BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.1335/2016

DATED ON THIS THE 7^th December 2018

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

                     2) Sri. Devakumar.M.C.                   

                                                B.E., LLB., PGDCLP   - MEMBER

Sri. Devakumar,M.C.                           

Member

1.     The complainant filed the complaint under section 12 of the C.P.Act 1986 against the opposite party, alleging unfair trade practice and seeking a direction to pay a sum of USD 18,822.20 (Indian currency approximately Rs.12,65,000/-) being the hospital charges and a sum of Rs.2,00,000/- for the deficiency in service and mental agony and notice charges of Rs.5,000/- and cost of the proceedings Rs.20,000/-, in all a total sum of Rs.14,90,000/-together with interest at 12% from the date of claim till the date of payment with such other reliefs.
2.     The complainant obtained a policy from opposite party covering the risk for the period 15.08.2014 to 30.09.2014 with geographical coverage, on payment of Rs.7,440/- premium.  The complainant underwent treatment at Dignity Health, Mercy Hospital, Bakers field, USA, as an emergency, when she had been to USA, on 31.08.2014 and got discharged from the hospital on 01.09.2014.  The hospital authority preferred the claim with opposite party, without forwarding the necessary bills to the complainant.
3.      After lapse of about 1 ½ year i.e. on 22.02.2016, the opposite party intimated the repudiation of the claim for the reasons pre-existence of the diseases.  Several requests made, went in vain.  The complainant alleged the policy exclusion clause 2.4 and 02.04.2012 untenable in law and also amounts the deficiency in service.  The opposite party failed to reply the legal notice dated 20.06.2016.  Hence, the aggrieved filed the complaint seeking reliefs.
4.     The opposite party filed their version and submits the policy was subject to certain terms and conditions and the same excludes coverage of pre-existing ailments.  The medical records revealed the complainant was under treatment for his cardiac ailments and was consuming with Plavix and aspirin tablets for the same. The Gastro Intestinal bleeding was the result of complication involved in consumption of the said tablets.  The claim falls under exclusion clause of the policy, hence the claim of the complainant has been repudiated.  As such, there is no deficiency in service and hence prays for dismissal of the complaint.
5.     To establish the contention, both complainant and opposite party filed affidavit evidence and relied on several documents and literatures.  The complainant also got examined a doctor to establish his case.  Written arguments filed and made oral submissions.  Perusing the material on record, matter posted for orders.     
6.     The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service on the part of opposite party, for not settling the policy claims towards the treatment obtained for upper gastro intestinal bleed and thereby he is entitled for the reliefs sought?
2. What order?

7.    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 ::

8.    Point No.1:- The complainant, had takena medical insurance policy from opposite party, which provided geographical risk coverage for the period between 15.08.2014 to 30.09.2014.
9.    A sum of Rs.7,440/- was paid as premium.  The complainant suffered with upper G.I. bleed, when he went to USA during the subsistence of the policy period, and got admitted on 31.08.2014 at Dignity Health, Mercy Hospital, Bakers field, USA as an emergency and underwent an upper GI endoscopy and conservative treatment and got discharged on 01.09.2014.
10. The hospital authority not forwarded the treatment bill to the complainant, as there was insurance policy in force, but the same were forwarded to the opposite party and made the claim, which was repudiated by opposite party and intimated the same after the lapse of about 1 ½ years i.e. on 22.02.2016, on the ground of pre-existing diseases.  The total expenditure for the treatment at the above hospital was  18,822.20 US Dollars.  Aggrieved by repudiation of the claim, alleged deficiency in service and sought for the reliefs.
11. The opposite party admitted the insurance policy and contend that insurance is a contract and both parties are under the obligation to fulfil the terms and conditions of the policy.  The policy does not cover any pre-existing diseases and complications arising out of pre-existing diseases.
12. On perusal of the medical documents with the claim, it was learnt that, the complainant had pre-existing ailments i.e. cardiac ailment and was consuming with tablets, such as Plavix and Aspirin.  The gastro-intestinal bleeding suffered by complainant, was a result of consumption of the said tablets only.  Further, the opposite party contended that, as per policy terms under exclusion clause 2.4, they are not liable to make any settlement of claim for the complications arise due to diseases existed prior to the commencement of the policy.
13. Further, the complainant had filed an affidavit evidence of Dr.R.P.Wadhwa, Chief Gastro Entrologist at Apollo Hospital, according to him, the complainant had bled from Duodenal ulcer due to H.Pylori infection and not due to the consumption of Aspirin and clopidogrel and complainant never bled in the past, even though he was consuming the said drugs since 2005.  The opposite party contended the same was an after thought to support the case of the complainant only.  The opposite party also filed an affidavit evidence of one Dr.H.c.Asrani with literatures wherein the Dr. opined that, the GI bleeding was a complication arised due to the consumption of medicine such as Plavix and Aspirin for coronary heart disease such as H.Pylori, prior to taking the policy on 15.08.2014.  So, on thorough examination of the medical records and in accordance with the policy terms only, the opposite party have repudiated the claims.  Hence, there is no negligence or deficiency in service and the complainant is not entitled for any reliefs.
14. Considering the evidence and the material on record, admittedly, the complainant had taken a short term medical claim insurance policy valid between 15.08.2014 to 30.09.2014, before going abroad. When he had been to USA, suffered upper GI bleeding and underwent treatment for the same as in patient at Dignity Health, Mercy Hospital, Bakers field – USA and got discharged.  The hospital authorities claimed a sum of Rs.18,822.20 US dollars towards expenditure for the treatment provided to the complainant, under the mediclaim insurance policy from opposite party. 
15. The opposite party on scrutiny of the medical documents, found that, the complainant was a cardiac patient and was on medication such a Plavix and Aspirin tablets since 2005, i.e., prior to obtain the policy, upon the opinion of the doctor, the opposite party repudiated the claim of the complainant, on the grounds of suppression of pre-existing diseases.
16. However, the complainant has not placed any material to establish that the treatment, expenditure was 18,822.20 US dollar.
17. The complainant relied on several decisions rendered by the Hon’ble National Commission in support of his contention.
18. In view of the decisions, we opine most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made to suffer because the insurance companies relies on their exclusion clauses of the policy in repudiation of the claims. Further, though the complainant was under medication since 2005, had not suffered GI bleeding earlier.  So, the repudiation of claims by opposite party is not justified and the complainant is entitled for the reliefs.  Accordingly, the point No.1 is answered partly in the affirmative.
19. Point No.2:- In view of the above observations, the complainant is to be allowed in part and the opposite party is hereby directed to pay the treatment expenditure incurred by the complainant at Dignity Health, Mercy Hospital, Bakersfield – USA with compensation for the deficiency in service and the cost of litigation.  Hence the following

:: O R D E R ::

1. The complaint is allowed in part.
2. The opposite party is hereby directed to settle the claim amount, in accordance with the documents and bills submitted by the hospital towards treatment provided to the complainant in 60 days of this order.  Failing to pay, the opposite party is liable to pay interest at 12% p.a. on the amount from the date of filing the complaint i.e. 20.07.2016 till payment made.
3. The opposite party is directed to pay compensation of Rs.50,000/- for the deficiency in service and Rs.5,000/- towards cost of the litigation to the complainant, in 60 days.  In default, to pay, the opposite party is liable to pay interest at 10% p.a. on the said total sum of Rs.55,000/- until payment.
4. In case of default to comply this order, the opposite party to undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
5. Give the copies of this order to the parties, as per Rules.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 7^th December 2018)