IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM

Dated this the  13^th day of December, 2018

Present Sri. P.SatheeshChandran Nair, President

              Sri. K.N. Radhakrishnan, Member

              Smt. Renu.P.Gopalan, Member

CC No. 323/16(Filed on 21/11/16)

Between:

1. Mathew K.I

Kattuvallil House,

Manarcadu PO,

2. Bindu Mathew

Kattuvallil House,

Manarcadu PO,

     (Adv.Georgekutty C.A)

And:

1)Appollo Munich Health Insurance Co.Ltd.,

 Appollo Hospaital Complex,  Jubilee Hills,

 Hyderabad-500033, Andra Pradesh.

2)The Manager, Regional Office,

   Appollo Health Insurance Co.Ltd

   Uznaz Tower, 5^th floor, Pallimukkkku,

   Opp.Medical Trust Hospital,

  M.G.Road, Cochin 682016

  (Adv. Saji Isaac K.J)                                 …..Opposite parties         

O R D E R

Sri. P.SatheeshChandran Nair, President

          The case of the complainant is as follows.

          The 1^st complainant availed Health Insurance policy from the opposite parties vide Policy Number 110102/11051/AA00420364.  The said policy was valid from 26/5/16 to 25/5/17.  On 29/7/16 the 2^nd complainant met with a motor accident and sustained fracture for her left knee so that  she was admitted at Bharath Hospital, Kottayam from 30/7/16 to 9/8/16.  According to the complainant the final diagnosis of the hospital was ‘left tibial plateau fracture’. For the said treatment the 1^st petitioner spent Rs.60,000/-.  As a family insurance scheme being the wife of the 1^st complainant, the 2^nd complainant is eligible to get a medical reimbursement from opposite parties.  Though the complainant’s filed an application for reimbursement of the amount they repudiated the claim on ground that the 2^nd complainant suppressed the ailment of ‘Fibromyalgia’.  On 4/8/16 the opposite party informed a cancellation of the policy to the complainant.  According to the complainant there is no suppression of ailment ‘fibromyalgia’ from their part and the act of the opposite parties are clear deficiency in service  and unfair trade practice against the complainant.  At last on 17/8/16 the complainant issued a lawyer’s notice to opposite party for the same.  It is contented that the complainant paid a gross premium amount of Rs.12,286/- to the opposite party for the health insurance scheme.  Hence the case to review the health insurance policy infavour of the complainant and to reimburse to Rs, 60,000/- as damage towards the treatment expense, compensation, costs etc.etc.

          This Forum entertained the complaint and issued notice to opposite parties for appearance.  All the opposite parties entered appearance and filed a joint version as follows.  According to the opposite parties the case is not maintainable either in law or on facts.  The opposite parties contented that the complainant provided only few documents for verification when considering their claim.  The 2^nd complainant was having fibromyalgia since 2010 and the said disease was suppressed at the time of taking the policy.  It is also contended that the complainant did not file any claim before the opposite party but only claim the cashless request.  Upon receipt of the document it was noted that as per the records of the Bharath Hospital the 2^nd complainant had a history of fibromyalgia since 2010,thereby the claim was repudiated.  The complainant is bound rely the terms and conditions of the policy.  If the complainants have any objection with regard to the policy condition they would have get an option to cancel the policy within 15 days of  receipt of this policy.  It is find that the complainant suppressed the material fact so that the opposite party have every right to cancel the policy.  The opposite parties have no liability to reimburse the medical expense claimed by the complainant.  Therefore opposite parties prayed to dismiss the complaint with costs.

          On the basis of the complaint, version and records before us we framed the following issues for consideration.

1. Whether the complaint is maintainable before the Forum?
2. Whether the opposite parties are committed any deficiency in service as alleged by the complainant?
3. Regarding relief and costs?

