Date of Filing: 16-11-2017
Date of Order: 20-01-2020
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 Sri K.RAM MOHAN, B.Sc. M.A L.L.B MEMBER
HON’BLE Smt. CH. LAKSHMI PRASANNA, B.Sc. LLM. (PGD (ADR), MEMBER
ON THIS THE MONDAY THE 20th DAY OF JANUARY, 2020
C.C.No.480/2017
Between
Smt. Etish Sanghai,
W/o. Sri Kirti Sanghai,
Aged about 31 years, Occ:Households
R/o. # 8-3-3, Yellareddyguda,
Ameerpet, Hyderabad – 500 018. ……Complainant
And
- M/s. Religare Health Insurance Company Limited,
Rep.by its Managing Director, Having registered office at # D-3, District C enmtre
Saket, New Delhi – 110 017.
- M/s. Religare Health Insurance Company Limited,
Rep.by its Managing Director,
Correspondence Office at GYS Global,
Plot No.A-3, A-4 and A-5, Sector – 125,
Noida – 201 301, Uttar Presesh ……..Opposite party
Counsel for the complainants : M/s. Shyam S Agarwal
Counsel for the opposite Parties: Mr.N Srinath Rao
O R D E R
(By. Smt. CH. Lakshmi Prasanna,B.Sc. LLM (PGD ( ADR)., Member on behalf of
Bench)
- The complaint is filed under Sec.12 of The Consumer Protection Act against the Opposite parties for deficiency of service, seeking an appropriate direction to the Opposite Parties to pay health insurance claim of AUD$3,692.00 equivalent to a sum of Rs.1,90,285/- along with interest @24% p.a from the date of claim till the date of realization, Rs.5,00,000/- towards compensation, Rs,20,000/- towards expenses incurred by the complainant and Rs.50,000/- towards costs of litigation.
- The brief averments of the complaint are:-
The complainant obtained health insurance from the opposite parties vide Policy No. 10132762 on 7/8/2014 for a sum of USD$1,00,000/- each for herself and her two daughters under plan named International Travel Insurance EXP Platinum by paying the necessary premium and covering the period from 30/8/2014 to 27/11/2014. As per the terms of the policy, the complainant and her two daughters were insured for all medical emergencies including pre-existing conditions and those not relating to any pre-existing issues. Apparently, despite disclosing the fact that both the daughters of the complainant had medical history of neurological problems and congenital Cardiac Atrial Septal Defect and Ventricular Septal Defect showing the relevant medical reports, the same was not mentioned in the proposal by the Sales Representative of the Opposite Party, and failed to correct the same even after following up several times. In fact, the Sales Representative of Opposite Party did not respond to several calls of the complainant to correct the column of pre-existing diseases and remained unticked in the policy papers handed over to the complainant. Unfortunately, during their short sojourn to Australia in the last half of 2014, the complainant's younger daughter fell seriously ill with pneumonia and was admitted for emergency medical care in Princess Margaret Hospital, Perth on 6/11/2014 and underwent treatment for 6 days and discharged on 11/11/2014, just a few days before their travel back to India. The medical Bill for the said treatment was referred to the Opposite Party. To their utter dismay, the claim was rejected on the alleged ground that the complainant suppressed the pre-existing medical condition of their younger daughter. After repeated requests for about four months, by the complainant and her husband, the said health insurance claim was approved but partially, only to the extent of half of the claimed amount i.e.USD$5000 instead of USD$10,000 as promised in the policy, and finally an amount of USD$6,940 was paid in December 2015. In pursuance of the same, the complainant got issued a legal notice dt.9/2/2016 to the Opposite Parties calling on them to pay the balance claim for remaining outstanding bills amounting to USD$3,692 along with interest @24% thereon. On receiving the reply dt.16/3/2017 from the Opposite Parties denying any liability, the present complaint is filed seeking appropriate relief.
- In their written version, the Opposite Parties, while denying any further liability and deficiency of service on their part, affirmed the partial payment of USD$6,940 only on reconsidering their claim on good faith, although holding the complainant negligent for suppressing the pre-existing condition of the complainant's daughter in the policy document and not correcting the discrepancies, if any, within the stipulated period of 15 days as per the instructions and not returning within 15 days, if the terms and conditions are not acceptable as per Cl.5.9 of the policy. Further submitted by the Opposite Parties that the complainant falsely mentioned in the cashless request form that the hospitalization for treatment of Pneumonia was not on the basis of the pre-existing condition of the complainant's younger daughter whereas the Emergency Assessment Continuation dt.6/11/2014 states that the patient was hospitalized LRTI (Lower Respiratory Tract Infection) 12 months earlier. Hence, there is no cause of action and the complaint is liable to be dismissed.
- In the enquiry, the complainant filed her evidence affidavit reiterating the averments in the complaint supporting her claim with Ex A1 to A9 including the policy certificate, discharge summary, legal notice and the rejoinder. Ex B1 to B9 are marked on behalf of the Opposite Parties, including the original policy proposal forms, the medical reports of the policy holder in support of their written version and counter affidavit.
- Based on the facts and material brought on record, and written arguments submitted by both the parties, the following points have emerged or consideration:
- Whether there is deficiency of service on the part of the Opposite Parties
- Whether the complainant is entitled for the claim/compensation made in the complaint?
- To what relief?
