BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE                        

Dated this the 1^st April 2017

PRESENT

   SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

   SRI T.C. RAJASHEKAR                 : HON’BLE MEMBER

ORDERS IN

C.C.No.227/2014

(Admitted on 30.06.2014)

Mr. Yogesh Poojary,

s/o Venkappa Poojary,

Aged 30 years,

Daddani House, Nellikar Village,

Valpady Post, Dakshina Kannad 574236.

                                                                                  ….. COMPLAINANT

(Advocate for the Complainant: Sri ANN)

VERSUS

1. Bajaj Allianz General Insurance co. Ltd,

Health Administration team,

2^nd floor Bajaja Finsery Building 

Survey No.208/B 1, behind weikfield IT Park,

Off Nagar Road, viman Nagar, Pune 411014,

Represented by its Authorized signatory.

2. Bajaj Allianz General Insurance co. Ltd,

Branch office, 2^nd floor, Crystal Arcade,

Near Hotel Roopa Balmatta Road,

Mangalore 575001.

Represented by its Authorised Signatory.

                                                                                     …........OPPOSITE PARTIES

(Advocate for the Opposite Party No.1 and 2: Sri KP)

ORDER DELIVERED BY HON’BLE MEMBER

SRI T.C. RAJASHEKAR:

I. 1.   The above complaint filed under Section 12 of the Consumer Protection Act 1986 alleging deficiency in service against the Opposite Party claiming, to pay Rs.30,000/ towards the medical expenses incurred, to pay the interest thereon from the date of accident i.e. from 24.12.2013 till deposit, to pay Rs.10,000/ towards cost of this proceeding, to pay compensation of Rs. 50,000/ towards mental agony caused to the complaint.

2.      In support of the above complainant Mr. Yogesh Poojary, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C7 as detailed in the annexure here below.   On behalf of the opposite parties Mr. Sadashiva K (RW1) Legal officer and authorized signatory of Bajaj Allianz Gen. Ins. Co. Ltd., also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked at Ex.R1 to R7 as detailed in the annexure here below.  Dr. Kiran B (RW2) also filed affidavit evidence and answered the interrogatories served on him.

The brief facts of the case are as under:

Perused the complaint and the version of the parties.  The dispute is with regard to repudiation of claim for treatment taken under the mediclaim policy. The complainant alleges that he had taken a mediclaim policy from the opposite parties and he was hospitalized and taken treatment. On submission of the bill for expenses incurred the opposite party repudiated the claim on the ground of pre existing disease and hence deficiency in service. The opposite party contended that, the complainant had suppressed the material facts with regard to his health condition. In the proposal form and as such as per policy condition the claim is repudiated, hence no deficiency in service in service from their part. These are being the facts of dispute in resolving it we consider the following.

POINTS FOR ADJUDICATION.

          We have gone through evidence produced and the documents produced. The admitted facts are, the purchase of the policy by the complainant and presently renewed from 22.05.2013 to 21.05.2014, the admission to A J HOSPITAL Mangalore for treatment, the repudiation of the claim on the ground of non disclosure of pre existing disease as per policy condition. It is denied that the complainant is suffering from hyper tension and condition being consequential of renal failure due to renal transplantation, it is denied there is deficiency in service on the part of the opposite parties. Admissions and the denials reconciled and considered the following points for adjudication.

1. Whether the complainant is a consumer under the consumer protection Act 1986?
2. Whether opposite party proves that the repudiation is legal and proper and there is no deficiency in service on the part of them?
3. Whether the complainant is entitled for the relief prayed for?
4. What order?

We have considered the documents produced by the parties and the evidence lead. We have taken note of the notes filed and heard the party counsels submissions and answered the above points as under:

1. In the affirmative.
2. In the negative.
3. In the affirmative.
4. As per delivered order.

REASON

POINT NO 1: We have referred the EX-R2 the copy of the insurance policy issued by the Opposite parties. It shows the policy purchased by the complainant and it is not disputed. Hence we answered the point no 1 in the affirmative.

POINT NO 2: The core point is the repudiation on the ground of non disclosure of pre existing disease. As per complainant pleading the suffering from disease before taking of the policy is denied. The discharge summery given by the A J HOSPITAL Mangalore is not admitted. The complainant in his pleading states that, It is denied that the complainant is suffering from hyper tension and condition being consequential of renal failure due to renal transplantation,   we understood as the complainant is denying as, the present treatment is the consequence of renal failure due to renal transplantation and non disclosure. As per opposite party repudiation letter dated EX C 4 dated 20.01.2014 the repudiation was made on the ground that, the claimant is known to be suffering from hyper tension and chronic renal failure since 2011 which is pre-existing to the policy and has not been disclose on the proposal form. Post renal transplant is related to renal failure. 

