Complaint filed on: 10.09.2015
Complaint Disposed on:08.12.2016
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.121/2015
DATED THIS THE 8th DAY OF DECEMBER 2016
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
Mohiddin Iqbal K S/o K.M.Iddinabba,
A/a 38 years,Lakshmisha Nagara,
2nd Main, Near Samudaya Bhavana
Chikmagalur.
(By Sri/Smt. K.M.Abdul Jabbar, Advocate)
V/s
OPPONENT:
1. Apollo Munich Health Insurance
Company Limited, Registered Office,
Apollo Hospital Complex, Jubilee Hills,
Hyderabad – 500 033. Telangana
Available at Corporate Office,
1st Floor, SCF-19, Sector-14,
Gungaon – 122 001, Hariyana.
2. The Branch Manager, Canara Bank,
Main Branch, Chikmagalur.
(OP-1 By Sri/Smt. Sarath Chandra K.S., Advocate)
(OP-2 By Sri/Smt. K.V.Mahabala, Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos. 1 & 2 alleging deficiency in service in not settling the medical claim to the tune of Rs.27,185/-. Hence, prays for direction against OP Nos. 1 & 2 to settle the claim along with compensation for deficiency in service.
2. The brief facts of the complaint is that:
The complainant had obtained medical insurance policy from OP No.1 through OP No.2 vide policy No.120100/12001/2013/A003282/197 which is valid from 13.08.2014 to 12/08/2015. Such being the case, when the policy is in force, the complainant admitted for treatment of malignant melanoma of left leg on 20.04.2015 at KMC hospital, Attavara, Mangalore. During hospitalization he undergone operation to the left leg and discharged on 04/05/2015 after due treatment. The complainant at the time of hospitalization had approached the OP No.1 for cashless facility towards the medical treatment. But OP No.1 had not provided cashless facility and repudiated the claim. Further, after repudiation of the claim also terminated the policy (Ab-initio) stating that history of Schizophrenia was not disclosed at the time taking the proposal for health insurance. The complainant had not suppressed any material facts at the time of taking the medical policy from OP No.1. The OP No.1 without any valid reasons had repudiated the claim which is illegal and unjust. The complainant had taken a treatment for malignant melanoma to his left leg and it is no way related to schizophrenia. The said disease is not caused due to schizophrenia. Hence, the OP Nos. 1 & 2 rendered a deficiency in service in repudiating the claim made by complainant towards the settlement of medical claim. Hence, prays for direction against OP Nos. 1 & 2 to settle the claim along with payment of compensation of Rs.1,00,000/- for deficiency in service as prayed above.
3. After service of notice the OP Nos. 1 & 2 appeared through their counsels, but OP No.1 only filed the version.
The OP No.1 in his version has contended that this OP is going to settle the claim out of the common pool of funds belongs to the policy holders of the company and this OP has to check up the admissibility of the claim before settlement of the claim. The complainant has suppressed the material facts and wrongly interpreted the clause and filed this false complaint in order to gain wrongfully.
The complainant had taken policy for a sum assured of Rs.50,000/- from this OP basing on the declaration made by complainant and they have issued a policy vide policy bearing No.120100 /12001 /2013 /A003282/197 thereby accepting risk commencing from 13.08.2014 to 12.08.2015. The benefits under the policy are however subject to certain conditions and exclusions of the policy.
The complainant had submitted some documents on 12/06/2015 and upon scrutiny of the said documents, they noticed that the complainant is suffering from malignant melanoma and he first visited a Doctor at Chikmagalur on 13/02/2015 for treatment with three months history of non healing lesion over the left leg. Thus, upon conspicuous perusal of specific waiting period under Clause-5 of the policy, it is clear that the claim made by complainant is not admissible as per the exclusion. The section 5-C of the exclusion reads as follows:-
“Section 5 : Exclusions
Specific waiting periods:
c) The illness and treatments listed will be covered subject to waiting period of 1 years:
i) Illness: arthritis if non infective; calculus disease of gall bladder and urogenital system, cataract, fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant), osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.
The OP further contended that since the said hospitalization was for the illness which has a specific 1 year of waiting period as per the policy the claim was rejected on 09/07/2015 stating that the medical history details of schizophrenia is not revealed while taking the policy in the proposal form. Hence, there is no deficiency in service on the part of this OP and this OP in repudiating the claim of the complainant and thereby they are not liable to pay any compensation as claimed by the complainant and prays for dismissal of the complaint.
4. The complainant filed affidavit and marked the documents as Ex.P1 to P3. The Ops have not filed any affidavit evidence and also not produced any documents.
