Date of Filing:27.04.2022

Date of Disposal:07.03.2023

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

                                  ORDER

SRI RAMACHANDRA.M.S,

PRESIDENT

1. The complainant files a complaint with this Commission under Section 35 of the Consumer Protection Act of 2019 with a direction to the OP to pay Rs.2,00,000/- towards medical expenses along with interest at 2%  from 11.02.2021 to 11.02.2022 and award damages of Rs.2,00,000/- towards mental agony suffered by the complainant and such other reliefs.

2.   The following are the complaint's key facts: 

The complainant along with her husband have obtained Health insurance policy from OP insurance company for a period from 23.06.2020 to 22.06.2021 and also submits that she has received only health Insurance policy along with 02 health service card and except that she has not received any documents. Complainant submits that during the course ofthe policy the complainant had minor uterus problem and she approached the Altius hospital and by the advice of the doctor she admitted to the hospital on 11.02.2021 and undergone operation on14.02.2021 and same day she discharged from the hospital. The complainant further submits that while admitting to the hospital, she contacted the insurance agent to get procedure for cashless payment towards medical expenses and he suggested the cashless treatment in in selected hospitals and also suggested to reimburse claim amount from the OP insurance company. Complainant further submits that believing the words of the agent she has spent Rs.2,00,000/-by borrowing the same at the rate of 2% and there after sent the claim form to the OP-1. Pursuant to the same the OP-1 issued two reminder to the complainant to furnish discharge summary, original bills, investigation report etc., on 19.05.2021 the complainant furnished the same to the OP-1 through post. The OP-1 has acknowledged all the documents, but not settled the claim and not given any answer why the claim denied and also not returned the original hospital documents. The complainant further submits that it is the bounden duty of the OP Company to reveal all the terms and conditions at the time of issuance of the policy, but the OP has not replied the reasons for not settling the claim. Complaint submits that due to the act of the OP the complainant undergone much mental agony and further an account of assurance she will get the insurance amount from the OP. Hence, due to the act of the OP, the complainant was forced to file the present complaint.

3.    Notice to OPs served, even represented by the counsels they have failed to file version well within 45 days. Hence, the commission taken the version as not filed.

4. The complainant filed chief-examination affidavit and also relies on documents in support of the pleadings.

5. Heard arguments. The matter is reserved for order.

6.  The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency of service on the part of the OPs as alleged in the complaint and thereby prove that he is entitle for the relief sought?
2. What order?

7. The findings on the above points are as under:

Point No.1               :       Negative

Point No.2               :       As per final order

REASONS

8. POINT NO.1:-Admittedly when the complainant has availed health insurance policy along with her husband at the instigation of the OP agent and the policy came to be issued by OP by receiving premium pertaining to the policy. The validity of the policy is covered from 23.06.2020 to 22.06.2021.

9. After availing the said policy on 11.02.2021 the complainant got admitted to the Altius Hospital Pvt. Ltd., Bengaluru. As per the advice of the Doctor, she has undergone operation and during the hospital when the complainant made effort to get cashless payment of medical expenses, which is covered with the OP health insurance policy. As there is an insurance contract between the complainant and the OP, accordingly the complainant raised the claim a sum of Rs.2,00,000/-. It is the case of the complainant that despite of the discharge from the hospital as the cashless benefit of claim was not received by the OP. Subsequently, the complainant approached the OP Company for the payment of the insurance claim amount. The complainant alleged that even though all the original bills and required documents was provided to the OP Company. It is contended that they have failed to settle the insurance amount. Despite of the sufficient efforts when the  OP failed to settle the claim of the complainant. The complainant was forced to file the present complaint and sought for the relief of insurance claim amount along with other reliefs as prayed in the complaint.

10. The complainant filed chief-examination affidavit by reproducing the complaint allegations as against the OP. From the perusal of entire complaint averments, the commission is of the opinion that even though there is an insurance contract between the complainant and the OP and the validity of the policy as on the date of admission to the hospital is not in dispute. The only the fact that needs to be considered by the Commission is that whether the claim which raised by the complainant is legally payable or not. In answer to this, the complainant in his chief-examination affidavit at para-7 of the affidavit has specifically stated that the claim of the complainant is repudiated as the claim is not admissible as per policy clause by way of pleading, the complainant has categorically admitted that the rejection of the complainant’s claim is against the terms and conditions of the policy clause. As per the complainant’s contention the clause which is laid down in the insurance contract by the OP is agreed and accepted by the complainant and only by agreeing to the same he has entered into insurance contract. This specific term and conditions of the policy  that excluded the claim of the complainant as mentioned for the “waiting period” of 01 year. When the complainant accepted and entered into agreement, he shall abide by the terms and conditions of the policy. The conditions of the insurance agreement is paramount and both the parties to the insurance contract should adhere to the terms and conditions of the policy any violation in the clause of the agreement either of the parties have to face the consequences. The terms and conditions of the policy which is laid down by the OP company and when both the parties agreed and entered into insurance contract, no court or any commission has no power to rewrite the terms and conditions whatever is entered and agreed while entering into the insurance contract that should be binding on both the parties they should adhere for the same.

11.    In view of the above discussion, since the claim of the complainant is against the terms and conditions of the policy. The OP is not in a position to accept the insurance claim of complainant. When there is a clear violation of  terms and conditions of  policy, upon which liability should not be casted upon the OP Company.

12.  In view of the above discussion and by considering the contention of the complainant and also by observing the terms and conditions of the policy we are of the definite opinion that the rejection of the complainant’s claim is justified and it is in accordance with the terms and conditions of the insurance policy. Accordingly, the Point No.1 we answer Partly in Negative.

13. POINT NO.2:- In the result, we passed the following:

ORDER

1. The complaint filed by the Complainant U/s.35 of the Consumer Protection Act, 2019 is dismissed. No costs.

2. Furnish free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 7^th March 2023)

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)             (CHANDRASHEKAR S.NOOLA)       

         MEMBER                                        MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Smt.G.N.Vedavathi-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP-1 & 2 by way of affidavit: Nil

Documents produced by the OP- 1& 2:Nil

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*