THE DISTRICT CONSUMER DISPUTES REDRESSAL    

                 COMMISSION, AT MADIKERI ,KODAGU

             Dated this the 29^th  day of October,2021

PRESENT

SRI .PRAKASHA K.                                    : HON’BLE PRESIDENT

SRI. B.NIRMAL KUMAR                            : HON’BLE MEMBER

SRI. C.RENUKAMBHA                               : HON’BLE MEMBER

ORDERS IN

CONSUMER COMPLAINT NO.12/2019

(Admitted on:16.03.2019)

Mr. Cheriapanda Kushalappa Kashiyappa.

Aged 69 years,

Coffee planter,

Resident of Ponnampet,

South  Kodagu Karnataka.

 (Advocate for the Complainant: C.S.P)

…..Complainant

VERSUS

1.The Appollo Munich Health Insurance Company Limited,

Central Processing  Centre, 2^nd and 3^rd Floor,

ILABS centre , Plot No:

Udyoga Vihar, Phase III,Gurgaon-122016

Hariyana.

2. The Manager ,

Canara Bank, Ponnampet,

South Kodagu.

Opposite Party No.1 : D.M.K)

(Opposite Party No 2 Exparte)        ……. Opposite  Parties

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI .PRAKASHA K.

            1. This complaint is filed under section 12 of the Consumer Protection Act,1986  seeking direction  to the 1^st Respondent  to pay Rs.92,607=00 spent  by the complainant  for  his treatment  and medicines  with 12% interest  on the same from 14.11.2018 till realization and  also seeking  direction  to the respondent to pay a sum of Rs.25,000=00 as damages  to the  complainant for making  the complainant  to run from pillar   to post claiming  refund of the  amount  spent  for his treatment  and for making  the complainant suffer  mental agony.

2.      The brief facts of the case are as under:

      The complainant  under the intermediary of the 2^nd  respondent , obtained  Family  Floater health insurance from the1^st respondent  vide policy No.120100/2017/A007627/454. The policy  is in force  from 18^th   day of March 2018 till 17^th  day of March 2019. The complainant  is a customer of 1^st  respondent  since 2015.  The  complainant is entitled for  cashless  treatment  in case of his  hospitalization during  the existence  of the policy.  From 2015 the complainant has  not availed the facility.

        3.  For injury suffered  to right  Knee, the  complainant got hospitalized in St.Philomenas Hospital. No:4 Campbell, Road, Vivekanagar P.O. Bangalore 560047 on 12.11.2018. The complainant opted for cashless  benefit  and complied all requirements required to avail  cashless benefit for his  treatment.  The 1^st  respondent on 13.11.2018  refused to  provide  cashless benefit.   The complainant  was  discharged on 14.11.2018. Final hospital bill for his  treatment  was   Rs.86,864=00 which the  complainant has  paid, Medicines  bill was 05,743.18=00 which  the complainant  has  paid.

4.     After discharge  complainant submitted  one set of bills  to the  1^st  respondent  as there was  a scope  for settlement  despite  cashless  benefit  is refused.  The 1^st  respondent  did not  reply the claim of complainant.  If  the claim  was refused or not  considered the  policy provided  opportunity  for the complainant  to approach Grievance  cell of  the 1^st  respondent.    Accordingly  the complainant  issued  legal notice  to the  Grievance  cell of the  1^st  respondent  and called  upon them to consider  the  lawful request of the complainant and settle  his claim.  The complainant  also issued  notice to the 2^nd respondent  to prevail  upon the 1^st  respondent  to get the  lawful claim of the complainant  settled as  the respondent  is the  intermediary  between  the complainant  and 1^st  respondent.  The  legal notices sent  to the  respondent  were duly  served  upon them.  The respondent  did not  settle  the claim of the  complainant and did  not reply  the notice.  The 1^st respondent ought to have  settled  the lawful  claim of the  complainant  and the 2^nd  respondent ought  to have  prevailed  upon the 1^st  respondent  to settle  the claim of the complainant.  As both failed to provide service  which  they  ought  to have  provided, the respondents are  guilty of deficiency in service,  hence  this complaint.

