ORDER

SRI.H.R. SRINIVAS, PRESIDENT

1.     This is the complaint filed by the complainant against the Opposite Parties (herein referred to as OPs) under Section 35 of the Consumer Protection Act, 1986 for the deficiency of service in repudiating the insurance and also cancelling the further insurance and for reimbursement of Rs.1,62,179/- incurred towards the hospital expenses along with the interest on the said amount at 24% per annum from the date of discharge from the hospital till payment and Rs.36,000/- towards litigation costs and other reliefs as the commission deems fit.

2.     The brief facts of the complaint are: that the complainant obtained medical insurance earlier from United India Insurance Company Limited. It was a continuous one.  Afterwards, at the instance of the Canara Bank, he shifted his insurance company from United India Insurance Company Ltd to Bajaj Alliance Life insurance company which took over his existing policy in respect of medical insurance and further assured that the complainant would be entitle for all the continuity benefits and the same will continue as it is a continuation of existing policy. Earlier he was paying Rs.5,121/- as annual premium whereas the OP Bajaj Alliance Company Limited received Rs.19,676/- as premium for the sum assured of Rs.3,00,000/-.

3.     It is contended that on 29.03.2021 he was admitted to Sagar Hospital Kumaraswamy layout, Banashankari, Bangalore due to heart related problems for which he had to spent Rs.1,62,179/-. After discharge he claimed the same with OP with all original documents and hospital documents. To his utter shock and surprise, OP did not reimburse the expenses which he had incurred with the hospital on the ground that, he the complainant suffering from Hypertension did inform the same at the time of taking the policy and thereby suppressed the material facts and also on 03.05.2021 it sent a letter cancelling the policy whereas there is no mistake on his side as there is no provision in the application to disclose his medical condition. The act of OP amounts to deficiency in service and hence prayed the commission to allow the complaint.

4.     Upon the service of notice, OP-1, 2 and 3 appeared before the commission and filed the version contending that the complaint is not maintainable either in law or on facts and devoid of merits and there is no basis for the complainant to file the complaint.  The complaint filed is on false, malicious, incorrect; mala-fide reasons and liable to be dismissed under Section 26 of the Consumer Protection Act 1986. There is no cause of action or deficiency in service or negligence on the part of OP. Hence complainant cannot invoke the provisions of the Consumer Protection Act.

5.     It is further contended that OP is an insurance company registered under the relevant provisions of law and has been carrying on the business in insurance. There are set of policies standard terms and conditions as approved by IRDAI.

6.     Upon receiving the proposal duly signed by the complainant, the medi-claim insurance group canara bank previously syndicate bank, issued the insurance policy for the period from 24.02.2021 to 23.02.2022. The liability under the said policy is subject to the terms and conditions mentioned therein.  The complainant made a claim application for reimbursement of the hospital expenses incurred for taking treatment of acute coronary syndrome, unstable angina and hypertension and sought for the reimbursement of the said claim. On receiving the said claim, and ongoing through the record submitted by the complainant, it was found that the complainant was suffering from hypertension since four years which is much earlier to the date of issuing the insurance which was not at all disclosed.

7.     As per clause-C of exclusion the benefits are not available to any preexisting condition, ailment or injury until 36 months of continuous coverage have elapsed after the date of inception of the first medi-claim policy provided pre-existing diseases, ailment or injury is disclosed in the proposal form. In view of the non-disclosure of the hypertension which was preexisting before the date of issuance the policy, the same is excluded and do not cover the insurance in respect of the complainant. The relation between the insured and insurer is on the principle of the atmost good faith and trust. They are bound by the terms and conditions under which the policy is issued.  There is no liability on its part and complainant is alone responsible for the risk, cost and peril.  This forum has no jurisdiction to decide the case and denying the allegations made in each and every para of the complaint, prayed the commission to dismiss the complaint. 

8.     In order to prove the case, both parties have filed affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1. Whether the complainant has proved deficiency in service on the part of the opposite parties?

2. Whether the complainant is entitled to the relief prayed for in the complaint?

9.     Our answers to the above points are:-

POINT NO.1: IN THE AFFIRMATIVE

POINT NO.2 : PARTLY IN THE AFFIRMATIVE

                      For the following:

REASONS

POINT NO.1:

10.   It is not in dispute that the complainant is an insured person with OP and also underwent hospitalization for his ailment for which the hospital charged Rs.1,62,179/- which the complainant paid to the hospital and since he has obtained the insurance with the OP, made a claim for the said amount. The medical documents, the proposal form, the insurance documents, the discharge summary and the previous insurance obtained by the complainant has also been produced.

11.   It is to be noted here that the complainant obtained insurance for the first time during 2015 and has been continuing the same without there being any break. The document filed by the complainant shows to that effect.  At the relevant point of time, the complainant was having an insurance for Rs.3,00,000/- (insured amount) obtained from OP. It is during this time the complainant fell ill, got admitted to the hospital, obtained treatment by spending Rs.1,62,179/-which when claimed has been rejected by OP on the ground that he was having hypertension prior to the issuing of the insurance and hence it is a material suppression of facts. When the complainant has produced the earlier insurance dated back to 2015, the contention of OP that benefits will not be available for any preexisting condition ailment or injury until 36 months of continuous coverage have elapsed after the date of inception of the first medi-claim insurance policy provided the pre-existing disease/ailment or injury is disclosed on the proposal form cannot be accepted. 

12.   OP has not filed any document to show that the complainant was having hypertension before he obtain insurance policy for the first time in the year 2015. It is to be noted here that hypertension is no more a disease or medical condition it is only a physiological change occurred in the body due to various reasons, such as lacking of exercise, physical activity, mental tension and other physical and mental disabilities. 

13.   The Hon’ble Supreme Court of India in Civil Appeal No.8386/2015 decided on 06.12.2021 held that: “the object of seeking medi-claim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent which may occur if the insured suffers a sudden sickness or ailment which is not expressly excluded under the policy. A duty is caste on the insurer to indemnify the complainant for the expenses incurred thereon.”

14.   The Hon’ble Supreme Court of India, Hon’ble High Court of Delhi and Hon’ble NCRDRC in various cases have held that hypertension and diabetes are not at all diseases. It is held that to have the financial help at the time of distress, public will take insurance policy and in case the insurance companies reject the same on trivial grounds and on too technical points, then the purpose of obtaining the insurance policy which is a social piece of legislation under the Act will be defeated and no purpose will be achieved by taking such a technical and trivial issues to reject the genuine claim of the insured.  Even it has held that now a days hypertension and diabetic mellitus are so common and it cannot beheld as a medical ailment or diseases. Under the circumstances, it is to be held that rejection /repudiation of the claim of reimbursement of the hospitalization charges by OP amounts to deficiency in service and also unfair trade practice for having received a heavty insurance premium of Rs.19,676/- against a moderate premium of Rs.5,121/- by United India Insurance company Ltd Hence we answer POINT NO.1 IN THE AFFIRMATIVE.

POINT NO.2

15.   In view of the above answer, the complainant is entitle for reimbursement Rs.1,62,179/- being the amount which the complainant has spent with the said hospital for his treatment which was rejected by the OPs. The same is also liable to be paid along with interest at 12% per annum from the date of discharge from the hospital i.e 29.03.2021 till payment of the entire amount.  Further OP is also directed to pay a sum of Rs.25,000/- towards compensation for causing him mental agony, Physical hardship and financial loss and further Rs.10,000/- towards litigation expenses as he had to send a legal notice to  the OPs to demand his reimbursement and further had to pay the professional fee to prepare the brief and to file the complaint and conduct the case before this commission. In view of this, we answer POINT NO.2 PARTLY IN THE AFFIRMATIVE and pass the following:-

ORDER

1. The complaint is partly allowed with cost.
2. OPs are jointly and severally hereby directed to pay a sum of  Rs.1,62,179/- to the complainant along with interest at 12% per annum from the date of discharge from the hospital i.e 29.03.2021 till payment of the entire amount and to continue the insurance (further) by receiving the applicable premium.
3. Further OPs are also directed to pay Rs.25,000/- towards mental harassment and Rs.10,000/- towards cost of the litigation expenses to the complainant.
4. OPs are hereby directed to comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this Commission within 15 days thereafter.
5. Send a copy of this order to both parties free of cost.

Note: You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Commission on this day the 22^nd day of JULY 2022)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Copy of the medi claim insurance policy schedule

Ex P2: Copy of the RPAD.

Ex P3: Copy of repudiation letter.

Ex P4: Copy of the Ombudsmen’s office address

Ex P5: Copy of the letter by documentary recovery department along with postal receipt.

Ex P6: Copy of the Sagar Hospital medical bills of discharge summary of the complainant.

Ex P7: Copy of non disclosure of material facts.

Ex P8: Copy of the policy.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Sri Prabhakara, Sr. Executive of OP.

Copies of Documents produced on behalf of Opposite Party/s

Ex R1: Copy of the proposal form.

Ex R2: Copy of the claim form.

Ex R3: Copy of the Repudiation letter.

Ex R4: Copy of the correspondence letter.

Ex R5: Copy of the policy.

Ex R6: Copy of the policy wordings.

Ex R7: Copy of the Discharge summary issued by Sagar Hospital.

Ex R8: Copy of the concern letter issued by Sagar Hospital to the complainant.

MEMBER                PRESIDENT

RAK*