BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 29^TH DAY OF JUNE 2024

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. Direct the respondent to pay sum of Rs.3,86,343/- along with interest @ 18% p.a., to the complainant from 22.08.2023 till the date of realization.
2. To pay compensation of Rs.2,00,000/- towards deficiency in services  and also towards harassment, mental agony caused to complainant by the respondent.
3. Pass such other direction that this Hon’ble Commission deems fit to grant in the interest of justice and equity.

2. The case set up by the complainant in brief is as under:-

The complainant has availed the health insurance policy from the OP company vide policy bearing No.33098117202300.  The policy was issued on 18.03.2023 and expiry date was 17.03.2026 and the policy period is for three years.  The sum insured was Rs.5,00,000/-.  

3. The complainant was hale and healthy but in the first week of August 2023 the complainant has a mild pain in throat while swallowing food. Hence he consulted Dr.Sangi Reddy at Hope Hospital, situated at Old Madras Road, Bhattarahalli, Bangalore, with the complaint of mild pain in throat while swallowing. The doctor did all initial checkups and found no symptoms of either swelling in neck or infection in the throat and advised him to undergo other relevant investigations to find out the cause for pain.

4. As per the advise of the doctor relevant pre outpatient investigations were carried out and submitted the report to the doctor.  After going through the report the doctor has informed the complainant that there is a thyroid infection mostly aged around 2-3 months only and further advised him to undergo surgery to prevent further spread of infection and to remove the infection from the root cause. The doctor further informed the complainant that the thyroid infection is very initial stage and the swelling is unnoticeable through naked eye.  The thyroid was noticed by the doctor after perusal of the report.

5. The complainant as per the advise of the doctor has underwent surgery for thyroid problem at hope hospital, he was admitted to the hospital on 12.08.2023 and discharged on 22.08.2023.  After discharge and during the discharge process the complainant has requested the OP to settle the hospital bills as per the policy coverage.  The OP have initially processed to pay the hospital bills but at last they rejected the claim alleging that “the patient has a history of swelling in neck region since 1 year which is prior to policy start date.  This was not disclosed to us at policy issuance stage.  We regret the claim is not payable under non disclosure policy clause 8.2(b) and 8.12.”   

6. It is further case of the complainant that there was no swelling in the neck region since one year.  When the complainant has enquired the OP, they have pointed out that swelling since one year was referred in the discharge summary.  After that he consulted the doctor immediately and enquired about the reference of one year swelling in the neck when there was no such swelling and was never informed of any such swelling during the entire medication.  After that the senior doctor has also issued letter dated 10.12.2023 giving clarification to the OP’s queries. They have also clearly stated in the letter that after examination of reports a small nodule was found and it is improbable for the patient to have noticed the swelling a year ago going by the clinical means. They have further stated that it is probably a mistake by junior doctors to have assumed the findings. The said letter was submitted to the OPs. Even after submission of the letter the OP have rejected the claim, vide email dated 28.10.2023.  The complainant has paid the hospital bills by raising hand loans from his friends and relatives.  The complainant is legally entitle for the insurance claim medical bills amounting to Rs.3,86,343/-.  When the OPs have failed to honor the request of the complainant he has got issued legal notice on 11.12.2023. Even after service of legal notice, the OPs have not honored the request of the complainant. Hence this complaint is filed for deficiency of service on the part of the OP.

7. In response to the notice, OP has not appeared before this commission, hence OP placed exparte.

8. The complainant has filed his affidavit evidence and relies on 13 documents. 

9. Heard the arguments of advocate for the complainant.  Perused the written arguments.

10. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

11. Our answers to the above points are as under:

Point No.1:  Affirmative

Point No.2: Affirmative in part

Point No.3: As per final orders

REASONS

12. Point No.1 AND 2: These two points are inter related and hence they have taken for common discussion.  We have perused the allegations made in the complaint, affidavit evidence and written arguments and documents. Inspite of issue of notice the OP remained absent. Hence OP neither challenged the allegations made in the complaint and also documents and they remained unchallenged.

13. To prove their contention the complainant has filed his affidavit evidence and relied on Ex.P1 to P13. Ex.P1 is the Copy of the policy, Ex.P2 is the Copy of the patient admission card Ex.P3 is the Copy of the test report, Ex.P4 is the Copy of the discharge summary, Ex.P5 is the Copy of the letter issued by Dr.N.Sangi Reddy, Ex.P6 is the Copy of the email dated 28.10.2023, Ex.P7 is the Copy of the hospital bill, Ex.P8 is the Copy of the legal notice dated 08.12.2023, Ex.P9 & 10 are the Postal receipt and Postal acknowledgement, Ex.P11 and 12 are the Copy of the emails dated 01.01.2024.

