CC No.1672.2016

Filed on 17.12.2016

Disposed on.30.01.2019

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BANGALORE – 560 027.

DATED THIS THE 30^th DAY OF JANUARY 2019

CONSUMER COMPLAINT NO.1672/2016

PRESENT:

Sri.  H.S.RAMAKRISHNA, B.Sc., LL.B.,

                             PRESIDENT

                    Smt.L.MAMATHAB.A. (Law), LL.B.,

                           MEMBER,

    V/S

ORDER

BY SMT. L.MAMATHA, MEMBER

1. This Complaint was filed by the Complainant on 17.12.2016 U/s 12 of the Consumer Protection Act, 1986 and praying to pass an Order directing the Opposite Party to Claim amount of Rs.1,87,000/-, to cost of other expenses Rs.1,000/-, to pay compensation of Rs.1,87,000/-. 

2. The brief facts of the complaint can be stated as under:

In the Complaint, the Complainant submits that the Complainant is an Insurance Policy Holder under Royal Sundaram General Insurance Company Limited Policy No.GL00019355000102.  The Complainant who had type-II respiratory failure made the claim of Rs.1,86,827/- with Opposite Party.  On 16.09.2016 the Complainant visited Vinayaka Specialty Hospital, due to breathing problem.   There diagnosed as a Lung infection with reduced oxygen level as 65%.  Doctor suggested him to visit Apollo Hospital for further investigation.  

3. On 17.09.2016 the Complainant admitted in Apollo Hospital, his wife applied for cashless treatment within 24 hours.  Hospital Authority submitted all the papers according to their instructions.  After 8 days i.e., (23.09.2016) at the time of discharge insurance company refused to pay the amount to hospital.   After discharge, the Complainant sent mail to the Opposite Party on 24^th September 2016, for health reimbursement claim with scanned copy of discharge summary and Hospital Bills.   On 03.10.2016 applied for claim along with original documents.  Through mail the Opposite Party replied that they will revert within 21 days.  But he did not get any reply after 21 days.   Again he sent another mail but Opposite Party asked for 8 days.  On 16.11.2016 he received SMS that “claim has been repudiated and for repudiation has been mailed or couriered to the mailing address”.  Again the Complainant send an email to know the cause of action for rejection.  Afterwards one of the employee called to the Complainant and informed to him that his claim has been rejected on the basis of “Pre-existing ailment”.  On 28.11.2016 one of the employee of Opposite Party requested him to give 6 working days’ time to consider the case again on priority basis.    On 29.11.2016 he got letter from Opposite Party stating that the Complainant’s claim has been rejected on the basis of preexisting ailment.   Hence, this Complaint.   
4. In response to the notice, the Opposite Party put their appearance through their counsel and filed their version. In the version pleaded that the complaint is unsustainable, baseless and hence liable to be dismissed.  The Complainant is guilty of suppression of material facts and misrepresentation and have not come before this Hon’ble Forum with clean hands.  The present complaint is wholly misconceived since the Complainant has nowhere in his complaint mentioned the fact that he was suffering from Rheumatoid arthritis for 10 to 15 years and also that he was taking homeopathy medicines for the said ailment.  There is no ground made out by the Complainant whatsoever for grant of the order from this Hon’ble Forum. The Complainant has concealed the facts and history of his ailment and has willfully failed to produce all his medical records before this Hon’ble Forum.   The Complainant is an insurance policy holder with the Opposite Party from the Year 2011.  From the records furnished by the Complainant, it is also evident that he suffered from breathing problem and was diagnosed with lung infection and was treated for the same and further that the total bill charged by Apollo Hospital was Rs.1,86,827/-.  The Opposite Party refused to pay and repudiated the claim of the Complainant for the reason being that it is clear from the medical record of the Complainant that he was suffering from Rheumatoid Arthritis and Type II Respiratory failures from 10 to 15 years and that he has been taking homeopathy medicines for the same.  It is also evident that the Complainant is exposed to sulphuric acid and fumes for over 15 years.  The said ailments are prior to the policy of the Complainant with the Opposite Party and hence the same is pre-existing.    Preexisting ailments and its direct related complications are outside the scope of the policy as per the terms of the policy.   Hence, the Complainant is not entitled to any relief and complaint is liable to be dismissed.  Rheumatoid Arthritis or Kartagener’s syndrome is a rare genetic disease and the respiratory disorders are complications of Kartagener’s syndrome.  Such being the case, the Complainant has purposely concealed the details about his disease at the time of making the policy.  The Complainant has concealed about the fact of his ailments and his genetic disease at the time of making the policy.  There is no deficiency or delay on the part of the Opposite Party.   Hence prays to dismiss the complaint.

