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

DATED 01^ST DAY OF OCTOBER 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1.         This is a complaint filed by the complainant seeking direction against the OPs for payment of Rs.1,20,000/- towards medical expenses, Rs.1,00,000/- as damages and Rs.10,000/- being the cost of litigation.

2. The case of the complaint in brief is as follows:

The complainant being the policy holder for the period from 02.01.2019 to 01.01.2020 of OP1 took treatment in Fortis Hospital from 01.05.2019 till 05.05.2019 as inpatient for treatment of acute pancreatitis with deranged LFT by spending Rs.1,20,000/-.

3. The complainant had submitted a claim petition with OPs who illegally repudiated the claim.  The repudiation of claim amounts to deficiency of service.  In fact the disease for which he has taken for treatment was not pre-existing o the date of taking the policy.  The acute pancreatitis was not existed at any point of time and complainant experienced the problem only in April 2019. Hence this complaint.

4. In response to the notice, OPs appeared and filed version. They admit the policy, duration of policy and treatment taken by the complainant in Fortis hospital.  Complainant took treatment for pre-existing disease and as per the clause 4 of insurance policy terms and conditions, the complainant is not entitled to any reimbursement.  The repudiation of claim of the complainant is correct.  Therefore, OP requests to dismiss the complaint.  OP2 failed to appear and placed exparte.

5. The complainant files affidavit evidence and relies on 57 documents.  The affidavit evidence of Divisional head of OP1 has been filed and 4 documents came to be marked. Heard arguments. Perused the records.

6. The points that would arise for our consideration are as under:-

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

7. Our answer to the above points are as under:

       Point No.1 :- Affirmative

      Point No.2 :- Affirmative in part

       Point No.3:- As per the final order.            

                                REASONS

8. Point No.1 and 2:     At the first instance, we would like to refer the admitted facts. The complainant took the policy as per annexure A1 and Ex.R1 from the OP1 for the period from 02.01.2019 to 01.01.2020 for sum assured amount of Rs.3,00,000/- and domestic hospital limited of Rs.45,000/- by paying necessary premium amount of Rs.14,490/-.  Ex.A2 is the premium payment receipt.  Ex.PA3 is the report of NG Imaging Diagnostic in respect of complaint dated 29.04.2019.  This report is in respect of the liver of the complainant.  Ex.A5 to A10 are issued by the Karnataka Gastro centre and laboratory.  This report is also in respect of liver.  It is admitted fact that complainant was admitted as inpatient in Fortis Hospital on 01.05.2019 and discharged on 05.05.2019.  Ex.A12 to A17 are the details of medicine given to the complainant.  Complainant was referred to Fortis hospital by Dr.Umesh Jalehal.  It is admitted fact that the complainant took treatment under Dr.Umesh Jalihal.  Ex.A18, 19 are the reports issued by Kanva Diagnostic pvt. Ltd.  According to these reports liver was enlarged in size and chest base was normal.  Karnataka Gastro Centre headed by Dr.Umesh Jalihal issued Ex.A21 to 29.

9. The OPs relied on discharge summary, repudiated the claim referring clause 4 of terms and conditions of the insurance policy.  Ex.A30 discharge summary indicates that the complainant was diagnosed recurrent acute pancreatitis with deranged LFT.  Subsequently Dr.Jalihal issued letter dated 12.06.2019 in A51 that the initially it was suspected that the patient was suffer from Hepatitis and pancreatitis but the patient was suffering from DM, AIN, IHD and AF.  Subsequently on 19.11.2019 Dr.Jalihal issued A55 stating that in discharge summary due to inadvertence recurrent acute pancreatitis with deranged LFT is mentioned currently patient has no features of pancreatitis.  The complainant called upon the OP to settle the claim by issuing notice dated 11.12.2019.  The OP issued reply dated 20.02.2021 stating that discharge summary indicates that complainant was diagnosed recurrent acute pancreatitis with deranged LFT”.  Accordingly referring clause 4.1 of the policy, the claim of the complainant was repudiated.

10. The OP has produced the policy with terms and conditions. It is relevant to refer clause 4 and 4.1 of the terms and conditions of the policy which reads thus;

The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:

According to the above policy, the insured is not entitled for reimbursement and any expenses incurred in respect of any pre-existing conditions until 48 months of continuous coverage of such insured person have lapsed.Admittedly after taking the policy in the year 2019 the complainant took treatment and spent Rs.1,20,000/-.Ex.R2 indicates that on the basis of opinion of Dr.Jalihal, the OP had addressed a letter to Dr.Rakesh/Dr.Srinidhi for opinion.Dr.Rakesh gave opinion that there is no conclusive documentary evidence. Pancreatitis being recurrent are present since long time and unable to confirm pre existing disease.Hence decision can be taken as per the terms and conditions of the policy.When the opinion of Dr.Rakesh sought by the OP is not conclusive to show that the complainant had pre-existing problem of acute pancreatitis.The repudiation is not correct. Ex.R3 and annexure A57 are one and the same. Ex.R4 is the postal acknowledgement of the complainant.Once again it is relevant to refer Ex.R1 policy which speaks about pre-existing lungs/disease declared.As per this policy the complainant declared is pre-existing illness/disease namely diabetes, hyper tension report by Icon Diagnostic centre dated 078.12.2018 ECG report findings diabetes hyper tension abnormal ECG with indication.But there is no reference about acute pancreatitis in the policy.

11. The burden lies on the OPs to prove that the complainant took treatment for pre existing disease.  Dr.Rakesh is not sure about pre-existing acute pancreatitis.  Under such circumstances repudiation of the claim of the complainant by the OP1 referring clause 4.1 of the policy terms and conditions is not correct. Such repudiation amounts to deficiency of service. Therefore complainant is entitle to reimbursement of Rs.1,20,000/- spent for medical expenses during the existence of the policy.

12. Complainant seeks Rs.1,00,000/- compensation.  Dr.Jalihal clarified the doubt of the OP on 19.11.2019 and Dr.Rakesh also clarified the doubt of the complainant on the basis of Ex.R2 letter.  Even though repudiation of the claim of the complainant is not legally correct but claim of Rs.1,00,000/- as compensation is without any basis and excessive.  Under such circumstances the complainant is entitled to 8% interest from the date of repudiation i.e., from 20.02.2020 on Rs.1,20,000/- till the date of realization. Accordingly we answer point NO.1 and 2.

13. POINT NO.3: In view of the discussion complainant requires to be allowed in part against the OP1.  OP2 is only a third party which has not received any premium from the complainant.  Therefore, complaint against OP2 requires to be dismissed.  OP1 is liable to reimburse Rs.1,20,000/- with interest at 8% p.a., from 20.02.2020 till realization with cost of litigation of Rs.5,000/-. We proceed to pass the following;

O R D E R

1. Complaint is allowed in part against OP1
2. Complaint is dismissed against OP2.
3. OP1 shall reimburse Rs.1,20,000/- towards medical expenses to the complainant with interest at 8% p.a., as compensation and cost of Rs.5,000/- till realization.
4. OP shall comply this order within 60 days from this date.
5. Furnish the copy of this order to both the parties and return the extra pleading and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 1^st day of October, 2022)

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

Documents produced by the representative of opposite party :  

HAV*