D.O.F:28/01/2022       

                                                                                                             D.O.O:29/12/2023

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION, KASARAGOD

CC.18/2022

Dated this, the 29^th day of December 2023

PRESENT:

SRI.KRISHNAN.K                                         : PRESIDENT

SMT. BEENA. K.G                                      :MEMBER

Philip Lukose, aged 61 years

Ullattil House, Mundott

Rajapuram P.O, Pin – 671532

Vellarikundu Taluk, Kasaragod Dist.                                       : Complainant

(Adv: A.K.V Balakrishnan)

                                                                                    And

1. Mathew T.V

M/s. Speed Link Tours and Travels

Rajapuram, Vellarikundu Taluk

P.O Rajapuram – 671532

(Adv: Vinay.M.E)

2. Care Health Insurance Ltd.

Unit No. 604- 607,

6. th floor Tower C, unitech Cyber Park

Sector – 39, Gurgaon 122001,

• Haryana

(Adv: Shrikanta Shetty.K)

ORDER

SRI. KRISHNAN.K : PRESIDENT

          The case of the complainant is that he obtained a medical insurance policy from Opposite Party No:2  through Opposite Party No:1 for a period between 06/11/2020 to 04/04/2021.  Terms and conditions of the policy are agreed.  The complainant went to U.K, on reaching there complainant felt chest pain on 11/01/2021 and admitted to hospital for treatment and became impatient.  Hospital authority conducted various test.  Complainant was diagnosed with type 2 diabetes with hyper tension.  Complainant was referred to James cook university hospital.  Angioplasty was done and discharged on 26/01/2021.  The complainant claimed for insurance benefit by submitting all the details, complainant but it was rejected.  The complainant sent letter to opposite party.  Due to the deficiency in service and negligence complainant suffered financial loss and mental agony, for which complainant claim medical bill Rs. 10,00,000/-, and Rs. 2,00,000/- for mental agony and Rs. 25,000/- as cost of litigation.

          The Opposite Party no: 1 filed written version saying that Opposite Party No: 1 is a stranger to the allegation made in the complaint.  And also stated that there is no deficiency in service from Opposite Party No:1 and prayed to dismiss the complaint against Opposite Party No:1.

          The Opposite Party No: 2 the Insurance company filed written version Opposite Party No:2 admitted issuance of insurance policy to complainant for the period in questions.  They denied that the complainant is diagnosed for diabetes from the hospital for the 1^st time.  Treatment of complainant is admitted to the extent of medical treatment records.  Refusal of liability is denied.  The Opposite Party No: 2 justified repudiating the claim for the following reasons.  Insured was professionally diagnosed with acute ceremony syndrome.  The company received cashless claim.  The complainant has no history of diabetes or high blood pressure or as any other ailment.

          The Opposite Party prays to dismiss the complaint with costs.

     The complainant filed chief affidavit and was cross examined by Opposite Parties Ext A1 to A11 marked.  Ext A1 copy of policy, Ext A2 discharge letter issued from hospital, Ext A3 discharge summary, Ext A4 intimation hospital, Ext A5 invoice of treatment, Ext A6 is the intimating the claim to Opposite Party No:2, Ext A7 is cash less rejection letter by Opposite Party No:2 Ext A8 is rejection letter to complainant, Ext A9 bills, Ext A10 is letter by Opposite Party No:2, Ext A11 is letter send by complainant.   The Opposite Party produced documents marked as Ext B1 to B4.

          Following points arised for consideration.

1. Whether repudiation of insurance benefits of the complainant is justified by legal and acceptable evidence?
2. Whether there is any deficiency in service from the part of Opposite Party No:1 and 2?
3. Whether complainant is entitled for compensation and if so for what reliefs?

     All points are discussed together and findings were recorded accordingly.  The claim relates to obtaining of medi claim insurance policy.  The policy holder  is admitted to hospital for treatment and claimed insurance benefits there under.  But claim is rejected for the reason that the disclosure clause shows past medical history of diabetes hyper tension, from his ED summary which clearly mentions the current medication along with blood pressure recording of 198/113.  The summary mentions as newly diagnosed as per insured due to language barrier and current test reading the past history is being recorded during his admission he was treated to diabetes and hypertension and NSTEML.  Hence Opposite party justified rejections of the claim.  The complainant sent Ext A11 representation claiming the medical bills challenging the repudiation letter respectively marked A10 and A11.

     Written version of Opposite Party No:2 shows that insurance policy contract is signed by the complainant after understanding and admitting the contents of the policy.  The law relating to medi claim, misrepresentation, description, non disclosure of any medical particulars withheld from scrutiny that the company have no liability.  According to Opposite Party they have no liability to make payment of any claim and the company rejected of claim as per policy terms.

     The commission finds that the contract terms and conditions policy of exclusion of liability on the ground of prior illness is not read over, nor agreed to and not subscribed the signature with free consent unless the insurance company has no claim case that terms and condition are not finally read over to the policy holds and not claim any valid reasons for detecting it.  The Opposite Party No:2 is liable to reimburse the insurance benefit.  It is true that insurance is a contract between two parties in good faith and both parties are bound by terms of the contract.  The Opposite Party has not adduced any legal or acceptable evidence to prove terms and conditions of the policy.  But at the same time case of the complainant is that he suffered illness and undergone treatment from a renowned hospital and therefore barring provisions is not explained to the policy holder and conditions imposed by the court are to be performed in the letter of spirit.

     From the evidence on record it is clear that complainant is entitled for benefits.  Hence commission directs Opposite Party No:2 to pay the medical bills and rejection of benefit is deficiency in service for which complainant is entitled for compensation and cost of the litigation.

     In the result complaint is allowed in part Opposite Party No: 2 is directed to pay the medical bill covered by bills with 8% interest from the date of complaint till realization and also pay Rs. 10,000/- ( Rupees Ten thousand only) as compensation for deficiency in service and Rs. 10,000/- (Rupees Ten thousand only) as cost of the litigation within 30 days of the receipt of the order.

      Sd/-                                                                                                            Sd/-

MEMBER                                                                                                PRESIDENT

Exhibits

A1- Copy of the policy Dt: 04/11/2020

A2 - Discharge letter issued from hospital

A3- Discharge summary

A4- Intimation given to hospital under gmail

A5- Invoice

A6- Gmail copy for intimating the claim to OP No: 2

A7-Cashless Rejection letter

A8- Rejection letter to complainant

A9- Bills

A10- letter issued by the insurance company

A11- Letter send by complainant

B1- claim form submitted by the complainant

 B2 – Rejection letter

B3- E.D Episode summary- Darlington Memorial Hospital

B4- Policy certificate with terms and conditions

Witness Examined

Pw1- Philip Lukose

      Sd/-                                                                                                  Sd/-

MEMBER                                                                                      PRESIDENT

Forwarded by Order

                                                                      Assistant Registrar

Ps/