The case of the complainant consists of the proof affidavit filed by the 1^st complainant in lieu of his chief examination and  marked Ext.A1 to A5.  Ext.  A1 is the copy of insurance policy.  Ext.A2 is the copy of discharge summary.  Ext.A3 series is the copy of bills.  Ext.A4 is the copy of termination notice dtd.4/8/16.  Ext.A5 is the copy of lawyer’s notice dtd 17/8/16,  Ext.A5(a) is the postal receipt and Ext.A5(b) is the postal receipt.  Ext.A5(c) is the AD card.  Apart from the proof affidavit of the complainant one Dr. Sreekumar B, Bharath Hospital is also examined as PW1.  Through him the case sheet of the complainant related to the Bharath Hospital treatment is marked as Ext.X1.  On the other side the opposite party 1’s Senior Vice President Legal & Appollo Munich Health Insurance Company Ltd- Deepthi Rustagi who filed a proof affidavit and marked Ext.B1 to B7 in their favour.  Ext.B1 is the copy of the certificate issued by Bharath Hospital.  Ext.B2 is the copy of certificated issued by Bharath Hospital.  Ext.B3 is the copy of proposal form.  Ext.B4 is the copy of policy with terms and conditions.  Ext.B5 is the copy of pre-authorisation form.  Ext.B6 is the copy of the cashless rejection letter.  Ext.B7 is the copy of termination letter dated 4/8/16 and cancellation letter.  Apart from the proof affidavit of opposite party they filed another additional proof affidavit and marked Ext.B8 in their favour.  Ext.B8 is the medical documents of the complainant issued by Bharath Hospital.  After the closure of evidence we heard both sides.

Point No.1

          The opposite parties contented that the case is not maintainable either in law or on facts.  When we look into the evidence of this case it is revealed that the 1^st complainant who availed the health insurance scheme from the opposite parties for his family members and also find that the policy was in force at the time of claiming reimbursement.  Therefore we can easily come to a conclusion that the complainant’s are consumers of the opposite parties and the opposite parties are service providers of the complainants.  Hence  Point No.1 found in favour of the complainant.

Point No.2 and 3

          The case of the complainant is that he and his family availed a health insurance policy from the opposite parties by paying a total premium of Rs.12,286/- to the opposite party and at the time of claiming the reimbursement the said policy was in inforce.  In order to substantiate this contention to complainant  produced and marked copy of health insurance policy as Ext.A1.  When we verified the policy certificate we can find  that the policy was valid from 26/5/16 to 25/5/17.  The 2^nd complainant met with a motor accident on 29/7/16 and admitted in Bharath Hospital related to a fracture happened to her left knee.  The said date is within the valid period of the insurance policy.  As per Ext.A2 the discharge summary which shows that the 2^nd complainant suffered left tibial plateau fracture on her leg.  When we verify Ext.A3 series bill we can found that an amount of Rs.55130.54/- was spent by the complainants for the said treatment at Bharath Hospital.  Ext.A4 is the termination letter issued by the opposite party against the complainant on 4/8/16.  When we go through Ext.A4 we can see that the opposite party repudiated the claim of the complainants and also terminated the policy against the complainant.  Ext.A5 is the copy of the Advocate notice issued by the complainant against the opposite parties and Ext.A5(a) and(b) are the postal receipts and A.D card of Ext.A5.

          On the basis of the above evidence adduced by the complainant the main question to be considered is whether the opposite parties have any right to repudiate the cashless claim of the opposite party by raising the contention of suppression of pre-existing disease fibromyalgia.  The opposite parties seriously contented that when the complainant availing the policy he suppressed this fact in the proposal form.  When an insured is filing proposal form the opposite parties are normally demanding the medical certificate from the insured and only after verifying the medical certificate the insurer admit the insured in any insurance scheme.  There is no record before us to verify these facts or not even a suggestion from the opposite parties with regard to this material aspect.  Apart from the evidence of the complainant they examined Dr. Sreekumar B as PW1 in this case.  He is the doctor of Bharath Hospital who produced original case sheet of 2^nd complainant before this Forum and marked it as X1.  According to him the wife of the complainant was admitted in his hospital on 30/7/16 and on 1/8/16 surgery done on her.  In a question in chief he deposed  ‘surgery sNbvX Ime-b-f-hn patient \v fibromyalgia F¶ AkpJw D­m-bn-cp-¶-Xmbn Ext.X1 þ ImWp-¶p-t­m( Q)(A) CÃ. Fibromylagia bv¡v treatment Fs´-¦nepw FSp-¯n-cp-¶-¶-Xm-bn-X1þ ImWp-¶p-t­m( Q)( A)-C-Ã.  Fibromylagia F¶Xv Nn¡³ Kp\n-b, viral fever F¶n-h-sbms¡ hcp-t¼mÄ D­m-Ip¶ Hcp side effect AsÃ?(Q)(A) Fibromyalgia F¶-Xv Hcp Ah-Ø-bm-Wv, witness adds CXv Hcp Akp-J-a-Ã, ]\n-sbms¡ D­m-Ip-t¼mÄ AXnsâ IqsS D­m-Ip¶ Hcp \ocm-Wv.  hmXw t]mes¯ Hcp condition BWv   According to the testimony of the PW1 we can come to a conclusion that fibromyalgia is not a disease but it is a state of condition of a side effect of certain disease like chickenguniya, viral fever etc.  It is true that in cross examination he admitted Ext.B1 and B2 document.  Ext.B1 is a certificate issued from Bharath Hospital which shows that the complainant No.2 wife of complainant who suffered fracture of her left knee as a result of a motor accident.  Ext.B2 is an another certificate issued by the Administrative Medical Officer Dr. Vinood Viswanathan.  The said Ext.B2 was marked subject to proof.  So there is no need of going to the relevancy of Ext.B2 at this stage.  The opposite parties failed to prove  Ext.B2 before this Forum.  Ext.B3 is the proposal form filed by complainant No.1 infavour of opposite parties.  When we verify Ext.B3 we cannot see any mentioning with regard to any of the diseases.  Ext.B4 is the copy of the policy along with the terms and conditions.  When we verify the terms and conditions in Ext.B4 we cannot see any signature or any mode of acceptance of the said terms and conditions by the 1^st insured-1^st complainant.  Ext.B5 is the pre-authorisation form produced by the opposite party.  When we verify Ext.B5 we are not in a position to see that this pre-authorization (Ext.B5) form was filled up by the complainant.  There is no verification or signature of the complainant could have been  seen in Ext.B5.  So it is an incomplete pre-authorization form.  Ext.B6 is the copy of the denial of cashless payment to the complainant.  The suppression of history of fibromyalgia in 2010 was the reason for the repudiation.  Ext.B7 is the copy of a letter of termination of the said policy.  The said letter was also issued alleging the suppression of material fact as stated above.  Ext.B8 is the copy of the medical record issued by Bharath Hospital(Ext.B8 and Ext.X1 are one and the same)  The said Ext.B8 is a self attested true copy of the Medical records issued by Dr. Vinod Viswanathan, Administrative Medical Officer of Bharath Hospital Kottayam.  This Ext.B8 was marked in the light of the additional proof affidavit filed by Deepti Rustagi, Senior Vice President Legal & Compliance of Appollo Munich Health Insurance Company Limited for and on behalf of the opposite parties.   On the basis of above evidence the main contention of the opposite parties which shows that the complainant suppressed the material fact ‘fibromyalgia’ at the time of filing the proposal form.  It is true that the complainant did not mention the said fact in the proposal form.  According to the opposite parties the suppression of the above fact is only  a reason for the repudiation of the cashless claim of the complainant and subsequent cancelation of the policy.  As discussed earlier PW1 Dr. Sreekumar B who categorically deposed before this Forum to the effect that the said fibromyalgia is not at all a disease and the said fibromyalgia is only a state of condition and it happened only as a side effect of chicken guniya, viral fever etc.etc.    Though the opposite party cross examined about this aspect nothing brought out to discard the said opinion of the PW1.  If so we can find that fibromyalgia is not at all a disease thereby we are not in a position to blame the complainant with regard to the suppression of that fact in the proposal form of the insurance policy.  A person who is avail an insurance policy by believing the words of the insurance company for facing unforeseen incidents.    Here when the complainant was possessing a valid insurance policy her wife met with an accident and spend Rs. 60,000/- for the subsequent treatment.  All these facts are proved by the complainants with cogent and conclusive evidence.  Though the opposite parties strongly opposed the contention of the complainants by way of evidence on records they did not succeed to rebut the contention of the complainant.  Therefore we would like to allow the complaint and also find that opposite party 2 is the branch manager of opposite party 1 (the head office of opposite party 2).  Hence, opposite party 1 and opposite party 2 are jointly and severally liable to the complainant.  Hence Point No.2 and 3 found in favour of the complainant.

