stipulation of minimum of 24 hours hospitalisation (inpatient treatment) is not applicable for chemotherapy/radiotherapy.

21.4. It is noted from 3.14 of the policy that ‘chemotherapy/radiotherapy’ is listed under ‘Day care procedures’ waiving the minimum 24 hours consecutive treatments. It is broadly given as ‘chemotherapy/radiotherapy’ without being distinguished from ‘Adjuvant Chemotherapy/Radiotherapy’. It is also noted from the Exclusions of the policy that Adjuvant chemotherapy/radiotherapy is not excluded under Day Care Procedures. Thus, any form of ‘chemotherapy/radiotherapy’ taken on day care basis is admissible under the policy.

21.5. During the personal hearing, the Complainant has requested to consider the expenses incurred in the present policy which were incurred during previous policy period. He was informed that the sum insured is the maximum limit upto which the expenses incurred would be considered and not beyond. Expenses incurred in one policy period cannot be carried forward and considered in the next policy period. It was clarified that he would be entitled for expenses incurred in the subject policy period only.

21.8. The Self Contained Note (SCN) has not been sent by the Respondent Insurer. They are advised to ensure that the SCN would be submitted for the complaints being filed and also without delay.

A W A R D

Based on the above facts and circumstances of the case and the documents are available on the

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

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

6.25% + 2%) from 30 days from the date of filing of the last relevant document by the Insured till

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

Interests) Regulations, 2017.






Ombudsman.





OMBUDSMAN –NEERJA SHAH In the matter of: MS. T PRAVALLIKA V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Ms. Pravallika

# 189/23, Prashanth Colony

Behind Canara Bank Contonment

BELLARY – 583 102

Karnataka

Mobile # 96110 52818


2 Policy Number

Type of Policy


P/141214/01/2018/003149

Star Comprehensive Insurance Policy

31.03.2018 to 30.03.2019



Mr. T V S Kantha Rao

Mrs. Lakshmi Kanthamma



6 Reason for repudiation Non-completion of waiting period










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

15 Complaint how disposed Disallowed



The claim was rejected on the grounds of non-completion of waiting period of 36 months for

bariatric surgery. The Complainant represented to Grievance Redressal Officer (GRO) of the

Respondent Insurer for reconsideration of her mother’s claim. However the claim was not settled.

Hence the Complainant approached this Forum for settlement of her mother’s claim.



The Complainant’s father Mr. TVS Kantha Rao obtained the cited policy covering himself and his wife

for a basic floater Sum Insured of Rs. 7,50,000/- and Bonus of Rs. 7,50,000/-. He took the first policy

on 25.03.2015 and renewed with a gap of 6 days during 2016 and renewed continuously thereafter.

The insured person, Mrs. Lakshmi Kanthamma (49 years) was admitted to Endocare Hospital,

Vijayawada, Andhra Pradesh on 01.05.2018. As per Discharge Summary, she was diagnosed as

Morbid Obesity, Type II DM/ 6 months (HbA1C: 6.1%), Hypertension / 6 months, Knee Pains, Low

Back Pain, OSA, Excessive Snoring, Body Pains and Depression due to Obesity. She underwent

Laparoscopic sleeve gastrectomy and was discharged on 04.05.2018.

Initially cashless pre-authorisation was given for Rs. 1,50,000/- and subsequently it was withdrawn.

Reimbursement claim was rejected on the grounds of non-completion of waiting period of 36

months for bariatric surgery for morbid obesity.

She represented to GRO for reconsideration of her claim. However his claim was not settled.

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


The Respondent Insurer in their Self Contained Note (SCN) dated 16.11.2018 whilst admitting the insurance coverage submitted that the claim was reported in the 25th month of the Medical Insurance Policy since inception whereas the same was covered after 36 months of Star Comprehensive policy (2014-15). Since the waiting period of 36 months was not completed, the Complainant was not entitled for claim. Hence the Respondent Insurer sought to absolve them from the complaint made.



registered.




The issues which require consideration are (1) whether all the policies taken since inception were same or different and (2) whether waiting period of 36 months was completed for the present bariatric surgery.

21.1. The Complainant sent an e-mail stating that she would not attending the personal hearing and

requested to proceed with the hearing of the complaint. However she submitted that whatever was

provided in the Discharge Summary, the same was provided in the pre-authorisation form. She

further submitted that cashless approval for Rs. 1,50,000/- given initially should not have been

withdrawn as they were helpless at the time of discharge from the hospital.

21.2. The Forum notes that the insured patient is covered continuously since 25.03.2015. During the year 2015-16, the Insured persons were covered under ‘Star Comprehensive Insurance Policy’ bearing regulator’s approval ‘IRDA/NL/HLT/SHAI-H/V.II/398/13-14’. As per the said policy terms and conditions of the said policy, under exclusion 3.17, the Company was not liable in respect of ‘Expenses incurred on weight control services including surgical procedures for treatment of obesity, medical treatment for weight control/loss programs’. Thus this policy cannot be considered for reckoning the waiting period for obesity.

21.3.1. The Forum has further noted that the policies for 2016-17, 2017-18 and 2018-19 were of Star

Comprehensive Insurance Policy bearing regulator’s approval ‘‘IRDA/NL/HLT/SHAI-H/V.II/398/14-15’.

As per the said approval, under Section 6 – Bariatric Surgery was covered stating that ‘Expenses

incurred on hospitalisation for bariatric surgical procedure and its complications thereof are payable

subject to a maximum of Rs. 2,50,000/- including pre and post-hospitalisation expenses subject of a

waiting period of 36 months from the date of first commencement of this policy and continuous

renewal thereof with the Company.

21.3.2. As this policy (IRDA/NL/HLT/SHAI-H/V.II/398/14-15) has run for only 25+ months, the waiting

period of 36 months is not complied with.

21.3.3. Hence the rejection of the claim for non-completion of waiting for bariatric surgery is in tune

with the terms and conditions of the policy.

21.4. As regards the contention of the Complainant about providing cashless approval and withdrawing the same before discharge has put them to lot of inconvenience, the Respondent

Insurer is advised to be cautious while giving pre-authorisation so that it would not be withdrawn later.

A W A R D

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

Respondent Insurer agreeing for settlement, the rejection of the claim is found to be in

consonance with the terms and conditions of the policy and does not require any interference at

the hands of the Ombudsman.

The complaint is Disallowed.





OMBUDSMAN – NEERJA SHAH In the matter of: MRS. PURNIMA A KAMATH V/s TATA AIG GENERAL INSURANCE COMPANY LIMITED



1 Name & Address of the Complainant Mrs. Purnima A Kamath

# 53, 1st Main, 2nd Cross

BEML Layout 2nd Stage

Basaveshwarnagar


Mobile # 98801 06767


2 Policy /Cert. No.

Type of Policy


0235356678

Wellsurance Executive Policy

3103.2017 to 30.03.2018

3 Name of the Insured/ Proposer Ms. Purnima A Kamath


4 Name of the Respondent Insurer Tata AIG General Insurance Company Limited




8 Nature of complaint Rejection of claim and cancellation of policy for

non-disclosure of symptoms of ailment at

inception stage

9 Amount of claim ₹. 3,34,850 /-


11 Amount of relief sought ₹. 3,34,850 /-





b) For the Insurer Dr. Diraj Mhatre, Dy. Manager




The Complaint emanated from the rejection of for non-disclosure of pre-existing condition at the

inception stage. The Complainant took up with the Grievance Redressal Officer (GRO) of the

Respondent Insurer stating that the complaints were on and off and was not diagnosed as Multiple

Scelrosis and hence the same was not disclosed. However her claim was not settled and the policy

was cancelled. Hence, the Complainant has approached this Forum.

18. Cause of Complaint: a) Complainant’s arguments: The Complainant obtained the cited covering herself for In-hospital Benefit for Sickness, Critical Illness Benefits inter-alia for Multiple Scelrosis under Classic Plan for ₹.3,00,000/- and hospital cash.. The Complainant had symptoms of tingling and numbness in limbs associated with missing steps and difficulty in balancing in the month of July, 2017. She consulted Dr. J B Agadi, Consultant Neurologist on 28.09.2017 who suggested for further investigations. It was suspected to be demyelination disorder and not just diabetic neuropathy. Meanwhile she was admitted to National Institute of Mental Health and Neuro Sciences,( NIMHANS) Bengaluru on 12.10.2017 for complaints

of tingling sensagtion in the palms of both hands, insidious on set, more in the morning and improving with activity and also as day goes by. She also developed tingling sensation in the thighs when sitting for 4 hours and since last 3 months she developed tendency of fall suddenly to the left and tendency to fall back if she closed her eyes. She also developed tingling in the soles of the foot for the past 3 months. She underwent investigation and was diagnosed as Opticospinal demyelination - ? Cause and T2 Flair Hyperintensities in the courticospinal tract - ? Significance and was discharged on 18.10.2017. During the follow up review on 31.10.2017 she was diagnosed to be suffering from Multiple Sclerosis. She was admitted to Chord Road Hospital Private Limited, Bengaluru on 02.11.2017 and was diagnosed as Multiple Sclerosis and Type II DM. She was discharged on 07.11.2017 in a stable condition. The Reimbursement claim of Chord Hospital was rejected by the Respondent Insurer vide their letter dated 07.12.2017 stating the Complainant had relapsing remitting illness in 1996, 2001, 2007 and the present hospitalisation but the same was not disclosed whilst taking the first policy in 2012 and the policy was cancelled vide their letter dated 28.11.2017. She represented to the Respondent Insurer stating that diagnosis of Multiple Sclerosis was done during the present hospitalisation and not earlier. Hence the question of non-disclosure of Multiple Sclerosis would not arise. As regards non-disclosure of ‘tingling and numbness in hand and feet’, she submitted that during 1996 she was travelling about 90 kms a day by bus and the complaints of tingling of hands subsided after usage of vitamin tablets for a brief period. It was concluded that it was a stress related. Until she approached NIMHANS, it was thought to be a stress related and was not disclosed which was neither wanton nor intentional. For the same complaints when she approached Diacon Hospital on 24.07.2001 and was detected to be diabetic and the said complaints were treated as complications of diabetes and were diagnosed as ‘peripheral neuropathy’. In 2007 also she was treated for peripherical neuropathy induced by diabetes. Even in the present episode also she approached for the same complaints. It was a rude shock for her when she was diagnosed as Multiple Sclerosis in NIMHANS in October, 2017. As she was not aware that she was suffering from Multiple Sclerosis, the question of non-disclosing the same would arise. However her claim was not settled. Hence the Complainant approached this Forum for settlement of claim. b) Respondent Insurer’s Arguments: The Respondent Insurer in their Self Contained Note (SCN) dated 11.02.2019 submitted that the Complainant had continuous insurance from 31.03.2012 to 31.03.2018. The policy provided coverage Daily Benefit for each day under Section: In-hospital Benefit for Sickness for the maximum period shown on the policy subject to deduction of 1st day hospitalisation as in-patient. The subject policy also provided for a fixed benefit called ‘Critical Illness Benefits’ for a Sum Insured of ₹.3,00,000/-. The insured was holding a policy with United India through their Employer. On scrutiny of the hospital records, it was observed that the complainant had Tingling & Numbness in both thighs since 1996 and the same episode was repeated in 2001 and 2007. The complainant also underwent Stapedectomy (Ear bone removal) surgery in 2003 and D & C in the past but the same was not disclosed in the telephonic call recording of sales call of March, 2012. Diabetes was only disclosed during such tele-call. Due to such non-disclosure the policy was cancelled vide their letter dated 28.11.2017. The definite occurrence of multiple sclerosis must be supported by -

investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;

there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period at least 6 months (Our Observation – This condition was not fulfilling as Tingling & Numbness episodes used to last only for 1 month)

well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

Since all the above conditions also not fulfilled, the claim was denied. The rejection of claim was based on just and proper grounds. 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.

j. Complaint along with enclosures, k. Respondent Insurer’s SCN along with enclosures and l. 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 issues which require consideration are (1) whether symptoms of tingling were persisting continuously and medication was also taken continuously, (2) whether the said symptoms were diagnosed as MS prior to taking the policy (2) whether falling down symptoms were present along with tingling, (3) whether such symptoms could be considered as pre-existing disease and (4) whether the relevant questions were raised during telephonic talk the representative of respondent insurer had with the complainant for prospecting and finalisation of the policy. 21.1. During the personal hearing both the parties reiterated their earlier submissions. 21.2. The claim was rejected on the ground of non-disclosure of MS. 21.2.1. The Respondent’s Representative vehemently submitted that the Complainant failed to disclose tingling sensation which she had in 1996, 2001, 2007, Stapedectomy (Ear bone removal surgery) which she underwent in the year 2003 and D & C in the past. Hence the claim was rejected for the non-disclosure of the above pre-existing condition. 21.2.2. The Respondent Insurer played the audio conversation they had with the Complainant’s husband for prospecting and finalisation of the policy. 21.3.1. The Forum heard the full audio conversation and observed that the question raised by the telecaller of the RI was whether the proposed persons were suffering from any cancer/critical illness for the past 48 months. This would make it that the proposer was required to furnish information from 2008 onwards. Forum found that Stapedectomy was conducted in 2003 and definite duration was not given for D & C. Therefore the question of disclosing the above would not arise as they occurred prior to 2008 (i.e., 4 years prior to first policy commencement).

21.4.1. On verifying Primary Evaluation dated 24.07.2001 of Diacon Hospital, Bengaluru, it is noted that she visited the said hospital for complaints of numbness in hands and feet. She was diagnosed as Type II Diabetic and was concluded as ‘peripheral Neuropathy’. It is also noted from the PER-MR Whole Body Report dated 17.10.2017 of Department of Neuroimaging and Interventional Neuroradiology, NIMHANS, Bangalore that the patient was evaluated and suspected as diabetic neuropathy for her earlier episodes of same symptoms. The Complainant also submitted that the symptoms were on and off and were subsiding on taking some vitamin tablets and other medication for diabetes provided by the doctors.

21.4.2. Under the circumstances, it is noted that the said complaints were on and off with medication and were only diagnosed as attributable to Diabetes. The question that was raised in audio conversation was about cancer/critical illness only. As she was not diagnosed as cancer/critical illness (MS) on the date of audio conversation (before taking the policy), the Complainant could not have disclosed the same.

21.5.1. The next issue that arises for consideration is whether the said claim complies with the criteria as defined in the policy for ‘Multiple Sclerosis’.

21.5.2. Part D of the policy states that when the Insured is diagnosed to be suffering from a Critical Illness as defined hereunder:

21.5.3. Multiple Sclerosis with persisting symptoms are covered under C8 of Critical Illness Benefit

21.5.4. The definite occurrence of multiple sclerosis (MS). The diagnosis must be supported by all of the following:

1) investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;

2) there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period at least 6 months

3) well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

4) Other causes of neurological damage such as SLE and HIV are excluded.

21.5.6. As regards point no. 1 of the said definition, based on the PET-MR Whole Body Report dated 16.10.2017 and MRI Brain + Spine (Plain and Contrast) dated 16.10.2017, the group of doctors of NIMHANS dated 31.10.2017 opined that the patient was diagnosed to have probable Multiple Sclerosis but treatment was provided for MS also. Further it was diagnosed as ‘Multiple Sclerosis’ in the Discharge Summary of Chord Road Hospital Pvt Ltd., (from02.11.2017 to 07.10.2017) and was treated for MS. Under the circumstances, condition no. 1 of the said definition is complied with.

21.5.7. As regards point no. 2 of the definition, it is contested by the Respondent Insurer stating that the said condition was not fulfilled as Tingling & Numbness episodes were for one month only. In this connection it is noted from the Discharge Summary of NIMHANS (during 12.10.2017 and 18.10.2017) that the patient was alright one year before the hospitalisation. She developed the tingling sensation in the palms since a year. It confirms that this issue started since a year before the admission. It is also stated that since last 3 months she had the tendency to fall suddenly to the left and tendency to fall back if she closed her eyes along with a feeling of walking on the carpet. Tingling of soles of foot was experienced since last 3 months. Both tingling and the feeling of falling satisfy the condition of sensory and motor being impacted. Further the rejection of the claim was on the grounds of non-disclosure of tingling even though it was present at the inception stage. The policy itself ran for 6 years. Under the circumstances the condition is also deemed to be complied with.

21.5.8. As regards point no. 3, the report of group of doctors vide their dated 31.10.2017 opined it to be a probable multiple sclerosis based on the MRI & CT Reports and clinically examining the patient and going by the symptoms and the discharge of summary of Chord Road satisfies this definition.

21.6. Though the definition of multiple sclerosis as per the policy is not fulfilled strictly (though the sensory symptoms satisfy 6 months criteria, the motor symptoms were found only for 3 months), the Forum extends the benefit considering the Complainant had continuous insurance for 6 years.

21.7. The Complainant sought for revival of cancelled policy and to provide renewal for continuity of the policy.

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 Respondent Insurer is

advised to settle the claim as per the terms and conditions of the policy. The Respondent Insurer is

advised to revive the cancelled policy and renew the same. No order for interest.

Hence, the Complaint is Allowed.





Ombudsman.


(NEERJA SHAH)

INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – DR. D.K VERMA

Case of Mr. Divya Lal V/S HDFC ERGO General Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-018-1718-0490

1. Name & Address of the

Complainant

Mr. Divya Lal

D/o Krishan Kumar, H. No.- 1086, Sector- 15, Sonipat,

Haryana- 131001, Mobile No.- 9896449003

2. Policy No:

Type of Policy

Duration of policy/Policy period

295220086745530000011

Health Suraksha Policy Gold Plan

04-10-2014 To 03-10-2016

3. Name of the insured


Mr. Divya Lal

Mr. Divya Lal

4. Name of the insurer HDFC ERGO General Insurance Co. Ltd.

5. Date of Repudiation 11-09-2018

6. Reason for repudiation Non submissions of the required documents

7. Date of receipt of the Complaint 16-10-2017

8. Nature of complaint Not settle the claim

9. Amount of Claim Rs.470,000/-

10. Date of Partial Settlement N/a

11. Amount of relief sought Rs.470,000/-

12. Complaint registered under

Rule no: 13-1(b) of Insurance

Ombudsman Rules

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

by an insurer

13. Date of hearing/place 04-01-2019, /Chandigarh

14. Representation at the hearing

a) For the Complainant Ms. Divya Lal, Complainant

b) For the insurer Mr. Pankaj Kumar, Manager- Legal

15 Complaint how disposed Dismissed


17 Brief Facts of the Case:

On 16-10-2017 Ms. Divya Lal, had filed a complaint to this office that she has purchased a health

policy on 30.09.2014. She had Dengue fever and subsequently she got admitted in Deep Ayurvedic

Oshdhalaya, Gohana for treatment from 29-02-2016 to 12-04-2017. After discharge from the

hospital, the medical bills along with the required documents were submitted to the insurance

company for reimbursement. The insurance company required certain documents which were

provided but again and again they have been demanding the same documents and did not settled

the claim.

On 26-10-2017, the complaint was forwarded to HDFC ERGO General Insurance Co. Ltd, Regional

Office, Noida for para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 04.12.2018.

The insurance company submitted the SCN and stated that they have issued the health insurance.

The claim file was closed due to not submission of the requisite documents as sought by the

respondent. The numbers of the letter were sent to complainant but no response was received. The

complainant was admitted in the Deep Ayurvedic Aushdhlaya, Gohana for treatment of Dengue

Fever. After discharge claim bill was submitted and after scrutiny of the documents, some more

information was required which was not provided by the insured.

The complainant was sent Annexure VI-A for compliance, which reached this office on 28-11-2017.

18) Cause of Complaint:

a) Complainant’s argument: Complainant has stated that she had taken treatment for Dengue

fever from Deep Ayurvedic Aushdhlaya, Gohana from 29-12-2016 to 12-04-2017 (106 days).

Time and again she is asked by insurance company for compliance of documents and inspite

of her compliance her claim is not paid. She requested that her genuine claim may be given.

b) Insurers’ argument: Insurance Company stated that complainant has not provided requisite

documents for processing and in absence of same they are unable to process claim. Further

no justification from treating doctor was given for prolonged treatment of 106 days. Indoor

case papers including admission notes, doctor notes and TPR charts were not provided. All

investigation reports of her treatment. Complainant has also not given bifurcation of his

bills. Since complainant has not completed requirements her claim was made no claim.

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): On careful

consideration of various documents including the copy of complaint filed by complainant dated

16.10.2017, SCN submitted by insurance company, bills submitted by complainant in support of her

claim and the submissions of both the parties during the personal hearing, it is observed that

complainant was hospitalized as per her complaint at Deep Ayurvedic Oshdhalaya, Gohana for

treatment of dengue fever from 29.12.2016 to 12.04.2017 for a period of about 106 days. In support

of her claim, she has produced a copy of certificate of Deep Ayurvedic Oshdhalaya dated 09.01.2019

with details of the bills against the total payment made by her amounting to Rs. 4,70,030/- also

enclosed the receipt dated 29.12.2016, 22.01.2017 & 12.04.2017 for payment made by her on

account of hospitalization. I have also gone through the various receipts and discharge sheet of the

Deep Ayurvedic Oshdhalaya where complainant is supposed to have been admitted for treatment of

dengue fever. No date is mentioned on said discharge card. No admission slip or the documents

relating to course of treatment for such a long stay has been submitted by complainant. The lab

investigation reports dated 02.02.2017 & 12.04.2017 of Navjeevan Diagnostic Lab, Gohana are silent

about the platelet count which is an important indicator for diagnosis of dengue fever. Even the

dengue antigen and antibody test supposed to have been done on 02.02.2017 & 12.04.2017 also

does not indicate clearly about the presence or absence of dengue antigen/ antibody and both

reports have not been signed by any authorized person. Even the other findings in report about the

other parameters are also not clear about the extent of illness for which the complainant remained

admitted for such a long period in said hospital. No records relating to the hospitalization in the form

of proper treatment chart or course of stay in the hospital has been submitted by the complainant to

the insurance company. Even the receipts submitted by the complainant with amount totaling to Rs

4,70,030/- are not in proper format, there being lot of discrepancies in the bills submitted by

complainant vis-à-vis the receipts of the payment made to hospital. There is no proper bifurcation

of these receipts/bills under various heads like admission charges, Room rent, pharmacy, doctor fee/

consultation, etc. Even the diagnostic reports don’t justify in anyway the hospitalization for a period

of more than three months. Hence the decision of the insurance company is in order. Keeping in

view the above facts, the said complaint is hereby dismissed and no relief is granted.

AWARD

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

parties during the course of personal hearing, the said complaint is hereby dismissed on merits.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 25th day of February 2019.

D.K. VERMA

INSURANCE OMBUDSMAN

Copy to: 1) Complainant

2) Company

PROCEEDINGS BEFORE




Case of Mr. Ajit Deswal V/S Bajaj Allianz General Insurance Co. Ltd.



Complainant

Mr. Ajit Deswal

H. No.- 142 A/ Shanti Nagar, Panipat, Haryana- 132103

Mobile No.- 8569939480

2. Policy No:

Type of Policy


OG-16-9906-8418-00000007

Surgical Protection Plan

25-05-2015 To 24-05-2016



Mr. Ajit Deswal

Mr. Ajit Deswal

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd.

5. Date of Repudiation 23.09.15

6. Reason for repudiation Injury prior to inception of policy


8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs. 1,70,000/-

10. Date of Partial Settlement N/A

11. Amount of relief sought Rs. 1,70,000/-

12. Complaint registered under Rule 13 (1)(b) – any partial or total repudiation of claim by


Ombudsman Rules

an insurer

13. Date of hearing/place 04-01-2019 /Chandigarh


For the Complainant Mr. Ajit Deswal, Complainant

For the insurer Not Present




On 20-09-2017 Mr. Ajit Deswal, of Panipat had filed a complaint that he took one Surgical Protection

Plan from Bajaj Allianz Gen. Insurance vide policy no. OG-16-9906-8418-00000007 issued on

22.05.15. After taking policy, on 12.06.15 he got injury on knee due to fall from Bike and

complainant went to Sabharwal hospital Panipat for treatment on same day. Doctor arranged X-Ray,

gave medicines and asked for rest. On 17.06.15, as per Doctor’s instructions MRI was arranged and

subsequently his knee was operated on 02.07.15 from Malik Hospital. But insurance company has

rejected his claim with plea that injury had occurred prior to policy.

On 09-10-2017, the complaint was forwarded to Bajaj Allianz General 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 07-05-2018.

In the SCN, Insurance Company stated that complainant was insured for the period 25.05.15 to

24.05.16 for health insurance (Surgical protection Plan). On 23.07.15, intimation was received for

posterior Cruciate Ligament tear left knee with medical Meniscal tear for his accident which

occurred on 02.07.2015. Accordingly, investigator was appointed to look into veracity of the facts.

After investigation claim was repudiated on the ground of PED since he was known to be suffering

from the same injury prior to the inception of the policy. It was also found during investigation at

Chotu ram Stadium Rohtak from other players that complainant is on rest as he had undergone

surgery and he got injured while playing wrestling. Insurance company has produced an affidavit in

support of investigation done by Sh. Vishnu Sharma himself to confirm that injury has occurred

during wrestling. Therefore, claim was repudiated by the company on ground of PED.



a) Complainant’s argument: Complainant stated that his genuine claim is being denied on the

pretext of PED and requested for payment of his claim.

b) Insurers’ argument: The insurance company stated in their SCN that the reason for denial of

claim on the basis of PED and investigator report in which the complainant was suffering prior

from the inception of 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 various

documents available in the file including the copy of complaint dated 20.09.2017, company reply

dated 07.05.2018 and also submission made by complainant during the course of personal hearing,

it is seen that Insurance company has produced an affidavit in support of investigation done by

Sh.Vishnu Sharma, investigator himself to confirm that injury has occurred during wrestling but no

supporting documents/ statement of any other person is found in the claim file. Affidavit of Sh.

Vishnu Sharma, investigator can’t be considered because he stands deputed by the insurance

company and one cannot give his testimony/ affidavit for his own investigations. Company has failed

miserably to produce supporting documents in support of the reasoning given by them while

repudiating the claim. They have not produced any medical records pertaining to injury treatment

taken by complainant in past. Hence, repudiation of claim by insurance company is not justified.

Therefore, insurance company is directed to pay admissible claim amount subject to terms and

condition of policy to the complainant within 30 days from the receipt of award copy.

AWARD


parties during the course of personal hearing, admissible claim amount subject to terms and

condition of policy is hereby awarded to be paid by the Insurer to the Insured, towards full and

final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN


2) Company

PROCEEDINGS BEFORE




Case of Mr. Vinod Phogat V/S Cigna TTK Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vinod Phogat

Nill, Bhiwani,

Haryana-0

2. Policy No:

Type of Policy


PROHLR990010661

Health Insurance

29.11.2016 to 28.11.2017



Mr. Vinod Phogat

Mr. Vinod Phogat

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

5. Date of Repudiation 24-08-2017

6. Reason for repudiation Not cover under the policy terms and condition


8. Nature of complaint Not settle the claim

9. Amount of Claim Not provided

10. Date of Partial Settlement N/a

11. Amount of relief sought Not provided



Ombudsman Rules

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

claim by an insurer

13. Date of hearing/place 13-12-2018 , 04.01.19, 05.02.2019 Chandigarh


For the Complainant Not present on any date

For the insurer 13-12-2018

Mr. Vikas Chauhan, Deputy Branch Manager

04.01.2019 & 05.02.2019

Mr. Nitin Gera, Deputy Branch Manager

15 Complaint how disposed Dismissed in Default


17) Brief Facts of the Case:

On 29-08-2017 Mr. Vinod Phogat, had filed a complaint to this office that his health claim was not

settled .The required documents were submitted to the insurance company. After examination of

documents they rejected the claim and no reason was provided.

On 15-09-2017, the complaint was forwarded to Cigna TTK Health Insurance Co Ltd Regional Office,

Mumbai for para-wise comments and submission of a self- Contained note about facts of the case,

which was made available to this office on 10.12.2018.

18) As per SCN, Complainant filed with them reimbursement of claim against Meningitis. But they

observed from claim/hospital documents that:

a) Meningitis is a very serious condition and to confirm it Cerebro-Spinal Fluid examination should be

done which was not done in the present case.

b) Complainant submitted only one pharmacy bill of Rs.50,000/- which includes injection

Meropenum of Rs.45,000/-. There is no mention of IV fluids in pharmacy bills which would have

been administered to the patient as patient is not in a position to take anything orally.

c) Break up of hospital bills, pathological investigation reports confirming the diagnosis of

Meningitis, IPD papers, treatment chart have not been provided by complainant.

On the basis of above, insurance company concluded the above claim as fraudulent and not payable.

Complainant has not been able to prove / establish ailment and hospitalization. The complainant

also not provided all relevant documents in support of his claim after sending the proper mail.

19) Neither the complainant nor his representatives appeared for the personal hearing on

13.12.2018, 04.01.2019 and 05.02.2019. The absence of the complainant or his duly authorized

representative on the various dates fixed for personal hearing indicates that complainant has

nothing to say in this matter. The case is thus, dismissed in default and closed due to non-perusal of

case by complainant.


Dr. D.K. VERMA

INSURANCE OMBUDSMAN


2) Company

PROCEEDINGS BEFORETHE INSURANCE

OMBUDSMAN, CHANDIGARH


INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Rajender Kumar V/S Bharti AXA General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Rajender Kumar S/o Shri Ram Singh,

Ram Nagar Gali No.-2,

Opp. Housing Board Colony, Narnaul, Haryana-

123001

Mobile No.- 9812574610

2. Policy No:

Type of Policy


J9105218

Smart Health Insurance Policy Premium Plan

15-12-2016 To 14-12-2017



Mr. Rajender Kumar

Mr. Rajender Kumar

4. Name of the insurer Bharti AXA General Insurance Co. Ltd.


6. Reason for repudiation Fabrication & misrepresentation of facts



9. Amount of Claim Not mentioned

10. Date of Partial Settlement NA

11. Amount of relief sought Not mentioned


Rule no: Insurance Ombudsman Rules,

2017

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

claims by an insurer

13. Date of hearing/place 05.02.2019


For the Complainant Mr. Rajender Kumar

For the insurer Mr. Vishal




On 08-11-2017, Mr. Rajender Kumar had filed a complaint that his wife Shalu was hospitalized from

13.05.17 to 17.05.17 at Aggarwal Nursing Home, Narnaul due to abdomen pain and total bill was Rs.

37200/- but company rejected claim and given reasons of misrepresentation of material facts and

fraudulent activity. But as per complainant, there was no fraud and misrepresentation from his side

and he had submitted claim for genuine health expenses incurred only.

On 09-11-2017, the complaint was forwarded Bharti AXA General Insurance Co. Ltd.

Regional Office, New Delhi, for Para-wise comments and submission of a self-contained note about

facts of the case, which was made available to this office on 17-01-2018.

As per repudiation letter dt. 12.07.17, on perusal of claim documents, it is found by insurance

company that Mrs. Shalu Devi was admitted at Aggarwal Nursing Home on 13.05.17 with pain in

abdomen and discharged on 17.05.17.On scrutiny of documents, company found multiple

discrepancies with fabrication of documents leading mis-representation of material facts which is

also a fraudulent activity. As such due to this claim was repudiated under policy general conditions

7.1(Duty of disclosure) & 7.6 (Fraudulent claims).

As per SCN, Mrs. Shalu was admitted on 13.05.17 with pain in abdomen, c/o watery loose motion for

12 hrs, pain in abdomen and cramps for 2 hrs and was evaluated and diagnosed as a case of

intractable diarrhea/electrolyte imbalance. As per investigator of insurance company, few

discrepancies were observed like electrolyte imbalance remained stable during hospitalization but

dipped to 14 from 130 to 135 on date of discharge. No pathologist, no technician seen in hospital, no

monitoring of BP despite low BP, Hospital was not registered. Claim was repudiated under policy

exclusion 6.24.

