Date of filing: 16.05.2015 Date of Disposal: 11.04.2023
BEFORE THE III ADDITIONAL BANGALORE URBAN
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU – 560 027.
DATED THIS THE 11TH DAY OF APRIL, 2023
CONSUMER COMPLAINT NO.960/2015
PRESENT:
SRI.RAJU K.S,
S.N. Uma,
W/o. M.S.Vishwanth,
122B/R-3, “Sri Krishna Residency”,
-
-
-
(Rep. by In-person)
1) The Managing Director,
APOLLO MUNICH,
Health Insurance Company Limited,
Off. No.105-A-108A No.136,
-
Residency Road, Opp: Bangalore Club,
(Rep. by Sri.Prashant.T.Pandit, Advocate)
2) The Managing Director,
APOLLO MUNICH,
Heath Insurance Company Limited,
Ground Floor, Sri Niliya
Cyber Spazio, Road No.2,
Banjara Hills, Hyderabad-500034,
Andhra Pradesh.
(Rep. by Sri.Prashant.T.Pandit, Advocate)
3) The Senior Manager,
Canara Bank, 80 Feet Road,
Sanjayanagara, Bangalore-560094.
(Rep by Sri.S.Raghu, Advocate)
//JUDGEMENT//
BY SRI.SHIVARAMA K, PRESIDENT
01. The complainant in-person has filed this complaint on 16.05.2015 for a direction to Opposite party No.1 & 2 to restore the policy issued in favour of her and to settle the medical claim of Rs.48,000/- with interest at the rate of 9% per annum and such other relief as this Commission deems fit in the circumstances of the case.
02. On perusal of the record, it appears that, on 01.12.2016 counsel for opposite party No.1 & 2 had filed version with the IA under Order IX Rule 7 Read with Section 151 of CPC, 1908 seeking permission to file version. The said IA came to be dismissed by the order of this Commission on 23.02.2017, against which opposite party No.1 & 2 had filed Revision Petition No.34/2017 before the Hon’ble State Commission. On 23.09.2022 the Hon’ble State Commission has dismissed the said Revision Petition. Hence the order of rejection of the version filed by the Opposite party No.1 & 2 reached finality by the order of Hon’ble State Commission.
03. It is not in dispute that, the complainant had taken health insurance policy No.120100/12001/2014/A003873 /022 for Rs.10,00,000/- by paying premium of Rs.8,000/- which was debited from her husband’s account maintained at Canara Bank in Bangalore, in the month of November-2014. Further it is not in dispute that, the medical claim of the complainant has been repudiated by opposite party Nos.1 & 2.
04. It is the further case of the complainant that, the insurance company has tie up arrangement with Canara Bank branches in December-2014 and she got admitted to a nursing home for three days. The blood test reveals that, she had Wegener Granulomatosis with B/L anterior Sclaritis for the first time. Hence she was hospitalized for three days from 24.12.2014 to 26.12.2014. Further she was advised to undergo nine cycles of treatment. Accordingly she took treatment and hospital claimed bill of Rs.48,000/-. Since the opposite party No.1 & 2 have repudiated the claim, there is deficiency of service on the part of opposite party No.1 & 2.
05. It is the contention of opposite party No.3 that, as per the request of the complainant it had remitted the insurance premium to the debit of her savings bank account maintained with the opposite party and has remitted the insurance premium to the account of opposite party No.1 towards health insurance sought by the complainant. Further opposite party No.3 did not have any tie up arrangement with the opposite party No.1 & 2. Further opposite party No.3 is neither a subsidiary nor having any stake with opposite party No.1 & 2. Further opposite party No.3 was a collecting agent for a premium payment towards the insurance policies taken by any of the account holders of opposite party No.3. Further opposite party No.3 is not aware of the ailments covered under the alleged policy and opposite party No.3 does not have knowledge of the transaction took place between the complainant and the opposite party No.1 & 2. Hence sought to delete the opposite party No.3 from the cause-title.
06. To prove the case, the complainant has filed affidavit in the form of her evidence in chief and has produced documents and the Working Manager of opposite party No.3 has filed affidavit in the form of his evidence in chief.
07. Counsel for opposite party No.3 had filed written arguments.
08. The points that would arise for consideration are as under:-
(1) Whether there is deficiency of service on the part of the opposite parties?
(2) Whether the complainant is entitle for the
relief sought ?
(3) What order ?
09. 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
10. POINT NO.1:- The complainant and opposite party No.3 have reiterated the fact stated in their respective pleadings, in the affidavits filed in the form of their evidence in chief.
11. In support of the oral evidence, the complainant has produced the claim form submitted and has produced the discharge summary for having admitted to the hospital and taken treatment. On perusal of the same it appears that, on 24.12.2014 the complainant got admitted to the hospital at Basaveshwaranagar in Bangalore and discharged on 26.12.2014 and got admitted on 17.03.2015 and discharged on 17.03.2015 and further got admitted on 20.02.2015 and discharged on 20.02.2015. Further the complainant has produced the Xerox copy of the letter of repudiation dated: 30.03.2015 issued by opposite party No.1 & 2 in which it is stated that, the claim for Rs.6,324/- was denied for the reason that, the complainant had medical history of Glaucoma since 2006 and the same has not been revealed while taking the policy in the proposal form. Hence the complainant had concealed the fact and the same was in violation of terms and conditions of the policy. Further the certificate of insurance cash on Health purchased by the complainant indicates that, the coverage of the policy was from 18.11.2014 to 17.11.2015.
12. It appears that, the claim form was submitted on 16.02.2015 by the complainant. We have perused the documents produced by the opposite party No.1 & 2. On perusal of the same, it appears that, nowhere it is stated that, the complainant took treatment for the particular disease Wegener granulomatosis with B/L anterior Sclaritis. Further on perusal of the terms and conditions of the policy produced by the opposite party vide Annexure-5 it appears that, nowhere it is stated that, the disease alleged by the complainant is excluded from the coverage. Further the certificate of insurance indicates that, the insured amount was Rs.10,00,000/-. No doubt on perusal of the Discharge Summary dated: 24.12.2014 to 26.12.2014, it appears that, the complainant appeared before the hospital with the history of “increase redness and blurring of vision since 1 week” and the past history was “K/c/o Wegener’s Granulomatosis on treatment”. We feel that itself is not sufficient to hold that, the complainant took treatment to the said disease prior to the admission to the hospital in question. Unless a cogent evidence has been placed before us by producing necessary medical documents that the complainant had taken treatment for the disease in question, it cannot be inferred that, the complainant had the said disease and she had concealed the said fact in the proposal/claim form and had obtained the policy from opposite party No.1 & 2. Hence there is no merit in the repudiation made by the opposite party No.1 & 2 of the claim of the complainant.
13. It is the contention of learned counsel for opposite party No.1 & 2 that, the medical bills for Rs.2,238/- and Rs.2,694/- the complainant is not entitle for the reason that, it was not required to admit to the hospital for one day to take the injections referred. We feel taking medicine and admission to hospital of the patient differs from person to person. Hence there is no merit in the contention. Hence we answer this point in affirmative.
14. POINT NO.2:- It is not at all said in the complaint or in the evidence of complainant that, opposite party No.1 & 2 had cancelled the policy it is only said that, the insurance company has refused to settle the bills and unilaterally cancelled all benefits of the policy. Hence the question of restoring the policy does not arise. Further the complainant claimed a sum of Rs.48,000/- towards medical bills. The medical bills produced by the complainant indicates that, she had paid a sum of Rs.12,219/- for the treatment in between 24.12.2014 to 16.12.2014 and a sum of Rs.2,238/- on 17.03.2014 and a sum of Rs.2,694/- on 20.02.2015. The total of the same comes to Rs.17,151/-. The complainant did not produce medical bills for having spent a sum of Rs.48,000/-. Hence the complainant is entitle for Rs.17,151/-. Since the opposite party No.1 & 2 have repudiated the claim the complainant is entitle for interest at the rate of 9% per annum on the said amount from the date of repudiation dated: 30.03.2015 till realization.
15. Further the complainant claimed compensation of Rs.25,000/- and litigation expenses of Rs.10,000/-. We feel in view of the repudiation made by the Opposite party No.1 & 2 the complainant had suffered mental agony. Therefore the complainant is entitle for a sum of Rs.10,000/- towards mental agony and a sum of Rs.5,000/- towards litigation expenses. Since the role of opposite party No.3 is only remitting the premiums, opposite party No.3 cannot be made liable. Hence we answer this point partly in affirmative.
16. POINT NO.3:- In view of the discussion made above, we proceed to pass the following:-
ORDER
The complaint is allowed in part.
The opposite party No.1 & 2 are jointly and severally liable to pay a sum of Rs.17,151/- to the complainant with interest at the rate of 9% per annum from the date of repudiation i.e., 30.03.2015 till realization and a sum of Rs.10,000/- towards mental agony and a sum of Rs.5,000/- towards litigation.
The opposite party No.1 & 2 shall comply the order within 30 days from the date of the order. In case, the opposite party No.1 & 2 fail to comply the order within the said period, the above said amount of Rs.15,000/- carries interest at the rate of 9% p.a. from the date of order till realization.
Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.
Applications pending, if any, stands disposed-off in terms of the aforesaid judgment.
(Dictated to the Stenographer, typed by him, the transcript corrected, revised and then pronounced in the open Commission on 11th Day of April, 2023)
Witness examined for the complainant side:
Smt. S.N. Uma, the complainant has filed affidavit in the form of her evidence in chief.
Documents submitted by the complainant side:
- Copy of certificate of insurance
- Copy of claim form
- Copy of discharge summary from 24.12.2014 to 26.12.2014
- Copy of in-patient detail bill dt:26.12.2014
- Copy of letter dt: 28.02.2015
- Copy of in-patient detail bill dt.17.03.2015
- Copy of in-patient detail bill dt:20.02.2015
- Copy of letter dt:30.03.2015
- Copy of insured person’s details
Witness examined for the opposite party No.1 & 2 side:
Documents submitted by the Opposite Party No.1 & 2 side:
1. Copy of prescriptions
2. Copy of prescriptions
3. Power of Attorney dt: 02.03.015
4. Enrolment form
5. Policy schedule along with terms and conditions.
6. Claim form along with documents.
7. Letter dated: 28.02.2015
8. Copy of documents submitted by complainant
9. Copy of Doctor certificate
10. Copy of Rejection letter.
Witness examined for the opposite party No.3 side:
Sri. A.N. Nayak, Manager of Canara Bank, has filed affidavit in the form of his evidence in chief.
Documents submitted by the Opposite Party No.3 side:
