Karnataka

Bangalore 4th Additional

CC/1275/2019

Radha Ramesh Kulkarni, - Complainant(s)

Versus

M/s Religare Health Insurance Company Limited, - Opp.Party(s)

09 Mar 2020

ORDER

Complaint Filed on:05.08.2019

Disposed On:09.03.2020

                                                                              

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

 

 

 

 

 

09^thDAY OF MARCH 2020

 

PRESENT

SMT.PRATHIBHA. R.K., BAL, LLM - PRESIDENT

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

SMT.N.R.ROOPA, B.A., LLB, MEMBER

 

 

COMPLAINT No.1275/2019

 

 

COMPLAINANT	Smt.Radha Ramesh Kulkarni, Aged 69 years, W/o Ramesh Kashinath Kulkarni, Residing at #219, 5th Cross, RMV 2nd Stage, 2nd Block, Bangalore – 560 094.   Advocate – Smt.RaniNalwa.       V/s
OPPOSITE PARTy	M/s.Religare Health Insurance Company Limited., Bangalore Regional Office, T 301, III Floor, 216/13, Suraj Towers, III Block, 27th Cross, Jayanagar, Bangalore – 560 011.   Represented by Branch Manager.   And   Regd. Office: D-3, District Centre, Saket, New Delhi – 110017.   Represented by Branch Manager.

 

ORDER

 

SMT.PRATHIBHA. R.K., PRESIDENT

 

The complainant has filed this complaintU/s.12 of the Consumer Protection Act, 1986against Opposite Party (herein after referred as OP) with a prayer to direct OP to pay a sum of Rs.4,78,135-25 being hospitalization, Dialysis and other medical expenses and interest @ 12% p.a, to pay all other medical expenses incurred during the term of the policy and not claimed herein i.e., for the period 01.06.2019 – 16.10.2019, to pay Rs.1,00,000/- for causing harassment, stress, and agony, to pay Rs.50,000/- towards legal cost and pass such other orders.

 

2. The brief allegations made in the complaint are as under:

 

 

Complainant availed an insurance policy from the OP on 17.10.2014.  The name of the policy plan is “CARE”.  The complainant submitted that the said policy is renewed continuously upto 16.10.2019 for a sum of Rs.12,00,000/-. 

 

Complainant submitted that he had admitted to the M.S Ramaiah Hospital, Bangalore on 08.12.2018 under emergent conditions.  Accordingly applied for authorization of cashless hospitalization with the OP which was denied on 13.12.2019 stating that;

 

a) Non-disclosure of material facts/pre-existing ailments at time of proposal.  Patient having chronic kidney and hypertension prior to inception of the policy.  Rejection remain same.

b) Non-disclosure of material facts/pre-existing ailments at time of proposal.

 

For the above said treatment complainant spent Rs.2,48,886-92 and again on 04.03.2019 complainant admitted to the M.S Ramaiah hospital and spent Rs.1,18,848-33 and once again OP has verbally denied the claim of the complainant.

 

Complainant further submitted that the complainant has advised by her doctor is undergoing Dialysis treatment twice a week at her own expenses which the OP is obligated to pay.  Dialysis is to continue until further advice from doctor.  For the above said dialysis expenses for the period of 01.06.2019 to 16.10.2019.  The complainant spent for Rs.1,10,400/-.  The complainant applied for cashless facility from the OP and the OPs had illegally rejected the claim of the complainant.

 

Complainant further submitted that it is well established law that malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.  That before taking the subject policy for the first time on 17.10.2014 the complainant has never been treated for any kind of kidney related disease.  Therefore the contention of the OP that the claimant is a chronic kidney patient is ill-founded with the malafide and sole intention to deny her claim.

 

Complainant further submitted that the OP being an insurance company is under obligation to ensure before issuing policy whether a person is fit to be insured or not.  It is for the reasons that the complainant underwent the pre-requisite medical examination prescribed by the OP.  To the best of the complainant’s knowledge the medical reports issued by the OPs panelist doctors does not indicate her having chronic kidney disease.  That the insured complainant being a senior citizen has been otherwise living normal and healthy life and attending to her duties and daily chores like any other person and had not been declared as a diseased person.  Therefore, she cannot be held guilty for concealment of any disease.

 

The complainant further submitted that any pre-existing disease should not be bar to settle the claim of the complainant’s genuine claim in view of clause 4.1 (iii) of the policy which reads as under:

 

“(iii) Pre-existing Disease: Claims will not be admissible for any Medical Expenses incurred for Hospitalization in respect of diagnosis/treatment of any Pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first policy with the Company”.

 

The complainant has made no claim on her policy for the period 17.10.2014 – 17.10.2018 i.e., 48 months (four years) after the policy was first issued.  The claim was made in December 2018.  Therefore there is no reason for the OP to reject/deny her claim on the ground of pre-existing disease.  Hence complainant issued legal notice dated 27.02.2019 to the OP calling upon OPs to pay the claim amount.  OPs neither replied to the legal notice nor settle the claim of the complainant.  Hence complainant approached this Forum.

 

3. After registration of the complaint, notice was issued to OP.  Inspite of service of notice, OP remained absent without sufficient reason and cause.  Hence OP called out as absent and has been placed exparte.

 

4. In the course of enquiry into the complaint, the complainant has filed affidavit evidence reproducing what she has stated in her complaint.  The Complainant has produced documents along with complaint.  We have heard the arguments of the Complainant side and we have gone through the oral and documentary evidence of the Complainant scrupulously. 

 

5. Based on the above materials, the following points arise for our consideration;  

 

1. Whether the Complainant has proved that there is deficiency in service on the part of the OP, if so, whether she is entitled for the relief sought for?

