Date of filing:17.05.2019

                                                              Date of Disposal:27.10.2022

BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

                               BENGALURU – 560 027.

DATED THIS THE 27^th DAY OF OCTOBER, 2022

CONSUMER COMPLAINT NO.806/2019

PRESENT:

SRI.RAJU K.S,

SMT.REKHA SAYANNAVAR,:MEMBER

Kempuhuyeelegowda K.H,

Aged about 38 years,

R/at No.213/1, 8^th Cross, BHEL,

Rajarajeshwari Nagar,

Bangalore-560 098.……COMPLAINANT

Rep by Sri.C.Rajashekara, Advocate.

Max Bupa,

Health Insurance Company Limited,

Block B-1/1-2,

Mohan Co-operative

Industrial Estate,

Mathura Road,

New Delhi-110 044,

Rep by its Managing Director and

Chief Executive Officer. …….OPPOSITE PARTY-1

Max Bupa,

Health Insurance Company Limited,

G.R.Arcade, No.223,

Bengaluru-560 003,

Rep by its Manager. …….OPPOSITE PARTY-2

Rep by Sri.H.N.Keshava Prashanth, adv.,

*****

//JUDGEMENT//

BY SRI. RAJU K.S, MEMBER

The complainant has filed this complaint u/s 12 of the Consumer Protection Act-1986 seeking for reimbursement of medical expenses of Rs.1,33,919/- with interest at 18% p.a. from the date of repudiation.

2. The complainant had availed health insurance policy for a sum of Rs.26,00,000/- from opposite parties for the period of 16.06.2018 to 15.06.2019 by paying Rs.15,007/- on 14.06.2018.  The opposite party no.1 had issued a policy bearing No.30678460201801 on 14.06.2018 after receiving the payment to that effect.  The opposite parties had issued membership No.4160889 and customer ID No.2000308379 to complainant.  Earlier the complainant was indemnified by the opposite parties under health insurance policy No.30678460201700 for the period 16.06.2017 to 15.06.2018.  The complainant took treatment from 23.09.2018 to 26.09.2018 as in-patient in BGS Apollo Hospital, Mysore for PIVD, L4-L5 by paying Rs.1,33,919/- to hospital authorities.  The complainant had made claim No.369804 dt.21.11.2018 with opposite party no.2 for reimbursement of his hospital expenses.  Surprisingly, the opposite parties repudiated the claim of complainant by saying that he had undergone disc surgery on 22.04.2015 and the same has not been disclosed by the complainant.  The complainant did not take any kind of treatment to his disc or surgery in 2015 as stated in repudiation letter.  The repudiation of claim of complainant is illegal one and same should be honoured by allowing the complaint as prayed.

3. The opposite parties had admitted the inception of policy by the complainant and admitted that the policy was in force during treatment period.  But the opposite parties had taken specific contention that the complainant not disclosed the fact of earlier treatment i.e., on 22.04.2015 undergone for disc surgery.  Same has been suppressed by the complainant and the complainant not entitled to any claim, due to non-disclosure of material facts and repudiated the claim.

4. The complainant is examined as PW1 by filing affidavit and got marked EX.P1 to P10 documents. The opposite party has also examined his Branch Manager as RW1 by filing affidavit and got marked EX.R1 to R7 documents. 

5. Both the parties have filed written arguments. 

       6. The points that would arise for consideration are as under:

i) Whether the complainant proves the deficiency of service on the part of the opposite parties ?

ii) Whether the complainant is entitled to reliefs as sought for in the complaint ?

iii) What order ?

    7.   Our findings on the aforesaid points are as follows:

Point No.1 :  In affirmative

Point No.2 :  Partly in affirmative

Point No.3 :  As per the final order for the following;

REASONS

  8.POINT NO.1:- In this complaint, it is admitted fact that the complainant was indemnified by the opposite party under policy No.30678460201801 for the period of 16.06.2018 to 15.06.2019.  Further, it is also admitted fact that the complainant took treatment as in patient in BGS Apollo Hospital, Mysore on 23.09.2018 to 26.09.2018 for the PIVD L4-L5 disc surgery by paying Rs.1,33,919/-.  The opposite parties had repudiated the claim as per Ex.P6 and P7 by saying that the complainant had undergone surgery in 22.04.2015 and same was not informed to the opposite parties at the time of inception of policy and due to non-disclosure of material facts the complainant not entitled for reimbursement of claim.  EX.P8 Discharge Summary reveals that the complainant diagnosed for PIVD L4-L5 with RADICULOPATHY with complaint of low back pain since one day, and he had undergone surgery for L4-L5 LUMBAR DISCECTOMY on 25.09.2018.  But in hospital course and treatment given column said that the “Patient presented with above complaints.  HIS MRI LS Spine Showed PIVD L4-L5 with right L5 root compression. He underwent L4-L5 MICRO LUMBAR DISCECTOMY under GA on 22.04.2015.  Postoperative period was uneventful.  During his stay in the hospital he was treated with IV fluids, antibiotics, analgesics and other supportive measures.  He improved symptomatically.  