The complainant was sent Annexure VI-A for compliance which was not reached this office till date

of hearing.


a) Complainant’s argument: The complainant stated that company rejected claim and gave reasons

of misrepresentation of material facts and fraudulent activity but there was no fraud and

misrepresentation from his side and he had submitted claim for genuine health expenses incurred

only.

b) Insurers’ argument: The insurance company stated in their SCN that the Claim was repudiated

under policy exclusion 6.24.

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 examination of various documents it is seen that the health claim filed by complainant in respect

of treatment taken by his wife Shalu who was hospitalized from 13.05.2017 to 17.05.2017 at

Aggarwal Nursing Home, Narnaul has been repudiated by insurance company vide letter dated

12.07.2017 due to various discrepancies and the fabrication of documents resulting in filling of a

fraudulent claim as per policy clause no. 7.1 & 7.6 of the policy. The complainant’s wife duly covered

under policy as per hospitalization records was admitted to Aggarwal Nursing Home with symptoms

of pain in abdomen, loose motions, cramps and was diagnosed as a case of intractable diarrhea/

electrolyte imbalance. The insurance company while rejecting the claim has relied upon the findings

given by investigator in investigation report done during verification of claim. According to the

investigation report of investigator most of which is factual except that the various electrolytes were

within normal limits though the patient was diagnosed to be a case of electrolyte imbalance, it was

also observed that no pathologist was found in hospital and the patient’s BP was not monitored

regularly though she has low BP. Further added that Nursing home has only 12 working beds though

hospital is claiming to have 25 working beds. On careful examination of the various issues raised in

investigation report it is seen that the patient was admitted on 13.05.2017 and discharged on

17.05.2017. The reports of various electrolytes annexed with laboratory investigation report have

been done from 15.05.2017 to 17.05.2017 but reports of 13.05.2017 have not been submitted by

insurance company. Just on basis of laboratory investigation report that has been carried out from

15.05.2017 to 17.05.2017 when the patient was already under treatment from 13.05.2017 in no way

supports the insurance company version that this is not a case of electrolyte imbalance. Another

ground taken by insurance company about the no. of beds in Nursing home also doesn’t entitle the

insurance company to arrive at conclusion that the claim filed by complainant is a fraudulent claim.

In view of above discussions the repudiation of claim by insurance company is not in order. Hence,

the insurance company is directed to settle the claim as per terms and conditions of the policy to the

complainant within 30 days from the receipt of award copy.

AWARD

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

the parties during the course of personal hearing, the insurance company is directed to settle

the claim as per terms and conditions of the policy to the complainant within 30 days from the

receipt of award copy.


Dated at Chandigarh on 05th day of February, 2019.

Dr. D. K. VERMA

INSURANCE OMBUDSMAN


2) Company





Case of Mr. Ramesh Kumar Goyal V/S The Oriental Insurance Co. Ltd.


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

H. No.- 3486, Street No.2-3, Bari Pauri,

Nai Abadi, Abohar, Punjab-0

Mobile No.- 9915003450

2. Policy No:

Type of Policy


233203/48/2017/212

Mediclaim Policy

18-06-2016 To 17-06-2017



Mr. Ramesh Kumar

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

5. Date of Repudiation Not provided

6. Reason for repudiation Hospitalization clause



9. Amount of Claim Rs.14523/-


11. Amount of relief sought Rs. 14523/-



2017

Rule 13 (1)(b) – any partial or total

repudiation of claim by an insurer



For the Complainant Mr. Ramesh Kumar Goyal

For the insurer Ms. Madhu Kaul

15. Complaint how disposed Award

16. Date of Award/Order 05.02.2019


On 14-09-2017, Mr. Ramesh Kumar Goyal had filed a complaint that he and his wife had gone to

Tohana to meet relative on 23.02.17, where suddenly his wife suffered with acute pain in chest and

has admitted in emergency in RMC hospital Tohana. She was discharged on 24.02.17. Intimation of

same was given to Medi-assist on same day i.e. 23.02.17 and also at local Oriental Insurance office,

Abohar. Complainant had mediclaim policy for 3 years. Medi-assist has denied the claim saying that

‘As per the policy terms and conditions OPD (Out Patient Treatment) is not payable and for any claim

24 hrs hospitalization is mandatory with active line of treatment.

No SCN submitted till 24.12.18.

Complainant vide his letter dt. 24.12.18 informed that he will be unable to present on date of

hearing and requested to dispose his case on basis of documents.


a) Complainant’s argument: The complainant has stated in his complaint that his wife suffered with

acute pain in chest and has admitted in emergency in RMC hospital Tohana. Intimation of same was

given to Medi-assist on same day i.e. 23.02.17 and also at local Oriental Insurance office, Abohar but

the insurance company rejected the claim as per terms and conditions of the policy.

b) Insurers’ argument: TPA stated that as per policy terms and conditions OPD (Out Patient

Treatment) is not payable and for any claim 24 hrs hospitalization is mandatory with active line of

treatment.

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

2017.


a) Complaint to the Company b) Copy of Policy Document c) Annexure VI-A


On perusal of various documents available in the file, copy of SCN submitted by insurance company,

discharge summary of hospital where the complainant’s wife was admitted with acute chest

discomfort with low backache. The policy schedule duly covered the complainant’s wife. As per

denial letter of TPA Medi-assist the claim have been denied on ground that OPD treatment is not

payable and for reimbursement of claim 24 hours hospitalization is mandatory with active line of

treatment. The policy is running in the 3rd year and as per the complainant no claim has been filed in

3 years. The version of insurance company to deny the claim is neither proper nor reasonable.

According to discharge summary the patient was admitted on 23.02.2017 at 10:30 am and

discharged on 24.02.2017 at 11:30 am. The stay in hospital obviously being more than 24 hours the

patient was treated with IV antibiotics and IVPPI. Further the insurance company has not produced

AWARD



the claim as per terms and conditions of the policy to the complainant within 30 days from the

receipt of award copy.


any evidence to counter the fact that the hospitalization was not required in the instant case and

same could have been managed in OPD. In view of above facts the repudiation of claim by insurance

company is improper. The insurance company is directed to settle the claim as per terms and

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


Dr. D. K. VERMA

INSURANCE OMBUDSMAN


2) Company




Case of Mr. Amarjit Singh V/S CignaTTK Health Insurance Co. Ltd.


1. On 11.10.2017, Mr. Amarjit Singh had filed a complaint in this office against Cigna TTK

Health Insurance Co. Ltd for not refunding premium for two policies. But the insurance

company did not refunded his premium for policy no. PROHLT010102530 and

PROHLT010102531.

2. The complainant had informed during personal hearing on 05.02.2019 that

he has received refund for his both policies i.e PROHLT010102530 and

PROHLT010102531 from insurance company and hence wants to withdraw his

complaint.

3. Hence, accordingly the complaint is closed.

To be communicated to the parties.

Dated : 05.02.2019 (Dr. D.K. VERMA)

PLACE: CHANDIGARH INSURANCE OMBUDSMAN


2) Company





Case of Mr. Pardeep Kumar V/S Religare Health Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Pardeep Kumar

House No.- 27, Basant Vihar, Jawadi,

Near Dugri, Phase-1, Ludhiana, Punjab- 141013

Mobile No.- 8146212000

2. Policy No:

Type of Policy


10006180

Care

14-12-2014 To 13-12-2015



Ms. Shashi Rani

Mr. Pradeep Kumar

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


6. Reason for repudiation Admission not justified




10. Date of Partial Settlement

11. Amount of relief sought Rs. 38988/-+ interest+ harassment



2017





For the Complainant Mr. Pardeep Kumar

For the insurer Mr. Prashant Singh

15. Complaint how disposed Agreement



On 08-11-2017, Mr. Pardeep Kumar had filed a complaint that in 2002 he had taken a CARE

INDIVIDUAL Policy no. 10006180 for his mother Smt. Shashi Rani, which was ported from Star Health

& Allied Insurance Co. She was admitted in HICARE Multi Speciality Hospital, Dugri, Ludhiana

from 6th Nov.16 to 15th Nov.2016 as advised by doctor for fever and pain in abdomen. The doctor

deputed by Religare Health Ins.co. visited hospital and also met the examinee doctor from whom

patient was getting treatment and also made certain enquiries. He was fully satisfied about the

genuineness of his disease and her admission in emergent situation. Initially company has refused to

give cashless and complainant has put case for reimbursement. But company refused the claim of

Rs.38988/- with the reason ‘REJECTED AS ADMISSION NOT JUSTIFIED’ on 06.04.17.

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

that they are ready to settle the claim amount of Rs. 38,340/- under policy bearing number

10006180 without interest.

19. Accordingly, an agreement was signed between the Company and the complainant on

05.02.2019.

20. The complaint is closed with a condition that the company shall comply with the agreement and

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

information and record.



(Dr. D. K. VERMA)

INSURANCE OMBUDSMAN


2) Company



Case of Ms. Gayatri Poddar V/s The National Insurance Co. Ltd.

COMPLAINT REF.NO: CHD-G-048-1718-0492

1. On 17.10.2017, Ms. Gayatri Poddar had filed a complaint in this office

against The National Insurance Co. Ltd. for not settling the health claim. The

required documents were submitted to the insurance company but the

insurance company did not settle the health claim under policy no.

401501/48/16/8500000562.

2. The complainant had filed a complaint in the District Consumer Disputes

Redressal Forum, Gurdaspur.

3. Hence, in accordance with Rule 14.5 of Insurance Ombudsman Rules, 2017

which states that “ No complaint before the Insurance Ombudsman shall be

maintainable on the same subject matter on which proceedings are

pending before or wants to file in the Consumer Forum or arbitrator”, the

complaint is closed.





2) Company



Case of Mr. Ashok Dhanuka V/s Star health and Allied Insurance Co. Ltd.


1. On 08.09.2017, Mr. Ashok Dhanuka had filed a complaint in this office

against Star health and Allied Insurance Co. Ltd. for not settling the health

claim. The required documents were submitted to the insurance company

but the insurance company did not settle the claim under policy no.

P/211121/01/2017/001031.

2. The complainant had filed a complaint in the District Consumer Disputes

Redressal Forum, Sirsa.

3. Hence, in accordance with Rule 14.5 of Insurance Ombudsman Rules, 2017









2) Company





Case of Ms. Alka Sehgal V/S The New India Assurance Co. Ltd.


1. Name & Address of the Complainant Ms. Alka Sehgal

5287, Modern Housing Complex, Manimajra,

Chandigarh, Mobile No.- 9872801480

2. Policy No:

Type of Policy


120700/34/17/04/00000003

01-04-2017 To 31-03-2018



Ms. Alka Sehgal

4. Name of the insurer The New India Assurance Co. Ltd.

5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Partial payment made


10. Date of Partial Settlement Not given

11. Amount of relief sought Rs.35,000/-



2017



13. Date of hearing/place 05/02/2019


For the Complainant Ms. Alka Sehgal

For the insurer Ms. Deep Shikha

Ms. Renu Munjal

15. Complaint how disposed Dismissed



On 09-11-2017, Ms. Alka Sehgal had filed a complaint that on 05.08.17 she had severe headache

consequently vomiting and loose motion started at 8.00 p.m. Afterwards her health got deteriorated

and she went to Fortis hospital in their emergency ward, with B.P. dropped down to 80 to 60(upper

& lower). Her husband gave request letter for the cashless facility since it was Sunday on 06.08.17,

cashless facility could not be activated. After admission, Fortis hospital conducted CT scan, X-Ray,

ECG and all blood tests & also shifted her to ICU to monitor her B.P. At 2 p.m. Doctor informed her

that now B.P. is stable and all her reports are normal. Upon enquiry they confirmed that they have

controlled everything due to their technology, one tablet Paramet was advised and discharge was

initiated.

On 09-11-2017, the complaint was forwarded The New India Assurance 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 24-11-2017.

As per SCN submitted on 24.11.17, complainant was admitted in hospital on 05.08.17 at 10.37 pm

and discharged on 06.06.17 at 5.33 PM (as per claimant mentioned in claim form) as she was

suffering from headache, vomiting & loose stool. Patient was hospitalized for less than 24 hrs.

During hospitalization, patient was treated with injections Perfalgan (for headache), Emset (for

nausea/vomiting) Optineuron (Vitamin B 12) & Neksium (for Gastroesophageal rellex disease). At the

time of discharge tablet Paramet was prescribed for headache. The treatment done does not fall

under list of specified procedures / treatment mentioned in Annexure III. Thus, amount of Rs.5000/-

towards CT Scan charges were paid as per Clause C which reads as Expenses relating to Diagnostic

tests without hospitalization and balance amount of Rs.35276/- was deducted as per Clause (G)

definitions, point no. 14, which reads as under,

‘Hospitalization means admission in a hospital for a minimum period of 24 in patient care

consecutive hours except for a specified procedures / treatments, where such admission could be

for a period of less than 24 consecutive hours.’

The complainant was sent Annexure VI-A for compliance, which reached this office on 22-11-2017


a) Complainant’s argument: The complainant stated that the claim bills were submitted to

insurance company for reimbursement but they declined the claim on the basis that the

hospitalization was less than 24 hours.

b) Insurer’s argument: The insurance company stated in their SCN that they repudiated the

claim as per terms and conditions of the policy.


2017.





On perusal of various documents and after consideration of submissions made by both the

complainant and the insurance company during the course of personal hearing, it is seen that the

mediclaim request of the complainant who was admitted in Fortis hospital on 05.08.2017 at 10:37

pm and discharged on 06.08.2018 at 5:33 pm has been repudiated by insurance company on the

ground that the hospitalization was less than 24 hours. On examination of discharge summary of the

hospital where the complainant was hospitalized it is evident that the patient was admitted with

symptoms of headache, vomiting, loose stools & had a past history of Migraine. It is also evident

from the MMR dated 14.08.2017 duly signed by the attending doctor that the total period of

hospitalization was less than 24 hours. The complainant is duly covered under the mediclaim policy

issued to employees of LIC of India. According to the terms and conditions of policy hospitalization

means admission in a hospital for a minimum period of 24 in patient care consecutive hours except

for specified procedures/ treatments, where such admission could be for a period of less than 24

consecutive hours. Since in the instant case the hospitalization was less than 24 hours, the

repudiation of claim by insurance company and reimbursement of amount of Rs. 5000 towards CT

scan charges are in order. Keeping in view the above facts, the said complaint is hereby dismissed

and no relief is granted.

AWARD


parties during the course of personal hearing, the said complaint is hereby dismissed.



Dr. D. K. VERMA

INSURANCE OMBUDSMAN


2) Company





Case of Mr. Abhishek Mehra V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Abhishek Mehra

Flat No. 4-B, Tower-5, Central Park-II Bellevue,

Sector-48, Sohna road, Near Subhash Chowk,

Gurgaon, Haryana- 122018

Mobile No.- 9619418737

2. Policy No:

Type of Policy


111200/48/2017/623/707



Mr. Abhishek Mehra


5. Date of Repudiation Not provided

6. Reason for repudiation Adjustment Chemotherapy not payable as per T & C’



9. Amount of Claim Rs.1,61,555/-


11. Amount of relief sought Rs.1,61,555/-(62888+33300+65367)



2017


claim by an insurer

13. Date of hearing/place 09-01-2019/05.02.19


For the Complainant Mr. Krishan Kumar Mehra (Father)

For the insurer Mr. Madhu Kaul




On 08-09-2017, Mr. Abhishek Mehra had filed a complaint that his mother Mrs. Rita Mehra was a

patient of breast cancer in stage III. Her treatment was going on in Fortis Memorial Research

Institute, Sector-44, Gurgaon. While seeking approval of 13th cycle of Herclon injection the request

was declined by TPA M/s Paramount assigning reason that this procedure is not permissible in Day

Care. Later on insurance company approved the payment. Now, while seeking approval for 14th

cycle, TPA has declined the request again assigning reason that ‘Adjustment Chemotherapy not

payable as per T & C’. Details of three pending bills are as under.

a) Rs. 62888/- bill dt. 30.06.17 refused by TPA M/s Paramount. No reply given by Oriental Insurance

also.

b) Rs. 67885/- bill dt. 21.07.17 and Rs.65415/- dt. 11.08.17 refused by TPA, Although earlier same

TPA settled the claim for same treatment through New India Insurance Co. which was preferred by

his brother through his policy.

c) Rs. 65367/- bill dt.01.09.17, claim pending with New India under complainant’s elder brother

policy with M/s New India. (NOT ENTERTAINABLE)



a) Complainant’s argument: The complainant stated that his mother taking the same

treatment earlier also and the insurance company has been settling the claims for same

treatment for 13 cycles but has surprisingly declined for remaining 4 cycles.

b) Insurer’s argument: The insurance company stated that the complainant’s mother taking

treatment by chemotherapy being not payable as per terms and conditions of the policy.


2017.





On examination of various documents available in file including the copy complaint about

repudiation of the claim in respect of chemotherapy treatment taken by complainant’s mother for

her breast cancer at Fortis hospital, Gurgaon, the repudiation letter of TPA dated 24.06.2017 for

denial of cashless benefit, discharge summary of Fortis hospital where the patient had been

admitted for chemotherapy in day care on 30.06.2017, it is seen that the complainant’s mother

suffering from right side breast cancer and was admitted for treatment by chemotherapy at Fortis

hospital on 30.06.2017. It is also seen that she had been taking the same treatment earlier also and

the insurance company has been settling the claims for same treatment for 13 cycles but has

surprisingly declined for remaining 4 cycles. The reason for repudiation given by TPA in repudiation

letter dated 24.06.2017 for denial of claim, the chemotherapy being not payable as per terms and

conditions of the policy. During the course of personal hearing the complainant reiterated the

contents of the complaint and also added that the amount spent by him on treatment of his mother

for cycle no. 14,15,16 & 17 of chemotherapy has not been reimbursed by insurance company

whereas the earlier claims for the same treatment has been sanctioned by insurance company. I

have also gone through the terms & conditions of the policy. It is clear that the insurance company

has acted in an arbitrary manner to deny the claim which is very much payable and duly covered

under day care procedure. However the complainant has already been reimbursed the claim amount

in respect of the treatment taken by his mother for cycle no. 15, 16 & 17 by New India Assurance

Company. The claim on that account is not admissible and not entertainable for the same treatment.

In view of above facts the insurance company is directed to settle the claim for treatment taken by

complainant’s mother at hospital for cycle no. 14 for amount of Rs. 62,888/- as per terms and

conditions of policy and interest for delayed payment @ 6% from the date of filling complaint till the

date of payment within 30 days from the receipt of award copy.

AWARD



the claim for treatment taken by complainant’s mother at hospital for cycle no. 14 for amount

of Rs. 62,888/- as per terms and conditions of policy and interest for delayed payment @ 6%

from the date of filling complaint till the date of payment within 30 days from the receipt of

award copy.



Dr. D. K. VERMA

INSURANCE OMBUDSMAN


2) Company

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, CHANDIGARH


OMBUDSMAN – DR. D.K. VERMA

Case of Mr. Amarjit Singh V/s Religare Health Insurance Co. Ltd.


1. On 11.09.2018, Mr. Amarjit Singh had filed a complaint in this office against the

Religare Health Insurance Co. Ltd. for non settlement of his health claim despite

several requests. The required documents were submitted to the insurance company

well in time but the insurance company repudiated the claim.

2. This office pursued the case with the insurance company to re-examine the complaint

and they agreed to reconsider the claim.

3. Mr. Amarjit Singh has confirmed through letter dated 05.02.2019 that the insurance

company has settled his claim and wanted to withdraw his complaint.

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: 25.02.2019 (Dr. D.K. VERMA)



2) Company

PROCEEDINGS BEFORE




Case of Mr. Ishwar Chand Garg V/s. ICICI Lombard General Insurance Co. Ltd.


1. On 01.01.2019, Mr. Ishwar Chand Garg had filed a complaint in this office against ICICI

Lombard General Insurance Co. Ltd. for non settlement of his health claim despite several

requests. The required documents were submitted to the insurance company well in time

but the insurance company repudiated the claim.



3. Mr. Ishwar Chand Garg has confirmed through email dated 18.01.2019 that after filing

the complaint in this office company is ready to renew the policy as needed. Therefore,

he wants to close his complaint in this office.

4. The insurance company confirmed through email dated 31.01.2019 that they have

renewed the policy.






2) Company

PROCEEDINGS BEFORE




Case of Mr. Rajendra Malviya V/s. Star Health & ALlied Insurance Co. Ltd.


1. On 04.11.2017, Mr. Rajendra Malviya had filed a complaint in this office against Star

Health & Allied Insurance Co. Ltd. for non settlement of his health claim despite several

requests. The required documents were submitted to the insurance company well in time

but the insurance company repudiated the claim.



2. Mr. Rajendra Malviya has confirmed through email dated 21.02.2019 that the insurance

company has settled his claim and he has received the claim amount and wanted to

withdraw his complaint.





PROCEEDINGS BEFORE




Case of Mr. Anil Kumar V/s. Star Health & ALlied Insurance Co. Ltd.


1. On 20.12.2018, Mr. Anil Kumar had filed a complaint in this office against Star Health &

Allied Insurance Co. Ltd. for non settlement of his health claim despite several requests.

The required documents were submitted to the insurance company well in time but the

insurance company repudiated the claim.



3. The insurance company confirmed through email dated 30.01.2019 that they have

settled the health claim. The claim amount of Rs. 2,39,192/- has been credited to bank

account of Mr. Anil Kumar through NEFT.

4. Mr. Anil Kumar has also confirmed telephonically that the insurance company has

settled his claim and he has received the claim amount and wanted to withdraw his

complaint.





PROCEEDINGS BEFORE




Case of Mr. Vijay Kapoor V/S Max Bupa Health Insurance Co. Ltd.



Complainant

Mr. Vijay Kapoor

H.No.- 36 A, Ward No.-9, Village Budhanpur,

Panchkula, Haryana- 134109

Mobile No.- 9814454630

2. Policy No:

Type of Policy


30428516201601

Heartbeat Gold

20-05-2016 To 19-05-2017



Mr. Vijay Kapoor

Mr. Vijay Kapoor

4. Name of the insurer Max Bupa Health Insurance Co. Ltd.

5. Date of Repudiation N/A

6. Reason for repudiation N/A


8. Nature of complaint Cancellation of policy

9. Amount of Claim N/A


11. Amount of relief sought Restoration of policy



Ombudsman Rules


claim by an insurer

13. Date of hearing/place 04-01-2019, 05.02.19, 25.02.19/Chandigarh


For the Complainant 04-01-2019, 05.02.19, 25.02.19

Complainant was absent without any intimation

For the insurer 04-01-2019, 05.02.19, 25.02.19

Mr. Bhuwan Bhaskar, Manager (Legal)

15 Complaint how disposed Dismissed/ Closed



On 19-09-2017 Mr. Vijay Kapoor, had filed a complaint that he took Health Insurance policy

from Max Bupa on 20.05.15 and renewed the same in May 2016. In Nov.16, he admitted in

Alchemist Hospital, Panchkula for Chest Pain, which was diagnosed as Coronary Artery Disease. The

disease was cured and reimbursement done. But when complainant visited Max Bupa branch

Chandigarh for policy renewal in May17, it was informed to him that his policy has been terminated

in the month of Jan’2017. His policy was terminated without any intimation to him. Complainant

requested for revival of his policy.

On 04-10-2017, the complaint was forwarded to Max Bupa Health Insurance Co. Ltd. Regional

Office, Delhi for para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 12-02-2018.


18) As per SCN, Mr.Vijay Kapoor, complainant filled health proposal form on 18.05.15, on the basis

of which company issued him policy no., 30428516 which was effective from 20.05.15 to 19.05.16,

and which was renewed from time to time. Company received Pre-authorization request for

admission from 12.11.16 to 14.11.16 in Alchemist Hospital for treatment of CAD. On verification of

Pre Auth it was found that insured had history of HTN since last 3 yrs and was on regular medication

for the same. The medical documents provided at the stage of Pre Auth provided ample proof of the

non disclosed HTN. In Proposal form, all the questions were answered with a NO. The company has

decided to apply necessary exclusion as applicable and sent recorded exclusion letter, SMS & an e-

mail dt.18.11.16 to the complainant. The company has delivery proof that the complainant received

the exclusion letter on 24.12.16. Company did not receive his consent to the exclusions applied &

ultimately cancel the policy.

19) Neither the complainant nor his representatives appeared for the personal hearing on 04-01-

2019, 05.02.19 and 25.02.19. The case is thus, dismissed in default and closed due to non-perusal of



D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




Case of Mr. Abhishek Sikka V/s. Star Health & ALlied Insurance Co. Ltd.


1.On 31.10.2017, Mr. Abhishek Sikka had filed a complaint in this office against Star Health

& Allied Insurance Co. Ltd. for non settlement of his health claim despite several requests.

The required documents were submitted to the insurance company well in time but the

insurance company repudiated the claim.

2.Mr. Abhishek Sikka has confirmed through email dated 24.02.2019 that he is no more

with this insurance company and want to take his complaint back.

3.In view of the above, no further action is required to be taken by this office and the

complaint is closed & disposed off accordingly.



PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH



Case of Mr. Surjit Singh Summan V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Surjit Singh Summan

H. No. - 1716, Sector 49-B, Nirwana co-op.

H/B Society, Chandigarh- 160047

Mobile No.- 8427225050

2. Policy No:

Type of Policy


231290/48/2017/2191

PNB- Oriental Royal Mediclaim Policy

07-03-2017 To 06-03-2018



Mr. Surjit Singh Summan

Mr. Surjit Singh Summan


5. Date of Repudiation N/A

6. Reason for repudiation N/A


8. Nature of complaint Deduction were made in claim


10. Date of Partial Settlement Not provided

11. Amount of relief sought Rs.52430/-



2017


claim by an insurer

13. Date of hearing/place 09.01.2019, 05.02.19, 25.02.19/ Chandigarh




For the insurer 09-01-2019, 05.02.19, 25.02.19

Ms. Madhu Kaul, Deputy Manager




On 16-10-2017, Mr. Surjit Singh Summan had filed a complaint that he has submitted his bill for Rs.

77968/- for his left Eye cataract surgery. But TPA Raksha Health Insurance Pvt. Ltd. has sanctioned

only Rs. 25,538/-, i.e. have been less paid by amount of Rs. 52,430/-. As per claim settlement

voucher of Raksha TPA, Rs.15000/- has been less paid in Surgeon fee, Rs.2430/- under hospital

Services and Rs.35000/- under implants cost deducted with reason ‘Non payable as per Reasonable

and Customary Rates’.

18) As per SCN submitted by insurance company, insured underwent cataract left eye operation on

11.03.17 from Grewal Eye Institute Chandigarh. The insured did not avail cashless facility at the

hospital but submitted a bill of Rs. 77,968/- to M/s Raksha TPA for reimbursement. The package for

cataract operation under cashless is fixed at Rs.24,000/- at Grewal Eye Hospital by GIPSA companies

and duly agreed by the said hospital. Accordingly, M/s Raksha TPA reimbursed an amount of

Rs.25,538/- including pre post medicine bills submitted by the insured thereby deducting an amount

of Rs.52,430/- paid by insured on his own.


2019, 05.02.19 and 25.02.19. The absence of the complainant or his duly authorized representative

on the various dates fixed for personal hearing indicates that the complainant has nothing to say in

the matter. The case is thus, dismissed in default and closed due to non-perusal of case by

complainant.


D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. M.L.Mittal V/s the United India Insurance Co. Ltd.


1.On 19.09.2017, Mr. M. L. Mittal had filed a complaint in this office against The United

India Insurance Co. Ltd. for not settling the health claim. The required documents were

submitted to the insurance company but the insurance company did not settle the claim

under policy no. 500100/48/15/41/00000535.

2. The complainant through letter dated 20.02.2019 has confirmed that he

has filed a case in the Consumer Court, Moga (Punjab) in the instant case.

3.Hence, in accordance with Rule 14.5 of Insurance Ombudsman Rules, 2017












Case of Mr. Ashok Kumar Kansal V/S The Star Health and Allied Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Ashok Kumar Kansal

R/o # 310, Phase-1, Model Town, Bathinda,

Punjab- 151001, Mobile No.- 9888823753

2. Policy No:

Type of Policy


P/211200/01/2017/001875


16-09-2016 To 15-09-2017



Mr. Ashok Kumar Kansal

Mr. Ashok Kumar Kansal

4. Name of the insurer The Star Health and Allied Insurance Co. Ltd.


6. Reason for repudiation Attendance certificate not match with hospital dates


8. Nature of complaint Claim repudiated






2017

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

by an insurer

13. Date of hearing/place 09-01-2019, 05.02.19, 25.02.19/ Chandigarh




For the insurer 09-01-2019, 05.02.19, 25.02.19

Ms. Mamta Gupta, Manager




On 12-10-2017, Mr. Ashok Kumar Kansal had filed a complaint that his health Insurance

claim under policy number P/211200/01/2017/001875, Intimation No. CLL/2017/211200/0432561 in

the name of Master .Pratham Kansal was rejected by insurance company with remarks that as per

discharge slip of hospital admission and discharge is mentioned as 24.02.17 and 01.03.17 but as per

certificate dt. 10.04.17 issued by the Principal of RBDAV Sr.Sec.School, the insured patient was

absent for school only on 25.02.17 & 28.02.17. Thus, there is misrepresentation of material facts.

Later on, complainant vide e-mail dt. 20.04.18 informed that he received the main claim but bills of

post hospitalization expenses for Rs.3558/- was still pending. (As per note dt.02.07.18 placed in the

file, complainant certified that he has received the claim amount). On 09.03.18, Sh.Ashok Kumar

Kansal sent one more complaint, stating that her daughter Kritika Kansal was admitted in hospital

due to stomach pain on 19.02.17 & discharged on 01.03.17 from Mohal Lal Garg Hospital, Bathinda.

The claim was rejected first but passed thereafter after application of reconsideration. Post

Hospitalization documents for Rs.4560/- submitted in Aug.2017, but insurance company passed only

Rs.360/-.

18) In the repudiation letter insurance company stated complainant has sought reimbursement for

Master Pratham Kansal due to hospitalization expenses incurred on treatment of acute viral

hepatitis. As per discharge summary of hospital he was admitted on 24.02.2017 and got discharge

on 01.03.2017. But as per school certificate dated 10.04.2017 issued by Principal R.B.D.A.V.SR.SEC

Public School, insured patient was absent for school on 25.02.2017 and 28.02.2017. Thus, there is

misrepresentation of materials fact. Accordingly, as per condition No 8 of the policy issued claim was

repudiated for misrepresentation of facts.


2019, 05.02.19 and 25.02.19. The case is thus, dismissed in default and closed due to non-perusal of



D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant MR. KHUSHAAL SAHU VS ORIENTAL INSURANCE CO LTD

COMPLAINT REF NO: GUW-G-050-1819-0106 : Award No: IO/GUW/A/GI/0100/2018-2019

1. Name & Address of the Complainant MR. KHUSHAAL SAHU

2. Policy No:

Type of Policy


321201/48/2018/548

Mediclaim



Mr. Basudeb Sahu Mr. Khushaal Sahu

4. Name of the insurer Oriental INSURANCE CO. LTD.

5. Date OF OCCURANCE OF LOSS/CLAIM 23.04.2018

6. DETAILS OF LOSS Rs.96308 ( as per TPA letter claim amount is 68685)

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

Mediclaim.

