Date of Filing:27-07-2015
Date of Order:25 -2-2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. D.NIRMALA, B.Com., LLB., MEMBER
Monday, the 25th day of February, 2019
C.C.No.356 /2015
Between
- Sri T.Panduranga Vittal,
S/o.Late Sri T.Satyanarayana Murthy,
Aged about 42 years, Occ: Self employee,
R/o.H.No.12-11-1238/1, Boudha Nagar,
Warasiguda, Secunderabad – 76
- Smt. T.Aruna, W/o.Sri T.Panduranga Vittal,
Aged about 41 years, Occ: Household,
R/o.H.No.12-11-1238/1, Boudha Nagar,
Warasiguda, Secunderabad – 76
(Complainant No.2 as added as party as per the orders
Passed in I.A.No.226 of 2016 dated 8-2-2017.) ……Complainants
And
M/s. Apollo Munch Health Insurance Co.Ltd.,
Duly Rep. by its authorized signatory
Reg. office, # Apollo hospitals Complex
Jubilee Hills, Hyderabad – 33 ….Opposite Party
Counsel for the complainants : M/s. V.Sunil Kumar
Counsel for the opposite Party : Mr.K.Visweswara Rao
O R D E R
(By Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint is filed under Section 12 of C.P. Act of 1986 alleging repudiation of claim by the opposite party amounts to deficiency of services and unfair trade practice and in consequence of it to grant a compensation of Rs.7,00,000/- and to reimburse an amount of Rs.62,600/- spent for the treatment of the second complainant and a direction to restore the policy by setting aside termination order dated 23-05-2014 and cost of this complaint at Rs.50,000/-.
- The complainants case in brief is that they are husband and wife and obtained medical policy from opposite party in the year 2010 in policy bearing No.130100/11051/1000110295. Later the said policy was renewed regularly from 2010 to till 2014 without interruption. In the year 2013 an agent of opposite party informed about another policy known as “Optima health restore” having features of more coverage and change of policy does not amount to interruption of policy period and previous one will continue and there will be no affect of seniority. For the first three years 2010 to 2012 they have paid a sum of Rs.7,059/-P.A and 4th year paid Rs.9,816/- and thus for all the four years the amount paid by them is at Rs.30,993/-. While issuing the policies the opposite party never asked about the health details of the complainants and never asked them to undergo medical examination and submit the reports. Also the opposite party never explained the details of the clauses in the policies except informing that they can get reimbursement of the amount incurred for any of the treatment based on seniority.
While the matter stood thus the second complainant suffered with stomach pain hence visited Woodland hospital where Dr. Ramesh after conducting necessary tests confirmed that she was suffering with Umbilical Hernia and she has to be get operated to cure it. He also advised some more clinical tests and come with reports. Accordingly the second complainant underwent various tests and approached the same doctor with reports. The copy of the policy was also shown and she was informed by the doctor that she will be eligible for cashless treatment and they will send a report to the opposite party in that regard.
On 13/5/2014 the management of the Woodland hospital intimated the opposite party for cashless treatment. Though the second complainant was suffering with pain was waiting for confirmation from the opposite party. Later a message was received informing that request for cashless treatment was rejected. When enquired by phone the reasons for rejection, the concerned person at opposite party informed that original policy was transferred to new policy but it was not up dated in their system and there are technical problem and after updating records they will consider request for cashless treatment. Thereafter on 14-5-2014 the complainants as well as the management of the hospital received message that opposite party company agreed for cashless treatment request for Rs.35,000/-. Thereafter second complainant was got admitted in the hospital on 15-5-2014 and underwent surgery on 16-5-2014. The opposite party sent a message to the hospital management asking for some more documents and same was complied. While sending the documents complainant unknowingly mentioned that the patient was diabetic for the past 5 years and basing on that the opposite party rejected the claim on 23-05-2014 and further informed that the complainants can apply for cashless reimbursement. Accordingly on 27-05-2014 the complainants have applied for reimbursement and submitted original record received from the hospital authorities. But in the meanwhile on 17-05-2014 itself opposite party rejected the reimbursement request on the ground that complainants have furnished false declaration while submitting the proposal form by suppressing the fact of second complainant suffering with diabetic for past 5 years.
