BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 30th March 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : HON’BLE MEMBER
ORDERS IN
C.C.No.187/2015
(Admitted on 2.6.2015)
Ashwin,
S/o Late Ramappa Poojary,
Aged about 28 years,
R/at Adyar Padav House,
Post Adyar, Mangalore,
Dakshina Kannada District,
Karnataka 575007.
……… Complainant
(Advocate for Complainant by Sri. TP)
VERSUS
Star health and Allied Insurance Company Limited,
Branch office, 2nd floor,City light complex,
Balamatta Road, Mangalore 575001.
Represented by Authorised Signatory.
…. Opposite Party
(Advocate for Opposite Party by Sri AKK)
ORDER DELIVERED BY HON’BLE MEMBER
SMT. LAVANYA M. RAI
- This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service against the opposite party claiming certain reliefs.
The brief facts of the case are as under:
The complainant is obtaining medi classic insurance policy since 4.12.2012 from Opposite Party which is the branch office of the Star health and Allied Insurance company. The Opposite Party is yearly collecting premium from the complainant assuring him that he will give full medical benefits while the policy is enforce. The complainant is renewing the policy yearly after paying the premium amount demanded by the Opposite Party. The complainant had renewed the policy on 2.12.2013 as per policy No. P/141211/01/2014/006785. Thereafter he has further renewed the policy on 5.12.2014 after making the payment of Rs.5,640/ and Opposite Party has issued policy No. P/141211/01/2015/007056 and it is valued up to 4.12.2015. The complainant and his wife Dikshitha jointly obtained Medi classic insurance policy the policy and since 4.12.2012 they have not made any claim from the Opposite Party. On 16.3.2015 complainant had suddenly undergone pain in his right lower abdomen and it was gone to increase and on 18.3.2015 complainant was not bale to bear the pain and hence he was shifted to S.C.S Hospital pvt. Ltd Mangalore. That after taking X Ray Dr. Rithin Suvarna told to the complainant that due to kidney stone he is facing pain in a lower stomach. That Dr. Prajwal done URS + on 19.3.2015. The complainant had informed about the health policy issued by Opposite Party while admitting to the hospital. that on 20.3.2015 one lady named Smitha came to the hospital and informed the complainant that she has sent by Opposite Party company for grant the claim and she required signature and obtained one signature from the complainant and two signature of his wife. That time a pipe was fixed to complainant for discharge of urine and he was facing acute pain hence without enquiring about the details he has gave signature and also told to his wife to give signature believing her that Opposite Party will grant claim to him.
On 20.3.2015 doctor said to the complainant pay sum of Rs.30,291/ alleging that Opposite Party has not sanctioned the claim amount and handed over the letter to the complainant issued by Opposite Party to him. As per said letter Opposite Party has stated that as per verification complainant had similar complaints 3 years ago and treated on OPD base and provide consultation taken on OPD 3 year back. Since 2 days before admission to SCS Hospital suddenly complainant got stomach pain and did not faced a stomach pain earlier and also not taken any treatment either for stomach pain or any other ailments. Thereafter the complainant came to know that the lady who has visited to hospital from Opposite Party created a story for avoid the claim after obtaining signature on blank paper alleging that it require for pay the claim amount. He had specifically informed to his doctor that since 2 days he was facing stomach pain. This facts reveals in a discharge summary issued by the S.C.S hospital. Hence the complainant issued a letter to the corporate office of the Opposite Party and sent the copy to the Opposite Party and said that the lady named Smitha obtained signature to the blank papers and complainant never took any treatment as alleged by her and requested to grant the claim. The corporate office of the Opposite Party issued reply demanding the OPD treatment record. The complainant not in a position to submit the records demanded by the Opposite Party as never took any treatment as alleged by the Opposite Party. Thereafter the complainant issued notice to the Opposite Party on 4.4.2015 on 16.4.2015 the Opposite Party replied the notice issue by the complainant but not refunded the claim. Hence the above complaint filed by the complainant before this forum under section 12 of the C.P.Act 1986(here in after referred to as the Act) seeking direction from this Fora to the Opposite Party to refund a sum Rs.30,291/ with 15% interest from the date of claim till payment, to pay Rs.10,000/ towards the compensation, to pay Rs.2,000/ towards the cost of legal notice and cost of this proceedings.
