PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR
CONSUMER COMPLAINT NO.23/2020
Present-Dr. Ramakanta Satapathy, President,
Sri. Sadananda Tripathy, Member,
Ompati Devi Agarawala,
W/O-Shrikishan Agarwala,
R/O- Hospital Road, Khetrajpur, PO/Ps-Khetrajpur,
Dist-Sambalpur, Odisha. ...………..Complainant
Versus
- Branch Manager, Manipal Signa Health Insurance Co. Ltd.,
Bhubaneswar Branch, Road No.3, 2nd Floor Dindayal Bhawan,
Ashok Nagar, Unit 2, Bhubaneswar, Dist-Khorda.
- Union Bank of India, Sambalpur Branch,
Near Church of G.M. College Road, Sambalpur,
Counsels:-
- For the Complainant :- Sri. B.K.Mahaptra, Advocate & Associates
- For the O.P. NO.1 :- Sri. B.K.Purohit, Advocate
- For the O.P. No.2 :- Sri. B.Meher, Advocate
Date of Filing:09.09.2020,Date of Hearing :22.05.2023, Date of Judgement : 19.06.2023
Presented by Dr. Ramakanta Satapathy, PRESIDENT
- The Complainant, her husband Shrikishan Agrawal and sons Anil and Sunil have availed policies from Sigma TTK Health Insurance Co. from 04.05.2017 to 03.05.2018 and renewed for 2018-19 and 2019-20. The Complainant and her husband have taken insurance policies jointly 100100004787/02/00 and Master Policy No. 100200000001/02/00 which was valid from 04.05.2019 to 03.05.2020 for Rs. 10.00 lakhs. Andhra Bank was the Master policy holder later it was merged with O.P. no.2. Likewise sigma TTK Health Insurance Company Merged with O.P. No.1
During Policy No. 100100004787/02/00 validity period 04.05.2019 to 03.05.2020 the Complainant suffered from fever, treated at Sambalpur and then shifted to Appolo Hospital, Bhubaneswar. In general Medicine department of Appolo Hospital she was admitted from 23.11.2019 to 30.11.2019. It was ascertained that the Complainant was affected with 720M, HTN Drooped fever with shortness of breadth and features of Sepsis. After discharge came back to Sambalpur on a hired ambulance.
On 27.11.2019 Complainant requested O.P. No.1 for cashless treatment in Appolo Hospital but it was rejected with allegation that she was suffering from K/C/ODM since 8 years and HTN since 7 years and not disclosed in proposal form. Again on 28.11.2019 husband of Complainant requested for reconsideration but on the same day it was rejected.
The Complainant has paid Rs. 24,404/-, Rs. 25,041/- and Rs. 25,041/- for the insurance policy for the year 2017-18, 2018-19 and 2019-20 respectively. Policies have been issued after proper examination by panel doctors of O.P. no.1. The Complainant has paid Rs. 1,85,000/- to Appolo Hospital for treatment, Rs. 20,000/- Ambulance charges and Rs. 10,000/- to-wards loding and fooding charges. The O.P. no.1 deficient in its service.
- The O.P. No.1 insurance Company submitted that the Complainant is not a consumer of O.P. No.1 as she had never obtained the policy from the Company. Husband of the Complainant as an account holder of O.P. no.2 enrolled as member under Manipal ProHealth G.I. Policy.
Andra Bank was the Master Policy holder of Prohealth Group Insurance Policy No. 100200000001/02/00 issued by Manipal Cigna Health Insurance Company and Anil Kumar Agrawal as a member under the said master policy issued with certificate of Insurance (CO1) No. 100100004784/02/00 which subsequently renewed till 2020. The CO1 covered the insured Shrikishan Agrawal and Ompati Devi Agrawal with sum assured Rs. 10.00 lakhs.
At the time of proposal suppression has been made on facts. On 23.11.2019 application for cashless hospitalisation made but on the ground of “pre-existing disease” the claim was repudiated. The reconsideration letter was also rejected.
Three separate certificate of Insurance has been issued by insurance company for different periods after receiving three separate proposals through Andra Bank in which O.P. No.1 has got no control on the proposals. The Complainant has not disclosed material facts at the time of proposal and violated the policy terms conditions VI (I). The repudiations made is proper. There is no deficiency on the part of the O.P. No.1.
- The O.P. No.2 not filed any version.
- Perused the documents filed by the Complainant. The Complainant relied on decision of hon’ble Supreme Court of India in Civil Appeal No. 8386/2015, Manmohan Nanda Vs. United India Assurance Co. Ltd. & another case. Further the Complainant relied on life Insurance Corporation of India V Narmada Agrawal and after 1993 ACJ 2023.
It is the submission of Complainant that on 27.11.2019 the O.P. No.1 rejected the cashless request alleging that as per initial assessment sheet the Complainant was suffering from K/C/ODM since 8 years and HTN since 7 years and not disclosed in proposal form at the time of policy inception. The discharge summery issued infavour of the Complainant by Apollo Hospital does not disclose that the Complainant was suffering from K/C/ODM since 7 years although there was discussion of treating doctors mentioned in the summary.
In the summary of discharge letter of Apollo Hospital It is discussed “Mrs Ompati Devi Agrawal, 59 years old lady a known case of T2DM, HTN developed fever with cough and shortness of breath for 1 week ……………” The Complainant was admitted in Apollo Hospital on 23.11.2019 and disclosed on 30.11.2019. The O.P. no.1 submitted that as per the initial assessment sheet policy holder in K/C/ODM since 8 years and HTN since 7 years. The O.P. No.1 has not submitted any documents to show that the Complainant was suffering from K/C/ODM and HTN on the basis of which claim was rejected.
Secondly, the learned advocate for O.P. No.1 submitted that while submitting insurance proposal the Complainant has submitted false information relating to medical and life-style information which is a violation of policy conditions VI(1). The O.P.No.1 not submitted the proposal form nor the treatment details along with observation of panel doctor which making proposal. On a mere statement of discussion it can not be concluded that the complainant is having pre-existing disease. Further it is specifically mentioned by Complainant while applying for cashless she has diagnosed SEPSIS SCRUB TYPHUS. From the supra discussion it is clear that the O.P. No.1 while repudiating the claim not applied their mind properly. Accordingly, the repudiation of the claim is not proper. The object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness which was not provided by the O.P. No.1 rejecting the cashless and claim in time. It amounts to deficiency in service.
It is the admission of both the parties that during the period of treatment in Apollo Hospital the policy was valid and the O.P. No.1 has received Rs. 25,041/- from Anil Kumar Agrawal and under the said policy No. 10020000001/1/03/00 certificate No. 100100004787/03/00 third renewal has been made. No doubt the Complainant has not made party to the Medi Assist Insurance TPA Pvt. Ltd. but the O.P. no.1 has not uttered a single word for the TPA. So by not making TPA as a party does not frustrate the complaint.
- From Supra discussion the Complainant is entitled for her claim. The Complainant submitted Bill No. ODB-ICs 72504 dated 30.11.2019 for Rs. 1,65,000/- and cash of Rs. 20,000/- totalling Rs. 1,85,000/-. No any other vouchers are submitted.
Accordingly, following order is made:
ORDER
The complaint is allowed partly against O.P. No.1 on contest and dismissed against O.P. No.2. The O.P. No.1 is directed to pay claim amount of Rs. 1,85,000/- w.e.f. 27.11.2019 along with 7% interest P.A. Within one month of this order. The O.P. No.1 is to pay litigation cost of Rs. 5000/-. In case of non-payment the entire amount shall cover 12% interest P.A. till realisation.
Order pronounced in the open court on 19th June of 2023
Supply free copies to the parties.
