Date of Filing: 19.05.2018
Date of Order: 19-03-2020
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – 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
HON’BLE Smt. CH. LAKSHMI PRASANNA, B.Sc. LLM. (PGD (ADR) MEMBER
On this the Thursday, the 19th day of March , 2020
C.C.No.213 /2018
Between
Mr. Y.Venkateswara Rao,
S/o.Sri Late Sri Y.Seetha Ramaiah,
Aged 68 years, Occ: Retired Employee,
R/o. Plot No.83, Shivbagh Colony,
Hyderabad, Telangana State – 500 016 …Complainant
A N D
1. Religare health Insurance Co..Ltd.,
Rep.by its Managing Director.
Regd./Office: 5th Floor, 19, Chawla House,
Nehru Palace, New Delhi - 110 019.
2. Religare health Insurance Co..Ltd.,
Rep.by its Regional Manager,
Begumpet, Hyderabad – 500 016,
Telangana State. ….Opposite parties
Counsel for the complainants : M/s. B.Sreehari
Counsel for the opposite Parties1to2 : Mr.Sreenath Rao
O R D E R
(By Smt. CH. Lakshmi Prasanna,B.Sc. LLM (PGD ( ADR)., Member on behalf of Bench)
1) The complaint is filed under Sec.12 of The Consumer Protection Act against the Opposite parties for deficiency of service, seeking an appropriate direction to the Opposite Parties to pay health insurance claim of Rs.2,33,091/- along with interest @18% p.a from the date of repudiation till the date of realization, Rs.2,00,000/- towards compensation, Rs,5000/- towards costs of litigation.
2) The brief averments of the complaint are:-
The complainant and his wife obtained health insurance from the opposite parties vide Policy Nos. 10109241 and 10052846 for an insured sum of Rs.4,00,000/- and Rs.3,00,000/-respectively from 26/5/2014 with yearly renewal till 25/5/2017 by paying the necessary premium mentioned therein. The complainant underwent medical treatment for Coronary Artery Disorder( CAD), Mild LV Dysfunction, CAG, Mild Renal Impairment, DM-II and Hypertension from 23/6/2017 to 26/9/2017 in Star Hospitals, Hyderabad and the medical bill of Rs.2,44,101/- for the said treatment was submitted to the Opposite parties for cashless treatment Claim No.80136126, which was rejected vide Letter dt.13/11/2017 on the grounds that as per the policy No.10052846, the complainant is not covered. Subsequently, reviewing the complainant's claim pertaining to the Policy No.10109241, was again rejected vide Letter dt.27/12/2017 stating that the benefit is not covered in the insurance policy and issued a notice dt.17/2/2018 for cancellation of policy and forfeiture of entire premium alleging non-disclosure and misrepresentation of pre-existing diabetes by the complainant. Aggrieved with the repudiation of his insurance claim and the above cancellation notice on false and baseless grounds, the present complaint is filed seeking appropriate relief.
3) In their written version, the Opposite Parties, while denying the allegations contended that the complainant's medical insurance claim was legally and validly repudiated on the grounds of non-disclosure and misrepresentation of pre-existing disease of diabetes which the complainant is allegedly suffering from more than 20 years in the pre-policy medical examination form and hence liable to cancel the complainant's policy as per the terms & conditions under Clause 7.13 of the policy.
4) In the enquiry, the complainant filed his evidence affidavit reiterating the averments in the complaint supporting his claim with Ex A1 to A13 including the policy certificate, discharge summary, the repudiation letter and notice of cancellation of the policy issued by the Opposite Parties.. Ex B1 to B11 are marked on behalf of the Opposite Parties, including the original policy proposal forms, terms and conditions of the policy, pre-policy medical examination form, expert opinion and medical certificate in support of their written version and counter affidavit.
5) Based on the facts and material brought on record, and written arguments submitted by both the parties and supporting judgments submitted by the complainant, the following points have emerged or consideration:
1. Whether there is deficiency of service on the part of the Opposite Parties
2. Whether the complainant is entitled for the claim/compensation made in the complaint?
3. To what relief?
6) Point No.1:- The undisputed facts of the case are that the complainant purchased Mediclaim policy from opposite parties and that the complainant underwent medical treatment from 23/6/2017 to 26/9/2017, within the policy period and after discharge from the hospital, he lodged the claim for the reimbursement of medical expenses furnishing all required documents with opposite parties and the same was rejected initially vide Letter dt. 13/11/2017 ( Ex A10) on the grounds that as per the policy No.10052846, the complainant is not covered. Subsequently, reviewing the complainant's claim pertaining to the Policy No.10109241, the same was again rejected vide Letter dt.27/12/2017 ( Ex A11) stating that the benefit is not covered in the insurance policy and issued a notice dt.17/2/2018 ( Ex A12) for cancellation of policy and forfeiture of entire premium alleging non-disclosure and misrepresentation of pre-existing diabetes by the complainant. Ex B4 is the claim denial letter dt. 20/12/2017 sent by the Opposite Parties to the complainant stating that the subject claim is not payable on the grounds of non-disclosure of correct medical history- pre-existence of diabetic condition for more than 20 years.