Condition at discharge, comfortable ambulant, no radicular pain, aferbrile, vitals stable, CVS/RS/PA:NAD.  He is being discharged with the following advice.”

9. From the reading of above words, the complainant was treated for his L4-L5 MICROLOMBAR DISCETOMY Surgery under general anaesthesia on 22.04.2015.  As per complaint version it was on clerical error/typographical mistake happened in EX.P8.  For that aspect he examined the author of EX.P8 one Dr.Lokesh B.L (Neurosurgery) consultant Neuro and Spine Surgeon, Apollo BGS Hospital, Mysore by appointing court commissioner one Sridhar S.G Advocate.  The court commissioner duly executed the warrant on 06.03.2021 by giving notice to all necessary parties and examined the said Doctor Lokesh B.L as PW2 in their presence.  In pursuant of Hon’ble Commission order the court commissioner submitted deposition of PW2 with report.  In the deposition, PW2 Dr.B.L.Lokesh categorically denied the treatment taken by the complainant on 22.04.2015.  But based on operative notes, nursing notes and hospital records he deposed that he treated the complainant and the complainant underwent surgery on 25.09.2015 in his supervision and he was not treated the complainant in 2015 as stated in the EX.P8.  Further PW1 categorically said in page No.4 of his deposition the date mentioned as 25.04.2015 was a “clerical error”. 

10. From the evidence of PW2 and on reading EX.P8 in entirety it appears that the complainant took treatment on 25.09.2018 not on 25.04.2015.  Hence, the repudiation of claim of complainant is not at all sustainable.  Same is to be honoured by the opposite parties.  Further, as per policy condition the complainant is entitled for cashless treatment and same was unnecessarily rejected by the opposite parties.  Further other than the say in EX.P6 repudiation letter that in the Year 2015 GA operation was done no documents been produced by opposite parties to prove the same.  From the above discussion, we feel that the opposite parties are liable for deficiency in service to the complainant and they have to reimburse the claim of the complainant with interest from the date of discharge.  Hence, we answer point No.1 in affirmative. 

11.POINT NO.2:- The complainant claimed Rs.1,33,919/- hospital expenses paid to the BGS Apollo hospital Mysore. The same is not disputed by the opposite parties.  Hence, the complainant is entitled for Rs.1,33,91/- with 9% interest from the date of discharge i.e., 26.09.2018.  Further, the complainant is entitled to Rs.20,000/- towards mental agony and Rs.10,000/- towards litigation cost.  Hence, this point is answered partly in affirmative.

12.POINT NO.3:- In view of the discussion made above, we proceed to pass the following;

Complaint is allowed in part.

The opposite parties are directed to pay a sum of Rs.1,33,919/- to the complainant with interest at the rate of 9% p.a. from 26.09.2018 till realization.

Further, the opposite parties are directed to pay a sum of Rs,20,000/- towards mental agony and a sum of Rs.10,000/- towards litigation cost. 

The opposite parties shall comply the order within 30 days. In case, the opposite parties fail to comply the order within the said period, the above said amount of Rs.30,000/- carries interest at the rate of 9% p.a. from the date of order till realization.

Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.

Applications pending, if any, stand disposed of in terms of the aforesaid judgment.

(Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 27^th day of October, 2022)                                            

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA. K)    
•  

//ANNEXURE//

Witness examined for the complainantss side:

Sri.Kempuhuyeelegowda K.H, the complainant has filed his affidavit.

Documents marked for the complainants side:

1. The insurance certificate in respect of the policy no.30678460201801 issued by the opposite party in favor of complainant.
2. Another insurance certificate in respect of policy No.30678460201700 issued by the opposite party in favour of complainant along with the covering letter.
3. The policy documents which are in the form of two booklets issued by the opposite party.
4. The letter of denial of authorization dt.25.09.2018 addressed to Apollo BGS Hospital.
5. The denial letter dt.20.11.2018 sent to the complainant by the opposite party. 
6. The g-mail communication made by customer care to the complainant.
7. The copy of the discharge summary pertaining to the complainant dt.26.09.2018 issued by the Apollo Hospital along with the discharge summary.
8. Copy of the medical sickness certificate dt.03.10.2018.
9. Copy of the legal notice dt.11.12.2018 got issued by the complainant through his advocate to the opposite party and postal receipt.

 Witness examined for the opposite party side:         

Sri.Shiva Kumar, Branch Manager in opposite party-2 company has filed his affidavit.

Documents marked for the Opposite Parties side:

1. The terms and conditions of the policy.

2. The letter dt.25.09.2018 showing the denial of the authorization.

3. Pre-authorization form for cash less facility.

4. Copy of the membership card.

5. Insurance TPA beneficiary details.

6. Copy of the claim form submitted by the complainant.

7. Copies of the documents collected from the hospital pertaining to the complainant after taking his consent.

8. The claim reimbursement check list.

9. The payment details.

10. Letter dt.21.11.2018 addressed to the complainant sent by opposite parties cancelling the policy.

11. Investigation report.

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA, K)    
•