Date of Filing:30/08/2018
Date of Order:25/05/2019
BEFORE THE BANGALORE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHANTHINAGAR BANGALORE - 27.
Dated:25th Day of MAY 2019
PRESENT
SRI.H.R. SRINIVAS, B.Sc., LL.B. Rtd. Prl. District & Sessions Judge And PRESIDENT
SRI D.SURESH, B.Com., LL.B., MEMBER
COMPLAINT NO.1454/2018
COMPLAINANTS: | 1 | MR.SANJAY JOSEPH.N Aged about 46 years, |
|
| 2 | MRS. SUMI GEORGE, Aged about 40 years, Both Residing at: 108 Palm court apartments, Jakkur Plantations Road, Jakkur, Bangalore 560 064. Karnataka. (Complainants: In person) |
Vs
OPPOSITE PARTIES: | 1 | RELIGARE HEALTH INSURANCE COMPANY LIMITED, Having its Registered Office at: 5th Floor, 19 Chawla House, Nehru Place, New Delhi 110 019. |
| 2 | RELIGARE HEALTH INSURANCE COMPANY LIMITED, Having its Correspondence office at: Vipul Tech Square, Tower C, 3rd Floor, Gurugram, Haryana 122 009. |
| 3 | RELIGARE HEALTH INSURANCE COMPANY LIMITED, 2nd Main, 8th Cross, Soundarya Sampige, Sampige Main Road, Malleshwaram, Bangalor, Karnataka 560 003. (Adv.for O.Ps:Prema Rani) |
ORDER
BY SRI.H.R.SRINIVAS, PRESIDENT.
1. This Complaint is filed by the Complainant U/S Section 12 of Consumer Protection Act 1986, against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service in repudiating the insurance policy and not honouring the claim made in respect of the expenses incurred towards the medical treatment and hospitalization charges of the 2nd Complainant to the extent of Rs.1,11,096/- and Rs,1,00,000/- as damages towards causing mental harassment and agony and to pass such other relief as this Hon’ble Forum deems fit.
2. The brief facts of the complaint are that, the complainants obtained medical health policy from Star Health and Allied Insurance Co., for the period from 25.02.2016 to 24.02.2018 and afterwards ported to the OPs company by paying single premium of Rs.37,107/- towards the health insurance for them, for their son Joshua Joseph.N and daughter Alisha Martha Joseph to cover to the extent of Rs.15,00,000/-. The policy period was from 25-02-2018 to 24-02- 2019.
3. It is contended that, on investigation, it was found that the Complainant No.2 who had undergone ultrasound scan of the pelvic – TVS at Sai Manohar Poly Clinic due to heavy mensural cycle experienced in previous months, it was noted that she was having Bilateral Policystick Overies and the doctor did not advise any treatment at that point of time. The Pelvic scan was done in May 2017 when the policy was inforce with Star Health Insurance.
4. Afterwards on 22.05.2018, OP.No.2 was operated for total abdominal hysterectomy with bilateral Salpingoophorectomy in Aster CMI Hospital, Bangalore by Dr.Chitralekha N.D, Consultant Obstetric and Gynecologist and Complainant was also diagnosed with cyst in right ovary with a vascular papillary projection.
5. It is further contended that on 18.04.2018, the OPs were informed regarding the medical conditions of the complainant with all medical records through email and WhatsAap for cash less treatment.
6. On 21.05.2018, Complainant No.2 was admitted to the hospital for surgery and also OPs were provided with all other additional information required by them. The complainant was operated on 22.05.2018. On the same day Complainant received a letter from OPs stating that request for cashless admission and operation was rejected due to non-disclosure for material facts/pre-existing ailments at the time of proposal and the patient was having history diabetes and abnormal uterine bleeding before inception of the policy, which were far from truth. The doctor in the hospital one Rekha by mistake had issued such a letter that the said ailments were pre existing to the OPs. After realizing her mistake, Dr.Rekha the resident doctor of Gynecology of Aster CMI hospital admitting her error sent a letter to reconsider the objections. Inspite of it, the same was not considered and even his claim for Rs.98,936/- which he paid to get complainant NO.2 discharged was also rejected on the same ground and further mentioned that the complainants have suppressed the pre existing diseases and also not giving the full facts in the proposal.
