STATE CONSUMER DISPUTES REDRESSAL COMMISSION OF TELANGANA :
At HYDERABAD
FA 442 of 2017
AGAINST
CC 429 of 2014, DISTRICT FORUM III, HYDERABAD
Between :
Max Bupa Health Insurance Co. Ltd
2nd floor, 10-5-11/12, Main road,
Masab Tank, Road No. 1, Banjara Hills,
Hyderabad – 500 028 .. Appellant/opposite party
And
Dr. P. Rama Devi
W/o P.S.N. Prasad,
6-3-788/33, Ameerpet, Hyderbad .. Respondent/complainant
Counsel for the Appellant : Sri S. Sravan Kumar
Counsel for the Respondent : M/s. K. Jawahar
Coram :
Honble Sri Justice B. N. Rao Nalla … President
And
Sri Patil Vithal Rao … Member
Tuesday, the Tenth Day April
Two Thousand Eighteen
Oral order : ( per Hon’ ble Sri Justice B.N.Rao Nalla, Hon’ble President )
***
1) This is an appeal filed under Section 15 of the Consumer Protection Act by the opposite party praying this Commission to set aside the impugned order dated 17.11.2015 passed in CC 429 of 2014 on the file of the DISTRICT FORUM -III, Hyderabad.
2) For the sake of convenience, the parties are described as arrayed in the complaint before the District Forum.
3). The case of the complainant, in brief, is that she obtained a health insurance policy bearing No.30209259201300 covering medical expenses for herself and her husband for the period from 16-04-2013 to 15-04- 2015 by paying a premium of Rs.1,99,600/-. On 05-03-2014 the Complainant had an accidental fall and sustained a fracture and she took treatment at Apollo Hospital, Hyderguda. She informed the same to the TPA of Opposite Party with an intention of utilizing the facility of cashless treatment. However, she was denied the same and hence she preferred a claim for a sum of Rs.1,24,035/- towards the medical expenses incurred by her. It was repudiated on the ground that she was suffering from diabetes mellitus since 2 to 3 years and suppressed the same at the time of submission of proposal form, which was false and the repudiation of the claim is arbitrary and illegal. She issued a legal notice dated 11-04-2014 for which she received a reply dated 08-05-2014 without any explanations for the issues raised by her. Hence the complaint to direct the opposite party to pay the medical expenses of Rs.1,24,035/- and also to pay a sum of Rs.50,000/- towards compensation for mental agony along with interest @ 24% p.a. from the date of accident till realization.
04. The opposite party opposed the above complaint by way of written version, while admitting the issuance of the policy in question to the complainant for Rs.15 lakhs for two adults and that the Complainant suffered an accidental fall and sustained a fracture of the shaft of Radius and hospitalized on 05-03-2014 for surgery and that the Opposite Party received pre-authorization request for cashless facility from the hospital authorities, contending that the Complainant had been suffering from diabetes 3 mellitus since 2 years from the inception of the policy and since the same was not disclosed, hence they repudiated the claim of the Complainant on the grounds of suppression of material fact. Hence there is no deficiency in service on their part and prayed to dismiss the complaint.
5) During the course of enquiry before the District Forum, in order to prove her case, the complainant filed her evidence affidavit and got marked Ex.A1 to A-5 and the Opposite Party has filed an evidence affidavit and got marked Ex.B1 to Ex.B9. The Complainant has filed written arguments in support of her complaint. The Opposite Party filed a Memo to treat evidence affidavit as written arguments.
6) The District Forum, after considering the material available on record, held and directed the opposite party to pay to the Complainant a sum of Rs.1,24,035/- towards claim of the Complainant, to pay a sum of Rs.50,000/- towards compensation and Rs.2,000/- towards costs. Time for the compliance is Thirty (30) days only.
7) Aggrieved by the said order, the opposite party preferred this appeal before this Commission.
8). Both sides have advanced their arguments reiterating the contents in the appeal grounds, rebuttal thereof along with written arguments.
