Date of Filing: 18/12/2015
Date of Order: 28/09/2017
ORDER
BY SRI.SYED ANSER KHALEEM, PRESIDENT
- This is the complaint filed under Section 12 of the C.P. Act 1986 against the O.P alleging the deficiency in service and praying for orders to direct the O.P to pay medical bills of Rs.3,63,262.17 with interest at the rate of 18% from the date of filing claim form till the date of settlement of claim amount and to grant further relief as this Forum may deems fit.
2. The facts of the complaint in brief are that, the complainant’s son Harish Kumar taken the Health Insurance policy in the name of his father Sri. S.Kumar and mother Smt. Girija Kumar from O.Ps by paying premium amount of Rs.23,920/-. The policy bearing No.10046184 under the plan name CARE and the sum assured is Rs.5,00,000/- and the policy period commencing from 24.10.2013 to 24.10.2014. Further complainant stated that the O.Ps offered the benefits to the insured such as hospitalization expenses, pre -hospitalization and post hospitalization expenses, ambulance cover, organ done cover, domiciliary hospitalization, health checkup, second opinion charges and no claim bones, also the O.Ps offered tax benefits. Further complainant stated that he visited Gayatri Pharamacy, Magadi Main Road for routine checkup and on 02.04.2014 Dr.G.S.Ramachandran who advised the complainant to takes medicine for 3 days and on 15.04.2014 once again visited the same doctor for pain and gastro problem and the doctor prescribed some tablets. It is stated that, after consuming the tables no improvements and again revisited the doctor on 2.5.2014 and on 12.06.2014 ultimately doctor opined that the problem due to tongue ulcer, and advised for biopsy of ulcer and x-ray of chest and referred to surgeon and other treatment.
3. Further complainant states that he visited Health Care Global Enterprises, Sampangi Ramnagar, Bangalore on 20.06.2014, NUSG of Thyroid was done and Microscopy and diagnosis was done on 23.06.2014, it was found that Moderately differentiated squamous cell carcinoma left lateral tongue and MRI Neck was done on 24.06.2014. The complainant was admitted on 24.06.2014 and operation was done 25.06.2014 and discharged on 30.06.2014. Further states that the complainant took treatment for CARCINOMA LEFT LATERAL BORDER OF TONGUE and complainant spent Rs.2,38,262.17, complainant submitted insurance claim to the O.Ps but surprisingly received letter from the O.Ps that the complainant had diabetics since 7 years and it was not disclosed at the time of taking the policy. Complainant submits that the Ops while issuing the medical policy the doctors of Ops have done medical checkup and after due medical checkup the policy was issued when the complainant not chronic diabetic patient 7 years back. Further states that O.Ps sent a letter dated 08.08.2014 repudiating the claim on the ground that because of non discloser of material information at time of proposal, the insurance policy stands void ab-initio and the premium has been forfeited. Hence this complaint.
4. Upon issuance of notice, O.Ps appeared their entrance through their counsel and filed their version. In the version it is contended that O.P.No.1 is a M/s Religare Health Insurance Co. Ltd is regulated by the IRDA constituted under the Act of Insurance and Development Authority Act 1999. It is contended that, son of the complainant has approached the O.Ps and has obtained the health insurance policy for himself and his parents and submitted the duly filled and signed proposal form after knowing the terms and conditions of the Insurance Policy. It is admitted that a medi-claim insurance police was issued vide policy bearing No.10046184 on 24.10.2013 covering the complainant, his parents and his wife. It is also admitted that the sum assured was of Rs.5,00,000/- based on the declaration provided by the complainant in his proposal form and the pre-policy medical examination report. It is contended that on 24.06.2014 the complainant has requested the O.Ps for cashless facility for the treatment at HCG hospital and has submitted the pre-authorization form. It is further contended that O.Ps has requested the complainant to provide the additional information in order to process the claim and also requested to provide previous treatment records and consultation papers of last two months and the treatment records for Excision Biopsy done on 14.06.2016. It is submitted that on going through the information provided O.Ps has approved for the cashless facility for an amount of Rs.90,000/- on 28.06.2014. It is contended that on going through the medical records i.e. consultation sheet of HCG hospital it was revealed complainant is a diabetic patient from past seven years and therefore immediately on the same day this O.Ps have denied the cashless facility and the same was informed to hospital authorities. It is also contended that the cash less benefit was denied due to non-disclosure of facts, since the insured never disclosed that the complainant is suffering from diabetes mellitus at the time of obtaining the policy. It is also contended that as per clause 6.1 of the terms and conditions of the policy if any untrue or incorrect statement are made or there has been a misrepresentation, mis-discription or nondisclosure of any material fact the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the complainant. Further contended that company may at any time cancel this policy on the ground as specified in the clause 6.1 by giving 15 days notice in writing by registered post acknowledgement due. Hence O.Ps in view of suppression of material facts cancelled the policy and the premium amount paid by the insured is forfeited. Further O.Ps denies all the allegations made in the complainant and also contended that there is no cause of action accrued to the complainant to file this complaint and the complaint is filed with mala-fide intention and on other grounds prays for dismissal of complaint.