7. Even though, the doctor of Aster CMI hospital specifically admitting the mistake in giving the information regarding the history of the patient regarding the diabetes and other aspects, OP did not consider the same. OPs did not seek any information from them at the time of receiving the premium for porting the policy from Star Health insurance. They only issued the Welcome letter, policy certificate, premium acknowledge and premium health insurance card.
8. After repudiating the policy which was informed, the complainant made a complaint to the customer care of the OP which also rejected his claim. The act of the OPs in rejecting the cashless facility, and rejecting the claim on the ground of false/wrong information given by the hospital authorities without verifying the truth of the matter amounts to deficiency in service and also unfair trade practice and OPs have humiliated the complainant’s in that respect and subjected them to harassment, mental agony. On these ground filed the complaint and prayed same to be allowed.
9. Upon the service of notice, One Prema Rani advocate filed power on behalf of the OPs. Inspite of obtaining several opportunity, did not file the version. The Forum considered that the OPs have no interest to file the version and evidence of complainant recorded. OPs did not show any interest to adduce any evidence. Heard the arguments of the complainants. OP and counsel did not address their arguments. The following points arise for our consideration:-
(1) Whether the complainant has proved the
deficiency in service on the part of the O.Ps?
(2) Whether the complainant is entitled to
the relief prayed for in the complaint?
10. Our answers to the above points are:-
POINT 1: In the Affirmative.
POINT 2: Partly in the Affirmative
for the following:
REASONS.
POINT No.1:-
11. The complaint, documents produced and the oral evidence of the complainant is perused. As per the documents Ex.P1 which is the insurance policy it becomes clear that complainant earlier had medical insurance policy from Star Health and Allied Insurance Co. for the period from 25.02.2016 to 24.02.2018 i.e. Ex.P1(a) and afterwards ported to the OPs company by paying single premium of Rs.37,107/-. In view of this, it is not a fresh policy purchased by the complainants, whereas, it is ported to the OPs company from Star Health and Allied Insurance. Hence whatever the disclosure made with the Star Insurance company continues and holds good and whatever medical problems that arise during the pendency of the said policy with the Star Health Insurance and thereafter porting with OPs, the claim has to be paid.
12. It is not in dispute that, the OPs have rejected the cashless entry to the hospital and also the claim for expenses of hospital treatment, and repudiated the insurance policy and the claim. In this respect it has issued the endorsement as per Ex.P5, wherein OPs have rejected the claim on the basis of non-disclosure of material facts/pre existing ailments at the time of proposal patient is having diabetes and abnormal uterine bleeding before inception of the policy and non-disclosure of material facts /pre-existing ailments at the time of proposal.
13. OPs have not produced the proposal form signed and verified by the complainants at the time of obtaining the policy either from Star Health Allied Insurance co or at the time of porting to their company. Their basis is only on the entries made and information given by the Aster CMI Hospital.
14. As per letter dated 22.05.2017, Aster CMI hospital has written a letter addressing to whomsoever concern “This is to inform that the patient name Sumi George has no co marbiditis such as Diabetes or Hypertension. The notes given earlier was about the patient’s father diabetic status and not that of patient. Kindly reconsider the case and do the needful.”
15. Upon the said letter, again Complainant No.1 made a request to OPs for reconsideration of his claim. In the discharge summary given by the Aster CMI Hospital, it is mentioned in the family history, father is diabetic, and Mother had uterine fibroid and has CA stomach and past history of the patient nothing significant, no history of diabetic mellitus and hypertension. Diagnosis abnormal uterine bleeding with Right Overian Cyst since March 2018 having irregular menstrual cycle with heavy flow. 10 days to 45 days Associated with clots. She used to change around 10-pads per day, not associated with mass per abdomen. On USG right overian cyst with Pappilary projections. Hence posted for total abdominal hysterectomy and the procedure was done.
