Date of Filing:15-03-2016
Date of Order: 23 -7-2019
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 Smt. D.NIRMALA, B.Com., LLB., MEMBER
Tuesday, the 23rd day of July, 2019
C.C.No.142 /2016
Between
K.Sivarama Krishna,
S/o.K.Padmanabhaiah,
Aged: 46 years, R/o.Plot No.19,
Savera Residency,
Flat No.102, 2nd floor,
Rajeev Nagar, Hyderabad – 500045 ……Complainant
And
Religare Health Insurance Company Ltd.,
Rep. by its Manager,
Brij Tarang Commercial Complex,
C-Block, 2nd floor,
H.No.6-3-1191/1 to 6-3-1196/2C,
Besides white House Building,
Begumpet, Hyderabad – 500016 ….Opposite Parties
Counsel for the complainant : Mr.A.Jaya Raju
Counsel for the opposite Party : Sri N.Srinath Rao
O R D E R
(By Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint has been preferred under Section 12 of C.P. Act of 1986 alleging that repudiation of the mediclaim submitted by the complainant amounts to unfair trade practice and deficiency of service hence a direction to pay hospitalization amount of Rs.1,94,992/- with interest at 12% P.A from 1-10-2015 to the date of payment and to award a compensation of Rs.1,00,000/- for causing mental agony to the complainant and his family members and cost of this complaint.
- The complaint averments in brief are that complainant and his family members have opted for Group Care Insurance policy from the opposite party under the scheme for Indusland bank customers and paid a sum of Rs.16,286/- as premium for the period covering from 18-4-2015 to 17-4-2016. The scheme complainant and his family members for hospitalization expenses up to Rs.8,00,000//-.
On 26-09-2015 around 5.00P.M complainant with a complaint of weakness on the right upper limb and lower limb was rushed to Yashodha hospital at Somajiguda and after examination of team of doctors he was diagnosed as CERBRO VASCULAR ACCIDENT RIGHT HEMIPLEGIA WITH APHASIA AND POST IV THROMBOLYSIS RECOVERED HYPOKALAEMIA FOR EVALUATION VITAMIN D INSUFFICIENCY HYPERTENSION. He was administered medicines and revived and was discharged from the hospital on 1-10-2015. Before the discharge from the hospital an estimation for Rs.1,94,992/- was obtained from the hospital and transmitted to opposite party for cashless treatment. But opposite party in its letter dated 29-09-2015 informed to the hospital that it is known case of HTN on regular medication pre existing nature of ailment cannot be ruled hence liability of insurer cannot be taken at that moment and cashless facility was denied. Subsequent to discharge complainant submitted claim for the bill amount but it was rejected and intimated by letter dated 20-11-2015.
To dispel the doubt entertained by the opposite party and to inform that the complainant is not a B.P patient and was not on medication he obtained a certificate from the doctor of Yashoda hospital stating that his blood pressure was under control during admission and same was forwarded through letter dated 27-11-2015 and it was acknowledged by opposite party on 3-12-2015. After receipt of it the opposite party cancelled the policy and communicated through letter dated 23-2-2016 on the ground of non disclosure of the material information at the time of proposal.
The complainant is hale and healthy and the reasons attributed for repudiating the claim by the opposite party stating that he is known HTN is not based on material facts and there is no documentary evidence for it. Opposite party for issuing the policy lured the complainant and his family members and collected huge amount towards premium and when health problem arose opposite party unreasonably rejected the claim amounts to deficiency of service. Hence the present complaint.
- Opposite party in the written version admitted the issuance of the subject policy covering complainant and his family members and collecting of premium amount covering period from 18-4-2015 to 17-4-2016 to a tune of Rs.8,00,000/- to all the members but denied the allegation of unfair trade practice and deficiency of service on its part.
The defence set out in the written version is that the complainant at first instance approached for a cashless facility relating to hospitalization for the ailment of Acute Cerebro Vascular Accident and same was denied in terms of the policy conditions. Later he filed reimbursement of the claim for the hospital bill amount of Rs.1,81,071/- and same was rejected under the clause 9 for non-disclosure of material fact as the patient was a known case of hypertension since 2010 and communicated the same by letter dated 20-11-2015.
