BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU – 560 027.

DATED THIS THE 2^nd DAY OF MARCH, 2023      

CONSUMER COMPLAINT NO.1223/2019    

PRESENT:

SRI.RAJU K.S,

                     SMT.REKHA SAYANNAVAR,:MEMBER                                  

Sri. Manjegowda,

S/o Lakshmegowda,

Aged about 40 years,

No.64/1, Room No.7,

Lakshmi Commercial Complex,

Bengaluru-560 020.…COMPLAINANT

Sri. K.L.Srinivasa, Adv.

Reliance general Insurance,

Unnati arcade,

5/111 & 6/112, st Floor,

Bengaluru-560 010. …OPPOSITE PARTY

Sri. B.C. Shivanne Gowda, Adv.

*****

//JUDGEMENT//

BY SMT. REKHA SAYANNAVAR, MEMBER

The present complaint is filed under section 12 of Consumer Protection Act 1986 for a direction to the opposite party to pay a sum of Rs.3,00,000/- covered under the health policy bearing number 140121728280000883 along with interest at the rate of 18% per annum from 02.07.2018 and also to pay compensation of Rs.5,00,000/- for mental agony along with interest @ 18% per annum and to grant such other reliefs in the interest of justice and equity.

2.  The brief facts of the complaint is as under;

The complainant had obtained the Health Gain Insurance policy bearing number 140121728280000883 from the opposite party.  The said policy period is from 23.11.2017 to 22.11.2018 which covers the complainant, his wife and his dependant minor daughter. The assured sum was Rs.3,00,000/-.  The said policy was purchased by the complainant on 22.11.2017 by paying the annual insurance premium of Rs.10,861/-.  The opposite party had issued the premium certificate and identity cards for the same.

3. Further the counsel for the complainant submits that due to his ill-health he was admitted to the M.S. Ramaiah Memorial Hospital on 02.07.2018 as an inpatient.  The complainant as per the policy issued by the opposite party had requested in the prescribed form enabling the hospital authority to receive the full hospital expenses from opposite party under the cashless scheme and the same was also informed to the hospital authorities about the said policy. The complainant was diagnosed with dengue fever and low platelet count. It was diagnosed as ITP (Idiopathic Thrombocytopenia Purpuria) and he was treated in the said hospital as in patient from 02.07.2018 to 08.07.2018. At the time of the admission in the said hospital he intimated to the hospital authorities that he was having diabetic since four years and it is under well controlled and the same intimation has been forwarded to the opposite party by the hospital authorities in order to claim cashless scheme payment towards the treatment of the complainant.

4. The opposite party rejected the cashless claim of the complainant and refused to pay the amount towards the treatment of the complainant on the ground that the complainant had not disclosed about his diabetics he had at the time of obtaining the said health policy from the opposite party.

5. Further the counsel for the complainant submits that due to the repudiation of claim of the insurance policy by the opposite party the complainant suffered mentally and his health got deteriorated and he was again admitted to the MS Ramaiah Hospital. Due to his financial difficulties he was shifted from MS Ramaiah Memorial Hospital to M.S.Ramaiah College Hospital.  Where he took the treatment and got discharged.  The complainant submits that he had spent more than Rs.4,50,000/- and also spent more than one lakh rupees for follow-up treatment after the discharge.  

6. Further the complainant submits that the complainant fall sick due to the Dengue fever and not due to the diabetic.  In spite of the same the opposite party without taking into consideration straightaway rejected his claim and refused to pay and made the complainant to suffer mentally and financially.  The complainant left with no other alternatives, approached this commission for the deficiency of service of the opposite party under the consumer protection act 1986.  Hence, this complaint.

7. The counsel for the opposite party had filed detailed version, partly denied the averments made in the complainant.  It is contended that the claim of the complainant was rejected due to non-disclosure of the material facts at the time of the inclusion of the said policy. Hence, claim stands repudiated under NDC clause 5.1 "duty of disclosure of health gain policy terms and conditions” Thus, the complaint may be dismissed with heavy cost.

8. The complainant has filed affidavit in the form of his evidence in chief and marked Ex.P1 to P30. Opposite party has also filed an affidavit in the form of their evidence in chief and marked Ex. R1 and R2.                                   

9. Both party counsels have filed their detailed written arguments.

 10.    On the basis of the pleadings and documents, the points that would arise for consideration are as under:

  i) Whether the complainant proves the deficiency of service on the part of the opposite parties?

   ii) Whether the complainant is entitled for the reliefs as sought in the complaint?

   iii) What order?

       11.     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

      12. POINT NO.1:- PW1 and a RW1 had reiterated the facts of the complaint and version.  On perusal of the documents EX.P1 to P30 and EX.R1 and R2, it appears that it is the case of the complainant who had purchased the health policy of the opposite party bearing number 140121728280000883 on 22.11.2017 by paying the premium of Rs.10,861/-. The sum assured was three lakh rupees and the period covered was 23.11.2017 to 22.11.2018.

13. The counsel for the opposite party contended that the complainant had not disclosed the material fact of  diabetic at the time of the inception of the said health policy and rejected his claim for the same under clause 5.1  of the terms and conditions of the said policy, which reads as 5.1:- In the event of any illness or Injury or occurrence of any other contingency which has resulted in a Claim or may result in a Claim covered under the Policy, the Policyholder/ Insured Person, must notify the Companyeither at the call center or in writing immediately.

In the event of

1. Planned Hospitalization, the Policyholder/Insured Person will intimate such admission at least 48 hours prior to the planned date of admission.
2. Emergency Hopsitalization, the Policyholder/ Insured Person will intimate such admission within 24 hours of such admission.

