NAtional Insurance4 Co ltd.., V/S Chandrashekar Shetty Satwadi - Consumer Court Case

Karnataka

Bangalore Urban

CC/08/2811

Chandrashekar Shetty Satwadi - Complainant(s)

Versus

NAtional Insurance4 Co ltd.., - Opp.Party(s)

VIshweanthy Sabharad

27 Feb 2009

ORDER

BANGALORE URBAN DISTRICT CONSUMER DISPUTES REDRESSLAL FORUM, BANGALORE, KARNATAKA STATE.
Bangalore Urban District Consumer Disputes Redressal Forum, Cauvery Bhavan, 8th Floor, BWSSB Bldg., K. G. Rd., Bangalore-09.
consumer case(CC) No. CC/08/2811

Chandrashekar Shetty Satwadi						...........Appellant(s)
Vs.
NAtional Insurance4 Co ltd..,						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

COMPLAINT FILED: 26.12.2008 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN) 27th FEBRUARY 2009 PRESENT :- SRI. A.M. BENNUR PRESIDENT SMT. M. YASHODHAMMA MEMBER SRI. A. MUNIYAPPA MEMBER COMPLAINT NO. 2811/2008 COMPLAINANT Sri. Chandrashekar Shetty Satwadi, Aged 65 years, No. 806, Surabhi Apartments, Bannerghatta Road, Bangalore 76. Advocate (Viswanath Sabarad) V/s. OPPOSITE PARTIES 1. The Divisional Manager, National Insurance Company Limited, No. 64, Lalbagh Road, (old mission road) Bangalore 27. Advocate (O. Mahesh) 2. The Managing Director, Vipul Medcorp TPA Pvt. Ltd., No. 515, Udyog Vihar Phase-5, Gurgaon, Haryana. Also at, No. 154, Mallige Complex, KHB Colony, 5th Block, Koramangala, Bangalore 95. O R D E R This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the insurance claim for Rs.2,27,369/- and pay a compensation of Rs.50,000/- for such other reliefs on an allegations of deficiency in service. The brief averments, as could be seen from the contents of the complaint, are as under: Complainant obtained tie-up health policy from OP which was valid from 12.11.2007 to 11.12.2008. Complainant is hale and healthy. During the month of December 2007 he developed pain in the left shoulder, he immediately approached the Wockhardt Hospital. He was subjected to TMT and for other tests. It was noticed he had some ischemia. He was advised to undergo coronary angiography. On 04.01.2008 a stenting was done at Wockhardt Hospital, Bangalore, thereby he has spent nearly Rs.2,27,369/-. After the discharge he submitted the claim to OP to reimburse the medical expenses. Unfortunately OP repudiated the claim on 08.06.2008 on the ground that he has taken treatment for the pre-existing disease, hence he is not entitled for the expenses incurred. The repudiation is unjust and improper. Hence complainant caused the legal notice on 30.06.2008. Again there was no response. Complainant felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly. 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant is suffering from hypertension for the last 21 years and the treatment that is taken from the Wockhardt Hospital was for the pre-existing disease. Under such circumstances OP is justified in invoking its power under the exclusion clause 4.1. After thorough investigation and verifying the medical records OP repudiated the claim. There is no deficiency in service on the part of the OP. The complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint. 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard. 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order? 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Affirmative Point No.2:- Affirmative in part Point No.3:- As per final Order. R E A S O N S 6. At the outset it is not at dispute that the complainant took tie-up health policy from OP which was inforce from 12.11.2007 to 11.12.2008. According to the complainant he is hale and healthy. Unfortunately in the month of December 2007 he experienced some pain in the left shoulder, that is why he approached the Wockhardt Hospital, Bannerghatta Road, Bangalore. He was subjected to TMT which showed ischemia, he also underwent CT coronary angiography. Then on 04.01.2008 he underwent PTCA and stenting. He was admitted in the said hospital and later on he was discharged. During the course of his treatment he has spent nearly Rs.2,27,369/-. The bills issued by the hospital are produced. OP has produced the discharge summary and other connected documents issued by the concerned hospital. 