The complainants informed the opposite party that the patient was diabetic only from November 2012 onwards but unknowingly the attendant of patient present at the time of hospitalization for surgery informed that patient is diabetic and hypertensive for past 5 years which is incorrect. Thereupon opposite party asked to get a letter from the hospital authority to that affect. Accordingly hospital authority gave a letter on 17-07-2014 stating that patient is diabetic only from November, 2012 but even after the said clarification from the hospital authorities opposite party has not reimbursed the amount spent for the treatment. The efforts of the complainants by way of letters and representations to get the reimbursement were ended not fruitful as the opposite party is delaying the issues on one pretext or the other.
After the surgery the second complainant developed cough and cold which effected in coping the stitches, hence she was forced to visit hospital for every alternative day for a period of 2 months. The complainants with great difficult could pay the hospital bills by borrowing the amounts from outsiders. The rejection of the claim is illegal as the complainants have 4 years seniority in the policy. That apart diabetic is not the reason for umbilical hernia. The company never asked the complainant and their family members to get medical tests done before taking the policy. Having collected the premium for 4 consecutive years opposite party company rejected the claim and it amounts to unfair trade practice and deficiency of service. Hence the present complaint for the above stated reliefs.
2. Opposite party in its written version denied the material allegations of unfair trade practice and deficiency of service on its part as insurer of the complainants. The defense set out by the company is that as per the standard practice every proposer applies for a policy by means of an application in the form of a standard Proposal form wherein the proposer is required to fill in material information printed therein. Complainants have applied for an easy health insurance through a duly filled in and signed a proposal form on 31-08-2010 for availing health insurance policy covering both the complainants and their daughter Ms T.Sreetha. In the proposal form all the medical questionnaire the complainants replied negative. The said policy was renewed till August 2013 and thereafter the complainants have requested to change a plan from “Easy health” to Optima Restore plan” and submitted a proposal form on 21-08-2013 duly filled and signed by them. In the said proposal form also all the medical questionnaire were answered negatively. The proposal form filled and signed by the complainants is the basis for issuance of insurance policy, hence the complainants were to discloses all the facts relevant to the persons proposed to be insured which will effect decision of the company in issuing policy with terms, conditions and exclusions. Non-compliance of it will result in avoidance of policy. Clause 9 relates to declaration and warranty on behalf of all persons proposed to be insured by which the applicants will declare that the statements made in the proposal form are true and correct in all aspects and that declaration is a contract between the company and all persons submitting proposal from.
Believing the declarations, information and details provided by the applicants policy will be issued to the applicants. The proposal form submitted was basis of issuance of policy to the complainants and their daughter on 24-08-2013 covering the period from 31-08-2013 to 30-08-2014. The policy Kit contains all relevant documents including policy wording and it was delivered to the complainant thereby giving them an opportunity to verify and examine the benefits, terms and conditions of the policy and at no stage was any communication/objection for any of the clauses or exclusions.
On 13-5-2014 a pre authorization request note was received from Woodlands hospitals for treatment of second complainant and having gone through the initial authorization was given by the company for a sum of Rs.35,000/- and the hospital was asked to provide of treatment record including consultation and reports etc. In response to it the hospital submitted a letter dated 22-05-2014 stating that “regarding Diabetes and Hypertension patients husband states that they did not have any records of consultation the declaration and the letter provided by the complainant to the hospital there is a clear mention that patient is a diabetic and hypertension for the last 5 years. Thus the information received from the treating hospital regarding the patient’s health revealed that patient is a known case of hyper tension and diabetic Mellitus since 5 years which fact was completely suppression from the day of subscribing for the policy.