9) The points that arise for consideration are,
(i) Whether the impugned order as passed by the District Forum suffers from any error or irregularity or whether it is liable to be set aside, modified or interfered with, in any manner?
(ii) To what relief ?
10). Point No.1 :
There is no dispute that the respondent/complainant obtained a health insurance policy titled as Heart Beat Platinum vide policy No. 30209259201300 for the period from 16-04- 2013 to 15-04-2015 for Rs. 15 lakhs for her and her husband vide Ex.A1 = Ex. B1 policy. There is no dispute that the respondent/ complainant suffered an accidental fall and sustained a fracture of the shaft of Radius and hospitalized at Apollo Hospital on 05-03-2014 for surgery and that the Opposite Party received pre-authorization request for cashless facility from the hospital authorities vide Ex. B-3. There is no dispute that the appellant/ opposite party denied the cashless treatment and it needs further verification vide Ex. B4. There is no dispute that the respondent/complainant incurred an amount of Rs.1,24,035/ - towards medical expenses. There is no dispute that the claim submitted by the respondent/complainant was repudiated by the appellant/ opposite party on the ground that she was suffering from Diabetes Mellitus for two years.
11). The claim submitted by the respondent/complainant vide Ex. B5 was repudiated on the ground that the respondent/complainant had been suffering from diabetes 3 mellitus since 2 years from the inception of the policy. On the other hand, the respondent/complainant rebutted the same.
12). From Ex.A4 and Ex. B8, out patient assessment form, the District Forum observed that “she is a known diabetic for 2 years. She has no history of hypertension and is not on medication. By mistake diabetes mellitus is mentioned as hypertension. Even diabetic medication is not being taken regularly but on diet control” and that the respondent/ complainant cannot be categorized as suffering from chronic diabetes mellitus and the appellant/opposite party did not place any material on record to show that the respondent/complainant was a chronic diabetic patient. Further, there has been no direct nexus between the accidental fall and diabetes mellitus of the respondent/complainant and opined that repudiation of the claim amounts to deficiency in service.
13). The appellant/opposite party relied on Ex. B8, Out Patient Assessment Form, stating that she is a known Diabetic since 2 years. It is a Certificate said to have been issued by Dr. M. Hari Sharma. He is the Doctor in Orthopedics. He is not the doctor in Diabetologist. Further, he was not examined to prove the authenticity of the certificate and his competency in giving the said Certificate. It is not on record that he has given the said certificate on the basis of any medical records. It appears, the said Certificate was obtained by the appellant Insurance Company for the purpose of this case in support of their repudiation because no DATE was mentioned by the said doctor on the said certificate. Though, Ex.B6, Discharge Summary, mentions Diabetes Mellitus, but, it did not show any time period, and that too, without any supportive medical reports of the respondent/ complainant. There is no evidence on record to show that there is any nexus in between the Diabetes Mellitus and the said fracture, even if we consider that she has been suffering from Diabetes Mellitus. In the absence of the above, it cannot be considered that the respondent/complainant suppressed the Diabetes Mellitus at the time of submission of proposal form and the repudiation of the claim is justifiable. However, we are of the opinion awarding an amount of Rs.50,000/- towards compensation is on higher side, reducing it to Rs.30,000/- would meet the ends of justice,
14). After considering the foregoing facts and circumstances and also having regard to the contentions raised on both sides, this Commission is of the view that there are no merits in the appeal and hence it is liable to be dismissed, however, reducing the compensation amount from Rs.50,000/- to Rs.30,000/-, while confirming the costs of Rs.2,000/- as awarded by the District Forum. Hence, the point framed at para 9, supra, is answered accordingly.
15). Point No. 2 :
In the result, the appeal is dismissed confirming the impugned order dated 17.11.2015 in CC 429 of 2014 passed by the District Forum III, Hyderabad to the extent of awarding an amount of Rs.1,24,035/- towards the claim and Rs.2,000/- towards costs of the complaint while reducing compensation amount from Rs.50,000/- to Rs.30,000/-. Time for compliance four weeks.
PRESIDENT MEMBER Dated : 10.04.2018.