5.     The policy was in force as on date of injury and  hospitalization of the  complainant.  The  treatment  obtained  by complainant  does not fall under  the  exclusion clause.  The complainant has not  violated  any terms  and conditions   

 of the policy.  As  per the  terms of  the policy the 1^st  respondent  ought  to have  given approval for the  cashless treatment, by not  considering  the request of the complainant for cashless treatment  the 1^st  respondent is  deficient  in service.   Further  the 1^st  respondent  ought to have  accepted  the claim of the  complainant and ought to have  settled  the claim of the complainant, further  after  complaining to the  Grievance  Cell the 1^st  respondent  ought to have  settled  the claim  of the complainant.  At least  the 1^st  respondent should have  shown the courtesy  to reply the claim and legal notice   which  they have not.  The 1^st  respondent  by failing   to do the aforementioned  acts  which the  1^st respondent was  bound to do, is deficient in service. Non settlement of the  lawful   claim of the complainant  has  amounted  to deficiency in service.

   6. The respondent have made  the complainant to run from  pillar to post  begging  to settle his claim.  The  respondent by failing  to  indemnify the  expenses  incurred  by the  complainant for  his treatment  has made the complainant  suffer  mental agony.   The acts attitude of the  respondents have made  the complainant suffer  financial loss.  The  very purpose  of obtaining  the policy  is defeated.  Hence  the  respondent are jointly  and severally  liable to  pay sum of  Rs.25,000=00 as damages to the complainant.    

   7.  After service of notice to Respondents 1&2,Respondent No.1 appeared through his counsel, Respondent No.2 did not appeared hence Respondent No.2/Opposite Party No.2  placed to experte. Opposite Party No.1 has filed the version as under :-

Opposite Party No.1 contends that the complainant has made misconceived and baseless allegations of deficiency of services   without any documentary evidence in support of his allegation. Further contends that the complaint filed by complainant   does not fall within the definition of consumer dispute as there is  neither any unfair trade practice  adopted   by this Opposite Party nor any deficiency of service being establish against this Opposite Party. Opposite Party NO.1 further contends that in this case complainant failed to disclose of material medical facts. Hence  Opposite Party rightly repudiated the claim of the complainant on the  ground of providing in correct good health declaration.  

         8. Opposite Party No.1 further  contends that the policy was initially issued for a period of 1 year  and upon the receipt of the   subsequent year premium(s), the coverage was accordingly extended  and on 24.03.2017,  the insurance cover was  extended  for the period 18.03.2018 till 17.03.2018 and  therefore, on 19.03.2018 the coverage  was further extended  for the period  18.03.2018 till 17.03.2019 upon  receipt  of the premium.

9. Opposite Party No.1 further contends that   they received a claim from the complainant  on  dated 13.11.2018.  Wherein  it was  stated that  the complainant  was  diagnosed with  Medical Meniscus Injury   in Right Knee and further  sought  the approval for  cashless treatment  at St. Philomena’s Hospital, Bangalore.

      10.They further contends that  Cashless facility cannot  be granted  due to  incorrect  good  health  declaration (BPH prior to policy inception) at  the time of policy inception, which  are observed  in the  documents  provided  during  current  hospitalization .

11. Opposite Party further contends that the complainant  in December,2017  had submitted a claim when the complainant  had  difficult in passing  Urine.  The said  Claim of the  complainant  was  evaluated  and it was  found  that the  complainant  was  diagnosed  with  Benign Prostatic Hyperplasia (BPH) with  Chronic  Prostatitis and  underwent  Transurethral  resection of the  prostate (TURP) in the year  2013 and further contends that the report  of Bhagwan Mahaveer Jain Hospital dated  07.11.2013 and  Ultrasonography report dated  09.08.2013 be looked  into. Further contends that  the said  material  fact was  suppressed by the  complainant  while  submitting  the proposal  from dated 17.03.2015 with  the Opposite Party.  hence  the claim submitted by the Opposite Party.  

