BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 11^TH DAY OF JULY 2024

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. Refund a total sum of Rs.6,21,010/- being the amount paid by the complainant.
2. Pay Rs.3,36,010/- being interest accrued on aforesaid sum of Rs.1,35,000/- @ 15% p.a.,
3. Pay future interest @ 15% p.a., or as decided by this Hon’ble Commission from 01.06.2021 till date of payment.
4. Pay Rs.1,00,000/- towards compensation for financial loss and mental agony endured by the complainant on account of deficiency in service as well as unfair trade practice on the part of the OPs.
5. Pay Rs.50,000/- towards litigation expenses in prosecuting the matter as against the OPs.
6. Such other reliefs as this Hon’ble Commission.

2. The case set up by the complainant in brief is as under:-

OP1 is a policy bazaar, is a company having its office at Haryana and also at Bangalore.  The OP1 is Indian insurance aggregator and multinational financial technology company in Gurgav founded in June 2008.  The OP1 offers a comprehensive range of business insurance products across multiple categories.  OP1 is specialized in making comparative analysis of insurance product on the basis of price quality and key benefits.  The OP2 is insurance company.

3. It is further case of the complainant that the complainant in the year 2021 ported his insurance policy on the basis previous eight years no claim bonus and all the inclusive continuously from previous insurance company. The policy No.19810596 and plan name is CARE and starting date of the policy 27.01.2021 and end of the policy 27.01.2022.  the complainant has ported his policy with the belief and good faith the insurance have covered all the ailments which is inclusive of mental health ailments for which the OP have mentioned the benefit in their letter dated 27.01.2021.  The insurance policy is for an amount of Rs.6,00,000/- with portability benefit from December 2015 onwards for each of the family members i.e., the complainant, his late wife and the complainant’s son with an opted option of auto recharge facility.
4. It is the specific case of the complainant that he and his son were infected with covid 19 virus and admitted to M/s Apollo International Hospital approved by the OP2 during the second waive of covid 19. After discharge the complainant has submitted details bill to the OP1 to claim the insurance amount claiming Rs.6,12,226/-. 
5. At the time of claiming insurance amount from OP1 the complainant submitted the hospital bills of his son Abhipriya Mitra, aged about 25 years, who is under the care and custody of the complainant and he is the natural guardian. His son was admitted and taken treatment for 11 days for covid 19 infection. The claim of the complainant’s son was rejected under the pretext that the mental disorder was not disclosed at the time of purchasing the policy.
6. The complainant has repeatedly reached out to OP1 through email regarding rejection of the claim. The complainant wants only the insurance claim towards covid 19 hospitalization. Upon repeated emails sent by the complainant the OP1 responded stating that the OP2 is responsible for further claims and the complainant even he was going through the difficult time has not claimed for further more bills from OP1 and OP2.
7. It is further case of the complainant that he has purchased the policy from the OP upon the assurance of the letter sent by OP1.  On account of deficiency in service as well as unfair trade practices the complainant has sustained huge loss and hence he is entitled for adequate compensation with interest.  In addition to this the complainant also suffered mental agony and financial distress.  The OP1 and 2 have harassed the complainant by repeatedly requesting the complainant to submit the documents.  The complainant being a patient admitted in hospital with oxygen during covid 19 second waive received several calls from the OP. Inspite of that the OP2 has repudiated the claim of the complainant. Hence the complainant has filed this complaint.
8. In response to the notice, OP1 and 2 appears and files version. It is the case of the OP1 that they are only an intermediary between the service provider and customer. It does not have any interference in the modus operandi or working of merchants /service providers and the liability for any changes, deficiency related to the services provided by the service providers. This OP is merely a facilitators of service on behalf of the third party service providers. It is platform where the service providers and customers meet and it markets insurance services provided by the insurance company and conditions pertaining to the insurance policy and help the user make an informed choice while purchasing the policy.  In any event this OP can be made liable for the acts of the service provider like delay of claim payment rejection of any claim or cancellation of the policy.
9. It is further case of the OP1 that as per the OP2 the insured hide some material facts at the time of issuance of the policy i.e., he failed to disclose his pre existing disease at the time of applying the policy after received the claim and at the time of scrutiny of documents they came to know that the complainant’s son was suffering from autism spectrum disorder prior to the issuance of the policy which he did not disclose at the time of purchase. Hence the insurance company had rejected the claim because of non disclosure of pre existing disease.  The OP2 is liable for all the services with respect to the insurance and they are answerable to the complainant. This OP1 is not liable to pay any claim to the complainant.  The complaint is liable to be dismissed against this OP.
10. OP2 has filed version, had admitted about the issuance of the policy bearing policy No.19810596 and it is valid from 28.01.2021 till 27.01.2022 for a sum insured upto six lakhs subject to policy terms and conditions. The said policy was ported from oriental insurance company ltd., wherein the date of enrollment was 11.11.2019 and further the policy was renewed till 27.01.2023.  
11. The OP2 further admitted that he has received the reimbursement claim for the hospitalization of the complainant’s son at Apollo hospital from 13.04.2021 till 19.04.2021 as he was diagnosed with covid 19 pneumonia known case of psychiatric illness. After receipt of the claim this OP2 has demanded few queries and reminders and complainant was asked to provide the proposed documents. After that the OP2 has sent a denial letter on 01.06.2021 to the complainants wherein the claim was rejected for the reason none disclosure of schizo obsessive disorder and bipolar disorder at the time of policy inception.  The rationale for rejection was as per the consultation paper of Dr.Tharaksha dated 09.10.2020. The patient was diagnosed with above disorder.
12. The OP2 further received another reimbursement request from the complainant for the hospitalization of the complainant’s son at Apollo hospital from 20.04.2021 till 23.04.2021 as he was diagnosed with covid 19 pneumonia known case of psychiatric illness.  Upon receipt of the claim documents the company settled the claim and paid Rs.36,720/- towards claim number 91677396-00 and Rs.9,180/- towards claim No.91677396-01.  However the claim towards claim No.91677396-02 was rejected on the ground of non disclosure of schizo obsessive disorder and bipolar disorder at the time of policy inception.
13. It is further case of the OP2 that another reimbursement claim No.91686759 -00-01 was received for hospitalization of the complainant at Apollo hospital on 13.04.2021 till 19.04.2021 as he was diagnosed with covid 19 pneumonia. After receipt of the claim documents the OP2 has settled the claim and paid Rs.1,01,141/- towards claim No.91686759-00 and Rs.33,623/- towards claim No.91686759-01.  The complainant has also submitted reimbursement of claim No.91688029 of the hospitalization of the complainant at Apollo hospital from 20.04.2021 till 30.04.2021 as he was diagnosed with covid 19 pneumonia.  After receipt of the claim documents the OP2 settled the claim and paid Rs.76,441/-.
14. It is further case of the OP2 that the insured Mr.Abhipriya Mitra had the chance to disclose about his past medical history schizo obsessive disorder and bipolarity at the time of filing proposal form but the complainant failed to disclose the same for the best reasons known to him.  In the proposal form under the heading additional details the complainant has made the mis-declaration about does any person(s) to be insured have any pre-existing disease? The answer was no.
15. Depending on the disclosures made by the complainant at the time of proposal this OP company decides whether to accept the risk and provide the policy to the customer or not. It is the duty of the insured to disclose correct and accurate information about his current health status at the time of proposal for accurate assessment of risk.  The complainant by not disclosing the correct health status has blatantly violated the principal of utmost good faith and terms and conditions of the policy. The complainant herein is not only acting in breach of the policy terms and conditions governing the policy but also acted in blatant violations of regulation. Hence the burden of proving the deficiency of service held on the complainant. Complainant has failed to establish any deficiency on the part of the OP. Hence the complaint is liable to be dismissed with cost.
16. The complainant has filed his affidavit evidence and relies on 08 documents. Counsel for OP1 filed Affidavit evidence on behalf of OP along with 03 documents, but the authorized person of OP1 is not present. Hence affidavit evidence of OP1 is rejected. Counsel for OP2 filed affidavit evidence and relies on 18 Documents.
17. Heard the arguments of advocate for the complainant and OP2 only.  Perused the written arguments filed by the complainant and OP2. OP1 has not addressed their arguments nor filed any written arguments. Hence arguments of OP1 is taken as nil.
18. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OPs?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

