BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 18^TH DAY OF NOVEMBER 2023

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. To pass an order directing the OP to clear and reimburse the legitimate claim of Rs.3,73,552/-  to the complainant.
2. To direct the OP to issue fresh health insurance policy in favour of the complainant in continuation of earlier health insurance policy.
3. For mental agony, trauma and hardship, damages for your deficiency of service of Rs.7,00,000/-.
4. Cost of legal expenses quantified at Rs.25,000/-.

2. The case set up by the complainant in brief is as under:-

The complainant purchased the health insurance policy bearing No.4128i/P-HSHA/234697701/00/000 for Rs.50 lakhs(Joining date 26.12.2021 and policies have been renewed in time since then till 25.12.2022) payment of premium of Rs.38,792/- for assured sum of Rs.50 lakhs. The complainant had purchased earlier health insurance policy with OP and he has also purchased health insurance policies with oriental insurance company ltd., for continuous period more than 10 years and he has never claimed any claims for his any illness and he had no preexisting disease as alleged by the OP while rejecting the claim of this complainant.

3. It is the main grievance of the complainant that due to muscle pain in the legs he was initially admitted to Manipal Hospital at Whitefield, which is near his residence. After due checkups the hospital had intimated the complainant for treatment for Peripheral Angioplasty and stenting underwent Cath lab and at the time of admitting in the hospital itself, complainant had intimated OP company with regard to the admission and medical claim for his treatment and the OP have not responded to the mail sent by the hospital for free approval.  The complainant has paid Rs.3,73,552/- since the OP company have not responded to the mail sent by the hospitals the complainant had to borrow money from others to clear the hospital bills to get discharged. In view of the delay made by the OP for approval of the mediclaim.  
4. After discharge on 29.09.2022 the complainant had approached the OP office to follow-up medical claims for treatment. The complainant had submitted all his medical bills, doctors certificate and discharge summary along with claim form to the OP.  The OP did not honor the medical bills till today and the OP have communicated through email and letters about the termination of the policy on the ground of non-disclosure of preexisting disease at the time of renewal of the policy/purchasing the health policy and the OP have rejected the claim of the complainant.  The OP have not paid the claim amount as per the terms and conditions of the policy. The insurance for the medical claim is covered for the ailment stated by the complainant and the same is not a preexisting disease and these facts have been clearly evidenced in the health insurance policies issued since from 2010, the OP policy clearly evidenced that there was no preexisting disease to the complainant.
5. It is the main grievance of the complainant that he had never admitted to the hospital earlier to this admission and there is no such ailment earlier to his admission, the OP company has continuously renewing the policy of the complainant. Due to the Ops deficiency of service the complainant has suffered mental stress. The complainant after submitting all the documents with the OP they have declined to release the claim amount to the complainant and even they did not properly replied to the complainant. The complainant was made to run pillar to post of the office of the OP for reimbursement of the claim amount as per the policy and due to differential attitude and non-compliance of the claim of the complainant by the OP, this complainant has suffered great hardship and inconvenience. The complainant also got issued legal notice on 12.12.2022. Inspite of service of the notice, the OP neither replied nor complied to the demand of the complainant. Hence the complainant had filed this complaint.
6. In response to the notice, OP appears and files version. They have admitted about the issuance of the policy in favour of the complainant. The main contention taken by the OP is that the complaint is not maintainable. The complainant is guilty of suppressing material and pertinent relevant facts for the adjudication of this complaint apart from filing vexatious and frivolous complaint. The complaint deserves to be dismissed on this ground alone. There is no cause of action to file this complaint.
7. It is the case of the OP that they have issued the policy No.4128i/P-HSHA/234697701/00/000 for the period from 26.12.2021 to 25.12.2022, with no history of preexisting disease disclosed at the time of proposal.  The policy is based on the statements and declaration provided at the time of proposal and is subjected to receipt of requisite premium and also governed by the policy terms and conditions.
8. The OP further admitted that they have received the claim application from the complainant that he was admitted to Manipal Hospital on 27.09.2022 wherein he was diagnosed with Peripheral vascular disease bilateral iliac occlusive disease and discharged on 30.09.2022 after the surgery, in this regard he has submitted a claim vide claim No.220100876856.
9. It is further objection raised by the OP that after verification of the documents submitted by the complainant it was found that the complainant was a known case of hyper tension since past 15 years and the same was not disclosed at the time of inception of the policy as per part 3 of the policy general terms and conditions.  As per the terms and conditions of part 3 the policy shall be null and void and no benefit shall be payable in the event of untrue of incorrect statements, misrepresentation, misdescription or non-disclosure in any material particular in the proposal form, personal statement declarations and connected documents or any material information having been withheld or a claim being fraudulent or any fraudulent means or devises being used by insured or any one acting on his behalf to obtain benefit under the policy.  Based on the above reason the claim was repudiated vide repudiation letter dated 12.11.2022 and further the OP have also cancelled the policy vide their letter dated 26.11.2022 for the non-disclosure of material facts at the time of filing the proposal form.  The medical documents submitted by the complainant clearly indicates that he was suffering from the pre-existing ailments prior to the policy inception date, it was not disclosed at the time of taking the policy.  The insured must disclose to the insurer all the facts material to an insurer’s appraisal of the risk which are known or deem to be known by the insured, but neither known or deemed to be known by the insurer.  Therefore the complainant is legally not entitled to pray for payment of any claim benefits under the policy. Hence the OP prayed for dismissal of the complaint.
10. The complainant has filed his affidavit evidence and relies on 09 documents.  Affidavit evidence of official of OP has been filed and OP relies on 04 documents.
11. Heard the arguments of advocate for the both the complainant.  Perused the written arguments filed by the complainant and documents filed by both the parties.
12. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

