Karnataka

Bangalore 4th Additional

CC/758/2016

S.V. Srinivas Rao - Complainant(s)

Versus

Apollo Munich Health Insurance Co. Ltd - Opp.Party(s)

02 Apr 2018

ORDER

Complaint filed on: 26.05.2016

                                                      Disposed on: 02.04.2018

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

 

 

CC.No.758/2016

DATED THIS THE 2^nd APRIL OF 2018

 

PRESENT

 

 

SRI.S.L.PATIL, PRESIDENT

SMT.N.R.ROOPA, MEMBER

 

Complainant/s: -                           

S.V.Srinivas Rao

No.80, 17^th cross,

33^rd main, 6^th phase,

J.P.Nagar, Bengaluru-78.

 

By Adv.Sri.B.S.Shekhar     

 

V/s

Opposite party/s

Respondent/s:-

 

1. Apollo Munich Health

Insurance co., ltd.,

Corporate Office: 1^st floor,

SCF-19, Sector-14,

Gurgaon-122001,

Haryana,

Rep. by its Director.

 

Also at

Apollo Munich Health

Insurance co., ltd.,

Registered office:

Apollo Hospitals Complex, Jubilee Hills,

Hyderabad – 500033,

Telangana.

 

By Adv.Smt.Geetha Raj

 

2. Mr.Manikantan,

Zonal Manager,

Apollo Munich Health

Insurance co., ltd.,

#105-A-108-A, 1^st floor

Cears Plaza, Residency Road, Opp.Bangalore Club,

Bengaluru-25.  

 

Ex-parte

 

 

PRESIDENT: SRI.S.L.PATIL

 

 

            This complaint is filed by the Complainant against the Opposite party no.1 & 2 (herein after referred as Op.no.1 & 2 or Ops) seeking issuance of direction to refund the entire claim of Rs.73,838.56 with interest at 18%. Further direct them to pay nominal damages of Rs.50,000/- towards mental agony, restore the policy till the contractual date, cost and to grant such other reliefs deem fit for which the Complainant is entitled to.

 

          2. The brief facts of the case of the Complainant are that, Op.no.1 floated the health insurance scheme to public at large and boasted of cashless medical benefits to subscribers at a premium on terms & conditions printed and in the form of standard from contract. It is the case of the Complainant that, he is insured under “Easy Health Group Insurance” (hereinafter referred as the said policy) through Canara bank with Op.no.1 under policy no.120100/12001/2015/A004932/008 covered for the period 31.10.15 to 30.10.16 and the policy covered all medical claims including hospitalization and further the accidental death, permanent disability etc., as assured under the policy. The said policy was insured for a sum of Rs.10 lakhs for an optional critical illness in a sum of Rs.50,000/- and is in currency till 30.10.16. The Complainant further submits that, due to complaint of fever on and off since last week of Jan 2016, complaint of wound over left groin since the same date, general weakness, giddiness, Complainant was admitted to Sagar hospitals as an inpatient on 07.02.16 and was attended by Dr.Shobha Naidu and was treated for Inguinal Abscess with Sepsis and treated with no other illness/injuries/diabetic/IHD etc., till his discharge on 11.02.16. The said treatment was completely covered under the policy. The Complainant further submits that, in respect of the treatment, the Sagar hospitals raised a bill for Rs.52,113/- being the medical charges, consultation, bed charges, medicines etc., The Complainant since he was covered under the policy sought reimbursement of the same through claim form forwarded from Sagar hospital to Apollo Munich. The same was apparently refused vide office communication dtd.10.02.16. On contacting, the hospital authorities stated that, Complainant should provide his IHD (Ischemic heart Disease) documents since 1996 to till date, which in reality had absolutely no relevance to the claim submitted for Inguinal Abscess with Sepsis. The Complainant further submits that, adding insults to injury the Ops sent a notice dtd.11.02.16, terminating the policy mentioned above, unilaterally, without giving scope for explanation/rejoinder. Although the letter of 11.02.16 was loosely coined as ‘Notice for termination’, it regretfully did not give scope for rejoinder or natural principals of justice. It unashamedly stated that the policy stands revoked after 30 days, showing scant respect for aged ailing person, that too violating contractual obligations and violating natural justice with absolute impunity.  It may be pertinent to add here that the reason stated under revocation of 11.02.16 is unwarranted for the simple reason that his treatment was for Inguinal Abscess with Sepsis and not for IHD and that too during the currency of the policy. Presuming for argument but not admitting that policy can be revoked, the Op was bound to honor all his commitments till 11.02.16, the date of revocation. The discharge summary dtd.11.02.16 states about ISH with moderate LV Dysfunction (EF-35%), which apparently appears to be the cause of rejection of claim. The Complainant further submits that, the discovery is in Feb 2016 and hence will not invalidated the policy, which is in currency since 2014. Further the Complainant is affected 35% and it is not fatal. The Complainant further submits that, he furnished all the details while taking the policy and has furnished true information as per the format. The history of IHD was not sought in the application and he was not aware as to what he should declare voluntarily, since he was a lame man without background of either medicine or medical insurance laws. The standard format was filled with utmost care answering the entire questionnaire. The Complainant further submits that, he is aged about 68 years with no permanent vocation or income and is living on frugal income/support from children. Hence prays to allow the complaint.

