BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

                             BENGALURU – 560 027.

DATED THIS THE 10^th DAY OF MAY, 2022

CONSUMER COMPLAINT NO.788/2018

PRESENT:

SRI. RAJU K.S:MEMBER

                    SMT.REKHA SAYANNAVAR,:MEMBER

S/o Lakshmpathi,

Aged about 68 years,

Residing at No.27,

Hare Krishna Road,High Grounds,

Bengaluru-560001. ……COMPLAINANT

(Rep by Sri.D.N.Manjunath, Adv)

V/s

M/s Max Bupa Health

Insurance Company Limited,

Represented by its Chief operations

Officer & Chief Quality Officer,

Having their registered office

and place of business at B-1/1-2,

Mohan Co-operative Industrial Estate,

Mathura Road,

New Delhi-110044.                              ….OPPOSITE PARTY-1

M/s Max Bupa Health

Insurance Company Limited,

Represented by its Branch Manager,

Having their Regional Branch office,

30/1, First floor, Vaishnavi Silicon Terrace,

Hosur Main Road,

Near Adugodi Police Quarters,

Bengaluru,

Karnataka-560095.                           ….OPPOSITE PARTY-2

M/s Max Bupa Health

Insurance Company Limited,

Represented by its Branch Manager,

Having their Branch office,

G.R.Arcade, No.223, 14^th Cross,

Sampige Road,

Malleshwaram,

Bangalore-560003.                           ….OPPOSITE PARTY-3

(OPs no.1 to 3 Rep by Sri.H.N.Keshava Prashanth, Adv)

M/s Apollo Speciality Hospital,

New No.2, Old No.21/2, 14^th Cross,

3^rd Block, Near Madhavan Park,

Jayanagar,

Bengaluru-560011.                            ….OPPOSITE PARTY-4

(Opposite party-4 rep by Smt.S.Radha Pyari, Adv)

******

//JUDGEMENT//

BY SMT. REKHA SAYANNAVAR, MEMBER

The present complaint is filed on 08/05/2018 by the complainant through his counsel with a prayer to direct the opposite parties to pay a sum of Rs.10,25,551/- together with interest @ 24% per annum and to pay cost of this complaint and to grant such other reliefs as this Hon’ble Commission may deems fit by considering the facts and circumstances of the case.. 

2. The brief facts of the complaint is as under;

 In the Complaint, the complainant submits that he had obtained the opposite parties No.1 to 3 policy titled the "Heartbeat Gold 05 lacks 1 Adult" from its agent by name Revanna Siddappa on 20/11/2015 bearing policy number 30374642201501 and the said policy was in force for 1 year from 20.11.2015 to 19.11.2016 to be renewed on or before 19.11.2016.   The said policy renewed for one year from 20.11.2016 to 19.11.2017. Again renewed for one year from 20.11.2017 to 19.11.2018.

3. It is further submitted that the complainant had developed the first time pain b/w the Legs and approached Dr.Sanjay Pai of M/s Apollo hospital, Jayanagar. After detailed examination the expert had given the opinion that the complainant should go for total knee replacement of both the Legs as there was no other treatment or medication avail to relieve the complainant's pain and suffering.

 4. It is further submitted that the complainant agreed to undergo surgery on 21.11.2017 in M/s Apollo Hospital, Jayanagar and they charged a sum of Rs.6,36,545/- towards surgery, treatment and all other medical procedures. The complainant had already brought the same to the notice of opposite parties No.1 to 3.  After submitting all the medical reports and opposite party no.1 to 3 also issued a pre-authorization letter and approved a sum of Rs.89,921/- on 11.11.2017. 

5.  It is further submitted that the complainant after obtaining the pre-authorization letter from the opposite parties No.1 to 3 underwent operation of both the knees on 21.11.2017.  To the shock and surprise of the complainant, the opposite parties No.1 to 3 on 25.11.2017 refused to make the full and final settlement towards the surgery and other treatments pre and post and made the complainant to make payment the said hospital bills by himself. The complainant issued a legal notice on 03.02.2018 to the opposite parties No.1 to 3. The opposite parties No.1 to 3 directly denied the complainant's lawful claim. Hence this complaint. 

6.  In support of the complaint, the complainant has filed affidavit in the form of his evidence along with the documents. Ex.P1 to Ex.P14 marked.  Notice to opposite parties No.1 to 3 served.   Counsels for opposite parties 1 to 3 filed the Vakalath, version along with the documents and lead the evidence and marked Ex.R1 to R8. Opposite party No.4 filed Vakalath. Version and evidence of opposite party No.4 taken as ‘Nil’. 

7.  The opposite parties No.1 to 3 in their version denied all the averments made in the complaint by the complainant and prayed for it's dismissal.   Further opposite parties No.1 to 3 submit its ground on which the Opposite Party Insurance Company had repudiated complainant's claim that the complainant has been suffering from knee pain since 15 years, History of Right Arthroscopy since 10 years and also from hypertension since 7 years.  At the time of inception of the insurance policy these facts are not disclosed and also in the proposal form or during the premedical examination at the time of policy inception by the complainant. 

8. Further opposite party no.1 to 3 submitted that the contracts of insurance are contracts of oberima fides - at most good faiths and every material fact must be disclosed,. otherwise there is a good ground for a recession of the contract and cited the Supreme Court cases in their support. The complainant and the opposite parties have filed their written arguments respectively.

9.  Heard the arguments. 

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

i) Whether the complainant has proved the alleged deficiency of service by the opposite parties ?

ii) If so, to what relief the complainant is entitled for?

