Date of Filing: 17.07.2018
Date of Order: 20.01.2021
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B., PRESIDENT
HON’BLE Sri K.RAM MOHAN, B.Sc. M.A L.L.B., MEMBER
On this the Wednesday the 20th day of January, 2021
C.C.No. 290 /2018
Between
P. Karnakar Reddy S/o P. Ram Reddy,
Aged 30 years, Occ: Employee,
R/o Flat No. 405, Sri Sai Laxmi Residency,
Bolaram, Hyderabad - 500010
….Complainant
And
- M/s Religare Health Insurance Company Ltd,
Vipul Tech Square, Tower C, 3rd Floor,
Golf Course Road, Sec 43,
Gurugram – 122009.
Haryana.
Rep by its Chairman - Managing Director
- M/s Religare Health Insurance Company Ltd,
Local office Address :
H.No. 6-3-1196/2C, Brig Tarnag Commercial
Complex, beside Greenland Guest House,
Begumepet, Hyderabad – 500016,
Rep by its Authorized Signatory.
… Opposite Parties
Counsel for the Complainant : Mr. G.V.S. Prasad Rao
Counsel for the Opposite parties No.1 & 2 : Mr. N. Srinath Rao
O R D E R
(By Sri P.VIJENDER, B.Sc. L.L.B., PRESIDENT on behalf of the Bench)
1. This Complaint is preferred U/s 12 of Consumer protection Act 1986 alleging that repudiation of the complainants Mediclaim by the opposite parties amount of unfair trade practice and deficiency of service.
2. The complainants case in brief is that to take care of himself and his family medical expenses he obtained Health Insurance Policy from the opposite parties in policy card No. 12113890 and as per the terms of the said policy, the opposite parties are liable to pay costs of the medical treatment availed by the complainant and his family members from the list of hospitals given complainant suffered abdominal pain few months back and an suggestion by Pharmacist in the medical hall he took some medicines and was relieved of pain. In the month of May 2018 he again suffered similar pain, hence visited Sunshine Hospitals at Secunderabad on 05.05.2018. In the said hospital he was diagnosed as suffering from accurate Pancreatitis and was admitted in the hospital and underwent for a surgery and was discharge on 22.05.2018. After discharged from the hospital complainant raised a claim with the opposite parties under the policy with relevant documents as desired by them. The opposite parties denied the claim by letter dt. 20.06.2018. The complainant submitted of the necessary documents and bills, hence denial of the claim on the ground of deficiency not replied is not correct. The opposite parties in order to avoid the claim made a false allegations and it amounts to unfair trade practice and deficiency of service. Hence the present complaint.
3. The stand of the opposite parties in their Written version is that they have issued Health Insurance Policies to the complainant under the plan care with effect from 15.02.2018 to 14.02.2019 providing insurance coverage to him and his family members for a some assured amount of Rs. 4,00,000/- subject to the terms and conditions. During the said policy period the complainant was diagnosed with accurate Pancreatitis , Etiology & Adenopathic and he approached the opposite parties with a requests for cashless treatment from the hospital. The opposite parties asked the complainant to provide investigation report supporting diagnosis treating Doctors certificate for the etiology of ailment and past history of the aliment diagnosed and all previous records, as they were necessary to asses the requests made by the complainant. Since the complainant has not complied the same claim was closed on 09.05.2018, and denied cashless request. The complainant filed claim for reimbursement of the amounts spent along with document. On verification of the documents it came to the knowledge of the opposite parties that the complainant had a second episode of Pancreatitis, hence the complainant was asked to submit the post hospitalization OPD treatment record and previous 7 month old consultation when he had similarly episode. Complainant provided his treating Doctor certificate as justification for the hospitalization and said certificate revels the complainant had similar episode 7 months earlier and he did not visit a doctor. It is clear that complainant was having a history of Pancreatitis prior to the inception of policy and deliberately he concealed it while obtaining the policy to have an unlawful gain, hence the claim was rejected. As per the policy terms and conditions claim will not be admissible for any medical expense incurred for hospitalization in respect of treatment of any pre-existing decease until 48 months of continues period has a lapsed, from the inception of the first policy. The complainant had an opportunity to declare that about the pre-existing decease at the time of filling of a proposal form but no such disclosed was made by him.
4. He deliberately concealed his pre-existing history of accurate Pancreatitis in order to secure Health Policy from the opposite parties , hence rejection of the claim submitted is justified and the complainant is not entitled for any relief in the present complaint.