26.11.18

9. Amount of Claim Rs. .96308

10. Date & Amount of Partial Settlement Nil

11 Amount of relief sought Rs. .96308

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati, ON 23.01.19


For the Complainant Mr. Khushal Sahu

For the insurer Mrs. Madhuchanda Dhar

15 Complaint how disposed Through personal Hearing


17) Brief Facts of the Case: Khushaal Sahu dependent son of Sri Basudeb Sahu was admitted at Keshav Hospital Pvt. Ltd.

Patna on 23.04.2018 and was discharged on 28.04.2018. They had a happy family floater policy covering 4 members for

sum assured of Rs.200000 with co-pay 10 %. He submitted his claim of Rs.96308. TPA called for some requirements vide

letter dt.23.05.2018. As per the claimant he had submitted all documents and requirements but insurance co neither

settled the case nor repudiated . First hearing was conducted on 23/01/2019 where claimnant was represented by

Mr.Basudev Sahu who was directed to submit the required paper and representative of Insurance Company agreed to

proceed the claim.On 26/02/2019 Mr.Khushal Sahu produced photo copy of all documents which he has submitted to

the TPA of Insurance Company & also handed over one set of papers alongwith original money receipt to the

representative of Insurance Company.

18a) Complainant’s argument: . Khushaal Sahu dependent son of Sri Basudeb Sahu was admitted at Keshav Hospital

Pvt. Ltd. Patna on 23.04.2018 and was discharged on 28.04.2018. It was a happy family floater policy covering 4

members for sum assured of Rs.200000 with co-pay 10 %. He submitted his claim of Rs.96308. TPA called for some

requirements vide letter dt.23.05.2018. As per the claimant he has submitted all documents and requirements but

insurance co neither settled the case nor repudiated.

18b) Insurers’ argument: - on 18/05/2018 TPA called 12 no of requirements. On 13/06/2018 Company called

9 no of requirements as Company received 3 requirements out 12 called earlier. On 19 December 2018

Company repudiated the claim for non-submission of proper documents. However on 26/02/2019 the

representative of insurance co admitted that policy holder has submitted some documents to their Nagaon

office & took Xerox copy of all documents & assured for follow-up of the claim for settlement.

Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval from honorable

ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on 23.01.2019 & again on 26/02/2019. The complainant Mr. Basudeb Sahu was present on 23/01/2019 & Mr Khushal Sahu represented on 26/02/2019.On both the dates the insurer was represented by Mrs.Madhuchanda Dhar.

DECISION We have taken in to consideration the facts and circumstances of the case aside from the documentary

as well as verbal submission made by the insured and the representative of insurance company during

the course of hearing. We have also gone through the records. Policy holder has clear evidence of

submission of all documents to the insurer. Insurer kept the file pending for a cause best known to

them. As per the letter dated 02/05/2018 the Oriental Insurance Company confirmed that they have

received the claim documents on 02/05/2018 which has been forwarded to Raksha TPA private limited

on same date & Raksha TPA acknowledged the receipt of documents under seal & signature on

04/05/2018.On 26/02/2019 the representative of Insurance Co.has taken photo copy of all

documents.However the original money receipt were attained with the Insured through oversight and

the same was handed over to the Insurer’s representative in course of hearing.

Under the circumstances and in order to ensure fairness to the policy holder an amount of Rs. 96308/-

less any mandatory deduction as per the policy conditions if any less 10% co-pay is hereby awarded to be paid by

the insurer , towards the full and final settlement of the claim.


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 acceptance letter of the Complainant and shall intimate the compliance to

the Ombudsman.

Dated at- Guwahati on the 26th Day of February 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

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

OMBUDSMAN – K.B. SAHA CASE OF: : Complainant MRS LALITA DEVI AGARWAL VS TATA AIG GEN. INSURANCE CO LTD


1. Name & Address of the Complainant MRS. LALITA DEVI AGARWAL

2. Policy No:

Type of Policy


02858254735

PERSONAL ACCIDENT policy



LATE SHYMLAL AGARWAL LATE SHYMLAL AGARWAL

4. Name of the insurer TATA AIG Gen. insurance co. ltd.


6. DETAILS OF LOSS 5,00,000


8.a

Nature of complaint

Son of Lalita Devi late Shyamlal Agarwal met tragic

motor vehicle accident on 22.01.2017. He had an

account with Axis Bank his debit card no was

5346800016545332 and he was covered under

personal accident policy no 02858254735 for

Rs.500000. His Axis Bank account no was

916010038720636 at Axis bank Bilasipara branch.

After the death of only son of Lalita Devi Agarwal she

lodged two nos of letters on Feb 13 and 6th March

2018 but bank has not responded to it. Tata AIG Gen

insurance co. registered a complaint under CPGRAMS

Complaint no.DPG/1/2018/00258, incident

no.201807252104. Which was informed vide letter

dtd.25th July 2018. On same date company called

seven nos of requirements from Mrs. Lalita Devi

Agarwal. Axis bank vide letter dtd. 06.12.2018 declined

the claim on the ground of non- submission of

documents within 90 days.

8.b Date of receipt of the complain 12.12.18

9. Amount of Claim Rs.500000


11 Amount of relief sought Rs.500000


13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati, on 23.01.19


For the Complainant MR.SAJAN KUMAR AGARWAL

For the insurer MS ARUNDHUTI GHOSH



17) Brief Facts of the Case: Son of Lalita Devi late Shyamlal Agarwal met tragic motor vehicle accident on 22.01.2017. He

had an account with Axis Bank his debit card no was 5346800016545332 and he was covered under personal accident

policy no 02858254735 for Rs.500000. His Axis Bank account no was 916010038720636 at Axis bank Bilasipara branch.

After the death of only son of Lalita Devi Agarwal she lodged two nos of letters on Feb 13 and 6th March 2018 but bank

has not responded to it. Tata AIG Gen insurance co. registered a complaint under CPGRAMS Complaint

no.DPG/1/2018/00258, incident no.201807252104. Which was informed vide letter dtd.25th July 2018. On same date

company called seven nos of requirements from Mrs. Lalita Devi Agarwal. Axis bank vide letter dtd. 06.12.2018 declined

the claim on the ground of non- submission of documents within 90 days.

First hearing was scheduled on 23/01/2019 where Lalita Devi was present but representative of insurance company did

not attended the hearing.Second hearing scheduled on 11/02/2019 where representative of both insured & insurer

were present. During the course of hearing insurance company informed that this policy belongs to another

Mr.Shyamlal Agarwal of Orissa who is alive & the policy is in existence, whose spouse named smt.Lalita Devi Agarwal.

The matter was brought to the notice of the claimant by the company.

Representative of the claimant requested the forum to allow him sometime to collect certificate from Axis Bank

confirming that Late Shyamlal Agarwal Debit Card was covered under this policy of TATA AIG. Accordingly the Forum

allowed him time up to 16th February 2019.Claimant again applied to allow her time for submission of document from

Axis Bank up to February 2019 which has not been allowed to her.

On 14th Feb2019 the Forum received a letter from chief manager personal accident & travel of TATA AIG General

insurance co.ltd confirming that they do not have any tie-up with Axis bank towards providing personal accident

coverage to the savings account holder using debit cards for the year 2016-17 & 2017-18.

18a) Complainant’s argument: They informed the bank on 13th Feb and 6th March 2018. They have complied

other requirements also but as the mother was at shocked stage on death of his only son so there was some

delay in submission of the documents. There must be some authority to condone the delay and requested

for payment of the claim.

18b) Insurers’ argument: - As all documents were not submitted within 90 days so claim has been rejected.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after

proper approval from honorable ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for

hearing on 11/02/2019. The complainant Mrs. Lalita Devi Agarwal was represented by Mr Sajan Kumar Agarwal and the insurer was represented by Ms Arundhuti Ghosh.

DECISION

We have taken in to consideration the facts and circumstances of the case aside from the documentary


the course of hearing. We have also gone through the records. Claimant was given time to produce

certificate from Axis Bank confirming that Late Shymlal Agarwal was covered under Group Policy

Number on which claim has been lodged. She could not produce the same within the stipulated time.

TATA AIG General Insurance Company vide letter dtd 05/02/2019 confirmed that TATA AIG General

Insurance company limited has not issued any group personal accident policy for providing personal

accident coverage to the holders of debit card/credit card issued by the Axis Bank ltd .

TATA AIG vide letter dated 14/02/2019 again confirmed us that they do not have any existing policy

with Axis Bank towards providing personal Accident coverage to their saving bank account holders using

debit card for 2016-17 & 2017-18.

Under the circumstances the forum dismisses the case for lack of merit.

HENCE THE COMPLAINT IS TREATED AS CLOSED.

Dated at- Guwahati on the 26th Day of FEBRUARY 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE


OMBUDSMAN – K.B. SAHA CASE OF: : Complainant PRANATI KAR VS SBI GENERAL INSURANCE CO LTD

COMPLAINT REF NO: GUW-G-040-18-19-0094 : Award No: IO/GUW/A/GI/0080/2018-2019

1. Name & Address of the Complainant MRS PRANITI KAR

2. Policy No: 0000000006213672 AND 0000000006213672-01

Type of Policy


GROUP HEALTH INSURANCE POLICY

27/3/17 TO 26.03.18 AND 27/03/2018 TO 26.03.2019



MRS PRANATI KAR

4. Name of the insurer S B I GENERAL INSURANCE CO LTD.


6. DETAILS OF LOSS Rs.34550/-


8.a

8.b

Nature of complaint


SBI Claim no HI101572 under group Health Insurance

policy was registered towards reimbursement of

expenses for medical treatment of insured Mrs.

Pranati Kar AGE 62 YEARS, for cataract of both the

eyes. She was also effected with resistant pupil,

diabetes mellitus, hypertension, hypothyroidism,

coronary artery bypass grafting. Phacoemulsification

of right eye was also done with intraocular lens

implantation at SRI SANKARDEVA NETHRALAYA

Expenses incurred was Rs.34550. On submission of the

claim Insurance Co repudiated the claim on the ground

of pre-existing as policy has not completed 48

consecutive months. But as per clause no 7 of the

policy “ it is hereby declared and agreed that the

exclusion clause no 1 of the exclusion stands deleted

and insurer will pay the expenses up to the limit and

sub limit as mentioned in the schedule against the

insured persons all other terms and conditions under

the policy remain unaltered” .

24.10.2018

9. Amount of Claim 34550.00

10. Date & Amount of Partial Settlement DOES NOT ARISE

11 Amount of relief sought 34550/


13(1)(b)

13. Date of hearing/place 10.01.2019 at Guwahati


For the Complainant Mr. Sankar Lal Kar husband of Mrs. Pranati Kar

For the insurer MRS Komol Agarwalla

15 Complaint how disposed On the basis of the HEARING in presence of both the

parties.


17) Brief Facts of the Case- SBI Claim no HI101572 under group Health Insurance policy was registered towards

reimbursement of expenses for medical treatment of insured Mrs Pranati Kar ,for both the eyes age related Cataract,

resistant pupil, diabetes mellitus, hypertension, hypothyroidism, coronary artery bypass grafting and relation thereto,

her right eye phacoemulsification with intraocular lens implementation was done at SRI SANKARDEVA NETHRALAYA

and incurred expenses of Rs 34550. On submission of the claim Insurance Co repudiated the claim on the ground of pre-

existing. But clause no 7 of the policy states as “it is hereby declared and agreed that the exclusion clause no 1 of the

exclusion stands deleted and insurer will pay the expenses up to the limit and sub limit as mentioned in the scheduled

against the insured persons all other terms and conditions under the policy remain unaltered”.

Complainant’s argument: As per the advise of Dr. Harsha Bhattacharjee she was admitted in Hospital on 14.05.18 for

PHACO +FIOL TECINS + VISCOT+ HOOK Surgery of her right eye and was discharged on same day. She spent Rs 34550 and

submitted the claim n time but insurance company vide letter dt 29.05.2018 informed her regarding the repudiation of

the claim for PED . But as per policy condition no7 “it is hereby declared and agreed that the exclusion clause no 1 of the

exclusion stands deleted and insurer will pay the expenses up to the limit and sub limit as mentioned in the scheduled

against the insured persons all other terms and conditions under the policy remain unaltered” so it is payable.

18) Insurers’ argument: - stated as in item no 17.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval

from honorable ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure VII A c) S C N d)copy of the policy e)Annexure VII A

DECISION

We have taken into account facts & circumstances of the case aside from Documentary as well as Verbal

submission made by both the parties during the course of hearing. As per the hospital report diminision of vision

for dist.and near, duration is 2 years and gradually worsening. Age –related cataracts duration is 3 years. Past

medical history – Diabetes mellitus duration is 20 years and open heart sx done 2 years ago. But pre existing case

could not be established as it is a group policy and as per policy clause 7 “it is hereby declared and agreed that the

exclusion clause no 1 of the exclusion stands deleted and insurer will pay the expenses up to the limit and sub limit

as mentioned in the scheduled against the insured persons all other terms and conditions under the policy remain

unaltered” Hence in order to meet the end of Natural Justice, we have relied upon logical, LITERAL as well as

technical interpretation of the policy terms and conditions and hereby direct the insurance co. to pay Rs.34550/-

(less mandatory deduction for non-payable items if any).

The complaint is thus treated as CLOSED.

The attention of the complaint and the insurer is hereby invited to the following provisions of insurance ombudsman

Rues, 2017.

According to the Rules 17(6)of the said rules,2017 the insurer shall comply with the Award within 30 days of the receipt

of the award and shall intimate the compliance to the same to the ombudsman.

Dated at Guwahati on the 10th day of JANUARY 2019.

K.B.Saha INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant Ms Sampa Das Vs SBI General Insurance Company Limited

COMPLAINT REF NO: GUW-G-040-1819-0128 : Award No IO/GUW/A/GI/0098/2018-2019

1. Name & Address of the Complainant SAMPA DAS

2. Policy No:

Type of Policy


Sum Insured

0000000009040170;HEALTH POLICY

FROM 26/02/2018 TO 25/02/2019

Rs.100000/-



SAMPA DAS SAMPA DAS

4. Name of the insurer SBI GENERAL INSURANCE COMPANY LIMITED

5. Date OF OCCURANCE OF LOSS/CLAIM 24/03/2018

6. DETAILS OF LOSS RS.160277/-


8.a

8.b

Nature of complaint


MEDICLAIM

28/01/2019

9. Amount of Claim RS.160277/-

10. Date & Amount of Partial Settlement NIL

11 Amount of relief sought RS.160277/-


13(1)(b)

13. Date of hearing/place 26/02/2019; O/o Insurance Ombudsman Guwahati


For the Complainant Rupak Kumar Das

For the insurer Ms. Komol Agarwala



17) Brief Facts of the Case : Ms. Sampa Das had a Mediclaim with SBI General Insurance Company Ltd for Sum Insured

Rs.100000/-. She was hospitalized from 24/03/2018 to 25/03/2018.She sent all the original documents by registered

post on various dates within the stipulated period of submission of claim to Insurance Co’s TPA. But the TPA has been

asking for the same documents again & again & it is not possible for the claimant to send original document twice.

Under this ground the claim was repudiated.

18 ) Complainant’s Argument: As mentioned in point No.17.

18 b) Insurers’ Argument: - The claim was repudiated only because of the complainant’s negligent behavior

and non-submission of required documents which are:

i. Original pre-printed numbered money receipts required for the hospital bill amount of Rs.136297.ii.All

investigation reports are required for investigations done during hospitalization dated

17/03/2018,19/03/2018,22/03/2018 and 23/03/2018 is required.

iii. Supporting doctor’s advice for investigation done on dated 17/03/2018,19/03/2018,22/03/2018 and

23/03/2018 is required.

iv. attending doctor to certify the commencement of symptoms, the duration of ailment.

v. all prescriptions/treatment papers related to the treatment of the disease prior to hospitalization.

vi. Provide all past treatment papers related to the same disease.




hearing on 26/02/2019. The complainant was represented by her husband,Mr.Rupak Kumar Das & the insurer was represented by Ms. komol Agarwal.

DECISION We have taken in to consideration the facts and circumstances of the case. We have also taken into

consideration the documentary as well as verbal submission made by the representative of the Insured

& representative of the Insurance Co. during the course of hearing. From the documents it is established

that the claimant has photocopy of all documents as mentioned in 18(b) which are essential to process

the claim by the Insurance Company. During the course of hearing a set of all papers has been handed

over to the representative of Insurance Co.& written acknowledgement of the same was also obtained

.Claimant produced copy of one money receipt of Rs.136297 & other money receipt also alongwith the

other papers.As the basic sum insured is Rs 100000/- so claim cannot be more than that.The Forum

directs the Insurance Company to settle the claim of Rs 100000/ as full & final settlement .






the Ombudsman.

Dated at- Guwahati on the 26th Day of February 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE


OMBUDSMAN – K.B. SAHA CASE OF: : Complainant MR. SANJAY KUMAR PATNI VS STAR HEALTH ALLIED INSURANCE CO LTD


1. Name & Address of the Complainant MR. SANJAY KUMAR PATNI

2. Policy No:

Type of Policy


P/191113/01/2018/006082

Mediclaim

16.12.17 to 15.12.2018 , S.A.2500000/-



Sanjay kumar Patni Sanjay kumar Patni

4. Name of the insurer Star Health allied insurance co. ltd.


6. DETAILS OF LOSS 1941697


8.a

8.b

Nature of complaint


Mediclaim.

12.12.18

9. Amount of Claim Rs. 1941697


11 Amount of relief sought Rs. 1941697


13(1)(b)



For the Complainant Mrs. Sangeeta Patni w/o Sanjay kumar Patni

For the insurer Mr. Arif Hussain



17) Brief Facts of the Case: The patient was suffering from MOTOR NEURON DISEASE as per the indoor case records of

Charnock Hospital, where he was admitted on 02.05.2018. Patient was diagnosed at AMRI Hospital Kolkata as Motor

Neuron Disease with a background of Diabetes Mellitus. Patient was admitted at AMRI Saltlake with breathlessness and

productive cough where he was diagnosed as an acute exacerbation of COPD an managed on Non-invasive Ventilation.

He had an episode of aspiration pneumonia, was intubated and ventilated. Tracheostomy was done on 28.03.2018 at

AMRI Saltlake in view of prolonged mechanical ventilation. Patient was shifted to AMRI Dhakuria on 02/04/2018.

Patient is taking home ventilator support with heated humidifier. Taking feeds orally as well as through PEG tube, Daily

physiotherapy is being continued.

18a) Complainant’s argument: The indoor records of Charnock Hospital of his suffering from MOROR

NEURON DISEASE for past 7-8 months i.e. prior to date of commencement of policy is not correct as he was

on tracheostomy tune so he was unable to speak about period of disease. So claim should be settled.

18b) Insurers’ argument: - As per the indoor case record of Chamock Hospital admission dt.02.05.2018 the

complaint was suffering from MOROT NEURON DISEASE for past 7-8 months . Date of commencement of the

policy is 16.12.2017 . So he was suffering from the disease prior to commencement of the policy so it is PED

hence claim is repudiated as per policy condition.




hearing on 23.01.2019. The complainant Mr. Sangeeta Patni w/o Mr. Sanjay Kr. Patni was present and the insurer was represented by Mr. Arif Hussain.

DECISION



the course of hearing. We have also gone through the records.

As per the records it could not be established that the policy holder was not suffering from MOTO

NEURON DISEASE for past 7-8 months as mentioned indoor case records of Charnock Hospital, where he

was admitted on 02.05.2018 and date of commencement of the policy is 16.12.2017. Hence PED can not

be denied and decision of insurer of repudiation is uphold by this forum.






the Ombudsman.

Dated at- Guwahati on the 23rd Day of January 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE


OMBUDSMAN – K.B. SAHA CASE OF: : Complainant MR. SUBRATA SEN VS STAR HEALTH & ALLIED INSURANCE CO LTD

COMPLAINT REF NO: GUW-G-044-1819-0096 : Award No : IO/GUW/A/GI/0084/2018-2019

1. Name & Address of the Complainant MR. SUBRATA SEN

2. Policy No:

Type of Policy

P191311/01/2019/001078

Duration of policy/Policy period 26 th May 2018 to 25th May 2019



Mrs. Satya Sen Mr. Subrata Sen

4. Name of the insurer Star Health & Allied INSURANCE CO. LTD.

5. Date OF OCCURANCE OF LOSS/CLAIM 29.06.2018.

6. DETAILS OF LOSS Patient was admitted in the Sanjevani hospital

Guwahati with c/o Bleeding P/V-4 months not

responding to D&C and medicines O/E Pulse:74/min,

BP 120-80 mmhg chest:clear, CVS SIS2(N), ASD: UT N/P

USG & MRI PELVIS: adenemyosis of uterus ( Diagnosis

Adenomyois, Endometriosis & Scar Endometriosis).


8.a

8.b

Nature of complaint


Mediclaim.

29.10.18


10. Date & Amount of Partial Settlement No partial settlement



13(1)(b)



For the Complainant Mr. Subrata Sen

For the insurer Mr. Arif Hussain



17) Brief Facts of the Case: Insured was admitted in Sanjivani Hospital on 29.06.2018 for treatment of Bleeding P/V-4

months ( but in the discharge summery it was written as 4 years which was subsequently corrected and a separate

certificate also in this regard obtained from the Doctor) not responding to D&C and medicines O/E Pulse:74/min, BP

120-80 mmhg chest:clear, CVS SIS2(N), ASD: UT N/P USG & MRI PELVIS: adenemyosis of uterus ( Diagnosis Adenomyosis,

Endometriosis & Scar Endometriosis). Company rejected the claim on the ground of PED as in the discharge summery it

was mentioned (subsequently corrected) that the insured has previous history of P/V bleeding for the past 4 years.

Company subsequently asked for previous treatment records relating to P/V bleeding. As company has not received the

necessary documents so claim was not processed. However company offered him Rs.82826 against bill of Rs.113164

and deduction being Rs.30338. Company enclosed a working sheet of details of deduction of Rs.30338 which enclosed

professional fee Rs.1000, medicine Rs.3696, investigation Rs.5707 others 4400 pre hospitalization 10980 post

hospitalization 4555.

18 a)Complainant’s argument: Company agreed to pay vide letter 24.12.2018 Rs.82826/-. During the course

of hearing insured produced document of Rs. 14991 out of total deduction 30338/- which the company

agreed to pay in all the company agreed to pay Rs.97817 as full and final settlement.

18 b) Insurers’ argument: - Company agreed to pay vide letter 24.12.2018 Rs.82826/-. During the course of

hearing insured produced document of Rs. 14991 out of total deduction 30338/- which companies ready to

pay so company agreed to pay Rs.97817 as full and final settlement.




hearing on 10.01.2019. The complainant Mr. Subrata Sen was present and the insurer was represented by Mr. Arif Hussain

DECISION



the course of hearing. We have also gone through the records. Both insured and insurer has given a

joint written statement agreeing to payment of Rs.97817 as full and final settlement of the claim after

verification of the documents by both the parties.

Under the circumstances and in order to ensure fairness to the policy holder an amount of Rs. 97817/- is

hereby awarded to be paid by the insurer , towards the full and final settlement of the claim.






the Ombudsman.

Dated at- Guwahati on the 10th Day of January 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE


OMBUDSMAN – K.B. SAHA CASE OF: : Complainant MR. UMESH KUMAR VS UNITED INDIA INSURANCE CO LTD


1. Name & Address of the Complainant MR. UMESH KUMAR

2. Policy No:

Type of Policy


500100/28/17/P/11707405

Group mediclaim



Mr. Umesh Kumar

4. Name of the insurer United India INSURANCE CO. LTD.


6. DETAILS OF LOSS Rs.226514


8.a

8.b

Nature of complaint


Mediclaim.

24.10.18

9. Amount of Claim Rs.226514

10. Date & Amount of Partial Settlement Rs.400000 settled out of total SA of Rs.400000

11 Amount of relief sought Rs. 226514


13(1)(b)



For the Complainant Mr. Umesh Kumar

For the insurer Mr. D.B. Upadhaya



17) Brief Facts of the Case: Being the employee of Central Bank of India he was covered under Group Mediclaim for S.A.

400000. He incurred Rs.705183 towards mediclal expenses self and her mother Ms. Kamili Devi. He exhausted basic S.A.

Rs.400000 and lodged claim for left over amount under corporate buffer. (Corporate buffer: if employee of any PSU bank

is exhausted his total sum assured, he may claim his leftover claim under corporate buffer scheme for specified diseases

if otherwise eligible). He submitted the claim but company neither rejected nor accepted the claim hence he lodged

complaint.

Complainant’s argument: On submission of all documents company has neither repudiated nor admitted the

claim under corporate buffer policy under which he claimed Rs.226514 under claim no.CCNMID292862.

18) Insurers’ argument: - SCN not received.



20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A

e) S C N Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for

hearing on 23.01.2019. The complainant Mr. Umesh Kumar was present and the insurer was represented by Mr. D B Upadhya

DECISION

We have taken in to the facts and circumstances of the case aside from the documentary as well as

verbal submission made by the insured and the representative of insurance company during the course

of hearing. We have also gone through the records.

As per corporate buffer policy if employee of any PSU bank is exhausted his total sum assured, he may claim his

leftover claim under corporate buffer scheme for specified diseases if otherwise eligible. Company could not justify

the ground of repudiation so as per policy conditions after deduction of any mandatory deductable amount

company is to settle the claim of Rs.226541. Claimant produced the Xerox copy of all the original

documents as original submitted to the company along with the claim and subsequently. On 10.01.2019

on the date of 1st hearing he submitted photocopy of all document and handed over one set of the

documents to the representative of insurance co. to follow up the case and 10 days time was given to

him to take up with TPA and settle the admissible amount.

As on the date of 2nd hearing on 23.01.2019 insurance co. neither settled nor informed about the

progress of the settlement of the claim. Under the circumstances and in order to ensure fairness to the

policy holder an amount of Rs. 226541/- less any mandatory deduction as per the policy conditions if any is

hereby awarded to be paid by the insurer , towards the full and final settlement of the claim.






the Ombudsman.

Dated at- Guwahati on the 10th Day of January 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE


OMBUDSMAN – K.B. SAHA. CASE OF: : Complainant MR. VIVEKANANDA BOSE VS UNITED INDIA INSURANCE CO LTD


1. Name & Address of the Complainant MR. VIVEKANANDA BOSE

2. Policy No:

Type of Policy


SPF NO.6346 & Health card no.HHS80700321737

Group Mediclaim Retired employee of UBI



Mr. Vivekananda Bose

4. Name of the insurer United Insurance Ins. co. Ltd.

5. Date OF OCCURANCE OF LOSS/CLAIM 23.08.2016 to 03.09.2016 , however on different dates

he was admitted in different hospitals.

6. DETAILS OF LOSS Rs.136955 + 221805/-


8.a

8.b

Nature of complaint


Mediclaim

18.12.2018

9. Amount of Claim Rs. 136955 + 221805/-


11 Amount of relief sought 136955 + 221805= 358760/-


13(1)(b)



For the Complainant Mr. Vivekananda Bose

For the insurer Ms. B.D. Upadhaya



17) Brief Facts of the Case: Insured submitted claim of Rs. 136955 + 221805=358760/- in two separate claims. Insurance

co. could not settle bill as claim was not submitted in time. InTPA letter dated 25/11/2017 it was mentioned that those

retiree’s United India Insurance Company had kept open the window till 10/01/2017 to submit the claim documents. As

per letter dated 10/01/2017 the claimant has submitted both the claims on 10th Jan 2017 which duly received by

Heritage Health Insurance TPA under seal & signature.

18a) Complainant’s argument: As a retired employee of UBI he had covered of Rs.400000 with United India

insurance and top up of Rs.600000 with National Insurance co. ltd. He submitted his 1st claim of Rs.136955

for Dangue treatment with TPA family health TPA of National insurance company. As basic Sum Assured has

not been utilized so National Ins. returned the claim.

He submitted his second bill of Rs.221805 with same TPA and on the same ground the TPA returned the

claim. When he submitted his both the claims to the Haritage Health ins TPA Pvt. Ltd. again on 10/01/2017

who is TPA of United India , by this time it was too late and on the ground of delayed submission his both

the claim rejected by the company.But as per the letter dated 25/11/2017 the last date was extended upto

10/01/2017 on which date he submitted both the claim & got the acknowledgement under seal & signature

of TPA.TPA returned one of his claim of Rs.136955 & since then there is no information about his second

claim of Rs.221805.

18b) Insurers’ argument: - Claim was not submitted as per the stipulated time as per policy conditions so

claim could not processed and settled.




hearing on 23.01.2019. The complainant Mr. Vivekananda Bose was present and the insurer was represented by Mr. B.D. Upadhaya.

DECISION



the course of hearing. We have also gone through the records. He has multiple claim of hospitalization

and it is observed that he has not submitted the claims in time to the United India insurance co.

Under the circumstances and in order to ensure fairness to the policy holders as well as to the insurance

co., from the record it has been observed that the claimant has submitted his both the claim on

10/01/2017 i.e. on last date of submission allowed by the Company. So non-submission of the claim in

due time to the insurance co could not be established. Hence the forum directs the insurance company

to settle both of his claims of Rs. 358760/- as per the policy condition as the total claim is within his sum

assured of Rs.400000/-. The Company is also directed to pay interest for delayed settlement of the

claim of the senior citizen @ 2% above Bank rate from 10/01/2017 to the date of payment.






the Ombudsman.

Dated at- Guwahati on the 23rd Day of January 2019.

K.B.Saha INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(Under Rule No.17(1) of the Insurance Ombudsman Rules, 2017)

COMPLAINT REF: NO: CHN-L-033-1819-0108

Shri T.B.Gopalan Vs PNB Metlife India Insurance Co.Ltd.

AWARD NO: IO/CHN/A/L/0138/2018-19

1. Name & Address of the Complainant Shri T.B.Gopalan,

No.104, Swati Apartment,

47,Gandhi Road,

Srirangam, Trichy-620006.

2. Policy No/SA /DOC /

Pol. Term/Prm. Paying Term

Premium/Mode

Type of Policy

Date of Death

Duration

22285842/639659/12.8.2017

10y/5y 1,50,000/yly

PNB Metlife Endowment Saving Plan Plus

11.11.2017

0y-2m-29days

3. Name of the insured Name of the Policy holder

Mrs.Radhaigopalan Mr. T.B.Gopalan

Name of the insurer PNB METLIFE INDIA Insurance Company

Limited

5. Date of Rejection 20.02.2018/27.03.2018

6. Date of receipt of the Complaint 19.04.2018

7. Nature of complaint Non-settlement of Death Claim


9. Date of Partial Settlement --

10. Amount of relief sought Rs. 20,00,000/-

11. Complaint registered under Rule 13(1) (b) of the Insurance Ombudsman

Rules,2017.

12. Date of calling SCN

Date of receipt of SCN

07.05.2018

01.08.2018

13. Date of hearing/place 19.11.2018/Chennai


a) For the Complainant Shri T.B.Gopalan

b) For the insurer Smt. Sarath Mala, Asst. Manager.

15. How the case disposed off Award

16. Date of Award 20.02.2019

17. Brief Facts of the Complaint:- The Complainant Shri T.B.Gopalan (the policyholder and

Husband of the Diseased Life Assured (DLA) Smt. Radhaigopalan) stated in his complaint letter that

he had taken a Life Insurance Policy for his wife from PNB Metlife India Insurance Company on

12.08.2017 (Policy No. 22285842) with a Sum Assured of Rs. 6,39,659/- by paying yearly premium

of Rs.1,50,000 under PNB Metlife Endowment Savings Plan Plus Scheme. Since the DLA died on

11.11.2017, the complainant approached the Insurer to settle the claim. But the Insurer has ordered

for claim investigation, since it is an early claim, in which death occurred within 3 months from the

date of inception of the policy. The claim was repudiated by the Insurer on the ground of non-

disclosure of the material fact that the DLA was suffering from Diabetes, Hypertension and Moderate

LV Dysfunction and has taken treatment before the inception of the Policy.

