BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI
Consumer Complaint No.219 of 2015
Date of institution: 12.05.2015
Date of Decision: 05.10.2015
Harinder Pal Singh Jolly son of Hardit Singh resident of House No.4801, New Sunny Enclave, Kharar, District Mohali.
……..Complainant
Versus
1. ICICI Lombard Health Insurance Co. Limited, Corporate Office, ICICI Lombard House, 414, Savarkar Marg, New Siddhi Vinayak Temple, Prabha Devi, Mumbai 400025 through its Director.
2. ICICI Lombard Health Insurance, Plot No.149, 4th Floor, Industrial Area, Phase-1, Next to Hotel Hometel, Chandigarh.
3. Max Super Speciality Hospital, Near Civil Hospital, Phase-VI, SAS Nagar, Mohali through its Director.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
CORAM
Mrs. Madhu. P. Singh, President.
Shri Amrinder Singh Sidhu, Member
Mrs. R.K. Aulakh, Member.
Present: Ms. Rani Nirula, counsel for the complainant.
Shri Simrandeep Singh, counsel for OP No.1 and 2.
OP No.3 exparte.
(Mrs. Madhu P. Singh, President)
ORDER
The complainant has filed the present complaint seeking following directions to:
(a) OP Nos.1 and 2 to pay him claimed amount of Rs.2,83,989/- along with interest 2 12% per annum from the date of admission till actual realization.
(b) OP Nos.1 and 2 to pay him Rs.2.00 lacs as compensation for harassment, mental agony, inconvenience and deficiency in service and unfair trade practice.
(c) OP No.3 to pay Rs.2.00 lacs as compensation for harassment, mental agony, inconvenience and deficiency in service and unfair trade practice.
The case of the complainant is that he got himself medically insured vide policy No.4034i/FPPBX/70886350/00/000 by paying premium of Rs.20,496/- for sum insured of Rs.4.00 lacs effective from 12.04.2012 to 11.04.2014. On the allurement of the Ops, the complainant took another policy No.41131XOLB/70886946/00/000 on 30.04.2012 at a premium of Rs.4270/- for sum insured of Rs.10.00 lacs effective from 12.04.2012 to 11.04.2014. The complainant got these policies renewed by paying premium of Rs.20,216/- and Rs.4,270/- respectively from 12.04.2014 to 11.04.2016. Before issuance of these policies, the complainant was got medically examined by the OPs from the Board of Doctors. On 28.06.2014 the complainant felt pain in chest and got admitted in OP No.3. After investigation, the doctors of OP No.3 advised to go for treatment as Percutaneous Transluminal Coronoary Angioplasty. The complainant remained admitted in OP No.3 from 28.06.2014 to 01.07.2014. During his admission with OP No.3 the complainant requested OP No.3 to provide cashless facility as per terms and conditions of the policy which was declined by TPA vide letter dated 30.06.2014 on the ground that there were some discrepancies in the note given by the doctor about suffering of complainant from Diabetes Mellitus. The complainant was not suffering from DM which was clarified by the hospital vide letter dated 30.06.2014 but wrongly mentioned that the complainant is a known case of hypertension whereas the complainant informed the doctor that he had taken ‘amlopress’ medicine for two days 3-4 years back as per advise of the doctor. The complainant after discharge from the hospital on 01.07.2014 submitted his claim of Rs.2,83,989/- to OP No.1 and 2 but the same was repudiated on the ground that the complainant has withheld information regarding his being diagnosed as k/c/o HTN 3-4 years back. The complainant vide letter dated 17.09.2014 requested OP Nos.1 to 2 to review his claim and the request of the complainant was turned down vide letter dated 24.09.2014. With these allegations the complainant has filed the present complaint.
2. OP Nos.1 an 2 in the preliminary objections of the written statement have pleaded that the claim was repudiated on the ground that the complainant was suffering from a pre-existing disease which he did not disclose. As per Part III of the Schedule, Clause 1 of the policy and its terms and conditions it is provided that the policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statement, misrepresentation, mis description or non disclosure of any material information. OP No.3 vide medical record dated 28.06.2014 stated that the patient is k/C/O HTN (Hypertension) and the Ops asked for first consultation papers from OP no.3 who stated that as per the documents, the complainant is on regular treatment. Hence the cashless claim request was cancelled. As per medical record of the complainant, he himself mentioned that he was a known case of hypertension for last three years and at the time of taking insurance policy, the complainant did not mention about this fact. Accordingly, the claim of the complainant was rejected vide letter dated 11.09.2014 under Incontestability & Duty of Disclosure Clause of the policy. On merits the OP No.1 and 2 have denied any deficiency in service on their part, and have sought dismissal of the complaint.
3. As per Post Tracking Report, the notice was delivered to OP No.3 on 12.06.2015. None appeared for it. Thus, OP No.3 was proceeded against exparte vide order dated 07.07.2015.
4. To succeed in the complaint, the complainant tendered in evidence affidavit Ex.CW-1/1 and copies of the documents Ex.C-1 to C-9.
5. Evidence of OP No.1 and 2 consists of affidavit of Ms. Meenu Sharma their Legal Manager Ex.OP-1/1 and copies of documents Ex.OP-1/2 to OP-1/13.