II. Notice served to the opposite party by RPAD and filed version stating that the Opposite Party the issue the Medi Classic Insurance Policy bearing no. P/141211/01/2015/007056 to the complainant. However, the claim if any, under the said policy is subject to the terms, conditions and exclusion clauses attached there in, which are duly furnished to the complainant along with the policy which are part and parcel of the policy. The insured was admitted in SCS Hospital on 18.3.2015 for treatment of right PUJ Calculus. As per pre authorization request form dated 19.3.2015 from the treating hospital, the insured was admitted with the complaints of pain in abdomen and the provisional diagnosis is for right PUJ Calculus. The cashless was approved for Rs.7,000/ vide letter dated 19.3.2014 subsequently a query has been raised to submit all mandatory documents for further processing of claim. The field visit Doctor Report revealed that the wife of the patient Smt. Dakshita informed that the patient had similar complains three years before and took Opposite Party treatment for the same. Hence, Opposite Party issued letter dated 20.3.2015 called for OPD records along with USG reports which are mandatory for processing the claim. The same was not submitted by the insured. The claim and obtained the OPD records No. 01139701 dated 21.6.2011 from the Father Muller Hospital, the said report revealed that the insured had complaints of left Lumbar Pain radiating from Joint and advised USG. The complainant has not submitted so far the documents sought by this Opposite Party. The complainant has suppressed the said pre-existing deceases while availing first policy from this Opposite Party. If this is disclosed in the proposal form the company would have not issued the policy to the insured. Hence, the claim for treatment of Pre Existing Disease is not allowed under Exclusion No.3(1) and (3) of the policy. Hence prays for dismissal of the complaint.
III. In support of the above complaint the complainant Mr.Ashwin, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked Ex.C1 to C9 as detailed in the annexure here below. On behalf of the opposite party Melwin DSouza (RW1) Branch Manager, of opposite party also filed affidavit evidence and document No.1 and 2 and answered the interrogatories served on him.
IV. In view of the above said facts, the points for arise for our consideration in the case are:
- Whether the Complainant proved that the Opposite Party committed deficiency in service?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
We have considered the arguments submitted by the complainant and also considered the materials was placed before the Fora and answered the points are as follows:
Point No. (i) : Affirmative
Point No. (ii) : Affirmative
Point No. (iii): As per the final order.
REASONS
V. POINTS No. (i) and (ii) :
In the instant case. It is undisputed fact that the complainant is obtaining medi classic insurance policy 4.12.2012 from Opposite Party as per Ex.C2. The complainant had renewed the policy on 2.12.2013 as per policy no. P/141211/01/2014/006785. On 5.12.2014 the complainant renewed the policy by paying Rs.5,640/ as per Ex.C1 and it is valued up to 4.12.2015. It is the case of the complainant that on 16.3.2015 the complainant had undergone pain in his right lower abdomen and admitted to SCS Hospital. Due to kidney stone the complainant facing pain in lower stomach and also O+URS done on 19.3.2015 which reveals the Ex.C3 and Ex.C4. At the time of admission to the hospital complainant sent a claim but it was rejected on the ground that the complainant treated on OPD base and provide consultation taken on OPD 3 year back. After rejection of claim from Opposite Party complainant sent a letter to grant the claim, but Opposite Party issued reply demanding OPD treatment record. The complainant not in a position to submits the records demanded by the Opposite Party as he never took any treatment as alleged by the Opposite Party.