14. It is clear from the above evidence and documents that the complainant has availed the health insurance policy from the OP company as per Ex.P1 and the policy commencement date was 18.03.2023 and the policy period is for three years and the expiry date is 17.03.2026 and the sum assured was Rs.5,00,000/-. 

15. The complainant was hale and healthy. On 08.08.2023 the complainant has mild pain in his throat while swallowing food and hence he has consulted the doctor at Hope Hospital, Old Madras Road, Bangalore. After physical and initial examination the doctor found no symptoms of either swelling in neck or infection in the throat and has advised him to undergo for relevant pre-outpatient investigation to find out the cause for pain. The complainant underwent the investigations and submitted the reports to the doctor. After going through the report the doctor found that there is a thyroid infection mostly aged around 2-3 months only and further advised him to undergo surgery to prevent further spread of infection and to remove the infection from the root cause.

16. As per the advise the complainant was admitted to hospital on 12.08.2023 and he was underwent surgery of total thyroidectomy + Right FND + CCND under GA 12/08/23 and he was treated as an inpatient till 22.08.2023 as per the discharge summary issued by the hospital as per Ex.P4.  The complainant has also submitted the medical bills paid by him amounting to Rs.3,86,343/-.  He has also produced all medical bills as per Ex.P7.  When the OPs have repudiated the claim of the complainant by sending email as per Ex.P6 the complainant has also sent the letter issued by his doctor stating that the complainant has noticed this problem only 2-3 months at the time of admission to the hospital and not one year and it is wrongly mentioned in the discharge summary Ex.P4 due to the mistake committed by the junior doctors in their hospital.  Even after submitting the same to the OP they have rejected the claim of the complainant.  After that the complainant has got issued legal notice as per Ex.P8 and it was served on the OP and they have issued reply notice.

17. The main grievance of the OP is that after scrutinizing the claim document submitted by the complainant and also investigation done by them it is found that the patient complainant has a history of swelling in neck region since one year which is prior to policy start date, this was not disclosed to them at the stage of issuance of the policy.  Hence they are not liable to pay due to non disclosure under policy clause 8.2(b) and 8.12.  Hence the claim was denied by the OP as per policy terms and conditions.

18. Admittedly the policy Ex.P1 was issued policy commencement date is 18.03.2023.  The complainant has admitted to hospital in the month of August 2023 when he noticed the pain in the throat while swallowing. After that he was approached the doctor and after investigation they have opined that the complainant has got the infection in the thyroid and they have advised him to go for surgery.  Even though the complainant has clearly stated before the doctor that he has got this problem only about one week prior to consultation of the doctor and not one year, while preparing the discharge summary by hospital authorities a mistake was committed by the author of the discharge summary Ex.P4 that he has complained of swelling in the neck region since one year and he got mild pain in throat while swallowing since one week.  After that the senior doctor has given clarification for the wrong information written in Ex.P4 that the size of the nodule is 2X2.5 cms., even in the pathologist notes and also report and also in the CT scan report.  Without the help of the medical reports it is improbable for the patient to have noticed the swelling a year ago.

19. Under these circumstances, when the complainant was not suffering from any pain or problem in the throat he was not disclosed the same in the proposal form at the time of taking the policy Ex.P1.  The OPs have rejected the claim of the complainant even after the doctor has given explanation in the wrong entry committed in the discharge summary by the hospital authorities.

20. On perusal of all the medical documents and the reports and also the letter Ex.P5 issued by the doctor it is clear that the complainant was not at all suffering from any problem at the time of issue of policy and he has got the problem only after issuance of the policy in the month of August 2023. The OPs have remained absent inspite of service of notice by this commission. They would have appeared before this commission and filed their version by taking all the contentions for repudiating the claim of the complainant.  When the OPs have not at all challenged the evidence and documents placed by the complainant before this commission there is no reason to disbelieve the evidence and documents of the complainant.  When the policy is in force and sum insured is Rs.5,00,000/- the OPs are bound to pay the claim made by the complainant.  When the OPs have repudiated the claim of the complainant, the complainant was suffered mental shock and also financial loss and he was forced to borrow loan from his close relatives to meet the medical expenses at the time of his discharge.  Under these circumstances, the complainant is entitled for the relief claimed in the complaint.  Hence we answer point No.1 in affirmative and point No.2 partly in affirmative.

21. Point No.3:- In view the discussion referred above we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. OP is directed to pay Rs.3,86,343/- with interest at 12% p.a., from 22.08.2023 to till realization to the complainant.
3. OP is further directed to pay compensation of Rs.50,000/- with litigation cost of Rs.20,000/- to the complainant.
4. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 14% p.a. after expiry of 60 days on Rs.3,86,343/- till final payment.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 29^TH day of JUNE 2024)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;

NIL