Star Health and Allied Insurance Co. Ltd v. V. P. Satheesh Menon
2019-10-29
N.NAGARESH
body2019
DigiLaw.ai
JUDGMENT : The writ petitioner, a health insurance company challenges Ext.P8 order dated 16.11.2012 in Complaint No.IO/KCH/GI/11-017-566/2011-12 on the file of the Insurance Ombudsman, Kochi. The facts emerging from the pleadings reveal that the respondent had taken a Medi-Classic Health Insurance Policy from the petitioner. Ext.P1 policy was issued to the respondent. The period of insurance was from 8.2.2011 to 7.2.2012. The policy was taken after a preliminary medical examination. The respondent suffered throat pain on 11.3.2011 and was admitted in SUT Royal Hospital, Kochulloor, Trivandrum. He was diagnosed as suffering from Papillary Carcinoma Thyroid and was advised to remove the Thyroid Gland immediately. The respondent underwent a surgery on 16.3.2011. 2. The respondent thereafter made a claim for insurance amount. As the petitioner did not respond, Ext.P2 complaint was preferred by the respondent before the Insurance Ombudsman. The respondent stated before the Insurance Ombudsman that he was approached by the Agent of the insurance company on 2.2.2011, was subjected to medical check up on 3.2.2011 and as and when the formalities were over, the respondent had paid the full premium amount. However, the insurance policy which ought to have been made effective from 3.2.2011 was made effective only from 8.2.2011. The petitioner insurance company is illegally denying insurance to the respondent. 3. The petitioner submitted before the Ombudsman that as per clause 3.2 of Ext.P4 containing conditions of insurance, the petitioner shall not be liable to make any payment under the policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of any disease contracted by the insured person during the first 30 days from the date of commencement of the policy. The petitioner pointed out to the Insurance Ombudsman that Ext.P6 discharge summary would go to show that the respondent was admitted in the hospital on 15.3.2011 and he had a 'swelling front of neck' for 10 days. Therefore, the respondent had symptoms of the disease from 5.3.2011 onwards. This date falls within the excluded period of 30 days from the commencement of the insurance policy. The petitioner further pointed out that in Ext.P7 medical certificate filled in by the treating Doctor, it has been stated that the date of first consultation is 11.3.2011 and 5 days' were given as the period of suffering by the patient prior to the date of consultation.
The petitioner further pointed out that in Ext.P7 medical certificate filled in by the treating Doctor, it has been stated that the date of first consultation is 11.3.2011 and 5 days' were given as the period of suffering by the patient prior to the date of consultation. The petitioner pointed out that in fact initially 10 days' was shown in the said medical certificate, which is seen subsequently struck off and made 5 days'. Therefore the disease was contracted by the respondent at least on 5.3.2011. The date clearly falls within the 30 days exclusion period provided under clause 3.2 of Ext.P4. The respondent is therefore not entitled to insurance claim. 4. The learned Ombudsman considered the complaint on the basis of materials provided by the petitioner as well as the respondent. The Ombudsman noted the contentions that the respondent had paid part premium on 3.2.2011 and the balance premium on 8.2.2011. The Ombudsman further noted the contention of the respondent that the entire premium was paid to the insurance Agent on 3.2.2011. However the policy was issued only on 8.2.2011. The Ombudsman noted the legal argument of the respondent that for the delay on the part of the Agent in remitting the insurance premium to the company, which resulted in delayed issuance of policy, the respondent cannot be found fault with. 5. On merits of the claim, the Ombudsman held that the policy commenced on 8.2.2011 and the 30 days waiting period provided under clause 3.2 of the conditions expired on 9.3.2011. As far as contracting of ailment, what is material is knowledge of the contract of ailment. The respondent went to the hospital for consultation merely on the basis of a throat pain and a mere throat pain cannot be attributed as knowledge on the part of the complainant. The learned Ombudsman held that diagnosis and knowledge of the aliment was on or after 11.3.2011, which was beyond 30 days from the date of inception of the policy. Therefore the repudiation by the petitioner of the claim made by the respondent cannot be sustained. On these premises, the Ombudsman adjudicated that the petitioner insurer is liable to pay Rs.60,189/-to the respondent complainant.
