BEFORE THE ADDITIONAL BENCH DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT
MYSURU.
Consumer Complaint (C.C.)No. 1142/2016
Complaint filed on 03.03.2016
Date of Judgement.28.03.2018
PRESENT : 1. Shri Ramachandra M.S., B.A., LL.B.,
PRESIDENT
2. Shri Thammanna,Y.S., B.Sc., LL.B.,
MEMBER
Complainant/s : 1.Smt. Bharathi A Bhat
W/o Sri. Ashok Bhat
Aged about 42 years,
Residing at Door No. 3406,
20th D main, 2nd stage, Vijayanagar,
Mysuru-570017.
2.Sri. Ashok Bhat
S/o Sri .Vishweshwar Bhat
Aged major
Residing No. 3406, 20th D main,
2nd stage, Vijayanagar,
Mysore-570017.
(Sri Emmanuel Suresh Kumar., Advocate)
V/s
Opponent /s : M/s Star Health and allied Insurance co. Ltd
No. 51, 1st Floor, 5th Cross, 8th Main
Above Professional Courier
Saraswathipuram
Mysuru-570008.
Represented by its Branch Manager
(Sri. D.N.Shashidhar., Advocate)
Nature of complaint | : | Deficiency in service |
Date of filing of complainant | : | 03.03.2016 |
Date of Issue notice | : | 22.04.2016 |
Date of Order | : | 28.03.2018 |
Duration of proceeding | : | 2 year 24 days |
SHRI RAMACHANDRA . M.S.,
PRESIDENT
JUDGEMENT
The complainant filed the complaint Under Section 12 of Consumer Protection Act, 1986 against the opposite party seeking for relief of refund medical claim amount and prayed for other relief.
2. The brief facts of the complainant is a beneficiary (patient) and the second complainant is a primary policy holder and is none other than the husband of the first complainant. The second complainant Sri.Ashok Bhat purchased a family health optima insurance plan from the opposite party for self, spouse and two children as a floater policy for a sum of Rs. 10,00,000/- vide policy P/141116/01/2015/005780 effective from 14.03.2015 which is valid till midnight of 13.03.2016. The policy is that any person in the family who is covered under the said policy may avail the benefit up to the sum insured of Rs. 10,00,000/- and the said policy is a floater policy. A copy of the policy is enclosed in the list of documents and marked as annexure-A.
3. In the said policy, the first complainant is also covered and the name of the first complainant is found in Sl.No. 2 of the policy as a spouse. The first complainant all of a sudden developed profuse bleeding and she was admitted to Sigma Hospital at Mysore as inpatient No. 2914 on 09.12.2015 which is one of the best hospitals in Mysore and she was diagnosed to have adenomyosis and on emergency basis the complainant was taken for total Laparoscopic Hysterectomy on the same day. The firs complainant after the operation and post operation treatment was discharged from the hospital on 11.12.2015. A copy of the discharge summary dated 11.12.2015 and the certificate dated 11.12.2015 are enclosed and marked as annexures –B& c with the list of documents.
4. The treating hospital for the operation and all the treatment issued a bill to the complainants vide bill no.265 dated 11.12.2015 for a sum of Rs. 58,000/- and the complainants paid the bill amount to the hospital. The complainant has also incurred some expenses for laboratory tests as per the bill no.115655 dated 09.12.2015 for Rs. 1500/- copies of these two bills and receipts are enclosed and marked as annexure D and E to the list of documents.
5. In addition to the above expenses, the complainant has also incurred some more medical expenses for scanning, laboratory tests and other medicines as prescribed by the doctor. With all these expenses together the complainant made a claim of Rs. 78,000/- in all for reimbursement of the Expenses incurred by the complainant with the opposite party and the same was registered as claim intimation number CL1/2016/14116/0281209. The claim application is with the opposite party with all the necessary documents. The complainant has furnished all the required documents along with the claim. The opposite party without any proper application of mind, repudiated the claim of the complainant vide their letter dated 31.12.2015 by quoting the exclusion clause 3(c) kof the policy saying the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of the above mentioned disease during the first two years of continuous operation of the insurance cover. A copy of the repudiation of claim dated 21.12.2015 is enclosed and marked as annexure-F with the list of documents.
6. The complainant got a legal notice dated 23.01.2016 sent to the opposite party through RPAD and explained the circumstances in which the complainant was taken for operation on an emergency basis and by considering this aspect advised the opposite party to release the claim amount within 15 days from the date of receipt of the said legal notice. A copy of the legal notice dated 23.01.2016 is enclosed and marked as annexure-G with the list of documents.
7. The opposite party has acknowledged the said legal notice and responded vide their letter dated 12.02.2016 addressed to the complainant’s advocate and again denied the claim by quoting the exclusion clause available in the policy. Further the opposite party has even not considered the aspect of the continuous coverage under a different mediclaim policy in which the complainant was covered and that previous policy was in still vogue even at the time of the complainant purchasing the policy with the opposite party. The complainant was continuously covered under different mediclaim policy and there was no lapse or break in continuity of the policies. Even on this count also the complainant is entitled to get the medical expenses reimbursed by the opposite party. A copy of the reply dated 12.02.2016 from the opposite party is enclosed and marked as annexure –H to the list of documents.
