BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE URBAN

    18^th DAY OF JANUARY 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1. This is a joint complaint filed by wife and husband against the OP for the following reliefs:-

(a) The Hon’ble Forum be pleased to declare that the OP is guilty of deficiency of service and unfair trade practice under the provisions of the Consumer Protection Act, 1986.

(b) This Hon’ble Forum be pleased to order and direct the OP to pay an amount of Rs.10,00,000/- towards expenses incurred by the hospital for complainants for treatment of ailment.

(c) This Hon’ble Forum be pleased to order and direct the OP to pay to the complainants the cost for the present proceedings and

(d) to pass any other or further orders as this Hon’ble Court deems fit in the interest of justice

(e) To award costs of the present proceedings.

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

The complainants have availed policy for the period from 12.10.2017 by paying premium of Rs.42,480/- from the OP.  The complainants got renewed the policy for the period from 14.10.2018 to 13.10.2019 vide policy No.P/141132/ 01/2019/000918 by paying annual premium of Rs.42,480/-.

3. It  is further case of the complainants that on 29^th July, 2019 the complainant No.2 suffered from BP, Bengin Prostatic Enlargement,  pursuant to which complainant No.2 was hospitalized at Manipal North Side Hospital, Malleshwaram.  Subsequently, the complainants made a claim petition before the Op.  But, the OP without any valid reason repudiated the claim of the complainants. Hence, this complaint.

4. After receipt of notice, OP appears and files version.  OP admits issuance of insurance policy and receipt of the premium.  The OP also admits filing of claim petition.  The OP repudiated the claim as the complainants fail to disclose the pre-existing disease prior to obtaining the policy.  Therefore, repudiation of the claim was legal and as per the terms of the policy.   Therefore, there is no deficiency of service. Therefore, the OP requests to dismiss the complaint.

5. The complainant No.1 has filed affidavit evidence and relies on certain documents.  The affidavit evidence of Legal Officer of OP has been filed and OP relies on 10 documents.

6. Heard the arguments of advocate for complainant only.  No argument is advanced on behalf of OP.  We perused the written arguments.

7. The following points arise for our consideration as are:-

1.  Whether the complainants prove deficiency of service of the OP?
2. Whether the complainants are entitled to relief mentioned in the complaint?
3. What order?

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

       Point No.1:  In the affirmative.

      Point No.2: Affirmative in part.