 

2.  What order?

 

6. Our findings on the above points are as under:

 

Point No.1:  Partly in the affirmative

                 Point No.2:  As per the order below

 

REASONS

 

 

7. Point No.1: The complainant has firmly stated oath in the affidavit that, the complainant had obtained health insurance policy in the year 2014 with effect from 17.10.2014 to 16.10.2015 as per Ex-A1.  The said policy renewed from time to time till 16.10.2019.  The policy plan obtained by the complainant from OP called ‘CARE’.  The complainant had admitted to the M.S Ramaiah hospital on 08.12.2018 and discharged on 14.12.2018 and again complainant admitted to the said hospital on 04.03.2019 and discharged on 07.03.2019.

 

8. For the above said treatment the complainant spent Rs.2,48,886-92 + Rs.1,18,848-33 respectively.  Thereafter the complainant advised to undergo dialysis.  For the said Dialysis expenses for a period of 29.12.2018 to 09.06.2019 the complainant spent Rs.1,10,400/-.  The complainant approached the OP for the above said claim and OP has rejected the claim of the complainant on the ground that the complainant is having a pre-existing disease.  The same has not been disclosed by the complainant at the time of obtaining the policy.  Hence claim of the complainant was rejected.

 

9. The complainant submitted that the complainant does not have a pre-existing disease at the time of inception of the policy.  Further OP cannot reject the claim of the complainant on the ground of complainant is having a pre-existing disease as per clause.4.1 (iii) terms and conditions of the policy. 

 

10. To rebuttal the evidence of the complainant, the OP has not appeared in the instant case though the notice was duly served and thereby the OP remained absent in the sense the OP either admits the averments of the complainant in toto or they have nothing to say contrary to the complainant’s averments.  If the matter is viewed on this line, it proves that the OP has agreed the same impliedly.  In this regard, the decisionreported in 2018(1) CPR 325 (NC) in the case of Kotak Mahindra Old Mutual Life Insurance Ltd., vs. Dr.Nishi Gupta, wherein it is held that, “non-filing of the written version amounts to admission of allegations made by the Complainant in the consumer complaint”.

 

11. On perusal of the discharge summary Ex-A2 and A-4 nowhere it is stated that the complainant is having pre-existing disease of Chronic Kidney Disease.  Be that as it may as per policy clause 4.1 (iii) which reads here as under:

 

“(iii) Pre-existing Disease: Claims will not be admissible for any Medical Expenses incurred as Hospitalization Expenses for diagnosis/treatment of any Pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first Policy with the Company”.

 

12. Admittedly the complainant has obtained the policy on 17.10.2014 and the same was renewed from time to time till 16.10.2019.  The complainant was admitted to the hospital on 08.12.2018 i.e., after lapse of 48 months of inception of the policy.  As per clause 4.1 (iii) it clearly mentioned that pre-existing disease will not be admissible until 48 months of continuous coverage since the inception of the first policy.  In the instant case the complainant admitted to the hospital after lapse of 48 months from the date of inception of first policy.  Even though the complainant is having pre-existing disease the complainant is entitled for the claim amount as per the terms and conditions of the policy.  On the discussions made hitherto in our view the repudiation made by the OP on the ground that the complainant is having pre-existing disease and the same was not disclosed by the complainant at the time of obtaining the policy is arbitrary and illegal. 

 

13. Looking to the facts and circumstances of the case, we feel it appropriate to direct the OP to pay the claim amount together with interest @ 12% p.a from the date of complaint till the date of realization.  Further we feel it appropriate to direct the OP to pay compensation of Rs.20,000­­/- to the complainant for deficiency of service resulting in hardship, inconvenience and mental agony, together with litigation cost of Rs.10,000/-.  Accordingly we answer the point No.1 affirmative in part.

 

 

 

 

 

          14. Point No.2: In the result, we passed the following:         

 

 

 

O R D E R

 

1) The complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is allowed in part. 

 

2) OP is directed to pay the claim amount to the complainant together with interest @ 12% p.a from the date of complaint till the date of realization. 

 

3) Further OP is also directed to pay compensation of Rs.20,000/- to the complainant towards deficiency of service together with litigation cost of Rs.10,000/-.

 

4) This order is to be complied by the OP within 30 days from the date of receipt of this order.

 

5) Supply free copy of this order to both the parties.

 

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this09^thday of March 2020)

 

 

 

                                                                        

(ROOPA.N.R)    MEMBER

(SURESH.D)             MEMBER

(PRATHIBHA.R.K)    PRESIDENT

 

 

Witnesses examined on behalf of the complainant by way of affidavit:

 

Smt.Radha Ramesh Kulkarni.

 

 

 

Copies of documents produced on behalf of complainant:

 

 

Ex-A1	Original insurance policy No.10155835 – Plan name:CARE (FY 14-15, 17-18) policy certificates, Renewal premium receipts.
Ex-A2	Copies of discharge summary dated 14.12.2018, medical reports, and hospital and medicine bills.
Ex-A3	Original denial letter dated 13.12.2019.
Ex-A4	Copies of discharge summary dated 07.03.2019, medical reports and hospital and medicine bills.
Ex-A5	Original dialysis bills for the period 29.12.2018 to 16.10.2019.
Ex-A6	Copy of legal notice dated 27.02.2019.
Ex-A7	Copy of reply to the legal notice dated 09.04.2019.
Ex-A8	Original renewal letter issued by OP.

 

 

 

Witnesses examined on behalf of the Opposite party - Nil

 

 

 

                                                                        

(ROOPA.N.R)    MEMBER

(SURESH.D)             MEMBER

(PRATHIBHA.R.K)    PRESIDENT