The Complainant further approached the Grievance Redressal Officer(GRO) of the insurer for

reconsideration of the claim. But the GRO also repudiated the claim vide their letter dated 20.02.2018

stating the reason of medical non-disclosure by the DLA. Hence the complainant has approached this

Forum with a request to order the insurer to settle the claim for full Sum Assured.

Insurer’s Version: The respondent insurer has stated in its Self Contained Note(SCN) dated 31.7.18,

that the DLA Smt. Radhaigopalan, misrepresented her medical history and with motive best known to

her , did not disclose the correct medical history in the proposal form.

The DLA had applied for a policy through the proposal dated 10.08.2017, after clearly understanding

the features, investment risks, charges, benefits and the terms and conditions. The insurer also issued

the policy on the basis of the material facts furnished in the proposal papers with the date of

commencement of the policy as 12.8.2017.

The Insurer stated further that the complainant intimated the death of the DLA on 11.11.2017 and

submitted the claim forms on 21.12.2017. Since the death claim had arisen within 3 months from the

date of commencement of the policy, the insurer conducted Claim investigation and found that the

DLA had not disclosed her pre-proposal illness details and related treatment particulars. Hence the

Insurer repudiated the claim vide their letter dated 20.02.2018 on the ground of concealment of

medical history at the inception of the policy by the DLA.

The Insurer also submitted that the investigation Report revealed that the DLA was a known case of

DIABETES, HYPERTENSION for last 10 years and was under regular medication. The medical

reports also suggested that the blood sugar levels of DLA were dangerously high. The Insurer

submitted the discharge Summary of Eswara Hospital dated 8.6.2017, which recorded that the DLA

was experiencing chest pain, profuse sweating and difficulty in breathing and she had been admitted

and taken treatment from 06.06.2017 to 08.06.2017.

The Insurer has also submitted the relevant medical records/documents obtained from Q-Med

Hospital, 25, Officers’ Colony, Puthur, Trichy where the DLA has taken treatment from 20.10.2017 to

01.11.2017. Thereafter the DLA was admitted in the Bharat Heavy Electricals Limited Hospital,

Trichy from 01.11.17 to 10.11.17. After that the DLA was referred to Neuro One Hospital at Trichy

where the she died on 11.11.17, cause of death being Pontine infarct/DM/HT/Pneumonitis.

The Insurer prayed before the Forum to dismiss the instant complaint in the light of the documentary

evidences which prima facie established a case of non-disclosure of pre-existing illness of Coronary

Artery disease and a history of Systematic Hypertension since 10 years.

18) Reason for Registration of Complaint: This is a case of repudiation of death claim and comes

within the scope of Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017.

19)The following documents were submitted to the Forum for perusal.

a) Complainant’s letter dated 15.04.2018 to this Forum.

b) Annexure VI A submitted by the complainant

c) Copy of the proposal form and Policy schedule.

d) Claim rejection letters dated 20.02.2018 and 27.03.2018

e) Discharge Summary issued by Easvara Hospital, Tallakulam, Madurai.

f) Discharge Summary issued by Q-Med Hospital, Puthur, Trichy.

fg Death summary issued by the Neuro One Hospital, Trichy.

gh BHEL Hospital Records with blood sugar level readings and the medication details.

i) Insurer’s Self Contained Note (SCN) dated 31.07.2018

20) Result of hearing with both parties (Observations & Conclusion): Based on the submissions

of both the parties made during the hearing and documents submitted, it is observed as under:

1) The Complainant Shri T.B.Gopalan had taken a Endowment Savings Plan Plus policy on

the life of his wife Smt. Radhaigopalan by submitting a proposal on 10.08.2017 and the

proposal is duly witnessed by Shri T.B.Gopalan. The Policy is taken from PNB Metlife

India Insurance Company Ltd with date of commencement of policy as 12.02.2017.

2) The above policy resulted in death claim due to the demise of the DLA Smt. Radhaigopalan

on 11.11.2017.

3) Easvara Hospital , Tallakulam, Madurai reported that the DLA was admitted in the hospital

from 06.06.17 to 08.06.2017 and taken treatment for Chest pain associated with profuse

sweating/difficulty in breathing . The above report also confirms that the DLA was a

known case of Diabetes Mellitus (DM)/Systemic Hypertension (SHT), on treatment for the

past 10 years. In Final Diagnosis it was mentioned that she was suffering from “ CAD

ACS A/C AWMI./DIABETES/HYPERTENSIVE/MODERATE LV DYSFUNCTION”.

4) Medical records of BHEL Hospital, Trichy clearly established the Blood Sugar levels of

DLA in the years 2016 and 2017(prior to proposal dates) and that DLA was suffering

from and taking treatment for Diabetes.

5) The DLA and the complainant have both concealed the above facts and given incorrect

answers to Question Nos. E.3 and E.4 in the proposal form concerning medical details and

the additional medical details.

Q.No.E.3: Medical Details.

E.3.1.: High Blood Pressure, Chest Pain, Angina, Heart Attack or

any other ailment pertaining to the Heart or Circulatory System?

E.3.7. :Diabetes, Thyroid or any other Gland Related Disorders?

E.3.13. During the past five years,

a) Have you consulted any doctor or health practitioner for illness lasting

for more than 4 days except for fever, common cold or cough?

Q.No.E.4.: Have you been or are you suffering from any other illness, injury

disease condition or have undergone medical examination:

For all the above questions the DLA has answered in the negative. It is the

submission of the insurer that if the material information was disclosed in the application

form, they would not have issued the policy at all.

6) Hence insurer’s decision to reject the death claim for the reason of material non-disclosure

is in order.

In this case the date of calling the policy in question being 20.02.2018 (date of repudiation

of claim) and duration of the policy being less than 3 years , it is governed by provisions of

Section 45 of Insurance Act, 1938 (as amended on 26.12.2014). Since the insurer

repudiated the liability under the policy on grounds of non-disclosure and not on the ground

of “fraud”, provisions contained in Section 45(4) apply to this case. In terms of IRDAI’s

instructions dated 28.10.15 and provisions contained in Section 45(4) of Insurance Act,

1938, the premiums collected under the policy till the date of repudiation shall be

refundable within a period of 90 days from the date of repudiation. The DLA had paid only

one premium of Rs. 1,50,000/- on 17.8.2017 under the subject policy, and hence the insurer

should refund the said amount to the complainant and also pay interest thereon from the

due date of payment to the date of refund of premium.

AWARD

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

both the parties during the course of hearing, this Forum is of the view that the Insurer’s

decision to repudiate the liability under Policy No.22285842 due to non-disclosure of material

fact is justified and does not warrant any interference.

The respondent insurer is, however, directed to refund the premium of Rs.1,50,000/- to the

complainant as per section 45(4) of the Insurance Act, 1938 and in addition pay interest from

due date of payment to date of settlement as per Rule 17(7) of the Insurance Ombudsman Rules,

2017 .

The Complaint is, therefore, not allowed.

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

the Insurance Ombudsman Rules, 2017:

a. As per Rule 17(6) of the Insurance Ombudsman Rules, 2017 the Insurer shall

comply with the Award within 30 days of the receipt of the award and intimate

the compliance of the same to the Ombudsman.

b. As per Rule 17(7) of the said rules the complainant shall be entitled to such

interest at the 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. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be


Dated at Chennai on this 20th day of February, 2019.

(M.VASANTHA KRISHNA)

INSURANCE OMBUDSMAN

STATE OF TAMIL NADU & PUDUCHERY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU &PUDUCHERRY



M.Umarani Vs Max Life Insurance Company Limited



Complainant

Smt.M.Umarani,

53,Teachers’ colony, Papparapatty post,

Pennagaram Tk. Dharmapuri- 636809.

2. Policy No/SA /DOC /

Pol. Term/Prm. Paying Term

Premium/Mode

Type of Policy

Date of Death & Cause

Duration

260873831/Rs.500000/16.2.15

20y/11y

Rs.13825/- - Annual mode

Max Life Premium Return Protection Plan

10.01.2017 – Heart Attack

1year 10months and 24 days


Name of the Policy holder

Shri K.Deivakumar

Shri K.Deivakumar

Name of the insurer Max Life Insurance Company Limited

5. Date of Rejection 30.06.2017, 09.07.18 & 20.07.18

6. Nature of complaint Non-settlement of Death Claim



9. Date of Partial Settlement --

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


Rules, 2017.



05.09.2018

14.11.2018



c) For the Complainant Smt, M.Umarani

d) For the insurer Shri K.Chandrasekhar,


16. Date of Award 20.02.2019

17. Brief Facts of the Complaint:- The Complainant Smt.M.Umarani (wife of the Deceased Life

Assured Shri K.Deivakumar) submitted that her husband had taken a Life Insurance Policy (Policy

No. 26087383) from Max Life Insurance Co. Ltd on 12.08.2017, with a Sum Assured of

Rs.5,00,000/- by paying yearly premium of Rs.13,825/- under Max Life Premium Return Protection

Scheme. Since the DLA died on 10.01.2017, the complainant approached the Insurer to settle the

claim. The Insurer ordered for claim investigation, since it is an early claim, in which death occurred

within 2 years from the date of inception of the policy. Later, based on the findings of the

investigator, the claim was repudiated by the insurer on the ground of non-disclosure of the material

fact that the DLA was suffering from Diabetes Mellitus with Psychosis since 2013 which is prior to

signing the proposal form.

The Complainant further approached the Grievance Redressal Officer(GRO) of the insurer for

reconsideration of the claim . But the GRO upheld repudiation of the claim vide their letter dated

20.07.2018 for the same reason of medical non-disclosure by the DLA. Hence the complainant has

approached this Forum with a request to order the insurer to settle the death claim.

Insurer’s Version: The insurer has stated in its Self Contained Note(SCN) dated 14.11.2018, that

DLA Shri K. Deivakumar withheld relevant information and provided wrong and false information to

them with malafide intention of grabbing the sum assured.

The DLA had applied for a policy through the proposal dated 16.02.2015, after clearly understanding

the features, investment risks, charges, benefits and the terms and conditions. The Insurer also issued

the policy on the basis of the material facts furnished in the proposal papers with the date of

commencement of the policy as16.02.2015.

The Insurer stated further that the complainant intimated the death of DLA and submitted the death

claim forms. Since the claim has arisen within 2 years from the date of commencement of the

policy they conducted claim investigation through Sri Guru Raghavendra Associates, Chennai.

The investigation revealed that the DLA was a compulsive drinker and was under treatment for

Diabetes and Psychosis since 2013 and also suffering from Chronic Bronchitis. The DLA had

deliberately not disclosed these pre-proposal illness details and related treatment particulars in the

proposal and if the above stated facts been disclosed to the insurer, the policy would not have been

issued.

Hence the Insurer repudiated the claim vide their letter dated 20.07.2018 on the ground of

concealment of material medical history at the inception of the policy by the DLA.

The Insurer has also submitted the relevant medical records/documents obtained from the following

hospitals wherein the DLA has taken treatment.

1. Pranitha Hopital, Dharmapuri

2. Ammakannu Memorial Hospital, Dharmapuri

3. Manipal Hospital, Salem.

The Insurer therefore requested the Forum to dismiss the instant complaint in the light of the

documentary evidences which prima facie established a case of non-disclosure of pre-existing illness

of Diabetic Mellitus with Psychosis and Chronic Bronchitis .




a) Complainant’s Letter dated 20.08.2018 to this Forum.

b) Copy of the Proposal Form and Policy Schedule.

c) Records of Pranitha Hospital, Dharmapuri, Manipal Hospital, Salem and Ammakannu Hospital,

Dharmapuri

d) Investigation Report of Sri Guru Ragavendira Associates.

e) Insurer’s Self Contained Note (SCN) dated 14.11.2018

f) Claim Repudiation letters dated 30.06.17 and 20.07.2018.

g) Annexure VI A submitted by the complainant



1. The Complainant’s husband and the Insured Mr. K.Deivakumar had covered himself under

Max Life Premium Return Protection plan of the insurer by submitting a proposal on

16.02.2015. The policy resulted in death claim due to the demise of the DLA Shri

K.Deivakumar on 10.01.2017. Investigation carried out by the insurer revealed that the DLA

has taken treatment for the Diabetic Mellitus and Psychosis and Chronic Bronchitis prior to

the issuance of the policy from the following three Hospitals since 2013.

a. Pranitha Hospital, Dharamapuri (Dr. Arumugam Kannan’s Prescription and Lab

report which shows high level of sugar:- fasting- 232, Post Prandal – 335).

b. Ammakannu Memorial Hospital (Sep.2013) recording details of. Out-patient

treatment taken from Dr.V.Shanmugam,

c. Manipal Hospital, Salem, which records details of Out-patient treatment taken from

pulmonologist. (Feb.2013)

2. The above treatment particulars were suppressed from the insurer at the time of proposal by

answering “NO” to the questions No. 3(iii) and (iv) in the proposal form. The details of the

same are given below:-

Q.No.3: Have you been investigated, treated or diagnosed with any of the following

conditions. If Yes, Please provide details including Doctor’s name and dates (or attach

relevant Questionaire)

iii) Diabetes - NO

iv) Asthma, Bronchitis, tuberculosis, persistent cough, shortness

of breath or any other respiratory conditions. - NO

3. The death claim was repudiated on the basis of the above medical non-disclosure vide

insurer’s letter dated 30.06.2017 and the decision was reiterated on 20.07.2018, in response to

the grievance representation of the complainant.

4. The repudiation was as per para 9.6 - Fraud of the Terms and Conditions, which reads as

under:

“9.6 FRAUD

9.6.1. If You or anyone acting at Your direction or within Your knowledge, or any person

under or in respect of this Policy makes or advances any claim knowing it to be false or

fraudulent in any way, then We will cancel this Policy immediately by paying the

Surrender Value, if any, subject to such fraud being established by Us in accordance with

Section 45 of the Insurance Act”.

However, while responding to the representation made by the complainant, the insurer

cited clause 9.5.1 of the Terms and conditions of the Policy, reading as under.

9.5.1 – “Insurance is a contract of utmost good faith and we rely and trust upon your

representations. This policy has been underwritten and issued by us based on the

information provided by you in/with the proposal from. In case of any concealment, non-

disclosure, fraud or misrepresentation, we shall cancel the policy immediately by paying

the surrender value if any, subject to such concealment, non-disclosure, fraud or

misrepresentation being established by us in accordance with Section 45 of the Insurance

Act.”

Notwithstanding the repudiation of claim on the ground of fraud, the insurer offered

to refund the premium collected under the policy as per Section 45(4) of the

Insurance Act, 1938. Based on this action of the insurer, the Forum concludes that

the intention of the insurer was to reject the claim under section 45(4) on the ground

of non-disclosure and not under Section 45(2) on the ground of fraud.

5. During the hearing, the complainant informed that her husband’s health conditions was

informed to the agent at the inception of the policy, but the agent had not filled in the details

in the proposal form. The Forum does not consider this as a tenable argument and is of the

opinion that the DLA failed in his duty of disclosure.

AWARD





The respondent insurer is, however, directed to refund the premium of Rs.27,650/- to the

complainant as per Section 45(4) of the Insurance Act, 1938 .




d. As per Rule 17(6) of the Insurance Ombudsman Rules, 2017 the Insurer shall



e. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be




INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU &PUDUCHERRY



A.Pitchaiammal Vs Max Life Insurance Company Limited



Complainant

Smt.Pitchaiammal,

Plot No.90, Club Road,

GS Pillai Nagar, Mettu Bungalaw

Kadampadi, Nagapattinam-611001.

2. Policy No/SA /DOC /Pol.

Term/Premium Paying Term

Premium/Mode

Type of Policy

Date of Death & Cause

Duration

715978771-Rs.500040-28.03.2016

10years/5years

Rs.50,004/- - Yearly Mode

Max Life Fast Track Super – Ulip policy

25.08.2017 – Cancer

1y 4m and 27 days


Name of the Policy holder

Shri K.Anbazhagan

Shri K.Anbazhagan

4. Name of the insurer Max Life Insurance Company Limited

5. Date of Rejection 24.12.17, 31.03.2018 and 24.07.2018


7. Nature of complaint Repudiation of Death Claim


9. Date of Partial Settlement Rs. 50,010/- on 16.01.2018 through NEFT

Rs. 50,004/ by chq. dated 4.7.2018 – returned

sinceDLA’s name was written on the cheque.

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


Rules, 2017



05.09.2018

14.11.2018



e) For the Complainant Shri G.Jayapalan (Complainant’s father)

f) For the insurer Shri V.Chandra Sekhar


16. Date of Award 20.02.2019

17. Brief Facts of the Complaint:- The Complainant Smt. A.Pitchaiammal, wife of the Deceased

Life Assured(DLA) Shri K.Anbazhagan informed the Forum that her husband had taken a Life

Insurance Policy (Policy No.0715978771) from Max Life Insurance Co. Ltd on 28.03.2016, with a

Sum Assured of 5,00,040/- by paying yearly premium of Rs.50,004/- under the Max Life Track

Super Scheme. Since he died on 25.08.2017 due to cancer, the complainant approached the Insurer

to settle the death claim. But the Insurer repudiated the claim for alleged non-disclosure of the

material fact of DLA suffering from Lung Cancer prior to the issuance of policy and undergoing

treatment at Cancer Institute, Chennai . The Complainant further approached the Grievance Redressal

Officer (GRO) of the insurer for reconsideration of her claim. But the GRO also repudiated the claim

vide their letter dated 20.07.2018 stating the same ground. Hence the complainant has approached

this Forum with a request to order the Insurer to settle the death claim.

Insurer’s Version: The respondent insurer stated as follows in its Self Contained Note(SCN) dated

14.11.2018.

The DLA had applied for a policy through the proposal form dated 24.03.2016, after clearly

understanding the features, investment risks, charges, benefits and the terms and conditions. The

Insurer also issued the policy on the basis of the material facts furnished in the proposal papers with

the date of commencement of the policy of 28.03.2016.

The Insurer stated further that the Complainant had intimated the death of the DLA and submitted the

claim forms. The Insurer conducted claim investigation through Sri Guru Raghavendra Associates,

Chennai.

The investigation revealed that the DLA was under treatment for Lung Cancer Stage – IV with

Cancer Institute, Chennai since 16.01.2015, which is prior to the commencement of policy and was

under continuous treatment even on the date of purchase of policy, which information he withheld

from the insurer at the time of proposal. As such the claim was repudiated by the insurer on the basis

of medical non-disclosure.

The insurer claimed that the DLA had deliberately not disclosed his above pre-proposal illness details

and related treatment particulars and if the above stated facts been disclosed to the insurer, the policy

would not have been issued.

Hence the insurer repudiated the claim vide their letter dated 24.12.17, 31.03.2018 and 24.07.2018 on

the ground of concealment of medical history at the inception of the policy by the DLA.

The Insurer also submitted the following relevant medical records/documents of treatment taken by

DLA, obtained through Sri Guru Raghavendra Associates, the investigating agency.

4. Discharge Summary of Park Hospitals, Nagapattinam –

Date of Admission: 19.4.2017 , Date of Discharge : 22.4.2017

Provisional Diagnosis: Cancer Lungs.

5. Cancer Institute (WIA), Chennai

Date of consultation: 16.01.2015 Diagnosis : Cancer Lungs Stage IV.

The Insurer therefore requested the Forum to dismiss the instant complaint in the light of the

documentary evidences which prima facie established a case of non-disclosure of pre-existing illness

of Lung Cancer Stage-IV by the DLA.




a) Complainant’s Letter dated 28.05.2018 to this Forum

b) Copy of the Proposal Form and Policy Schedule

c) Claim rejection letters dated 24.12.2017, 31.03.2018 and 24.07.2018

d) Investigation Report of Sri Guru Ragavendira Associates

e) Cancer Institute, Chennai – Case summary dated 30.11.2017

f) Park Hospital, Nagapattinam - Discharge summary dated 22.04.2017

g) Insurer’s Self Contained Note (SCN) dated 14.11.2018

h) Written submissions on behalf of the complainant at the hearing dt. 19.11.2018



7) The Complainant’s husband and the Insured Sri. K.Anbazhagan covered himself under

Max Life Fast Track Super Plan by submitting a proposal on 24.03.2016. The Policy

was taken from Max Life Insurance Company Ltd with date of commencement of policy

as 28.03.2016.

8) The policy resulted in early death claim due to the demise of the DLA on 25.08.2017,

when the policy had run a for a period of only 1 year, 4 months and 27 days. Investigation

arranged by the insurer revealed that the DLA had been diagnosed and treated for Cancer

Lungs Stage IV since 16.01.2015 at the Cancer Institute (WIA), Adyar, Chennai.

9) The said medical treatment particulars were not brought to the information of the Insurer at

the time proposal, and by answering “NO” for the questions No. 3(iii) and (iv) in the

proposal form, the DLA suppressed the same from the insurer. The details of the above

questions are given below:-

Q.No.3: Have you been investigated, treated or diagnosed with any of the following

conditions. If Yes, Please provide details including Doctor’s Name and Dates (or attach

relevant Questionnaire)

iii) Diabetes - NO

iv) Cancer, lungs - NO

10) The death claim was repudiated on the basis of the above medical non-disclosure vide

letters dated 24.12.17, 31.03.2018 and 24.07.2018. While the letter dated 24.12.2017 is the

original repudiation letter, the other two letters were addressed by the insurer to the

complainant, in response to her representation to reconsider the decision to reject the claim.

11) As per letter dated 24.12.2017, rejection of claim for non-disclosure was in terms of

clause 11.11 of the policy which reads as under:

“11.11 FRAUD, MISREPRESENTATION AND FORFEITURE

Fraud, misrepresentation and forfeiture would be dealt with in accordance with provisions

of Section 45 of the Insurance Act, 1938, as amended from time to time”

The insurer did not allege fraud on the part of the DLA but invoked non-

disclosure/suppression of facts material to the life expectancy of the DLA as per Section

45(4) to reject the claim. They also confirmed that the policy would not have been issued

if the said facts were disclosed at the underwriting stage.

12) In accordance with Section 45(4), the insurer also offered to refund the premium paid by

the DLA.

13) In her correspondence with the insurer, the Complainant stated that the DLA had taken

only Ayurveda Treatment and hence she did not have any medical records. Also, during

the hearing the complainant’s father who represented her had informed that his son-in-law

was in good health at the time of taking the policy. However, both these averments are

proved to be wrong based on the documents and evidence placed before the Forum.

14) The Forum also received independent confirmation from Cancer Institute, , Chennai, that

the DLA had taken treatment there from April, 2015 and he was diagnosed as Carcinoma

Lung, Adenocarcinoma , Stage IV (Contralateral lung nodules). Carcinoma lung

bronchoscopic biopsy was done on 23.01.2015.

9) Based on the evidence placed before it, the Forum is of the opinion that the Insurer’s

decision to reject the death claim for the reason of material medical non-disclosure is in

order.

10) The insurer has collected two annual premiums from the DLA, but refunded only one

premium to the complainant through NEFT on 16.01.2018, consequent to their offer to

refund the premium. The other premium of Rs. 50,004/- was issued as a cheque payment

in the name of DLA on 04.07.2018 and hence returned by the Complainant.

AWARD





The respondent insurer is, however, directed to refund the premium of Rs.50,004/- to the

complainant, in case the amount is not already paid and in addition pay interest from the due

date to the date of payment as per Rule 17(7) of the Insurance Ombudsman Rules, 2017 .




f. As per Rule 17(6) of the Insurance Ombudsman Rules, 2017 the Insurer shall



g. As per Rule 17(7) of the said rules the complainant shall be entitled to such

interest at the 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.

h. As per Rule 17(8) of the said rules, the award of Insurance Ombudsman shall be




INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(UNDER RULE NO: 17 (1) OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M.VASANTHA KRISHNA

CASE OF: G.LATHA Vs ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. REF: NO: CHN-L-021-1819-0369

AWARD NO: IO/CHN/A/LI/0128/2018-19

1. Name & Address of the Complainant Ms G.Latha

W/o (late) Murali Sai.N

Flat C-20, Anmol Abhinandan Apartments,

First Main Road, Seshadripuram Baby Nagar,

Velachery,

Chennai-600 042

2. Policy No.

Sum Assured

DOC

Type of Policy

Mode of payment of premium

Instalment Premium

19276091

Rs. 10,10,000

20/04/2015

ICICI Pru Wealth Builder II

Yearly

Rs. 1,01,000

Policy term & Premium Paying term

Date of death of the Life Assured (LA)

Duration of the policy @ 11/02/18

Total Premiums paid

Status of the policy

10/5 years

11/02/18

2Y 9M & 21D

Rs. 3,03,000

Force

3. Name of the Life Assured

MURALI SAI N

4. Name of the insurer ICICI Prudential Life Insurance Company Limited

5. Date of Repudiation First level: 24/04/18

Final level: 22/06/18

6. Reason for repudiation

Suppression of material facts in the Proposal

7. Date of registration of the complaint 05/09/18

8. Date of receipt of Annexure VI-A 17/09/18

9. Nature of complaint Non-settlement of Death claim

10. Amount of Claim (as per policy)

A or B or C whichever is higher:

A=SA including Top-up SA, if any

B=Fund value including Top-up fund value, if any

C=Minimum death benefit

11. Date of Partial Settlement Rs. 3,13,634.70 (Total Fund value) on 31/05/18

12. Amount of relief sought Rs. 10,00,000

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

14. Date of hearing & Place of hearing 19/11/18 & Chennai

15.

Representation at the hearing

a) For the complainant Ms G.Latha (Complainant)

b) For the insurer Shri N.Ravikumar,

ICICI Prudential Life Insurance Co. Limited, Chennai

16. Complaint how disposed By Award

17. Date of Award 19/02/2019


The Deceased Life Assured (late) Murali Sai N, the complainant’s husband, took a policy

(No. 19276091) for Rs. 10.10 lakhs from ICICI Prudential Life Insurance Company Limited,

herein the insurer. The policy resulted into death claim on 11/02/18 and duration of the

policy was 2 years 9 months and 21 days from the date of commencement of risk.

Thereupon, Ms G.Latha, the complainant herein, who is also the nominee under the policy,

staked her claim under the policy. The insurer, vide its letter dated 24/04/18, informed the

complainant that liability under the policy was repudiated on account of suppression of

material fact in the proposal by the DLA while proposing for insurance. Not satisfied with the

decision, the complainant preferred an appeal to Grievance Redressal Committee of the

insurer. The Grievance Redressal Committee reviewed the case and was satisfied with the

decision taken by the company. Nevertheless, the insurer credited total Fund value

amounting to Rs. 3,13,634.70 under the policy to her bank account on 31/05/18. Still

aggrieved, the complainant has filed this complaint.


a) Complainant’s argument:

The complainant states that in November 14, her husband successfully underwent partial

glossectomy which was non-tumourous. She further states that the policy was not taken

“on-line”, as claimed by the insurer. It is her contention that information relating to Section-I

of the proposal form alone was sought at the time of taking the policy and wrong information

was given under Q nos. 2a, 5c and 5d of the proposal form. Her stand is that the DLA

underwent test/investigation in the year 2014 followed by surgery in the same year. The

complainant adds that in August 2016, he again underwent surgery as his pain relapsed and

he was diagnosed of cancer. The complainant further adds that from December 16 to

February 17, the DLA had undergone several radiotherapy and chemotherapies in Kauvery

Hospital and the expenses thereto were covered by ICICI Lombard. The complainant

concluded with a request to pay the sum assured under the policy. During hearing, the

complainant submitted that the DLA was not informed about the need to disclose health

particulars in the proposal form. She added that even the details of height of the DLA were

wrongly mentioned in the proposal. She further added that no written communication was

received from the insurer regarding the amount credited into her account and also workings

regarding fund value.

b) Insurers’ argument:

The policy was issued based on the information provided by the DLA in the

application/proposal form (electronically generated application/proposal form) and policy

document was dispatched to him on 21/04/15 along with copy of the proposal form. After

careful evaluation of the medical records obtained during claim assessment, it was noted

that the DLA had past history of left Hemiglossectomy for cancer tongue in November 2014

for which he was hospitalized on 23/11/14, diagnosed of carcinoma tongue and underwent

left partial glossectomy. Even though all these were prior to submitting his proposal, he didn’t

disclose the medical adversities at the time of availing the policy. It is the duty of the

proposer/life assured to disclose the material information regarding his state of health at the

time of availing the policy for underwriting. While forwarding the policy document to the DLA,

copy of the proposal form was sent to him for verification of the replies given to various

questions in the proposal form and revert to the company in case any reply was wrong or

wrongly recorded. The DLA, however, never approached the company stating that answers

to the questions were wrongly recorded. The DLA, in fact, deliberately misled the company

to accept the proposal by concealing material information and furnishing false information in

the proposal form. This being so, the claim put forth by the complainant was rejected, vide

letter dated 24/04/18. However, applicable surrender value of Rs. 3,13,634.70 was credited

into her bank account on 31/05/18. The GRC considered her representation but upheld the

repudiation decision.

20) Reason for Registration of Complaint: This is a case of repudiation of claim and

hence, comes within the scope of Rule 13 (1) (b) of the Insurance Ombudsman Rules, 2017.

21) The following documents were submitted to the Forum for perusal.

a) Proposal form dated 18/04/15 b) Customer Declaration Form (CDF) dated 18/04/15 c) Policy Certificate dated 20/04/15 d) Discharge summary of Apollo Speciality Hospitals, Chennai e) Histopathology report dated 27/11/14 f) Discharge summary of Premji Neuro Hospital, Vellore g) Repudiation letter dated 24/04/18 h) E mail dated 22/06/18 of the insurer i) Complaint dated 21/08/18 to the Forum j) Annexure VI-A dated Nil submitted by the complainant k) Self Contained Note (SCN) dated 09/10/18 of the insurer 22) Result of hearing with both parties (Observations & Conclusion): Based on the

submissions of both the parties made during the hearing and the documents submitted, it is

observed as under:

a) The case of the insurer, as per letter dated 24/04/18, is that the DLA, at the time of

availing the policy gave false answers to Q nos. 5 (c) (d) & (f) (ii) of Section III of the

“Proposal form for single life” dated 18/04/15. The insurer’s stand is that the DLA was

hospitalized on 03/11/16 with past history of left Hemiglossectomy for cancer tongue in 2014

and prior thereto also, the DLA was hospitalized on 23/11/14 & diagnosed of carcinoma

tongue and underwent left partial Glossectomy.

b) The relevant questions where under the DLA made mis-statements in the proposal form,

as per the repudiation letter dated 24/04/18, and the replies given by the DLA are as under:

5 (c): Have you undergone or been advised to undergo any tests or investigations in the last 5 years? No

5 (d): have you ever undergone or been advised any surgery or hospitalized for observation or treatment in the past? No

5 (f): Have you ever suffered or been diagnosed or been treated for any of the following:

ii) Cancer, tumour, growth, polyps or cysts? No

c) In repudiating liability under the policy, the insurer relied upon the “Discharge Summary of

Apollo Speciality Hospital, Chennai”, “Histopathology report dated 27/11/14 of Apollo

Speciality Hospital, Chennai” and also, “Discharge Summary of Premji Neuro Hospital,

Vellore”. The said records were perused and following are the observations of the Forum:

i) According to the Discharge Summary of Apollo Speciality Hospital, Chennai, the DLA

underwent left partial Glossectomy on 24/11/14 during the period of his hospitalization from

23/11/14 to 26/11/14 (pre-proposal period). The discharge summary mentions the diagnosis

as “Carcinoma Tongue”.

ii) Histopathology report dated 27/11/14 (pre-proposal period) of Apollo Speciality Hospital

records the following impressions-“Well differentiated (Grade II) squamous cell carcinoma,

left side, tongue”, “Moderate to severe dysplasia involving posterior and lateral mucosal lines

of resection” and “Deep line of resection and medial and anterior mucosal lines of resection-

negative for tumor”.

iii) Discharge Summary issued by Dr. G.Prem Kumar, Consultant Neurosurgeon of Premji

Neuro Hospital relates to the period of treatment from 02/01/18 to 13/01/18 (post-proposal

period). The discharge summary reveals that the DLA who was admitted with the history of

upper neck swelling and pain, was diagnosed of “Recurrent Squamous cell carcinoma” and

underwent “Trepezius subcutaneous skin flap” surgery on 11/01/18. As regards “past

medical history”, it is mentioned that the DLA underwent left Hemiglossectomy for CA in a

private hospital in the year 2014.

iv) All these documents prove the following: Prior to his proposing for insurance, the DLA

was diagnosed of “Carcinoma Tongue” in November 14 and underwent left partial

Glossectomy on 24/11/14 in a hospital. It is also observed that he underwent Histopathology

test on 24/11/14 in a hospital.

v) Nevertheless, while availing the policy, the DLA didn’t truthfully disclose these details

while replying to Q nos. 5 (c) (d) (f-ii) of the “Proposal form for single life” dated 18/04/15

which was filled on-line.