7. It is further contended by the complainant that after discharge he made claim to OP to settle the medical bills. Unfortunately OP repudiated the claim on 08.06.2008. The repudiation letter is produced. OP invoked exclusion clause and repudiated the claim on the ground that he has taken treatment for the pre-existing disease. Complainant felt that the said repudiation is unjust and improper, that is why he got issued the legal notice. The copy of the legal notice is produced. The evidence of the complainant appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. It is a quality of evidence that is more important than that of the quantity. 8. As against this impeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake. Para.3 of the version itself discloses that when complainant submitted his proposal he did mention that he is suffering from blood pressure. He has not suppressed any material fact nor hided the things. With all that OP accepted his proposal, collected the premium, covered the risk and issued the policy. People go for the insurance in a good faith that the insurance company like OP will come to their assistance and aid in an hour of need. But if OP has repudiated the said claim on technical grounds, it is unfortunate. People may loose faith in the whole insurance system. When the complainant has not suppressed any material fact about the fact of he suffering from high blood pressure, it would have been more fair on the part of the OP to subject him to medical examination. If they are not satisfied with the health condition then they would not have accepted his proposal. But no such steps are taken nor there is any proof that the complainant has taken treatment for the hypertension. 9. Merely because the hospital records show that he is suffering blood pressure from last 21 years, is no ground to discard his claim. The blocking suffered by the complainant may not be a direct result of he suffering from high blood pressure, there may be some other reasons for the said blocks also. It is for the OP to substantiate their defence that complainant took treatment for the said hypertension earlier and present ailment is the offshoot of H.P. But no such records are produced. Under such circumstances we find the defence of the OP does not hold much force. Complainant has spent substantive amount in making payment of the hospital bills. Those bills are not disputed or denied by the OP. 10. We have also gone through the insurance policy, the sum assured is for Rs.2,00,000/-. Complainant must have spent an amount of Rs.2,27,369/-. But in view of the risk coverage undertaken by the OP the justice will be met by restricting the claim for Rs.2,00,000/-. We are satisfied that the complainant is able to prove the deficiency in service. For no fault of his, he is made to suffer both mental agony and financial loss. Under such circumstances he is entitled for certain relief. Accordingly we answer point nos.1 and 2 and proceed to pass the following: O R D E R The complaint is allowed in part. OP is directed to settle the insurance claim for Rs.2,00,000/- and pay the same to the complainant within 4 weeks from the date of communication of this order. In view of the nature of dispute no order as to costs. If OP fails to pay the said amount as ordered, complainant is entitled to claim interest at the rate of 12% p.a. on Rs.2,00,000/- from the date of repudiation of the claim (08.06.2008) till realization and also entitled for a litigation cost of Rs.1,000/-. (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 27th day of February 2009.) MEMBER MEMBER PRESIDENT p.n.g.

