COMPLAINANT Sri. Kumsi Rama, S/o. Late Huchuraya, Aged about 56 years, Retired Police Officer, Karnataka State Police Department, C/o. No. 31, 3rd Main Road, Hanumantha Nagar, Bangalore – 560 019. Advocate (R. Jayaprakash)
1. M/s. United India Assurance Company Limited, Divisional Office 011100, II Floor, Sudarshan Building, New No. 27 (Old No. 14), Whites Road, Chennai – 600 014. Advocate (A.M. Venkatesh)
2. The Manager, IOB, Jayanagara Branch, Bangalore. Advocate (H.V. Nagaraja Rao)
O R D E R
This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to pay the medical bill under the health care policy with interest and pay compensation of Rs.5,00,000/- and for such other reliefs on an allegations of deficiency in service.
The brief averments, as could be seen from the contents of the complaint, are as under: Complainant got the health policy issued by the OP.1 along with the policy of IOBHC+ issued by OP.2. He enjoyed the said policies from 2003 to 2006. Due to the communication gap he did not continue the said policies after the expiry on 30.12.2006, but he took the policy on 07.03.2007 which was inforce up to 06.03.2008. On 02.05.2007 complainant undergone surgery for PAN CREATD JEJUND STOM at Bangalore Hospital. He was an inpatient and finally he was discharged on 23rd May 2007. Towards the said surgery and hospitalization he incurred expenses of Rs.1,81,979/-.
After the discharge he made claim to the OP to settle the medical bills, it went in vain. Then he got issued the legal notice on 08.09.2008. Again there was no response. Due to the negligence and hostile attitude of the OP, complainant for no fault of his, is made to suffer both mental agony and financial loss. Under the circumstances he felt the deficiency in service. Hence he is advised to file this complaint and sought for the relief accordingly.
2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. It is contended by OP.1 that there is no renewal of the earlier policy. The policy which complainant took on 07.03.2007 is a fresh policy. Hence he is not entitled for the earlier benefits. At the time of taking up of the fresh policy complainant is expected to disclose about the pre-existing disease, but he failed to do so. The discharge summary issued by the Bangalore Hospital shows he is a known case of chronic pancreatitis and a DM for the last 1 year and he has also donated the left kidney in the year 2006 itself. Though complainant is aware of the same, he failed to mention the pre-existing disease when he took the fresh policy. Hence OP is not obliged to settle the said medical expenses as it is not covered under the policy. The complaint is devoid of merits. Among these grounds, OP.1 prayed for the dismissal of the complaint.
3. OP.2 filed the separate version mainly contending that it issued IOBHC+ policy placing on the information furnished by the complainant. The complaint is bad for misjoinder of necessary parties. Complainant is not entitled for the policy benefits when there is no continuity or renewal of the old policies starting from the year 2003. The policy which complainant took for the year 2007 is a fresh policy. Complainant undergone a major surgery within a period of 2 months from the date of taking of fresh policy suppressing the existence of the serious ailment and donation of a kidney. The approach of the complainant is not fair and honest. There is no deficiency in service on the part of the OP.2. The complaint is devoid of merits. Among these grounds, OP.2 prayed for the dismissal of the complaint.
4. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced the documents. OP’s have also filed the affidavit evidence. Then the arguments were heard.
5. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP’s? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order?
6. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Affirmative Point No.2:- Affirmative in part Point No.3:- As per final Order.
R E A S O N S
7. At the outset it is not at dispute that the complainant has taken IOBHC+ policy issued by the OP.2 and OP.1 having covered the insurance under the category of health policy from 01.01.2003 to 30.12.2006. Now it is the grievance of the complainant that due to some unavoidable circumstances as he was out of station he could not renew the policy before expiry date that is 30.12.2006. He took the policy on 07.03.2007 which is inforce up to 06.03.2008. The documents to that effect are produced. It is further contended by the complainant that on 02.05.2007 he got admitted at Bangalore Hospital for surgery of PAN CREATD JEJUND STOM, he was operated then he was discharged on 23.05.2007. The documents to that effect are produced.
8. It is further contended by the complainant that for the said treatment he has spent nearly about Rs.1,81,979/-. The discharge summary and hospital bills are produced. Then he made a claim to the OP’s to settle the bills, but it went in vain. Hence he got issued the legal notice on 08.09.2008. The copy of the legal notice and postal acknowledgement are produced. Again there was no response. The evidence of the complainant appears to be very much natural, cogent and consistent, which finds full support from the contents of the undisputed documents. There is nothing to discard his sworn testimony. As against this unimpeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake, may be to shirk their responsibility and obligation.
9. It is contended by the OP.2 that the policy obtained by the complainant on 07.03.2007 is a fresh policy, hence there is no continuity or renewal of the earlier policies. One thing is admitted that complainant took IOBHC+ policy from OP.2 and health policy from OP.1. We have gone through the said policy copies. The further allegation of the OP is that though complainant is aware of certain ailment that too with regard to donation of one kidney and he being suffering from chronic pancreatitis and DM, he failed to mention the same in his fresh proposal. When it is the health care plus policy an obligation lies on the OP to subject the complainant for the thorough medical examination before accepting his proposal. But that step is not taken by the OP. They simply issued the policy, collected the premium and when the question of payment of medical bills aroused, they have come up with this untenable defence.
10. The approach of the OP’s does not appears to be as fair and honest. There is a fault committed by the OP’s in not subjecting the complainant for thorough medical examination. In addition to that when OP says that the policy dated 07.03.2007 is a fresh policy, then there should be a fresh proposal. What is the information complainant has furnished in the said proposal about his health conditions or his previous history is not known. The proposal form is not produced by the OP. If OP produced the proposal form and if there is no mention about the so called donation of the kidney and he being a chronic pancreatitis patient with DM, then there would have been some meaning in the defence set out by the OP. But in absence of production of such documents, the bare and vague allegations of the OP rather alone cannot be believed. We do not find force in the defence set out by the OP’s. The repudiation made by the OP’s appears to be unjust, improper and without due application of mind.
11. Complainant has taken the said treatment within the policy coverage period and when the sum assured is for Rs.2,00,000/- with regard to IOBHC+ status and health care policy scheme, it would have been more fair on the part of the OP to settle the bill immediately. OP’s has not disputed the expenses incurred by the complainant and the documents produced by him. When that is so, the hostile attitude of the OP’s must have naturally caused both mental agony and financial loss to the complainant, that too for no fault of his. We are satisfied that there is a proof of deficiency in service on the part of the OP’s. Hence they are jointly and severally liable to reimburse the medical expenses. Accordingly we answer point nos.1 and 2 and proceed to pass the following:
O R D E R The complaint is allowed in part. OP’s are jointly and severally directed to settle the claim for Rs.1,81,979/- and pay the said amount to the complainant along with a litigation cost of Rs.1,000/- within 4 weeks from the date of communication of this order. Failing in which complainant is entitled to claim interest at the rate of 12% p.a. on the said amount from June 2007 till realization along with a litigation cost.