13. Our answers to the above points are as under:

Point No.1:  In the Affirmative

Point No.2: Affirmative in part

Point No.3: As per final orders

REASONS

14. Point No.1 AND 2: These two points are inter related and hence they have taken for common discussion.  We have perused the allegations made in the complaint, version, affidavit evidence, written arguments filed by the complainant and documents filed by both the parties.
15. It is undisputed fact that the complainant has purchased the health insurance policy bearing No.4128i/P-HSHA/234697701/00/000 for Rs.50,000/- as per Ex.P1, the policy was in force from 26.12.2021 till 25.12.2022. The complainant ahs also paid the premium of Rs.38,792/- and the sum assured is Rs.50,00,000/-.  The complainant has purchased the earlier health insurance policy with OP company and also purchased health insurance policy with oriental insurance company for a continuous period of more than 10 years and he has never claimed any claim for his illness and he has no preexisting diseases.
16. It is also clear from the Ex.P2 the discharge summary with medical bills issued by the Manipal Hospital that due to muscle pain in the legs the complainant was initially admitted to Manipal Hospital at Whitefield, Bangalore. After due checkups the hospital has intimated the complainant that he has go for the treatment for peripheral angioplasty and stenting underwent cathlab and the hospital authorities have made the bill of Rs.3,73,552/-.
17. The complainant has also relied on the final bill issued by the hospital authorities with admission and discharge slip as Ex.P2. 
18. It is the main grievance of the complainant that even though he has informed the OP company with regard to his admission and also medical claim for his treatment they have not responded to the mail sent by the hospital for free approval.  In view of this the complainant was forced to pay the bills amounting to Rs.3,73,552/- with great difficulty from borrowing the amount from his relatives and friends. Immediately after the discharge he has approached the OP and filed claim application before the OP claiming an amount of Rs.3,73,552/- along with all medical bills and discharge summaries and doctors certificate.  The Ops did not honor the mediclaim made by the complainant and later they have communicated to the complainant that they have terminated the policy on the ground of non disclosure of preexisting disease at the time of renewing the policy. They have made a serious allegation that this complainant had not disclosed his preexisting disease at the time of renewal /purchase of health policy and they have rejected the claim of the complainant.  
19. It is the case of the complainant that he was not at all having any preexisting disease and he came to know that he is having the BP only after renewal of the policy and hence he could not inform the same. On the other hand, the complainant has also produced the cancellation letter issued by the OP as per Ex.P3 and also produced the copies of the earlier policies and also the rejection claim letter sent by the OP.  It is clear from the rejection claim letter that the Ops have rejected the claim of the complainant stating that “as per the documents furnished patient is k/c/o hypertension prior to policy inception the same was not disclosed at the time of policy inception, hence the claim stands rejected.  They have also quoted the part 3 of the policy general terms and conditions.” 
20. On the other hand, the contention taken by the OP is that they have issued the policy and it is valid from 26.12.2021 till 25.12.2022 with no history of pre existing disease disclosed at the time of the proposal.  The policy is based on the statement and declaration provided at the time of the proposal and is subjected to receipt of the requisite premium and also governed by policy terms and conditions.  
21. The main objection raised by the Ops is that the complainant was taken treatment as an inpatient from 27.09.2022 to till 30.09.2022 wherein he was diagnosed with peripheral vascular disease bilateral iliac occlusive disease and he was discharged on 30.09.2022 after the surgery. In this regard he has submitted the claim. On verification of the repudiation letters submitted by the complainant it was found that the complainant was a known case of hypertension since past 15 years and the same was not disclosed at the time of inception of the policy as per part 3 of the policy general terms and conditions based on the said reason the claim of the complainant was repudiated vide repudiation letter dated 12.11.2022 and further they have also cancelled the policy and communicated the same through letter dated 26.11.2022 for the non disclosure of material facts at the time of filing of the proposal form.  
22. The Ops have also relied on four documents Ex.R1 to R4. Ex.R1 is the copy of the policy, Ex.R2 is the copy of the proposal form and R3 is the claim form submitted by the complainant and R4 is the repudiation letter.
23. Except the say of the OP in Ex.R4 the repudiation letter that as per the medical documents furnished by the complainant they came to know that the complainant is a known case of hypertension prior to the policy inception and the same was not disclosed at the time of policy inception.