6. We have heard learned counsel for the parties and have also gone through the written arguments submitted by them.
7. The medi claim policies i.e. (i) policy No.4034i/FPPBX/70886350/00/000 for a premium of Rs.20,496/- for sum insured of Rs.4.00 lacs effective from 12.04.2012 to 11.04.2014 and (ii) policy No.41131XOLB/70886946/00/000 for a premium of Rs.4270/- for sum insured of Rs.10.00 lacs effective from 12.04.2012 to 11.04.2014 and further renewal of these policies from 12.04.2014 to 11.04.2016 is admitted by OP No.1 and 2 meaning thereby that both the policies were in currency when on 28.06.2014 the complainant felt chest pain and got himself admitted with the hospital of OP No.3. During stay in the hospital from 28.06.2014 to 01.07.2014 the complainant requested OP No.3 to provide cashless facility as per terms and conditions of the policy. OP No.3 has submitted the claim documents to the TPA vide letter dated 30.06.2014 for providing cashless facility and the same was declined on the ground that there are some discrepancies in the note given by the doctor about the complainant being suffering from Diabetes Mellitus whereas the complainant was given treatment as indoor patient for Percutaneous Transluminal Coronoary Angioplasty. The clarification sought by the TPA has been explained by the hospital wherein OP No.3 has admitted having written by mistake the status of the complainant as known case of hypertension and has taken medicine ‘amlopress’ for 2-3 days 3-4 years back as per advise of the doctor. Since the complainant was not given benefit of cashless facility, therefore, upon discharge from hospital he has submitted his claim for reimbursement of Rs.2,83,989/- to OP No.1 and 2 on 01.07.2014. The submission of medi claim for reimbursement by the complainant is not denied by OP Nos.1 and 2. OP Nos.1and 2 have repudiated the claim on the ground that the complainant has withheld the information regarding his being diagnosed as K/c/o HTN 3-4 years back and, therefore, has violated the terms of the policy i.e. Incontestability & Duty of Disclosure Clause of the policy. Hence, the Ops have denied any deficiency in service on their part and stood by their version of repudiation of the claim in the written statement. Aggrieved by the act of the OP Nos.1 and 2 the complainant has filed the present complaint.
8. In order to prove his case of fair and bonafide disclosure about the status mentioned in the proposal form, the complainant has relied upon Ex.C-1 i.e. the policy document containing information sheet Page-22 wherein he has disclosed under the column ‘pre existing illness/injury – None’ and the Ops have relied upon the same and issued the complete health insurance policy. Further the complainant has filled up the questionnaire Ex.OP-1/8 while answering the claim query on 29.08.2014 wherein a specific question has been asked by the Ops to the complainant “since when have you been suffering from hypertension and what treatment have you taken for the same, answer – had high blood pressure four years back in the year 2010 and took amlopress for 3-4 days.” Further as per complainant the treating doctor has inadvertently and wrongly entered DM instead of HTN in the emergency notes and the said correction has been clarified to the TPA vide Ex.C-6 by OP No.3. As per discharge summary Ex.C-7 issued by OP No.3, against the column ‘past history’, the following remarks have been entered by the treating doctor:
“Patient was not taking and medication for hypertension and he took ‘amplopress’ for two days 3-4 years back as told by the patient himself.”
9. As per the complainant there is no misrepresentation or incorrect statement, misdescription or non disclosure of his previous illness of hypertension in the proposal form which has been duly relied upon by the Ops while issuing him the policy. The stand of the Ops of repudiating the claim as per Ex.C-9 is based on the case history as mentioned in the discharge summary Ex.C-7 issued by OP No.3. The mere reliance of OP Nos.1 and 2 on the past history of the patient as recorded in the discharge summary without producing any cogent evidence to prove that the complainant has taken treatment of hypertension from any other hospital prior to purchase of the policies does not prove the stand of the Ops to repudiate the claim on the basis of non disclosure of his pre existing disease.
10. The information regarding the hypertension status of the complainant has been fairly disclosed by him while signing the questionnaire duly signed on 29.08.2014. At no point of time there is inconsistency regarding the stand of the complainant regarding his hypertension status and the treatment taken by him either while clarifying the claim query against claim No.220100278661 or giving past history to the treating doctor while admission in the hospital. The onus was on the Ops to prove the existence of pre-existing disease K/c/o HTN 3-4 years back at the time of purchase of policies and subsequently at the time of renewal of the policies and the Ops have failed to produce any cogent evidence in this regard. Thus, the repudiation of the claim by the OP No.1 and 2 on wrong footing by taking the shelter of pre existing disease within the exclusion clause of the policy i.e. 48 months before the policy inception i.e. 12.04.2012 is not legal and the act of OP Nos.1 and 2 is an act of deficiency in service and unfair trade practice on their part. In support of our above findings we reply on the decision of Hon’ble National Commission in Manager, Bajaj Allianz Life Insurance Co. Ltd. & others Vs. Mrs. Raj Kumar, 2014(3) CLT 49. As the complainant has not been able to prove the act of deficiency in service on the part of OP No.3, therefore, qua OP No.3 the complaint is dismissed. Thus, the complaint deserves to be allowed against OP Nos.1 and 2 and the complainant deserves to be compensated for mental agony and harassment.
12. The complaint is allowed against OP No.1 and 2. Both OP No.1 and 2 are jointly and severally liable to:
(a) pay to the complainant the amount of Rs.2,83,989/- (Rs. Two lacs eighty three thousand nine hundred eighty nine only) against claim No.220100278661 alongwith interest @ 9% per annum w.e.f. 22.04.2015 till realization.
(b) pay to the complainant a lump sum compensation of Rs.25,000/- (Rs. Twenty five thousand only) for mental agony, harassment and costs of litigation.
13. Compliance of the above order be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.
Pronounced.
October 05, 2015.
(Mrs. Madhu P. Singh)
President
(Amrinder Singh Sidhu)
Member
(Mrs. R.K. Aulakh)
Member
