BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MYSORE-570023

CONSUMER COMPLAINT NO.21/2018

DATED ON THIS THE 11^th January 2023

Present:      1) Sri. B.Narayanappa

M.A., LL.B., - PRESIDENT  

                     2) Smt.Lalitha.M.K.,

M.A., B.A.L., LL.B., - MEMBER  

                        3) Sri Maruthi Vaddar,

                                                B.A., LLB (Special)  - MEMBER

Sri MARUTHI VADDAR,

MEMBER

This complaint has been brought under Section 12 of the erstwhile C.P.Act, 1986 by the complainant Basavaraju.P., resident of Mysuru alleging deficiency in service against the opposite parties directing the opposite parties to pay Rs.3,54,078/- expenditure towards hospital charges and Rs.50,000/- towards financial loss and Rs.2,00,000/- towards mental and physical torture and Rs.5,000/- towards cost of this proceedings.

2. The brief facts of the complaint in a nutshell is as here under:-

It is alleged in the complaint that, the complainant being the medical insurance group policy holder of the opposite parties since from 02.05.2017 bearing policy No.OG-18-1000-6021-00005208, starting from 02.05.2017 to 01.05.2018.  The said policy includes the family members of the complainant i.e. himself, his wife and a child. The opposite parties liable to pay to Rs.10,00,000/- money to the family members of the complainant if they hospitalized for any disease. The opposite parties used to recover the monthly premium from the complainant. But, on 01.06.2017 the daughter of the complainant got her blood tested on the advice of the Apollo Hospital doctor and later it came to know that his             daughter was suffering from blood cancer i.e. A.L.L. (Acute Lymphocytic Leukemia).  On 01.06.2017 the said kid was admitted as in-patient at Bharath Hospital and took the treatment.  After enquiry he came to know that the said hospital was not facilitated with opposite parties and immediately complainant went to 2^nd opposite party branch and enquired regarding the subject who told to come along with bills having incurred one month hospital bill and assured to made payment for every month bill.

It is further alleged that as per the assurance of the opposite parties, the complainant has given all the bills to the office of 2^nd opposite party.After receipt of the bills, the opposite parties assured to deposit directly to the complainant account within 10 days after verification.But, on 12.08.2017, the opposite parties sent a notice to mention “three points” then the complainant has mentioned the three points and sent the same to opposite parties.On 13.10.2017 the opposite parties sent another notice repudiating the claim stating that within 30 days from the date of issuance of the policy, claim cannot be given.As per the policy, it commenced from 02.05.2017 to 01.05.2018 but 30 days have been completed from 02.05.2017 to 31.05.2017 and 31^st day started from 01.06.2017, without giving hospital expenses that the complainant incurred, the opposite parties rejected the same.Hence, this complaint.

3. After the registration of the complaint, notices were ordered to be issued to the opposite parties, in pursuance of the notices, opposite party No.1 did not appeared, hence placed exparte. The opposite party No.2 was appeared through its counsel and filed written version stating that the 2^nd opposite party has denied all the allegations of the complaint paras and further stated that it is well settled law that when the voluminous evidence and complicated questions are involved in the Consumer complaint, the better course is to direct the complainant to approach the Civil Court to get the grievance resolved by leading cogent, oral and documentary evidence.  This 2^nd opposite party admits about the complainant taking mediclaim insurance policy No.OG-18-1000-6021-00005208 valid from 02.05.2017 to 01.05.2018 and has provided the said mediclaim insurance cover subject to specific terms and conditions as stipulated in the insurance policy.  The insurance policy does not cover any pre-existing ailments or complications arising out of pre-existing ailments or any claim within 30 days from its inception except medical expenses incurred out of any accidental.

It is further contended that the complainant submitted a claim form dated 01.07.2017 and preferred a claim of reimbursement of the medical expenses incurred towards the treatment given to his daughter Disha.On scrutiny of the claim papers, it was observed that his daughter was diagnosed for Acute Lymphoblastic Leukemia and she has taken treatment at HCG Bharath Hospital and institution of Oncology, Mysuru from 01.06.2017 to 03.06.2017 and hence the 2^nd opposite party come to a conclusion that the claim is not payable as the same falls under the exclusion of the policy and thus the 2^nd opposite party repudiated the claim by its letter dated 28.09.2017.Hence, the complainant is not entitled to the claim of Rs.3,54,078/- towards medical expenses, Rs.50,000/- towards financial loss and Rs.2,00,000/- towards physical and mental agony and Rs.5,000/- towards the cost of the proceedings, there is no deficiency of service on the part of the 2^nd opposite party, hence the complaint is not maintainable and is liable to be dismissed.

4. The complainant has filed the affidavit towards his chief-examination and the same was taken as P.W. 1 and got marked the documents as Ex.P.1 to Ex.35.  On the other hand, the 2^nd opposite party has also filed its affidavit towards its chief-examination and the same is taken as R.W.1 and did not chose to mark any documents.
5. The points that would arise for our consideration are as here under:-  

1. Whether the complainant proves the alleged deficiency in service on the part of the opposite parties and thereby he is entitled to the reliefs as sought for?
2.  What order?

6. Our findings on the aforesaid points are as follows:

      Point No.1 :- Partly in the affirmative.