5. In the enquiry complainant has got filed his evidence affidavit reiterating the material allegations made in the complaint and has got exhibited 7 documents. For the opposite party evidence affidavit of their manger (Legal) is got filed and substance of the same is in tune with the defense set out in the written version five documents are exhibited for the opposite parties. For the complainant written arguments are filed in addition to the oral submissions.
6. On a consideration of material brought on the record the following points have emerged for consideration.
- Whether the rejection of the complainants claim by the opposite
parties is in terms of policy document.? - Whether the complainant is entitled for the reliefs prayed for .?
- To what relief.?
Point No.1:-
Obtaining of Health Policy by the complainant from the opposite parties after paying necessary premium and hospitalization of the complainant during the policy period are not in dispute. The opposite parties contention is as per the certification issued for the complainants treating Doctor under Ex.A3 the complainant was suffering with accurate Pancreatitis even to prior to obtaining of the subject policy but he did not disclosures it in the proposals form submitted for the issuance of health policy. It is pertinent to bear in mind that the complainant has categorically stated at para 2 of complaint that he suffered abdominal pain a few months earlier to taking of subject policy from the opposite parties and he took some medicines as suggested by the Pharmacist in medical shop. So he did not go to any hospital and did not consult any doctor for diagnosing the reason for abdominal pain at that time. It was quit possible that complainant was under the impression of an ordinary abdominal pain, hence took medicines as suggested by the Pharmacist It is not the case of the opposite parties that complainant visited any hospital and he was diagnosed aliment of Pancreatitis so as to say that he deliberately suppressed while taking subject policy from the opposite parties. It is evident that the complainant himself had no knowledge that he was suffering with any ailment before obtaining of subject policy. The definition given for a Pre Existing Decease in the policy under Ex.B1 is condition Utmost or injury or related condition for which insured person had signs or symptoms were diagnosed and received medical advise within 48 months prior to the first policy issued. In the instance case as already said there is no evidence on the record to say that the complainant was diagnosed with the ailment and he has taken treatment for it with any Doctor or hospital before taking the policy from the opposite parties. The opposite parties can not allege that the complainant suppressed the Pre Existing Decease while obtaining the subject policy from the opposite parties. Hence denial of the claim on the ground of suppression of the fact of pre existing decease amounts to unfair trade practice on the part of the opposite parties. Accordingly the point is answered.
Point No.2:-
In view of the above findings it is to follow that the complainant is entitled to the direction to the opposite parties to settle the claim for reimbursement amount spent for treatment of ailment. Opposite parties by rejecting the claims caused hardship and inconvenience to the complainants, hence liable to pay compensation of Rs. 25,000/- to the complainant. The opposite parties are also liable to pay sum of Rs. 10,000/- towards costs of the complaint.
Point No.3
In the result, the complaint is allowed in part, directing the opposite parties to settle the complainant claim for reimbursing the amount paid by the complainant for treatment. The opposite parties are further directed to pay a compensation of Rs. 25,000/- to the complainant and a further sum of Rs. 10,000/- towards costs of this complaint.
Time for compliance 45 days from the date of service of this order.
Dictated to steno, transcribed and typed by him, pronounced by us on this 20th the day of January, 2021.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1– Copy of Claim dental letter dt. 20.06.2018
Ex.A2 – Copy of Deficiency letter dt. 14.06.2018.
Ex.A3 - Copy of Sunshine Hospitals Certificate dt. 11.06.2018
Ex.A4 – Copy of Ops E-mail (Yahoo mail) dt. 02.06.2018.
Ex.A5 - Copy of Sunshine Hospitals Certificate dt. 22.05.2018.
Ex.A6 – Copy of Deficiency letter dt. 18.05.2018.
Ex.A7 – Copy of Discharge Summary dt. 22.05.2018.
Exhibits filed on behalf of the Opposite parties:
Ex.B1– Copy of Policy along with terms and conditions dt. 14.02.2018
Ex.B2 – Copy of Query letters dt. 07.05.2018, 08.05.2018 & 09.05.2018.
Ex.B3 - Copy of Doctors Certificate dt. 22.05.2018.
Ex.B4 – Copy of Claim Rejection letter dt. 15.11.2018.
Ex.B5 – Copy of Proposal Forum dt. 14.02.2018
MEMBER PRESIDENT