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

Point No.1 :  Affirmative

Point No.2 :  As per the final order for the following;

REASONS

12. POINT NO.1:- In order to avoid the repetition of facts, I have discussed both the points together.  On perusal of the pleadings along with the documents produced by the complainant, it reveals that the opposite party No.1 to 3 are leading reputed insurance company.  The complainant obtained the opposite party’s policy titled the “Heartbeat Gold 05 lakhs 1 adult” on 20.11.2015 which was renewed for two times.  The said policy was in force, during the cause of action i.e., from 20.11.2017 to 19.11.2018.

13. The complainant further submits that he had developed the pain in between the legs and consulted Apollo Hospital, Jayanagar Dr.Sanjay Pai and the same was brought to the knowledge of opposite party No.1 to 3.  The opposite party No.1 to 3 issued the Pre-authorization letter dt.11.11.2017 with approval of Rs.89,921/- to the complainant.  The hospital charged a sum of Rs.6,36,545/-.  The complainant underwent both legs knee replacement surgery on 21.11.2017, on the advice of the said doctor as there was no alternative relief was left for the complainant to relieve from his pain.  To the shock and surprise of the complainant, the opposite party no.1 to 3 refused to make full and final payment towards the surgery and other treatments pre and post on 25.11.2017.  The complainant issued legal notice on 03.02.2018, the opposite parties directly denied the complainant lawful claim.  Hence, the complainant filed this complaint.  The complainant filed an affidavit in the form of his evidence.  EX.P1 to E.P14 are marked.  The opposite party no.1 to 3 denied all the averments made in the complaint.

14. On perusal of opposite party no.12, it appears that Dr.Sanjay Pai, who is the expert and the surgeon, officially certified that the Knee pain is present since 6 months and as aggravated in the past 4 months. The hypertension is "not relevant" in this consequential surgery as certified by him EX.P12. 

15. This commission considers EX.P12 document Dr.Sanjay Pai issued by as valid and looked into opposite parties document in page number 189-191 of the medical examination report. 

16.  With respect to the term Pre-condition of the policy.  Since the complainant is a sports person, the Knee pain is neither acute nor chronicle one it may be a normal pain in nature.   Further since the pain in the knee was from 15 years, it cannot be a serious one and the same cannot be a stigma for re-imbursement of insurance.

17.  The Knee injury has No medical evidence of previous surgery.   We consider that the complainant was not only a “Consumer” but also a “Vulnerable Consumer” as the complainant is a senior citizen. In addition to, during this Covid situation elderly persons are highly vulnerable to the infections. The health hazardous is extremely serious. As a senior citizen his travel and time cost be given by the Opposite Parties No.1 to 3 along with Pre and Post Medical charges and mental agony sustained of Rs.10,000/-. Even though, the complainant had claimed a sum of Rs.10,000/- towards pre-operation charges and Rs.80,000/- towards post operation charges, he has not produced any documents in support of the same.

18. In addition to the Medical Report says negative on cardiovascular issues.  Hence, the Commission dismisses the plea of the Opposite parties No.1 to 3 that the complainant had suppressed the fact.  Accordingly, we answer point No.1 and 2 as affirmative.  

ORDER

The Insurance Company Max Bhupa must provide the relief to the Complainant by providing full reimbursement of the insured amount of Rs.6,50,000/- along with interest at the rate of 9% per annum from the date of surgery within 30 days from the date of this order. 

The legal charges of the complainant Rs.15,000/- pre and post medical charges and for mental agony of Rs.10,000/- to be paid by the Opposite Parties No.1 to 3. 

All said reliefs must be given by the Max Bhupa Insurance Company within 30 days.   In case, the opposite parties fail to pay the above said amount of Rs.25,000/- within 30 days, the complainant is entitled for 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.

  (Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 10^th day of May, 2022)                                            

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

Witness examined for the complainants side:

Sri.Ramprakash, who being the complainant has filed his affidavit.

Documents marked for the complainant side:

1. The notarized copy of election ID card.
2. The Summary of the bank account as on 28.11.2017 pertaining to the complainant issued by ICICI Bank.
3. The report from department of radiology, dt.20.11.2017 and 04.07.2017.
4. The discharge summary dt.25.07.2017 issued by Apollo hospital.
5. The final interim bill dt.25.11.2017 issued by Apollo Hospital.
6. The deposit receipt dt.25.11.2017.
7. The copy of cheque bearing No.100158 dt.25.11.2017 for a sum of Rs.6,36,545/- is favouring Apollo hospital.
8. The fax copy of the letter of authorization.
9. Pre-authorization form(cashless) in two sheets.
10. The denial of authorization letter dt.25.11.2017 issued by Apollo Hospital.
11. “To Whomsoever Concern” certificate issued by Dr.Sanjay Pai, opposite party no.4.
12. The two original policy documents, dt.20.11.2015 and 30.11.2015 respectively, issued infavour of complainant, which are in the form of booklet, bearing policy No.30374642201501 and 30374642201703.
13. The copy of the legal notice dt.03.02.2018 to the opposite parties.
14. The postal receipts and acknowledgements.
15. The certificate of merit dt.03.05.2015 issued to the complainant by Century Club.
16. The certificate of Golfing Excellence confirming on complainant having achieved the distinction which is dt.14.04.2015.

 Witness examined for the opposite party side:

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

Documents marked for the Opposite Parties side:

1. The letter of authorization duly attested dt.28.08.2019.

2. The policy documents with policy certificate and covering letter dt.21.11.2014 addressed to the complainant.

3.The attested cop of Medical Examination Report pertaining to the complainant.

4. The pre-authorization form for cashless benefit.

5. The letter of authorization dt.11.11.2017.

6. The investigation report.

7. Letter of Denial of authorization dt.25.11.2017.

8. The attested copy of the letter dt.28.11.2017 addressed to the complainant intimating that we arere-underwriting the proposal.

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