 

3. Inspite of notice served on Op.no.2, it did not appear, hence placed exparte. Op.no.1 did appear and filed version denying the contents of the complaint. It is also the contention of Op.no.1 that, there is no any deficiency of service on its part. Complaint filed by the Complainant was on the basis of fraudulent information. Further he has suppressed material facts at the time of obtaining the policy i.e. to say pre-existing disease/disorder in the enrolment form at Point no.4 Declaration and warranty on behalf of all persons to the Insured. The contents of version at para 2, 3 & 4 are in respect of availment of the said policy by the Complainant bearing no.120100/12001/2015/AA004932/008 was issued for a sum assured opted as per proposal form, to the proposer for the period 31.10.14 to 30.10.15 and renewed the same for 31.10.15 to 30.10.16. Further it is the contention of the Op that, Complainant was diagnosed with Inguinal Abscess with Sepsis and admitted from 07.02.16 to 11.02.16 at Sagar hospital, Banashankari. The Complainant raised cashless request which was put on hold seeking further medical documents from the Complainant with respect to past history of Hyper tension and heart disease vide letter dtd.08.02.16. Thereafter Op refused cashless request as required information/documents had not been provided to the insurer to decide admissibility by letter dtd.09.02.16. Cashless request was rejected but it was also clarified via letter that insured can file the claim for reimbursement post completion of the treatment with all medical and financial records. Complainant thereafter submitted certain medical documents and Op through letter dtd.10.02.16 repudiated the claim of the Complainant due “to non-disclosure of material facts (Ischemic heart disease since 1996) which were observed in the documents provided during hospitalization. Further the policy of the Complainant vide letter dtd.11.02.16 was also terminated since the insured Complainant had not disclosed his medical condition at the time of application for health insurance coverage and had obtained the insurance through incorrect good health declaration. When the Complainant has suppressed the pre-existing disease at the time of availment of the policy, hence, the claim repudiated by Op are justifiable and does not call for interference. Hence on these grounds and other grounds prays for dismissal of the complaint.

         

          4. The Complainant to substantiate his case filed affidavit evidence and got marked the documents as Ex-A1 to A11 and filed written arguments. Op.no.1 did not file the affidavit evidence but produced documents as R1 to R6. We have gone through the available materials on record. Heard both side.

  

5. The points that arise for our consideration are:

1. Whether is there any deficiency of service on the part of Ops, if so, whether the Complainant entitled for the relief sought for ?  
2. What order ?

 

 

6.  Our answers to the above points are as under:

 

Point no.1: In the Affirmative  

Point no.2: As per the final order for the following

 

REASONS

 

          7. Point no.1:  Before embarking on the facts of the case, we would like to place reliance on the following decisions, on which we have disposed the similar type of cases, in respect of, how the claims are repudiated without application of mind.