5. Heard the arguments:
6. In the proceedings, the following points do arise for our consideration and decision:
Whether there is deficiency in service on the part of OPs.
Whether complainant entitled for any relief & what Order?
7. Our findings on the above points are as follows:-
Point No.1: Affirmative.
Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
8. It is admitted that the OP No.1 has issued a health insurance policy through OP No.2 to the complainant which is valid from 13/08/2014 to 12/08/2015. During the policy is in force, the complainant admitted to KMC Hospital at Mangalore for the treatment of malignant melanoma of left leg on 20/04/2015 and discharged on 04/05/2015. At the time of taking treatment the complainant approached the OP for cashless benefit. But the OP repudiated the claim and also terminated the policy for the reason that the complainant has history of schizophrenia and complainant was not disclosed the said disease at the time of taking the policy.
9. The complainant has sworn affidavit that he took a treatment at KMC Hospital for malignant melanoma from 24/04/2015 to 04/05/2015 and not for schizophrenia, but OP has repudiated the claim for the reason not disclosing the said schizophrenia at the time of taking policy. Hence, submits deficiency in service and prays for settlement of the claim.
10. The complainant at the time of filing affidavit had produced the repudiation letter issued by OP No.1 dated:08/07/2015, marked as Ex.P1 and a letter issued by OP No.1, marked as Ex.P2 and also produced copy of the card issued by OP Nos. 1 & 2, marked as Ex.P3. Except these documents, no further documents produced for perusal of this Forum. Apart from that the OP also not produced any materials to substantiate his defense.
11. On going through the repudiation letter we noticed that the OP had repudiated the claim for the reason that the complainant had illness history of schizophrenia and it was not revealed at the time of taking the policy as per Clause 5(C) of the policy terms and conditions. The OP No.1/Company had repudiated the claim for the reason for P2 existing disease of Schizophrenia and OP No.1 stated in his version that the complainant was suffering from said Schizophrenia before taking the policy and took a treatment at local hospital at Chikmagalur. But the OP has not produced any materials to show that the complainant had took treatment before taking the policy at local hospital at Chikmagalur for Schizophrenia. Apart from that we noticed and admitted by OP that the complainant took treatment at KMC medical Hospital at Mangalore for the reason of malignant melanoma of left leg. The said disease is covered under the policy.
12. On going through the Clause 5C of the policy terms and conditions as narrated in the version and affidavit, we noticed that the said disease is not excluded from the coverage after taking the policy. Instead of settling the claim made by the complainant the OP had repudiated the claim by quoting another reason because the complainant admittedly has not taken any treatment for Schizophrenia at KMC medical hospital and he claimed for treatment took for malignant melanoma. Without considering the said treatment the OP had repudiated the claim illegally. Hence, the OP No.1 rendered a deficiency in service in not settling the claim of the complainant. Hence, the OP No.1 is liable to settle the claim of complainant towards medical expenses and the OP No.1 is also liable to pay compensation of Rs.10,000/- for deficiency in service along with litigation expenses of Rs.2,000/-.
13. The complaint against OP No.2 is liable to be dismissed because the OP No.2 is only acted as an agent on behalf of OP No.1 who issued the policy to the complainant and there is no transaction took place between OP No.2 and complaint with respect to medical claim. As such the complaint is liable to be dismissed against OP No.2. Hence, for the above said reasons, we answer the above points accordingly and proceed to pass the following:-
: O R D E R :
The complaint filed by the complainant is allowed in part.
The OP No.1 is directed to pay eligible claim to the complainant under policy No. 120100 / 12001 / 2013/A003282/197
The OP No.1 is further directed to pay Rs.10,000/- towards compensation and Rs.2,000/- towards litigation cost to the complainant.
The OP No.1 is further directed to comply the above order within 30 days from the date of receipt/knowledge of the order, failing which the payable amount shall carry interest @ 9% P.A. from the date of complaint to till realization.
The complaint against OP No.2 is hereby dismissed.
Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 8th day of December 2016).
(RAVISHANKAR)
President
(B.U.GEETHA) (H. MANJULA)
Member Member
ANNEXURES
Documents produced on behalf of the complainant:
Ex. P1 - Repudiation letter issued by OP Dt:08/07/2015
Ex.P2 - Termination notice with respect to Group health
Individual policy No.EG 05499765
Ex.P3 - Copy of the card issued by Canara Bank with respect to
Group Insurance
Documents produced on behalf of the OPs:
NIL
Dated:08.12.2016 President
District Consumer Forum,
Chikmagalur.
Tss