It is admitted that the complainant was in patient in SCS Hospital from 18.3.2015 to 20.3.2015 as per Ex.C3 it reveals that the doctor done URS+ and signed the discharge summary. On the other hand Opposite Party’s contention is that the complainant admitted to SCS Hospital Mangalore on 18.3.2015 with the complaint of pain in lower abdomen and URS+ done there after complainant discharged on 20.3.2015. the cashless was approved for Rs.7,000/ vide letter dated 19.3.2014 and a query has been raised to submit all mandatory documents for further processing of claim but not submitted by the insured. After that Opposite Party obtained the OPD records from the Father Muller Hospital. The said report revealed that the insured had complaints of left Lumbar Pain radiating from joint and advised USG. The complainant has suppressed the said pre existing decease while availing first policy from the Opposite Party. The Opposite Party has found that the complainant has under gone treatment for same kind illness on 21.6.2011 at Father Muller Hospital Kankanady Mangalore. The OPD No. 01139701 as per document No.2 it reveals that the complainant treated for same kind illness in the year 2011 which the complainant has suppressed the pre existing disease while availing first policy.
After perusal of the document No.2 produced by the Opposite Party it reveals that the out patient record was not original and does not contain the seal and signature of the authorised person and hospital hence the document produced by the Opposite Party is not a genuine one. Except allegation Opposite Party not produced genuine document of pre-existing disease. In a reported the case III (2009) CPJ 196 (NC)
The Honble National commission held that This policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and, hence, they cannot be made liable to suffer because the insurance company relies on their Exclusion Clause of the policy in a Mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre existing in the system totally unknown to him which he is not aware of The commission further held: In hindsight, everyone realizes much later that the symptoms were indicative of a disease. But common people are not all familiar with the medical knowledge and so they cannot diagnose their own diseases. If they were expected to be so aware of their medical condition at all times, there would be no use of insurance policies. And allow the revision petition. And another ruling cited III (2005) C.P.J 204 Honble Chhattisgarh State Commission held that Reimbursement claim repudiated contention, steroid therapy could have been administered without hospitalisation, not acceptable every medical treatment preceded by clinical or other examination of patient and discretion as to nature and manner of such tests lies with doctor Repudiation unjustified
Considering the above the evidence and documentary evidence proved that the Opposite Party commited deficiency in service. Mere allegation is not sufficient to prove in the case, hence the claim of Opposite Party is not believable. In view of the above discussion we are of the considered opinion that the Opposite Party shall pay a sum of Rs.30,291/ as per Ex.C4 along with 9% interest from the date of claim i.e. 18.3.2015 till the date payment and also pay Rs.10,000/ towards compensation for mental agony and sufferings further pay for Rs.2,000/ as cost of the litigation expenses as per the complaint is justified hence answer point no. 1 and 2 is affirmative.
In the result, accordingly we pass the following Order.
ORDER
The complaint is allowed. Opposite Party shall pay a sum of Rs.30,291/ along with 9% interest from the date of claim 18.3.2015 till the payment and also pay Rs.10,000/ and further pay for Rs.2,000/ as cost of the litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.
Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.
(Page No.1 to 10 dictated by Member to the Stenographer typed by him, revised and pronounced in the open court on this the 30th March 2017)
MEMBER PRESIDENT
(LAVANYA M RAI) (VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Mr.Ashwin,
Documents marked on behalf of the Complainant:
Ex.C1: 5.12.2014: Original Receipt issued by the Opposite Party No.1 for having paid the premium amount of Rs.5,640/.
Ex.C2: 5.12.2014: Original Medi classic insurance policy issued by the Opposite Party.
Ex.C3: 20.3.2015: Original Discharge summary issued by SCS hospital pvt. Ltd. Mangalore.
Ex.C4: 21.3.2015: Original inpatient bill issued by SCS Hospital pvt. Ltd. Mangalore.
Ex.C5: 20.3.2015: Original query letter for enhancement authorisation issued by the Opposite Party handed over by Hospital to the complainant.
Ex.C6: 4.4.2015: Office copy of the legal notice issued by the complainant to the Opposite Party.
Ex.C7: 7.4.2015: original Postal Acknowledgement for having served the legal notice to the Opposite Party.
Ex.C8: 7.4.2015: Original postal acknowledgement for having served the legal notice to the corporate office of the
Opposite Party.
Ex.C9:16.4.2015: Original Reply given by Corporate office of the Opposite Party.
Witnesses examined on behalf of the Opposite Party:
RW1: Melwin DSouza, Branch Manager
Documents marked on behalf of the Opposite Party:
Nil
Dated: 30.03.2017 MEMBER
