ORDER

SMT.NANDINI.H.KUMBHAR, MEMBER

1. The Complaint is filed by the complainant under section 35 of the C.P.Act, 2019 against OP seeking direction to OP to pay claim of Rs.6,03,882/- with interest at 18% p.a. from date of claim and also direct the OP to pay compensation of Rs.2,00,000/-  towards deficiency in service and such other reliefs.

2. The brief facts of the case is as follows:

       This is the case of the complainant that  the complainant is the policy holder of policies mentioned below  issued by  OP.

The complainant submits that on 03.07.2022 the complainant admitted to the Trustwell hospital, Bengaluru for treatment of his Acute onset of left upper limp and lower limb weakness and hospital have done initial CT scan head showed right M2 dot sign and MRI brain showed right MCA infarct, MRA showed right distal M1/M2 and during the stay in the hospital he was provided Physiotherapy and he was able to walk and then on 09.07.2022 the complainant was shifted to ward and again on 10.07.2022 he had fever with chills and urinary bladder distension with Hematuria  and on 11.07.2022 the complainant underwent  repeat cystoscopy, blood clots were evacuated for urinary bladder  and new 22F1 Feoly’s Catheter was inserted with irrigation of bladder and  on 18.07.2022 the complainant was discharged from the hospital. The complainant submits that after discharge the complainant made claim bearing No.1222210112903 by submitting all documents claiming hospital and treatment  expenses of Rs.6,03,882/-, but the OP have issued letter dt.03.09.2022 stating that they are unable to approve for reimbursement claim for the reason that the complainant was admitted for Acute Stoke, Left Hemi paresis and the patient is known case of Hypertension since 03 years and diabetes since 02 years is prior to the inception of policy and the policy and was not disclosed to the OP  on proposal form.  The complainant submits that in the discharge summary dt.18.07.2022 the complainant past history mentioned as “No past h/o CVA” with is very clearly mentioned that no past history of the complainant for  and above said problem, but the OP have without documentary evidence come to the conclusion that the complainant is known case for Hypertension and Diabetes and refused the reimbursement claim.  The complainant submits that again the complainant approached the OP, but the OP have not offered any explanation to the same.   Aggrieved by the act of OP, the complainant filed the present complaint seeking  relief as prayed in the complaint.

3.  Notice to the OP duly served, OP represented by counsel filed written version and affidavit along with relevant documents in support of their defense.

4. Complainant filed chief examination affidavit by re-iterating the complaint allegations and also filed relevant documents in support of their plea.

5.  Heard arguments and matter is reserved for orders.

6. The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency of service on the part of the OP as alleged in the complaint and thereby prove that he is  entitled for the relief sought?
2. What order?

8. The findings on the above points are as under:

Point No.1           :       Partly in Affirmative

Point No.2           :       As per final order.

REASONS

9. POINT NO.1:-  OP represented by counsel filed written version by denying complaint allegations and any deficiency in service. The OP had admitted that, the OP had issued policy to the complainant for a period from 03.07.2022 till 18.07.2022 based on the statement declaration provided at the time of proposal, but the OP had rejected the claim of the complainant on the ground that for non-disclosure of history of Hypertension since 03 years and Diabetes since 02 years and same was not disclosed at the time of obtaining the insurance policy,  as the said ailment is pre-existing and hence cashless  treatment was not possible at the said juncture. As per terms and conditions of the policy the OP has rejected the claim of the complainant  and denied any deficiency on their part. By contending the same, the OP company prays for dismissal of complaint as against them.

10. The complainant filed chief examination affidavit by reproducing the complaint allegations as against OP and also produced relevant documents marked as C1 to C6 in support of their contention. That the complainant was admitted in the hospital on 03.07.2022 for the treatment of his Acute onset of left upper limb and Lower limb weakness  and also taking treatment and fully recovered  from the said ailment. After discharge from the hospital  on 18.07.2022, at the time of hospitalization the complainant having valid policy with coverage of Rs.10,00,000/-  and the complainant had made claim along with  bill documents marked as Annexure-C3 before OP for the pre-hospitalization expenses, but the contention taken by the OP insurance company initiated  and  denying the claim by assigning the reason that, the complainant is known case of Hypertension since 03 years and Diabetes since 02 years is prior to policy inception and not disclosed at the time of obtaining  the policy. For which the OP has rejected the claim of the complainant as per policy terms and conditions. When the OP has undertaken to indemnify the claims and losses of insured party, it is the bounden duty of the OP to honour the legitimate claim of the complainant. In this case, the contention taken by the OP is that non-disclosure of pre-existing diseases  cannot be considered for simple reason that the complainant was suffering from Hypertension from past several years and cashless hospitalization  cannot be approved and the complainant has failed to disclose the material facts at the time of proposal, for which no liability could be casted upon OP insurance company for violation of terms and conditions of the policy.

11. On this ground the commission relied on the judgment rendered by the Hon’ble  NCDRC, New Delhi, in a case between Mamata Kumari V/s Bharathi Axa Life Insurance  co. Ltd. which is ordered in 2016, insured having an Hypertension does not amount to suppression of material facts as it is being a life style disease. And another judgment between Sunil Kumar Sharm V/s Tata AIG Life Insurance co. Ltd. and another  dt.01.03.2021, it is also  discussed in this case, that it has been clearly mentioned that, Hypertension and Diabetes are life style diseases and it do not amounts to suppression of material illness. And also observed in detail that, it is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like Diabetes and Hypertension. If the insurance company is ready to take the risk at this stage of the proposer, without any preliminary  medical examination, the company should be ready to honour the claim. The ratio laid down by the Appellate authority, that , the Hypertension and Diabetes, it is life style of the people in the society. The fact that the  complainant having Diabetes and Hypertension does not amount to suppression of material fact which cannot be considered as disease as per the ratio of Appellate Authority.

12. In view of the above discussion and considering the facts of both the parties by following the principles laid down by the Appellate Authority and the conduct of the OP, it is apparent that they have issued policy for the sake of premium amount and failed to honour the legitimate claim by assigning the  above reason. Such act and conduct of the OP  is not a valid reason under law. Upon which, the claim amount cannot be repudiated and the rejection of the claim of the complainant is not justified. The act and omission of the OP attracts deficiency in service, for which the OP is held liable to pay the claim of  the complainant along with other reliefs. Accordingly, we answer the Point No.1 in partly affirmative.

13. POINT NO.2:- In the result, for the forgoing reasons,  we passed the following:

                                      ORDER

1. The complaint is hereby allowed in part.
2. The OP is  directed to pay a medical reimbursement claim of Rs.6,03,882/-  along with interest at 6% p.a. from the date of repudiation till entire payment is made to the complainant.
3. The OP is directed to pay compensation of Rs.10,000/- for deficiency in service, Rs.5,000/- towards pain and suffering along with Rs.10,000/- towards cost of the proceedings.
4. The OP shall comply this order within 45 days from the date of this order, failing which the OP shall liable to pay interest at 6% p.a. on all the above said amounts.
5. Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 29^th June 2024)

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                   (SHRINIDHI.H.N)            

                    MEMBER                                     MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Sri Ramakrishnaiah-Who being the complainant.

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit:-

Sri Swastik Chandra

Documents produced by the OP:

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                 (SHRINIDHI.H.N)            

         MEMBER                                    MEMBER                                       

SKA*