8. The complainant needed an emergency operation as per the advice of the treating doctor hence the operation was conducted as an emergency case on the date of admission itself. This proves that the operation was not a planned operation. In the event the operation was not conducted on an emergency basis, the complainant would have developed more complications and it would have been a threat to her life. The case of the complainant was an emergency case and under the circumstance, the exclusion clauses cannot be made applicable in this case. Therefore the complainant is entitled to get the medical expenses reimbursed from the opposite party and the same cannot be made applicable in this case. Therefore the complainant is entitled to get the medical expenses reimbursed from the opposite party and the same cannot be denied to the complainant as it is a genuine case.
9. In addition to the above, the complainant was also covered under the group medical insurance policy with united India Insurance Company Ltd a nationalized insurance company under the policy no BLR-UI-A-1054-001-0000050-A to D since about 15 yeas continuously. The said insurance policy was valid from 01.06.2014 till 31.05.2015. The complainant was covered under the same policy with a number BLR-UI-A-1054-001-0000050-B and she had the continuity of medical insurance policy. While the united India insurance policy was still in existence, the complainant purchased another medical insurance policy from the opposite party effective from 14.03.2015 and this shows that there was no break in policy period. A photocopy of the I D card issued by Vidal Health who is the third party agency of United India Insurance company is herewith produced and marked as annexure-J. As per sub clause 2 of clauses 3 of the policy conditions the exclusion shall not apply in case of the insured person having been covered under any health insurance policy with any of the Indian Insurance Companies for a continuous period of preceding 12 months without a break. The complainant and her family was covered under the group medical insurance policy as mentioned above for more than 15 years continuously without any break and from the expiry date of the previous policy and beginning date of the new policy with the opposite party is well within the time without any break policy. Complainant deserves to get the medical claim reimbursement under the policy purchased from the opposite party. Hence this complaint is filed seeking for the relief of settlement of insurance claim amount along with other relief as prayed in the complaint.
10. Notice to the opposite party duly served represented by counsel has filed version.
11. The complainant and opposite party filed chief examination affidavit and filed documents arguments heard, reserved for orders.
12. Heard arguments.
13. The points that arise for our consideration are;
- Whether the complainant proves that there is deficiency in service on the part of opposite party by not paying the insurance claim amount and thereby he is entitle for the relief sought?
- What order?
14. Our answer to the above points is as follows;
Point No.1: In the affirmative
Point No.2: As per final order for the following;
REASONS
15. Point no.1 :- The 1st complainant is a beneficiary and 2nd complainant is primary policy holder and is none other than the husband of 1st complainant. the 2nd complainant Shri Ashok Bhat purchased a family health optima insurance plan policy from the opposite party company for self, spouse and two children as a floater policy for a sum of Rs. 10,00,000/- vide policy no P/141116/01/2015/005780 it is valid from 14.03.2015 to 13.03.2016 the policy is that at any person in the family who is covered under the said policy may avail benefit of claim the sum assured is of Rs. 10,00,000/-.
16. The 1st complainant all of a sudden developed profuse bleeding and she was admitted to Sigma hospital at Mysuru as in patient no.2914 on 09.12.2015. in the hospital 1st complainant was diagnosed to have adenomyosis and on emergence basis the complainant was taken for total “laparoscopic hysterectomy ” procedure on the same day. The 1st complainant after the operation and post treatment was discharged from the hospital on 11.12.2015 .
17. Further the treating hospital for the operation and for all the treatment issued bill to the complainant dated 11.12.2015. for a sum of Rs. 58,000/- the complainant paid bill to the hospital .Thereafter complainant has also incurred some more medical expenses for scanning laboratory test and other medicine as prescribed the doctor and all this expenses together the complainant made claim of Rs. 78,000/- incurred by the complainant along with required documents. The opposite party has repudiated the claim of complainant by quoting the exclusion clause 3(c) of the policy by saying the company is not liable to make any payment in respect of any expenses incurred by the insured person treatment of the above mentioned deceases during the 1st two years of continuous operation of the insurance cover. For which the complainant got issued legal notice by requesting the opposite party to settle the claim and the notice was replied by the opposite party by once again denying the claim of complainant by quoting exclusion clause available in the policy. Upon which with no other alternative the complainant was forced to file the complaint seeking for relief for settlement of insurance claim amount of Rs. 78,000/-.
18. Here the opposite party company clearly admits issuance of insurance policy to the 1st and 2 complainant and it is also accepted that the policy was valid as on the date of alleged operation to the 1st complainant, they only deny the claim for the reason since there is violation of policy terms and conditions i.e., exclusion sub clause 2 of clause 3 of policy that amounts’s to breach of insurance terms on that grounds the opposite policy contends they are not liable for the settlement of insurance claim.
