Date of Filing:16.05.2022

Date of Disposal:19.05.2023

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

ORDER

SRI RAMACHANDRA.M.S,  PRESIDENT

1. The complainants files a complaint with this Commission under Section 35 of the Consumer Protection Act of 2019 with a direction to OP to reimburse Hospital expenses amounting to Rs.7,73,732/- along with 18% interest and compensation of Rs.25,00,000/- for mental torture, mental strain, humiliation and harassment caused and Rs.1,00,000/- towards cost of litigation and such other reliefs.

2.   The following are the complaint's key facts: 

This is the case of the complainant that complainant has availed a health insurance policy from the OP company vide No.2828101118922700 for the period 26.10.2021 to 25.10.2022 and the sum assured which is covered under the policy is Rs.15,00,000/-. Thereafter, the complainant was admitted to Sri Arogya Hospital on 04.01.2022 as he was having fever and after admission to the hospital when the tests were done and complainant was tested Covid-19 positive and he was admitted to the ICU as he was having breathing difficulty and he was to under goes rigorous treatment for 17 days in the said hospital. While discharging from the hospital the complainant’s hospital bill was raised by OP hospsital for a sum of               Rs.7,73,732/-. After paying the bill the complainant got discharged from the hospital and subsequently when the complainant raised the claim with the OP company as he was insured with the health insurance poicy of the OP company. The OP after scrutining the claim of the complainant, the OP have rejected the claim of the complainant on the ground that as per terms of the  policy if any claim is made in any manner dishonest/fraudulent or is supported by any dishonest/fraudulent means or devices whether by insurance person  or anyone acting on behalf of the insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence, this claim is being repudiated as per letter dt.28.02.2022 issued by OP. The complainant got issued legal notice dt.25.03.2022, but the OP have not reimbursed the insurance claim amount. Aggrieved by the act of the OP company the complainant was forced to file the present complaint and sought for the relief of the insurance claim amount.

3. Notice to OP-duly served, OP  represented by counsel, filed  detailed version. Despite sufficient opportunity, OP has not filed chief examination affidavit.

4.  The complainant filed chief-examination affidavit along with relevant documents in support of his contention.

5.  Heard arguments. The matter is reserved for order.

6.  The points that arise for our consideration are;

1. Whether the complaint is maintainable?
2. Whether the Complainant prove that there is deficiency of service on the part of the OP as alleged in the complaint and thereby prove that he is entitle for the relief sought?
3. What order?

7. The findings on the above points are as under:

Point No.1               :  Negative

   Point No.2                 : In view of the findings given to point  no.1, consideration for Point No.2 does not arise.

Point No.3                 :  As per final order

REASONS

8. POINT NO.1:-  From the perusal of the the complainat assertions, it is found that the complainant has availed a health insurance policy from the OP by paying premium as per the policy issued by OP company vide No.2828101118922700 for the period 26.10.2021 to 25.10.2022 and the sum assured which is covered under the policy is Rs.15,00,000/-. Thereafter, the complainant was admitted to Sri Arogya Hospital on 04.01.2022 as he was having fever and after admission to the hospital when the tests were done and complainant was tested Covid-19 positive and he was admitted to the ICU as he was having breathing difficulty and he was under goes rigorous treatment for 17 days in the said hospital. While discharging from the hospital the complainant’s hospital bill was raised by OP hospsital for a sum of               Rs.7,73,732/-. After paying the bill the complainant got discharged from the hospital and subsequently when the complainant raised the claim with the OP company as he was insured with the health insurance poicy of the OP company. The OP after scrutining the claim of the complainant the OP have rejected the claim of the complainant on the ground that as per terms of the  policy if any claim is made in any manner dishonest/fraudulent or is supported by any dishonest/fraudulent means or devices whether by insurance person  or anyone acting on behalf of the insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence, this claim is being repudiated as per letter dt.28.02.2022 issued by OP. Aggrieved by the act of the OP company the complainant was forced to file the present complaint and sought for the relief of the insurance claim amount.