The insurer’s stand is that it received duly signed Customer Declaration Form (CDF) dated

18/04/15. The insurer, in its SCN, stated that in the said CDF, the DLA gave a declaration

that he answered all questions truly & completely after understanding the nature of questions

asked and further declared that he had not withheld any material information and agreed that

the company holds the right to repudiate the claim in case of suppression of material facts or

mis-statement.

vi) Principle of utmost good faith (Uberrimae fidei) is a very basic and first primary principle

of insurance. According to this principle, the insurance contract must be signed by both the

parties (i.e. insurer and insured) in absolute good faith or belief or trust. The person getting

insured must willingly disclose to the insurer his/her complete true information

regarding the subject matter of insurance. As a corollary, the insurer's liability gets void if

any facts, about the subject matter of insurance are either omitted, hidden, falsified or

presented in a wrong manner by the insured.

vii) Based on the above documents and submissions made during the hearing, this Forum is

of the view that the insurer proved its stand, with hospital records, that the complainant had

pre-proposal illness prior to his taking the policy.

d) i) The policy resulted into claim on 11/02/18 which was subsequent to the amendment

made to Section 45 of the Insurance Act, 1938. The insurer repudiated the claim on account

of non-disclosure of correct medical history by the DLA in the proposal for insurance. The

insurer communicated its decision (regarding repudiation of the claim) to the claimant, herein

the complainant, vide its letter dated 24/04/18. In other words, the insurer called the policy

into question (for suppression of material facts) on 24/04/18. The risk commencement date

being 20/04/15, it is manifest that the insurer called the policy into question after expiry of

three years from the date of commencement of risk under the policy.

ii) Section 45 (1) of the Insurance Act, 1938 stipulates that no policy of life insurance shall be

called into question on any ground whatsoever after the expiry of three years from the date

of the policy, herein the date of commencement of risk. In short, no life insurance policy shall

be called into question on any ground after three years of commencement of risk.

iii) This being so, this Forum is of the opinion that the insurer’s repudiation of liability under

the policy after the expiry of the three year period from the date of commencement of risk is

in violation of provisions contained in Section 45 (1) of the Insurance Act, 1938 and hence,

the repudiation is not sustainable. The complainant is, therefore, entitled to full death claim

as per the terms and conditions of the policy.

23)

AWARD

Taking into account the facts and circumstances of the case & the submissions

made by both the parties during the course of hearing, this Forum is of the view

that the Insurer’s decision to repudiate the liability under Policy (no. 19276091) is

not justified and hence, warrants interference.

The insurer is, therefore, directed to settle the claim of the complainant for

Rs. 10,10,000, for the eligible amount as per the terms and conditions under the

24) The attention of the complainant and Insurer is hereby invited to the following provisions

of the Insurance Ombudsman Rules, 2017.

a) According to Rule 17 (6) of the Insurance Ombudsman Rules, 2017, the Insurer shall

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

the compliance 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 IRDAI 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 the

Insurance Ombudsman shall be binding on the Insurer.

Dated at Chennai on this 19th day of February 2019.


INSURANCE OMBUDSMAN STATE OF TAMIL NADU & PUDUCHERY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SMT. SANDHYA BALIGA

CASE OF SANJAY KULSHRESTHA V/S MAX BUPA HEALTH INSURANCE CO. LTD. NEW

DELHI

COMPLAINT REF: NO: NOI-G-031-1819-0150

AWARD NO:

1. Name & Address of the Complainant Sanjay Kulshrestha

R/O K-981, Sector 23, Sanjay Nagar,

Ghaziabad ,U.P-201001

2. Policy No:

Type of Policy


30700077201700

Health Insurance Policy

19.09.2017-18.09.2018



Sanjay Kulshrestha

Sanjay Kulshrestha

4. Name of the insurer Max Bupa Health Insurance Co. Ltd., N.Delhi


6. Reason for repudiation P.E.D.


8. Nature of complaint Denial of cashless payment


10. Date of Partial Settlement None

11. Amount of relief sought Rs.72,686


IOB rules

13 (1) (b)

13. Date of hearing/place 21.02.19 at Noida


g) For the Complainant Mr. Sanjay Kulshreshtha. Self

h) For the insurer Mr. Bhuwan Bhaskar, Manager Legal

15 Complaint how disposed Award in the favour of complainant


17. Brief Facts of the Case:- This complaint is filed by Mr. Sanjay Kulshrestha against Max Bupa Insurance

Company Limited for denial of cashless payment of claim and non-payment on reimbursement basis.

18. Cause of Complaint:-

Complainant’s argument : The complainant had purchased Health Insurance cover from Max Bupa vide

Policy No. 3070077201700 for the period from 19.09.2017 to 18.09.2018 for the sum insured of Rs. 3,00,000/-

(Rupees Three lacs only). At the time of taking the policy the complainant was in good health condition and the

same was certified in Annexure B (copy of medical questions). On 06.06.2018 the complainant whilst on office

duty, suddenly got indisposed and was brought to Max Super Speciality Hospital, Vaishali, Ghaziabad and was

admitted there with the complaint of giddiness with multiple episode of vomiting and inability to walk. After

completion of treatment including necessary tests, he was discharged from the hospital on 8.6.2018. The bill for

the above hospitalization and treatment including medicines amounting to Rs. 72,686/-.

After getting Pre-authorization request dated 7.6.2018 for cashless treatment, the Insurance Company had

approved the same vide Letter of Authorization dated 7.6.18 addressed to the hospital, approving the claim

amount of Rs. 54,000/- but on 8.6.18 they again sent a letter for denial of authorization to the hospital for

cashless payment. The complainant requested the Insurance Company to reimburse the amount of Rs. 72,686/-

towards his hospitalization but the Company refused to pay the claim amount on frivolous grounds.

Insurer’s argument:- The insurance company in their SCN dated 26.10.2018 has explained that the

complainant had been admitted in the hospital from 06.06.18 to 08.06.18 and was diagnosed with complaints of

giddiness with multiple episode of vomiting and inability to walk. The Company had received pre-authorization

request for cashless treatment from Max Hospital, Vaishali for the treatment of Transient cerebral ischemic

attacks and related syndrome and the same was authorized by them for Rs. 54,000/- on 7.6.18. Later on, on

8.6.18, the pre-authorization request for cashless was denied with the reasons that the hospitalization is for

primarily evaluation and investigation purpose only and the inpatient hospitalization is not justified also the

patient is k/c/o HTN as mentioned in past history, the fact is denied upon query thus there is misrepresentation

and discrepancy in the statement and documents. They also requested the insured to provide all the original

documents for reimbursement claim processing.

The Company has received reimbursement claim for the above said hospitalization. The claim is still under

evaluation and they have been requesting the insured to submit all past treatment and consultation records of

hypertension to enable them to process the claim. In this regard the Co. has sent letters dated 19.9.18, 26.9.18,

10.10.18 and last dated 24.10.18 giving him a time of seven days for submitting the past medical records. The

Co. has not repudiated the claim and has sought clarification from the Insured.

19) Reason for Registration of Complaint: - Non-settlement of Claim


a) Complaint letter

b) Rejection letter

c) Annex VI A

d) Policy

22) Results of hearing with both parties; (Observation & conclusion):

Hearing in the said case was held on 21.02.2019. Both the parties appeared for personal hearing and reiterated

their submissions. The representative of the Insurance Company stated that the claim was rejected as the

complainant is known case of hypertension as per medical history submitted by the hospital and this fact was

not disclosed by the complainant at the time of taking insurance policy, hence they have rejected the claim on

the basis of k/n/o HTN. The complainant denied that he is a known case of hypertension. He further referred to

the discharge summary of the hospital where no medicine to control high blood pressure was given to him

during his three days stay in hospital. He had stated that if he was having hypertension, the doctor would have

prescribed him some medicine to control BP. Further, the complainant also produced certificate dated

11.10.2018 from Max Hospital, Vaishali, wherein the doctor has certified that the complainant had no previous

history of any chronic illness like, DM, HTN or hypothyroid/hyperthyroidism.

During the hearing, the insurance company agreed to pay an amount of Rs. 68,141/- to the complainant in full

and final settlement. Accordingly, Mediation Agreement was signed by both the parties before the Ombudsman

willingly and amicably. In view of the above facts and circumstances, I feel it just, fair and equitable to make

recommendation about the settlement of the complaint as full and final on the basis of mutual agreement

between both the parties.

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


a. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer

within a period of 15 days from the date of receipt of this Award, a letter of acceptance that the Award is in

full and final settlement of his claim.

b. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of

the acceptance letter of the Complainant and shall intimate the compliance to the Ombudsman.

Place: NOIDA SANDHYA BALIGA

Dated: 27.02.2019 INSURANCE OMBUDSMAN

(WESTERN U.P AND

UTTARAKHAND)

AWARD

The matter has been settled through mediation between the complainant and the insurance

company. The insurance company agreed to pay an amount of Rs. 68,141/- towards full and final

settlement of the claim. The complainant has withdrawn his complaint.

The complaint is treated as Disposed Off accordingly.

PROCEEDINGS BEFORE




CASE OF SIMMI KHANNA V/S MAX BUPA HEALTH INSURANCE COMPANY LTD.


AWARD NO:

1. Name & Address of the Complainant Ms. Simmi Khanna

Alex B-906, Grand Omaxe, Sector 93B, Noida UP

2. Policy No:

Type of Policy


30241063201704

Health Insurance Policy – Family First Silver Plan

22.07.2017 to 21.07.2018



Ms. Simmi Khanna

Ms. Simmi Khanna

4. Name of the insurer Max Bupa Health Insurance Co. Ltd.

5. Date of Repudiation Not repudiated


na


8. Nature of complaint Partial Payment of hospitalization claim

9. Amount of Claim 48,000/-

10. Date of Partial Settlement 29.03.2018

11. Amount of relief sought 34,640/-


IOB rules

13 (1) (b)



i) For the Complainant Ms. Simmi Khana, Self

j) For the insurer Mr. Bhuwan Bhaskar, Manager-Legal

15 Complaint how disposed Award in favour of complainant


17) Brief Facts of the Case : Non payment of post hospitalization charges by the Insurance Company.


Complainant’s argument: The complainant was admitted in Apollo Hospital on 26.12.2017 as she was

suffering from severe head and ear pain. Some diagnostic tests were performed there and she was discharged

with the recommendation to go for surgery within a few months and she was put on medication. The

complainant, in the meanwhile, had consulted some other doctor and she was prescribed some more tests by the

doctor. All the prescriptions and bills alongwith test reports amounting to Rs. 52422/- were sent to the Insurance

Co. for reimbursement out of which an amount of Rs. 13360/- was allowed and balance were rejected by the

Insurance Company giving reason “Charges non related to present disease.’ She underwent diagnostic tests as

per doctors advice

Insurers’ argument: The Insurer in their SCN dated 11.02.2019 have stated that the policy named Heartbeat

Family First Silver 5L+15L bearing No. 30241063201704 has been issued to Ms. Simmi Khanna covering Self

and her son for the period from 22.7.2017 to 21.07.2018 for a sum insured for Rs. 25,00,000/-. The Company

had received pre-authorization of cashless treatment from Indraprastha Apollo Hospitals for treatment of acute

suppurative otitis media and the same was duly approved by the Company. The Company approved Rs. 34,432/-

out of total bill amount of Rs. 38,851/- and Rs. 4,419/- was not payable as per terms and conditions of the

policy.

The Company received reimbursement claim from the complainant for pre and post hospitalization for the

aforesaid mentioned hospitalization. Rs. 13,360/- out of Rs. 57,472/- was approved , mentioning the reason for

non-payment of balance claim amount viz. i) bill for Rs. 9472/- was not submitted ii) bills submitted for Rs.

34,640/- are not related to the present diagnosis. Treatment undertaken by the complainant was for acute

suppurative otitis media however, she has applied for the expenses incurred by her for Cancer check up, MRI

spine screening and MRI Venogram brain that is unrelated to the current diagnosis.

19) Reason for Registration of Complaint: - Partial payment of health claim


a) Complaint letter

b) Rejection letter

c) Annex VI A

d) Policy

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


their submissions. The matter was examined on the basis of documents on record and oral submissions during

the personal hearing and medical papers submitted by the Complainant. The representative of the Insurance

Company stated that the complainant was admitted for acute suppurative otitis media but she has submitted bills

for reimbursement for cancer check up and MRI spine screening, MRI venogram brain with contrast, which are

unrelated to the current diagnosis. The complainant had also not provided bill for Rs. 9472/-, hence this amount

was also not reimbursed.

The complainant has stated that, after discharging from hospital, she had consulted the doctor in Apollo

Hospitals for the same medical problem, where she was advised some diagnostic tests/medical examinations viz

MRI brain with contrast, MRI head, MRI spine etc. of the same side of the affected ear and for the same reason

for which she was admitted in the hospital. The insurance company stated that they were not provided with these

documents, whereas, according to the complainant, she had submitted all the documents to the insurance

company. The complainant was advised to submit the bill for which payment was not made by the insurance

company and directed to give photocopy of the doctor’s prescription for the MRIs and other diagnostic tests

related to it.

AWARD

Taking into account the facts of the case and the submissions made by Insurance Company and

Complainant during the course of hearing, an award is passed with direction to the Insurance

Company to pay the admissible amount of claim after receiving the necessary bills/prescription

from the complainant.

The complaint is treated as DISPOSED OFF accordingly.



a) According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer



b) As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of




(WESTERN U.P AND

UTTARAKHAND)

PROCEEDINGS BEFORE



OMBUDSMAN – SM. SANDHYA BALIGA

CASE OF RAKESH BHATIA V/S RELIGARE HEALTH INSURANCE COMPANY LIMITED


AWARD NO:

1. Name & Address of the Complainant Rakesh Bhatia

C-95 Assotech The Nest,Crossing Republik

Ghaziabad,U.P - 201010

2. Policy No:

Type of Policy


10715427

Health Plan

12.07.2016 to 11.07.2019



Rakesh Bhatia

Rakesh Bhatia

4. Name of the insurer Religare Health Insurance Company Limited


6. Reason for repudiation Non-disclosure of Material facts


8. Nature of complaint Repudiation of Claim


10. Date of Partial Settlement None



IOB rules

13 (1) (b)



k) For the Complainant Rakesh Bhatia,Self

l) For the insurer Dr.Nisha Sharma

15 Complaint how disposed Award in favor of the insurance company

16 Date of Award/Order

17). Brief Facts of the Case:- This complaint is filed by Rakesh Bhatia against Religare Health Insurance

Company Limited for repudiation of his medi-claim .

18). Cause of Complaint:-

c) Complainants argument :- The complainant stated that he had taken a health insurance policy bearing no.

10715427 covering himself and his spouse for the period from 12.07.16 to 11.07.19 for sum assured of

Rs.5,00,000/-. The complainant was admitted to Fortis Hospital,Noida from 04.01.2018 to 06.01.2018 with

complaint of pain and swelling in Right Lower Limb and was diagnosed as a case of Deep Vein

Thrombosis (DVT) right lower limb. The complainant applied for cashless treatment but the insurer

rejected the claim on 20.01.18 on the ground that he was a known case of DVT since 2003 but the same

was not disclosed in the proposal form.

d) Insurer’s argument:- The insurer stated that the complainant had approached the insurer with a cashless

request with respect to his hospitalization in Fortis Hospital,Noida from 04.01.18 to 06.01.18 for treatment

of DVT of Right lower limb. As per the pre-authorisation form filled by the complainant at the time of

hospitalization, the insured had been diagnosed with the same ailment in the year 2003 and had been treated

conservatively(prior to porting of policy) but the same was not declared in the proposal form at the time of

taking the policy with Religare Health Ins. Co.Hence the cashless claim and reimbursement claim of the

complainant was rejected by the insurer for non-disclosure of material facts as per Clause no.7.1 of the

policy terms and conditions. On denial of the claim the complainant approached the insurer for

reconsideration of the claim on the basis of a letter dated 06.01.18 of the treating doctor, Dr.Vaibhav

Mishra that the complainant does not have any clear history suggestive of DVT prior to this episode, as per

his knowledge. However the said letter was clearly an after-thought. Hence the claim was not considered.

19) Reason for Registration of Complaint: - Repudiation of claim


a) Complaint letter

b) Discharge summary

c) Rejection letter

d) SCN

e) Policy T & C

21)Result of Hearing (Observation and Conclusion): – Personal hearing was held on 10.01.2019 in which

both the complainant and the Insurance Company appeared and reiterated their submissions. The complainant

stated that he had never heard of the disease DVT prior to the present hospitalization. He never had any

symptoms or treatment of DVT earlier. The insurance company argued that it was mentioned in the cashless

pre-authorization form that he was a patient of DVT since 2003 and the same had been signed by the

complainant and counter-signed by the treating doctor. Hence the claim was rejected on the basis of non-

disclosure of material facts as per Clause 6.1 of the policy T & C which states that

“If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-

disclosure of any material particulars or any material information having been withheld or if a claim is

fraudulently made or any fraudulent means or devices are used by the policy holder or the insured person or

anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the

premium paid shall be forfeited to the company”.

Considering the documents exhibited and oral submissions during the hearing, I observe that the insurance

company had repudiated the claim due to non-disclosure of material facts thus violating the principle of Utmost

Good Faith as enumerated under Clause 19(4) of Protection of Policy Holder’s Interest Regulations ,2017. The

insured was asked to submit the doctor’s statement on an affidavit confirming that there was no past history of

DVT which he has not done till date. Hence I see no reason to interfere with the decision of the insurance

company.










(WESTERN U.P AND UTTARAKHAND)

AWARD


made by both the parties during the course of hearing, I find no reason to

interfere with the decision of the insurance company.

Hence, the complaint is treated as disposed off.

Copy To: 1) Complainant

2) Company

PROCEEDINGS BEFORE




CASE OF MOHIT BHATNAGAR V/S STAR HEALTH & ALLIED INSURANCE COMPANY LTD.

COMPLAINT REF: NO: NIO-G-044-1819-0095

AWARD NO:

1. Name & Address of the Complainant Mohit Bhatnagar

D-13, TDI City, Behind CL Gupta World School

Ramganga Vihar Phase II, Umri Kalan, Moradabad

UP – 244001.

2. Policy No:

Type of Policy


P/211119/01/2018/000915


23.07.2017-22.07.2018



Mohit Bhatnagar

Mohit Bhatnagar

4. Name of the insurer Star Health & Allied Insurance Company Ltd.

5. Date of Repudiation Not received


Not received



9. Amount of Claim Not specified

10. Date of Partial Settlement n.a.

11. Amount of relief sought Not specified


IOB rules

13 (1) (b)



m) For the Complainant Mr. Mohit Bhatnagar, Self

n) For the insurer Mr. Mantosh Kumar, Dy. Manager

15 Complaint how disposed Award in favour of Complainant


17) Brief Facts of the Case: This complaint is filed by Mr. Mohit Bhatnagar against M/s Star Health & Allied

Insurance Co. Ltd. for repudiation of pre and post hospitalization claim of himself.


Complainant’s argument: The complainant had purchased Family Health Optima Insurance Plan from M/s

Star Health vide Policy No. P/231119/01/2017/000527 for the period from 23.07.2017 to 22.07.2018, for a

floater sum insurance of Rs. 10,00,000/-, (Rupees Ten Lacs only) covering self and his dependent family

members. The complainant was admitted RG Urology & Laparoscopy Hospital, New Delhi on 11.06.2017 for

the treatment of Urinary bladder stone. Bill for hospitalization was settled by the Insurance Company on cash-

less basis. The complainant had submitted pre and post hospitalization bills to the Insurance Company for

reimbursement of claim on 06.07.2017. The Insurance Company has not settled the claim. Hence, he has

approached this forum for redressing his grievance.

Insurers’ argument: The Insurance Company in their SCN dated 10.06.2018 has explained that their

Moradabad Branch Office has issued Family Health Optima Insurance Policy covering Mr. Mohit Bhatnagar

and his family for a sum insured of Rs. 10,00,000/- . The complainant was covered with National Insurance Co.

for the years from 2009 to 2013 and from 2013 to 2018; he was covered with Star Health Insurance Co. The

complainant was admitted in RG Stone Urology and Laparoscopy Hospital, New Delhi, on 28.6.2017 for

treatment of Stent Removal. He has submitted pre-authorization form along with the documents on 28.6.2017

and the same was authorized for Rs. 5000/-.The hospital has not submitted the Day Care summary dated

28.6.2017 and original final bill dated 28.6.2017. Letter dated 8.8.2017 was sent to the complainant with a

request to submit the above documents and in reply he has submitted only previous discharge summary dated

11.6.2017. The complainant has not submitted the Original Final bill dated 28.6.2017 and Day Care Summary

dated 28.6.2017. They are not able to process the claim without the documents. They have submitted that on

receipt of the documents, they will process the claim as per terms and conditions of the policy.

19) Reason for Registration of Complaint: - Rejection of pre and post hospitalization claim.


a) Complaint letter

b) Rejection letter

c) Policy document

d) SCN

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


their submissions. The matter was examined on the basis of documents on record and oral submissions during

the personal hearing and medical papers submitted by the Complainant. The representative of the Insurance

Company stated his point of rejecting the claim that the hospital had not provided ‘day care summary’ and

‘original final bill’ of post hospitalization expenses. Only pre-post hospitalization bill was pending owing to the

non receipt of the documents. The Insurance Company submitted that they had not received the documents. The

complainant had referred to his letter dated 11.7.2018 whereby he had submitted all the original pre and post

hospitalization papers to M/s Star Health, Moradabad Office and the documents same were duly received and

acknowledged by them. The complainant was advised to provide photocopies of all the medical papers to the

insurance company once again to enable them to settle the claim. The insurance company is directed to process

the claim and pay the admissible claim amount to the insured.

AWARD

Taking into account the facts of the case and the submissions made by Insurance Company and

Insured during the course of hearing, an award is passed with direction to the Insurance

Company to pay the full amount of claim for pre and post hospitalization of complainant.

The complaint is treated as DISPOSED OFF accordingly.










(WESTERN U.P AND

UTTARAKHAND)

PROCEEDINGS BEFORE



OMBUDSMAN – SM. SANDHYA BALIGA

CASE OF NEERAJ MEHRA V/S THE NEW INDIA ASSURANCE COMPANY LIMITED


AWARD NO:

1. Name & Address of the Complainant Neeraj Mehra

A-65/2 Vaishali Colony

Garh Road Meerut

U.P 250005

2. Policy No:

Type of Policy


32110134172800000041

Family Floater Mediclaim Policy

13.05.2017 to 12.05.2018



Neeraj Mehra

Neeraj Mehra

4. Name of the insurer The New India Assurance Company Limited


6. Reason for repudiation Hospitalization not requred


8. Nature of complaint Non-settlement of claim





IOB rules

13 (1) (b)



o) For the Complainant Mr.Neeraj Mehra ,Self

p) For the insurer Ms.Monika Goyat,Admn.Officer,Legal

15 Complaint how disposed Award in favor of complainant


17) Brief Facts of the Case:- This complaint is filed by Sh.Neeraj Mehra against The New India Assurance

Co.Ltd for repudiation of his mediclaim.

18) Cause of Complaint:-

Complainants argument :- The complainant stated that he was covered under Family Floater Mediclaim policy

no. 32110134172800000041 for the period from 13.5.2017 to 12.5.2018 for himself and his family for sum

insured of Rs. 8 lakhs with New India Assurance Company Limited. The complainant was diagnosed with

Pemphigus Vulgaris in September 2014 and since then he has been under treatment for the above disease.

Injections of RITUXIMAB were prescribed to the complainant for the said treatment. The complainant had

applied for cashless facility as well as reimbursement option but the same were rejected by the Company. As per

the complainant he was continuously insured with the Company for the last 7 years and he was admitted in the

hospital as per advices of the doctor who wanted to keep the patient under observation for more than 24 hours.

The two Claims lodged by the complainant for the year 2016-17 were settled by the Company after award was

passed by the Hon’ble Ombudsman on 16.03.17 under Complaint no.NOI-G-049-1617-0250. Thereafter the

complainant had submitted claim papers with the insurance company relating to 3rd, 4th and 5th hospitalization

for infusion of RITUXIMAB injection. The same were again rejected by the company but were settled by the

insurer after award was passed on 05.09.17 by the Hon’ble Ombudsman under Case No.NOI-G-049-1718-101.

Insurer’s argument:- The insurance company in their mail dated 20.07.18 have explained that the Discharge

Summary of the insured reveals that the patient’s diagnosis was Rhenatoid Arthritis with Joint pain. During

hospitalization he was given injection MABTAS RA 500mg I/V infusion( other names Rituximab, Zytux

etc.).As per protocol of these injections this procedure is usually done on an OPD basis under medical

supervision and patient is monitored for 6-7 hours. This is the normal time taken for infusion of this drug, hence

admission is not required for a period of 24 hours. The insurer added that the procedure is not listed in day care

list under Clause 2.15 of the policy and such injections are not payable as per their Technical Manual dated

22.06.17.

19) Reason for Registration of Complaint: - Non- settlement of claim


a) Complaint letter

b) Policy copy

c) SCN

d) Annex VI

21) Result of Hearing (Observation and Conclusion): – Personal hearing was held on 10.01.2019 in which

both the complainant and the Insurance Company appeared and reiterated their submissions. The complainant

stated that he was admitted for treatment of Pemphigus Vulgaris as per the advice of the treating doctor. He was

administered injection MABTAS RA through I/V infusion. The insurance company argued that the admission

was for treatment of Rhenatoid Arthritis due to complaints of joint pain. It was not connected with Pemphis

Vulgaris for which generally injection Ritumaxicab is given similar to chemotherapy for cancer treatment. The

insured stated that there was some mistake in the discharge summary as he was suffering from Pemphigus

Vulgaris and not Rhenatoid arthritis. He was advised to submit the correct Discharge Summary from the

hospital along with affidavit from the treating doctor that the diagnosis and symptoms mentioned in the

Discharge Summary have been due to an error on his part. The insured agreed to do so. He has now submitted

afresh Discharge Summary from the Hospital which mentions the diagnosis as Pemphigus Vulgaris. He has also

submitted an affidavit from his side and from the treating doctor that he does not suffer from Rhenatoid Arthritis

but was hospitalized and administered MABTAS RA for treatment of Pemphigus Vulgaris.

I have examined the documents exhibited and oral submissions made. I do not find the contention of the

insurance company that hospitalization is not required as acceptable. The treating doctor is the best person to

decide whether the procedure can be done on OPD basis or as an in-patient. The insured got admitted on the

specific advice of doctor of AIIMS, since the patient had to be under medical supervision and his condition had

to be monitored during the time of infusion of the drug which normally takes 6-7 hours. Since the

administration of the injection is similar to Chemotherapy procedure which is covered under Day Care

procedures rejection of the claim by the insurer time and again stating that the injection can be given in OPD, is

nothing but deliberate harassment of the complainant. This is the third complaint of the insured in this forum in

a span of two years pertaining to the same treatment. In both the earlier cases, awards were passed by this forum

directing the insurer to pay the legitimate claim to the complainant. Further there is a judgement of Vijaywada

DCDRF in Case No.CC/59/2013 of Sm. P Susheela vs.Star Health and Allied Ins. Co. ltd. wherein the judge has

opined that it is not for the insurance company to decide whether the patient required hospitalization or not, or

whether injection Riumaxicab should be given or not. It is for the treating doctor to take the decision. Hence the

insurance company is directed to pay such admissible claim to the complainant without forcing him to approach

this forum every time he is hospitalized for administration of I/V injection for the treatment of Pemphigus

Vulgaris.








Place: Noida. SANDHYA BALIGA


(WESTERN U.P. & UTTARAKHAND)

AWARD

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

both the parties during the course of hearing, the insurance company is directed to pay

the admissible claim amount to the complainant.

Hence, the complaint is treated as disposed off.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu, IRS

Case between: Mr. R. Madhusudhan ………………The Complainant

Vs

M/s National Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD) G -048-1819-0145

Award No. : I.O.(HYD)/A/GI/0192/2018-19

1. Name & address of the complainant Mr. R. Madhusudhan, # 12-126, Kuppuswamy House, Karamchedu, Ponnur, Prakasam Dist., Andhra Pradesh – 523 168.

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

361900/48/16/8500000662 Mediclaim Insurance Policy From: 06.06.2016 to 05.06.2017

3. Name of the insured Name of the Policyholder

Mr. R. Madhusudhan Mr. R. Madhusudhan

4. Name of the insurer M/s National Insurance Co. Ltd.




8. Nature of complaint Partial settlement of mediclaim

9. Amount of Claim Rs.161,200/--

10. Date of Partial Settlement Rs.66,326/- settled on 08.05.2018

11. Amount of Relief sought Rs.94,800/-

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

Rule 13 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer

Rules, 2017 or the Health insurer

13. Complaint how disposed Allowed – (Statistical Purpose)

14. Date of Order/Award 04.02.2019


The Complainant, Mr. R. Madhusudhan, covered himself and wife under BOI National Swasthya Bima Policy with the respondent insurer, from 06.06.2016 to 05.06.2017 for a floater SI Rs.5.00 lakhs. As per the complaint filed, the complainant was admitted in Aayush Hospitals, Vijayawada on 25.02.2017 with complaint of blurred vision. He underwent renal biopsy on 27.02.2017 and was discharged on 28.02.2017. The initial cashless treatment request was denied by the insurer / TPA as per policy clause 4.1 and requested him to file a reimbursement claim. The complainant filed a reimbursement claim and the TPA settled only Rs.66,326/- out of total hospital bill of Rs.1,61,200/-. The complainant represented to the insurer for settlement of balance claim amount of Rs. 94,800/- but in vain. Aggrieved, the complainant filed complaint with this Forum for Redressal of his grievance. 16) Cause of Complaint: Short settlement of mediclaim.

17) Reason for Registration of Complaint:

The claim preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered.

The complaint is scheduled for hearing on 07.02.2019. On contacting the complainant for fixing the hearing schedule the complainant intimated that the claim was settled by the insurer. He was asked to send confirmatory mail. He sent the mail on 23.01.2018 confirming the same and withdrawing the complaint. Hence, the complaint is closed.

A W A R D The complaint is treated as resolved & closed as Allowed for statistical purpose.

Dated at Hyderabad on the 4th day of FEBRUARY, 2019.