The contract of insurance is based on the principles of “uberrima fide” and suppression of material fact renders the policy void. The incorrect information in the proposal given by the assured with regard to her pre-existing disease and health condition vitiates the contract of insurance. In the light of it the second complainant is not entitled for the claim hence it was repudiated on 26-5-2014. The claim was re-submitted for reimbursement with date of admission as 15-5-2014 and date of discharge as 22-5-2014 and final bill amount of Rs.62,600/-. After scrutiny of records having confirmed that patient is known case of diabetic and hypertension since 11 years it was rejected. Clause No.6 of the proposal form in the Medical & life style information category of the insured person it was expressed that none of them are suffering with any of the disease and that they were hale and healthy and it goes to show that the second complainant has suppressed the history of diabetic and hypertension for 5 years back which is prior to the start of the policy. Had she disclosed the said fact of medical condition in the proposal form the company could not have issued an insurance covering risk of uncertainty and not certain risk like in the instant case. Since policy of insurance is based on a policy of utmost good faith and misleading information was given by the complainant a notice of termination of the policy was sent to the complainants in the form of a letter dated 23-05-2014 and subsequently notice of termination was issued on 04-07-2014 and the policy was cancelled ab initio by letter dated 4th July 2014. The repudiation of the claim and termination of the policy was as per the terms and conditions. As such there is no illegality either in repudiating the claim or terminating the policy and thus the complaint is devoid of merits and liable to be dismissed.
In the enquiry stage both complainants have filed their evidence affidavits which are replica with each other and got exhibited 14 documents. For the Opposite Party evidence affidavit of Deepti Rustagi Sr.Vice President- legal and Chief compliance officer is got filed and through him 10 documents are exhibited. Both sides filed written arguments and made oral submissions also.
On a consideration of material available on the record the following points have emerged for consideration .
- Whether repudiation of the claim submitted by the complainants and termination of the policy amounts to either unfair trade practice or deficiency of service on part of the opposite party ?
- Whether the complainants are entitled for the revival of policy and the amounts claimed under different dates?
- To what relief?
Point No.1: Obtaining of policy by the complainants and their daughter T.Sreetha
initially in the year 2010 and renewal of the same for 3 consecutive years is not in dispute. It is fact that for the 4th year the complainants have shifted to policy captioned as Optima health restore on the assurance stated to have been given by agent of the opposite party that the policy seniority will continue from the date of obtaining of the original policy. The admission of second complainant in the hospital with the complaint of stomach pain and diagnosis as umbilical hernia and consequent treatment in the same hospital are not in dispute. Though ultimately opposite party rejected the claim on the ground suppression of material information relating to health condition of second complainant in the proposal form submitted, in the initial stage they have sent a message to the complainants and the hospital authorities when second complainant was admitted that she is eligible for cashless treatment. Thereafter on a request by the opposite party the hospital authority appears to have sent additional documents and reports wherein there is mentioned that the patient is known case of a diabetic and hypertensive for the past 5 years. Because of the said information opposite party company rejected the cashless treatment and appears to have advised the complainant to file a claim for reimbursement of the amount spent for the treatment.
The material placed on record shows the complainants after paying the bill amount to the hospital submitted a claim for reimbursement of the amount which was finally rejected for the same reason mentioned above. The case of the complainant is attendant of the patient unknowingly informing to the doctor concerned in the hospital that the patient has been suffering with diabetic and hypertensive for the past 5 years but in fact the diabetic occurred only in the month of November 2012 which means after taking 2 consecutive policies. ExA11is letter stated to have been issued by Dr.Suresh Goud of treating hospital to the opposite party stating that as per the records of treatment for diabetic and hypertension maintained by the patient it is found that actually patient is a known case of diabetic and hypertensive since 2012 only. But opposite party did not consider the Ex.A11 letter issued on 17-7-2014. Ex.A12 is Xerox copy of hand written letter from the first complainant to the opposite party staging that he obtained a policy in the month of August 2010 for himself and second complainant and their daughter and renewed the policy for 4 consecutive years without interruption. It is further stated by him that after death of his mother in the year 2012 the second complainant was complaining about the giddiness then went to the doctor in the month of October 2012 and the doctor after examination informed that she was suffering with diabetic and blood pressure. It is further stated by him when he shifted to Optima restore plan the agent of the opposite party did not ask the details hence for the new policy he did not declare of health problem out of ignorance. This letter dated 6-6-2014 Ex.A7 is the discharge summary filed by the complainants in which there is a specific mention that patient is a known case of diabetic and hypertension for the 5 years and Rx.H/o LSCS 11 years back.