24. We have gone through the entire medical reports submitted by the complainant. The Ops have not at all submitted any medical documents to show that the complainant is a known case of hypertension.  On the other hand the medical documents produced by the complainant as per Ex.P2 the discharge summary discloses that there is no such history mentioned in the discharge summary. The complainant was diagnosed as Peripheral vascular disease bilateral iliac occlusive disease. The complainant was admitted to hospital on 27.09.2022. If the complainant is a known case of hypertension and he was having the hypertension from the last 15 years, the hospital authorities would have clearly mentioned the same in the discharge summary and in their other medical records. The complainant has also produced the copy of the medical reports for having taken treatment from one Dr.Ramesh Gurumurthy of Ramesh Clinic and these two certificates discloses that the complainant went to the doctor on 21.12.2021 and also on 05.01.2022 with a complaint of head ach with giddiness. The doctor has advised him to take some medicines. If really the complainant was having the BP the doctor would have mentioned in the medical certificate that this complainant is having the BP from the last 15 years. Except the say of the Ops in their repudiation letter there is nothing on record to show that the complainant is a known case of hypertension and he was taking treatment for the BP from the last 15 years from the date of inception of the policy.
25. Under these circumstances it is clear that the Ops have raised this objection only in order to escape from their liability to pay the mediclaim claimed by the complainant.  It is also clear from the documents produced by the complainant that he has not at all claimed any mediclaim from the Ops from the inception of the policy till their repudiation in this case. The complainant has claimed this medicalim for the first time after inception of the policy, even though he was having the mediclaim policy from the last 15 years.  
26. The burden is on the Ops to establish that the complainant is a known case of hypertension and he has not disclosed the same and hence they have repudiated his claim. Nothing prevented the Ops to subject the complainant for medical examination at the time of renewal of the policy every year.  The Ops have made these allegations against the complainant even though they have no medical records in support of their contention. Under these circumstances, the repudiation made by the OP is illegal. When the complainant is having a valid insurance policy and he is regular in paying the premium and the policy was in force during the time of the treatment taken by the complainant it is the duty of the Ops to reimburse the claim made by the complainant.
27. In view of the repudiation made by the Ops the complainant has to pay the medical bills on his own by lending money from his relatives and friends and he was put to mental agony and financial loss. Even though the complainant was having the insurance policy and the amount assured is rupees fifty lakhs the Ops have repudiated the claim made by the complainant only for Rs.3,73,552/- by making false allegations against the complainant. Under these circumstances, the complainant has clearly established the negligence, deficiency of service on the part of the Ops and further clearly established the mental agony and the financial loss sustained by him in view of the unexpected repudiation made by the Ops. Apart from repudiating the claim of the complainant the Ops have also cancelled the policy on the same ground even though they had failed to establish the same.  The cancellation of the policy made by the OP is also illegal.
28. The complainant has also claimed the compensation of Rs.7,00,000/- and legal expenses of Rs.25,000/- apart from the medical claim of Rs.3,73,552/-. The compensation claimed by the complainant is on the higher side. Hence we restrict the compensation to Rs.2,00,000/- against the claim made by the complainant for Rs.7,00,000/- the complainant is also entitled for the litigation expenses of Rs.10,000/-. Hence we answer point No.1 in affirmative and point No.2 partly in affirmative.
29. Point No.3:- In view the discussion referred above we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. OP is directed to refund the mediclaim of Rs.3,73,552/- with interest at the rate of 12% p.a., from the date of repudiation till realization.
3. OP is further directed to pay compensation of Rs.2,00,000/- with litigation expenses of Rs.10,000/- to the complainant.
4. The Ops are further directed to issue fresh health insurance policy in favour of the complainant in continuation of earlier health insurance policy.
5. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 16% p.a. after expiry of 60 days on Rs.3,73,552/- till final payment.
6. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 18^TH day of NOVEMBER 2023)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;