19. Our answers to the above points are as under:

Point No.1:  Affirmative

Point No.2: Affirmative in part

Point No.3: As per final orders

REASONS

20. Point No.1 AND 2: These two points are inter related and hence they have taken for common discussion.  We have perused the allegations made in the complaint, version, affidavit evidence of complainant and OP2, written arguments of complainant and OP2 and documents.

21. The complainant in support of his contention has filed his affidavit evidence and relied on 8 documents. Ex.P1 is the Copy of the letter dated 27.01.2021, Ex.P2 is the Copy of the policy documents, Ex.P3 is the Copy of the Apollo International Hospital bills along with rejection of claim by OP1, Ex.P4 is the Copy of the email communication, Ex.P5 is the Copy of the bill, Ex.P6 & P7 are the Copy of the emails dated 27.01.2021 & 01.06.2021.

22. The complainant ported his insurance policy in 2020-21 based on previous eight years no claim bonus and all inclusive continuously from his previous insurance company.  The policy was Rs.6,00,000/- including portability benefit from December 2015 onwards for each family members.  The complainant and his dependent son Abhipriya Mitra were infected with covid 19 and were admitted to Apollo International Hospital approved by the OP.  After discharge the complainant has submitted the hospital bills to OP1.  The OP1 has paid only 45% of the total claim Rs.2,76,215/- and rejected the remaining 55% of the amount.  The claim made by the complainant in respect of his son Abhipriya Mitra was rejected due to the pretext that the mental disorder was not disclosed at the time of purchase of the policy.  