(I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. K. Srinivas ………………The Complainant

Vs

Max Bupa Health Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).G .11.031.0114/2018-19

Award No.: I.O.(HYD)/A/GI/0194/2018-19

1. Name & address of the complainant Mr. K. Srinivas,

Plot No.302, Ramya Residency,

Near Ahmed HP Gas Agency, Gunadala,

Vijayawada – 520 008, AP


30060779201706

Health Companion (Silver) Policy

From: 19.11.2017 to 18.11.2018


Master K. Sai Abhinav

Mrs. D. Harika

4. Name of the insurer Max Bupa Health Ins. Co. Ltd.


6. Reason for repudiation As per policy clause no.6.10


8. Nature of complaint Rejection of Mediclaim



11. Amount of Relief sought Rs.156421/-

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

13. Date of hearing/place 22.01.2019 / Hyderabad


a) For the complainant Self

b) For the insurer Ms. Shital Patwa, Manager (Legal)

15. Complaint how disposed Allowed


17) Brief Facts of the Case: Mrs. Harika Davuluri took Heart beat Gold Mediclaim Policy, through telesales, with Respondent Insurer and covered herself for a SI of Rs.5 Lakhs from 19.11.2011. At the time of renewal during 2013, she added her husband, Mr. K. Srinivas, her daughter Baby Anvitha and son Master Sai Abhinav and opted for a family floater policy by changing the plan to Health Companion Silver for a floater SI of Rs.4.00 Lakhs. The policy was continuously renewed since then without any break in renewal. As per the complaint filed, during the policy period from 19.11.2017 to 18.11.2017 her son was admitted for treatment of post infective scar contracture of right hand and wrist. He underwent surgical procedure at Rainbow Children’s Hospital, Vijayawada from 03.05.2018 to 06.05.2018. She filed reimbursement claim for Rs.1,56,421/- on cancellation of pre-authorisation approval given earlier for Rs.77,500/- on 02/05/2018. The insurer rejected the claim quoting clause 6.10 – cosmetic surgery. She represented to the insurer to review the decision but in vain. Aggrieved, Sri K. Srinivas, husband of the insured, filed complaint with this Forum. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that his son suffered from urinary infection three years back and he was treated with IV fluids as an out-patient. During the treatment he acquired IV cannula infection and it resulted in a wound near right hand wrist. After one month of treatment the wound was cured but thick contracture was formed. Doctors said that it would go off with growing age. But, by growing age, his right hand wrist and fingers were twisting right side and he is facing problems in holding objects and his fingers were not together. Hence, they consulted orthopedician and he advised them to consult plastic surgeon. The plastic surgeon, after careful examination of his son advised removal of contracture to bring back wrist and fingers to its normal position. Accordingly, the child was admitted in Rainbow Children’s Hospital, Vijayawada on 03/05/2018 and was discharged on

07/05/2018. Before admission they have sent pre-authorisation request to the insurer and they have approved Rs.77,500/- for the surgery. After surgery, when the hospital authorities have sent the final bill, the insurer rejected the total approval alleging that the surgery undergone by his child as ‘cosmetic surgery’. The surgeon who performed the surgery and the hospital authorities have clarified that it was not a cosmetic surgery. In spite of that the insurer declined the approval. He filed reimbursement claim for Rs.1,56,421/-. It was also rejected on the same ground. The complainant stated then approached the Grievance Cell of the insurer to review the decision but they too concurred with their original stand. Hence, the complainant pleaded this Forum to direct the insurer to settle his genuine claim. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that they have received pre-authorisation request for cashless treatment from Rainbow Hospitals, Vijayawada for treatment of complainant’s son Master Sai Abhinav for post infective scar control. It was initially approved for Rs.77,500/- on 02/05/2018. The hospital sent final bill for Rs.1,56,421/- with discharge summary and other medical documents. On evaluation of the documents provided to the company the earlier given cashless approval was denied as the insured patient underwent ‘Z-Plasty’ procedure for cosmetic purposes. The reimbursement claim was also rejected on the same ground after obtaining independent medical opinion from Dr. Arvind M. Das who opined that the treatment undergone by the insured child was not due to the reason stated by the complainant and it appears like a past surgical scar nature not known. In view of the medical opinion, the in-house medical team treated it as a cosmetic surgery and there was no review on the decision when the complainant approached GRO of the company. The insurer further stated that the complainant failed to substantiate and provide proof beyond doubt that the procedure which his son had undergone does not fall under cosmetic and reconstructive surgery. With the above submissions, the insurer pleaded for the dismissal of the complaint. 19) Reason for Registration of Complaint:

The claim preferred by the complainant was rejected by the insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions b. Discharge summary c. Rejection letter d. Correspondence with insurer e. Self Contained Note with its enclosures 21) Result of the personal hearing with both the parties:

Pursuant to the notices given by this Forum both the parties attended personal hearing at Hyderabad on 22.01.2019. The complainant once again narrated the sequence of events that had led to the present ‘Z-Plasty’ and shown the photographs of his son before surgery. The photographs clearly depicting the functional disability of the right hand. The representative of the insurer was asked to examine the same and correlate the same with other medical documents and treating doctor’s opinion that it was not a cosmetic surgery and it was done to avert further deformity and to achieve normal functionality of the hand.

The insurer’s representative assured that she would take it up once again with their higher-ups for one more review of the case. The insurer intimated vide their e-mail dated 28/01/2019 that they have reviewed the claim and agreed to settle the claim for Rs.1,55,304/- after deducting the non-medical expenses of Rs.1,117/-. The settlement done by the insurer was found to be in order in terms of the policy. The insurer is directed to pay the amount without any further loss of time.

A W A R D The insurer is directed to pay the claim amount of Rs.1,55,304/- towards full and final settlement of the claim without any further loss of time. The complaint is treated as allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance


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 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 7th day of FEBRUARY 2019.

(I. SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. GVS Rama Rao ………………The Complainant

Vs


Complaint Ref. No. I.O.(HYD).G -031-1819-0095


1. Name & address of the complainant Dr. GVS Rama Rao,

H.Noi.8-17/25, Flat No.303, Sylvan Shelter,

Dilsukhnagar, Hyderabad – 500 060, Telangana


30612821600

Health Companion Insurance Policy

From: 20.12.2016 to 19.12.2018 ( 2 Years)


Mr. GVS Rama Rao

Mr. GVS Rama Rao



6. Reason for repudiation Non disclosure of previous medical history


8. Nature of complaint Rejection of mediclaim










a) For the complainant Self Smt. G. Padmavathi Devi, Daughter-in-law




17) Brief Facts of the Case: The complainant, Mr. GVS Rama Rao, took Health Companion Policy for himself with the respondent insurer from 20.12.2016 to 19.12.2018 for SI of Rs.5.00 Lakhs. As per the complaint filed, the complainant underwent keratoplasty surgery to his right eye in Maxi vision Hospitals, Hyderabad on 22.08.2017. The complainant filed reimbursement claim for Rs.63706/-. The insurer rejected his claim stating that the insured patient had previous history of undergoing cataract surgeries in 1998 and 2005 years and the same was not disclosed at the time of inception of the policy. The claim for reimbursement was denied under PED exclusion of the policy. The complainant represented to the insurer to review the decision but in vain. Aggrieved, Dr. GVS Rama Rao filed complaint with this Forum. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that he was 85 years of age and the respondent insurer issued him Health Companion health insurance policy for two years from 19/12/2016 to 18/12/2018 after satisfied with pre-acceptance medical reports undergone by him at a designated lab/centre of the insurer. He underwent treatment at Maxi Vision Laser Centre for diagnosed ailment of ‘psedophakic Bullos’ in his right eye on 22/08/2017. The insurer rejected the claim filed for Rs.60,000/- on 14/10/2017 stating that “as per the investigation conducted by them it was noticed that the insured patient had history of surgery for cataract done in 2005 and 1998 but it was not disclosed at the time of taking the policy and the present ailment is a complication of the same, which means non-disclosure of material facts” and quoted PED exclusion clause in support of their rejection. The complainant strongly contended that his present claim filed was for ‘keratoplasty’ and it was entirely different from cataract surgery. Cataract is opacity of the lens in the eye and the keratoplasty means replacement of cornea of an eye. By any stretch of imagination these two operations cannot be called the same or as a complication one another. The cataract surgery in right eye was performed during 1998. This was beyond 48 months period as per the definition of PED stated under the policy. The complainant further stated that he had disclosed about his undergoing cataract surgeries to the sales team and since they were beyond periods that warrant any recording of the same it was not recorded by the sales team. He further stated that he did not have any hypertension or diabetes. The

complainant stated that cornea in his right eye partially detached and so he underwent keratoplasty. The operation which he underwent on 22.08.2017 and for which he preferred the claim was covered under the policy stated under the columns “what I am covered for” and are not barred under “major exclusions” stated in the policy. The complainant further stated that he was asked to submit various other documents and also etiology of current ailment by treating doctor and all were submitted by him. In spite of that there was no revision in the decision of the insurer. Hence, he pleaded for the intervention of this Forum for settlement his claim by the insurer. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the complainant filed claim for the treatment undergone by him at Maxi Vision Eye Hospitals for ‘Psedophakic Bullos Keratopathy’. On verification it was known that the complainant had undergone cataract surgery to his right eye during 1998 and to left eye during 2005. It was evident from the documents that the present complications are a result of above mentioned pre-existing condition. Since PED is evident from the claim documents, the claim is not payable as per non-disclosure of material facts. The insurer further stated that the company had conducted general tests like urine, blood and ECG, based on the information provided in the proposal form. It was pertinent to note that none of the questions were time bound and the complainant was required to make disclosures regarding the same for medical examinations to be conducted in a fair manner. The medical examinations are triggered basis the declarations made by the complainant in the proposal form. Hence, the claim was declined for non-disclosure of material facts. With the above submissions, the insurer pleaded for dismissal of the complaint. 19) Reason for Registration of Complaint:

The claim preferred by the complainant was rejected by the insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions b. Discharge summary c. Rejection letter d. Correspondence with insurer e) Self Contained Note with its enclosures. 21) Result of the personal hearing with both the parties:

Pursuant to the notice given by this Forum both the parties attended personal hearing at Hyderabad on 22.01.2019. The complainant once again reiterated the sequence of correspondence he had exchanged with the insurer by submitting his earlier undergone cataract surgery documents stating that he had not undergone surgery during 2015 as stated by the insurer in their correspondence but it was in 2005 & 1998. He strongly contended that his earlier past cataract surgeries have no relation to his present surgery of keratoplasty. The representative of the insurer by submitting medical literature on causes for performing keratoplasty stated that due to improper cataract surgery the complications were developed and so the claim was rejected. When it was questioned how it related to the present condition when the complainant underwent cataract surgery to his right eye

during 1998, i.e. 20 years back, the insurer’s representative stated that the medical literature did not state any duration. The insurer issued Heath Insurance Policy to a Senior Citizen of 84 years old after satisfying themselves about health conditions of the complainant. They have related the present treatment of keratoplasty to the cataract surgery undergone by the complainant during 1998 simply relying on the medical literature which did not specify the duration for the cause of the ailment. If it was due to any damage of the surround cells during cataract surgery, the patient would have suffered from the complications immediately or within few months. Attributing it for a surgery which was undergone 20 years back is not at all reasonable to accept. The treating doctor had submitted etiology of the ailment clearly confirming its duration. Hence, this Forum holds that the insurer erred in repudiation of the claim on the ground of non-disclosure of PED.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to admit the claim for Rs.60,088/- towards full and final settlement of the claim. The insurer is also directed to pay interest in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017. The complaint is allowed.



c) 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.

d) 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.

e) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 7th day of FEBRUARY, 2019

(I. SURESH BABU )

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. N. Ravi Sri Rama Murthy ………………The Complainant

Vs




1. Name & address of the complainant Mr. N. Ravi Sri Rama Murthy,

H.No.2-22-70/1/101,Sivapuja Residency,

Vivekananda Colony, Kukatpally,

Hyderabad – 500 072, Telangana


30455461201702

Health Companion Insurance Policy

From: 29.08.2017 to 28.08.2018


Mr. N. Sri Rama Murthy

Mr. N. Ravi Sri Rama Murthy





8. Nature of complaint Short settlement of mediclaim


10. Date of Partial Settlement 27.04.2018












17) Brief Facts of the Case: The complainant, Mr. N. Ravi Sri Rama Murthy, took Health Companion Policy with respondent insurer and covered his father from 29.08.2015 and renewed it continuously till date. The present policy was renewed from 29.08.2017 to 28.08.2018 for SI of Rs.2.00 Lakhs. As per the complaint filed, the insured person first underwent left knee total knee replacement surgery for Osteoarthritis in Star Hospitals, Hyderabad from 20.02.2018 to 24.08.2018 and the total bill raised by the hospital for Rs.185630/- was paid by the insurer. The insured person, again underwent right knee replacement surgery for Osteoarthritis from 22.04.2018 to 26.04.2018 in Star Hospitals, Hyderabad and insured approved only Rs.94184/- as against the hospital’s total bill of Rs.181970/- The complainant stated that, before second hospitalization he had intimated the insurer that he would be availing refill option under the policy for the proposed right leg knee surgery. The complainant represented to the insurer to review the settlement but in vain. Aggrieved, Mr. N. Ravi Sri Rama Murthy filed complaint with this Forum. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that he had applied for pre-authorization approval on 17.04.2018 to undergo right leg knee surgery and insurer approved only Rs.94,184/-. On 18.04.2018 he had spoken to customer care representative seeking enhancement of preauthorized amount and he was told that he could avail refill option and to get full claim and suggested to send the request through hospital. It was sent through hospital. But to his surprise the insurer intimated that refill option was not applicable for the right leg knee replacement surgery. He represented to the insurer to clarify when joint replacement surgery was undergone for a different leg why this refill option should not be applicable and how the customer care representative assured him of his eligibility. After repeated reminders and escalations he got a reply stating that refill option was not applicable. He stated that he had represented again to the insurer to review the decision stating when treatment was undergone on a separate hospitalization and on a different leg how the

insurer treated it as a same treatment and same illness and how could they deny refill option to pay the full claim. There was no revision in the decision. The complainant pleaded this Forum to direct the insurer to settle his claim to its full value. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the insured person was covered from 29/08/2015 for a SI of Rs. 2 Lakhs. During the policy period from 29/08/2017 to 28/08/2018 the insured person was eligible to claim SI amount of Rs.2 Lakhs and no claim bonus of Rs.80,000/- in addition. The company received a claim for treatment of Osteoarthritis (OA) left knee for date of hospitalization for TKR from 20/02/2018 to 24/02/2018 at Star Hospitals, Hyderabad for an amount of Rs.1,85,630/- and it was processed and paid by the company. The company received another claim for Rs.1,81,970/- for treatment of OA right knee for TKR from 24/04/2018 to 26/04/2018 at Star Hospitals. It was also approved and paid up to the limit of balance SI + accrued cumulative bonus for which insured person was eligible, i.e. for Rs.94,184/-. The complainant raised his concern regarding refill option and this benefit can only be utilized for different illnesses it was not approved. The refill benefit clause of the policy states as under: “Refill Benefit – We will provide a Refill Sum insured equal to 100% of base sum insured in case base sum insured and no claim bonus has been partially or completely exhausted. Refill sum insured can only be utilized for different illnesses.” As per the above, the refill benefit can be availed/utilized only for different illness and not for same illness. In the complainant’s case the diagnosed ailment/disease was ‘Osteoarthritis’ and hence the complainant was not entitled for refill benefit. Hence, the claim was approved and paid by the company up to the limit of balance SI + No Claim Bonus amount and hence his request to consider the claim for full amount was not considered in terms of the policy.

With the above submissions, the insurer pleaded for dismissal of the complaint as the claim was settled for full eligible amount under the policy.


The claim preferred by the complainant was short settled by the insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy with terms and conditions 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 the parties attended personal hearing at Hyderabad on 22.01.2019. Both the parties reiterated their contentions stated in their respective complaint and self contained notes.

The complainant strongly contended that since his father had undergone surgery to a different leg in a different hospitalization period he was entitled to claim refill benefit under the policy.

The Refill Benefit clause under the policy {2.12(b)} clearly stated that the ‘Re-fill sum insured may be used for only subsequent claims made by the insured person and not against any illness (including its complications or follow up) for which a claim has been paid or accepted as payable in the current policy year under Section 2.12(a).’ The insured person was suffering from the ailment/illness which was diagnosed as ‘Osteoarthritis’ and he underwent left knee TKR surgery for which claim was paid by the insurer for his hospitalization from 20/02/2018 to 24/02/2018. During the same policy period, he was hospitalized to undergo right leg TKR for the same diagnosed illness/ailment of ‘Osteoarthritis’ from 24/04/2018 to 26/04/2018. The insurer paid the balance SI along with cumulative bonus amount. Though the insured person underwent surgery on different legs in different hospitalizations, the ailment/illness for which he underwent the TKR surgery being the same, i.e. ‘Osteoarthritis’ he is not entitled to the refill benefit under the policy. There is no infirmity in the decision of the insurer in disallowing the refill benefit.

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 requires no intervention by this Forum in the decision of

the insurer.

The complaint is dismissed without any relief.


(I. SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE


(Under Rule 16(1)/17 of Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. SURESH BABU, IRS

Case between: Mr. C. Bekkeswara Reddy……………The Complainants

Vs

M/s Cigna TTK Health Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. C. Bekkeswara Reddy,

Flat No.104, SMR Vinay Classic,

Kondapur, Hyderabad – 500 084


PROHLR010494909

Pro Health Insurance Policy

From: 17.11.2017 to 16.11.2018


Mrs. C. Nagaratnamma

Mr. C. Bekkeswara Reddy

4. Name of the insurer M/s Cigna TTK Health Insurance Co. Ltd.


6. Reason for repudiation Non-disclosure of previous health condition


8. Nature of complaint Rejection of Mediclaim & cancelled the policy





Rule 13 (b) –repudiation of claims by the Life insurer, General Insurer any partial or total or the Health insurer




b) For the insurer Mr. Farhan Siddiqui, Branch Training Manager Mr. Vijay Key Agency Manager



17) Brief Facts of the Case: The complainant, Mr. C. Bekkeswara Reddy proposed and took Pro-Health Insurance Policy to

his mother with the respondent insurer from 17.11.2017 to 16.11.2018 for SI of Rs.3.50 Lakhs.

As per the complaint filed, his mother Mrs. C. Nagarathnamma, aged 67 years, met with a

small accident, an auto hit her while she went for morning walk. She approached a doctor in

Tesla Diagnostic Centre, Kondapur, Hyderabad and he advised surgery. She visited Sunshine

Hospital, Hyderabad for second opinion and there also she was advised surgery. She was

further advised to check with the insurance desk for a cashless claim. Based on the

correspondence between the insurance desk and the insurer, the insurer sent a mail stating

that it was a case of non-disclosure of material facts about knee pain at the time of taking the

policy and cancelled the policy. Since the policy was terminated, she could not proceed with

the surgery. The complainant represented to the insurer to review the decision but in vain.

Aggrieved, Mr. C. Bekkeswara Reddy filed complaint with this Forum.

18) Cause of Complaint: Rejection of mediclaim. a) Complainant’s argument: The complainant submitted that his mother was covered under a Mediclaim Policy with New

India Assurance Company from 11.11.2002 for a SI of Rs.2 Lakhs. As they have not considered

his request to enhance the SI under the policy, he ported the policy to Cigna TTK as they

agreed for enhancement of SI and furnished previous five years policy copies as requested by

the insurer. The policy was issued by Cigna TTK from 17.11.2017 to 16.11.2018 for a SI of

Rs.3.50 Lakhs. His mother, after she was hit by an auto-rickshaw complained about knee pain

and they consulted a doctor at Tesla diagnostic centre and he advised knee surgery. To

undergo knee surgery, they went to Sunshine Hospitals during March 2018 and there he was

directed to approach insurance desk for getting cashless treatment approval. On submission

of request it was declined alleging that there was non-disclosure of material facts, i.e. leg

pain. The complainant stated that he had represented to the insurer to review the decision

by submitting his mother’s earlier policy coverage details since 2002. The insurer all of a

sudden sent a mail on 3.4.2018 cancelling his mother’s policy. His appeal to revive the policy

coverage has not yielded any response. Hence, he pleaded for the intervention of this Forum

for revival of policy and to direct the insurer to approve cashless treatment to undergo

bilateral knee replacement surgery.

b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the complainant approached the

Company to cover his mother under portability from New India Assurance Co. and submitted

portability form and proposal form on 09.11.2017. The policy was issued after medical

examination of the insured person from 17.11.2017 to 16.11.2018 for a SI of Rs.3.50 Lakhs.

On 24.03.2018, the complainant made a cashless request for bilateral knee replacement

surgery at Sunshine Hospitals for ‘osteoarthritis’. The duration of the ailment was stated as 1

year. To a query, the complainant furnished a consultation paper dated 5.03.2018 which

stated that the insured person was suffering from both knee pain since one year. The

complainant failed to furnish this information against a specific question under Section 5 of

the proposal form that:

“Have you or any of the insured persons proposed for insurance, ever suffered from or taken

treatment or hospitalized for or have been recommended to take investigations/ medication/

surgery for the following medical conditions?

c) Arthritis/Gout, Spondylitis Joint pain, Slip disc, Spinal Disorder, Chronic bachache or any

other disorder of the muscle/bone/joint?” Similarly, in the pre-policy medical check-up report

dated 15.11.2017 under Section 2 also a similar question was posed to the insured. However,

the questions were answered in negative as “NO”. Further, the same was not disclosed in the

portability form also.

The insured person was suffering from Grade IV bilateral Osteoarthritis which shows that the

insured has been suffering from the ailment since a long time. Hence, the cashless treatment

request was declined under Clause VIII.1 of the policy. The insurer further stated that if the

complainant had disclosed about previous health conditions/history of insured person at the

time of porting the policy, the proposal was further evaluated in terms of underwriting

guidelines of the company and we were deprived of the same. Due to material non-

disclosure/ misrepresentation of the material facts the policy was cancelled and premium

was forfeited to the company. The complainant was communicated the decision of the

company.

With the above submissions the insurer pleaded this Forum to absolve them from liability.

19) Reason for Registration of Complaint:- The cashless treatment request sent by the complainant was declined and policy was cancelled by the insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a) Policy with terms and conditions.

b) Rejection letter.

c) Correspondence with insurer d) Self contained note with enclosures e) Consultation papers of insured person f) Previous years policy copies.

21) Result of hearing with both parties:

Pursuant to the notices given by this Forum, both the parties attended the personal

hearing on 24.01.2019 at Hyderabad.

The complainant stated that his mother was covered under Mediclaim Policy from

2002 year and he ported the policy as the previous insurer did not consider his request to

enhance the SI under the policy. His mother was not advised any knee surgery earlier. Only

after she was hit by an auto her knee pain aggravated and so she was advised to undergo

bilateral knee surgery. She consulted a doctor nearer to their residence and he gave some

medication and advised surgery to get permanent relief from the pain. When it was

proposed to undergo surgery at Sunshine Hospitals, the insurer rejected the cashless

request alleging that there was non-disclosure of knee pain and all of a sudden, cancelled

the policy. Since policy was cancelled, they could not go for the surgery. He stated that the

insurer rejected the claim alleging that his mother had knee pain since 1 year which was

prior to the porting the policy and had hypertension since 2-3 years. He stated that he had

disclosed hypertension in the proposal form. Knee pain being a general complaint of old

age he could not declare it. She was advised surgery only after porting the policy. Earlier it

was not advised. He pleaded for restoration of the policy as he could not get a policy to his

mother from any other insurer with all continuity benefits and to approve cashless

treatment request to his mother.

The representatives of the insurer, referred to the medical literature and stated that

the complainant was suffering from Grade IV Osteoarthritis which shows that she has gone

through various stages of ‘osteoarthritis’ and currently reached to last stage of grade IV.

The complainant failed to furnish the relevant information against specific question in the

portability proposal from and also at the time pre-acceptance medical examination of the

insured person. Hence, the cashless request was declined and policy was also cancelled in

terms of Clause VIII.1 the policy.

The insurer declined the cashless request on the ground that the insured patient had

knee pain for a long time prior to porting the policy since it was diagnosed as Grade IV

osteoarthritis. The insurer also cancelled the policy treating it as a material non-disclosure

and it affected their underwriting/acceptance of the proposal under portability without

looking at the longevity of the policy coverage to the insured person for more than 15 years.

The insurer also failed to appreciate the reason for porting the policy by the complainant to

them and also failed to anticipate the medical issues of senior citizens. The insured person

was also subjected to pre-acceptance medical examination and she was examined by a

Medical officer. On his clearing of satisfactory health of the insured person, the proposal

was accepted by the respondent insurer and issued the policy. When an age related issue

aggravated due to a minor auto hit, the insured person consulted doctor and she was

advised to undergo surgery. The cashless treatment request sent by the hospital was

rejected merely on the ground of duration of knee pain stated in the consultation papers

was prior to the date of porting the policy. The policy was cancelled without any

consideration to previous coverage of insured person from 2002 year which totally defeated

the purpose of portability. The insured person might have knee pain prior to porting but it

had not necessitated any medical intervention until she met with an accident with auto.

Hence, this Forum holds that the insurer erred in cancelling the policy and directed to

restore the policy coverage to the insured person.

A W A R D

Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the insurer is directed to restore the policy coverage to the insured person. In the result, the complaint is treated as allowed.



f) 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.

g) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on 7th day of FEBRUARY, 2019.

(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mrs. Chandana Chakrabarti……………The Complainants

Vs

M/s Cigna TTK Health Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mrs. Chandana Chakrabarti,

Plot No.391/F Part, 2nd Floor, Road No.81,

Jubilee Hills, Hyderabad – 500 033


PROHLR010391238

Pro Health Insurance Policy

From: 29.01.2018 to 28.01.2019


Mr. Samrat Chakrabarti

Mrs. Chandana Chakrabarti

4. Name of the insurer M/s Cigna TTK Health Insurance Co. Ltd.


6. Reason for repudiation Non-disclosure of previous health condition





11. Amount of Relief sought Rs.2,10,000/-


Rule 13 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer




b) For the insurer Mr. Farhan Siddiqui, Branch Training Manager Mr. Vijay Key Agency Manager



17) Brief Facts of the Case: The complainant, Mrs. Chandana Chakrabarti, took Pro-Health Insurance Policy with the respondent insurer on 29.01.2017 and covered her son for SI of Rs.10.00 Lakhs. The Policy was renewed for a further period of one year from 29.01.2018 to 28.01.2019. As per the complaint filed, her son Mr. Chakrabarti Samrat, was hospitalized in Asian Bariatrics Hospital, Hyderabad on 26.02.2018 and underwent surgical procedure of laparoscopic adjustable gastric banding, and was discharged on 27.02.2018. The reimbursement claim filed by the complainant for payment of hospitalization expenses of Rs.2,10,000/- was rejected by the insurer alleging that there was non-disclosure of previous medical history/conditions. The complainant represented to the insurer to review the decision but in vain. Aggrieved, Mrs. Chandana Chakrabarti filed complaint with this Forum. 18) Cause of Complaint: Rejection of mediclaim. a) Complainant’s argument: The complainant submitted on 13.02.2018 she approached insurer with medical documents to ensure about coverage of the proposed surgery, advised by the doctor. He was suffering from disturbed sleep, heavy snoring, pain in knees with breathlessness; excessive weight gain in spite of all efforts with diet and exercise. He underwent laparoscopic adjustable gastric banding at Asian Bariatrics on 26/02/2018 and was discharged on 27/02/2018. She filed reimbursement claim for the surgical expenses incurred for Rs.2,10,000/-. The insurer rejected the claim stating that there was non-disclosure of health conditions which he was suffering, prior to the inception of the policy. Unfortunately, the doctor had made an inadvertent error in the certificate he provided where instead of writing “2 months” he wrote “2 years”. The same was informed to the insurer immediately and corrected by way of undertaking by two senior doctors with necessary certificates. The complainant stated that she made a representation to the grievance cell of the insurer on 22.08.2018. Subsequently, she received policy termination letter from the insurer on 09.05.2018. The termination letter stated that the policy has been forfeited w.e.f. 29.01.2018 which in fact start of the renewal policy. The complainant stated that she had ported the policy from Oriental Ins. Co. after two years coverage of his son for SI of Rs.5 Lakhs, to the Cigna TTK company for better service. When the time came for a potential coverage, the company has unilaterally decided to forfeit the policy, completely ignoring reason or fairness and without so much as a relevant

justification. The insurer holds on to a genuine mistake and totally ignored the correction and undertakings given by the concerned doctors by their certificates. The complainant stated that in the proposal form of the insurer neither has any question on snoring, knee-pain or breathlessness, nor do they ask for an essay on the policy seeker’s physical condition where one can describe in detail whatever innocuous aches and pains one may have. She further stated that how should a policy seeker give such information that does not come under “medical condition” unless they are diagnosed. With the above submissions, the complainant appealed to this Forum to kindly go through the merits of the case and ensure justice to the policy holders. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the complainant ported the policy by submitting portability and proposal forms on 12.01.2017. On the basis of the information provided in the proposal and portability forms the company issued the policy covering complainant’s son Mr. Samrat Chakrabarthy for SI of Rs.10.00 Lakhs. The policy was renewed subsequently for a further period of one year. The insured person was advised to undergo weight reduction surgery by Dr. Surendra Ugale. The complainant approached the company seeking clarification as to whether the said surgery would be covered under the policy by producing Dr. Surendra Ugale letter dated 13.02.2018 justifying the surgery. On evaluation of the document it was observed that the insured has been suffering from ‘disturbed sleep with heavy snoring and pain in knees and back with breathlessness on sustained activity since 2 years and this has resulted in limited mobility, which is causing increase in weight, in spite of all efforts with diet control and daily exercise more than 1 year; additionally, the certificate stated that the complainant has been using C-PAP (Continuous Positive Airway Pressure) since 2 years’ and these material facts were not disclosed at the time of porting the policy. The complainant failed to disclose relevant information about health conditions of the insured person against specific questions in the proposal & portability forms. If the complainant had disclosed true facts about pre-existing conditions of the insured person, at the time of porting the policy, the company would not have accepted the proposal. The policy was terminated under clause VIII.1 of the policy terms and conditions. The complainant subsequently approached the company for re-consideration of its decision to terminate the policy stating that the insured has been using C-PAP since 2 months and Dr. Surendra Ugale has by mistake mentioned it to be 2 years in his letter dated 13.02.2018. The complainant has also submitted letter dated 8.1.2017 from pulmonologist, Dr. A. Jayachandra and also letters from Dr. Surendra Ugale dated 9.3.2018 & 16.03.2018 and on evaluation of these letters the following observations were made.

The pulmonologist states that the insured person was presented to him with complaints of snoring, daytime sleepiness, choking spells with Excessive Daytime Sleepiness and was diagnosed to have classical sleep apnea syndrome. This shows that the insured has been having a history of symptoms prior to the diagnosis of Classical Sleep Apnea Syndrome.

Dr. Surendra Ugale in his letter dated 9.3.2018 again certified that the insured person has been suffering from disturbed sleep with heavy snoring and pain in knees and back with breathlessness on sustained activity since 2 years. This has resulted in limited mobility, which is causing increase in weight in spite of all efforts with diet control and daily exercise for more than a year. Thereafter, in his letter dated 16.03.2018 stated that he had mistakenly written that the complainant has been on C-PAP since two years instead of 2 months. The said letter does not deny the

statement that the complainant has been suffering from disturbed sleep with heavy snoring etc.