Opposite Party No.1  further contends that  upon receipt of  the cashless treatment  request  dated  13.11.2018 from the complainant.  The  Opposite Party  after going  through  the medical  documents decided  to reject  the cashless  treatment request  on the  same ground  for the  reason  that the  complainant   had provided  incorrect  information while  submitting  the proposal  form and the  complainant  intentionally  suppressed  and  concealed  the material  facts  with  respect to the  fact  that  the  complainant  was  diagnosed  with Benign Prostatic  Hyperplasia (BPH) prior  to the  issuance  of the policy.    Therefore  Opposite Party No.1 prays for dismissal of the above complaint  with exemplary  cost in fever of Opposite Party.

 12. In support of this case complainant filed his examination in chief by way of affidavit and his evidence considered as CW.1. Complainant also furnished 10 documents which are respectively marked as ExP.1 to ExP10 ,ExP7(a) and ExP.10(a) and(b) also  marked.  Affidavit of  Opposite Party No.1 filed and examination in chief  considered as RW-1. ExR.1ToExR.6marked.                                                                                                                                              We heard the  arguments on  both  sides. Learned counsel     

for complainant and Opposite Party  also filed  written notes  

of arguments.   

13. In view of the above said facts, the points that arise for our consideration in the case are:

1. Whether  complainant proves that there is deficiency in service on the  

                 part  of Opposite Parties ?

 (2)   Whether the Complainant is  

          entitled to  get relief   as prayed for?

 (3)   What order?

14.    Our findings  on the above points are as under :

        Point No.(1) :  In the affirmative  

        Point No.(2) :  In the  affirmative    

        Point No.(3) :  As per the final order

REASONS

15.    Point No. 1

   In the written arguments learned counsel for complainant  submit  that  the Respondent Para 9 of the objection  statement as stated that  in 2013 the complainant took  treatment in  Mahaveer Jain Hospital of Bangalore and this fact was not  revealed by him while obtaining the policy in the year 2015. Further in the same paragraph  the Respondent has stated that  complainant  in December 2017 submitted  claim  for the  treatment  which he had  taken  for difficulty in passing  the urine. This  claim  was rejected  by the respondent  holding  that complainant  did not  reveal the fact of taking  the treatment  Mahaveer Jain Hospital of Bangalore in 2013.

        16. In the written notes of arguments  the learned counsel   for   complainant  submits that  therefore  as on  December 2017 the Respondent  was aware of the fact that complainant  had taken treatment in Mahaveer Jain Hospital of Bangalore in 2013.  Knowing fully  this fact  the Respondent  rewarded  the policy  on 24.03.2017, thereafter on 19.03.2018 to 17.03.2019 received  premium from  the complainant. Now  when the complainant   has submitted  claim for the  treatment  which he took on 12.11.2018 the Respondent  has taken  up contention that  the complainant  has  suppressed  fact of taking  treatment  in Mahaveer Jain Hospital of Bangalore in 2013.

  17. Para 9 at page no.13 version of Opposite Party which read as under:-

“That the complainant  in December ,2017 had submitted a claim when the complainant  had  difficult in passing  Urine.  The said  Claim of the  complainant  was  evaluated  and it was  found  that the  complainant  was  diagnosed  with  Benign Prostatic Hyperplasia (BPH) with  Chronic  Prostitutes and  underwent  Transurethral  resection of the  prostate (TURP) in the year  2013. The report  of  Bhagwan Mahaveer Jain Hospital dated  07.11.2013 and  Ultrasonography report dated  09.08.2013 may please be looked  into. However,   the said  material  fact was  suppressed by the  complainant  while  submitting  the proposal  from dated 17.03.2015 with  the Opposite Party.  Hence  the claim submitted by the complainant   in December, 2017 was rejected  by the Opposite Party.  A copy of  the medical documents  are annexed  herewith  as Annexure Opposite Party.6”.