- Point No.1:- The undisputed facts of the case are that the complainant's two and a half years old daughter fell seriously ill with pneumonia and was admitted for emergency medical care in Princess Margaret Hospital, Perth on 6/11/2014 and underwent treatment for 6 days and discharged on 11/11/2014, just a few days before their travel back to India. Having obtained health insurance from the opposite parties vide Policy No. 10132762 for a sum of USD$1,00,000/- each for herself and her two daughters under plan named International Travel Insurance EXP Platinum by paying the necessary premium and covering the period from 30/8/2014 to 27/11/2014, the complainant claimed for the same w.r.t the medical expenses incurred for her daughter's treatment, which was initially rejected but was partially approved after several requests and follow up of the complainant.
What remains to be examined is the contention of the Opposite Parties that the insurance claim was repudiated on the grounds of suppression/non-disclosure of the pre-existing condition of the patient/policy holder who was having past medical history of neurological problems and congenital Cardiac Atrial Septal Defect and Ventricular Septal Defect, which are directly related to Lower Respiratory Tract Infection, for which she was hospitalized in Australia.
Hon'ble Supreme Court in the case P. Vankat Naidu Vs. Life Insurance Corporation of India & Anr. IV (2011) CPJ 6 (SC) 6 held that "......the finding recorded by the District Forum and the State Commission that the respondents had failed to prove that the deceased has suppressed information relating to his illness was based on correct appreciation of the oral and documentary evidence produced by the parties and the National Commission committed serious illegality by upsetting the said findings on a wholly unfounded assumption that the deceased has suppressed information relating to hospitalization and treatment."
In the instant case, the Opposite Parties did not produce any tangible evidence to prove that the complainant had withheld information about the medical problem of their daughter and there is no document/evidence has to prove that the complainant's daughter has a pre-existing medical condition as mentioned in Ex B-3 & B4 LRTI (Lower Respiratory Tract Infection) 12 months earlier, that predisposes her to contracting the illness again. In fact, in the case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon'ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued and hence the Insurance Company wrongly repudiated the claim of the complainant therein.
It is pertinent to mention that the wording on the policy package does not define pre-existing conditions, although pre-existing diseases are covered under the policy. Especially Insurance policies riddled with exclusions are too complicated and important to understand and make an informed decision about the policy's suitability. It is not out of context to mention that the way the policies are packaged and sold cutting corners, making it inevitable for further misinterpretations/ misunderstandings and hence it calls for a closer determination whether the intention of the party to exclude or limit liability has been appropriately explained to the other party or not, more so, because the benefit of such clause, as exclusion clause, would go to the insurer unless the same is explained in clear terms to the insured.
It is also relevant to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.
In view of the above discussion and findings, supported by the relevant case law, the point is answered in favour of the complainant.
- Point No.2:- As mentioned in the Policy terms and conditions, Clause no.2.1.1.F the present policy No 10132762 obtained for a sum of USD$1,00,000/- covers any emergency medical treatment rendered during the period of insurance for any sudden, unexpected, unforeseen development attributable to any pre-existing disease and the claim amount shall be 10% of the sum insured or the actual hospitalization expenses....,subject to the conditions mentioned therein. As the partial payment of USD$ 6,940 has been acknowledged by both the parties in their affidavits, the Opposite parties are liable to pay the balance amount of claim of AUD$3,692.00 equivalent to a sum of Rs.1,90,285/- to the complainant. Accordingly the point is answered in favour of the complainant.
8) Point No.3:- Sequel to our above discussion, the complaint is allowed and the following directions are issued to the opposite parties:
i) to pay the sum of AUD$3,692.00 equivalent to a sum of Rs.1,90,285/- to the complainant, along with interest at the rate of 9% per annum from the date of submission of the claim till realization;
ii) to pay 50,000/- towards compensation and
iii) to pay 5,000/- as litigation expenses.
This order be complied with by the opposite parties, within 45 days from the date of receipt of the order, failing which the amounts at Sr.No.(i)&(ii) above shall carry interest @18% per annum from the date of this order till actual payment.
Dictated to steno transcribed and typed by her and pronounced by us on this the 20th day of January, 2020.
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 - Brochure of the opposite party explore
Ex.A2 – Copy of policy certificates (2) dt.7.8.2014
Ex.B3 – Insurance policy dt.7.8.2014
Ex.A4 – Discharge summary of Baby Hitakshi Sanghai, dt.11.11.2014
Ex.A5 - Copy of legal notice dt. 18.2.2016
Ex.A6 - Reply notice dt. 16.3.2016
Ex.A7 – Rejoinder notice of the complainant dt. 2.5.2017
Ex.A8 - Reply of the opposite party to the rejoinder dt. 6.6.2017
Ex.A9 – Death certificate
Exhibits filed on behalf of the Opposite parties:
Ex.B1 – Policy terms and conditions.
Ex.B2 – Letter dt. 29.11.2014
Ex.B3 – Discharge Summary
Ex.B4 – Emergency Assessment
Ex.B5 – Inpatient progress notes
Ex.B6 – Letter dt.21.2.2018
Ex.B7 – Letter dt. 18.2.2016
Ex.B8 – Reply notice dt.16.3.2016
Ex.B9 – Rejoinder notice, 2.5.2017
MEMBER MEMBER PRESIDENT