2. We examined the date sequence of the incidence happened. The policy was renewed on 22.05.2013 which is undisputed. Obviously the first time the policy was taken on 22.05.2012. We referred the EX R 1 is the proposal form which was signed by the complainant on 18.05.2012 and policy was issued on 22.05.2012. As admitted by the opposite party the renal transplantation done on 06.10.2012 which is after the policy was issued.      

3. The un disputed discharges summery issued by A J HOSPITAL Mangalore EX C 2 given for the treatment taken on admission from date 24.12.2013 to 28.12.2013 discloses that the complainant admitted with status post: Renal transplant and the chief complaint stated as the complainant herein admitted with history of renal transplant 1year back now admitted with complaint of pain and swelling in the gluteal region since 3 days. These facts reveal that the complainant had renal problem and one year back renal transplantation done. This discharge summery was issued on 28.12.2013 and a year back means somewhere around 28.12.2012. The opposite party admits the renal transplantation done on 06.10.2012. The policy proposal signed on 18.05.2012 which is before renal transplantation. Apart from this discharge summery there are no any documents or medical record to show that the complainant was suffering from either hyper tension or renal problem before taking policy or since 2011. We cannot conclude that, because transplantation was done on 06.10.2012, the complainant was suffering from renal problem or hyper tension unless documentary evidence produced. The transplantation can be done just after diagnosed for renal problem too. Hence we are of the opinion that there is no non disclosure of pre existing disease on the part of the complainant. Hence opposite party not proved the repudiation as per policy conditions and it is only may be on imaginary ground of non disclosure. We hold the opposite party liable for deficiency in service. And we answered the point no 2 in the negative.

POINT NO.3: We as per our above discussion, concluded that because the opposite party not proved that the complainant was suffering from the hyper tension or illness of renal failure before signing the proposal form the repudiation was wrong and the opposite party are liable for deficiency in service.  The complainant stated he had admitted to A J HOSPITAL Mangalore and spent for treatment and claimed Rs.30,000/.  As such the complainant is entitled for reimbursement as per the expenses bill produced and the opposite party not disputed the admission to hospital and the treatment taken.  The complainant is entitled for an amount of Rs.29,522/ with an interest of    9 % per annum from the date of repudiation till the date of payment. Since there is negligence in appreciating the policy condition and applying, the complainant is entitled for an amount of Rs.15,000/ as compensation and Rs.6,000/ as legal expenses.

POINT NO 4: In the light of above discussion and adjudication of the above points we deliver the following

ORDER

The complaint is allowed. The opposite parties are jointly and severally pay the complainant an amount of Rs.29,522/ (Rupees Twenty nine thousand five hundred twenty two only) with an interest of 9% per annum from the date of repudiation till the date of payment and an amount of Rs.15,000/ (Rupees Fifteen thousand only) as compensation and Rs.6,000/ (Rupees Six thousand only) towards costs within 30 days from the date of order copy received.           

     Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.

(Page No.1 to 7 directly typed by Member, revised and pronounced in the open court on this the 1^st April 2017)

              MEMBER                                              PRESIDENT

     (T.C. RAJASHEKAR)                        (VISHWESHWARA BHAT D)

 D.K. District Consumer Forum                D.K. District Consumer Forum

  Additional Bench, Mangalore.                  Additional Bench, Mangalore.

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  Mr. Yogesh Poojary

Documents marked on behalf of the Complainant:

Ex.C1: Individual Health guard mediclaim policy bearing no.OG.14. 8401.00000 valid from 22.5.2013 to 21.5.2014.

Ex.C2: copy of discharge summary issued by Mangala Hospital

Ex.C3: copy of discharge bill issued by A.J. Hospital.

Ex.C4: letter of Opposite Party dated 20.1.2014.

Ex.C5: letter of Opposite Party dated 24.1.2014.           

Ex.C6: office copy of legal notice sent to Opposite Parties dated 21.2.2014 with postal receipts and acknowledgments.

Ex.C7: Reply of Opposite Parties dated 7.3.2014.

Witnesses examined on behalf of the Opposite Parties:

RW1  Mr. Sadashiva K, Legal officer and authorized signatory of Bajaj Allianz Gen. Ins. Co. Ltd.

RW2  Dr. Kiran B.

Documents marked on behalf of the Opposite Parties:

Ex.R1: 19.5.2012: Heath guard proposal form

Ex.R2: true copy of Health guard policy schedule with terms and conditions.

Ex.R3: 28.12.2013: Original discharge summary issued at AJ Hospital.

Ex.R4: 21.2.2014: legal notice received by the Opposite Party.

Ex.R5: 7.3.2014: Reply notice send to A. Nagaraj N, Advocate.

Ex.R6: 12.3.2014: Postal receipt.

Ex.R7: 12.3.2014: Acknowledgment.

Dated: 1.4.2017                                            MEMBER