Complaint filed on: 04-01-2023
Disposed on: 17-06-2023
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 17th DAY OF JUNE , 2023
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER
CC.No.02/2023
Sri. Somashekar B.S.
S/o Sri. B.N.Siddagangaiah,
Bidalur, Thyamagondlu (Hobli),
Nelamangala Taluk,
Bengaluru Rural District.
……………….Complainant/s
(By Smt. Govardhana V.S., Adv.)
V/s
1. Star Health and Allied
Insurance Company Limited,
No.184/82, 2nd & 3rd Floor,
(Above IDBI Bank),
Dr.Rajkumar Road,
Joganahalli, 2nd Block,
Rajajinagar, Bengaluru-560 010.
2. Star Health and Allied Insurance
Company Limited, Shiva Complex,
2nd Floor, 4th Cross, M.G.Road,
K.R.Extension, Tumakur-572101.
……………….Opposite Party/s
(By Smt. K.P.Mamatha, Adv.,)
:ORDER:
BY SRI.KUMARA.N., MEMBER
This complaint was filed by the complainant against the OPs alleging deficiency of service and prays to direct the OPs to settle the reimbursement of the medical claim of Rs.28,104/- and 2nd claim of Rs.11,978/- in total Rs.40,082/- along with interest at 18% PA from the date of claim to till realization and further prays to direct the OPs to pay compensation of Rs.7,00,000/- for mental agony and Rs.25,000/- towards cost.
2. In this case opposite parties are / were, M/S, Star Health and Allied
Insurance Company Limited, No.184/82, 2nd & 3rd Floor, (Above IDBI Bank), Dr.Rajkumar Road, Joganahalli, 2nd Block, Rajajinagar, Bengaluru-560 010. And M/S, Star Health and Allied Insurance Company Limited, Shiva Complex, 2nd Floor, 4th Cross, M.G.Road, K.R.Extension, Tumakuru-572101, here in after called as OPs.
3. It’s the case of the complaint, ,that the complainant had taken the health insurance policy bearing No.P/141131/01/2022/001327, which was in force from 16.07.2021 to 15.07.2022, with the customer code No.AA0013277849 and the complainant had paid premium (annual) amount of Rs.13,919/- on 21.06.2022 towards renewal of the policy bearing No.P/141131/01/2022/001327 for the period 2022 to 2023 , but the OPs did not responded property in spite of the continues E-mail correspondence and they did not renewed within the time period i.e. 15.07.2022 and the policy grace period (TAT) was up to 26.07.2022. It is further submitted that the E-mail forwarded by the OP No.1 to the OP No.2 on 16.07.2022 and in turn OPs E - mailed to the complainant stating that the premium amount received on 16.07.2022 and thereafter the complainant called the Tumakuru office (OP No 2) on 22.07.2022 and enquired about renewal, for that, the OP No.2 informed that, that renewal still under process and discussion is going on and advised the complainant to wait, and thereafter on 26.07.2022, the OP No 1 sent email to the OP No 2 regarding the complainant paid the premium amount of Rs.13,919/- on 21.06.2022, but the 2nd OP not responded properly.
It is further submitted that complainant and his wife, were not having knowledge of his son Master Parinai Gowda .S, suffering with seizure, the complainant shocked, when his son admitted to the People Tree Hospital, Bengaluru as inpatient on 06.04.2022 and after the examination by the Doctor, doctor diagnosed as unprovoked seizure, seizure disorder and made history that “child was apparently well / child presented with complaints of abnormal movements up rolling of eyes, tonic position for minutes, but up rolling of eyes continues, which lasted for 15-20 minutes followed by post ictal drowsiness and I episode of vomiting and there was no history of fever, trauma. The complainant son Master Parinai Gowda .S after the treatment, discharged on 06.04.2022. The complainant further submitted that the complainant intimated the matter to the OPs regarding the admission of his son for health claims, for that the OPs consented and advised the complainant to pay the said bill of Rs.28,104/- and submit the claim. The complainant on 29.04.2022 submitted claim along with documents for reimbursement and thereafter the OPs acknowledged the receipts of claim form on 11.05.2022, with note of, the policy is subject to the above pre-existing disease as permanent exclusion for the insured (Parinai Gowda .S) i.e. 11.05.2022, which is violation of natural justice and blindly issued to curtail the right of the insured. It is further submitted that, his son, was suffering with viral fever, and second time, he admitted to the JP Hospital Nelamangala on 18.07.2022 and after the treatment, he discharged on 20.07.2022 and paid the hospital bills of Rs.11,978/- and at that time said health policy ,not renewed by the OPs and the complainant contacted the OPs, over mobile phone and OPs replied as, the said policy in grace period, you pay the cash and later claim the bills, but OPs, The complainant approached the OPs many times, but OPs rejected the claims, by mailing to the complainant on 12.05.2022 without any genuine reason.
The complainant further submitted that the complainant paid the paid premium (annual) amount of Rs.13,919/- on 21.06.2022 towards, renewal of the policy, but the OPs, revert back the renewal amount to the complainant Bank account on 04.08.2022, without giving any proper reasons for not to renewal the health policy, in spite of the complainant several approaches, and the OPs intentionally rejected the medical claims and the complainant suffered, as not getting the opportunity of availing extra additional bonus value of Rs.2,00,000/-, as health policy not renewed. The Complainant served the legal notice dated 19.08.2022, inspite of it, OPs not settled the medical claim and renewal the health insurance policy bearing No. P/141131/01/2022/001327, hence this complaint.
