BEFORE THE BANGALORE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SHANTHINAGAR BANGALORE -  27.

CONSUMER COMPLAINT NO.425/2021

DATED ON THIS THE 23^rd FEBRUARY-2023

Present:        1) Sri. B.Narayanappa,

M.A., LL.B., - PRESIDENT  

                     2) Smt. Sharavathi. S.M,

                                               BA., LLB., MEMBER

ORDER’s passed by Sri. B.NARAYANAPPA,

                                                               PRESIDENT

Both the OPs are running Health Insurance Company in the name of “Cigna TTK Health Insurance”.The OPs contacted the complainants through their intermediary Mr. Gururaj. K with an offer to get a health insurance policy for which, complainants have agreed.Accordingly, the OPs issued health insurance policy bearing No.PROHLR 980049447.The complainant No.1 is the policy holder and complainant No.2 is the insured person.They have paid premium towards policy and the health policy covered by multiple/several benefits of all health related issues and the sum assured is Rs.10,00,000/-.The complainants are entitled for the coverage and benefits to the tune of Rs.10,00,000/-.The complainants had no any pre-existing disease/illness and they were hale and healthy on the date of policy issued to them.On 14.02.2021, the complainant No.2 was hospitalized and admitted in emergency department as an inpatient at Manipal Hospitals and she was diagnosed to have severe metabolic acidosis diabetic Ketoacidosis and was incubated and treated in the ER and admitted in MICU, the said disease is not a pre-existing in nature and she was discharged on 24.02.2021 and also she was treated as post hospitalization as outpatient and spent Rs.5,69,999/- towards medical expenses and also spent Rs.2,00,000/- towards pre-hospitalization, post-hospitalization, totally she has spent Rs.7,70,000/-.On 19.03.2021 reimbursement claim was registered with OP, the OP refused to consider the same and failed to reimburse the claimed amount on the ground that, the complainant was suffering from diabetic mellitus which is pre-existing in nature and the pre-existing diseases are not admissible under the policy for a period of 48 months.The Complainant No.2 had undergone for treatment of kidney stone operation at KIMS Hospital, Bangalore in the year 2016 and by that time, she was tested that, she has no diabetes or pre-existing disease.Hence, the question of pre-existing diabetes does not arise at all.The OPs have rejected the claim of the complainant on mechanical and technical grounds to escape from their liability and thereby violated the Rules and Regulations of insurance policy which is nothing but the deficiency in service on the part of OPs.Hence, this complaint.

5. our consideration are as under:

1. Whether the complainants prove that the alleged deficiency in service on the part of the opposite party and thereby they are entitled to the reliefs as sought for?

2.  What order?

      Point No.1:- Partly in the affirmative.

      Point No.2:- As per final order

                         for the following:

:: R E A S O N S ::

7.         Point No.1:- It is not in dispute that, the complainants have obtained 4 insurance policies continuously bearing Policy No.PROHLR 980049447 for the period from 27.03.2018 to 26.03.2019 and second policy for the period from 27.03.2019 to 26.03.2020, third policy for the period from 27.03.2020 to 26.03.2021 and 4^th policy for the period from 28.0.3.2021 to 27.03.2022 issued by the OPs and the issuance of said policies has been admitted by the OPs and the sum assured under the said policies is Rs.10,00,000/- each.  The policy holder is complainant No.1 and the insured person is complainant No.2 in all these health insurance policies and it is also not in dispute that, complainant No.2 was admitted to Manipal Hospitals on 14.02.2021 and she was diagnosed to have severe metabolic acidosis diabetic Ketoacidosis and was incubated and treated in the ER and admitted in MICU, the said disease is not a pre-existing in nature and she was discharged on 24.02.2021.  During the course of treatment of complainant No.2, the insurance policy was in force issued by the OPs and a sum of Rs.7,70,000/- has been spent towards medical expenses of complainant No.2.  It is the specific contention of the complainant that, the complainant No.2 was not suffering from any pre-existing disease even prior to inception of the policy and when she was tested in the Hospital at the time when she was admitted as inpatient in Manipal Hospitals, it was found that, the complainant No.2 was suffering from diabetes mellitus and the said disease was found for the first time when the complainant No.2 had undergone for test and it is further contention of the complainant that, the complainants made claim form with OP for reimbursement of medical expenses of Rs.7,70,000/- but, the OPs have repudiated the claim on the ground that, she was suffering from pre-existing disease such as diabetes mellitus and the OPs in their version have stated that, the claim of the complainant was not repudiated as per the policy terms and conditions but, the same was rejected since the complainant No.2 was suffering from diabetes mellitus since five years and she was operated for left VUJ calculus in 2016.  The said fact has not been disclosed by the complainant No.2 at the time of inception of the policy, accordingly violated the terms and conditions of the policy.  Therefore, the OPs have rejected the claim of the complainant vide letter dated 02.06.2021.  The OPs have relied upon the judgment of Hon’ble Supreme Court of India reported in III (2019) CPJ 31 (SC) wherein it is held that:

“Consumer Protection Act, 1986 – Sections 2(1)(g), 23 – Insurance(Mediclaim) – Exclusion clause – suppression of pre-existing disease – Claim repudiated – Alleged deficiency in service – Declaration which was furnished by proposer constituted basis for issuance of policy – Treatment record indicates that the complainant was operated for MVR – Nature of diagnosis has been reflected as rheumatic heard disease.There was a clear failure on the part of respondent to disclose that he had suffered from rheumatic heart disease since childhood – Ground for repudiation was in terms of exclusions contained in policy.

The afore-cited respected ruling is not applicable to the present set of facts of the case on hand.In the present case on hand, we have already come to the conclusion that, the complainant was diagnosed as diabetes mellitus when she was hospitalized on 14.02.2021.Prior to that, the policies issued by the OPs were in force since more than 2 ½ years i.e., almost waiting period for pre-existing disease had elapsed.Under such circumstances, with great respect, we are of the opinion that, the aforementioned decision of Hon’ble Supreme Court of India will not comes to the aid of OP. Complainants have produced copies of insurance policies and medical records, discharge summary issued by Manipal Hospitals and health test reports and medical bills issued by Manipal Hospitals.The medical bills disclosed that, the Manipal Hospital authority have billed a sum of Rs.6,18,453/- towards medical expenses.The discharge summary discloses past history that the complainant No.2 was suffering from diabetes mellitus since two years prior to the date of admission to Hospital on 14.02.2021, prior to that also, the first policy issued by the OP was in force from 27.03.2018 till 26..03.2019.Second and third policies were in force from 27.03.2019 to 26.03.2020, and from 27.03.2020 to 26.03.2021 and the fourth policy was valid for the period from 28.03.2021 to 27.03.2022.By the time when the complainant was admitted to Hospital, almost two years have been elapsed from the date of inception of the first policy and in view of four consecutive policies issued by OP were in force from 27.03.2018 to 26.03.2019 and from 27.03.2019 to 26.03.2020 and from 27.03.2020 to 26.03.2021 and from 28.03.2021 to 27.03.2022.Under such circumstances, the contention of the OPs that, the complainant No.2was suffering from pre-existing diseases cannot be believed and accepted.In view of the complainants have obtained four policies continuously from 2018 to 2022 and those four policies were running continuously from the date of inception of first policy till obtaining the 4^th policy.It shows that, the complainants having good faith on the OPs have obtained 4 policies continuously for the period from 2018 till 2022.Under such circumstances, the OPs should have considered the claim of the complainant instead of rejecting the same which is nothing but the deficiency in service on the part of the OPs.Therefore, we are of the considered view that, the complainants are entitled for reimbursement of the medical expenditure and compensation and cost of the litigation and the OPs are liable to pay the same to the complainants. Hence, we answer point No.1 partly in the affirmative.

8. Point No.2:- For the aforesaid reasons, we proceed to pass the following:

:: ORDER ::

1. 2.   Considering the admissible and inadmissible medical bills, we are of the opinion that, the complainants are entitled to receive medical reimbursement of Rs.5,00,000/- and the OP No.1 and 2 are liable to pay the said amount with interest at 10% p.a within two months from the date of this order till payment.

3. Further, the OPs are liable to pay compensation of Rs.50,000/- for the deficiency in service caused to the complainant and Rs.5,000/-towards cost of the litigation to the complainant within 2 months from the date of this order.Failing which, compensation of Rs.50,000/- + cost of litigation Rs.5,000/- totally R.55,000/- shall carry interest at 10% p.a. till payment.

4. The complainant is at liberty to take action against the opposite party under Section 72 of the C.P. Act, 2019 for non-compliance of this order.

5. Furnish the copy of order to both parties at free of cost.

 (Dictated to the Stenographer transcribed, typed by him, corrected by us and then pronounced in open Commission on this the 23^rd February 2023)