1. Hon’ble Supreme Court, MANU/SC/0804/ 2000, AIR 2001 SC page 549, in the case of LIC of India & ors., v. Smt.Asha Goel and Anr, wherein at para 16 it is held that: In course of time the corporation has grown in size and at present it is one of the largest public sector financial undertakings. The public in general and crores of policy-holders in particular look forward to prompt and efficient service from the corporation. Therefore the authorities in-charge of management of the affair of the corporation should bear in mind that is credibility and reputation depend on its prompt and efficient service. Therefore, the approach of the corporation in the matter of repudiation of a policy admittedly issued by it should be one of extreme care and caution. It should not be dealt with in a mechanical and routine manner.
2. Hon’ble National Commission,1 (2008) CPJ 501 NC, in the case of National Insurance company ltd., v. Raj Narain, dtd.15.01.2008, wherein at para 7 it is held that: In Revision Petition no.1696/2005, Praveen Datnani v. Oriental Insurance co. ltd., IV (2006) CPJ 189 (NC) this commission has held that:

The District forum also relied on clause 4.1 of the policy which states that it is not material whether the insured had knowledge of disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the insurance company to disown the liability.

If this interpretation is upheld, the insurance company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the insurance company relies on their clause 4.1 of the policy in a malafide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc., prior to 11.08.2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the Complainant that he was thoroughly checked up by the doctors who were nominated by the insurance company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.

In view of the above discussions and from the records available before us, in our opinion, the Complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed.

 

3. Hon’ble National Commission Decision reported in II (2005) CPJ 78 NC, in the case of LIC of India Vs. Joginder Kaur & Ors, where in it is held that: Consumer Protection Act 1986 – Section 21(b) – Life insurance – Repudiation of claim – concealment of material facts alleged – contention, deceased suffering from diabetes mellitus, was chronic alcoholic and had an attack of jaundice, not acceptable in absence of any evidence in support – complaint rightly allowed by State Commission – no interference required in revision.
4. Hon’ble National Commission Decision reported in I (2005) CPJ 41 (NC), in the case of Life Insurance Corporation of India & Ors Vs. Dr.P.S.Aggarwal, where in it is held that: Consumer Protection Act 1986 – Section 21(b) – Life insurance – Repudiation of claim – Onus on company to prove material concealment of disease which directly proved fatal – alleged, deceased suffering from cough, expectoration, breathlessness, not recorded in proposal form – information collected from hospital not primary piece of evidence – Doctor who prepared discharge summary not produced – Deceased admitted in hospital or met with accident few years before death not proved – Extraordinary suspicious approach without pleading and without proof could not be justified – Death has no direct nexus with bronchitis – Nature of ailment not known to doctor of company despite detailed examination – material concealment not proved – Repudiation unjustified – Issuance of policy after 4 months itself amounts to deficiency of service – complaint allowed by State Commission setting aside order of Forum – No interference required in revision.
5. Hon’ble National Commission (Circuit Bench at Hyderabad) Decision reported in II (2005) CPJ 9 (NC), in the case of Life Insurance Corporation of India Vs. Badri Nageswaramma (deceased) & Ors, where in it is held that: Consumer Protection Act 1986 – Section 21 – Life insurance – Repudiation of claim – Deceased an old T.B patient, having diabetes, not known on date of proposal – burden to prove false representations and suppression of facts on insurer – Doctor’s certificate without affidavit in support no basis for repudiating the claim – No conclusive evidence produced to suggest suppression on part of deceased – company liable under policy.
6. Punjab SCDRC, Chandigarh decision reported in I (2001) CPJ 53 in the case of LIC of India Vs. Charanjit Kaur, wherein it is held that: Consumer Protection Act, 1986 – Section 15 – Appeal – Life insurance – repudiation of claim – suppression of material facts – onus of proving that deceased made false statement lies on insurance company – death due to hypertension and abdomen pain not proved – Complainant entitled to get policy amount along with interest.
7. Hon’ble National Commission Decision reported in II (1997) CPJ 1 (NC), in the case of New India Assurance co., ltd., & Anr Vs. P.P.Khanna, where in it is held that: Consumer Protection Act 1986 – Section 14(1)(d) – ‘Insurance’ – medical claim – suppression of facts – Complainant got hospitalization and domiciliary benefit policy – insurance company failed to settle claim – insurance company controverted that the Complainant was having heart ailment prior to the issue of policy – State Commission accepted the complaint – hence appeal.