      Point No.2 :- As per final order for the following

:: R E A S O N S ::

7. Point No.1:- To demonstrate the allegation carved out in his complaint, the complainant has been examined himself as P.W.1 by filing his affidavit towards his chief examination and got marked the documents as Ex.P.1 to Ex.P.35. The complainant has reiterated the averments of the complaint in his chief affidavit.  Ex.P.1 is the copy of the mediclaim policy.  Ex.P.2 is the letter issued by opposite parties.  Ex.P.3 is the letter issued by opposite parties. Ex.P.4 is the letter issued by Apollo BGS Hospital.  Ex.P.5 is the letter issued by Bharath Hospital.  Ex.P.6 and 7 are the registered post covers.  Ex.P.8 is the copy of Apollo BGS Hospital.  Ex.P.9 to 11 are the pathology report of Apollo BGS Hospital.  Ex.P.12 is the discharge summary of Bharath Hospital dated 03.06.2017.  Ex.P.13 is the discharge summary of Bharath Hospital dated 09.06.2017.  Ex.P.14 is the discharge summary dated 28.07.2017.  Ex.P.15 is the discharge summary dated 26.10.2017.  Ex.P.16 is the discharge summary dated 09.11.2017.  Ex.P.17 is the discharge summary dated 05.12.2017.  Ex.P.18 is the discharge summary dated 21.12.2017.  Ex.P.19 is the discharge summary dated 27.09.2017.  Ex.P.20 is the discharge summary dated 12.10.2017.  Ex.P.21 is the cash bill.  Ex.P.22 is the bill cum receipt. Ex.P.23 is the cash bill.  Ex.P.24 and 25 receipts and Ex.P.26 to Ex.P.35 are cash cum receipt bills.  After the testimony of the complainant, the 2^nd opposite party has also filed its chief affidavit towards its chief examination and did not marked any documents.  After the evidence of both parties, only the complainant has addressed his arguments but in spite of giving sufficient opportunities the 2^nd opposite party has not submitted its arguments.  After perusing carefully, the pleadings and documents put forth by both the parties, it is noticed that the complainant has obtained the mediclaim policy from the opposite parties covering himself and his family members which was valid from 02.05.2017 to 01.05.2018 bearing policy No.OG-18-1000-6021-00005208.  But, it is the specific allegation of the complainant that his daughter B.S.Disha was admitted on 01.06.2017 for blood cancer ALL (Acute Lymphocytic Leukemia in Bharath Hospital and after information, the said hospital was not facilitated by the opposite parties company.  The complainant inquired the 2^nd opposite party who told to bring the entire bills of the expenses of a particular month and accordingly, the complainant submitted the necessary bills to the opposite parties.  But, the opposite parties rejected the claim stating that within 30 days from taking the policy the claim is preferred.  As per the complainant already 30 days have been expired i.e. from 02.05.2017 to 31.05.2017 and 31^st day was starting from 01.06.2017 on which day his daughter was admitted to hospital and hence, prayed to honour the claim.
8. After going through the rival contention of both parties, it is not disputed that the complainant has obtained mediclaim policy from opposite parties covering himself, his wife and his daughter and the same was confirmed while perusing the policy which depicts about group health and the liability covered is “in patient hospitalization indemnity policy” sum assured Rs.10,00,000/-, number of persons: Self + spouse + 1 child.  After perusing the policy, it is noticed that there is exclusion clause which stated that “Any disease contracted and / or medical expenses insured in respect of any disease/illness by the insured during the first 30 days from the commencement of the policy except for accidental injuries”.  It is also such contention of the 2^nd opposite party in page No.8 of version.  But, according to the complainant, the period of 30 days have been completed from 02.05.2017 to 31.05.2017 and 31^st day was commencing from 01.06.2017 on that date the daughter of the complainant was admitted and took treatment by incurring expenses to the tune of Rs.3,54,078/- and hence the opposite parties liable to pay the same.  After looking into the contention of both parties, the contention taken by the 2^nd opposite party in page 8 of its version is not acceptable as the complainant daughter was admitted on 01.06.2017 i.e. on 31^st day from the commencement of the policy. By taking into consideration of admissible and inadmissible medical bills, we are of the opinion that it is just and proper to direct the opposite parties to pay Rs.3,00,000/- towards medical expenses. Hence, the opposite parties are held liable to pay Rs3,00,000/- under the insurance policy of the complainant. Hence, the complainant has partly proved his case against the opposite parties alleging deficiency of service within the meaning of Section 2(11) of the C.P.Act, 2019.  Hence, we answered the point No.1 in the partly affirmative.    

6. Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

1. The complaint of the complainant is allowed in part.
2. The opposite party Nos.1 and 2 are jointly and severally liable to pay Rs.3,00,000/- to the complainant towards medical expenses incurred with 6% interest p.a. from the date of repudiation of the claim till date within two month from the date of this order.
3. The opposite party Nos.1 and 2 are also hereby liable to pay Rs.10,000/- towards mental and physical torture and Rs.5,000/- towards the cost of the litigation to the complainant within 2 months from the date of this order failing which opposite parties are liable to pay the claim amount of Rs.3,00,000/- + Rs.10,000/- towards causing mental and physical torture + Rs.5,000/- as cost of litigation with 10% p.a. interest till payment.
4. The complainant is at liberty to take necessary legal action, under Section 72 of C.P.Act for non-compliance the order by the opposite parties.
5. Furnish the copy of order to both parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Commission on this the 11^th January 2023)