CC No.53.2016

Filed on 11.01.2016

Disposed on.18.12.2017

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU– 560 027.

DATED THIS THE 18^th DAY OF DECEMBER 2017

CONSUMER COMPLAINT NO.53/2016

PRESENT:

Sri.  H.S.RAMAKRISHNA B.Sc., LL.B.

        PRESIDENT

             Smt.L.MAMATHA, B.A., (Law), LL.B.

                      MEMBER

                                         V/S

ORDER

BY SRI.H.S.RAMAKRISHNA, PRESIDENT

1. This Complaint was filed by the Complainant on 11.01.2016 U/s 12 of the Consumer Protection Act, 1986 and praying to pass an Order directing the Opposite Party to pay a sum of Rs.7,37,593/- along with 12% p.a. interest from the date of this complaint until the date of its Payment as compensation and other reliefs.

2. The brief facts of the complaint can be stated as under:

In the Complaint, the Complainant alleges that the Complainant secured a policy of medical insurance bearing Policy No.30410762201500 titled as Heartbeat Gold 05 Lakhs One Adult Policy for a period of 1 Year commencing from 22.03.2015 to 21.03.2016.   The Complainant on 22.10.2015 fell from a staircase at his work place as a result of which he suffered fracture of middle finger on left hand, a fracture of the tailbone and a dislocation of his right shoulder.  The Complainant having suffered these injuries consulted Dr.Garav Sharma, who having reduced the fracture of the middle finger and suggested treatment for the fracture sustained to coccyx opined that considering the fact that the Complainant had suffered an injury on the same shoulder 6 years ago and had sustained another injury about 1 year ago, which had resulted in swelling of the joint, it was essential that the Complainant undergoes a surgery for the purpose of treating the injury that was suffered on 22.10.2015.  The Complainant also underwent a Magnetic Radiological Investigation on 23.10.2015.  The Complainant was scheduled to undergo surgery at the Bhagwan Mahaveer Jain Hospital on 09.11.2015.  As a precursor to said surgery the Complainant approached the Opposite Party and informed them of the accident and of the fact he would be required to undergo a surgery.  The Opposite Party affirmed to the Complainant that the expenses incurred for the treatment of the injuries consequent to the aforementioned accident would be covered under the insurance policy secured by the Complainant.  The Opposite Party required the Complainant to submit requisite papers for preapproval through the hospital designated for surgery, namely Bhagwan Mahaveer Jain Hospital.  Accordingly got admitted to Bhagwan Mahaveer Jain Hospital on 08.11.2015.  The Opposite Party a pre authorization was sought from the Opposite Party and the requisite documents for the same were submitted for preapproval by Bhagwan Mahaveer Jain Hospital.  On 10.11.2015 the Opposite Party granted a pre-approval for the surgery and sanctioned a sum of Rs.1,50,000/- towards the said medical procedure.  The Complainant was operated upon at the Bhagwan Mahaveer Jain Hospital on 09.11.2015.  The hospital informed the Complainant that he could be discharged on 11.11.2015.  Accordingly the hospital sent the details relating to surgery for the purpose of ensuring payment due to the hospital.  At this stage the Complainant now learnt that the Opposite Party has refused to make payment due to the hospital for the expenditures incurred on the surgery.  After repeated follow ups the Opposite Party addressed an email to the Complainant on 13.11.2015 informing that his claim has been rejected and the authorization previously given has been cancelled on the ground that since the Complainant had the similar accident 6 years ago the nature of ailment will be treated as a preexisting condition and accordingly will not be covered under the insurance policy secured by the Complainant.   In the result the Complainant had to undergo two additional days of hospitalization, i.e., on 12.11.2015 and 13.11.2015 only to be told on 13.11.2015 that the Opposite Party has refused to make required payments to the said hospital.  Faced with this circumstances, the Complainant was forced to borrow money from several persons to make the required payment to the hospital for the surgery that was conducted upon the Complainant.  The Complainant as a result of accident that he suffered on 22.10.2015, incurred various expenditure, which the Opposite Party was liable to have reimburse, i.e., a sum of Rs.2,37,593/-. After the Complainant was discharged from the hospital, the Complainant submitted the claim form with Opposite Party for reimbursement of the expenses incurred.  While the claim forms were submitted on 17.11.2015 the Opposite Party as on 23.12.2015 again rejected the claim of the Complainant.  However, on this occasion the claim has been rejected not on the ground that the accident was preexisting condition, but on the ground that the Complainant had failed to disclose a previous accident that he had suffered 6 years ago or of the swelling injury that he had about a year before the policy was secured.  The Complainant has truthfully answered all questions that were asked to him about his health condition. The Complainant did not have any preexisting illness or condition.  While it is true that the Complainant has previously sustained an injury, the claim of the Opposite Party that it was a preexisting condition is untenable.  The Complainant was never asked about the various injuries that he had suffered and sustained during his lifetime.  The Complainant was specifically queried about certain illnesses/physical conditions, all of which the Complainant has truthfully answered.  The assertions that the Complainant was under a duty to disclose that he had suffered a dislocation of shoulder about 6 years ago or that as a result of an impact the Complainant had swelling about 1 year prior to the date of surgery are not matters on which disclosure was required or essential at the time of taking the policy.  Non-disclosure of these facts in any event will not constitute “material non-disclosure”.   The Opposite Party, who was bound to honour its obligation to indemnify the Complainant, for the medical expenditure that the Complainant had to bear, as a result of an accident he met with on 22.10.2015, when he fell from staircase at his workplace.  The Opposite Party has sought to use a specious plea to deny the rightful claim of the Complainant.  The Complainant had to put immense effort to receive the payments towards the expenditure incurred for surgery.  The Complainant was made to run from pillar to post while he was hospitalized, only to receive no response what so ever.  To aggravate the agony of the Complainant, there was no source or point contact shared with him despite his request for the same and therefore the Complainant was unable to reach the concerned authorities to remedy the situation. In addition to this trauma, the Complainant had to undergo two further days of hospitalization while the doctors had indicated that he could be discharged. During this entire period, through different people, though the Complainant himself, through his brother and his other relatives and friends made several attempts to contact the Opposite Party, but there was no response from the Opposite Party.  The Opposite Party in rejecting the claim particularly after the claim was preapproved and thereby subjecting the Complainant to further trauma and harassment are also liable to compensate the Complainant in a further sum of Rs.5,00,000/- on this account.  Accordingly, it is just and essential that the Opposite Party be directed to pay a sum of Rs.7,37,593/.    Hence, this complaint.