Held: We have carefully considered the material placed on record. We find that the appreciation of the evidence by the State commission is reasonable and calls for no interference. There is no convincing and reliable material placed on the record by the Op to substantiate the allegations that the Complainant had suppressed material information while submitted the proposal form. In view of the stand taken by the Complainant that the material placed on record by the insurance company related to his son, it was incumbent upon the insurance company to examine the doctors concerned to fix up the identity of the Complainant. No steps were taken by the Op to that direction and they simply relied upon a certificate issued by the doctor. The only evidence led by the insurance company was by way of an affidavit of Sanadkumar, an employee of the Insurance company.

In these circumstances, the State Commission was justified in holding that the insurance company failed to prove that the statement made by the Complainant was fraudulently made by him with the knowledge of the falsity of the statement or that the suppression was of material facts which had not been disclosed.

The order of the State Commission is based on cogent reasons and does not suffer from any legal infirmity. We have no hesitation in confirming the order of the State Commission. In the result, the appeal fails and it is dismissed with costs which are quantified at Rs.2,000/-.  

 

8. In the light of the decisions cited supra, now we proceed to discuss the evidence on record, as to know whether the Complainant has suppressed pre-existing disease at the time of availing the policy. According to the case of the Complainant, in the month of Jan 2016, he got fever on and off and complaint of wound over left groin since the same date, general weakness, giddiness, hence, he admitted to Sagar hospitals, Kumaraswamy layout, Banashankari on 07.02.16. It is also his case that he was admitted as an in-patient under IP no.IPID0040891 alloted Bed no.SPT305A and has been attended by Dr.Shobha Naidu who treated him for Inguinal Abscess with Sepsis and treated with no other illness/injuries/diabetic/IHD etc., and he was got discharged on 11.02.16. With reference to this contention, we place reliance on the contents of discharge summary marked as Ex-A5 reads thus:

Diagnoses:

Inguinal Abscess with Sepsis

Diabetes Mellitus - Uncontrolled

Ischemic Heart Disease with Moderate LV Dysfunction (EF-35%)

 

History:

Complaints of fever on and off since 7 days.

Complaints of would over left groin since 7 days

History of generalized weakness

History of giddiness since 2 days

 

Past History:

Known case of diabetes mellitus since 25 years on treatment

 

9. If the above contents of discharge summary are strictly construed, one thing is clear that, he was got admitted to the hospital to take treatment for Inguinal Abscess with Sepsis. With regard to the Diabetes Mellitus – Uncontrolled is concerned, cannot be treated as proved, in the light of the decision reported in II (2005) CPJ 9 (NC), in the case of Life Insurance Corporation of India Vs. Badri Nageswaramma (deceased) & Ors. With regard to the Inguinal Abscess with Sepsis is concerned, which is not related to the diabetes mellitus and Ischemic heart disease. Hence, we are of the opinion that, the treatment taken by the Complainant with regard to Inguinal Abscess with Sepsis is concerned, the Op ought to have been considered it, as the said treatment was not related to any of the alleged diabetes mellitus and Ischemic heart disease. When such being the fact, the claim repudiated by the Op is unjust, arbitrary and illegal.