Therefore the repudiation by the petitioner of the claim made by the respondent cannot be sustained. On these premises, the Ombudsman adjudicated that the petitioner insurer is liable to pay Rs.60,189/-to the respondent complainant. Resultantly an Award was passed directing the petitioner to pay Rs.60,189/-to the respondent within a period of one month, failing which the amount shall carry an interest of 9% per annum from 14.10.2011, till payment is effected. The said Ext.P8 Award is under challenge. 6. The learned Standing Counsel for the petitioner-Insurer brought to the attention of the court Ext.P1 insurance policy and Ext.P4 conditions of insurance policy. Clause 3.2 of the Ext.P4 conditions provides as follows: “Any disease contracted by the Insured Person during the first 30 days from the date of commencement of the policy. This condition shall not however apply in case of the Insured Person having been covered under this scheme or group insurance scheme with any of the Indian Insurance companies for a continuous period of preceding 12 months without any break.” Since the policy commenced on 8.2.2011, the period up to 9.3.2011 is the waiting/exclusion period, contended the standing Counsel for the petitioner. Since even according to the respondent the disease was detected on 5.3.2011, the claim of the petitioner clearly falls within the waiting period and the petitioner is not liable to pay insurance amount to the respondent. The learned Standing Counsel for the petitioner pointed out that in Ext.P6 it has been clearly stated that the petitioner was admitted in hospital on 15.3.2011 and the symptoms were existing even during the past 10 days. Therefore, admittedly the contracting of the disease was clearly within the waiting period. The counsel further brought to my attention, Ext.P7 medical certificate issued by the treating doctor, wherein the date of first consultation was shown as 11.3.2011 and the past history of the patient with the duration of illness was initially shown as 10 days' and thereafter corrected as 5 days'. The overwriting and corrections made in the certificate is evident from Ext.P7, contended the learned Standing Counsel. The symptoms of illness on the basis of which the respondent resorted to medical consultation, fell within the 30 days waiting period. Therefore, the Ombudsman fell into error in allowing the claim of the respondent, contended the Standing Counsel.
The overwriting and corrections made in the certificate is evident from Ext.P7, contended the learned Standing Counsel. The symptoms of illness on the basis of which the respondent resorted to medical consultation, fell within the 30 days waiting period. Therefore, the Ombudsman fell into error in allowing the claim of the respondent, contended the Standing Counsel. The Counsel emphatically denied any delay on the part of the insurance company in issuing the policy. The full payment of premium was made by the respondent only on 8.2.2011 and the policy was made effective from that date. There is no laches on the part of the petitioner on that ground. 7. The learned counsel for the respondent asserted that the full premium in respect of the policy was paid on 3.2.2011 to the authorized Agent of the petitioner. If the authorized Agent delayed in communicating the payment to the insurance company till 8.2.2011, the respondent cannot be made to suffer. According to the counsel for the respondent, there is ample evidence and materials on record to show that the respondent contracted the disease only on 15.3.2011. Any minor symptoms prior to the diagnosis, cannot be treated as contracting of disease, as contemplated by clause 3.2 of the agreement, contended the learned counsel for the respondent. 8. I have considered the pleadings in the case and arguments raised by counsel on either side. The question whether the insurance premium was paid by the respondent on 3.2.2011 or was it made only on 8.2.2011, is of not serious significance in the matter, in view of the findings of the Insurance Ombudsman on the aspect of contracting of disease. The Ombudsman held that what is material, is the knowledge of contract of the ailment. A mere throat pain cannot be attributed to the knowledge on the part of the complainant that he had contracted a disease. The finding of the Tribunal cannot be said to be unreasonable or biased. 9. The Central Government, in exercise of the powers conferred by Section 114(1) of the Insurance Act, 1938 has framed Redressal of Public Grievances Rules, 1998. The Rule 14(2) of the said Rules, 1998 mandates that the Ombudsman shall dispose of a complaint fairly and equitably. Therefore the Ombudsman may take into account equitable considerations also while deciding a dispute.
9. The Central Government, in exercise of the powers conferred by Section 114(1) of the Insurance Act, 1938 has framed Redressal of Public Grievances Rules, 1998. The Rule 14(2) of the said Rules, 1998 mandates that the Ombudsman shall dispose of a complaint fairly and equitably. Therefore the Ombudsman may take into account equitable considerations also while deciding a dispute. In this case, the petitioner had a swelling on his neck, on the basis of which, the petitioner approached the hospital. After thorough diagnosis and testings, the petitioner was found to be suffering from Papillary Carcinoma Thyroid. The disease may have many symptoms and mere swelling of the neck cannot invariably mean that a patient is suffering from Papillary Carcinoma Thyroid. A disease can be said to be contracted for the purpose of insurance claim, only when after diagnosis it is clinically found that the patient is suffering from the disease. The symptoms related to the disease may be in existence for long periods prior to the diagnosis and the symptoms may be within the knowledge of the patient. The patient still may not be aware of the disease. For the purpose of an insurance claim, a disease can be said to be contracted only when it is diagnosed by a competent physicians and confirmed. The diagnosis of the disease of the petitioner happened only on 11.3.2011, which is beyond the waiting period of 30 days. In the circumstances, I find that the Ombudsman has considered the issue fairly and equitably and there is no error in the findings and Award passed by the Ombudsman. The writ petition therefore fails and it is dismissed.