3. In response to the notice, the Opposite Party put their appearance through their Counsel and failed to file their version.  The Opposite Party filed Application for permit him to file their version, but that application after hearing both parties rejected by this Forum as against this Order.  The Opposite Party approached the Hon’ble State Commission in Revision Petition No.47/2016, the said Revision Petition filed by the Complainant was also dismissed on 29.06.2017, thereby Order passed by this Forum is confirmed by the State Commission. 

4. The Complainant, Sri.Kiran G has filed his affidavit by way of evidence and closed his side.  Heard the argument.

5.      The points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Party ?
2. If so, to what relief the Complainant is entitled ?

6.     Our findings on the above points are:-

                POINT (1):-  Affirmative

POINT (2):-  As per the final Order

REASONS

7.   POINT NO.1:- It is the case of the Complainant that the Complainant secured Heartbeat Gold 05 Lakhs Medical Insurance Policy bearing No.30410762201500 for a period of 1 Year commencing from 22.03.2015 to 21.03.2016.   This fact is not been denied or disputed by the Opposite Party.  Further to establish the same, the Complainant in his sworn testimony, he has reiterated the same and produced copy of the policy.  By looking into this document, it clearly reveals that the Complainant had purchased policy bearing No.30410762201500 from Opposite Party commencing from 22.03.2015 to 21.03.2016 and sum assured Rs.5,00,000/-.  This evidence of the Complainant remains unchallenged.  Therefore, it is proper to accept the contention of the Complainant that the Complainant secured a Medical Insurance Heartbeat Gold 05 Lakhs policy bearing No.30410762201500 for a period of one year commencing from 22.03.2015 to 21.03.2016.

8. It is further case of the Complainant that on 22.10.2015 fell from a staircase at his work place as a result of which he suffered fracture of middle finger on left hand, a fracture of the tailbone and a dislocation of his right shoulder.  The Complainant having suffered these injuries consulted Dr.Gaurav Sharma, who having reduced the fracture of the middle finger and suggested treatment for the fracture sustained to coccyx opined that considering the fact that the Complainant had suffered an injury on the same shoulder 6 years ago and had sustained another injury about 1 year ago, which had resulted in swelling of the joint, it was essential that the Complainant undergoes a surgery for the purpose of treating the injury.   Even this fact is also not been denied or disputed by the Opposite Party.  Further to substantiate this, the Complainant in his sworn testimony, he has reiterated the same and produced Description issued by Dr.Gaurav Sharma.  As looking into this, it reveals that the Complainant fell from a staircase at his work place as a result of which he suffered fracture of middle finger on left hand, tailbone and a dislocation of his right shoulder and suggested treatment for the fracture sustained to coccyx opined.  This evidence of the Complainant remains unchallenged.  Therefore, it is proper to accept the contention of the Complainant that on 22.10.2015 the Complainant fell from a staircase at his work place as a result of which he had suffered fracture of middle finger on left hand, a fracture of the tailbone and a dislocation of his right shoulder.

