Date of Filing:29/02/2016

Date of Order:28/11/2018

BEFORE THE BANGALORE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHANTHINAGAR BANGALORE -  27.

Dated:28^th DAY OF NOVEMBER 2018

PRESENT

SRI.H.R. SRINIVAS, B.Sc., LL.B. Rtd. Prl. District & Sessions Judge And PRESIDENT

SRI D.SURESH, B.Com., LL.B., MEMBER

COMPLAINT NO.344/2016

Vs

ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT:

1.     This is the Complaint filed by the Complainant U/S Section 12 of Consumer Protection Act 1986, against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service by repudiating the medical claim and expenses of the complainant’s daughter and to direct the O.P to pay Rs.16,014/- towards medical expenses Rs.10,000/- towards litigation expenses and Rs.70,000/- as compensation and other reliefs as this Forum deems fit.

2.     The brief facts of the complaint are that: complainant for himself, his wife and three daughters obtained Health Insurance Policy from the O.Ps and renewed thereafter and valid up to 7^th December 2016.  His daughter by name Sophy Gray Veronica had throat pain on 13.08.2015 and was taken to Apollo Hospital and Doctor advised her to be admitted and was admitted as an inpatient from 04.12.2015 to 06.12.2015 (for a period of three days) and she was given  examined, given treatment and also given medicines and was discharged. The said health condition was no way related to her previous medical conditions as per the doctor’s report.  He made a claim for the hospital expenses which the O.P rejected on 10.02.2016 after obtaining the medical details of his daughter on the ground that he has suppressed and not disclosed his daughters previous diseases/medical conditions which is violative of first condition of the insurance policy and hence the complaint.

3.     Upon service of notice, O.Ps appeared before the Forum through its advocate and filed its version contending that the complaint is not maintainable, has no merit and is liable to be dismissed in limine. It is further contended that the complainant is not a consumer and no allegation of deficiency in service and unfair trade has been made against.  There shall be a pious relationship of Uberrima Fides between the parties. The claim of the complainant for cash less treatment was rejected.  The complainant has not disclosed the previous medical conditions and treatment taken by his daughter and hence is violation of the conditions laid down in the policy of insurance. It is also violation of Section 17, 18, and 19 of the Contract Act.  The complaint is filed on false and frivolous grounds. It has admitted the issuance of the policy in favour of the complainant and his daughter subject to the limitations, terms and conditions mentioned in the policy. At the time of taking the policy the same was revealed.  It has also admitted the claim made by the complainant and at the time of investigation, it was found that the complainants’ daughter that is the patient was diagnosed for deficiency of GGPD since 2008. The same was not disclosed. The claim made by the complainant in respect of his daughter is for nasal blockage,  headache and probable diagnosis of acute raino along with Sinusitis Tetany and  the claim is for Rs.16,014/-. After receipt of claim, complainant was requested to furnish the details of the treatment since 2012 and also past investigation reports, consultation paper and followup record pertaining to Sinusitis Tetany.

4.     After scrutiny of the documents produced, it came to know that the patient was suffering from Left Frontal Lobe Granuloma since 2012 and undergone treatment in Santosh Hospital. In view of the non-disclosure, it issued termination letter on 07.02.2015 and repudiation letter on 09.02.2016.  Hence prayed the Forum to dismiss the complaint on the basis of concealment of material facts and that there is no cause of action for filing the complaint.

5.   In order to prove the case, complainant and O.Ps filed affidavit evidence and also produced documents. Heard the arguments. The following points arise for our consideration:-

(1)   Whether the complainant has proved the

      deficiency in service on the part of the O.Ps?

(2)  Whether the complainant is entitled to

     the relief prayed for in the complaint?

6.     Our answers to the above points are:-

POINT 1:        In the Affirmative.

