CC No.446.2015

Filed on 05.03.2015

Disposed on.19.06.2017

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU– 560 027.

DATED THIS THE 19^th DAY OF JUNE 2017

CONSUMER COMPLAINT NO.446/2015

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 05.03.2015 U/s 12 of the Consumer Protection Act, 1986 and praying to pass an Order directing the Opposite Parties to sum of Rs.90,865/- i.e., Rs.82,264/- + Rs.8,601/- which is towards the Medical expenses, to pay a sum of Rs.50,000/- as compensation with interest at 24% p.a. and other reliefs. 

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

In the Complaint, the Complainant alleges that the Opposite Party insured the Complainant has policy Holder for the year 2012-13 for a sum of Rs.1,00,000/- policy bearing No.P/181211/01/2013/003/486 and paid insurance premium of Rs.7,180/- for the Health Insurance of the Complainant.  The said policy has been renewed and paid a sum of Rs.11,697/- dt.04.08.2014.  The Complainant was admitted to Kethams Hospital at Vidhyaranyapura on 01.02.2014.  The Complainant was inpatient for a period of one week and incurred Medical expenses of Rs.82,264/-.  He was discharged from there on 07.02.2014.  Since the Complainant had taken policy from the Opposite Party at Ernakulam office, the Complainant had sent a claim form along with the relevant documents to the Opposite Party to their Ernakulam office demanding the aforesaid amount.  The Opposite Party in spite of paying the amount, issued a baseless reply refusing the claim and tried to avoid the payment.  Since the Opposite Party did not perform their part of service and also have illegally and unlawfully deprived the Complainant from payment, the Complainant got issued legal notice to Opposite Party.  The said notice has been served to the Opposite Party.  After the receipt of the said notice, the Opposite Party has given a reply.  Hence, this complaint. 

3. In response to the notice, the Opposite Party Nos.1 & 2 put their appearance through their counsel and filed their version.  In the version pleaded that the complaint is not maintainable.  The Complainant has taken the alleged policy for the period 12.09.2013 to 11.09.2014 subject to the terms and conditions.  As per Exclusion clauses of the policy, the Complainant shall not be liable to make any payments under the policy in respect of any expenses what so ever incurred by any insured person in connection with excluded ailments in respect of Pre-existing diseases.  On perusal of the claim records sent to the Opposite Party relating to the disease and its treatment and expenses alleged incurred, it is observed that, the said expenses incurred for cerebrovascular disease(CAV), Left Lower Meduallary Infract Diabetes Mellitus Type-2.  On scrutiny of the claim records it is observed that (1) as per Discharge Summary  the insured is a known case of diabetes Mellitus and Hypertension and the present ailment is due to the complications of the Hypertension.  (2) The high blood pressure can cause hardening and thinking of the arteries (atherosclerosis), which is can lead to heart attack, stroke or other complications like what is claimed by the Complainant as suffered.  The said hospitalization was for the management of an ailment, which is related to pre-existing condition.  Hence, as per Exclusion No.1 of the policy, the Company is not liable to make any payment in respect of the expenses for treatment of the pre-existing disease.  The Complainant has obtained the first policy and has renewed the same for the second year.  The Opposite Party to process the claim subject to scrutiny of the documents that will be furnished by the insured, the claim will be examined accordingly, if payable, it will be paid and if, the claim falls under any exclusion clauses of the contract, the decision will be taken accordingly.  Thus in the case of the Complainant also, the claim since has fallen under Exclusion clause of the policy, the Opposite Party is not bound to pay any amount.  The transaction is purely contractual and the deciding of the facts will be only within the agreed scope of the contract, no independent or sympathetic farfetched view of e contract can be taken, contrary to the agreed terms and conditions and the Rules, Regulations and procedures enshrined in the Insurance laws. Hence, the complaint is not maintainable and prays to dismiss the complaint. 
4. The Complainant, Mr.N.K.Suresh Kumar filed his affidavit by way of evidence and closed his side.  On behalf of the Opposite Parties, the affidavit of one Sri.John Noronha has been filed.   Heard the arguments of both parties.