9. It is further case of the Complainant that the Complainant underwent a Magnetic Radiological Investigation on 23.10.2015. The Complainant was scheduled to undergo surgery at the Bhagwan Mahaveer Jain Hospital on 09.11.2015.  As a precursor to said surgery the Complainant approached the Opposite Party and informed them of the accident and of the fact he would be required to undergo a surgery.  The Opposite Party affirmed to the Complainant that the expenses incurred for the treatment of the injuries consequent to the aforementioned accident would be covered under the insurance policy secured by the Complainant.  The Opposite Party required the Complainant to submit requisite papers for preapproval through the hospital designated for surgery, namely Bhagwan Mahaveer Jain Hospital.  Accordingly got admitted to Bhagwan Mahaveer Jain Hospital on 08.11.2015.  The Opposite Party a pre authorization was sought from the Opposite Party and the requisite documents for the same were submitted for preapproval by Bhagwan Mahaveer Jain Hospital.  On 10.11.2015 the Opposite Party granted a pre-approval for the surgery and sanctioned a sum of Rs.1,50,000/- towards the said medical procedure.  The Complainant was operated upon at the Bhagwan Mahaveer Jain Hospital.  The hospital informed the Complainant that he could be discharged on 11.11.2015.  Accordingly the hospital sent the details relating to surgery for the purpose of ensuring payment due to the hospital.  At this stage the Complainant now learnt that the Opposite Party has refused to make payment due to the hospital for the expenditures incurred on the surgery.  After repeated follow ups the Opposite Party addressed an email to the Complainant on 13.11.2015 informing that his claim has been rejected and the authorization previously given has been cancelled on the ground that since the Complainant had the similar accident 6 years ago the nature of ailment will be treated as a preexisting condition and accordingly will not be covered under the insurance policy.   Even this fact is also not been denied or dispute by the Opposite Party.  On the other hand, to substantiate this, the Complainant in his sworn testimony, he has reiterated the same and produced MRI Right Shoulder.  As looking into this, it clearly reveals that the Complainant had depressed fracture of the postero-supero-lateral portion of head of humerus is noted suggestive of Hill-Sachs Lesion.   Neck of the humerus is normal, Greater and lesser tuberosities are normal, Acromio-clavicular joint arthritis, Supraspinatus tendon appears hyperintense on PDFS suggestive of tendinosis and also produced the admit instructions issued by the Bhagwan Mahaveer Jain Hospital and History and Initial Assessment Form, it is clearly reveals that the Complainant fell from a stair case on 22.10.2015 and sustained injuries, as a result dislocation of his Right Shoulder.  For that reason, the Complainant admitted to the Bhagwan Mahaveer Jain Hospital, Dr.Gaurav Sharma has advised to undergo surgery, he also produced the Pre Authorization Form.  As looking into this Pre Authorization Form, the proposed surgery cost approximately Rs.2,52,450/- and also produced the Operation Record.  By looking into the document, it is very clear that the Complainant undergone surgery at Bhagwan Mahaveer Jain Hospital on 09.11.2015 and also produced the Denial of Authorization.  As looking into this document, it clearly reveals that the Denial of Authorization issued by the Opposite Party Bhagwan Mahaveer Jain Hospital with respect to the Complainant informing that Pre Authorization Form request for the above customer.  Our medical consultants appreciate sending the Information and have processed the same.   Regret to inform that the Opposite Party cannot issue a Letter of Authorization for the hospitalization of the above customer due to reasons detailed below.  In accordance with Clause 4(a), benefit will not be available for Pre-existing Conditions until 48 months of continuous coverage have elapsed since inception of the first Policy.  Hence this cashless request cannot be approved.  This evidence of the Complainant has not been denied or disputed by the Opposite Party. From this evidence placed by the Complainant, it is very clear that the Complainant fell from a staircase at his work place on 22.10.2015 as a result, he had a fracture and dislocation of his Right Shoulder and after consultation with the Dr.Gaurav Sharma, he has advised to undergo surgery, on his advice the Complainant admitted in Bhagwan Mahaveer Jain Hospital and also undergone surgery on 09.11.2015 but the Opposite Party failed to honour the cashless facility.  On the ground that the accident was preexisting condition.