5. In order to substantiate the case of the parties and both parties filed their affidavit evidence and also heard the arguments and the parties have also filed the written arguments.
6. On the basis of the pleadings of the parties, the following points will arise for our considerations are:-
(A) Whether the complainant has proved
deficiency in service on the part of the O.Ps?
(B) Whether the complainant is entitled to
the relief prayed for in the complaint?
(C) What order?
7. Our answers to the above points are:-
POINT (A) & (B): In the Partly Affirmative.
POINT (C): As per the final order
for the following:
REASONS
POINT No.(A) & (B):-
8. On perusing the pleadings of the parties and the documentary evidence placed on record, it is an undisputed fact that, the son of the complainant by name Mr. Harish Kumar was obtained the medi-claim Insurance policy for himself and his parents. On perusal of the insurance policy it discloses that the period of policy commencing from 24.10.2013 to 23.10.2014 and the premium amount is paid a sum of Rs. 23,920/- the sum assured is Rs.5,00,000/-. It is also not in dispute that the father of the complainant underwent surgery and treatment for ulcer in the left lateral tongue since 2-3 months and underwent surgery for left hemithyroidectomy + Wide Local Exision of Tongue Lesion + Left modifies Neck Dissection. Further on perusing the bills issued from the HCG Hospital it is also not in dispute the complainant incurred expenditure of Rs.2,38,262.17.
9. It is the sole allegation of the complainant is that though complainant not a chronic diabetic patient but the O.Ps repudiated the claim on the ground that since seven years complainant having diabetics.
10. Per-contra O.Ps contended that, the insurance policy issued subject to terms and conditions of the policy. As per the clause 6.1 and 6.3 the complainant suppressed the material facts about the diabetics and thereon contended that if any untrue or incorrect statement are made or there has been a misrepresentation, mis-discription or nondisclosure of any material fact the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the complainant. Further contended that company may at any time cancel this policy on the ground as specified in the clause 6.1 by giving 15 days notice in writing by registered post acknowledgement due. Hence O.Ps in view of suppression of material facts cancel the policy and the premium amount paid by the insured is forfeited.
11. The crux of the matter is to consider that whether the complainant is suppressed the material facts?
12. In order to establish the case of the complainant, the complainant filed affidavit evidence reiterated all the averments made in the complaint and also produced documentary evidence. It is the grievance of the complainant is that before undergoing surgery concerned surgeon will checkup the sugar level and when reached to the normal level then only they will perform the operation. It is pertinent to note that, the complainant underwent surgery whether there is any nexus to the diabetis and to the surgery underwent by the complainant. The O.Ps issued the policy after examination of the complainant. If such being the case on examination if there is a diabetic it can be revealed. Further O.Ps did not place any cogent evidence on account of diabetic only the complainant underwent surgery. Hence we are of the considered opinion that, the O.Ps did not produce any credible evidence in order to establish that due to diabetic only the complainant underwent surgery. Therefore, it cannot be gain said that the complainant suppressed the material facts and hence Clause 6.1 and 6.3 as per the terms of the policy is not attracted as contended and canvassed by the O.Ps.
13. Furthermore, the insurance is a contract based on utmost faith. Both parties i.e. insured and insurer has to act with an utmost faith. The object insurance is to seek help when the persons in destitute to overcome financial problem. If the insurance companies stick on to some technical grounds without any sound reasons it is nothing but denying the service to its customers for which they are entitled. The non-settling of the claim to the complainant it obviously amounts to deficiency in service and the O.Ps cannot exonerate their liability for mere technical ground not coupled with any sound reasons. The complainant discharged his burden by placing the oral and documentary evidence and the burden shifts on the O.Ps but the O.Ps did not examine any expert doctor to show that since seven years complainant was a diabetic and it only causes the complainant to undergo surgery and incurred medical expenditure. In the absence of vital and credible evidence the contentions raised by the O.P is not acceptable one. Under the circumstances, we are of the considered opinion to hold that complainant is entitled for the reimbursement of the medical expenditure covered under the policy. Therefore we direct the O.Ps to reimburse the medical expenditure of Rs.2,38,000/- to the complainant along with 7.5% per annum from the date of complaint till its realization and also to pay Rs.2,000/- towards the cost of the proceedings and it will meets the ends of justice. Accordingly we answered these points in the partly affirmative.
POINT (C):
14. On the basis of findings given while answering the Points (A) & (B) and in the result, we proceed to pass the following:-
ORDER
- The complaint is allowed in part with cost.
- The O.P No.1 and 2 are jointly and severally liable to pay a sum of Rs.2,38,000/- to the complainant along with 7.5% per annum from the date of complaint till its realization
- Further the O.Ps are hereby jointly and severally directed to pay Rs.2,000/- towards the cost of the proceedings.
- The O.P No.1 and 2 are hereby directed to comply the order of this Forum within 30 days from the date of receipt of this order and submit the compliance report to this forum within 45 days.
- Send a copy of this order to both parties free of cost.
(Dictated to the Stenographer, transcribed and computerized by him, corrected and then pronounced by us in the Open Forum on this the 28th Day of September 2017)
MEMBER MEMBER PRESIDENT
*RAK