5.   The Complainant, Sri.Ravi R.Kopp filed his affidavit by way of evidence and closed his side. On behalf of the Opposite Party, the Authorized Signatory Sri.Sandeep S.K Reddy has been filed.   Heard arguments of both parties.

6.       The points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Party ?
2. If so, to what relief the Complainant is entitled ?

7.       Our findings on the above points are:-

POINT (1)             :-   Affirmative  

POINT (2)             :-  As per the final order

REASONS

8.   POINT NO.1:- As looking into the averments of the Complainant and also version filed by the Opposite Party, it is not in dispute that the Complainant is an insurance Policy Holder with the Opposite Party from the Year 2011.  The Complainant who had type-II respiratory failure made the claim with Opposite Party for Rs.1,86,827/-.  On 16.09.2016 he visited Vinayaka Specialty Hospital, due to breathing problem.  There diagnosed him as a lung infection with reduced oxygen level 65% and suggested him to visit Apollo Hospital for further investigation.  On 17.09.2016 the Complainant was admitted in Apollo Hospital.  The result suggested that he had been suffering from type-II respiratory failure, Rheumatoid arthritis and Kartagener’s syndrome.  At the time of admission his wife applied for cashless treatment within 24 hours.  Hospital Authority submitted all the papers according to their instructions.  After 8 days Opposite Party refused to pay hospital bill amount.  Being a patient Complainant faced very difficult to arrange huge amount of Rs.1,87,000/-.  After cash arrangements from his friends and relatives he got discharged.  Due to this, he suffered mental agony.  On 24.09.2016 he sent mail to Opposite Party for reimbursement.  As per Opposite Party’s formality he applied for claim along with original documents on 3^rd October 2016.  The Opposite Party replied through mail that they will revert back within 21 days.  But the Complainant did not get reply from Opposite Party even after lapse of 21 days.  The Complainant send another mail.  The Opposite Party asked for 8 days.  On 16.11.2016, the Complainant received SMS that “Your claim has been repudiated and reason for repudiation has been mailed or couriered to your mailing address”.  Again the Complainant sent an email to know the cause of rejection. One of the Opposite Party’s employee called Complainant and gave the reason as being “pre-existing ailment” amount cannot be reimbursed.  After discussion the Opposite Party requested to give 3 working days to time to review the reason.   But the Complainant did not get any email for review of his claim.  On 28^th November 2016, employee of Opposite Party requested to give 6 working hours’ time to consider the case again on priority basis.  In the meantime i.e., on 29.11.2016 the Complainant got a letter from Opposite Party that claim has been rejected on the basis of “Pre-Existing Ailment”. 

9. The defence of the Opposite Party is that the complaint is baseless, unsustainable and hence liable to be dismissed.  The Complainant is guilty of suppression of material facts and misrepresentation and have not come before this Hon’ble Forum with unclean hands.  The present complaint is wholly misconceived since the Complainant has nowhere in his complaint mentioned the fact that he was suffering from Rheumatoid arthritis for 10 to 15 years and also that he was taking homeopathy medicines for the said ailment.  There is no ground made out by the Complainant whatsoever for grant of the order from this Hon’ble Forum. The Complainant has concealed the facts and history of his ailment and has willfully failed to produce all his medical records before this Hon’ble Forum.   The Complainant is an insurance policy holder with the Opposite Party from the Year 2011.  It is also evident from the records furnished by the Complainant that he was suffered from breathing problem and was diagnosed with lung infection and was treated for the same and further that the total bill charged by Apollo Hospital was Rs.1,86,827/-.  The Opposite Party refused to pay bill and repudiated the claim of the Complainant for the reason clearly seen from the medical record of the Complainant that he was suffering from Rheumatoid Arthritis and Type II Respiratory failures from 10 to 15 years and that he has been taking homeopathy medicines for the same.  The Complainant is exposed to sulphuric acid and fumes for over 15 years.  The said ailments are prior to the policy of the Complainant with the Opposite Party.    Preexisting ailments and its direct related complications are outside the scope of the policy as per the terms of the policy.   Hence, there is no deficiency on the part of the Opposite Party. In support of this defence, Sri.Sandeep S.K has been filed his affidavit.  In his sworn testimony, he has reiterated the same, but except interested version and affidavit, the Opposite Party had not furnished any supporting evidence.

