SMT. RAVI SUSHA: PRESIDENT
Complainant has filed this complaint U/S 12 of Consumer Protection Act 1986 for getting an order against opposite parties 1 to 3 to pay an amount of Rs. 2,22,258/- as the claim amount of Medi-claim Health Insurance coverage from the opposite party with interest @ 18% from 03/10/2019 till the payment of amount together with Rs.50,000/- towards compensation for the deficiency of service and pay the cost of the proceedings.
The facts in brief, are that the complainant is the Policy holder of the 1st &2nd OPs insurance company vide individual Medi-claim Health insurance policy. The complainant got the insurance policy named easy Health group insurance with policy No.120100/12001/2015 through the 3rd OP. The complainant submits that, prior to issuing the insurance policy, the OP informed him that, as per the terms and condition of the OPs’ insurance policy, that if during the continuance of the policy by renewal any insured person shall suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require any such insured person, upon the advice of duly qualified medical practitioner or of a duly qualified surgeon to incur hospitalization/domiciliary hospitalization expense for medical/surgical treatment at hospital in India as an inpatient, the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person. The complainant was admitted in Sakra World Hospital Bengaluru on 29/09/2019 and underwent (Right Orchidectomy+ Left Vasectomy Cystoscopy+ VIU Under SA” on 30/09/2019 by Dr. Ajay Shetty, of same hospital and discharged on 02/10/2019. The details of Hospitalization and the expenses incurred for his treatment have informed to the 1st and 2nd OP within the time frame through the hospital above mentioned, during the time of treatment. The complainant applied for his Medi-claim for availing cashless facility by submitting duly filled up application form along with all the relevant medical bills and other documents during the time of his hospitalization. The complainant also got confirmation of receipts of his application from the 1s t and 2nd OP and the approval of the amount of Rs.45,000/- as initial treatment expenses. On 02/10/2019, the date of discharge of the complainant from the hospital, the hospital authorities informed that the 1st and 2nd OPs repudiated the cashless facilities offered by OPs as per the letter dated 02/10/2019 to the Hospital Authorities. There after the hospital authorities directed the complainant to pay the entire discharge bill of Rs.2,22,258/-. At last the complainant arranged the amount demanded by the hospital authorities by staying one more days in the hospital after his discharge and he paid an amount of Rs.2,22,258/- for his treatment on 03/10/2019 and returned from there. The reason is that the complainant has given an incorrect good health declaration, ie past history of “bph” prior to policy inception. The complainant have no such past history of “bph” prior to policy inception and the allegation made by the OPs are not true or correct. So the complainant is entitled to get full insured amount of Rs.2,22,258/- the amount he expended for his treatment and the compensation of the physical and mental agony he faces due to the unfair trade practice of the OP. The complainant submits that there is a total deficit in service and unfair trade practice on the side of OP, which they are liable to compensate in monetary terms. The complainant further submit that, whenever he approached to the OP, for the claim amount, they dragged the matter by saying lame excuses. The complainant is entitled to get medical benefits as an insured person as stated above from the OPs with interest, cost and compensation towards deficiency of service. Hence this complaint.
The OPs 1 and 2, in its reply denied the entire allegation raised by the complainant against them. It is submitted that the complainant had availed a policy from the 1st and 2nd OPs and willfully withheld material information while submitting the enrolment form and during the continuance of the policy. The complainant, who was the proposer had knowledge of the fact that he had suffered BPH for 5 years as on 02/10/2019 and BHP for more than 10 years and was obliged to disclose it particularly while answering question in the enrolment form. Further submitted that the terms and conditions of the policy stipulate that “if any claim is in any manner dishonest of fraudulent, or is supported by any dishonest or fraudulent means or devices whether by you or any insured person or any one acting on behalf of you or an insured person, then this policy shall be void and all benefits paid under it shall be forfeited.” The policy of the complainant had become void to suppression of material fact. The cashless request of the complainant for his hospitalization was repudiated as the cashless facility cannot be granted due to incorrect good health declaration at the time of policy inception. The policy itself was obtained by the complainant by suppressing material facts and hence the complainant is not entitled to any benefit under the policy. Contract of insurance being a contract uberimmae fidei, parties are bound to observe utmost good faith and the OP is duty bound to disclose all existing medical conditions pertaining to the health of the persons proposed to be insured. While making a disclosure of the relevant facts, the duty of the insured to state them correctly cannot be diluted. These OPs are under the conditions of the policy entitled to reject the claim of the complainant as the policy holder had not disclosed true, complete or correct facts in relation to the policy and had acted in a dishonest and fraudulent manner in relation to the policy. Hence the complainant is not entitled to the amount of Rs.2,22,258/- or for compensation of Rs.5,00,000/-. There has been no deficiency in service or unfair trade practice on the part of these OPs. The complainant is not entitled to any of the prayers in the complaint. Hence prayed for the dismissal of complaint.
OP No.3 also filed version stated that this OP denies entire allegation in the complaint except those that are expressly admitted hereunder. OP No.3 is only the branch Manager of the Canara bank and he has no personal liability to the complainant and therefore complaint is bad for misjoinder of parties. OP3 submits that the complainant was fully aware of the terms and conditions of the health insurance and there was no compulsion on the part of OP3 for purchasing the health insurance. The certificate of insurance was issued by Appolo Munich Health Insurance company Ltd. and OP3 has never entered into any agreement or contract with the complainant at any point of time. OP3 acted only as an intermediary between the complainant and Insurance Company. There is no denial of policy from the part of OP3. As soon as the complainant submitted all the medical bills and documents of the complainant to the OP3, OP3 immediately transferred them to Apollo Munich Health Insurance Company Ltd. without delay. There was no negligence or deficiency in service on the part of OP3 and is not liable to pay any compensation. Hence, prayed for the dismissal of complaint against OP3.
The parties led evidence in support of their case. Complainant has filed his proof affidavit and documents. He was examined as Pw1 and the documents were marked as Ext.A1 to A5 and medical records summonsed from Sakra world hospital, Bangalore marked as Ext.X1, X1(a). From the side of OPs, documents submitted by OPs1 and 2 were marked as Ext.B1 to B5. After that the learned counsel for complainant made oral argument and the learned counsel of OP3 filed written argument notes.
We have heard the counsel for the complainant, considered the submission of OPs and have gone through the evidence and records of the case carefully.
The counsel for the complainant submitted that as per the terms and conditions of the OP’s insurance policy, if during the continuance of the policy by renewal any insured person shall suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require any such insured person, upon the advice of duly qualified medical practitioner or of a duly qualified surgeon to incur hospitalization/domiciliary hospitalization expense for medical/surgical treatment at hospital in India as an inpatient, the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person. Further submitted the complainant was admitted in Sakra World Hospital Bengaluru on 29/09/2019 and underwent (Right Orchidectomy+ Left Vasectomy Cystoscopy+ VIU Under SA” on 30/09/2019 by Dr. Ajay Shetty, of same hospital and discharged on 02/10/2019. The details of Hospitalization and the expenses incurred for his treatment have informed to the 1st and 2nd OP within the time frame through the hospital above mentioned, during the time of treatment. The complainant applied for his Medi-claim for availing cashless facility by submitting duly filled up application form along with all the relevant medical bills and other documents during the time of his hospitalization. But on 02/10/2019, the date of discharge of the complainant from the hospital, the hospital authorities informed that the 1st and 2nd OPs repudiated the cashless facilities offered by OPs as per the letter dated 02/10/2019 to the Hospital Authorities. There after the hospital authorities directed the complainant to pay the entire discharge bill of Rs.2,22,258/-. Complainant submits that there is deficit in service and unfair trade practice on the side of OP. So they are liable to compensate and the complainant is entitled to get the policy benefit from OPs.
On the other hand the learned counsel of OPs1 and 2 submitted that the complainant himself had disclosed during his treatment at Sara World Hospital that he had BPH for 5 years and BHP for more than 10 years. Medical documents produced from the hospital also shows that the complainant was having BPH for 5 years. But complainant had withheld material information while submitting the enrolment form and during the continuance of the policy. OP submitted that when information on a specific aspect is asked for in the enrolment form, an assured is under a solemn obligation to make a true and disclosure of the information on the subject which is within his knowledge. Further submitted that the terms and conditions of the policy stipulate the “if any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices whether by you or any insured person or any one acting on behalf of you or an insured person, then this policy shall be void and all benefits paid under it shall be forfeited.” The policy of the complainant had become void due to suppression of material fact. The complainant in instant case had also violated the disclosure to information norm where by the policy shall be void and all premium paid herein shall be forfeited to OPs in the event of misrepresentation, mis-description or non-disclosure of material facts. The cashless request of the complainant for his hospitalization was repudiated as the cashless facility cannot be granted due to incorrect good health declaration at the time of policy inception. OPs also submitted citations of Hon’ble Supreme court of a number of cases.
Here the question to be decided whether there is suppression of material facts relating to the health by the complainant while filling the proposal form of the policy.
OP submitted that in Ext.B4 a photocopy of certificate issued from Sakra Hospital dated 02/10/2019 stated that the patient himself was treated in outside hospital for BPH duration 5 years and BHP duration is more than 10 years. On perusal of Ext.B4, the name of medical officer who issued the said certificate is not mentioned. Moreover, it is a photocopy. So Ext.B4 cannot be accepted as a conclusive proof to come to a point that the complainant had BPH since 5 years and BHP since 10 years from 02/10/2019. Moreover the OPs 1 and 2 did not produce the treatment certificate of the patient (complainant) from the outside hospital or examine the doctor who issued the Ext.B4 certificate. From Ext.B4 we cannot assume that the facts mentioned in the document was given by the complainant himself.
On careful perusal of Ext.X1 the case records of complainant from Sakra Hospital we cannot find out the enrolment in the past history of the patient that he had BHP duration more than 10 years and BPH duration more than 5 years and was treated in outside hospital. In Ext.X1(a) dated 29/09/2019 past history k/c/o Diabetes mellitus, Hyperthyroidism and hypertension on treatment, k/c/o BPH on treatment. We can see that the period from which the patient suffered from the above said diseases in not mentioned. More over in page 8 of Ext.X1 it is stated that past history DM since 4 years HTN since 4 years. From this statement it is revealed that the patient had suffered DM and HTN from 9th September 2015. For clarifying the past history of the complainant examination of the treating doctor is necessary. From the facts stated in the medical records is not sufficient when the complainant denied the contention of the OPs about the past history of 10 years duration of BHP and 5 years duration of BPH.
Hence from the aforesaid facts, there is no evidence that the complainant had suppressed the material facts relating to his health in the enrolment form. So the repudiation of the claim submitted by the complainant, made by OPs 1 and 2 is unjustifiable. Complainant is entitled to get the policy benefit. Ext.A4 shows that the OPs 1 and 2 had approved a total of Rs.45,000/- to the complainant. But it was also not given. Ext.A3 in patient bill of complainant from Sakra hospital shows that he was admitted in the hospital on 29/09/2019 and discharged on 03/10/2019 in urology department and was under treatment of Dr.Ajay Shetty. The Net payable amount for treatment was 2,22,258/-. Complainant submitted that the said amount was paid by him to the hospital. There is no dispute about the said submission. So OPs 1 and 2 has to reimburse the said treatment amount to the complainant. There is deficiency in service on the part of OPs1 and 2 in repudiating the claim approval of the complainant. Since OP3 has no role in repudiation of the claim form of complaint and as OP3 has sent all the documents given by complainant to OPs 1 and 2 without any delay there is no deficiency in service on the part of OP3.
In the result complaint is allowed in part. Opposite parties No.1 and 2 is directed to pay Rs.2,22,258/- to the complainant. Opposite parties are further directed to pay Rs.20,000/- towards compensation and Rs.10,000/- towards cost of the proceedings of the case. Opposite parties 1 and 2 shall comply the order within one month from the date of receipt of this order, failing which the amount Rs.2,22,258/- carries interest @ 9% per annum from the date of order till realization. Complainant is at liberty to realize awarded amount by filing execution application against OPs 1 and 2 as per provisions in Consumer protection Act 2019.
Exts.
A1- Policy certificate
A2-Discharge summary dated 02/10/2019
A3- Medical bills
A4- Text messages
A5- Denial letter
X1,X1(a)-Medical records from Sakra Wold Hospital Banglore
B1-Enrolment form
B2-Certificate of insurance
B3-Pre-Authorization form
B4- Additional information from Sakra world hospital
B5-Discharge summary of Sakra world hospital
Pw1- Complainant
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