The following details are to be provided to the Company at the time of intimation of Claim:

1. Policy Number
2. Name of the Policyholder
3. Name of the Insured Person in whose relation the Claim is being lodged
4. Nature of Illness / Injury
5. Name and address of the attending Medical Practitioner and Hospital
6. Date of Admission
7. Any other information as requested by the Company

        14. Though the complainant is having diabetic since four years but it is nothing to do with the present illness and hospitalisation treatment and the claim for the same. The complainant suffered from dengue fever and low platelet count, it does not relate to it and it is a well-known fact that diabetic is not a disease it is just a disorder. The commission has also observed here a Case law “Biman Krishna Bose V/s United India Insurance Co”, Civil Appeal No.3438/1995 that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the insurance company.  Moreover hypertension is not a material disease which is fatal in itself.

          So far as diabetes is concerned, the same parameter will apply.  Disease of diabetes is so common in our country men, at least in this part of the country that almost every third person is suffering from it.  If proper check is maintained on that disease it is not fatal and a person suffering from diabetes can live even for 20 to 30 years if he is taking proper medicines.  Therefore non-disclosure of this disease by the assured does not entitle the Insurance Companies to repudiate the insurance claim”. 

          Apart from that the opposite party did not produce any document to prove that the complainant had knowledge about the subject decease on the day or prior to taking of the policy. It is the contention of the learned counsel for the complainant that the opposite party has failed to prove the said defence taken. Hence, the repudiation is wrong. In support of the contention counsel relies the judgement rendered by Hon'ble NCDRC 2022 SCC Online NCDRC 41 LIC of India versus Mamta Sipani. The principle laid down in the said case supports his contention.

15. On the basis of the above case law. We hold that diabetic is just the disorder and not the disease and the repudiation of the claim of the complainant by the opposite party on this ground is not justiciable and maintainable. The repudiation by the opposite party amounts to deficiency of service of the opposite party enumerated U/sec. 2(g) of 1986 CP Act which caused the complainant to suffer mentally and financially. Hence, we consider point no.1 in affirmative.

16. POINT NO.2:- The complainant in his prayer made a prayer for the direction to pay the assured sum of Rs.3,00,000/- under the said policy bearing number 140121728280000883 with interest at the rate of 18% from 02.07.2018 and also to pay the compensation of Rs.5,00,000/- towards mental agony and  financial hardship. The interest at the rate of 18% is an exorbitant one.  The sum assured of the said policy was Rs.3,00,000/-. The complainant is the policy holder of the said policy which was in force at the time of his hospitalisation and he had produced premium paid receipt EX.P2, ID cards EX.P3,4,5 all his medical bills EX.P23 to EX.P29 and records to substantiate his claim for a sum of Rs.2,83,000/-.  Opposite party did not dispute the geniuses of the medical bills. Therefore, he is entitled for the reimbursement of the hospital bill of Rs.2,83,000/- along with interest at the rate of 9% p.a. from the date of 02.07.2018 from the opposite party. In addition, the complainant is entitled for the compensation of Rs.20,000/- towards mental agony and financial friendship and Rs.10,000/- towards litigation expenses. Hence, we answer point no.2 partly in affirmative.

17. POINT NO.3:- In the result, for the foregoing reasons, we proceed to pass the following;

       The complaint is allowed in part.

The opposite party is directed to reimburse the medical expenses of Rs.2,83,000/- at the rate of 9% p.a. from 02.07.2018 till realisation.

Further the opposite party is directed to pay the compensation of Rs.20,000/- towards mental agony and financial hardship and Rs.10,000/- towards litigation expenses.

Applications pending, if any, stand disposed of in terms of the aforesaid judgment.

     Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.

  (Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 2^nd day of March, 2023)                                            

(REKHA SAYANNAVAR)            (RAJU K.S)          (SHIVARAMA. K)    

//ANNEXURE//

Witness examined for the complainant side:

Sri. Manjegowda, the complainant has filed his affidavit.

Documents marked for the complainant side:

1. Original policy issued by opposite paty.
2. Original premium issued by opposite party.
3. ID cards.
4. Copy of email.
5. 33 medical reports from page no.9 to 55.
6. Three X-ray.
7. Medical prescription issued by M.S.Ramaiah Hospital 12 in number.
8. Hospital bill issued by Manipal Hospital and M.S.Ramaiah Hospital from page no.71 to 90.
9. 64 medical bills MSR pharma
10. Discharge summary issued MSR hospital for the period 02.07.2018 to 08.07.2018.
11. Discharge summary issued M.S.Ramaiah Hospital for the  period 29.09.2018 to 01.08.2018
12. Discharge summary issued M.S.ramaiah Hospital for the    period 01.08.2018 to 08.08.2018.
13. Patient registration from dt.29.07.2018 issued by Manipal Hospital, discharge summary issued M.S.Ramaiah Hospital for the period 02.07.2018 to 08.07.2018.
14. Medical reports issued by Manipal hospital from page no.162 to 166 discharge summary issued M.S.ramaiah Hospital for the period 02.07.2018 to 08.07.2018.
15. Copy of discharge summary.

Witness examined for the opposite party side: 

Sri. Santhosh B.L, the opposite party filed his affidavit.

Documents marked for the Opposite Party side:

1. Copy of the claim declaration of the insured.
2. Copy of the repudiation letter.

(REKHA SAYANNAVAR)            (RAJU K.S)          (SHIVARAMA. K)