23. Even though the complainant has been contacting the OPs via email regarding rejection of the claim for covid 19 hospitalization the OPs have not refunded the amount. In view of this the complainant suffered severe financial loss due to the deficiency in service and unfair trade practice on the part of the OP.

24. On the other hand OP1 has taken the contention that it is only a plat form and they are only a service facilitator and not a service provider and they are acts as an inter-mediatory between the customer and the service provider.  In no event this OP1 can be made liable for the acts of the service provider like delay of claim payment rejection of any claim or cancellation of the policy.  

25. On the other hand the contention taken by the OP2 is that they have admitted about the issuance of the policy and further admitted that the policy was in force from 28.01.2021 till 27.01.2022 which covers the complainant his spouse and his son for an insured amount upto Rs.6,00,000/- subject to policy terms and condition.  The policy was ported from Oriental Insurance company Limited, wherein the first date of enrollment was 11.11.2019 and further the policy was renewed till 27.01.2023. 

26. On the other hand OP2 has filed his affidavit evidence and relied on 18 documents, Ex.R1 is the Copy of the policy certificate, Ex.R2, 7 & 11 are the Copy of the pre-authorization form, Ex.R3, 8, 12 & 14 are the Copy of the discharge summary, Ex.R4 is the Copies of the query letters & reminder letters are collectively, Ex.R5 & 10 are the Copy of the claim denial letter, Ex.R6 is the Copy of the evidence, Ex.R8 is the Copy of the discharge summary, Ex.R9 is the Copies of the settlement letter, Ex.R13 is the Copies of the settlement letters are collectively, Ex.R15 is the Copy of settlement letter, Ex.R16 is the Copy of the proposal form, Ex.R17 is the Copy of the terms and conditions and Ex.R18 is the Copy of the authorization letter.

27. It is the main contention taken by the OP2 that they have received the reimbursement claim for the hospitalization of complainant’s son at Apollo hospital from 13.04.2021 till 19.04.2021 as he was diagnosed with covid 19 pneumonia and he is known case of psychiatric illness.  After that they have made some queries by issuing reminders to the complainant and also requested the complainant to provide the documents.  After that they have rejected the claim of the complainant for NON DISCLOSURE OF SCHIZO OBSESSIVE DISORDER AND BIPOLAR DISORDER AT THE TIME OF POLICY INCEPTION.  The OP2 has entertained the claim made by the complainant for his hospitalization from 13.04.2021 till 19.04.2021 as he was diagnosed with covid-19 pneumonia and they have settled the claim by paying Rs.1,01,141/-.  Again this OP2 have settled the claim of the complainant for his covid treatment by paying Rs.76,441/-.  They have rejected the claim made by the complainant for his son for non disclosure of the mental illness of his son at the time of submitting the proposal and also at the time of issue of the policy.

28. It is clear from the evidence and documents that the complainant is claiming Rs.6,12,226/- for the treatment taken by the complainant’s son from April 13 to 23^rd of April 2021 for 11 days and for the treatment taken by the complainant from 13.04.2021 to 30.04.2021 for 18 days totally claiming Rs.6,12,226/-.  The complainant and his son both were taken treatment from the hospital for only covid 19 infection during the second waive.  Admittedly the complainant’s son has also suffered from covid 19 and the complainant and both were treated in the hospital for 11 days and 18 days respectively.  The claim made by the complainant is totally Rs.3,75,920/- for his covid treatment and out of that the OP have paid only Rs.2,76,215/- and they have rejected the remaining claim including the claim of the complaint’s son Rs.2,36,305/-.   The complainant has not claimed any medical expenses for his son for taking treatment for his mental illness. It is also clear from the hospital records that the complainant’s son was also suffering from covid 19 and the hospital authorities treated him for covid 19.  They have mentioned in the hospital records that the complainant’s son is a known case of psychiatric illness.  The complainant has claimed only the medical expenses spent by him towards the treatment of his son for covid 19.  The claim for covid hospitalization is not a mental treatment. Inspite of that the OPs have repudiated the claim made by the complainant and his son.

29. When the policy was in force and the amount claimed by the complainant is within the limits of the policy it is the duty of the OP2 to refund the amount claimed by the complainant. In view of rejection of claim by the OP2 the complainant and his son have suffered mental agony and also financial loss.  The OP2 have repudiated the claim without any reason only in order to escape from paying the amount. Therefore the complainant has clearly established the deficiency of service and also negligence on the part of the OP in repudiating his claim.  Hence we answer point No.1 in affirmative and point No.2 partly in affirmative.

30. Point No.3:- In view the discussion referred above we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. OP2 is hereby directed to refund Rs.6,21,010/- with interest at 9% p.a., from the date of repudiation till realization.
3. OP2 is further directed to pay compensation of Rs.50,000/- with litigation cost of Rs.10,000/- to the complainant.
4. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 12% p.a. after expiry of 60 days on Rs.6,21,010/- till final payment.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 11^TH day of JULY 2024)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party2 – R.W.1;