      Point No.3: As per final orders

REASONS

9. Point Nos.1 and 2:  Even though both the parties have reiterated the facts pleaded by them in the complaint, version and in their affidavit evidence.  But, it is relevant to refer some of the admitted facts.  The complainants have initially took a policy by paying annual premium of Rs.42,480/- for sum assured of Rs.5,00,000/- + Rs.5,00,000/- for the year 2017 to 2018.  Subsequently, the complainants got renewed this policy by paying premium of Rs.42,480/- for the period from 14.10.2018 to 13.10.2019 for sum assured amount of Rs.5,00,000/- + Rs.5,00,000/-.  The complainant No.2 was admitted in Manipal Hospital and after the discharge, the complainants had submitted claim petition with OP.  The OP referring the exclusion clause of the terms and conditions repudiated the claim of the complainants by letter dated 05.08.2019 stating that the complainants have not declared the details of CVA, Seizure, Chornic, Pancreatitis relating to the complainant No.2 while taking policy for the period from 14.10.2017 to 13.10.2018.  Accordingly, the OP has cancelled the policy. The complainants have produced Annexure 1 to 7 which are not in dispute.  Annexure 1 is the proposal form submitted by the complainants on 12.10.2017.  It is also admitted fact that the complainants paid the premium of Rs.42,480/- along with proposal form. It is also admitted fact that subsequently the complainants got renewed the policy for the period from 14.10.2018 to 13.10.2019 by paying total premium of Rs.42,480/.  It is also admitted fact that sum assured amount is Rs.5,00,000/- + Rs.5,00,000/- for each of the complainants.  Annexure 3 is the request for cashless hospitalization for medical expenses.  But cashless hospitalization facility is not provided.  Along with Annexure-3 complainants have filed two bills of Rs.95,602/- and Rs.85,768/-.  It means complainants have spent Rs.1,81,370/- for the treatment of complainant No.2.  Condition No.3 of Annexure -4 terms and conditions speaks about exclusions.  Condition No.3 (1), the policy holder must disclose pre-existing disease as defined in policy until 12 consequential months of the continuous coverage have lapsed since inspection of the first policy with any Indian insurer.  The OP after receipt of the claim form repudiated the claim of the complainants by letter dated 05.08.2019 stating that pre-existing disease was not disclosed by the complainants in respect of complainant No.2 while taking policy for the period from 14.10.2017 to 13.10.2018.  The complainants and OP have produced the copy of proposal form for the year 2017 under Annexure-1 and Annexure (b1).  Even 3^rd page of this proposal form bears a signature of the proposer i.e. complainant No.1, but page Nos.4 and 5 do not bear signature of either of the complainants.  Even though there is reference of existence of B.P. since 2008 and use of remipril and amuls define since 2018 so far complainant No.2 is concerned.  It is rightly argued by the advocate for complainants that page Nos.4 and 5 do not bear the signature of the complainant No.1 and this page Nos.4 and 5 do not bind the complainants.  No explanation is offered by the OP, why the signature of complainant No.1 as a proposer and complainant No.2 as a beneficiary are not obtained on page Nos.4 and 5.  Under such circumstances, the so called declaration at page Nos.4 and 5 of Annexure -1 produced by the complainants and OP are not binding on the complainants.  In the absence of proof of this declaration as legal, the repudiation of the claim of the complainants is illegal.
10. It is not the case of the OP that the complainants refused to sign page Nos.4 and 5 of the first proposal.  The documents produced by the OP under Ex.B.2 to B.10 are not in dispute. It is proved documents produced by the OP side that OP cancelled the policy for the period from 14.10.2018 to 13.10.2019 and OP has credited Rs.21,240/- i.e. part of the premium amount to the account of the complainant No.1.  Even though complainants have not disclosed receipt of Rs.21,240/- either in the complaint or in the affidavit.  But, it is proved that the complainant No.1 has received Rs.21,240/- part of the premium refund amount from the OP.
11. Even though complainants claim Rs.10,00,000/- as medical reimbursement but complainants have produced only two documents to show that they have spent in all Rs.1,81,370/- for the complainant No.2.  It has been proved that the complainants have received Rs.21,240/- part of the premium amount as refund.  Under such circumstances, complainants are entitled to Rs.1,60,030/- i.e. (Rs.1,81,370/- medical expenses – Rs.21,240/- refunded of premium amount).  The complainants have not established their claim of Rs.10,00,000/- except to prove the claim of Rs.1,60,030/-, the repudiation of this claim amounts to deficiency of service.  Therefore, the complainants are entitled to refund Rs.1,60,030/- with interest at 8% p.a. from 05.03.2019 till realization.
12. Point No.3:- In view of the discussion referred above, the complaint requires to be allowed in part.  The OP is liable to pay Rs.1,60,030/- with interest at 8% p.a. from 05.03.2019 till realization.  When we are awarding interest on this amount, there is no need to award compensation.  The complainants have engaged service of advocate. Therefore, complainants are entitled to Rs.10,000/- towards litigation costs.  Hence, we proceed to pass the following

  O R D E R

1. The complaint is allowed in part.
2. The OP shall pay Rs.1,60,030/- (Rupees one lakh sixty thousand thirty only) with interest at 8% p.a. from 05.03.2019 till realization and pay Rs.10,000/- (Rupees ten thousand only) as litigation cost  to the complainants.
3. The OP shall comply this order within 60 days from this date, failing which the OP is liable to pay interest at 10% p.a. from the date of expiry of 60 days on Rs.1,60,030/- till realization.
4. Furnish the copy of this order to both parties and return the documents to the parties with extra pleadings.   

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 18^th day of January, 2022)

Documents produced by the Complainants which are marked as Ex.A.1 to Ex.A.6:-

Documents produced by the OP which are marked as Ex.B.1 to Ex.B.10:-