IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 29th day of September 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 124/2021 (Filed on 23-07-2021)
Petitioner : Babu George,
S/o. George Thomas,
Vadakkekkuttel House,
Nazareth Hill, Kuravilangadu,
Kottayam - 686633
(Adv. Jagan James) Vs.
Opposite party : (1) Reliance General Insurance Co.
Ltd. 2nd Floor, Jackson’s Plaza,
Near Malayala Manorma Jn.
Chelliyozhukkom Road,
Kottayam-686001.
(2) Reliance General Insurance
Rcare Health,
No.1-89/3/40 to 42/KS/301
3rd Floor, Krishe Block,
Krishe Sapphire Madhapur,
Hyderabad, Telangana – 500081
(Adv.Agi Joseph)
O R D E R
Sri. Manulal V.S. President
The complaint is filed under Section 35 of the Consumer Protection Act, 2019.
The case of the complainants is as follows:
The complainant, on 22-9-2020 subscribed the health insurance policy of the first opposite party vide policy number 1002032816P113459761. The complainant and his family members are covered under the policy and the sum assured was one lakh. On 26-5-2021 the complainant was diagnosed with covid -19 and admitted at Caritas hospital Thellakom.
Complainant was treated there as an impatient and discharged on 3-6-2021. The complainant has spent 57,485 as treatment expenses. But the opposite parties illegally rejected the claim of the complainant. According to the complainant the act of the opposite parties amounts to deficiency in service and he had suffered much hardship and loss due to the deficient act of the opposite parties. Hence this complaint is filed by the complainants praying for an order to direct to pay Rs.57,485/- as claim amount and compensation of Rs.20,000/-.
Upon notice opposite parties appeared before the Commission and filed joint version as follows:
The claim of the complainant has dishonoured on proper and valid reason. The reason for the repudiation stated in the letter is that cashless facility cannot be extended as pre-existing disease/non -disclosure related to associated comorbidities cannot be ruled out at juncture, hence we regret to inform you that the claim is denied. Kindly confirm possible re-imbursement. The complainant has not approached the opposite party with proper documents. The complainant had been suffering chest disease prior to the admission. The complainant had been suffering diseases at the time of inception of policy. The complainant has not disclosed the said facts at the time of taking the policy. The act of the complainant is in violation of the policy condition and the opposite party is not liable to pay the insurance claim. Hence the complainant’s claim was repudiated as per the clause of the insurance policy; there is no deficiency in service on the part of the opposite party.
Complainant filed proof affidavit in lieu of chief examination and marked exhibits A1 to A4. Cherian Kurian who is the manager -legal of the opposite parties filed proof affidavit and marked exhibit B1 to B3 from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points,
- Whether there is any deficiency in service on the party of the
opposite party?
- If so, what are the reliefs?
Point number 1 and 2
The specific cases of the complainant is that he had to undergo for the treatment for Covid -19 from 26-5-21 to 3-6-21 at Caritas hospital. His claim was illegally repudiated by the opposite parties. It is proved by exhibit A1 that the complainant had availed a Reliance Health Infinity Insurance policy from the first opposite party vide policy number 1002032816P113459761.
On perusal of exhibit A1 we can see that complainant is one of the insured and the period of insurance was 22-9-20 to 21-9-21. Admittedly the complainant was admitted in Caritas Hospital for the treatment of Covid -19 on 26-5-21and discharged on 3-6-21. Exhibit A2 proves that the complainant had spent Rs.57,485/- in caritas hospital for the treatment. The claim of the complainant was repudiated by the opposite parties vide exhibit A3.
The complaint was resisted by the opposite parties on the ground that the complainant had been suffering chest disease at the time of inception of policy and the complainant has not disclosed the said facts at the time of taking the policy in violation of the policy condition.
Definition clause 56 of section 8 of B1 policy terms and conditions defines pre-existing disease as any condition, ailment, injury or disease: (i) is diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or (ii) for which medical advice or treatment was recommended by or received from, a physician within 48 months prior to the effective date of the policy issued by insurer or its reinstatement.
Thus, the opposite party is not liable to pay any expenses regarding to the treatment for any ailment which is diagnosed or received a treatment or recommended for treatment within 48 months prior to the inception of the policy.
In the present case, the opposite parties have repudiated the genuine claim of the complainant on the basis of unfounded assumption. Hon’ble Supreme Court in case P. Vankat Naidu Vs. Life Insurance Corporation of India & Anr. IV (2011) CPJ 6 (SC) 6 held in Paras No.6 & 7 as follows:
6. We have heard learned counsel for the parties and carefully perused the record. In our view, 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.
7. Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment.
Therefore, the National Commission was not justified in interfering with the concurrent finding recorded by the District Forum and the State Commission by making a wild guesswork that the deceased had suppressed the facts relating to his illness.
The opposite parties did not produce any evidence to prove that the complainant had any disease at the time of availing the policy and he had suppressed such a condition at the time of availing the policy.
Now a days it seems that the Insurance Companies are only interested in earning the premiums, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the affected people to fight for getting their genuine claims.
In the light of above discussions and available evidence we are of the opinion that the opposite parties have committed deficiency in service by rejecting the cashless facility to the complainant by repudiating the genuine claim of the complainant without any cogent reason. No doubt the act of the opposite parties amounts to much hardship and loss to the complainant for which the opposite parties are liable to compensate.
Therefore, we allow the complaint and pass the following order.
(1)We hereby direct the opposite parties to pay Rs.57485/- i.e. the amount which incurred for the treatment to the complainant.
(2 )We hereby direct the opposite parties to pay Rs.15000/- as compensation to the complainant for deficiency in service on the part of the opposite parties.
We hereby direct the opposite parties to pay Rs.2500/- to the complainant as cost of this litigation.
Order shall be complied within 30 days from the date of receipt of Order. If not complied as directed, the award amount will carry 9% from the date of Order till realization.
Pronounced in the Open Commission on this the 29th day of September, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Health insurance policy issued by opposite party
A2 – Discharge bill issued by Caritas Hospital to petitioner
A3 – Copy of letter dtd.18-06-21 by opposite party to Caritas Hospital
A4 – Discharge summary issued by Caritas hospital to petitioner
Exhibits marked from the side of opposite party
B1 – Copy of letter dtd.31-05-2021 by opposite party to Caritas Hospital
B2 – Copy of policy with terms and conditions
B3 – Copy of discharge summary issued by Caritas hospital to petitioner
By Order
Assistant Registrar