10. It is further case of the Complainant, the Complainant had to undergo two additional days of hospitalization, i.e., on 12.11.2015 and 13.11.2015 only to be told on 13.11.2015 that the Opposite Party has refused to make required payments to the said hospital. Faced with this circumstances, the Complainant was forced to borrow money from several persons to make the required payment to the hospital for the surgery that was conducted upon the Complainant.  The Complainant as a result of accident that he suffered on 22.10.2015, incurred various expenditure, which the Opposite Party was liable to have reimburse, i.e., a sum of Rs.2,37,593/-.  After the Complainant was discharged from the hospital, the Complainant submitted the claim form with Opposite Party for reimbursement of the expenses incurred.  While the claim forms were submitted on 17.11.2015 the Opposite Party has on 23.12.2015 again rejected the claim of the Complainant.  However, on this occasion the claim has been rejected not on the ground that the accident was preexisting condition, but on the ground that the Complainant had failed to disclose a previous accident that he had suffered 6 years ago or of the swelling injury that he had about a year before the policy was secured.  The Complainant has truthfully answered all questions that were asked to him about his health condition.  The Complainant did not have any preexisting illness or condition.  While it is true that the Complainant has previously sustained an injury, the claim of the Opposite Party that it was a preexisting condition is untenable.  Even this fact is not denied or disputed by the Opposite Party.  Further to substantiate this, the Complainant in his sworn testimony, he has reiterated the same and produced bills.  By looking into these bills, it clearly reveals that the Complainant had spent sum of Rs.2,22,668/-.  After discharged from the hospital, the Complainant submitted the Claim Form, but the Opposite Party instead of honour the Claim Form rejected this claim of the Complainant, but on the ground that the Complainant had failed to disclose a previous accident.  The rejection of the Claim of the Complainant is due to previous accident, he had suffered a dislocation of shoulder about 6 years back, but there is no evidence.  Therefore, it is not proper on the part of the Opposite Party to reject the claim of the Complainant instead of honouring the Claim Form.  On the other hand, as the evidence placed by the Complainant, it clearly reveals that the Complainant had sustained injury as a result of which he suffered a fracture and due to that on the advice of Dr.Gaurav Sharma, he had been admitted to the Bhagwan Mahaveer Jain Hospital and undergone surgery on 09.11.2015 before conducting surgery the Complainant made request with the Opposite Party for cashless facility.  Initially, the Opposite Party had sanctioned Rs.1,50,000/- but subsequently, the Opposite Party cancelled the said sanction as per Letter dt.13.11.2015. As a result, the Complainant unnecessarily had to stay in the hospital for two days and thereafter the Complainant with help of his friends and relatives.   The Complainant had paid Medical expenses incurred for surgery.  From this evidence, further reveals that the Complainant had spent sum of Rs.2,22,668/- but the Opposite Party instead of honour the claim rejected the claim of the Complainant.  On the ground that there is a Preexisting condition, thereby the rejection and repudiation of the claim of the Complainant is not on a proper ground and the Opposite Party is not adopted proper procedure before rejecting the claim of the Complainant, thereby, it amounts to deficiency of service.  Even though the Complainant made several requests to honour the claim of the Opposite Party, the Opposite Party failed to honour the claim and it causes mental agony to the Complainant, thereby the Complainant is entitled for compensation for causing mental agony and also he is entitled for reimbursement of the Medical expenses of Rs.2,22,668/-.  Hence, this point is held in the Affirmative.

11. POINT NO.2:- In the result, for the foregoing reasons, we proceed to pass the following order:

ORDER

The complaint is allowed partly holding that there is deficiency of service by the Opposite Party.

The Opposite Party is to reimburse the Complainant for a sum of Rs.2,22,668/- which was the medical expenses incurred by the Complainant for his treatment at Bhagavan Mahaveer Jain Hospital.

The Opposite Party is directed to pay a sum of Rs.50,000/- as compensation for causing mental agony to the Complainant.  The Opposite Party is also liable to pay a sum of Rs.5,000/- towards cost. 

The Opposite Party is directed to pay the aforesaid amount within 30 days from the date of receipt of this order.  Failing which the aforesaid amount will carry interest at 12% p.a. from the date of order till the date of payment.

Supply free copy of this order to both the parties.  (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, 18^th day of December 2017)

       MEMBER                                            PRESIDENT

LIST OF WITNESSES AND DOCUMENTS

 Witness examined on behalf of the Complainant:

1. Sri.Kiran G, who being the Complainant has filed his affidavit.

 List of documents filed by the Complainant:

1. Copy of Insurance Policy issued by the Opposite Party.
2. Copy of the prescription issued by Dr.Gaurav Sharma on 22.10.2015.
3. Copy of the MRI Report.
4. Admission records relating to the Complainant at Bhagwan Mahaveer Jain Hospital
5. Copy of the pre authorisation form for cashless hospitalisation and treatment of the Complainant at Bhagwan Mahaveer Jain Hospital
6. The operation Record
7. Copies of the communication cancelling the pre authorisation
8. Bills and invoices evidencing the expenditure incurred by the Complainant
9. Email Correspondences with the Opposite Party.

Witness examined on behalf of the Opposite Party:

                             -NIL-

List of documents filed by the Opposite Party:

-NIL-

MEMBER                                           PRESIDENT