19. Further as per the complainant averments it is contended that the sub clause 2 of clause 3 of policy conditions the exclusion clause shall not be applied it reads as follows “ In the case of the insured person having been covered under any health insurance policy with any of the India insurance companies for a continuous period of proceeding for a continuous period of proceeding 12 months without a break”. The complainant strongly agitated in view of the above conditions the repudiation of claim is to be held as unlawful and also it amount’s to violation of policy terms and conditions, the complaint vehemently argued prior to this policy 1st complainant has already taken insurance policy for herself and family members with United India Insurance company .Ltd., policy No. BLR-41-Al054-001-0000050-A to D. Since 15 years it was valid from 01.06.2014 to 31.05.2015.
20. Further, the OP’s claim is that the complainant has not revealed the previous policy information at the time of proposal hence the earlier policy will not be of any use hence the exclusion clause still remains. When the exclusion clause is diluted it cannot be made applicable as per the policy condition itself provided if the policy holder is covered earlier in any of the Indian insurance policy and there is no break in policy period, then the exclusion clause is not applicable. In the present case on hand, the complainant produced the documents before this Forum to establish that the complainants were having the medical insurance policy from United India Insurance Company effective from 01.06.2014 to 31.05.2015 which is produced as Annexure-J to the complaint. The date of insurance policy from the op is from 14.03.2015 to 13.03.2016 and it is established that the complainants had continuity of policy and they were covered earlier also. Since the first complainant got admitted to the hospital on 09.12.2015 and got discharged on 11.12.2015 for the said operation under emergency condition, the complainant never had any break in policy and they had continuity of the insurance policy. Hence the exclusion clause is not applicable in so far as the complainant is concerned. The complainant has produced a document and proved that they were covered under the previous medical insurance policy and therefore the complainant is entitled to get the medical expenses reimbursement from the opposite party.
21. The opposite party in support of their contention have on relied on the judgment rendered by Hon’ble supreme court of India in special leave to appeal no 31406-2017 in a case between MS Middle High School Vs H.D.F.C ERGO General Insurance company limited and others The principles of ruling cited by opposite party is not applicable to the complaint.
22. The complainant in support of their contention has relied on a judgment rendered by( 1) .Hon’ble Supreme Court of India in case between Untied India Insurance company Ltd Vs Gian Chan and other 2)Hon’ble State Consumer redressal Commission Punjab , in a 1st appeal no 184 of 2014 in a case between Star Health and allied Insurance company Limited Vs Har jiderjeet sigh and others.
(3) The judgment rendered by Hon’ble National Commission, New Delhi, reported in CPJ 2014 part 2at page 194 in case between Rajendra Singh Vs Life Insurance corporation India . When two reasonable , “interpretations of terms of policy are possible, interpretation which favours insured is to be accepted and not the interpretation which favours insurer”.
23. The second ruling relied by complainant is rendered by State Consumer Redressal Commission, Punjab the facts and issue in the complaint is one and the same. It is also similar to the complaint on hand. The principles laid down by the appellant commission is aptly applicable to the complaint. It is significant to note that first appeal in the above ruling is preferred by star health insurance company and the opposite party company in the complaint on hand is also star health insurance company ltd. The principles of the ruling is aptly applicable to the complaint.
24. Therefore in view of above discussion and on perusal of facts and documents by relying on the ruling cited by complainant. It is our definite observation that repudiation of complainant claim is not justified. It is in contrary with their own terms of policy. When such being the case , the rejection of claim is to be held as unlawful and also against public policy. The act and conduct of opposite party company is nothing but deficiency in service on their part. For which they are liable to pay lawful claims of complainant.
25. Further the complainant has proved his case beyond reasonable doubt and also deficiency of service on the part of opposite party Under such circumstance the complaint is liable to be allowed. Accordingly we answered point no.1 in the affirmative.
26. Point no.2:- From the above discussion we hereby proceed to pass the following :-
ORDER
- The complaint is hereby allowed in part.
- The opposite party is directed to pay sum of Rs. 78,000/- to the complainant within 30 days of this order with interest at the rate of 10% p.a. from the date 11.12.2015 till payment made.
- The opposite party is directed to pay sum of Rs. 5,000/- towards deficiency in service and Rs.3,000/- towards costs of the proceedings, to the complainant, within 30 days of this order.
- In default to comply the opposite party shall pay interest at 8% p.a. on the said total sum of Rs. 8,000/- from the date of this order till payment.
- In case of default to comply this order, the opposite party shallundergo imprisonment and also liable for fine under section 27 of
the CP Act, 1986.
- Give copies of this order to the parties as per rules.
(Dictated to the stenographer transcribed , typed by her, transcript corrected by us and then pronounced in open court on the 28th March 2018)
Shri Thammanna. Y.S., Shri Ramachandra. M.S.,
Member. President.