Admittedly the discharge summary was issued prior to the letter under Ex.A11. In Ex.A11 there is mention of examinations, records of treatment for diabetic and hypertension maintained by the patient but said record is not placed before this Forum. Interestingly first complainant in his hand written letter under Ex.B4 dated 22-5-2014 addressed to family health plan Ltd, Hyderabad categorically stated that his wife Mrs. Aruna is patient of diabetic and hyper tension for 5 years and at the time of taking of the policy he discloses the same and for that they have been paying additional premium and the consultation papers are not available with him. By this Ex.B4 letter it is clear that the complainants are not having consultation papers relating to the treatment of the second complainant for diabetic and hypertension then how could the doctor issued Ex.A11 letter saying that he examined the records of treatment for diabetic and hypertension maintained by patient is not explained. Ex.B4 letter has to be given credence as it is prior in time to Ex.A11 letter of the doctor. This would go to show that the medical officer who issued Ex.A11 letter issued it at the request of the complainants to overcome the decision taken by the company basing on the Ex.B4. Apart from this Ex.B4 as already said discharge summary also refers that the patient is known case of diabetic and hypertension for 5 years prior to the date of admission in the hospital. So about one year prior to the obtaining of policy the second complainant was suffering with diabetic and hypertension but in the proposal form submitted for the policy the opposite party the same has been suppressed. The policy is a contract issued basing on the utmost faith of the party who submitted the proposal form as rightly pleaded by the opposite party. If the complainants disclosed the stats of health of second complainant in the proposal form the company may not have insured the policy. So it is clear case of suppression of material fact and since policy is a contract suppression of any material fact vitiates the contract from the inception itself hence rejection of claim does not amount to either deficiency of service or unfair trade practice on the part of opposite party. Similarly the cancellation of policy by the company is also justified. Hence the point is answered against the complainant.
Point No.2: Since the repudiation of the claim and cancellation of the policy by the opposite party does not amount to deficiency of service and unfair trade practice the complainants are not entitled for any of the claim made in this complaint.
Point No.3: In the result, the complaint is dismissed. No order as to costs.
Dictated to steno transcribed and typed by her pronounced by us on this the 25th day of February , 2019
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Exs. filed on behalf of the Complainant:
Ex.A1 tests preferred by hospital dated 2//5/2014
Ex.A2 is complete medical reports
Ex.A3is bill cum receipt
Ex.A4 is complete hospital record from the date of admission till date of discharge
Ex.A5 is complete medical reports
Ex.A6 is break up bill of medicines and consumables
Ex.A7 is discharge summary
Ex.A8 is bill and receipt
Ex.A9 is insurance policy along with letter dt.13-09-2010
Ex.A10 is submission for cash less treatment
Ex.A11 is letter stating the complainant’s wife diabetic status along with complete reports
Ex.A12 is representation
Ex.A13 is letter dated 14th May 2014 with regard to the policy details
Ex.A14 is termination notice
Exs. filed on behalf of the Opposite party
Ex.B1 is proposal form
Ex.B2 is policy wording
Ex.B3 is details of the third party administrator
Ex.B4 is letter of the complainant No.1 dated 22-05-2014
Ex.B5 is cashless service denial
Ex.B6 is claim form dated 26-05-2014
Ex.B7 is Woodlands Hospital case sheet with investigation reports till 22-05-2014
Ex.B8 is discharge summary
Ex.B9 is repudiation letter dated 19-06-2014
Ex.B10 is cancellation of the policy dated 4-7-2014
MEMBER PRESIDENT
