BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.397/2018

DATED ON THIS THE 30^th January, 2020

      Present:   1) Sri. C.V.Maragoor

B.Com., L.L.M., - PRESIDENT   

                     2) Sri. Devakumar.M.C.           

                                        B.E., LLB., PGDCLP   - MEMBER

Sri C.V.MARAGOOR,

President

1.       This complaint has filed by Sri K.Nagesh Shet, aged 71 years resident of Mysuru to direct the opposite party No.2 – Apollo Munich Health Insurance Co.Ltd., to settle his hospital expenses of Rs.55,410/- with interest at the rate of 18% p.a. from the date of discharge on 21.09.2018 till the date of realization, compensation of Rs.1,00,000/- for mental agony and litigation cost of Rs.10,000/-.
2.       The opposite party No.1 is Canara Bank, Kuvempunagar Branch, Mysuru and opposite party No.2 Apollo Munich Health Insurance Company Ltd., The complainant has taken mediclaim policy from the opposite party No.2 by paying premium amount of Rs.6,180/- from his account maintained in opposite party No.1 on 05.02.2018 and the policy was in force from 06.02.2018 to 05.02.2019.  The complainant has undergone Anus – fistula on 16.09.2018 in Kamakshi Hospital, Mysuru and discharged from the hospital on 21.09.2018.  The opposite party No.2 has assured cashless treatment benefit under the policy but instead of paying the treatment expenses of Rs.55,410/- it has raised queries with regard to Gilbert Syndrome.  Later on the opposite party No.2 has repudiated the claim as the complainant has suppressed the fact of Gilbert Syndrome disease.  Hence, this complaint for deficiency in service on the part of opposite party No.2.
3.       The opposite party No.1 Canara Bank has filed version admitting that mediclaim premium was credited to the account of opposite party No.2 by making the debit entry to the account maintained by the wife of complainant.  There is no liability on the part of this bank as such, it asked to dismiss the complaint.
4.      The opposite party No.2 appeared through its learned counsel and filed written version admitting that the complainant has taken mediclaim policy for the period from 06.02.2018 to 05.02.2019.  The opposite party No.2 further admitted that the complainant has undergone Anus-fistula operation in Kamakshi Hospital and paid medical expenses.  The complainant has failed to produce records in respect of Gilbert Syndrome disease as such it has repudiated the mediclaim of the complainant.
5.       The complainant filed his affidavit evidence and produced documents in support of his case.  That one M.Tippeswamy, Senior Manager of opposite party No.1 Bank filed affidavit evidence and produced statement of account of the wife of complainant.  That one Deepti Rustagi, Senior Vice President – Legal and Compliance of opposite party No.2 filed their affidavit.
6.      We have heard the oral arguments advanced by the complainant and learned counsel for the opposite party No.2 in addition to written brief submitted by the complainant and the points that would arise for determination are as under:-  

1. Whether the complainant proves that the repudiation of his mediclaim by the opposite party No.2 is illegal and improper amounts to deficiency in service?
2.  Is complainant entitled to the reliefs sought for?

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

Point No.1:- In the affirmative;

Point No.2:- Partly in the affirmative as per final order for the following

:: R E A S O N S ::

8.            Point Nos.1 and 2:- The complainant submitted that for the alleged Gilbert Syndrome he has not taken any treatment as on today as such, the question of suppressing the material fact does not arise.  As against this learned counsel for the opposite party No.2 has argued that the complainant has not produced material documents with regard to Gilbert Syndrome.
9.           The complainant has produced mediclaim policy issued by opposite party for the period from 06.02.2018 to 05.02.2019 and sum assured is Rs.5,00,000/-.  The complainant further produced discharge summary issued by Kamakshi Hospital and according to this, the complainant was admitted as in-patient on 16.09.2018 and discharged on 21.09.2018.  History and clinical findings is that pain, swelling over Anus since one month hence admitted for further management – K/C/O Gilbert Syndrome.  The opposite party No.2 has not disputed issue of mediclaim policy for the complainant for a sum of Rs.5,00,000/- and during the relevant period he was admitted as in-patient and has undergone Anus-fistula.  The opposite party No.2 further admitted that during the hospitalization when the claim was submitted they have raised queries is as under:-

1. To provide the treating doctors certificate for past history duration of Gilbert Syndrome.
2. To provide the first and previous consultation letter related to Gilbert Syndrome.
3. To provide all past treatment records prior to hospitalization.

10.       The complainant answer is that till date he has not taken medical treatment for Gilbert syndrome and no medical treatment is required.  The complainant has produced certificate dated 25.10.2018 issued by Kamakshi Hospital wherein it is stated that Gilbert Syndrome is not a diriara but genetic disorder and has got no specific treatment.  It is not associated with the anus problem.  Gilbert Syndrome a cause the skin and whites of the eyes to have a yellow tinge due to the build up of bilirubin.  Gilbert Syndrome is typically harmless and treatment is not required.
11.       The complainant has specifically stated that he has not taken any treatment for Gilbert Syndrome.  When the complainant has not taken any treatment, the question of providing information to the opposite party No.2 does not arise.  The doctor who treated the complainant has not prescribed any medicine for Gilbert Syndrome.  When the complainant has not taken any treatment for the alleged Gilbert Syndrome the question of suppressing the material fact by him does not arise.  Then the burden shifts on the opposite party No.2 to get the information with regard to treatment taken by the complainant for the alleged Gilbert Syndrome.  The opposite party No.2 has not placed any material to show that the complainant was taking treatment for the alleged disease prior to taking mediclaim health policy.  Therefore, repudiating the medical claim of the complainant by the opposite party No.2 is not justified.  The complainant being 71 years old and the opposite party No.2 has compelled him to approach the Forum at this age, as such the opposite party No.2 shall liable to pay compensation of Rs.10,000/- in addition to litigation cost of Rs.5,000/-.  Accordingly, we proceed to pass the following;         

:: ORDER ::

1. The complaint filed by Sri K.Nagesh Shet is partly allowed directing the opposite party No.2 to pay a sum of Rs.55,410/- to the complainant with interest at the rate of 10% p.a. from 21.09.2018 till payment.
2. It is further ordered that the opposite party shall pay Rs.15,000/- towards compensation and litigation costs to the complainant within 30 days from the date of order. Otherwise, it carries interest at the rate of 10% p.a. from the date of filing complaint till payment.
3. Complaint is dismissed against opposite party No.1.
4. Furnish the copy of order to the complainant and opposite parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Forum on this the 30^th January, 2020)

                                                  (C.V.MARAGOOR)    

                                                       PRESIDENT     

                                                (DEVAKUMAR.M.C.)

                                                       MEMBER