          In the result we pass the following orders.

1. Opposite party 1 and opposite party 2 are hereby directed to reimburse the medical expense of Rs.55130/-(as per Ext.A3)(Rupees Fifty five thousand one hundred and thirty) to the complainant with 10% interest from the date of filing of this case ie 21/11/16
2. Opposite parties are also directed to renew the insurance policy of the complainant with a liberty to receive the necessary premium and renewal fees if any from the 1^st complainant.
3. Opposite parties are also directed to pay a compensation of Rs.10,000/-(Rupees Ten thousand) along with a cost of Rs.2500/-(Rupees Two thousand Five hundred) to the complainant with 10% interest from the date of receipt of order onwards.

Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Forum on this the 13^th  day of December 2018.

                                                                             Sd/-

              Sri. P.SatheeshChandran Nair,

                         ( President)

 Sri. K.N. Radhakrishnan, Member               Sd/-

           Smt. Renu.P.Gopalan, Member                            Sd/-

Appendix

Witness examined on the side of complainant

PW1-Dr.Sreekumar B

Exhibits marked on the side of the complainant

Ext.  A1 - copy of insurance policy.

 Ext.A2 -copy of discharge summary. 

Ext.A3 series - copy of bills.

 Ext.A4 - copy of termination notice dtd.4/8/16.

 Ext.A5 - copy of lawyer’s notice dtd 17/8/16, 

Ext.A5(a) - postal receipt

Ext.A5(b) - postal receipt. 

Ext.A5(c) - AD card

Exhibits marked on the side of the opposite parties

Ext.B1 - copy of the certificate issued by Bharath Hospital. 

Ext.B2 - copy of certificated issued by Bharath Hospital. 

Ext.B3 - copy of proposal form.

 Ext.B4 - copy of policy with terms and conditions. 

Ext.B5 - copy of pre-authorization form. 

Ext.B6 - copy of the cashless rejection letter. 

Ext.B7 - copy of termination letter dated 4/8/16 and cancellation letter..

 Ext.B8 -copy of medical documents the complainant issued from Bharath

               Hospital.

Court Exhibit

Ext.X1-Medical Record

By Order,

Senior Superintendent.

Copy to: 1)Mathew K.I,Kattuvallil House,Manarcadu PO,Kottayam.

              2)Bindu Mathew,Kattuvallil House,Manarcadu PO,Kottayam.

    3)Appollo Munich Health Insurance Co.Ltd., Appollo Hospaital Complex

     Jubilee Hills, Hyderabad-500033, Andra Pradesh.

 4)The Manager, Regional Office,   Appollo Health Insurance Co.Ltd

    Uznaz Tower, 5^th floor, Pallimukkkku,   Opp.Medical Trust Hospital,

               M.G.Road, Cochin 682016

           5)  S.F