 

          10. With regard to the termination of the policy is concerned, Op has placed reliance on the contents of Ex-A4, wherein it is stated that Mr.S.V.Srinivasa Rao – History of Ischemic Heart Disease (IHD) since 1997. The termination of the policy by the Op is illegal in the light of one of the decision cited supra, reads thus:

Hon’ble National Commission,1 (2008) CPJ 501 NC, in the case of National Insurance company ltd., v. Raj Narain, dtd.15.01.2008, wherein at para 7 it is held that: In Revision Petition no.1696/2005, Praveen Datnani v. Oriental Insurance co. ltd., IV (2006) CPJ 189 (NC) this commission has held that:

The District forum also relied on clause 4.1 of the policy which states that it is not material whether the insured had knowledge of disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the insurance company to disown the liability.

If this interpretation is upheld, the insurance company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the insurance company relies on their clause 4.1 of the policy in a malafide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc., prior to 11.08.2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the Complainant that he was thoroughly checked up by the doctors who were nominated by the insurance company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.

In view of the above discussions and from the records available before us, in our opinion, the Complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed.

 

11. At the time of obtaining the policy, whether the Complainant has subjected to the medical examination is concerned, there is no positive evidence on record. The Ops have never put any extra effort to examine the Doctor who examined the Complainant and given the health report. In the absence of it, it is unsafe to arrive at the conclusion that, Complainant has suppressed the alleged pre-existing disease. When such being the fact, the repudiation of the claim as well as the terminating the policy of the Complainant are illegal. Hence this forum has no other go except to accept the claim of the Complainant and to direct the Ops to process the medical claim amount covered under the medical bill dtd.11.02.16 marked at Ex-A5 page 17 for an amount of Rs.52,113/-. With regard to the nominal charges towards mental agony is concerned, the Complainant has prayed to award Rs.50,000/-. The claim of the Complainant has been illegally repudiated by Ops. In this context, an amount of Rs.50,000/- towards mental agony is appears to be just and proper, hence we are inclined to award Rs.50,000/- towards mental agony. We also direct the Ops to restore the policy no.120100/12001/2015/A004932/008 shown at Ex-A1 till the contractual date i.e. 30.10.2016. With regard to the cost of litigation is concerned, we fix it to Rs.10,000/-. Accordingly we answered the point no.1 in the affirmative.

 

           12. Point no.2: In the result, we passed the following:

 

ORDER

 

          The complaint filed by the Complainant is hereby allowed in part.

 

2. Op.no.1 & 2 are jointly and severally liable to pay the medical bill amount of Rs.52,113/- and Rs.50,000/- towards mental agony to the Complainant within six weeks from the date of receipt of this order. If not, the said amounts carried interest at the rate of 6% p.a. from the date of repudiation till the date of realization.

 

3. Ops are also directed to restore the policy no.120100/12001/2015/A004932/008 shown at Ex-A1 till the contractual date i.e. 30.10.2016.

 

4. Ops are also directed to pay Rs.10,000/- being the cost of litigation to the Complainant.

 

          Supply free copy of this order to both the parties.

 

          (Dictated to the Stenographer in the open forum and pronounced on 2^nd April 2018).

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT

                                                                        

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

 

Sri.S.V.Srinivas Rao, who being the complainant was examined. 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Medical insurance policy
Ex-A2	Previous insurance policy
Ex-A3 & A4	Letters dtd.10.02.16 & 11.02.16 from Op
Ex-A5	Deficiency of service with bills
Ex-A6 & A7	Legal notice dtd.18.03.16, 05.05.16
Ex-A8	Postal acknowledgement
Ex-A9	Returned cover from Op.no1
Ex-A10	Postal confirmation dtd.06.05.16
Ex-A11	Letter of cancellation of policy dtd.31.03.16

 

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

 

• NIL -

 

Copies of Documents produced on behalf of Opposite party no.1

 

Ex-R1	Enrollment form
Ex-R2	Certificate of insurance-health & certificate of insurance-personal accident
Ex-R3	Order passed in WP(c)976/2015 dtd.02.02.15 by Highcourt of Delhi
Ex-R4	Preauthorization form
Ex-R5	Medical documents of the Complainant
Ex-R6	Cashless denial

 

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT