Date of Filing: 01-02-2017
Date of Order:04 -11-2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B., PRESIDENT
HON’BLE Sri K.RAM MOHAN, B.Sc. M.A L.L.B., MALE MEMBER
HON’BLE Smt. CH. LAKSHMI PRASANNA, B.Sc. LLM., LADY MEMBER
Monday, the 4th day of November, 2019
C.C.No.103 /2017
Between
Karnela Venkata Siva Prasad,
S/o.K.Ranga Rao
Age: 33 years, Occ: Pvt Employee,
R/o.H.No.7-2-49/A/7/1, Ashok Colony,
Sanath Nagar, Near Sanath Nagar Bus stop,
Pin – 500018, Telangana State ……Complainant
And
- Bajaj Allianz General Insurance Company Ltd.,
Rep. by M.D
G.E.Plaza, Airport Road Yerwada
Pune – 411006, India Head office
- Bajaj Allianz General Insurance company Ltd
Health Administration Team
Rep. by Administrative Manager
2nd floor Bajaj Finsevu Building Servay No.208/B,
Behind Weikied IT Park Off, Viman Nagar Road,
Pune – 411014
- Prime Hospital
Reg by its Authorized officer
Plot No.4 Behind Mythrivanam
Building Ameerpet, Hyderabad – 500038
- Prime Hospitals Branch Hospital
A unit of Sri Sainath multispecialty hospitals Pvt.Ltd.,
MIG 113 And 114, Road No.1, KPHB colony,
Kukatpally, Hyderabad – 500072 ….Opposite Parties
Counsel for the complainant : M/s. G.Mallesh
Counsel for the opposite Party No.1 &2 : Mr. S.Pramod Kumar
opposite Party No.3 &4 : Absent
O R D E R
(By Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint has been preferred under Section 12 of C.P. Act 1986 alleging that opposite party No.1&2 repudiated the claim unreasonably on the writing of opposite party No.3&4 and thereby opposite parties have caused deficiency of service hence a direction to opposite party No.1&2 to award a sum of Rs.2,00,000/- with interest at 24% P.A towards medical insurance policy and Rs.5,00,000/- as compensation for causing hardship and a direction to opposite party No.3 &4 to pay damages of Rs.5,00,000/- for the inconvenience caused to the complainant by filing in correct information with opposite party No.1&2 and also to award cost of this complaint.
- The complaint averments in brief are that the opposite party No.1&2 are the insurance companies and the complainant obtained individual health policy on 16-7-2015 covering the period from 16-7-2015 to 15-7-2016. At the time of issuing the policy the opposite party No.1&2 have checked the health condition of the complainant and satisfied with his health as perfect and issued the policy. The policy covers the expenses for Ambulance, checkup and other incidental expenses.
On 17-8-2015 about 8.00PM complainant had sudden fall while watching TV. Immediately his neighbors called his family members and shifted him to nearby clinic and on the advice of doctor at the clinic he was taken to opposite party No.3 &4 hospitals at about 10.30PM. He was advised for immediate surgery. For the treatment period of 17-08-2015 to 21-8-2015 hospital raised a bill for a total sum of Rs.56,730/-. A surgery was conducted and the amounts spent for it Rs.2,86,730/- and same was paid. Later he was informed by the doctors that second surgery is also needed and accordingly 2nd surgery was conducted on 3-11-2015 and the amounts spent for it was Rs.93,867/- and after remaining in the hospital he was discharged on 6-11-2015 in stable condition. Thus the total amount spent for two surgeries in the hospital of opposite party No.3 & 4 was Rs.3,80,597/- which amount was raised by him by way of hand loans from friends and relations.
The concerned authorities at opposite party No.3 & 4 hospital without enquiring the complainant’s family members and confirmation have written wrong report that complainant was suffering with hypertension and diabetes since four months which is totally in correct. A friend of the complainant by name Mr. Rajesh stated to have informed the hospital authorities that the complainant was suffering with hyper tension and diabetes for four months. The said Rajesh is not a family member of the complainant and not aware of the complainant’s health condition before his hospitalization. As such the said information furnished by Rajesh is not true. Basing on the said information furnished by opposite party No.3 &4 hospital the medical claim of the complainant was rejected by opposite party No.1 &2 stating that complainant has not disclosed that he was suffering with hypertension and diabetes in the proposal form furnished for obtaining the policy. The opposite party No.3 & 4 hospitals colluded with the opposite party No.1 &2 insurance companies to cause loss to the complainant. The complainant approached the opposite party No.3 & 4 hospital and informed that he was not having any illness or prior hospitalization. Thereupon the hospital authorities after going through the medical record issued a letter rectifying the mistakes on 25-1-2016. The complainant is suffering with health problems post operation. There is inflammation and swelling on the right side of forehead and the operations conducted was partially successful and he was not informed of post operation health problems by opposite party No.3&4 hospitals who assured of 100% success of surgeries. Thus there is deficiency of service on the part of the opposite party No.3 &4 in treating him and opposite party No. 1&2 have an un reasonably rejected the claim. Hence the present complaint for the above stated reliefs.
- Opposite party No.3&4 despite service of notice of the complaint did not appear.
- Opposite party No.1& 2 alone appeared and filed a common written version admitting issuance of the policy to the complainant but denied the allegation of deficiency of service on their part.
The stand taken by opposite party No.1& 2 in the written version is that after submission of the claim by the complainant it was processed and appointed an investigator who submitted the report stating that the complainant has been suffering with diabetes and Hypertension for four months prior to the consultation on 17-8-2015 which is pre-existing of the policy. The policy was issued to the complainant in July 2015 whereas he has been suffering from diabetes and Hypertension from April –May 2015 and same was suppressed by the complainant in the proposal form. The investigator after collecting necessary information submitted the report. The claim documents submitted by the complainant revealed that the complainant was hospitalized for treatment of Cerobro Vascular accident left Hemiparesis and it is known case of diabetes and Hypertension since four months from the date of consultation on 17-8-2015. Since the complainant has not disclosed his pre existing ailment and suppressed the same while submitting the proposal form hence the claim was rejected and communicated to the complainant.
The policy issued to the complainant contains terms, conditions and exclusions. Clause one exclusion reads that benefits will not be available for any pre-existing condition, ailment or injury until 48 months of continuous coverage have elapsed after the inception of the first health guard policy with the company. This exclusion shall cease to apply if the complainant maintained a health guard policy with the company for a continuous period of a full four years without break from the date of first health guard policy with the company.
The complainant with a malafied intention got issued a legal notice and he was informed of the reasons for repudiating the clam. The repudiation of the claim is in terms of policy conditions and exclusions which are binding on the complainant. Hence there is no deficiency of service on the part of the complainant and complaint is deserved to be dismissed.
In the enquiry the complainant got filed his evidence affidavit reiterating the material facts narrated in the complaint. He got exhibited Fifty four (54) documents. Similarly for the Opposite Parties evidence affidavit of their Senior Executives is got filed and the substance of the same is in line with the defense taken in the written version. Five (5) documents are exhibited for opposite party No.1&2. Both sides have filed written arguments.
On a consideration of the material brought on record by the complainant and as well as opposite party No.1&2 the following points have arose for consideration:
- Whether the complainant could be able to substantiate deficiency of service on the part of the opposite party 1&2 in dealing with the subject policy ?
- Whether the complainant is entitled for the amounts claimed in the complaint?
- To what relief ?
Point No.1: The documents placed on record by the complainant are relating to his medical bills, prescriptions etc for treatment undergone by him in opposite party no.3&4 hospital which are not being disputed by opposite parties. Similarly the documents filed for opposite party No.1&2 consist of policy document, letter of intimation repudiating the claim , the report of investigator appointed by the company to investigate the claim of the complainant and a C.D stated to have contained the conversation and these documents are also not in dispute. In the light of it now it is to be seen that material on the record reveals deficiency of service on the part of the opposite parties 1 to 4.
Complainant’s case of his admission in the opposite party No.3& 4 hospital when he had a sudden fall at his house and subsequent treatments are not being disputed by opposite parties 1&2. Complainant himself specifically mentioned that one Mr.Rajesh who is a neighbor of him stated to have intimated to the hospital authorities while attending him that he has been suffering with Hypertension and diabetes for four months before admission in the hospital. But the said Rajesh has no knowledge of his health condition earlier to admission in the hospital and this fact was brought to the notice of opposite party No.3 & 4 hospitals who stated to have rectified the said information furnished by Rajesh. But the record relating to it is not filed here. The complainant also has not filed the affidavit of said Mr.Rajesh stating that he has no knowledge of complainant’s health condition prior to admission in the opposite party No.3 hospital. In the absence of it a self serving statement of the complainant that wrong information was furnished in the opposite party No.3 hospital either by said Rajesh or any other neighbor of him who stated to have shifted him in the hospital cannot be taken as sacrosanct. The opposite parties have also filed the evidence affidavit of one Kaleru Santosh working as investigating officer in Truth Mining, Claims Investigation & Allied services and was appointed as investigator in the subject matter by opposite party. His evidence affidavit shows he investigated the matter by verifying hospital records and statements given by concerned and found that complainant was suffering with HTN and DM both are pre-existing as the policy inception is July as per Aug ICP HTN and DM since four months which means the complainant is diabetic and hypertensive since April – May 2015 which proves pre-existence. The detailed information provided to him at the hospital was submitted to the insurance company and the said investigation report is placed on record by the opposite parties. Thus the documentary evidence placed on record by the opposite parties clearly proved that the complainant is a known case of hypertension and diabetes from April- May 2015 but he suppressed the same in the proposal form submitted to opposite party No.1 &2 in the month of July 2015 for obtaining subject policy. Health policy is contract between the parties the terms and conditions there in are binding on them. Under the exclusion clause the policy will not cover a pre-existing ailment or disease as such the repudiation of the claim by the opposite party No.1&2 is in terms of exclusion clause in the subject policy and it does not amounts to deficiency of service. Accordingly point is answered.
Point No.2: In view of above findings it is to follow that the complainant is not entitled for the amounts claimed in the complaint.
Point No.3: In the result, the complaint is dismissed. No order as to costs.
Dictated to steno, transcribed and typed by her, pronounced by us on this the 4th day of November , 2019
LADYMEMBER MALEMEMBER PRESIDENT
APPENDIX OF EVIDENCE
Exs. filed on behalf of the Complainant:
Ex.A1-Bajaj Allianz Policy issued on 16-7-2015
Ex.A2-receipt for an amount of Rs.5,000/- dated 17-8-2015
Ex.A3- First operation bill of Rs.1,00,000/- dated 21-08-2015
Ex.A4-First operation bill of Rs.21,730/- dated 21-8-2015
Ex.A5- First operation bill of Rs.30,000/- dated 21-08-2015
Ex.A6- First operation bill of Rs.20,000/- dated 21-08-2105
Ex.A7- to A26 copy of bills and advance receipts in various dates and amounts
Ex.A27 – copy of emergency certificate dt.1-10-2015
Ex.A28- discharge summary
Ex.A29- Lama admitted date 17-08-2015
Ex.A30- Department of Radiology C.T.Scan Brain plain
Ex.A31- Essentially certificate
Ex.A32 to A44 – copy of bills in various dates and amounts
Ex.A45- discharge summary
Ex.A46 -letter dated 29-01-2016
Ex.A47- Miscellaneous bill dated 13-01-2016
Ex.A48- LAMA, duplicate pages 1 to 61
Ex.A49- legal notice dated 17-11-2016
Ex.A50- RPAD with acknowledgments dated 18-11-2016
Ex.A51- acknowledgment card
Ex.A52- reply notice dated 14-12-2016
Ex.A53- reply notice cover
Ex.A54- email correspondence
Exs. filed on behalf of the Opposite party
Ex.B1 – copy of policy schedule
Ex.B2- repudiation letter 06-01-2016
Ex.B3- C.D
Ex.B4- Investigation report
Ex.B5- medical documents
LADYMEMBER MALEMEMBER PRESIDENT