Therefore, the company intimated the complainant about rejection of the claim and their stand on termination of the policy under Clause VIII.1 of the policy. With the above submissions the insurer pleaded this Forum for dismissal of the complaint. 19) Reason for Registration of Complaint:- The claim preferred by the complainant was repudiated by the insurer. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a) Policy with terms and conditions.

b) Rejection letter. c) Correspondence with insurer d) Doctor letters.


Pursuant to the notices given by this Forum, both the parties attended the personal hearing on 24.01.2019 at Hyderabad. Both the parties reiterated their contentions stated in the complaint and self contained note respectively.

The insurer rejected the claim and cancelled the policy on the ground that there was non-disclosure of past medical history/conditions, mainly Classical Sleep Apnea Syndrome, at the time of porting the policy to them on 12.01.2017. The Insurer relied upon the duration of the ailment specified by the treating doctor in his first letter dated 13.02.2018, i.e. 2 years. The complainant strongly contended that her son’s problem was diagnosed during December 2017 and pleaded to take letters/ certificates issued by Senior Pulmonologist Dr. A. Jayachandra and treating doctor Dr. Surendra Ugale letters as proof as she did not have any background papers which were given away to the hospital. This Forum observed that the pulmonologist letter was dated 08/12/2017 which was much before the proposed surgery and enquiries about the coverage of the surgery by the complainant. Before any query why that letter was obtained by the complainant was not known and went unexplained. Hence, the complainant was asked to submit purchase details of C-PAP machine by submitting a copy of the purchase invoice. The complainant, in her letter dated 02.02.2019, intimated that she had nothing more to submit in support of her contentions. Obtaining a duplicate purchase invoice/bill from the supplier/manufacturer is not a difficult task for any person. C-PAP machines are supplied by very few suppliers and definitely they keep track of their customers for service related issues. C-PAP machine purchase details would have strengthened the case of the complainant. As she could not produce invoice, this Forum is of the opinion that there is no need for the intervention in the decision of the insurer.

A W A R D

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

submissions made by both the parties during the course of personal hearing, the complaint

being devoid of merit is dismissed without any relief.

Dated at Hyderabad on 7th day of FEBRUARY, 2019.

(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. Rahim Virani ……………The Complainant

Vs

National Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. Rahim Virani,

Regal Footwear, Gandhi Chowk,

Nizamabad, Telangana– 503 001.

2. Policy No. /Collection No. Type of Policy Duration of Policy/Policy period

551302/48/16/8500000871


From 01.01.2017 to 31.12.2017


Smt. Ruksana Virani

Mr. Jamaluddin Virani

4. Name of the insurer National Insurance Co. Ltd.


6. Reason for repudiation Rejection of Mediclaim due to dishonor of cheque



9. Amount of Claim Rs.1,92,330 /-




Rule 13 (b) – – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 27.12.2018 & 10.01.2019 / Hyderabad



b) For the insurer Sri T.B. Rao, Manager Smt. K. Sharada Kamble, Asst. Manager Dr. Leela Brindavanam, AO



17) Brief Facts of the Case: The complainant’s father took National Mediclaim policy and covered himself and his wife from 2003 year and the policy was continuously renewed thereafter. For renewal of the policy from 01.01.2017 to 31.12.2018 the insured issued his cheque bearing No. 689602 dated 22.12.2016 drawn on Vijaya Bank for Rs.41,201/-. As per the complaint filed, the complainant’s mother took treatment in S.S.K. Hospital, Nizamabad and underwent stunts to her arteries during November, 2017 and he filed reimbursement claim for Rs.192330/- with the insurer during December 2017. The insurer rejected the reimbursement claim stating that the premium cheque was dishonored and hence, the claim cannot be payable

for non-compliance of Section 64V(B) of the Insurance Act, 1939 and policy was cancelled for non-realisation of consideration. The complainant contended that there was no communication from the insurer regarding dishonor of premium cheque only after reporting the claim the insurer intimated about it. The complainant represented to the insurer to review the decision, but in vain. Aggrieved, the complainant, Mr. Rahim Virani, filed complaint with this Forum. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that his father took Mediclaim Policy with Respondent Insurer during 2003 year and covered himself and his mother. The policy continuously renewed without any break. He paid the premium for renewal of the policy from 01.01.2017 to 31.12.2017 and issued his cheque bearing No. 689602 dated 22.12.2016 drawn on Vijaya Bank, Nizamabad for Rs.41,201/-. His mother underwent treatment for her heart ailment at SSK Hospitals, Nizamabad and they preferred the claim for Rs.1,92,330/- during December 2017. On reporting the claim, the insurer intimated that they could not admit the claim as the premium cheque was dishonored for technical reasons. The complainant stated that they have issued the cheque after maintaining the sufficient balance in the account. There was no fault on their side and dishonor of cheque was due to bank’s fault. The insurer had not intimated about dishonor of the cheque to them until they report the claim. As there was no fault, the insured person cannot be penalized by rejection of genuine claim. The complainant further stated that he had escalated the matter to the Grievance Cell of the insurer but there was no resolution for their problem. Hence, he pleaded for the intervention of this Forum for Redressal of his grievance. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the premium cheque issued by the insured on 22.12.2016 was deposited to our office account for clearance and the same was returned by the bank stating the reason “Others-CTS Rejected” on 28.12.2016. Due to dishonor of the cheque, as per company norms, we have passed cancellation endorsement, in compliance to the provisions of Section 64 V(B) of the Insurance Act, 1939 and it was intimated to the insured vide our letter dated 28.12.2016 by registered post ack. due. However, the ack. due card was not received from the postal department. The complainant filed claim for Rs.1,92,330/- to the policy servicing TPA and the claim was repudiated for dishonor of the premium cheque. With the above submissions the insurer pleaded for dismissal of the complaint as the claim

was rightly rejected in terms of the policy and in compliance to the provisions of the Section

64 V(B) of the Insurance Act, 1939.


The claim preferred by the complainant was rejected by the insurer. As the complaint fall under Rule 13(d) 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. Rejection letter c. Correspondence with insurer d. Self contained note

e. Bank statement 21) Result of the personal hearing with both the parties:

Pursuant to the notices given by this Forum, both the parties attended personal hearing at Hyderabad on 27.12.2018. Both the parties reiterated their contentions for and against the complaint. The complainant pleaded that he was not informed about non-payment of cheque by the insurer as he was their customer since a long time. He had not received any registered letter said to have been sent by the insurer intimating dishonor of his premium cheque due to technical reasons and not for insufficient funds. He further stated that he had maintained balance in the account. He demanded proof of delivery of insurer’s communication to him. Had he been communicated he would have paid the premium immediately. The insurer stated that they were not under any mandatory obligation to inform the insured about their decision to cancel the policy for non-realisation of premium amount. Once, the premium cheque is returned un-paid for any reason, the policy shall be cancelled ab-initio for non-compliance to the provisions of Section 64 V(B) of the Insurance Act, 1939. They further stated that they have sent a communication to the Postal Dept. to provide delivery particulars and still awaiting their response. The complainant was directed to furnish his bank statement from the date of issuance of the premium cheque to the date of hospitalization of insured person. The insurer vide their mail dated 24.01.2019 communicated that the Postal authorities informed them that they could not search the details with the furnished information. The complainant also had furnished the bank statement of Vijaya Bank, Nizamabad bearing account No. 401800300000777, in the name of Regal Foot Wear. On verification of the statement, it was observed that apart from the cheque bearing No. 35-689602 issued towards premium for Rs.41,201/- two more cheques 35-689604 & 35-689606 were also returned 0n 12/01/2017 & 10/02/2017 and cheque return charges of Rs. 382/- was debited by the bank on respective dates. As there was history of cheque return, the complainant failed to verify the status of premium cheque, either with the banker or with the insurer. Further, he is not maintaining sufficient balance in the account. As and when he issued a cheque he is transferring the amount/depositing the cash equal to the issued cheque amount. Since, the cheque issued to the insurer towards renewal of the Mediclaim policy, returned unpaid, there was balance in the account and it was utilized for other purposes by the insured without complying with the bank rules. Since complainant/insured failed to maintain sufficient bank balance for the cheque issued to the insurer in his account, this Forum is of the opinion that there was no infirmity in the decision of the insurer in cancellation of the policy for non-realisation of the cheque.

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 being devoid of any merit is dismissed without any relief.


(I. SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. Ch. Sandeep ……………The Complainant

Vs

National Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. Ch. Sandeep,

Flat No.G2, Ist Floor, YSR Enclave,

Road No.25, Panchavati Colony,

Manikonda, Hyderabad – 500 089.


560702501710000457

Parivar Mediclaim Policy

From 15.09.2017 to 14.09.2018


Mr. Ch. Sandeep

Mr. Ch. Sandeep

4. Name of the insurer National Insurance Co. Ltd.




8. Nature of complaint Short settlement of mediclaim

9. Amount of Claim Rs.355576 /- (3 claims)

10. Date of Partial Settlement 03.02.2018, 21.03.2018 & 13.08.2018


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. Complaint how disposed Allowed (Statistical purpose)


15) Brief Facts of the Case: The complainant, Mr. Ch. Sandeep took Parivar Mediclaim Policy with the respondent Insurer for himself for a floater SI of Rs.5.00 Lakhs in 2014 year and it was continuously renewed till date. The present policy was renewed from 15.09.2017 to 14.09.2018. As per the complaint filed, the complainant met with a road accident on 26.01.2018 while travelling in a car near Hubli. He was admitted in Suchirayu Hospital, Hubli and was treated for accidental injuries from 26.01.2018 to 03.02.2018. The claim preferred by the hospital, under cashless treatment for Rs.237509/- was approved and settled by the insurer for Rs. 1,99,179/-. To undergo further treatment he got admitted in Sunshine Hospital, Secunderabad from 04.02.2018 to 05.02.2018. He filed a reimbursement claim for Rs.67067/- with the insurer/TPA and insurer rejected the claim alleging that there was no active line of treatment. Subsequently, the insured/complainant was admitted for the same ailment in Max Cure Hospitals, Hyderabad from 20/03/2018 to 21/03/2018 and the TPA allowed cashless facility and approved the claim for Rs.39,411/-. The complainant approached the grievance cell of the insurer for non-settlement of his Sunshine Hospital admission claim but, there was no revision in the decision of the insurer. Aggrieved, Mr. Ch. Sandeep filed complaint with this Forum. 16) Cause of Complaint: Short settlement of Mediclaim.


The claim preferred by the complainant was rejected by the insurer. As the complaint fall under Rule 13(d) 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.11,410/- on 16/08/2018. The entitlement under the policy was restricted to 50% of SI for all the expenses incurred for any one illness. The complainant’s eligibility for the fractures sustained in an accident on 26/01/2018 was 50% of the sum insured, i.e. 50% of Rs.5.00 Lakhs = Rs.2.50 Lakhs. The insurer reimbursed/paid entire eligible amount under the policy (Rs.199179/- +Rs.39,411/- + Rs. 11410/-). Hence, the complainant had consented to withdrawn his complaint against Respondent insurer for short settlement of Mediclaim and requested to close the complaint.

A W A R D The complaint is treated as resolved & closed as “Allowed” for statistical purpose.


(I. SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA

AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mrs. Parveen Bano ……………The Complainants

Vs

M/s Apollo Munich Health Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).G-003-1819-0167

Award No: I.O.(HYD)/A/GI/0207/2018-19

1. Name & address of the complainant Mrs. Parveen Bano

H.No.3-1-231, Plot No.52, Sowbhagya Nagar,

L.B. Nagar, Hyderabad – 500074.


130100/11129/AA00634407

Energy Silver Insurance Policy

From 30.06.2017 to 29.06.2018


Mrs. Parveen Bano

Mr. Pankaj Anantra Bhuva

4. Name of the insurer M/s Apollo Munich Health Insurance Co. Ltd.


6. Reason for repudiation Waiting period & non-disclosure


8. Nature of complaint Rejection of mediclaim & cancellation of policy

9. Amount of Claim Rs.15265/- + Rs. 19916/-

10. Date of Partial Settlement NIL

11. Amount of Relief sought Rs.19916 /-

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




b) For the insurer Dr. Mahesh Bohini, Manager



17) Brief Facts of the Case: The complainant, Mrs. Parveen Bano, stated that her husband Mr. Pankaj Anantra Bhuva took health insurance policy with Respondent Insurer and covered her under “Energy-Silver Plan” policy from 30.06.2017 to 29.06.2018 for a SI of Rs.3.00 Lakhs by disclosing her previous medical history. The complainant stated that she was admitted in Kamineni Hospitals, Hyderabad on 25.07.2017 and was discharged on 26.07.2017 for complaints of nasal block, headache, low grade fever and giddiness. Her ailment was diagnosed as ‘Sinusitis’. She filed reimbursement claim for Rs.15265/-. The insurer rejected the claim stating that there was specific waiting period of 2 years for the diagnosed ailment. The insurer sent notice of closure on 22.06.2018 by citing a reason that colostomy closure surgery was not disclosed in the proposal form. The complainant stated that she had represented to the insurer on 05.07.2018 to refund the premium paid for the policy, as the notice was given on invalid grounds. There was no response from the insurer. Aggrieved, Mrs. Parveen Bano filed complaint with this Forum. 18) Cause of Complaint: Rejection of mediclaim a) Complainant’s argument: The complainant submitted that the advisor of the insurer at Apollo Hospitals, Hyderabad adviser her and her husband ‘Diabetes patient insurance policy –Energy Plan’ and she only completed the proposal form and collected all her surgical profile reports and did not allow them to complete/fill the forms and collected the premium cheque for Rs.19,916/-. She further stated that she underwent pre-acceptance medical tests at S.B. Diagnostics and there the doctor took her signature on a blank form. She stated that she had disclosed her past three surgical histories – Hysterectomy on 23.06.2012, Colostomy on 02.07.2012 and colostomy closure on 28.08.2012 and submitted its reports. They collected the pre-acceptance medical reports from the insurer and noted that the doctor of diagnostic centre committed a grave mistake in ultra sound test report of abdomen dated 07.06.2017. He recorded presence of ‘uterus’ whereas uterus was removed in the TLH surgery done on 27.06.2012. The claim preferred for sinusitis treatment for Rs.15,265/- by her was rejected by the insurer stating that there was specific waiting period of 2 years on 02.08.2017. Just before renewal due date the insurer sent notice of termination dated 22.06.2018 alleging that she had not disclosed history of colostomy closure on 03.09.2012. She stated that she had sent reply to the notice asking the insurer to review the medical reports submitted by her carefully and also stated that as per clauses she need not disclose beyond five years past medical history. She stated that she claimed refund of premium as policy was cancelled on un-reasonable ground. She pleaded for the intervention of this Forum for Redressal of her grievance. b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the complainant’s husband proposed “Energy Insurance – Silver Plan Policy” to her and submitted enrolment form after going through all the terms and conditions of the policy. The proposer also signed the declaration that the statements made in the enrolment form are true and complete. Basing on the enrolment form the policy was issued from 30.06.2017 for a SI of Rs. 3.00 Lakhs. The company received a reimbursement claim on 29.07.2017 for Rs.15,265/- for the patient’s admission from 25.07.2017 to 26.07.2017 and her ailment was diagnosed as ‘sinusitis’. The claim could

not be admitted as the diagnosed ailment had a specific waiting period of 24 months in the policy. Hence, the claim was rejected. The insurer further submitted that the complainant alleged that she had submitted all medical reports and has undergone pre-medical check-up and hence the company was aware of her medical conditions. The insurer stated that pre-policy check up shows only the basic vitals. However, in the pre-policy check up sheet it was clearly mentioned that “have you ever suffered any illness/surgery/accident not mentioned above?” to which the reply given was “NO”. The surgery of colostomy cannot be diagnosed with the test plan with pre-policy check up. Hence, the onus rests with the proposer/complainant to provide the details of the surgery if any undergone. They were not disclosed in the enrolment form or pre-policy check up reports. Since, ‘colostomy’ is a declined risk as per underwriting guidelines and hence the policy stands cancelled due to incorrect/non-disclosure of material facts. The point raised by the complainant that ‘uterus’ removal was irrelevant here in terms of non-disclosure of surgery as both are not related to each other as one is gastrotomy and the other is reproductive organ. Therefore, it was clear that the complainant had not disclosed the material facts of surgery undergone while taking the policy the cancellation in terms clause 4.j of the policy was in order. With the above submissions, the insurer pleaded for dismissal of the complaint. 19) Reason for Registration of Complaint:- The claim preferred by the complainant was rejected by the insurer and policy cancelled. As the complaint falls under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a) Policy with terms and conditions.

b) Rejection letter. c) Correspondence with insurer d) Medical reports


Pursuant to the notices given by this Forum both the parties attended personal hearing at Hyderabad on 05.02.2019. Both the parties reiterated their contentions for and against the complaint.

The complainant strongly contended that the advisor of the respondent insurer obtained signatures on the blank form and collected all reports for issuance of the policy. At the time of her undergoing pre-policy check-up also she was asked to sign the blank form by the doctor. The insurer cancelled the policy on the ground of non-disclosure of complainant’s surgical history which was beyond five years. The complainant raised her objection to the termination notice issued by the insurer on 4.j clause of the policy and demanded refund of the premium pointing out discrepancies in the medical reports while accepting that her claim for sinusitis treatment was hit by waiting period clause of the policy. The policy clause 4.j referred by the insurer deals with non-disclosure or misrepresentation only. As per the Regulator’s guidelines, in case of cancellation of the policy on the ground of misstatement or suppression of a material fact, and not on the ground of fraud, the premium collected on the policy shall be paid to the insured. Though

the complainant raised her claim for refund of premium, the insurer had not refunded it. Hence, the insurer is directed to refund the premium collected under the policy.

A W A R D Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the insurer is directed to refund the premium of Rs.19,916/- (subject to deduction of minimum policy administration charges) with interest in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017. In the result, the complaint is allowed.



h) 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.

i) 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.

j) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I. SURESH BABU)

INSURANCE OMBUDSMAN


AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. K. Santosh Kumar ……………The Complainants

Vs

M/s Religare Health Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant

Mr. K. Santosh Kumar,

H.No.8-71/4/1, Sainagar Colony, Balapur,

R.R. District – 500 005.


11288749

Platinum WW Travel Insurance Policy

From 17.05.2017 to 12.11.2017


Mr. K. Monaiah

Mr. K. Monaiah

4. Name of the insurer M/s Religare Health Insurance Co. Ltd.


6. Reason for repudiation Non-disclosure of PED - HTN & Asthma


8. Nature of complaint Rejection of Overseas Mediclaim

9. Amount of Claim US$ 15,000


11. Amount of Relief sought US$ 15,000





a) For the complainant Sri K. Monaiah, Father/Insured person

b) For the insurer Dr. S. Vijay, Head-U/W.



17) Brief Facts of the Case: The complainant, Mr. K. Santosh Kumar took Platinum WW Travel Insurance Policy for his parents for their visit to USA from 17.05.2018 to 08.11.2018 for SI of US$ 50000 each. As per complaint filed, his father Mr. K. Monaiah was admitted in Norton Audubon Hospital, USA on 26.10.2017 with a complaint of left side chest pain. The complainant sent a request for approval of cashless treatment to the Medical Assistance Department of the insurer. The request was declined stating the reason as non-disclosure of pre-existing medical conditions, i.e. hypertension and asthma. After treatment he was discharged on 27.10.2017. He incurred around US$ 15000. The complainant filed reimbursement claim and approached Grievance Department stating that the information was furnished and there was no non-disclosure of material facts. But there was no revision in the decision of the insurer. Aggrieved, Mr. K. Santosh Kumar filed complaint with this Forum. 18) Cause of Complaint: Rejection of claim under Overseas Medical Travel Ins. Policy. a) Complainant’s argument: The complainant submitted that when his father suffered from chest pain on 26.10.2017 at USA he was shifted to Baptist Hospital and there the doctor did ECG test and referred him to join in the hospital for further treatment. So he was joined in the hospital. When a claim was filed for the treatment expenses, the insurer rejected the claim alleging that there was non-disclosure of health conditions of ‘Asthma & BP’. The complainant stated that they have disclosed his father’s health conditions to the agent who had come to them for the policy. He further referred to the policy schedule and stated that his father’s diabetes was recorded against ‘Other PED’ column of the policy and under ‘PED column’ it was recorded as ‘Others’ which they assumed that all other health issues of his father was noted against that column. The rejection on the ground of non-disclosure was not acceptable as they have not suppressed any health conditions of insured person/s. The complainant stated when he represented to review the claim; the insurer rejected the claim with another reason that non-cardiac chest pain due to orthopedic condition was not payable. The insurer rejected the claim on two different reasons. The complainant pleaded for intervention of this Forum for settlement of claim by the insurer. b) Insurer’s argument:

In the Self Contained Note, the insurer submitted that the insured person was admitted in Norton Anudubon Hospital, USA from 26.10.2017 to 27.10.2017 for treatment of left sided chest pain. On the basis of documents received from the hospital it was noted that the insured person had pre-existing symptoms/conditions, i.e. hypertension and asthma at the time of taking the policy. As they were not disclosed, the cashless request was declined as per clause 5.1 of the policy. Further it was noted from the X-ray report that the insured had a sub-acute/mid body clavicle fracture with mild inferior displacement of distal fragment of unknown chronicity (as per the patient he had history of accident in 1995). As per the discharge summary the insured person had non-cardiac chest pain due to lifting of his grand children.

The insurer submitted that the policy was purchased through on-line and had to answer certain questions with respect to any pre-existing history w.r.t. any illness/disease/injury. He failed to disclose his hypertension and asthma history against relevant questions in the online web portal proposal. The insurer stated that the contention of the complainant that two separate PEDs were marked in the policy was wrong and denied. The insurer stated that under PED condition the primary category is specified as “others” whereas in the following column “Other PED” specifies the sub-category as “Diabetes”. The claim preferred by the complainant was rejected on two grounds, i.e. non-disclosure of previous health conditions (clause 5.1) and under clause 2.1.3(iii) which categorically excluded any orthopedic treatment taken during the policy period by the insured person.

With the above submissions, the insurer pleaded for dismissal of the complaint as it was rightly rejected in terms of the policy. 19) Reason for Registration of Complaint:- The claim(s) preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal:

a) Policy with terms and conditions.

b) Rejection letter. c) Correspondence with insurer d) Self Contained Note with its enclosures.

e) Discharge Summary & other medical documents

21) Result of hearing with both parties: Pursuant to the notices given by this Forum, both the parties attended personal hearing at Hyderabad on 05.02.2019. Both the parties advanced their arguments for and against the complaint. The complainant strongly contended that when he had disclosed ‘diabetes’ why he fail to disclose less complicated hypertension and asthma and he was not on any medication for asthma. The complainant further stated that before undertaking overseas travel he himself underwent medical tests to check his fitness to travel and only after doctor clearing the same he travelled to USA.

The insurer by submitting copy of web-filled proposal form stated that the

complainant had not disclosed his father’s hypertension and asthma history and he had

disclosed only diabetes. Hence, it was only shown under Other PED column of the policy. If

the same were disclosed they too could have reflected under the policy. The insured person

was hospitalized for chest pain and he was evaluated to rule out any cardiac abnormality in

view of past history of hypertension and diabetes as he was on medication for the same

before travel. After evaluation, the final diagnosis was non-cardiac chest pain. Hence, there

was non-disclosure of pre-existing ailments – hypertension and asthma. For non-disclosure

the claim was rejected. The insurer further stated that an X-ray was taken at the hospital on

27/10/2017 and as per the x-ray report the insured had sub-acute/mid-body clavicle

fracture with mild inferior displacement of distal fragment of unknown chronicity (as per

insured patient he had history of accident in 1995). Hence, the claim was also not admissible

under clause 2.1.3(iii) – any treatment of orthopedic diseases or conditions except for

fractures, dislocation and/or injuries suffered during the period of insurance. The total claim

received by the company from the hospital was for US$ 16152.

The treating doctor opined in his discharge summary that the patient was admitted

with left-sided chest pain and after evaluation of cardiac enzymes he stated it as non-

cardiac chest pain and opined that it was most likely coming from his shoulder joint

secondary to lifting of his grandchildren and was also advised to see an orthopedic doctor

for his left shoulder pain. The patient had past history of road accident and fracture of

clavicle bone. The claim of the complainant was hit by policy exclusion clause 2.1.3(iii) and

the insurer’s decision of repudiation was upheld.

A W A R D

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

submissions made by both the parties during the course of personal hearing, the complaint

being devoid of any merit it was dismissed without any relief.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mrs. B. Naga Ratnamma ………………The Complainant

Vs

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




Mrs. B. Naga Ratnamma,

W/o Late B. Uchirappa,

House No.1/1778, Gandhi Nagar,

Yemmiganuru Post, Kurnool-518360, AP.


433101/48/2011/1065

Happy Family Floater Insurance Policy

From 24.02.2011 to 23.02.2012

3. Name of the insured/Policy-holder Mr. B. Uchirappa





8. Nature of complaint Mediclaim settled but amount not received by the complainant. P.A. benefit not paid

9. Amount of Claim Rs.266931/- + Rs.3.00 Lakhs

10. Date of Partial Settlement Nil

11. Amount of Relief sought Rs.266931/- + Rs. 3.00 lakhs

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





b) For the insurer Smt. Nirmala N Dhepe, Regional Manager Sri P. Pradeep Kumar, Manager

15. Complaint how disposed Partially Allowed



The deceased, Bana Uchariah, took Happy Family Floater Policy with the respondent insurer and covered his family for a floater SI of Rs. 3.00 Lakhs from 24/02/2011 to 23/02/2012. The policy had an add-on cover of Personal Accident Benefit on payment of additional premium. The insured person met with road accident on 18/03/2011 and died while undergoing treatment on 27.03.2011. Smt. B. Naga Ratnamma, wife of the insured deceased, filed complaint for payment of hospitalization expenses for Rs.2,66,931/-. The TPA processed the claim and settled it for Rs.2,19,970/-. Since it was not credited to complainant’s account or her husband’s account she insisted to furnish the details of account to which it was credited. The details were not furnished by the TPA or the insurer. She appealed to the Grievance Cell of the insurer and it was informed to her that the cheque was realized on 30.12.2011 itself by furnishing some account details. Aggrieved, Smt. Bana Nagarathnamma filed complaint with this Forum. 18) Cause of Complaint: Non receipt of settled Mediclaim claim amount and non-settlement of Personal accident death benefit under the policy. a. Complainant’s argument: The complainant submitted that her deceased husband late Bana Ucharaiah was covered under insurer’s Happy Family Floater Policy for Medical expenses reimbursement and Personal accident benefits for a SI of Rs.3.00 Lakhs each. The policy coverage was from 24.02.2011 to 23.02.2012 and he paid the premium of Rs.9340/-. On 17.03.2011, while coming home on his motor cycle he met with accident and sustained head injury. While undergoing treatment he died on 27.03.2011. The claim was filed for reimbursement of medical expenses incurred at Rs.2,66,931/- along with police documents to Adoni branch of insurer on 15.07.2011. During August 2011 she was informed by the postman that a letter was received from the TPA which was addressed to her husband and it was not delivered to her. When she contacted her Adoni branch they refused to interfere in the matter and directed her to approach TPA only. In spite of several trips to Hyderabad and Adoni branch the cheque was not given to her and every time they directed her that it would be sent by post only on her name. The status of her claim for Personal Accident benefit was also not known. When she approached for the same, the Adoni branch staff directed her to contact TPA and DO Kurnool only. Due to her ill-health and family problems she could not follow it up further for some time. When she took-up the matter further, it was informed that the claim was settled for Rs.2,19,970/- and a cheque/DD bearing No. 433424 dated 13.08.2011 drawn on HSBC Bank was cleared on 30.12.2011. She stated that she do not know to whom this amount was paid. When she took up the issue with Regional Office, Hyderabad on 23.07.2018 they refused to take-up the issue and stated that the claim was closed. The complainant stated that she was again directed to approach Adoni branch for personal

accident claim. When she approached Adoni branch they refused to admit the PA claim stating that no additional premium was paid for coverage of add-on benefit of PA. The complainant stated that it was a built-in cover and there was no need to pay any additional premium for its coverage. The complainant pleaded for the intervention of this Forum, for settlement of her Mediclaim and Personal Accident death benefit claims by the insurer. b. Insurer’s argument:

The insurer, in their Self Contained Note, submitted that the claim filed by the complainant for reimbursement of hospitalization expenses of deceased insured Bana Uchariah for Rs.2,66,931/- was settled by E-Meditek TPA for Rs.2,19,970/-. The E-Meditek TPA informed vide their mail dated 23.03.2018 & 16.01.2019 that the amount was cleared/paid on 30.12.2011 itself. The representatives of the insurer further stated that Personal Accident is not an in-built cover as claimed by the complainant. It is an ‘add-on’ cover on payment of extra premium. Since no extra premium was paid, PA benefit was not payable under the policy and hence rejected. A detailed letter about settlement of claim and non-coverage of Personal Accident cover under the policy was sent on 11.12.2018. With the above submission, the insurer pleaded for dismissal of the complaint. 19) Reason for Registration of Complaint:

The claims preferred by the complainant were not settled by the insurer. As the complaint fall under Rule 13(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) Correspondence with insurer c) Self contained note 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 12.02.2019. The complainant reiterated that her claims were not settled by the insurer. The representatives of the insurer stated that after repeated reminders to inform the account details to which the settled amount was credited, the E-Meditek informed that the amount of Rs.2,19,970/- which was said to have been transferred to the deceased/beneficiary account, late Bana Uchariah was not actually not credited to his account but the clearing was cancelled by the Bank and credited back the amount E-Meditek account on 30.12.2011. Hence, we request the complainant to furnish NEFT details of the legal heir/s along with copies of following original claim documents for verification and return:

i. Legal heir certificate ii. Death certificate of late Bana Uchariah iii. Aadhar card/s of the legal heir/s iv. Original bank pass book/s.

The complainant agreed to submit the required documents and claimed interest for inordinate delay in settlement of the claim. The insurer pleaded to consider payment of interest from 23.07.2018 as the claim was not pursued for several years by the complainant

when it was settled and communicated by the TPA during August 2011 itself. The request of the insurer was not accepted as the amount was with them and complainant was not properly addressed and guided by the insurer when she approached their Adoni branch and TPA. The insurer is directed to pay the interest from 01.09.2011 to till the date of this award. On perusal of the documents placed on record, policy copy and on scrutiny of the premium computation sheet filed before the Forum the deceased insured had not paid the premium for extension of policy for ‘PA add-on cover’ and hence the claim of the complainant for payment of PA death benefit is not considered.

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, the insurer is directed to pay Rs.2,19,970/- (Rupees Two Lakhs Nineteen thousand Nine hundred and seventy only) towards full and final settlement of the Mediclaim. The complainant is also directed to submit the additional claim documents stated during hearing to the insurer for settlement of the claim. The insurer is also directed to pay the interest from 01.09.2011 on Rs.2,19,970/- till the date of this award in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017. In the result, the complaint is partially allowed.



k) 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.

l) 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.

m) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I. SURESH BABU )

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. B. Suryanarayana ………………The Complainant

Vs

M/s Star Health and Allied Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD) G -044-1819-0150


1. Name & address of the complainant Mr. B. Suryanarayana, H.No.1-10-81, Flat No.301, Chidambar Residency, Street No.9, Main Road, Ashoknagar, Hyderabad – 500 020.


