Date of Filing:14.12.2020

Date of Disposal:22.05.2023

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 pay  medical claim of Rs.7,41,417.31/- along with future  medical bills and to pay Rs.5,00,000/- for deficiency of service and  Rs.75,000/- for legal expenses and such other reliefs.

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

This is the case of the complainant that during 2016 the complainant secured health insurance policy from OP by paying insurance premium and the policy is No.30584801201600 and policyperiod from 26.09.2016 to 25.09.2018. Subsequently, the policy was renewed from 26.09.2018 up to 25.09.2020 and again policy was renewed vide no.30584801202002 from 26.09.2020 to 25.09.2022. The complainant further submits that during the course of the policy on 25.06.2020 the complainant admitted to hospital for Chronic Kidney Disease (CKD), Diabetes and Hypertension. The complainant discharged on 04.07.2020 with advice for follow up treatment of dialysis 03 times in a week. During the time of hospitalization the complainant informed the hospital authorities about health insurance coverage and Hospital authorities forwardeda cashless request to the OP, but the OP have declined to pay the medical claimstating that “the details submitted along with the pre-authorization suggest that patient has adverse medical condition due to which it is not possible to ascertain the liability at this juncture (due to gross non-disclosure of material facts(11.9)-diabetes, hypertension 25 years, CDK 08 years), hence cashless cannot be extended to this case and needs further verification” and also the OP declined the complainant medical claim of Rs.1,22,495.50/-. It is further submitted that the complainant was admitted to St.Martha’s Hospital on 23.07.2020 for the aforesaid ailments and discharged on 24.08.2020 and at the time of discharge the complainant was tested Covid-19 positive and he was treated in the same hospital for Covid-19 and discharged on 04.08.2020, for the above said treatment the complainant submitted Rs.2,08,348.53/- to the OP, but the OP declined the claim.  Once again the complainant admitted to the hospital and spent Rs.3,67,014.78/- for treatment. In all the complainant submits claim of Rs.7,41,417.31/- to the OP, but OP declined to refund the medical expenses.  The complainant got issued legal notice to OP on 20.10.2020 calling upon the OP to pay the all medical expenses of Rs.7,41,417.31/-. After receipt of notice the OP declined to settle the medical claim and finally OP has taken unilateral decision to terminate the Policy between 26.09.2020 to 25.09.2022 and refunded health insurance premium of Rs.85,314/- to the complainant.  Aggrieved the said act of the OP the complainant was forced to file the present complaint with such other reliefs.

3. Notice to OP-duly served, represented by counsel and filed written version and chief examination affidavit and also produced relevant documents in support of their pleadings.

4.  The complainant filed chief-examination affidavit along with relevant 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 Complainant prove that there is deficiency in service on the part of the OP as alleged in the complaint and there by prove that he is entitle for the relief sought?
2. What order?

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

Point No.1               :       Negative

Point No.2               :       As per final order

REASONS

8. POINT NO.1:-   On perusal of chief examination affidavit and also relevant documents of both parties and annexures  both in “A” series and “R” series, the commission opined as follows that the issuance of health insurance policy from OP to the complainant is not at all disputed by OP. It is also not in dispute that the said policy is valid policy as on the date of the admission of the complaint to the hospital and the treatment which took as inpatient during that period. The only dispute between the policy holder and OP insurance company is that due to non-disclosure of material facts (11.9) diabetes, Hypertension for 25 years, CKD for 08 years, for the violation of the terms and conditions of the policy which is mentioned at clause-11.9, cashless facility to the policy holder cannot be extended. By assigning said reason the OP Company has declined to settle the mediclaim of the complainant. On this ground the OP Company has rejected the insurance claim of the complainant which is covered under the said policy obtained by the complainant.

9. The complainant filed chief examination affidavit, wherein he has reiterated the complaint averments and also produced some of the relevant documents in support of their contention. The OP has also filed detailed chief examination affidavit and also produced relevant documents in support of their defence. The series of OP documents which are produced by the company got marked as “R” series from R1 to R11. On perusal of the documents, the commission found that Ex. annexure R8 & R9 is the clinching document which is produced by the OP company in order to substantiate the defence for the rejection of the complainant claim. These two piece of documents which are  got marked by OP- one is annexure R8 indoor case paper, which is produced by OP company. Wherein the doctor who has treated the complainant  when he took the treatment as inpatient clearly entered in the case sheet of the policy holder treatment, that the complainant was known patient  of CKD (Chronic Kidney Diseases)  since 08 years and this piece of document is followed by doctor certificate is another  clinching documentary evidence which is got marked as  annexure R-9, wherein doctor who has treated the policy holder stated when  was inpatient in the hospital has issued doctor certificate. The 2^nd document which is produced by OP company clearly goes to prove that the policy holder was CKD patient since 08 years, which is much prior to the availing said insurance policy. When this fact is not disclosed at the time of availing the policy by the policy holder, as per terms and conditions of the policy the conduct of the policy holder is a clear violation of insurance contract and its conditions laid down in the policy. The rejection of the complainant’s insurance claim by the OP Company is for the above said reason and when it is clearly established by the OP company that there is clear violation of the terms and conditions of the policy by policy holder and they are not liable to pay insurance claim amount to the policy holder. The terms and conditions of the policy are paramount in the insurance contract. If any one of the parties to the insurance contract violates the terms and conditions of the policy, the consequence is as per the insurance contract terms and conditions. The OP company has clearly and categorically established the defence with supporting evidence. The rejection of the insurance claim of the complainant is justifiable as per terms and conditions of the insurance contract. When such being the case, rejection of the complainant’s insurance claim amount is in accordance with law and also as per terms and conditions of the policy and it is observed that OP company has justified, their rejection of insurance claim. Under such circumstances, the claim of the complainant is hereby rejected. Accordingly, the Point No.1 we answer in negative.

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

                           ORDER

1. Complaint is hereby dismissed. 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 22^th May 2023)

(RAMACHANDRA M.S.)

PRESIDENT

       (NANDINI H KUMBHAR)             (CHANDRASHEKAR S.NOOLA)       

                 MEMBER                                        MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Smt.Rensilla Fernandes-who being the SPA holder of complainant

Documents produced by the complainant:

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

Documents produced by the OP:

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*