Date of Filing:15.05.2009<br /> Date of Order: 06.11.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 6TH DAY OF NOVEMBER 2009<br /> <br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> COMPLAINT NO: 1123 OF 2009<br /> <br /> D. Srinivas<br /> S/o. Late Doddaiah<br /> R/at No. 342, 7th Main<br /> 6th Cross, RPC Layout<br /> Vijayanagar II Stage<br /> Bangalore 560 040 Complainant<br /> <br /> V/S<br /> <br /> 1. M/s. New India Assurance Co. Ltd.<br /> Indicom House, II Floor, No. 327/5<br /> Mysore Road, Bangalore 560039<br /> Represented by its Manager<br /> <br /> 2. M/s. Medi Assist India (Pvt.) Ltd.<br /> No. 49, 1st Main Road<br /> Sarakki Industrial Layout<br /> 3rd Phase, J.P. Nagar<br /> Bangalore 560 078<br /> Represented by its Manager Opposite Parties<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act.<br /> The complainant had obtained mediclaim policy from opposite party No. 1. Policy was renewed for a further period of one year from 14.01.2009 to 13.01.2010. The complainant was inpatient for a period of 8 days from 15.01.2009 to 22.01.2009 at M/s. BGS Global Hospitals, Kengeri, Bangalore. He submitted that claim form along with all relevant documents and bills claiming reimbursement of Rs. 51,934/- under the mediclaim policy. Claim was not admitted and rejected by the opposite party No. 2. Policy was issued after satisfying that no pre-existing diseases. Complainant forwarded certificate of Consultant Nephrologist stating that there was no pre-existing disease and he had no symptoms suggestive of kidney failure, opposite party failed and neglected the claim which amounts to deficiency in service. Complainant submitted that he has also incurred expenses of Rs. 85,219/- towards maintenance dialysis as an inpatient. Opposite parties are liable to admit the claim under mediclaim policy. Complainant submitted that he had issued legal notice. The rejection of the claim on the ground of pre-existing disease is unwarranted, illegal and illogical. Opposite parties failed to consider the certificate issued by the Consultant Nephrologist, BGS Global Hospital, Bangalore. Therefore, the complainant prayed that opposite parties be directed to pay two mediclaims submitted by him with interest.<br /> 2. After admitting the complaint notice issued to opposite parties. Opposite parties appeared through counsel. Defence version filed admitting that complainant had filed complaint for reimbursement of medical expenses of Rs. 51,934/- and Rs. 85,212/-. It is admitted by the opposite parties that they had issued hospitalization Benefit Policy / Mediclaim Policy to the complainant and his family members. The opposite parties also admitted that complainant has paid premium amount of Rs. 18,248/- and opposite party had issued the said policy as renewal of previous policy is also admitted. It is also admitted by the opposite parties that complainant was an inpatient for a period of 8 days from 15/01/2009 to 22/01/2009 at BGS Global Hospitals, Bangalore and submitted bills, reports, discharge certificate to the opposite parties. The opposite parties are also admitted that complainant has incurred expenses of Rs. 85,219/- subsequently towards maintenance dialysis. The hospital has sought cashless treatment which as denied. The complainant submitted that bills for Rs. 85,219/- is also submitted. The opposite parties have taken defence that the claims of the complainant were repudiated on 17.02.2009 under exclusion clause No. 4 (1) of the policy since, complainant was suffering from pre-existing hypertension and diabetes Mellitus. The opposite party submitted that they are not liable to reimburse any medical bills. Therefore, requested to dismiss the complaint.<br /> 3. Complainant has filed his affidavit evidence. Smt. Nagarathna H.R., Senior Manager of opposite party No. 2 and K. Sathishchandra, Admn. Officer of opposite party No. 2 filed their affidavit evidence. The complainant and opposite parties have filed documents. I have gone through the pleadings of parties and the affidavit evidence.<br /> 4. Heard the arguments.<br /> 5. The points for consideration are:<br /> 1. Whether there was deficiency of service on the part of opposite parties?<br /> 2. Whether repudiation of the mediclaim submitted by the complainant is justified?<br /> 3. Whether the opposite parties can be directed to allow the claim and pay the amount?<br /> 6. It is admitted case of the parties that the complainant had taken hospitalization benefit policy for himself and his family members. The period of policy was from of 14.01.2008 to 13.01.2009 and this policy was again renewed and obtained renewal policy and period of policy was 14.01.2009 to 13.01.2010. Copies of policy have been produced. The complainant has paid premium amount of Rs.18,248/-. The complainant was admitted to BGS Global Hospitals, Bangalore as inpatient from 15.01.2009 to 22.01.2010. He has submitted the claim for reimbursement of Rs 51,934/- to the opposite parties. The complainant had incurred medical expenses of Rs. 85,219/- subsequent to the submission of first claim towards dialysis and other medical expenses and he has submitted this claim also to the opposite parties along with bills, documents and certificates. Unfortunately, the opposite parties repudiated the claim of the complainant relying on Clause 4 (1) of policy on the ground that the complainant was suffering from a pre-existing disease like hypertension and diabetes. The complainant has produced certificate of Dr. Anil Kumar, Consultant Nephrologist dated 16.02.2009 wherein it has been clearly stated by the doctor that ‘there were no pre-existing risk factors like diabetes and hypertension. In the past he had no symptoms suggestive of kidney failure’. So by this certificate who is an expert in nephrology clearly stated that the complainant was not suffering from kidney related problem earlier to the admission to the hospital. Admittedly, the complainant was admitted to hospital during validity of policy period and he was inpatient to the hospital and he was treated for kidney problem. Admittedly, the opposite parties have not produced any documents or records to show that the complainant has taken treatment for the kidney related problem before obtaining policy. The opposite parties have not established or produced any documents to show that the complainant at any time was admitted to hospital for kidney problem. Before repudiating claim of the complainant the opposite parties should clearly establish or prove that the complainant had pre-existing disease relating to kidney. In this case the opposite parties have not at all produced any evidence or documents to show that the complainant was suffering from kidney disease and he had knowledge of that disease and intentionally suppressed the disease at the time of taking policy. So under these circumstances when the complainant had no knowledge of kidney ailment or disease and he had not taken any treatment in respect of kidney disease before the policy was taken how can the opposite parties repudiate the claim which is a genuine and legal claim. The complainant has produced an article of Dr. Sudarshan Ballal who is a specialist in nephrology appeared in newspaper ‘Arogya’. In this article Dr. Sudarshan Ballal has clearly stated that 90% people will not be knowing the kidney related ailment until the last stage of the kidney disease. So under these circumstances when the complainant was not aware of his kidney disease or ailment the question of suppression of fact does not arise at all. The opposite parties have not at all proved and established that the complainant has intentionally suppressed his pre-existing disease. So under these circumstances the repudiation of the claim of the complainant is not justified. The opposite parties could have accepted the claim and paid the amount to the complainant by taking into consideration all his sufferings and amount spent towards his treatment, hospitalization and the treatment taken in hospital as inpatient. BGS Global Hospitals is a very famous hospital. The doctor working in the said hospital who is a consultant nephrologist had clearly given certificate that complainant was not having any previous risk factors like diabetes and hypertension and he had no symptoms suggestive of kidney failure. When this is the case the repudiation of the just and proper claim of the complainant on the part of opposite parties is absolutely not fair and justified. The complainant is entitled for the reimbursement of the amount spent for his medical treatment. The sum assured under the policy is Rs. 5,00,000/-. The complainant has put up cashless claim of Rs. 51,934/- and another claim of Rs. 85,291/- and submitted all the necessary claim application, documents and bills to the opposite parties. As regards the bills and the amount claimed by the complainant there is absolutely no dispute. Opposite parties have not disputed or taken any objections with respect to the claim submitted by the complainant. Therefore, the complainant is entitled for the amount claimed by him under two claims submitted to the opposite parties. Total amount for the two claims comes to Rs. 1,37,153/-. The learned advocate for the complainant vehemently argued that complainant is seriously suffering from kidney ailment and still is under treatment and his condition is very serious and submitted that if he receives the claim amount it will be great help to him to meet out his medical expenses. The Consumer Protection Act is a social and benevolent legislation intended to protect better interests of consumers. The interest of the complainant who is suffering from kidney disease deserves to be protected since he had obtained mediclaim policy. The repudiation of the genuine claim of the complainant really amounts to deficiency of service on the part of opposite parties. In the result I proceed to pass the following:<br /> ORDER<br /> 7. The complaint is allowed. The opposite parties No. 1 & 2 are jointly and severally directed to pay Rs. 1,37,153/- to the complainant. The complainant is also entitled for 6% interest p.a. on the said amount from the date of complaint till payment / realization.<br /> 8. The opposite parties are directed to comply the order within four weeks from the date of this order.<br /> 9. The opposite parties are directed to send the cheque / D.D. to the complainant directly with intimation to this forum.<br /> 10. Send the copy of this Order to both the parties free of costs immediately. <br /> 11. Pronounced in the Open Forum on this 6TH DAY OF NOVEMBER 2009. <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> MEMBER<br /> <br />