P/131127/01/2018/003016 Star Comprehensive Insurance Policy From: 17.08.2017 to 16.08.2018


Mrs. B. Vimala Mr. B. Suryanarayana

4. Name of the insurer M/s Star Health and Allied Ins. Co. Ltd.


6. Reason for repudiation PED – Diabetes Mellitus




10. Date of Partial Settlement Nil

11. Amount of Relief sought Rs.25,256/-






b) For the insurer Sri M. Ravi Kumar, AGM (Legal) Dr. Annapurna, Manager




The Complainant, Mr. B. Suryanarayana, took Star Comprehensive Insurance Policy for a SI of Rs.5.00 Lakhs from 17.08.2017 to 16.08.2018 and covered himself and his wife. As per the complaint filed, his wife Smt. B. Vimala was admitted in Eashwar Lakshmi Hospital, Hyderabad on 13.01.2018 and was diagnosed to have been suffering from viral pyrexia, UTI and diabetic ketoacidosis (DKA). The insurer initially approved Rs.5000/- for cashless treatment. On submission of final bill the insurer rejected the total claim for the incurred hospitalization expenses from 13.01.2018 to 16.01.2018 for Rs.29,500/- stating that treatment was for diabetes and some manipulation in ICP was noticed. The complainant stated that she filed reimbursement claim and it was rejected under PED exclusion of the policy. The complainant represented to the insurer to review the decision. There was no revision in the decision of the insurer. Aggrieved, Mr. B. Suryanarayana approached this Forum for resolution of his grievance. 18) Cause of Complaint: Rejection of Hospitalization claim.

a. Complainant’s argument: The complainant stated that his wife was hospitalized for acute stomach ache, vomiting and

fever at Eashwar Lakshmi Hospital, Hyderabad from 13/01/2018 to 17/01/2018. The policy

was taken by him during August 2017, duly disclosing diabetes history of his wife. The insurer

initially gave cashless approval for Rs.5000/- and it was declined at the time of discharge

alleging that the ailment suffered by his wife was a complication of diabetes. He strongly

contended that the treating doctor clearly stated in the discharge summary that the treatment

undergone by his wife was not a complication of diabetes. Hence, rejection of claim by the

insurer on the ground of pre-existing disease exclusion was unlawful and unfair. The

complainant pleaded for the intervention of this Forum for redressal of his grievance and

settlement of the claim.

b. Insurer’s contentions: In the Self Contained Note, the insurer submitted that the claim was reported during first year

policy and the policy was issued noting ‘Diabetes and its complications’ as PED to the

complainant’s wife Smt. B. Vimala. The complainant’s wife was admitted with complaints of

acute gastro-enteritis vomiting, high fever, poor oral intake. The hospital sent pre-

authorization request with provisional diagnosis of ‘Gastro Enteritis’ and it was approved for

Rs.5000/-. But on verification of indoor case papers and other documents at the time of

discharge and while seeking enhancement to the earlier approved amount it was observed

that there was change in the diagnosis from diabetic ketoacidosis to Viral Pyrexia, UTI. The

insured patient was primarily diagnosed for Diabetic Ketoacidosis, which was a complication of

diabetes. Since, diabetes was recorded as pre-existing disease the claim was rejected. It was

also noted that the Indoor case papers were manipulated. Hence, relying on the primary

diagnosis, the reimbursement claim was also rejected.

With the above submissions, the insurer pleaded for dismissal of the complaint as

the claim of the complainant could not be considered for the reasons stated above.


The claim preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(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) Correspondence with insurer c) Self Contained Note with enclosures

d) Discharge summary e) Rejection letter

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 12.02.2019. The complainant reiterated the contents of the complaint. The representatives of the insurer stated that they have further reviewed the claim and agreed to settle the claim for Rs.24,572/- towards fever management after deducting diabetes related treatment expenses for which the complainant was also consented.

A W A R D

The insurer is directed to pay Rs.24,572/- immediately as agreed, without any further loss of

time. The complaint is treated as resolved & closed as ALLOWED.



n) 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.

o) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I. SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Mr. K. Gopala Krishnam Raju ………………The Complainant

Vs

M/s The New India Assurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. K. Gopala Krishnam Raju,

H.No.8-3-222/B7/35/36, D-92 & 93,

Flat No.304, Sri Ramana Enclave,

Madhura Nagar, Hyderabad – 500 038.


960000341728000000079

Floater Mediclaim Policy

From 09.09.2017 to 08.09.2018


Mrs. K. Vasantha Rajya Lakshmi

Mr. K. Gopala Krishnam Raju

4. Name of the insurer M/s The New India Assurance Co. Ltd.


6. Reason for repudiation As per the policy clause No.3.14.1










a) For the complainant Self Smt. K. Vasantha Rajya Lakshmi, wife

b) For the insurer Sri J S D Guru Raja, Manager Dr. N. Nivedita, Asst. Manager, Dr. Sumalatha, A.O. (Medical) Dr. J. Shyam, A.O. (Medical) Dr. Pratap – GHPL TPA




The complainant, Mr. K. Gopala Krishnam Raju, took New India Floater Mediclaim Policy with Respondent Insurer and covered himself and his wife from 09.09.2017 for a floater SI of Rs. 5 Lakhs. As per the complaint filed, his wife Smt. K. Vasantha Rajya Lakshmi was hospitalized from 18.04.2018 to 19.04.2018 at Care Hospitals, Hyderabad and underwent treatment for skin ailment. She was administered with Inj. Rituximab during hospitalization period. On rejection of cashless treatment request, the complainant filed reimbursement claims for Rs.1,81,747/-. The insurer rejected the same quoting policy exclusion 4.1 and policy clause 3.14.1 in support of their rejection. The complainant represented to the Grievance Cell of the insurer to review the decision, but GRO upheld the earlier decision of repudiation. Aggrieved, Sri K. Gopala Krishnam Raju filed complaint with this Forum. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that his wife, Smt. K. Vasantha Rajya Lakshmi, was a known case of ‘Pemphigus Vulgaris’ from 2013 year and due to its recurrence, she got admitted in Care Hospitals, Hyderabad on 18.04.2018, on the advice of treating doctor. During the course of her hospitalization, she was treated with Inj. Rituximab and other medications. The hospital sent preauthorization request for cashless treatment. The processing TPA declined the same under PED exclusion. After discharge, he filed reimbursement claim for Rs.97,172/-. The insurer rejected the same quoting policy PED exclusion clause 4.1 and Policy clause 3.14.1. The complainant stated that he had represented to the GRO of the company by submitting a letter from the treating doctor who explained clearly the need for hospitalization as the injection being administered for the first time. The insurer’s Grievance Cell had not reviewed their decision. He further stated that his wife was administered with second dose of Inj. Rituximab on 03.05.2018 under Day care and he incurred Rs.84,575/- for the treatment. He filed the claim and it was also rejected. He pleaded for the intervention of this Forum for Redressal of his grievance. b) Insurer’s argument:

In the Self Contained Note, the insurer submitted that the complainant and his wife are covered under Floater Mediclaim Policy issued by them for SI of Rs.5 Lakhs from 09.09.2017. The complainant’s wife, Smt. K. Vasantha Rajya Lakshmi, was admitted in Care Hospitals, Hyderabad on 18.04.2018 on recurrence of ‘Pemphigus Vulgaris’ which she was diagnosed during 2013 year. The hospital sent pre-authorization request to provide cashless treatment and it was declined by the claims processing TPA on the ground of pre-existing ailment. She was administered with Inj. Rituximab and the complainant filed claim towards medical expenses incurred for the same. After discharge, the complainant filed reimbursement claim for Rs.97,172/-. After scrutiny of all medical documents filed in support of the claim, the claim was rejected under PED exclusion clause 4.1 and also 3.14.1 clause of the policy. The insured person was diagnosed to have been suffering from ‘Pemphigus Vulgaris’ during 2013 and the policy inception date was from 09.09.2017. She underwent treatment for her earlier diagnosed ailment by administration of inj. Rituximab only. The ailment fell under Pre-existing exclusion clause of the policy. Further, on rejection of claim, the complainant represented to the GRO along with a certificate/letter issued by treating doctor stating that the insured person facing side effects due to her previous treatment, it was decided to administer Inj. Rituximab which was one of the first lines of treatment for her diagnosed ailment. Since it had many side effects like hypotension, chills, fever and anaphylaxis it was compulsory to administer the injection Rituximab in MICU under continuous monitoring of the patient. However, on further evaluation of submitted medical documents, the claim could not be admitted in terms of the policy in lieu of policy clauses 4.1 & 3.14.1.

With the above submissions, the insurer pleaded for dismissal of the complaint. 19) Reason for Registration of Complaint:-

The claim preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal:


b) Correspondence with insurer c) Self Contained Note with its enclosures. d) Discharge summaries. e) Old claims settlement details

21) Result of hearing with both parties: Pursuant to the notices given by this Forum both the parties attended personal

hearing at Hyderabad on 07.02.2019. The complainant stated that the claims preferred by him were rejected by the

insurer stating that hospitalization was not justified and the treatment could have been taken on out-patient basis. The complainant further stated that the injection being administered for the first time, the doctor stated that it was necessary to monitor the patient for side effects. He also stated that the treating doctor in her letter clearly stated the reasons for in-patient treatment. He further stated that the policy was shifted from Oriental Insurance Company, by disclosing coverage of insured patient, and she was covered from 2006 year.

The team representing the insurer stated the following reasons in support of their rejection of claims.

The claims were reported during first year policy with the Company.

The skin disorder, ‘Pemphigus Vulgaris’ for which the insured patient was administered Inj. Rituximab was diagnosed during 2013 and so it was pre-existing ailment and not covered for 48 months from the inception of the policy with the company (Exclusion No. 4.1).

The policy had a waiting period of 2 years for skin disorders (Exclusion 4.3.1).

The procedures/treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours. (Clause 2.15)

For the second claim there was no 24 hours hospitalization. The line of treatment for skin disorder by administration of inj. Rituximab was not a listed day care procedure stated under clause 2.15 of the policy where 24 hours admission was exempted.

The policy was not ported to the company under Portability norms. Previous policy details were not furnished to the company. Hence, waiting periods were not waived.

The complainant was asked to furnish past five previous year’s policy copies under which the insured patient was covered. The complainant furnished the policy copies stating that they were earlier covered under individual policies and ‘New India’ issued them Family Floater Policy saying that they can reduce the premium under this policy. He reconfirmed that he had given policy copies to the Agent on 31st August 2017 itself seeking continuity of the cover from existing policy expiry date. On verification of policy issued by the Respondent Insurer, it was noted that the premium was paid by the complainant on 31.08.2017 and policy was issued by the insurer from 09.09.2017 denotes that the insured person was covered earlier up to 08.09.2017 and so coverage was opted from 09.09.2017. On further verification of the proposal which said to have been submitted by the complainant, it was noted that it does not bear either the complainant or his wife’s signature on it. Someone else had signed the proposal and the insurer relied upon it to deny the claim. Previous policy coverage details of either the complainant or the insured patient were not furnished in the proposal. The complainant was with respondent insurer since 09.09.2012. His policy details were also not furnished. Hence, it strengthens the contention of the complainant that he had disclosed previous coverage details to the agent and he trusted him that he will incorporate all the details while converting individual policy into a family floater policy. As it was disclosed to the agent, he was under the impression that the insurer had taken care off to pass on the credits for earlier coverage. It is absurd to note that the policy was renewed/shifted to family floater policy, foregoing all benefits for earlier coverage. Under portability norms of IRDAI, the insured person gets credit of coverage for his/her previous policy years by means of waiver of waiting periods. At the same time, the agent won’t get any commission if it is underwritten under portability. Hence, the agent might have hidden the old policy details. The insurer further contended that there was no coverage with the ‘Company’, to waive the waiting periods, since policy was not ported under portability norms of the IRDAI. However, on perusal of the policy conditions, either 4.1 or 4.3.1, did not specify that the insured person gets waiver only when he/she covered under any health insurance policy issued by respondent insurer only. Since the insured person was covered for more than 48 months

continuously, gets waiver for maximum waiting period of 48 months under the policy. As such, the complainant claim does not fall either under 4.1 or 4.3.1 of the policy. These conditions states that the waiting period is to be reckoned from the date of inception, stated in the policy schedule. The insurer failed to record the inception date in their policy even after submission of previous year’s policy copies by the complainant at the time of taking the policy. Hence, this Forum holds that the exclusion clauses 4.1 & 4.3.1 are not applicable to the insured patient. The other ground on which the insurer contended is that the out-patient treatment was converted into ‘in-patient’ treatment only to get benefit out the policy. The treating doctor’s letter was not acceptable to them as the insured patient was administered with only Inj. Rituximab during the period of hospitalization and the hospital documents filed for the claim do not justify 24 hours hospitalization. For monitoring, side effects if any, it requires only 6 hours to monitor the patient for the given injection and it is possible to take same on out-patient basis. No patient was an option on the ‘line of treatment’ or period of hospitalization against the advice of treating doctor. The treating doctor’s letter cannot be ignored as she physically examined the insured patient, knew about her body condition about earlier line of treatment given and its reaction to the proposed injection being administered for the first time and insisted on compulsory admission because of chronic condition and associated side effects of the injection. Hence, the contention of the insurer that the hospitalization was not justified is overruled. As such, the complainant is entitled to get his claim for the first admission of the insured patient. Second admission on 03.05.2018 was done on a ‘day care’ and it did not fall under the notified list of Day Care Procedures by IRDAI. Hence, its rejection was upheld. The insurer is directed to give credit of the previous policy coverage to the insured patient in the present policy and subsequent renewals with the company.

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 Forum directs the insurer to admit the first claim of the complainant, filed for Rs.97,172/- in terms of the policy, towards full and final settlement. The insurer is also directed to pay the interest in terms of Rule 17(7) of the Insurance Ombudsman Rules, 2017. In the result, the complaint is partially allowed.



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 22nd day of FEBRUARY, 2019.

(I. SURESH BABU )

INSURANCE OMBUDSMAN


AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. N. Sudhir Kumar ……………The Complainants

Vs

M/s Religare Health Insurance Co. Ltd…………The Respondent




Mr. N. Sudhir Kumar,

Flat No.402, Block A, Medha Housing Colony,

Near MRO Office, Ghatkesar,

Hyderabad – 501 301.


10830664

Care (individual) Health Insurance Policy

From 11.10.2017 to 10.10.2018


Mr. N. Sudhir Kumar

Mr. N. Sudhir Kumar

4. Name of the insurer M/s Religare Health Insurance Co. Ltd.


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










a) For the complainant Self Smt. Kalyani, Wife

b) For the insurer Dr. S. Vijay, Head U/W



17) Brief Facts of the Case: The complainant, Sri Sudhir Kumar, was covered under Care Plan of insurer for a SI of

Rs.20.00 Lakhs from 11.10.2016. The policy was renewed for a further period from

11.10.2017 to 09.10.2018. He was also covered under his employer’s Group Mediclaim

Policy for a SI of Rs. 3.00 Lakhs. He underwent treatment at Yashoda Hospitals, Hyderabad

from 06/04/2018 to 26/04/2018 for tuberculosis. He incurred Rs.9,71,786/- for his

treatment. He got Rs. 2,09,454/-as cashless approval under his employer’s policy from ICICI

Lombard General Ins. Co. as per his total eligibility and available balance of SI. He filed

reimbursement claim for the balance amount of Rs.7,62,332/- with Respondent Insurer. The

insurer rejected the claim alleging that his ailment was a dissemination of his pre-existing

diabetes and quoted PED exclusion clause in support of their repudiation. The complainant

stated that he had represented to the insurer to review the decision but in vain. Aggrieved,

the complainant, Sri N. Sudhir Kumar filed complaint with this Forum.

18) Cause of Complaint: Rejection of claim under Health Ins. Policy. a) Complainant’s argument: The complainant submitted that on 23.02.2018 he suffered from hiccups and consulted

Aditya Hospitals, Uppal Hyderabad. As there was no relief he went again to the hospital on

24.02.2018 and underwent tests. The investigations/tests revealed that he had

tuberculosis. Its treatment was started. Suddenly on 05/04/2018 he suffered from

‘seizures’ and was rushed to Aditya Hospitals and from there he was referred to Yashoda

Hospitals, Hyderabad for further treatment and got admitted on 06/04/2018 and

underwent treatment up to 26/04/2018. He incurred Rs.9,71,786 for the treatment. He

got cashless approval under his employer’s GMP for Rs.2,09,454/- from ICICI Lombard. He

preferred the claim on Religare Health Policy for balance amount of Rs.7,62,332/- and it

was rejected by the insurer stating that ‘tuberculosis’ was a PED, a complication of DM and

not covered for 4 years from the date of inception of the policy. The complainant stated

that he had disclosed his past history of diabetes and hypertension at the time of taking the

policy and premium was loaded to cover these conditions by the insurer. In spite of taking

higher premium, the claim was rejected on the wrong ground attributing tuberculosis to

PED. He pleaded for the intervention of this Forum for settlement of his claim by the

insurer.

b) Insurer’s argument: In the Self Contained Note, the insurer submitted that the complainant was diagnosed with

TB Meningitis, disseminated Koch’s (tuberculosis), Pulmonary Koch’s, HTN, DM and took

treatment at Yashoda Hospitals from 06/04/2018 to 26/04/2018. The complainant is a

k/c/o diabetes and hypertension and complainant’s present ailment is directly attributable

to pre-existing condition of diabetes. Hence, 4 years waiting period applies to the ailment

for which the complainant made a claim with the company. The insurer further stated that

they have taken an independent specialist opinion from Dr. Manish M Shetty who opined

that “diabetes mellitus is a known and accepted risk factor for tuberculosis; it’s

dissemination into TB meningitis as well as ketoacidosis”. Hence, the claim was rejected.

The repudiation of the claim of the complainant was in adherence to the policy terms and

conditions and justified. As such there was no deficiency in service on the part of the

Respondent Company.

With the above submissions, the insurer pleaded for dismissal of the complaint as it was rightly rejected in terms of the policy. 19) Reason for Registration of Complaint:- The claim(s) preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal:


b) Rejection letter. c) Correspondence with insurer d) Self Contained Note with its enclosures.

e) Discharge Summary f) Doctor certificate

21) Result of hearing with both parties: Pursuant to the notices given by this Forum, both the parties attended personal hearing at Hyderabad on 05.02.2019. Both the parties advanced their arguments for and against the complaint. The complainant strongly contended that he had hypertension & diabetes and had disclosed them and also paid extra premium to cover them under the policy. His TB was diagnosed during February 2018 and he was on ATT. Suddenly he suffered from seizures during April 2018 and underwent treatment at Yashoda Hospitals. The tuberculosis can affect any person at any age group and contention of the insurer that his pre-existing condition of diabetes was the sole cause of his TB was not acceptable and rejection of claim on this ground was totally unfair. The insurer on the other hand, relying upon the medical opinion obtained from independent specialist, stated that the complainant’s ailment of tuberculosis was disseminated from his diabetes only and so it attracted PED exclusion. The claim was reported during second year policy. The insurer referred to waiting period exclusion 4.1.(iii) in support of their repudiation of claim. The referred clause stated that “claims will not be admissible for any medical expenses incurred for hospitalization in respect of diagnosis/treatment of any Pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first policy with the company. The policy was incepted with the company on 11.10.2016. At the time of inception of the policy the insured person was not suffering from any TB nor had any

signs and symptoms of the ailment. The insurer’s contention that the diabetes is ‘sole’ cause for TB, is not acceptable, since the medical documents placed on record do not support it. Further, in the given exclusion only pre-existing diseases/conditions were excluded for 4 years and not any complications arising out of it. The insurer had collected the extra premium for covering diabetes. Hence, rejection of claim for tuberculosis, linking it to pre-existing conditions of diabetes, is not justifiable.

A W A R D Taking into account the facts & circumstances of the case, the documents on record and the

submissions made by both the parties during the course of personal hearing, the insurer is

directed to admit the claim for Rs.7,09,267/- towards full and final settlement of the claim.

The insurer is further directed to pay interest in terms of Rule 17(7) of Insurance

Ombudsman Rules, 2017.

In the result, the complaint is allowed.



s) 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.

t) 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.

u) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.SURESH BABU)

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE




Case between: Dr. V. Sharat Kumar ..……………The Complainants

Vs

M/s United India Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Dr. V. Sharat Kumar,

# 42-282-1/1A, Street No.1, Maruthi Nagar,

Adj. to Dr. A.S. Rao Nagar,



500400/28/16/P1/03666002

AB Arogyadaan Health Insurance Policy

From: 09.06.2016 to 08.06.2017


Dr. V. Sharat Kumar

Dr. V. Sharat Kumar

4. Name of the insurer M/s United India Insurance Co. Ltd.


6. Reason for repudiation Claim for excluded treatment


8. Nature of complaint Rejection of Mediclaim for bariatric surgery









b) For the insurer Sri M.P. Srinivas, Dy. Manager Sri S.S.V. Narasimham, Dy. Manager Dr. Sudip, A.O (Medical). Dr. E. Pratap – GHPL TPA



17) Brief Facts of the Case: The complainant, Dr. V. Sharath Kumar, was covered under AB Arogyadaan Mediclaim Policy along with his spouse from 30.06.2005. The policy was continuously renewed and in the current year policy which was from 09.06.2016 to 08.06.2017, he was covered for a SI of Rs.5.00 Lakhs with additional Top-up cover of Rs.5.00 Lakhs. As per the complaint filed, the complainant underwent bariatric surgery at Sunshine Hospital from 15.02.2017 to 19.02.2017 for morbid obesity. He filed reimbursement claim for Rs.3,15,713/-on rejection of cashless treatment request. The insurer rejected the claim citing policy condition No. 6.9. The complainant approached Grievance Cell of the insurer to review the decision but in vain. Aggrieved, Dr. V. Sharath Kumar approached this Forum for redressal of his grievance. 18) Cause of Complaint: Rejection of Mediclaim. a) Complainant’s argument: The complainant submitted that, he is a doctor by profession and was covered under Mediclaim Policy from 2005. He stated that he was suffering from CAD-TVD-PTCA done in 2006, diabetes, Hypertension since 2008 and Osteo Arthritis, underwent Total Knee Replacement surgery to left knee in 2011 followed by pulmonary embolism, recurrent Urinary Tract Infection problems and there were admissions between 2012 to 2016 for all the above ailments and claims were admitted under his Arogyadaan Mediclaim Policy by the insurer. He

further stated that he developed sleep apnea. He used high doses of OHA and insulin for DM management, various anti hypertensive drugs, anti coagulants and statins for CAD. Number of times antibiotics were used for treatment of UTI. Because of this he had put up lot of weight due to restricted mobility and his weight was 126 Kgs just before his surgery on 17/02/2017. He underwent laparoscopic mini gastric bypass surgery at Sun Shine Hospitals from 15.02.2017 to 19.02.2017. After the above surgery, he lost significant excess weight of 48 Kgs (present weight 78 Kgs only). He had stopped all diabetes medication, anti hypertensive, pain killers for OA. He was presently using only anti coagulants, statins and supportive vitamins as on today as per his treating doctors advice. The claim preferred by him for reimbursement of bariatric surgery was repudiated by the insurer quoting exclusion clause 6.9 of the policy. He stated that he had represented to the insurer to review the decision and consulted the doctors of the insurer and explained the position. In spite of that the claim was not settled. Hence, the complainant pleaded for the intervention of this Forum for settlement of his claim by the insurer. b) Insurer’s argument: The insurer, in the self contained note, submitted that the complainant was covered under AB Arogyadaan Policy from 30.06.2005 continuously and he preferred claim for bariatric surgery undergone at Sunshine Hospitals, Secunderabad from 15.02.2017 to 19.02.2017 and filed reimbursement claim for Rs.3,15,713/-. On perusal of the claim documents it was noted that the complainant underwent treatment for morbid obesity (BMI 43.09) with past medical history of DM/HTN, CAD (Post PTCA) and UTI. As the claim fell under policy exclusion 6.9 of the policy, the claim was repudiated. Policy exclusion 6.9: 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 : Convalescence, general debility; run-down condition or rest cure, obesity treatment and its complications including morbid obesity, congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self injury, and use of intoxication drugs/alcohol.

The insurer pleaded that the claim of the complainant merits dismissal as it was rightly rejected in terms of the policy. 19) Reason for Registration of Complaint:- The claim preferred by the complainant was rejected by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a) Policy with terms and conditions.

b) Rejection letter. c) Correspondence with insurer d) Doctor Certificate e) Self contained note with its enclosures.

21) Result of hearing with both parties: Pursuant to the notices given by this Forum, both the parties attended the personal

hearing at Hyderabad on 26.02.2019.

The complainant, while reiterating the contents of his complaint, stated that morbid obesity is a vague term which can be primary or secondary that is in young age or old age because of contributory factors or diseases. A young man can have morbid obesity with various reasons including genetical inheritance which can lead to risk and needs treatment and even cosmetic surgery and it is termed as primary morbid obesity which was excluded under the policy. The secondary morbid obesity was due to various factors like age, diabetes, hypertension, coronary artery diseases, pulmonary embolism, respiratory apnea, sedentary life with restricted mobility with Osteo Arthritis and other problems also. Treatment expenses incurred for secondary morbid obesity needs to be reimbursed by the insurer as they were incurred to control metabolic and physiological ailment and not just for weight reduction and cosmetic purpose. He had undergone the surgery to reduce his morbidity rate to avoid the risk to his life, as his physical conditions were life threatening. He submitted that he had lost 48 Kgs of weight post surgery and he was not on any insulin and not on any hypertensive drugs. He submitted the medical reports prior to the surgery and also the present reports for comparative study.

The representatives of the insurer, on the other hand stated that the policy excluded any treatment expenses for morbid obesity treatment whether it was for a primary obesity or secondary obesity. No distinction was made in the policy exclusion. The rejection was made in terms of the policy.

The insured patient/complainant had severe metabolic and physiological ailments which resulted in excess weight within few years. He was advised to undergo bariatric surgery – laparoscopic mini gastric bypass for control of diabetes, hypertension and to prevent other complications which may result in life threatening conditions. Because of it, he underwent surgery which was attributed to weight loss control surgery/morbid obesity by the insurer and rejected the claim. Since the complainant had undergone the surgery, as a life saving surgery, because of his physiological and metabolic ailments, this Forum is of the opinion that it is to be treated as a surgery done for life saving and not for weight loss control/morbid obesity taking into account his age and past medical history. Hence, the insurer is directed to admit the liability in terms of the policy.

A W A R D

Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the insurer is directed to admit the claim in terms of the policy. The insurer is also directed to pay interest in terms of Rule 17(7) of Insurance Ombudsman Rules, 2017. In the result, the complaint is Allowed.



v) 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.

w) 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.

x) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I. SURESH BABU)

INSURANCE OMBUDSMAN


AND YANAM CITY

PROCEEDINGS BEFORE




Case between: Mr. V. Sankar Rao ..……………The Complainants

Vs

M/s United India Insurance Co. Ltd…………The Respondent



1. Name & address of the complainant Mr. V. Sankara Rao,

# 62 A, Madhura Nagar,



0514002817P105848581

Individual Health Insurance Poicy

From: 21.07.2017 to 20.07.2018


Mr. V. Sankara Rao

Mr. V. Sankara Rao

4. Name of the insurer M/s United India Insurance Co. Ltd.




8. Nature of complaint Partial settlement of Mediclaim

9. Amount of Claim Rs. 3,07,500/-








b) For the insurer Sri M.P. Srinivas, Dy. Manager Dr. Sudeep, A.O.(Medical) Dr. Gurmeet Kaur – E-Meditek TPA


16. Date of Order/Award 28-02-2019

17) Brief Facts of the Case: The complainant, Mr. V. Shankar Rao, is covered under Individual Health Insurance Policy, with Respondent Insurer from 21.07.2004. The present policy was renewed from 21.07.2017 to 20.07.2018 for SI of Rs.5.00 Lakhs. As per the complaint filed, he underwent treatment for his heart ailment at Care Hospitals, Hyderabad from 25/04/2018 to 30/04/2018 and incurred Rs. 9,25,000/- for the treatment. His reimbursement claim was settled for Rs.1,92,500/- only as against the SI of Rs. 5.00 Lakhs. He represented to the insurer to review the settlement but in vain. Aggrieved by the short settlement, the complainant filed claim with this Forum. 18) Cause of Complaint: Short settlement of Mediclaim. a) Complainant’s argument:

The complainant submitted that he suffered from chest pain and was admitted in Care Hospital, Hyderabad on 25/04/2018 and was discharged on 30/04/2018 after medical treatment and he incurred Rs.9,25,000/- for the treatment. He filed his reimbursement claim. The insurer settled the claim for Rs.1,92,500/- only as against the SI of Rs.5.00 Lakhs causing huge loss of Rs.3,07,500/- to him. When he approached the insurer for justice, they denied and replied that the claim was settled in terms of the policy only. The insurer quoted that he had hypertension and so the claim was restricted to the policy year SI of 2013-14 year. He stated that his hypertension was identified during 2007 year, i.e. after his taking first policy with the insurer in the year 2004. Hence, the hypertension was not a pre-existing ailment/condition/disease as alleged by the insurer and restricting the claim to the 2013-14 policy sum insured was not in order. When he approached grievance cell, he was informed that he had hypertension since 10 years and hence the claim was restricted to 2013-14 policy year sum insured and it was further subjected to 70% stating it as a major surgery. The complainant contended that in terms of policy condition No. 3.29 his hypertension was diagnosed after taking the policy and so it could not be treated as PED and so he was entitled to the claim for full SI limit of Rs.5.00 Lakhs. He pleaded for the intervention of this Forum for resolution of his grievance. b) Insurer’s argument: The insurer, in the self contained note, submitted that the insured person was covered for a Individual health Insurance Policy from 21/07/2004 and the SI was enhanced periodically. The SI was enhanced from 2015-16 policy to Rs.5.00 Lakhs from Rs.2.75 Lakhs. It was renewed for the same SI of Rs.5.00 Lakhs during the years 2016-17 & 2017-18 years. The complainant filed a reimbursement claim for Rs.9,25,000/- for the treatment undergone by him at Care Hospitals, Hyderabad for the diagnosis of ‘Hypertrophic cardiomyopathy, Non obstructive runs of NSVT, Dual Chamber ICD’ and a k/c/o hypertension since 10 years, history of CAG in 2007’. He was a k/c/o ventricular tachycardia. The claim was reported during 3rd year after enhancement of SI from Rs.2.75 Lakhs to Rs.5.00 Lakhs. Since, present hospitalization was related to pre-existing conditions, known disease, the claim was settled taking 48 months prior policy sum insured of Rs.2.75 Lakhs in terms of policy clause 5.12. Further, the admissible claim was restricted to 70% of admissible claim in terms of clause 1.2.1 and settled for Rs.1,92,500/-. The insurer stated that the settlement was done in line with policy terms and conditions, no further enhancement was considered when complainant approached Grievance department and he was communicated that the settlement done was in order.

With the above submissions, the insurer pleaded for dismissal of the complaint. 19) Reason for Registration of Complaint:- The claim preferred by the complainant was short settled by the insurer. As the complaint fell under Rule 13(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a) Policy with terms and conditions.

b) Rejection letter. c) Correspondence with insurer d) Self Contained Note e) Discharge Summary


Pursuant to the notices given by this Forum, both parties attended the hearing at Hyderabad on 17.01.2019. Both the parties reiterated their arguments for and against the complaint.

The policy expressly stated the entitlement of the insured person for pre-existing diseases /conditions under clause 5.12 in case of enhancement of sum insured under the policy. The clause stated that “notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof.” The ailment for which the complainant had undergone treatment fell under PED, in lieu of past medical history and waiting period of 48 months applies for enhanced sum insured. Hence, there is no infirmity in the settlement of claim taking 2013-14 policy year sum insured.

A W A R D Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the complaint being devoid of any merit is dismissed without any relief. In the result, the complaint is dismissed.

Dated at HYDERABAD on 28th day of FEBRUARY, 2019.

( I. SURESH BABU )

INSURANCE OMBUDSMAN



Documents

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN