Date of filing: 18.03.2019 Date of Disposal: 26.04.2023
BEFORE THE III ADDITIONAL BANGALORE URBAN
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU – 560 027.
DATED THIS THE 26TH DAY OF APRIL, 2023
CONSUMER COMPLAINT NO.517/2019
PRESENT:
SRI.RAJU K.S,
SMT.REKHA SAYANNAVAR,:MEMBER
Sri. P. Seethapathi Reddy,
S/o. P. Pattabhi Reddy,
Aged About 46 Years,
Residing at: #12, Basavannapura
Main Road, Gayathri Layout,
K.R.Puram, Bangalore-36.
(Rep by Sri. K.Muni Reddy, Advocate)
- V/s -
1) Branch Manager,
The Apollo Munich Health Insurance
Company Limited, Cears Plaza,
Residency Road, Opp. To
Bangalore Club, Bangalore-560025.
2) The Manager,
The Apollo Munich Health Insurance
Company Limited, 2nd & 3rd Floor,
Labs Centre, SCF 19, Sector 14,
Gurugon, Haryana State-122001.
3) The Manager/The Officer,
The Apollo Munich Health Insurance
Company Limited, Registered Office,
Jubliee Hills, Hyderabad-500033,
Telangana State.
(OP-1 to 3 are rep. by Sri. H.N.Keshava Prashanth, Advocate)
//JUDGEMENT//
BY SRI.SHIVARAMA K, PRESIDENT
01. The complainant has filed this complaint under section 12 of the Consumer Protection Act, 1986 seeking for a direction to the opposite parties to pay an amount of Rs.72,324/- in respect of the medical expenses and such other relief as this Commission deems fit in the circumstances of the case.
02. It is not in dispute that, the complainant had obtained the medi claim insurance policy from opposite party under Medi Claim Policy for the year 2009 covering the risk of the complainant, his wife, his son and daughter and the same was valid since from 10.11.2009 to 21.11.2018. Further it is not in dispute that, the complainant’s daughter by name baby Rossini suffered right knee pain on 26.03.2018 and took treatment at Narayana Multi-Specialty Hospital in Bangalore and the Doctors at there, conducted arthroscopic debridement and synovectomy of knee and synovil biopsy. Further it is not in dispute that, the opposite party had denied the claim on the ground that, the complainant did not disclose the pre-existing disease at the time of obtaining the policy. Further it is not in dispute that, on 13.03.2018 the opposite party had sent intimation to the complainant that, the policy was terminated by them. Thereafter the complainant got issued a legal notice dated: 21.07.2018 to the opposite parties to satisfy the claim dated: 27.03.2018, but the opposite parties did not respond for the same.
03. It is the further case of the complainant that, even though as per the conditions of the policy pre-existing diseases are covered after the waiting period of 36 months as contemplated Under Section 6(d) of Appolo Munich Health Insurance, the opposite parties did not satisfy the claim. Therefore the opposite parties wantonly to have a wrongful gain to their company had rejected the claim without following the IRDA guidelines. Hence complaint came to be filed.
04. It is the further case of the opposite parties that, since the complainant did not furnish the information with regard to the pre-existing disease as per Section 11 of the Insurance Act, 1938 the complainant is not entitled for any claim. Further the complaint is based on mere surmises and conjectures. Further the complainant did not inform to the opposite parties that, he did not understand the conditions of the policy with regard to any problem on the policy within the free look period of 15 days from the respective policy documents. Hence on valid reasons the opposite party had rejected the claim of the complainant for the cashless facility sought and sought to dismiss the complaint.
05. To prove the case, the complainant (PW.1) has filed affidavit in the form of his evidence in chief and got marked EX.P.1 to EX.P.6, EX.P.6(a) to P.6(f) documents. The Senior Manager at opposite party No.1 (RW.1) has filed affidavit in the form of his evidence in chief and got marked EX.R.1 to EX.R.15 documents.
06. Counsel for the complainant and opposite parties have filed their respective written arguments.
07. The points that would arise for consideration are as under:-
(1) Whether there is deficiency of service on the part of the opposite parties?
(2) Whether the complainant is entitle for the
relief sought ?
(3) What order ?
08. Our findings on the aforesaid points are as follows:-
Point No.1 : In affirmative
Point No.2 : Partly in affirmative
Point No.3 : As per the final order for the following;
REASONS
09. POINT NO.1:- The complainant (PW.1) and opposite party No.1 (RW.1) have reiterated the fact stated in their respective pleadings, in the affidavits filed in the form of their evidence in chief.
10. It is the contention of the learned counsel for opposite parties that, the complainant has suppressed the material fact with regard to the pre-existing disease. On perusal of EX.R.3 the proposal form submitted on 10.11.2009 to obtain the health insurance policy it appears that, the complainant did not disclose anything about the pre-existing disease in the required column of the proposal form.
11. According to PW.1 his daughter by name baby Rossini suffered from right knee pain on 26.03.2018 and took to Narayana Multi-speciality hospital, Bangalore, and after medical tests the Doctors at there, conducted Arthroscopic Debridement and Synovectomy of knee and Synovil Biopsy and the complainant did not produce any document with regard to the treatment taken as an inpatient and the particulars with regard to the diagnoses undergone and the findings of the Doctor with regard to the disease in question. Contrary to that, the opposite party has produced EX.R.7 i.e., copy of the out-patient case sheet with regard to the treatment taken on 26.03.2018 by the daughter of the complainant and the mention made in it is not legible.
12. Further the opposite party has also produced EX.R.8 the MRI report pertaining to right knee joint and the impression in the said report is that, “moderate effusion and no evidence of ligament tear”. On perusal of EX.R.9 the discharge summary issued by Wockhardi Hospital it appears that, the complainant’s daughter was admitted to the hospital on 21.05.2008 and discharged on 29.05.2008 and the Diagnosis page with regard to Congenital Heart Disease, TOF, Large Perimembranous VSD with right to left shunt, severe infundibular Pulmonary Stenosis and surgery was performed on 22.05.2008. EX.R.12 is the claim form. Hence admittedly the complainant did not disclose the treatment taken as per EX.R.9 in the hospital as an in-patient.
13. EX.P.1 is the conditions of the policy and its wordings in which it is stated that, as per section 7(t)(u)(v) “the insurance company can cancel the policy on the grounds of mis-representation, fraud, non-disclosure of material facts or non-cooperation by any insured person upon 30 days’ notice without refund of premium”. EX.R.12 is the claim form submitted on 27.04.2018. EX.R.13 is the notice issued by opposite party to the complainant intimating the complainant as to why the termination of the policy cannot be done. Further after lapse of 30 days from the notice been served the termination was made. Further as the complainant had supressed the material facts and the notice was came to be issued on 30.03.2018, the said notice was issued on the claim made by the complainant in claim ID No.439271/1, dated: 27.03.2018. Further EX.R.11 is the copy of denial of cashless service. EX.R.15 is the rejection letter dated: 01.05.2018 of the reimbursement of Rs.71,314/- sought with regard to the treatment taken at Narayana Multi-speciality Hospital from 29.03.2018 to 30.03.2018.
14. It is the contention of the learned counsel for the complainant that, since the claim was with regard to pre-existing disease after the waiting period of 36 months the complainant is entitle for the same as contemplated under section 6(d) of the clause mentioned in the policy. In Clause-6(d) of the policy it is stated that, pre-existing conditions will not be covered until 36 months of continuous coverage elapsed, since inception of the first easy health policy with the company. Admittedly the policy was a continuous one since from 10.11.2009 till 21.11.2018. The claim was for the period from 29.03.2018 to 30.03.2018 with regard to the treatment taken. We feel since 36 months waiting period has been completed the opposite party should not to have rejected the claim as per EX.R.15. Further we feel, no doubt, the complainant has not disclosed the pre-existing disease and has violated the conditions, but the opposite party did not cancel the policy at all till the completion of waiting period of 36 months and thereafter. Therefore we feel even though the complainant’s daughter had the past history of Congenital Heart Disease and the same has not been disclosed, by virtue of Clause-6(d) of the policy the complainant is entitle for reimbursement. Further we feel Clause-6(d) of the policy shown in EX.P.1 over-rides section 7(t)(u)(v) of the policy. Further admittedly the complainant did not make any claim under the subject policy previous to the present claim. Hence we feel the intimation to the complainant vide EX.R.1 dated: 01.05.2018 that, the claim was repudiated due to non-disclosure and concealment of fact and the policy is terminated is not tenable in law.
15. Further in EX.R.15 it appears that, the termination and repudiation of the claim was made on the same date. Therefore there is deficiency of service on the part of the opposite parties in issuing EX.R.15 rather honouring the claim of the complainant. Apart from that opposite party had terminated the policy after the claim was submitted by the complainant. Hence the policy was in force at the time of application for reimbursement been filed. Therefore there is no merit in the contention of learned counsel for opposite parties. Accordingly we answer this point in affirmative.
16. POINT NO.2:- The complainant claimed a sum of Rs.75,324/- in respect of the medical expenses. The opposite party did not dispute the quantum of the amount claimed. To substantiate the medical expenses made, the complainant has produced EX.P.5, 5(a), 5(b), 5(c), 5(d), 5(e), 5(f), 5(g), 5(h), 5(i) medical bills. The complainant is entitled for reimbursement of the same.
17. Further the complainant claimed the return of entire premium amount of Rs.95,480.07. We feel in view of section 7(t)(u)(v) of the policy conditions the complainant is not entitle for either the entire premium or any percentage of the same. Further the complainant claimed a sum of Rs.2,00,000/- as compensation. We feel since without analysing any reason opposite party had dis-honoured the claim of the complainant for which the complainant had undergone mental agony. Hence the complainant is entitle for a sum of Rs.15,000/- towards mental agony.
18. Further the complainant claimed a sum of Rs.25,000/- towards litigation expenses. The act of the opposite party made the complainant to get issued legal notice vide EX.P.6 and to approach this Commission for the relief in question. Hence the complainant is entitle for a sum of Rs.10,000/- towards litigation cost. Further since the reimbursement of the medical claim has not been made and it was rejected the complainant is entitle for the interest at the rate of 9% per annum from the date of rejection i.e., 01.05.2018 till realization. Accordingly we answer this Point partly in affirmative.
19. POINT NO.3:- In view of the discussion made above, we proceed to pass the following:-
ORDER
The complaint is allowed in part.
The opposite party No.1 to 3 are jointly and severally liable to pay to the complainant a sum of Rs.72,324/- with interest at the rate of 9% per annum from the date of rejection of the claim i.e., 01.05.2018 till realization and to pay a sum of Rs.15,000/- towards mental agony and a sum of Rs.10,000/- towards litigation cost.
The opposite parties shall comply the order within 30 days. In case, the opposite parties fail to comply the order within the said period, the above said amount of Rs.25,000/- carries interest at the rate of 9% p.a. from the date of order till realization.
Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.
Applications pending, if any, stands disposed-off in terms of the aforesaid judgment.
(Dictated to the Stenographer, typed by him, the transcript corrected, revised and then pronounced in the open Commission on 26th Day of April, 2023)
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
-
//ANNEXURE//
Witness examined for the complainant side:
Sri. P. Seethapathi Reddy, the complainant (PW-1) has filed affidavit in the form of his evidence in chief.
Documents submitted by the complainant side:
- The original policy documents pertaining to Health Insurance Policy No.120100/11001/1000051584 dt.12.11.2019 – EX.P.1
- Renewal letter dated: 24.11.2016 of Health Insurance policy from 22.11.2016 to 21.11.2018 – Ex.P.2
- Letter dt.30.03.2018 issued by OP for terminating the policy – EX.P.3.
- Denial of cashless service letter dt.28.03.2018 from OP to Narayana Multi specialty hospital – EX.P.4.
- Copy of the legal notice dt.21.07.2018 with postal receipts and postal acknowledgments & undelivered postal cover – EX.P.6, EX.P.6(a) to EX.P.6(f).
Witness examined for the opposite party No.1 side:
Sri. S.Yashwanth Kumar, Senior Manager in opposite party No.1 (RW-1) has filed affidavit in the form of his evidence in chief.
Documents marked for the Opposite Party No.1 side:
- Copy of authorization – EX.R.1.
- Copy of certificate in corporation of name of OP – Ex.R.2.
- Copy of proposal form – EX.R.3.
- Copy of insurance coverage letter with schedule copies – EX.R.4.
- Copy of terms & conditions – EX.R.5.
- Copy of request letter for cashless hospitalization – EX.R.6
- Copy of outpatient case sheet – EX.R.7
- Copy of MRI report – EX.R.8
- Copy of discharge summary – EX.R.9
- Copy of pediatric eco report – EX.R.10
- Copy of outpatient record – EX.R.11.
- Copy of claim form – EX.R.12.
- Copy of termination letter – EX.R.13
- Copy of denial of cashless letter – EX.R.14
- Copy of rejection letter – EX.R.15.
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
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