 5.     The points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Parties ?
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:- As looking into the averments made in the complaint and also the version filed by the Opposite Parties, it is not in dispute that the Complainant had obtained Health Insurance Policy for a sum of Rs.1,00,000/- policy bearing No.P/181211/01/2013/003/486 by paying premium of Rs.7,180/- for the Year 2012-14 and subsequently the said policy was renewed by paying premium amount of Rs.11,697/- on 04.08.2014.  Further to substantiate this fact, the Complainant in his sworn testimony, reiterated the same and produced the policy.  By looking into this document, it is very clear that the Complainant had obtained Medi Classic Health Insurance Policy from 14.08.2012 to 13.08.2013.  Under this policy, the policy is covered for Complainant and his children S.K.Uma Maheshwari and S.K.Siddharth.  This evidence of the Complainant remains unchallenged, thereby it is proper to accept the contention of the Complainant.
8. It is further case of the Complainant, the Complainant on 01.02.2014 taken a treatment in M.S.Ramaiah Memorial Hospital, Bangalore from 01.02.2014 to 07.02.2014 as an inpatient incurring a Medical expenses of Rs.82,264/-.  After discharge from the Hospital, the Complainant along with relevant documents submitted the claim form with Opposite Parties, but the Opposite Parties have failed to honour the claim.  On the other hand, the Opposite Parties have repudiate the claim in spite of demand and request made by the Complainant, the Opposite Parties have failed to comply with the demand of the Complainant.  To substantiate this contention, the Complainant in his sworn testimony, reiterated the same and produced the Discharge Summary.  As looking into this document, at first instance, the Complainant had taken a treatment at Kethams Hospital, Vidyaranyapura on 01.02.2014 on the same day he was discharged from there he admitted to the M.S.Ramaiah Hospital, it is further clear by looking into this Discharge Summary issued by the M.S.Ramaiah Hospital, by looking into this document, the Complainant had taken a treatment as an inpatient from 01.02.2014 to 07.02.2014 for Vertebrobasilar Insufficiency Lateral medullary syndrome and he also produced the Medical Bills issued by the M.S.Ramaiah Memorial Hospital.  As looking into this document, the Complainant had incurred Rs.82,264/-.  Even this evidence of the Complainant also remains unchallenged.  Therefore, there is no contra evidence to disbelieve the evidence of the Complainant, therefore, it is proper to accept the contention of the Complainant. 

9. Further it is coming evidence of the Complainant that the Complainant after discharge from the Hospital along with relevant documents filed the claim form before the Opposite Parties.  To substantiate this, the Complainant had produced the Claim Form it is dt.14.02.2014, but the Opposite Parties have repudiate the claim of the Complainant.  This is clear as seen from the letter dt.07.03.2014 addressed to the Complainant by the Opposite Parties and informed the Complainant.  After perusing the claim record, the insured patient had taken treatment of DM, HTN and its related complications are specifically excluded under the policy schedule, Complication of Pre-existing disease:- The medical documents submitted by the Complainant clearly reveals that the patient was suffering from DM and HTN prior to inception of policy.  Since the present illness (CVA) is a complication of pre-existing disease, it falls under Exclusion Clause No.1 of the policy and regretted to repudiate the claim.  So from this evidence of the Complainant the Opposite Parties have repudiate the claim.  On that ground the Complainant had Pre-Existing diseased at the time of obtaining the policy, it is evidence of the Opposite Parties, it is the duty of the Opposite Parties, to establish that the Complainant had Pre-existing disease i.e., hyper tension and DM and HTN.  In order to their defence, except the interested version of Sri.John Noronha, Asst. Vice President of the Opposite Parties have not produced any supporting evidence to show that the Complainant was suffering from DM and HTN at the time of obtaining the policy even assuming that the Complainant is having DM and HTN at the time of obtaining the policy.  In that event what is necessary for the Opposite Parties to issue policy in his name.  On the other hand, orally on the basis of the Discharge Summary issued by M.S.Ramiah Hopsital.  In that discharge Summary, it is noted in the history that the Complainant is having Pre-Existing disease.  On that ground they repudiate the claim of the Complainant, is not proper and in accordance with procedure and unreasonable and it amounts to causing unfair trade practice by the Opposite Parties.  On the other hand, the Complainant ought to have honour the claim of the Complainant.  Since during the policy inforce, the Complainant hospitalized had taken a treatment as inpatient for one week for his Vertebrobasilar Insufficiency Lateral medullary syndrome and for that he incurred expenses of Rs.82,264/-.   Hence, this point is held in the Affirmative. 

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

ORDER

The Complaint is allowed holding that there is deficiency of service by the Opposite Party No.1 & 2. 

The Opposite Party No.1 & 2 are directed to reimbursement of Hospital expenses of Rs.82,264/- with interest at 12% p.a. from 07.02.2014, till the date of payment. 

The Opposite Party No.1 & 2 are directed to pay a sum of Rs.10,000/- as compensation for causing mental agony to the Complainant.

The Opposite Party No.1 & 2 are also liable to pay a sum of Rs.5,000/- as cost to the Complainant.

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, 19^th day of June 2017)

        MEMBER                                             PRESIDENT

LIST OF WITNESSES AND DOCUMENTS

 Witness examined on behalf of the Complainant:

1. Sri.N.K.Suresh Kumar, who being Complainant has filed his affidavit.

 List of documents filed by the Complainant:

1. Copy of Insurance Policy
2. Copies of Doctors Prescription, Medical Bills and Discharge Summary
3. Reply Letter
4. Legal Notice dt.14.05.2014
5. Reply letter dt.18.07.2014
6. Rely for returning the documents.
7. Email dt.08.07.2014

Witness examined on behalf of the Opposite Parties:

1. Sri.John Noronha, Assistant Vice President, on behalf of the Opposite Parties by way of affidavit.

List of documents filed by the Opposite Party:

-NIL-

MEMBER                                                                             PRESIDENT