Clause 9 of subject policy reads as under:-
“If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars of any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the insured member or anyone acting his/their behalf, the company shall have no liability to make payment of any claim and the premium shall be forfeited to the company”
On examination of the document relating to the treatment of the complainant in the hospital the doctors initial assessment record shows the complainant is a known case of Hypertension and is on regular medication for the same namely “Tab Telma” and same was confirmed from daily progress note dated 226-09-2015 wherein it is mentioned that patient is a known case of hyper tension and is on treatment with medicine of Tab Telma 4mg. As per AMCU notes dated 26-09-2015 the complainant confirmed to be a known case of hypertension and is on medication for the same. As per the discharge summary issued by the hospital the complainant is a known case of hypertension and prescribed Tab Telma 20Mg which is a medicine for controlling blood pressure. The declaration signed by the complainant himself is he is a chronic smoker and having a history of blood pressure from 2010. As per the questionnaire filled and signed by the complainant during the reimbursement claim investigation is he is having hypertension since 2010.
In the light of these facts opposite party has taken a medico-legal opinion from an independent doctor for substantiating the fact that the present ailment of the complainant was due to pre-existing condition of hyper tension and habit of smoking. As per the information furnished by independent doctor complainant current CVA (Cerebro Vascular Accident) is related to his pre-existing hypertension as well as habit of smoking.
“It is further stated in the information by independent doctor that “ The hypertension places on your blood vessels make them weaken and predisposes them to damage. Your heart also has to work harder to keep your blood circulating. Once your blood vessels weaken they are more likely to block. This can cause ischemic stroke and hypertension is the most important cause of this type of stroke and also transient ischemic attacks”.
The complainant was given an opportunity to disclose his pre-existing condition of hypertension for the reasons best known to him which was otherwise. The complainant has not disclosed about the pre-existing condition of hyper tension from 2010 and personal habit of smoking at the stage or proposal. That the questionnaire in the proposal form relating to whether he is suffering from any illness or disease hypertension or B.P and answer by the complainant is no. For the other question whether he has been under medication/tablets for any illness or injury the answer given by the complainant was no. For the question of personal habits smoking he did not answer. Since the medical record examination and independent evidence obtained from the doctor reveal that the complainant is known case of hyper tension and same was not disclosed in the proposal form submitted based on which the policy was issued the Opposite party is justified in repudiating the claim.
As per the judgment in the case of Satwant Kaur Sandhu Vs. New India Assurance Company Ltd (2009) 8 SCC 316 material fact is to be understood to mean as any fact which influence the judgment of prudent insurer in deciding whether to accept the risk or not. If the proposer has the knowledge of such fact he is obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer will entitle the insurer to repudiate its liability because there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance which is based on the principle of utmost good faith. Hence the rejection of the claim is in terms and conditions of the policy and does not amount to unfair trade practice or deficiency of service. To the legal notice got issued by the complainant on 21-1-2016 a suitable reply was given on 12-2-2016 with reasons. Hence complainant is not entitled for any other reliefs prayed for.
In the enquiry the complainant has got filed his evidence affidavit reiterating the material facts of the complaint and to support to the same has got exhibited eleven (11) documents. Similarly for the Opposite Party evidence affidavit of its Corporate Manager Legal namely Sri Ramnique is got filed and substance of the same is in line with the defence set out in the written version . Opposite party also got exhibited eleven (11) documents . Both sides have filed written arguments.
On a consideration of material available on record the following points have emerged for consideration .
- Whether the repudiation of the claim amounts to deficiency of service or unfair trade practice on the part of the opposite party ?
- Whether the complainant is entitled for the amounts claimed in the complaint?
- To what relief?
