Complaints filed on: 04-09-2021
Disposed on: 26-08-2022
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 26th DAY OF AUGUST 2022
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER
CC.No. 71/2021
B.C.Umesh S/o Late Channappa
Aged about 61 years,
Residing of Bellavi Village,
Bellavi Hobli, Tumakuru Taluk,
Tumakuru District,
Karnataka State.
……….Complainant
(By Sri.M.S.Nagaraju., Advocate)
V/s
1. SBI General Insurance Co., Ltd.,
3rd and 4th Floor, Lotus IT Park,
Plot No.B, 18-19, Road No.16,
Wagle Industrial Estate,
Thane (West) Maharastra,
By its Authorized Officer.
2. SBI General Insurance Co., Ltd.,
4th Floor, Tower-D, IBC,
Bannerughatta Road, Bengaluru-29,
By its Authorized Officer.
……….Opposite Party
(By Sri.N.V.Naveen Kumar., Advocate)
:ORDER:
SMT.G.T.VIJAYALAKSHMI, PRESIDENT
This complaint is filed against the OPs with a prayer to direct the OPs to pay a sum of Rs.3,54,700/- along with interest @ 18% p.a. from the date of admission i.e. 07.01.2021 till the date of payment along with cost of Rs.50,000/-.
2. The brief facts of the complaint is as under:-
The complainant insured his life under the Police Arogya Plus vide policy No.0000000015543824-01 with the OPs during the year 2019 and subsequently renewed the same on 13.11.2020. The complainant suffered heart problem in the month of December 2020 and therefore taken check-up at Sri.Jayadeva Institute of Cardiology Hospital Science and Research and they advised to admit and hence the complainant admitted on 25.12.2020 and discharged on 31.12.2020. During the time of admission, the complainant claimed insurance through online, but the OPs refused the pay the amount even though the complainant answered to all the queries which were asked by the OPs again and against. Therefore, the complainant had paid the bill of Rs.14,000/- and got discharged from the hospital.
2(a) The complainant further submitted that he again admitted on 07.01.2021 at Narayana Institute of Cardiology Science, Bengaluru and where undergone heart surgery and was discharged on 28.01.2021 with an advice to take periodical check-up. During admission, he claimed Rs.3,54,700/- towards hospital charges and medical through online. But the OPs without making the payment have dragged even though complainant answered to the all the queries asked by the OPs. Hence, no other alternative, the complainant had paid Rs.3,54,700/- to the hospital.
2(b). The complainant further submitted that even though he had submitted all the original bills and other documents like discharge summary, medical bills and other records, the OP after putting number of enquiries repudiated the claim as not payable against the terms of the policy through letter dated:19.03.2021. The complainant had not suppressed any of the disease as stated in the repudiation letter and had not at all misrepresented any of the facts and suppressed any type of disease. The complainant had suffered and paid the medical bills by borrowing the same with a condition to repay the same with interest and have caused all sorts of mental torture and agony to the complainant and have failed in discharging their service and caused deficiency of service. Hence, the complainant has filed this complaint.
3. After service of notice, the OP appeared through their counsel and filed version, wherein the OP has contended that the cashless request under the Health Insurance Policy of the Applicant for the hospitalization dated:07.01.2021 to 28.01.2021 was denied by the respondent and communicated by the TPA (Third Party Administrator) since the medical documents of the complainant categorically states that the complainant was a known case of Diabetes mellitus (DM) since 25 years and Hypertensive (HTN) for two years whereas the policy in question was only 1 year old but this fact the complainant has not disclosed while taking the policy and thereby the complainant suppressed the material facts. The complaint is bad in law for suppression of true and material facts. It is not in dispute that the complainant had taken a health policy namely Arogya Plus and was issued under the Policy No.15543824-01 for the period 13/11/2020 to 12/11/2021 subject to terms and conditions of the policy and the sum insured under the policy is Rs.3.00 lakhs and the maximum liability in any case is restricted to that sum, hence any claim over and above the sum insured is untenable.
3(a) The OPs further contended that while proceeding claim, it is seen from the discharge summary of Narayana Hospital and Jayadeva Institute of Cardiovascular Science and Research, it was clearly mentioned respectively that “the complainant was a known case of long standing diabetes mellitus and Hypertension” and “Past History” known case of Type 2 Diabetes Mellitus and Hypertension and under the regular medication. Further as per the medical records of both the hospitals, the age of insured as 60 years whereas, for the health insurance policy they had mentioned 55 years. Undisputedly, age is also being determinant / risk parameter in a health policy, hence there is a clear misrepresentation of risk. The policy is also clear and categorical on the aspect of suppression of material facts. In any health insurance policy health conditions of the proposer are very important and material for insurer to evaluate the risk before granting the cover and also for quoting the premium and ascertain the risk. However, any willful withholding of such crucial information shall put the insurer in dark and the policy shall be void as the insurance is a contract of Utmost Good faith. In this regard, the law is well settled by the Hon’ble Supreme Court in Satwant Kaur Sandhu Vs New India Assurance company Ltd., Hence, there is no deficiency of service in repudiating the claim of the complainant. Hence, the OPs pray to dismiss the complaint.
4. The complainants and OPs have filed their affidavit evidence. The complainant has marked the documents at Ex.C1 to C7 and the OPs have marked the documents at Ex.R1 to R6.
