Date of Filing : 22.12.2010
Date of Order : 23.09.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 23rd SEPTEMBER 2011
PRESENT
Sri. S.S. NAGARALE, B.A., LL.B. (SPL) …. President
Smt. D. LEELAVATHI, M.A., LL.B. …. Member
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 2973 / 2010
Mr. Giridhar Srinivas,
S/o. Mr. Srinivas,
Aged 54 years,
R/at No. A-14, ‘Casa Lavelle’,
Lavelle Road,
Bangalore – 560 001. ……. Complainant
V/s.
1. M/s. ICICI Lombard General Insurance
Company Limited,
II Floor, SVR Complex 89,
Hosur Main Road, Madiwala,
Bangalore – 560 068.
2. M/s. ICICI Lombard General Insurance
Company Limited,
Regd. Office: ICICI Towers,
Bandra-Kurla Complex,
Mumbai – 400 051. …… Opposite Parties
ORDER
(By the President Sri. S.S. Nagarale)
This Complaint is filed by the Complainant u/s. 12 of the Consumer Protection Act, 1986.
2. Brief facts of the case are that Complainant has taken health insurance policy from OP for the period from 27.12.2009 to 26.12.2010. OP collected premium amount of Rs.15,000/-. The sum assured is Rs.3.00 Lakhs. On 15.07.2010 due to shoe bite and fever he had taken treatment as out-patient. The Complainant admitted as an in-patient in the Hospital from 03.08.2010 to 21.08.2010 at Lakeside Medical Center Hospital, near Ulsoor Lake, Bangalore and incurred medical expenses of more than Rs.1,92,627/- and requested OPs to provide cashless facility. But there was no response from the OP. As such, immediately after discharge from the Hospital on 24.08.2010 he made claim with OPs with all enclosures. OPs though acknowledged the claim form has failed to reimburse the amount. OP by its letter dtd. 08.09.2010 requested the Complainant to submit additional documents. Complainant provided all the documents to OP. OP instead of reimbursing the medical expenses, intimated the complainant vide its Letter dtd. 19.10.2010 that claim cannot be settled since the claim was made with respect to pre-existing illness. Complainant made all efforts for convincing the OP that there was no pre-existing illness, but all his efforts went in vain. Complainant got issued legal notice calling upon the OP to pay the amount. As per Discharge summary, there was no significant of past history and it was found recently. Complainant was put to inconvenience, humiliation and mental agony. OP committed deficiency of service. Even after sending the notice, OP has not bothered to comply the demand nor given any reply to the legal notice. Hence, Complainant prayed that OPs be directed to pay Rs.1,92,627/- with interest and compensation of Rs.25,000/- for mental agony & harassment.
3. OP has filed defence version admitting issuance of health insurance policy. On the basis of the documents produced by the Complainant, it is noticed that treatment taken by the Complainant was for pre-existing disease and the same is not covered under the Policy. Hence, claim has been rejected by the OP on 19.10.2010 and the Complaint is liable to be dismissed.
4. Affidavit evidences are filed and Complainant has produced documents.
5. Arguments are heard.
6. Points for consideration are as under:
(1) Whether the Complainant has proved deficiency of service on the part of OP?
(2) Whether the Complainant is entitled for claim amount?
(3) Whether the OP is justified in repudiating the Mediclaim?
(4) What order and relief ?
7. I have gone through the pleadings of the parties and the documents very carefully. It is the case of the parties that Complainant has taken health insurance policy from 27.12.2009 to 26.12.2010. Complainant has paid premium amount of Rs.15,000/-. Benefit of hospitalization is Rs.3.00 Lakhs as per the Policy. Copy of the Policy is produced by the Complainant. The Complainant was admitted to Lakeside Medical Center & Hospital, Bangalore. The date of admission was on 03.08.2010 and the date of discharge was on 21.08.2010. Complainant has produced Discharge Summary of the Hospital. In the Discharge Summary of the Hospital, there is nothing to show that the Complainant had taken treatment for pre-existing disease. The only defence taken by the OP is that treatment taken by the Complainant was for pre-existing disease. But, the OP has not produced any single document or iota of evidence to show that the Complainant has taken treatment in any Hospital for his illness or disease before admitting to Lakeside Medical Center & Hospital on 03.08.2010. In the absence of any documentary evidence / proof, the defence of the OP cannot be accepted at all. It is very easy to take defence that disease was pre-existing and for that Complainant has taken treatment, but there must be some proof or documentary evidence to establish this defence. OP except taking defence in the version has not produced any evidence or Hospital records / documents to show that the present Complainant had taken treatment for pre-existing disease and he was suffering from the illness before taking health insurance policy. OP has not established or proved the fact that the Complainant has suppressed the pre-existing disease and by suppressing the fact he had obtained the Policy. So, under these circumstances, the repudiation of the claim of the Complainant by the OP is wholly unjustified. There are no reasonable or cogent and just reasons to reject / repudiate the Mediclaim submitted by the Complainant. Complainant requested the OP for cashless facility, but unfortunately OP has not given the said facility. Complainant has produced final bill of Lakeside Medical Center & Hospital. As per final Bill, he has paid in all Rs.1,57,380/- to the Hospital. Complainant has also produced some medical bills & vouchers. Total amount for having purchased the medicines according to the vouchers comes to Rs.24,368/-. In this way total medical expenses incurred by the Complainant comes to Rs.1,81,748/-. Therefore, Complainant is entitled for this amount from the OPs. Complainant has claimed compensation of Rs.50,000/- for mental agony. There is no evidence or proof as to how he has suffered mental agony, harassment & humiliation on account of rejection of claim. Therefore, there is no legal basis or foundation to grant compensation for mental agony. In the result, I proceed to pass the following:
ORDER
Complaint is allowed. OPs are directed to pay a sum of Rs.1,81,748/- to the Complainant within 60 days from the date of this order.
In the event of non compliance of the order within 60 days, Complainant is entitled for interest @ 9% P.A. from the date of the order till the date of payment / realization from the OP.
Send copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 23rd day of September 2011.
Order accordingly
PRESIDENT
We concur the above findings
MEMBER MEMBER
SSS