9. The OP admitted the issuance of the policy to the complainant and also they have not disputed the validity of the policy as on the date of complainant got admitted to the hospital for treatment. The only dispute is in respect of the claim which is raised by the complainant. The OP contended that even though it is valid policy as on the date of the admission of the complaiannt. For the violation of the terms and conditions of the policy which is agreed and accepted by the complainant while availing the policy, as the complainant has violated the terms and conditions of the policy, claim of the complainant is not payable for the violation of the policy terms and conditions. The specific contention of the OP is  that in their version statement at para-4&5 the OP has clearly contended that the complainant has mis-represented and forged all the documents pertaining to Sri Arogya hospital, where the alleged complainant have been treated for the said disease and it is also specifically contended by the OP that there is a survey report by the surveyor  of the OP company, wherein they have visited the said hospital and on investigation the OP came to know that  the said Doctor has alleged not to have been treated the complainant has recorded the statement to the investigators of the OP company that said complainant has not at all visited Sri Arogya hospital and said doctor has also stated that the complainant was not treated and performed under supervision of the said doctor. It is the specific case of the OP that it is a clear case of mis-representation by way of fraud and also case of fabrication of documents in order to get the insurance claim from the OP company. By contending the same the OP has clearly denied any deficiency of their part and also contended that the claim of the complainant falls under the mis-representation by fradulant act of the complainant and the complainant is also involved in fabrication of the documents in the process of getting claim from the OP company. All these facts cannot be decided by the consumer commission in a summary trial. The allegations which has been made by the OP required to be examined under full pledged and detailed trial by any other appropriate authority. This commission is not vested any jurisdiction to deal with the issue of fraudulent and cheating act by way of evidence. All these facts and point of law cannot be adjudicated on the merits in a summary trial. On this point the OP has rendered the judgment renderd by Hon’ble New Delhi State Consumer Disputes Redressal Commission, which is reported in 2023(II) CPR 59 in the case of  Lakshminarayana Nagapal and others V/s  State Bank of India in Consumer complaint No.5/2013 “Whether the said commission is empowered to adjudicate the allegation of fraud or forgery alleged by  OP. As the primary question of fraud or forgery which does not come under the jurisdiction of the consumer complaint and appropriate evidence is required in order to decide the case on merits. Thereforre, the parties are  directed to present the case before the appropriate court having jurisdiction to adjudicate and decide the matter on merits.

10. The reported judgment OP opt applicable to the case by applying ratio laid in judgment, the commission is of the definite  opinion that the allegation of fraud and fabrication of  documents which is mady by the OP company is against the complainant in order to adjudicate the complaint on merits. The commission is not empowered and statute has not vested with any powers to adjudicate the said issue in a summary trial in order to deal with the case of the complainant  which requires a detailed trial and the commission is not at all vested with any power to deal with said issue which involves fraud and cheating and also fabrication of documents.

11. In view of the  above discussion and also by taking the contention of both the parties and also  by considering the citation relied by the OP, the commission is of the clear opinion that the complaint  deserves to be dismissed as not maintainable, the Point No.1 we answer in negative.

12. POINT NO.2:- In view of the findings given to point  no.1, consideration of Point No.2 does not arise.

13. POINT NO.2:- In the result, we passed the following:

ORDER

1. Complaint is hereby dismissed as not maintainable. No costs.
2. Furnish free copy of this order to both the parties.

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 19^th                May  2023)

(RAMACHANDRA M.S.)

PRESIDENT

       (NANDINI H KUMBHAR)             (CHANDRASHEKAR S.NOOLA)       

                 MEMBER                                        MEMBER

Witness examined on behalf of the complainant-1 by way of affidavit: Sri Prakash.G-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit: Nil

Documents produced by the OP:  Nil

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*