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

CONSUMER COMPLAINT NO.523/2021

DATED ON THIS THE 7^th FEBRUARY-2023

Present:        1) Sri. B.Narayanappa

M.A., LL.B., - PRESIDENT  

                     2) Smt. Sharavathi. S.M,

                                               BA., LLB., MEMBER

Judgment Delivered by Sri B.NARAYANAPPA,

                                                               PRESIDENT

During November 2017, the marketing officer of the OP approached the complainant andexplained about the Group Health Insurance Policy and gave a brochure.After going through the brochure, the complainant purchased the Group Insurance Policy bearing No.120100/12586/2019/A017521/PE01869643 for the period from 26.11.2019 to 25.11.2020.During September 2019, the complainant was experiencing health issues.Therefore, she approached Ramesh Cardiology Clinic and underwent Echocardiography test on 13.09.2019 and she was diagnosed for Mitral Volve prolapse and advised operation.Thereafter, on 03.01.2020, the complainant requested the OP for extending cashless services and admitted to Fortis Hospital, Bannerghatta, Bangalore on 04.01.2020 and underwent surgery and she was discharged on 10.01.2020.But due to the shock and surprise of the complainant, on 04.01.2020, the complainant received a letter from the OP repudiating the cashless request for the reasons that, there is an incorrect good health declaration hiding of the fact of IHD and Mitral Volve Prolapse in 2012.On 06.01.2020, the OP sent another letter terminating the Health Insurance Policy.On 21.01.2020, the complainant submitted the claim for Rs.7,88,143/- and also sent an e-mail on 05.02.2020 to OP to consider the claim.But, the OP rejected claim on 06.02.2020 stating that, the policy has been cancelled due to incorrect good health declaration and it is further submitted that, complainant during the month of September 2012 was experiencing difficulties in breathing and approached the Ramesh Cardiology Clinic and underwent Echocardiography test and diagnosed Ischemic Heart diseaseAngina Mitral Volve Prolapse and the complainant was discharged without any problem in good health condition and normal medication was prescribed and she stopped the medication after 15 days and no blockage were found.On 13.12.2012, the complainant approached Hrudayadhama Cardiology Clinic and got Holter report which shows normal health condition.The complainant sent repeated e-mails to consider the claim and continuation of the insurance policy but, the OP did not heed to the request of the complainant.On 06.05.2012, the complainant sent a representation to insurance ombudsman requesting to review the decision of the OP.The Ombudsman informed not to entertain the review and it is further contended that, the complainant never gave incorrect good health declaration.The repudiation of the claim by the OP is arbitrary.Hence, it is alleged the deficiency in service on the part of OP.From October 2012 onwards, no issues were notified and no Doctor was consulted by the complainant again till 23.09.2019 on which date it was revealed Mitral Volve Prolapse and advised MVR.Therefore, filed this complaint.

5. our consideration are as under

1. Whether the complainant proves that the alleged deficiency in service on the part of the opposite party and thereby she is 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 an undisputed factthat, OP issued the Master Health Insurance policy bearing No. 2999203834944600000 namely policy No. 2811203852205000000 through intermediary M/s Canara Bank for the sum assured amount is Rs.10,00,000/- + Rs.2,00,000/- totally Rs.12,00,000/- and individual policy in the nameof complainant bearing No. 120100/12586/2019/A017521/PE01869643  for the period from 26.11.2019 to 25.11.2020.  The complainant got marked Ex.P-4 insurance policy issued by OP.  The OP also got marked Ex.R-2, the insurance policy issued to the complainant.  Therefore, the issuance of aforementioned master policy and individual policy in the name of complainant is stands established and it is not in dispute that, the sum assured amount is Rs.12,00,000/-.  After obtaining the insurance policy, the complainant in the month of September 2019, experienced ill-health.  Therefore, she approached Ramesh Cardiology Clinic and underwent Echocardiography test on 13.09.2019 and also she took treatment in Fortis Hospital on 04.01.2020 and underwent surgery. On 03.01.2020, the complainant requested the OP for extending cashless services.  On 10.01.2020, the complainant was discharged from the Hospital.  The OP repudiated the cashless requests on 04.01.2020 on the ground that, there is an incorrect good health declaration and hiding of the fact IHD and Mitral Volve Prolapse in 2012.  On 21.01.2020, the complainant made claim with OP claiming reimbursement of medical expenditure of Rs.7,88,143/- but, the OP has not only rejected the claim and also cancelled the insurance policy issued to complainant on the ground that, the complainant did not disclose the pre-existing disease such as Ischemic Heart disease  Angina Mitral Volve Prolapse found in the year 2012.  The complainant has relied upon Ex.P-1 to P-24 i.e., Policy wordings, Insurance policy, Medical bills, Claim Form, rejection letter etc. Therefore, the present complaint is filed by the complainant.  The complainant produced inpatient details running bill issued by the Fortis Hospital for Rs.7,77,965-86.  The OP has not disputed the amount incurred by the complainant for her medical treatment but, rejected the claim of the complainant only on the ground that, the complainant has suppressed the pre-existing disease such as Mitral Volve Prolapsed in 2012.

8. policy was issued on 23.11.2019 and the validity of the said policy was from 26.11.2019 to 25.11.2020 and during the validity period of the said policy, the complainant took treatment in Fortis Hospital from 04.01.2020 to 10.01.2020 and underwent for surgery on her heart ailment and spent Rs.7,77,965-86 and made a claim to OP for reimbursement of the said medical expenditure but, OP not only repudiated the claim and also cancelled the insurance policy as we have stated above on the ground that, the complainant has suppressed the pre-existing disease without disclosing the same in the proposal form.  It is the clear contention of the OP that, the complainant has suppressed the pre-existing disease such as Mitral Volve prolapsed in the year 2012 and according to the complainant, she took treatment for the said ailment i.e., she only she underwent for medical tests not for any surgery and the Doctor prescribed medicine for a period of 15 days and after 15 days, she stopped taking medicine and her health condition was good since from October 2012 till 23.09.2019 i.e., for a period of almost 7 years, the complainant was keeping good health.  After 7 years from the year 2012 i.e., in the year 2019, the complainant had obtained the aforementioned group insurance policy issued by the OP and during the validity period of the policy in question, she took treatment in Fortis Hospital from 04.01.2020 to 10.01.2020 after a long gap of 8 years from 2012.  Under such circumstances, the OP cannot contend that, the complainant had suppressed the pre-existing disease such as Mitral Volve Prolapsed in the year 2012 and the said contention of OP cannot be believed and acceptable and the repudiation of the claim by the OP on the said ground is un-just and arbitrary only with an intention to escape from its liability of payment of insurance amount to the complainant.  The OP should have considered the claim made by the complainant but, it has declined it and also cancelled the insurance policy issued in the name of complainant which is not fair on the part of the OP.  The repudiation of the claim of the complainant and cancellation of the policy issued in the name of complainant by the OP itself is nothing but the deficiency in service on the part of OP.  Therefore, we are of the considered view that, the complainant has proved that, the OP has committed deficiency in service on the part of OP.  Hence, we answer point No.1 partly in the affirmative.

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

:: ORDER ::

1. The complaint of the complainant is hereby allowed in part.

2. The opposite party is hereby directed to pay medical expenditure of Rs.7,88,143/- incurred by the complainant for taking treatment in Fortis Hospital with  interest at 6% p.a. within two months from the date of this order till payment.

3. Further opposite party is hereby directed to pay compensation of Rs.50,000/- for mental agony 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, the 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 7^th February 2023)