10.  The learned Counsel for Complainant argued that he was Policy Holder since 2011.  On 16.09.2016 he visited Vinayaka Specialty Hospital for breathing problem.  There diagnosed him as a lung infection with reduced oxygen level as 65% and suggested to visit Apollo Hospital and on 17.09.2016 he admitted in Apollo Hospital.  There he took treatment for Type-II respiratory failure.  But Opposite Party refused the pay bill amount, since Complainant suffered from pre-existing disease of Rheumatoid arthritis.  But the Complainant admitted for treatment of Type-II respiratory failure.  If it is preexisting ailment, why did Opposite Party issued policy.  Before taking the policy the Opposite Party have never informed about any precondition to the Complainant.  Thereby there is deficiency on the part of the Opposite Party. 

11.    On the other hand, learned Counsel for Opposite Party argued that the Complainant concealed the facts that he was suffering from Rheumatoid arthritis for 10 to 15 days and also that he was taking homeopathy medicines for the said ailment.  Hence, there is no deficiency on the part of the Opposite Party. 

12.  With this argument, nodoubt the Complainant is a customer of Opposite Party and he is policy holder under Opposite Party since from 2011, his policy Number is GL00019355000102.  The Complainant admitted to Apollo Hospital for Type-II respiratory failure.  At the time of admission his wife applied for cashless treatment within 24 hours.  But after 8 days Opposite Party refused to pay the amount to hospital by stating that it was pre-existing ailment.  It is the duty of the Opposite Party to inform about any precondition to the Complainant.  If Complainant suffered preexisting ailment, why did Opposite Party issued policy.  Before issuing policy, it is the duty of Opposite Party to make full health checkup of the Complainant.  As per policy prospectus of the Opposite Party, it is very clear that waiting period for preexisting disease is, benefits will not be available for preexisting disease for classic variant until 48 months, for supreme variant until 36 months and for elite variant until 24 months of continuous coverage have elapsed since the inception of the first policy with us or policy is enforced with any other insurance company.  According to the Opposite Party’s own prospectus they cannot reject the claim of the Complainant after a period of 6 years, which is after purchase of policy in the Year 2011 and completion of waiting period of their own prospectus.  Without any valid reason the Opposite Party rejected the claim of the Complainant.   Due to this, the Complainant suffered financially and mentally.  This clearly shows that the act of Opposite Party amounts to deficiency of service.    Hence, this point is held in the affirmative.

13. In the result, for the foregoing reasons, we proceed to pass the following order:

ORDER

The Complaint is allowed holding that there is deficiency of service on the part of the Opposite Party.

The Opposite Party is directed to reimburse the Medical Expenses of Rs.1,87,000/- to the Complainant and also directed the Opposite Party to pay a sum of Rs.50,000/- as compensation for causing mental agony to the Complainant.

The Opposite Party is also directed to pay Rs.5,000/- towards cost to the Complainant.

The Opposite Party is directed to pay the aforesaid amount within 30 days from the date of receipt of the order.   Failing which the aforesaid amount will carry interest at 12% p.a. from the date of order, till the date of realization.

Supply free copy of this order to both the parties.

 (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, dt.30^th day of January 2019).

MEMBER                                                               PRESIDENT

LIST OF WITNESSES AND DOCUMENTS

Witness examined on behalf of the Complainant:

1. Sri.Ravi R.Kopp, who being the Complainant has filed his affidavit.

List of documents filed by the Complainant:

1. Royal Sundaram Health Alliance Insurance Company Limited.
2. Rejection Letter.
3. Discharge Summary (Apollo Hospital).
4. Final Bill statement.
5. Bill breakup statement.
6. Payment paid receipts.
7. Summary letter.
8. E-Mail Communications between the Complainant and the Opposite Party.
9. Pre admission Hospital Report.

Witness examined on behalf of the Opposite Parties:

1. Sri.Sandeep S.K, Authorized Signatory of Opposite Party by way of affidavit.

List of documents filed by the Opposite Party:

1. Claim Form for Health Insurance Policy dated.05.10.2016.
2. Physical record and patient history maintained by Apollo Hospital.
3. Discharge Summary along with medical bills of the Complainant.
4. Health Insurance Claim Note and Investigation Report of the Opposite Party.
5. Email correspondences between the Complainant and the Opposite Party.

          MEMBER                                                                       PRESIDENT