COMPLAINT FILED: 26.12.2008 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN) 27th FEBRUARY 2009 PRESENT :- SRI. A.M. BENNUR PRESIDENT SMT. M. YASHODHAMMA MEMBER SRI. A. MUNIYAPPA MEMBER COMPLAINT NO. 2811/2008 COMPLAINANT Sri. Chandrashekar Shetty Satwadi, Aged 65 years, No. 806, Surabhi Apartments, Bannerghatta Road, Bangalore 76. Advocate (Viswanath Sabarad) V/s. OPPOSITE PARTIES 1. The Divisional Manager, National Insurance Company Limited, No. 64, Lalbagh Road, (old mission road) Bangalore 27. Advocate (O. Mahesh) 2. The Managing Director, Vipul Medcorp TPA Pvt. Ltd., No. 515, Udyog Vihar Phase-5, Gurgaon, Haryana. Also at, No. 154, Mallige Complex, KHB Colony, 5th Block, Koramangala, Bangalore 95. O R D E R This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the insurance claim for Rs.2,27,369/- and pay a compensation of Rs.50,000/- for such other reliefs on an allegations of deficiency in service. The brief averments, as could be seen from the contents of the complaint, are as under: Complainant obtained tie-up health policy from OP which was valid from 12.11.2007 to 11.12.2008. Complainant is hale and healthy. During the month of December 2007 he developed pain in the left shoulder, he immediately approached the Wockhardt Hospital. He was subjected to TMT and for other tests. It was noticed he had some ischemia. He was advised to undergo coronary angiography. On 04.01.2008 a stenting was done at Wockhardt Hospital, Bangalore, thereby he has spent nearly Rs.2,27,369/-. After the discharge he submitted the claim to OP to reimburse the medical expenses. Unfortunately OP repudiated the claim on 08.06.2008 on the ground that he has taken treatment for the pre-existing disease, hence he is not entitled for the expenses incurred. The repudiation is unjust and improper. Hence complainant caused the legal notice on 30.06.2008. Again there was no response. Complainant felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly. 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant is suffering from hypertension for the last 21 years and the treatment that is taken from the Wockhardt Hospital was for the pre-existing disease. Under such circumstances OP is justified in invoking its power under the exclusion clause 4.1. After thorough investigation and verifying the medical records OP repudiated the claim. There is no deficiency in service on the part of the OP. The complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint. 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard. 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order? 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Affirmative Point No.2:- Affirmative in part Point No.3:- As per final Order. R E A S O N S 6. At the outset it is not at dispute that the complainant took tie-up health policy from OP which was inforce from 12.11.2007 to 11.12.2008. According to the complainant he is hale and healthy. Unfortunately in the month of December 2007 he experienced some pain in the left shoulder, that is why he approached the Wockhardt Hospital, Bannerghatta Road, Bangalore. He was subjected to TMT which showed ischemia, he also underwent CT coronary angiography. Then on 04.01.2008 he underwent PTCA and stenting. He was admitted in the said hospital and later on he was discharged. During the course of his treatment he has spent nearly Rs.2,27,369/-. The bills issued by the hospital are produced. OP has produced the discharge summary and other connected documents issued by the concerned hospital. 7. It is further contended by the complainant that after discharge he made claim to OP to settle the medical bills. Unfortunately OP repudiated the claim on 08.06.2008. The repudiation letter is produced. OP invoked exclusion clause and repudiated the claim on the ground that he has taken treatment for the pre-existing disease. Complainant felt that the said repudiation is unjust and improper, that is why he got issued the legal notice. The copy of the legal notice is produced. The evidence of the complainant appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. It is a quality of evidence that is more important than that of the quantity. 8. As against this impeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake. Para.3 of the version itself discloses that when complainant submitted his proposal he did mention that he is suffering from blood pressure. He has not suppressed any material fact nor hided the things. With all that OP accepted his proposal, collected the premium, covered the risk and issued the policy. People go for the insurance in a good faith that the insurance company like OP will come to their assistance and aid in an hour of need. But if OP has repudiated the said claim on technical grounds, it is unfortunate. People may loose faith in the whole insurance system. When the complainant has not suppressed any material fact about the fact of he suffering from high blood pressure, it would have been more fair on the part of the OP to subject him to medical examination. If they are not satisfied with the health condition then they would not have accepted his proposal. But no such steps are taken nor there is any proof that the complainant has taken treatment for the hypertension. 9. Merely because the hospital records show that he is suffering blood pressure from last 21 years, is no ground to discard his claim. The blocking suffered by the complainant may not be a direct result of he suffering from high blood pressure, there may be some other reasons for the said blocks also. It is for the OP to substantiate their defence that complainant took treatment for the said hypertension earlier and present ailment is the offshoot of H.P. But no such records are produced. Under such circumstances we find the defence of the OP does not hold much force. Complainant has spent substantive amount in making payment of the hospital bills. Those bills are not disputed or denied by the OP. 10. We have also gone through the insurance policy, the sum assured is for Rs.2,00,000/-. Complainant must have spent an amount of Rs.2,27,369/-. But in view of the risk coverage undertaken by the OP the justice will be met by restricting the claim for Rs.2,00,000/-. We are satisfied that the complainant is able to prove the deficiency in service. For no fault of his, he is made to suffer both mental agony and financial loss. Under such circumstances he is entitled for certain relief. Accordingly we answer point nos.1 and 2 and proceed to pass the following: O R D E R The complaint is allowed in part. OP is directed to settle the insurance claim for Rs.2,00,000/- and pay the same to the complainant within 4 weeks from the date of communication of this order. In view of the nature of dispute no order as to costs. If OP fails to pay the said amount as ordered, complainant is entitled to claim interest at the rate of 12% p.a. on Rs.2,00,000/- from the date of repudiation of the claim (08.06.2008) till realization and also entitled for a litigation cost of Rs.1,000/-. (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 27th day of February 2009.) MEMBER MEMBER PRESIDENT p.n.g.