POINT 2:        Partly in the Affirmative

                       for the following:

REASONS

POINT No.1:-

7.     It is not in dispute that the complainant had obtained health insurance from the O.P No.1 for his daughter. It is also not in dispute that she was admitted to the hospital on 04.12.2015 for Sinusitis Tetany and was discharged on 06.12.2015. The complainant mentioned therein is, history of headache and nasal blockage since three days. History of pain and numbness feeling over the left hand since two days.  Complainant has also produced the receipt for having paid Rs.16,014/-, has also produced letter from the Apollo hospital issued by Dr. Raghavendra Prakash that Sofi’s case of Sinusitis Tetany is nowhere related to her pain or incidental finding of a frontal lobe granuloma. The claim made by the complainant in respect of his daughter has been rejected on the ground that earlier medical conditions /diseases were not informed and suppressed, which is violation of the conditions of the policy.

8.     O.P. rejected the claim for the above reason after collecting medical evidence to show that she was having Left Frontal Lobe Granuloma and same was suppressed by her.  Medical records have been produced to that effect.  Even if it is considered that the same was not intimated, it do not amount to suppression since as per the doctors letter, the said medical condition is in no way a reason for the Sinusitis Tetany suffered by the daughter of the complainant.  Sinusitis Tetany is a common phenomina due to the bad whether condition of Bengaluru and due to non-availability of good air for breathing and due to pollution of the air due to the presence of very high carbon monoxide emanating from the vehicular traffic.  In view of this the repudiation of the policy amounts to deficiency in service. Hence we answer Point No.1 in the Affirmative.

POINT No.2:

9.     There is no dispute regarding the amount claimed by the complainant.  The hospital receipts and bills shows that she has  paid Rs.16,014/- towards hospitalization charges which includes lab test, medicines, nursing charges and ward rent. Since the policy in force, she is entitle to the same. Though the O.Ps after the claim was made, rejected the claim and cancelled the insurance policy. This also amounts to unfair trade practice. 

10.   The complainant has claimed litigation charge of Rs.10,000/- and Rs.70,000/- as compensation. No proof of paying the advocate fee and incurring expenses to the extent of Rs.10,000/- and suffering to the extent of Rs.70,000/- has been placed before this Forum. Even then, the  complainant has been put to mental agony, stress and also physical strain and financial loss suffered on account of approaching this Forum and we quantify the same at Rs.5,000/- and also Rs.5,000/- towards the cost of the litigation expenses and direct O.P to pay the same to the complainant. Hence we answer Point No.2 Partly in the Affirmativeand pass the following:

ORDER

1. The Complaint is hereby partly allowed with cost.

2. O.P No.1 and 2 are jointly and severally hereby directed to pay a sum of Rs.16,014/- along with interest at the rate of 12% per annum from the date of repudiation till the date of paying full amount to the complainant.

3. Further O.Ps are directed to pay Rs.5,000/- towards damages and Rs.5,000/- towards cost of the litigation expenses.

4. The O.Ps arehereby directed to comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.

5.  Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 28^thDay of NOVEMBER 2018)

MEMBER                            PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

 Doc.No.1: Copy of the Aadhaar card of Sophy Gray Veronica R.

Doc.No.2: Copy of the Query Letter dtd:18.1.2016.

Doc.No.3: Copy of the First Reminder letter dt: 27.1.2016.

Doc.No.4: Copy of the Claim Form.

Doc.No.5: Copy of the Discharge summary.

Doc.No.6: Copy of the bills and prescriptions.

Doc.No.7: Copy of the query letter dt:11.12.2015.

Doc.No.8: Copies of hospital records.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Smt.Deepti Rustagi, Authorized Representative of O.Ps

Copies of Documents produced on behalf of Opposite Party/s

Annexure-1: Copy of the Power of Attorney.

Annexure-2:  Copy of the Proposal Form of O.P.

Annexure-3: Copy of the schedule of Easy Health Floater Standard policy

Annexure -4: Copy of Medial insurance policy issued by O.P.

Annexure-5: Copy of additional information request form dt:5.12.2015.

Anexure-6: Copy of cashless service letter dt:6.12.2015.

Annexure-7: Copy of the claim form.

Annexure-8: Copy of the query letter dated 12.12.2015.

Annexure-9: Copy of the consultation records.

Annexure-10: Copy of the letter for notice for termination.    

MEMBER                        PRESIDENT