5. We have heard the arguments from both parties. The complainant also filed the written arguments.
1) Whether there is any deficiency in service on the part of OPs?
2) Whether complainant has entitled for reliefs sought for?
6. Our findings to the aforesaid points are as under:
Point No.1: Partly in the Affirmative
Point No.2: As per the final order
:REASONS:
7. Admittedly the complainant took Arogya Plus Policy bearing No.0000000015543824-01 from OPs during the year 2019 and subsequently renewed the same on 13.11.2020. The sum assured under the policy is 3 lakhs. The complainant suffered heart problem in the month of December 2020. On 25.12.2020 admitted at Sri.Jayadeva Institute of Cardiovascular Science and Research and discharged on 31.12.2020. The complainant claimed insurance through online, but the OPs refused to pay the amount. Therefore, the complainant had paid the bill of Rs.14,000/- and got discharged from the hospital. It is the case of the complainant that on 07.01.2021 he was admitted in Narayana Institute of Cardiology, science, Bangalore as in patient and undergone heart surgery and discharged on 28.01.2021. The complainant paid a sum of Rs.3,54,700/- towards treatment charges.
8. To prove the case of complainant, the complainant has produced Ex.C1 to C7. Ex.C1 is the photo copy of policy/smartcard. Ex.C2 is the Repudiation letter dated:19.03.2021 issued by OP No.2, Ex.C3 is Discharge summary issued by the Jayadeva Institute of Cardiovascular Science and Research, Bangalore dated:31.12.2020. Ex.C5 is the Discharge summary issued by the Narayana Institute of Cardiology Science, Bangalore dated:08.01.2021.
9. The complainant made a claim for medical reimbursement, but the OP No.2 has repudiated the claim on 19.03.2021 on the ground that as per the collected discharge summary of Narayanan Institute of Cardiology, science, Bangalore and Sri.Jayadeva Institute of Cardiovascular Science and Research has been suffering from diabetes from 25 years and hypertension from 2 years, which was not disclosed by him at the time of taking the policy. Ex.C2 is the repudiation letter issued by the OP No.2 repudiating the claim on the above ground.
10. It is sated in his sworn affidavit of OP No.2 that the complainant made a claim for his hospitalization from 07.01.2021 to 28.01.2021 for undergoing heart surgery at Narayana Hrudalaya with discharge summary in support of his claim wherein it is mentioned the policy holder is known case of long standing diabetic mellitus and hypertension (HTN) for 25 years, 2years respectively, which was not disclosed by the insured at the time of taking policy and concocted the material fact in regard to his health. Thus, the OPs repudiated the claim of the complainant.
11. The learned counsel for the OPs argued that the insured intentionally concealed the material fact with regard to his health at the time of taking the policy. As per the medical record i.e. discharge summary of Narayanan Institute of Cardiology, science, Bangalore, the insurance Company repudiated the claim on "suppression of material facts" at the time of taking the policy.
12. The learned counsel appearing for the complainant contended that the complainant has not suppressed any material information in regard to his health. Moreover hypertension and diabetes is not a disease. On perusal of the terms and conditions of the policy, it is seen that it provides for exclusion in respect of pre existing diseases. It is the admitted fact that, the complainant is suffering from hypertension and diabetes. Complainant was suffering from coronary artery disease and surgery was done.
13. Except the statement in discharge summary stated by the Doctor, the OPs have not produced any evidence to prove that from diabetes only complainant undergone Coronary Artery Surgery. Coronary Artery disease is not a pre existing disease at that time when the policy was issued. If the treatment to the complainant is relating to diabetes or hypertension then it is pre existing disease and complainant is not entitled to claim any amount. The OPs have not produced any evidence to prove that the complainant has taken treatment for alleged disease prior to taking the policy.
14. In the catena of Judgments, the Apex Court and Hon'ble National Commission, New Delhi observed that "diabetes and hypertension is normal wear and tear of life, it cannot be taken as concealment of material fact. Every insured obtained the insurance policy with a hope that if any risk happened to his/her life in case of any hospitalization, the insurance amount will indemnity the loss". But the Insurance Company repudiated the claim on unreasonable ground.
15. We have perused all the material available on record, facts and circumstances of the case and in the light of observation made by the Hon'ble Apex Court and Hon'ble National Commission in catena of judgments, we found there is a deficiency of service on the part of OPs and thereby caused mental agony to the complainant.
16. The complainant claimed for Rs.3,54,000/-, for which he has produced medical final bills issued by Narayanan Institute of Cardiology, science, Bangalore, (Ex.C6). But the insured amount under the above policy is Rs.3,00,000/-. Hence, the complainant is entitled for an assured amount of Rs.3,00,000/- with interest @ 8% p.a. and Rs.5,000/- for mental agony and Rs.10,000/- as litigation expenses. Accordingly, we pass the following:-
:O R D E R:
The complaint is allowed in part with costs
The OPs are directed to pay Rs.3,00,000/- to the complainant along with interest @ 8% PA from the date of repudiation i.e. 19.03.2021 till realization.
The OPs are further directed to pay Rs.5,000/- towards compensation for mental agony and Rs.10,000/- towards litigation expenses.
Further, the OPs are directed to comply the above order within 30 days from the date of receipt/acknowledge this order.
Supply copy of this order to both parties with free of costs immediately.
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