Point No.1: It is not in dispute that the complainant as customer of Indusland bank obtained the Group Care insurance policy from the opposite party under Ex.B1 by paying requisite premium of Rs.16,286. Before issuance of the subject policy the complainant filled and signed the proposal form which contains a questionnaire. It is not in dispute that the complainant was got admitted in Yashoda hospital on 26-09-2015 and after due examination by a team of doctors it was diagnosed as CERBRO VASCULAR ACCIDENT RIGHT HEMIPLEGIA WITH APHASIA AND POST IV THROMBOLYSIS RECOVERED HYPOKALAEMIA FOR EVALUATION VITAMIN D INSUFFICIENCY HYPERTENSION and for a cashless treatment he made a request for an authorization from opposite party same was denied and later repudiated the claim by a letter dated 20-11-2015. The reasons assigned for the repudiation of the claim in the proposal form submitted by the complainant for obtaining Group Care Insurance Policy he suppressed the fact of hyper tension with which has been suffering from 2010 and the present ailment was result of Hyper tension. The complainant obtained a certificate from the doctor who treated him under Ex.A6 stating that he was admitted for the Acute Stroke with right Hemiplegia and his blood pressures was under control during the admission and hospital stay. The same was not taken into consideration by the opposite party and repudiated the claim. The learned counsel for the complainant submits that the complainant was hale and healthy till his admission in the Yashoda hospital on 26-9-2015 and non-mention of hypertension in the proposal form does not amount to suppression of material fact particularly in view of the certificate issued by the treating doctor under Ex.A6. To support of his arguments he placed reliance in the case of Satish Chander Madan Vs.Bajaj Allianz General Insurance Co.Ltd decide by Hon’ble National Consumer Disputes Redressal Commission on 11th January, 2016.
The facts in the above cited case are similar to the case on hand and at first instance District Forum allowed the same and it was set aside by the State Commission and the matter was taken before the Hon’ble National Commission. The complainant therein had a previous history of hyper tension and he was on medicine Telmisartan. The above reports did not mention that the complainant disclosed any previous history of heart problem. The only fact established by the reports was that the complainant prior to obtain insurance policy was having history of hyper tension. The Hon’ble National Commission held that this however does not lead to conclusion that petitioner was having previous history of heart problem, therefore the insurance claim submitted by the complainant for the treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease as such the repudiation of insurance claim by company is not justified. It was submitted before the Hon’ble National Commission by the counsel for the insurance company that the complainant was having previous history of hypertension and since hypertension can lead to heart problem the company was justified in repudiating the claim on the ground that heart problem suffered by the complainant was caused by pre existing hyper tension. The Hon’ble National Commission held that there is no merit in the contention raised by the counsel for the insurance company and further stated that hyper tension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hyper tension would always suffer a heart attack. Therefore the argument advanced by counsel for the insurance company is farfetched and is liable to be rejected. The facts of the case on hand are also identical one. In the light of it the rejection of the claim by the opposite party is not justified . Accordingly point is answered in favour of the complainant.
Point No.2: In view of the above findings it is to follow that the complainant is entitled for the bill amount of Rs.1,94,992/- with interest there on at 9% P.A from 1-10-2015 till the date of payment and compensation of Rs.50,000/- for the mental agony suffered by him and family members on account of repudiation of claim by opposite part. Accordingly point is answered.
Point No.3: In the result, the complaint is allowed in part directing the opposite party
- To pay to the complainant a sum of Rs.1,94,992/- with interest @ 9% P.A from 1-10-2015 till the date of payment
- Further to pay a compensation of Rs.50,000/- for the mental agony and to pay Rs.5,000/- towards costs of this complaint.
Time for compliance : 30 days from the date of receipt of this order
Dictated to steno, transcribed and typed by her, pronounced by us on this the 23rd day of July , 2019
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Exs. filed on behalf of the Complainant:
Ex.A1- certificate of insurance
Ex.A2- estimated amount
Ex.A3- letter from opposite party dated 29-09-2015
Ex.A4- discharge summary
Ex.A5- letter from the complainant to opposite party dt.28-11-2015
Ex.A6-medical certificate from Yashoda hospital dt.27-11-2015
Ex.A7-claim rejection letter dated 20-11-2015
Ex.A8- legal notice dated 21-1-2016
Ex.A9- reply to legal notice dt.12-2-2016
Ex.A10- policy cancellation letter from opposite party dt.23-02-2016
Ex.A11- hospitalization bills for Hospital
Exs. filed on behalf of the Opposite party
Ex.B1policy along with terms and conditions
Ex.B2- request for cashless hospitalization for medical insurance
Ex.B3-claim rejection letter dated 20-11-2015
Ex.B4- Assessment record
Ex.B5& B6- doctor’s notes dated 26-09-2015
Ex.B7- discharge summary
Ex.B8- letter (declaration)
Ex.B9- questionnaire
Ex.B10-letter dated 18-11-2015
Ex.B11- proposal form
MEMBER PRESIDENT