16. Even in Ex.P9 again the Doctor who has operated the Complainant No.2 has given a declaration dated 28.06.2018 regarding the patient’s increased menstruing bleeding from March 2018 and experiencing the same on and off for the past five years as per their history sheet. She is not a known diabetic as per their record. By oversight it was mentioned by mistake by their registrar that she is diabetic for two years in one of the letters sent for clarification. The same was sent before discharge. Kindly change in your records that Sumi George is not a known diabetic. When such being the case, a wrong information given by the doctor by their hospital authorities has made OPs to repudiate the claim.
17. As per Ex.P11 which is the Ultrasound scan of Pelvis –TVS dated 15.05.2017, it is mentioned there in that there is Bilateral Polycystic Overies. There are no materials placed by OPs to show that either before obtaining insurance from the Star Health Insurance Company or from Ops the complainants was suffering from such a health condition and the same was not disclosed. On perusing the entire medical records, it becomes clear that the medical conditions of Bilateral Polycystic Overies only came to knowledge of the complainants on 15.05.2017 that too when the policy the complainant had obtained from 2016 onwards was in force which was later ported to Ops company.
18. Further OPs have not at all taken in to consideration the mistake committed by the hospital authorities.
19. OPs have neither filed any version to defend their stand of repudiation, nor adduced any documentary evidence to show that the complainant No.2 was having the said Bilateral Polycystic Overies prior to obtaining the health insurance policy from Star Health Insurance by producing relevant proposal forms.
20. Hence we are of the opinion that, the repudiation of the insurance claim of the complainants and also the cashless entry amounts to deficiency in service. Further by collecting hefty health insurance premium, the OPs though the hospital authorities who have treated complainant No.2 admitted their folly/mistake and intimating to reconsider the same, have not reconsider the same which amounts to unfair trade practice also. Hence we answer POINT NO.1 IN THE AFFIRMATIVE.
POINT NO.2:
21. Ex.P2 is the various receipt produced by the complainants in respect of the hospital medical expenses incurred. OPs are bound to reimburse the same along with interest at 12% per annum from the date of making the claim. Further OPs for no good reasons and not investigating properly and not considering the certificate issued by the treating doctor, repudiated the insurance claim and thereby caused mental agony, harassment, and physical strain and also mental strain to the complainants for which the OPs have to compensate the complainants. We are of the opinion that if a sum of Rs.25,000/- towards the damages for causing physical and mental harassment and a sum of Rs.10,000/- towards legal expenses for forcing the complainants to approach this Forum to fight for their rights, if ordered to be paid would meet the ends of justice. Hence we answer POINT NO.2 PARTLY IN THE AFFIRMATIVE and pass the following.
ORDER
- The complaint is allowed in part with cost.
- The OP No.1 to 3 are jointly and severally hereby directed to pay a sum of Rs.1,11,096 /- being the hospital charges and medical charges incurred by complainants along with interest at 12% per annum from 24.05.2018 till payment of the entire amount.
- Further OPs are hereby directed to pay a sum of Rs.25,000/- towards damages and Rs.10,000/- towards cost of the litigation expenses.
- The O.Ps arehereby directed to comply the above order at within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
- Send a copy of this order to both parties free of cost.
Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be destroyed as per the C.P. Act and Rules thereon.
(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 25th MAY 2019)
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ANNEXURES
1. Witness examined on behalf of the Complainant/s by way of affidavit:
CW-1 | SUMI GEORGE – Complainant No.2. |
Copies of Documents produced on behalf of Complainant/s:
Ex P1: Copy of the Health Insurance Policy
Ex P1(a): Copy of Star Health and Allied Insurance co’s first policy and renewal policy.
Ex P2:Copies of cash bill cum receipts and out patient summary.
Ex P3:Copies of email correspondences and whatsapp images.
Ex P4:Copy of Deficiency letter.
Ex P5: Copies of email correspondences.
Ex P6:Copy of complaint.
Ex P7:Copies of final settlement bill and Discharge summary.
Ex P8:Copies of complaint No.2
Ex P9:Copies of email correspondences and declaration letter.
Ex P10: Copies of the OP’s rejection letter.
Ex P11:Copy of the report of Pelvic Scan.
Ex P12:Copy of email correspondences regarding porting.
2. Witness examined on behalf of the Opposite party/s by way of affidavit:
- Nil -
Copies of Documents produced on behalf of Opposite Party/s
- Nil -
MEMBER PRESIDENT
A*