     Thus on perusal of Para 9  version of Opposite Party at page no.13 it appears that, in this case on December2017 Opposite Party was  clear knowledge that the complainant had taken treatment in Mahaveer Jain Hospital of Bangalore in 2013. The claim submitted by the complainant  in December 2017 was rejected by  the Opposite Party. Even though Opposite Party  clearly aware complainant  had taken treatment in Mahaveer Jain Hospital of Bangalore in 2013 Opposite Party renew the policy on  24.03.2017 thereafter on 19.03.2017 to 17.03.2019 and collected the bill. Even though Opposite Party fully knowledge of complainant  disease in Para 6 of version  at page no.5 Opposite Party says any non disclosure of material  medical   facts or misrepresentation in the  proposal  Forms would  render the contract voidable  at the  option  of the  insurer. Thus when knowing fully that the complainant  had taken  treatment in Mahaveer Jain Hospital of Bangalore in 2013  and  it is in correct to say   that complainant  suppress the material facts of taking treatment in Mahaveer Jain Hospital of Bangalore in 2013. Thus it is  in correct to say that  they rightly  repudiated  the claim of the complainant   on the ground of  providing  incorrect good declaration.  Once the Opposite Party collected premium from complainant  side and even though they fully aware of the  fact  that the complainant  had taken treatment in Mahaveer Jain Hospital of Bangalore in 2013.  Then it is bounden duty of 1^st Opposite Party to  pay the amount to the complainant for his treatment and medicine otherwise people will lose the confidence with the Health Insurance Company. Thus in this case  after collecting premium from complainant  side Opposite Party failed to discharge their duty and thereby there is a clear deficiency in  service on the part of Opposite Party . Accordingly, point No.1 answered in the affirmative.     

   Point No.2

      18. In this case we already opined that Opposite Party No.1 committed deficiency in  service then it is bounden duty of the Opposite Party No.1 to pay amount to the complainant  for his treatment and medicine.  In this case complainant produce the  Xerox copy of the final bill of  St. Philomenas Hospital Bangalore and said bill is marked at ExP2. On perusal of ExP2 it clearly reveals that complainant spent  sum of Rs.86,864/- towards hospital bill. Further in this case ExP3 is Xerox copy of lab report in 5 sheets. ExP4 is the Xerox Copy of Medicine bill. On perusal of  said medicine bills it also appears that complainant   spent sum of Rs.5,743/- towards medicine bills. Thus complainant  is totally spent sum of Rs. 92,607/-for treatment and medicines. Accordingly  complainant  is entitled that amount.  Thereby point no 2 answered in the affirmative.

  Point No.3

          19. In the result, we proceed to pass the following:

ORDER

          The complaint filed by the Complainant under section 12 of Consumer Protection Act 1986 is allowed. Opposite party No.1 is directed to pay the complainant a sum of Rs.92,607 /- with  interest  at 6%p.a from the date of complaint  till realisation.

 Opposite Party No.1 is also directed to pay sum of Rs.5,000/- towards cost and damages.

        Opposite Party No.1 is directed to comply with the aforesaid relief within 30 days from the date of receipt of this order.

Copy of  this order as per statutory requirements, be

forwarded to the parties free of cost and file shall be consigned to record room.

(Page No.1 to 17 dictated to the Stenographer typed by her, revised and pronounced in the open Commission on this the 29^th day of October, 2021)

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Sri. Cheriapanda Kushalappa Kashiyappa. (Complainant)

Documents marked on behalf of the complainant   

Ex.P-8: Certificate of  insurance health policy.

Ex.P-9: office copy of the  legal notice dated 28.11.2018

Ex.P-10,P10(a)&(b):  postal receipt and Acknowledgement

Witnesses examined on behalf of the Opposite Party:

RW-1: Deepti Rustagi. D/o Subhash Chandra Rustagi.     

Documents marked on behalf of the Opposite Party:-

Ex.R-5: Denial of cashless service.

Ex.R-6: Request for cashless hospitalisation for medical insurance    

            policy.

Dated:29.10.2021                                                  PRESIDENT