It is pertinent to mention that Policy Certificate of the complainant Page -7 of Ex B1 clearly shows diabetes in the column of pre-existing disease. Further in support of their contention of denial of the complainant's claim, the Opposite Parties produced an expert opinion Ex B9 as to how, coronary artery disease (CAD) and diabetes mellitus, are related to each other. Even taking into consideration of the expert opinion Ex B9, notwithstanding the absence of affidavit of the expert doctor, for the sake of arguments, if CAD is attributable to diabetic condition of the complainant, the key question for determination, is, as to whether, there was a suppression of material fact, in his knowledge, by the complainant, fraudulently, at the time of filling up the proposal form, or not, and, as such, there was breach of the terms and conditions of the contract of insurance or not. The fact that Page -7 of Ex B, the Policy Certificate clearly shows diabetes in the column of pre-existing disease, leads to the irresistible conclusion that there is no suppression of the pre-existing diabetic condition of the complainant and further renewal of the policy till 2017 endorses and confirms that there is no . The Discharge Summary Ex A8 mentions that the complainant had a past history of diabetes mellitus type-II but does not specifically spell out any time period of the diabetic condition and the pre-policy medical examination form Ex B3 dt.23/5/2014 and the policy certificate clearly mention that the complainant was diabetic since two years. However, the Opposite Parties filed a Medical Certificate Ex B10 dt.24/10/2017 claiming that the complainant was diabetic for more than 20 years, thereby clearly showing that this is nothing but an afterthought sought to rebut the fact of existence of 2 years diabetic condition of the complainant as mentioned in the policy certificate.
The contention of the opposite parties that the complainant had diabetes pre- existing for more than 20 years and that there is suppression/misrepresentation of material facts by the complainant is not established by the opposite parties except the medical certificate which will not, by itself establish that the complainant was suffering from diabetes since 20 years there is no cogent and acceptable evidence on record to prove conclusively that the complainant was having diabetes since 20 years.
Hon'ble Supreme Court in the case P. Vankat Naidu Vs. Life Insurance Corporation of India & Anr. IV (2011) CPJ 6 (SC) 6 held that "......the finding recorded by the District Forum and the State Commission that the respondents had failed to prove that the deceased has suppressed information relating to his illness was based on correct appreciation of the oral and documentary evidence produced by the parties and the National Commission committed serious illegality by upsetting the said findings on a wholly unfounded assumption that the deceased has suppressed information relating to hospitalization and treatment."
In view of the above discussion and findings, supported by the relevant case law, the point is answered in favour of the complainant.
7) Point No.2 &3 :- As the Opposite Parties failed to establish suppression of pre-existing disease by the complainant, the notice dt.17/2/2018 for cancellation of policy and forfeiture of entire premium alleging non-disclosure and misrepresentation of pre-existing diabetic condition by the complainant, stands vitiated and the complainant is entitled to the relief prayed for. Accordingly, it is answered in favour of the complainant.
Sequel to our above discussion, the complaint is allowed in part and the following directions are issued to the opposite parties:
i) to pay the sum of Rs.2,33,091/- to the complainant, along with interest at the rate of 12% per annum from the date of submission of the claim till realization;
ii) to pay 50,000/- towards compensation and
iii) to pay 5,000/- as litigation expenses.
This order be complied with by the opposite parties, within 45 days from the date of receipt of the order, failing which the amounts at Sr.No.(i)&(ii) above shall carry interest @12% per annum from the date of this order till actual payment.
Dictated to steno, transcribed and typed by her, pronounced by us on this the 19th day of March, 2020.
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMIND
Nil
Exs. filed on behalf of the Complainant:
Ex.A1 – Original Mediclaim health insurance policy card dt.26.5.2014
Ex.A2 – Original Mediclaim health insurance policy card dt.26.5.2014
Ex.A3 – Letter sent by ops for renewal of policy to Ms.Rajani Yelamanchi
Ex.A4 - Letter sent by ops for renewal of policy to Ms.Rajani Yelamanchi
Ex.A5 – Patient Bill cash issued by Virinchi Hospitals, Hyderabad for Rs.6,169/-
Ex.A6 – Bill of supply amount of Rs.2,26,922/- paid by the complainant
Ex.A7 – Consolidated Pharmacy bill issued by star hospitals.
Ex.A8 – Discharge summary dt.26.9.2017
Ex.A9 – ICICI BANK Sanjeeva Reddy Nagar branch, statement ofg account
Ex.A10 & 11 –Letters sent by the opposite party to Ms.Rajani Y.
Ex.A12 – Notice for cancellation of policy, dt.17.2.2018
Ex.A13 – Copy of Aadhar card of the complainant.
Exs. filed on behalf of the Opposite party
Ex.B1 – Policy along with terms and conditions ( 10109241)
Ex.B2 - Policy along with terms and conditions (10052846)
Ex.B3 –Proposal form.
Ex.B4 – Rejection letters
Ex.B5 – Medical examination forms
Ex.B6 – Initial assessment sheet
Ex.B7 – Consultation sheet
Ex.B8 – Discharge summary
Ex.B9 – Expert opinion
Ex.B10 – Medical certificate issued by Dr.S.V.Prasad.
Ex.B11 – Cancellation letters.
MEMBER MEMBER PRESIDENT
