DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the  30^th   day of August 2017

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P.  Member                                 Date of filing:  16/12/2016

               : Sri.V.P.Anantha Narayanan, Member

                                                      (C.C.No.200/2016)

Sunny George,

S/o P.J.Varkey,

Pulikkathazhe, Kottappuram PO,

Palakakd. 679 513                                                   -        Complainant

(Adv.John John)

 V/s

1.  Appolo Munich Health Insurance Co. Ltd,           

     Ground Floor, Srinilaya, Cyber Spazio,

     Road No. 2, Banjara Hills, Hyderabad,

     500 034.    

2.  Rep. By Manager,

     M/s Canara Bank, Door No. 7/289,

     Main Road, Sreekrishnapuram,

     Palakkad.                                                          -        Opposite parties

(Adv.Shaji Isaac.K.J)

O R D E R

By Smt.Suma.K.P. Member

The complainant is a Policy Holder of a Health Insurance Policy No.120100/12001/2013/A003282 under Health Insurance Schemes of Opposite party No.1.  He subscribed the same through Opposite Party No.2.  All the formalities were compiled by the complainant and submitted to 2^nd Opposite party.  The policy covers the medical expenses of the subscriber.

The complainant was affected by Intermittent Fever and Cough and got admitted as an In-Patient on 23.02.2015 as PVS Memorial Hospital, Kaloor, Cochin.  His illness was diagnosed as Liver Disease with Hypertension and Lower Respiratory Tract Infection and was treated for the said ailment for five days as in-patient and was discharged on 28.02.2015.

The complainant incurred an expense of Rs.52,434/- for the treatment.  The complainant preferred a reimbursement claim ID No.273918/1 to 1^st opposite party through 2^nd party on 28.04.2015.  The complainant submitted all relevant documents in original, required for processing the claim through the 2^nd opposite party.  The 1^st Opposite party issued a letter on 26.05.2016 acknowledging the receipt of the claim and called for documents to process the claim.  The complainant despatched the same immediately. 

As subscriber of a valid Health Insurance Policy, the complainant is eligible to receive re-imbursement of all the medical expenses incurred by him for his treatment.  Instead of honouring the claim of the complainant, the 1^st  opposite party put so many queries and called for several documents repeatedly.  The complainant answered all queries and sent copies of all the documents to the 1^st  opposite party whenever it was called upon.  Though the process went on several times, the claim was not honoured.  Repeated reminders were issued by the complainant to which the first opposite party sent a letter dated. 12.08.2015 again calling for two more documents.  The complainant despatched the same with a request for early disbursement of the claim.  But finally, 1^st opposite party rejected the claim of the complainant stating that the complaint has been closed.  That act of the first opposite party was against the Law and amounts to deficiency of service.  As subscriber of a valid and existing policy, the complainant is entitled to reimbursement of the expenses incurred in treatment.  But the 1st opposite party wrongfully repudiated the claim showing untenable reasons. 

On 22.12.2015 the complainant issued a lawyer notice claiming reimbursement of Rs.52,434/- the actual amount sent for the treatment for which the opposite party issued a reply stating that the claim is not admissible in terms of policy.  Hence the complainant has approached before this Forum seeking an order directing the opposite parties to pay an amount of Rs.1,02,434/- (Rupees One Lakh two thousand four hundred and thirty four only) to the complainant as medical expenses along with  compensation with 12 % Interest till realization along with cost. 

Notice was issued to the opposite parties for appearance.  1^st opposite party entered appearance and filed their respective version.  2^nd opposite party remained absent inspite of accepting notice.  Hence he was called absent and sent ex-parte.  

1^st opposite party contended that the complainant was a known case of diabetes mellitus and hypertension since the last 10 years.  The complainant himself has admitted the fact of his hypertensive medical ailment in paragraph 2 of the complaint.  He was on regular medication since the last 10 years and had obtained the Insurance Policy from the 1^st opposite party by willfully suppressing material facts.  The complainant had answered in the negative to the specific questions in the proposal form pertaining to the health condition of the insured persons and had specifically stated the insured persons have not suffered in the last 5 years from any major disease/disorder/ailment or deformity.  The complainant was given the policy on the  premium which he had paid based on the information disclosed by the complainant.  The complainant had also declared in the proposal form that the statements and answers given were true and complete in all respects.  The complainant had sought treatment for chronic liver disease and also for esophagus varices.  Esophageal varices have direct nexus with the chronic liver disease of the complainant.  Esophageal varices are a direct result of high blood preasure in the portal vein.  This condition is called portal hypertension.  It causes blood to build up in nearby blood vessels, including those in the esophagus.  A potential cause for portal hypertension in cirrhosis.  The complainant was a known case of both portal hypertension and cirrhosis.  The policy incepted on 21.06.2014 and the said treatment was done on 23.02.2015.  It is further submitted that the 1^st opposite party has rightly repudiated the claim of the complainant as per the policy terms and conditions as the current treatment taken falls under the 1 year waiting period.  The 1^st opposite party in its best efforts to honour the claim had sought for all relevant documents from the complainant.  But the complainant had not furnished the necessary documents pertaining to his medical condition of chronic liver disease with hypertension.  Hence the cliam of the complainant could not be processed on account of willful non-disclosure of material facts, non-furnishing of necessary medical documents and also on account of the specific one year waiting period as specified in the terms and conditions of the policy.  The complainant is not entitled to any of the relief’s claimed.  The 1^st opposite party is not liable to pay Rs.1,02,434/- or interest or compensation to the complainant. 

Complainant filed chief affidavit.  Exts. A1 to A9 was marked from the side of the complainant.  1^st opposite party also filed chief affidavit.  Exts. B1 to B5 were marked from the side of the opposite party.  Evidence was closed and the matter was heard. 

The following issues that arises for consideration are.

1.Whether there is any deficiency of service from the part of opposite parties ?

2.If so what are the relief and cost?

Issues 1 & 2

          According to the opposite party in the complainant had suppressed material information which was vital in assessing the undertaking of risk by the 1^st opposite party.  The non-disclosure of facts relating to his pre existing diseases of diabetes and hypertension since, the last 10 years are material facts that have a direct bearing on the underwriting of risk by the 1^st opposite party.  According to the conditions of the policy, the opposite party is not liable to pay any claim in connection with or in respect of pre-existing disease.  The counsel for the complainant contended that complainant was hypertensive and was taking medication for the same at the time of purchase of insurance policy and since hypertension had no direct nexus with liver cirrhosis the insurance company was not justified in repudiating the claim on the basis of exclusion clause which excludes indemnification for the expenses incurred on pre-existing disease. 

          Learned counsel for the opposite party has contended that as per the terms and condition of the insurance contract, the insurance company was not required to reimburse the complainant for the expenses incurred by him on pre-existing disease. 

          We do not find merit in the above contention.  The only fact established by the opposite party is that the complainant prior to obtaining insurance policy was having history of hypertension.  This, however, does not lead to conclusion that complainant was also having previous history of cirrhosis.  The learned Counsel for the complainant had also placed a decision of our National Commission in revision petition 1/3619 of 2013 wherein our apex court has observed that hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack.  Likewise it is not necessary that a person suffering from hyper tension would always suffer from cirrhosis.  Therefore, the argument advance by the 1^st opposite party is farfetched and is liable to be rejected.

          In view of the above discussions the complaint is allowed.  The complainant had produced medical bill to the tune of Rs.52,434/- as medical expenses spent for the treatment.  Hence we direct the opposite parties jointly and severally to pay an amount of Rs.50,000/- (Rupees fifty thousand only) to the complainant for the medical expenses incurred by him along with Rs.10,000/- (Rupees ten thousand only) as compensation for the mental agony suffered by him.  Considering the facts of the above case the parties shall bear their respective cost.  

          The afore said amount shall be paid within one month from the date of receipts of this order failing which complainant will be entitled to realize interest at the rate of 9% p.a from the date of order till realization. 

Pronounced in the open court on this the 30^th   day of August 2017.

                                                                                         Sd/-

                      Shiny.P.R.

                      President 

                          Sd/-

                      Suma.K.P.

                      Member

                         Sd/-

    V.P.Anantha Narayanan

                    Member

Appendix

Exhibits marked on the side of complainant

Ext.A1  -  Photocopy of In patient Receipt No.RPN10133 dated. 28.02.2015 of PVS

               Memorial  Hospital, Kaloor, Kochi

Ext.A2   –  Photo Copy of Discharge Bill dated. 28.02.2015 of PVS Memorial

               Hospital, Kaloor, Kochi

Ext.A3   –  Photo copy of Patient Charge Details dated.28.02.2015 of PVS Memorial

               Hospital, Kaloor, Kochi

Ext.A4   –  Photo copy Discharge summary dated.28.02.2015 of PVS Memorial

               Hospital, Kaloor, Kochi

Ext.A5   –  Photo copy of letter of Acknowledgement dated. 26.05.2015 issued by the

                Opposite party No.1

Ext.A6   –  Photo copy of email sent by the complainant to 1^st opposite party

               12.08.2015

Ext.A7   –  True copy of letter (lawyer notice) sent by the Advocate of the complainant

                to 1^st opposite Party dated. 22.12.2015

Ext.A8   –  Postal acknowledgement

Ext.A9   –  Reply of notice issued by the 1^st opposite party dated. 25.07.2016

Exhibits marked on the side of Opposite parties

Ext.B1  -  Photocopy of Certificate of Insurance Health issued by 1^st opposite party to

              complainant dated. 20.06.2014

Ext.B2  -  Photocopy of Enrolment Form No. CB00054177 of Appolo Munich

Ext.B3  -  Photo copy Discharge summary dated.28.02.2015 of PVS Memorial

               Hospital, Kaloor, Kochi

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost :  

Nil