4. After the case registered, commission notice was issued to OPs and thereafter the OPs appeared and filed their version contending that the complainant took the policy vide policy No.P/141131/01/2022/001327 for the period from 16.07.2021 to 15.07.2022 (Inception of the policy during the year 2020 - P/141131/01/2021/001099. The complainant reported claim in the 2nd year of the medical insurance policy vide claim No.CIR/2023/141131/0017730. It is further contended that the complainant’s son Parinai Gowda, A/a 6 years admitted on 04.04.2022 at People Tree Hospital, Goragunte Palya, Bengaluru and discharged on 06.04.2022 for the treatment as narrated in the discharge summary diagnosis - UNPROVOKED SEIZURE - SEIZURE DISORDER and in history shows that child was apparently well / child presented with complaints of abnormal movements, unrolling of eyes, tonic position for 2-3 minutes, but unrolling of eyes continues, which lasted for 15-20 minutes followed by post ictal drowsiness and 1 episode of vomiting. No history of fever, trauma. Further, in past history - Similar 3 episodes in past 3 years, not on any medications and the same is revealed at Para-5 of the complaint.
The OPs further contended that the complainant raised pre-authorization of request to avail for cashless facility for his son and on perusal of the claim documents, it is observed in the discharge summary of People Tree Hospital, it is clearly mentioned that the complainant’s son is suffering from the said above disease from past 3 years which is prior to inception of the first policy, but the insured has failed to disclose the said disease in the proposal form. It is further contended that as per policy, expenses related to the treatment for the above disease and its direct complications shall be excluded until the expiry of 12 months and this amounts to concealment of material facts and hence the policy issued is void abinitio and therefore the claim for diagnose disease is not admissible due to concealment of material facts.
The OPs further contended that as per the terms and conditions of the policy issued to the complainant, if there is any misrepresentation or failed to disclose the pre-existing disease in the proposal form at the time of inception of the first policy, whether the insured person or any other person action on his behalf, the company is not liable to make any payment in respect to any claim. Therefore, the OPs unable to settle the claim made by the insured under the above policy and therefore the OPs repudiated the claim and the same was taken by the OPs as per terms and conditions of the policy and based on the claim details, documents submitted by the insured and the same was intimated to the insured and People Tree Hospital, Bengaluru vide repudiated letter dated:06.04.2022, and on 12.05.2022. It is further contended that it is settled law that terms of the policy shall govern the contract between the parties, they have to abide to definition given there in and insurance is a contract and in terms of contract, the relation of the parties shall abide by the terms and conditions. On these among other grounds, it is prayed to dismiss the complaint.
5. The Complainant has filed his evidence by way of affidavit and marked the documents at Ex.P1 to P14. One Mr.Manjunath T.L., Branch Manager has filed his evidence by way of affidavit on behalf of OPs. The OPs marked the documents at Ex.R1 to R15.
6. We have heard the arguments from both side counsels. The counsel for complainant also files written arguments.
7. The points that would arise for determination are as here under:
1) Whether the complainant proves the deficiency in service on the part of OPs?
2) Is complainant entitled to the reliefs sought for?
8. Our findings on the aforesaid points are as follows:
Point No.1: Partly Affirmative
Point No.2: In the partly affirmative for the below
:R E A S O N S:
9. The complainant counsel argued that, the complainant obtained health insurance policy i.e. Young Star insurance Policy, bearing No.P/141131/01/2022/001327 from the OPs, and the complainant paid the premium of Rs 13919.00 to the OPs & sum assured was Rs 500000.00, for the period 16.07.2021 to 15.07.2022, insured persons were Sri Somashekar BS, who is the complainant, Smt Manushree, spouse of the complainant, and the nominee to the said policy and Master Pariani gowda S. The complainant submitted that, complainant and his wife not aware of his son having UNPROVOKED SEIZURE disease, they came to know, when his son not feeling well, at that time approached the People Tree Hospital, Goragunte Palya, Bengaluru on 04.04.2022, after the check up, the Doctor diagnosed, as the complainant son suffering with UNPROVOKED SEIZURE - SEIZURE DISORDER. and after the treatment complainant son discharged on 06.04.2022.The complainant counsel submitted that, at the time of filling the insurance form, the OPs insisted Medical checkup nor Medical Report, the complainant being Rural hailed, as per the promise and the advice of the OPs, the complainant obtained the health insurance policy. The complainant son admitted to the hospital on 04.04.2022 and 18.07.2022 at People Tree Hospital Bangalore & JP Hospital Nelamangala, respectively, after the treatment, as per the advice and instructions of OPs, the complainant paid medical treatment bill of Rs.28,104.00 and 2nd claim of Rs.11,978.00 and submitted the claim to the OPs for reimbursement, but the OPs instead of reimbursing, by quoting non discloser of pre existing disease of the complainant son, repudiated the claim and not renew the insurance policy, even though the complainant paid the premium amount of Rs Rs.13,919/- on 21.06.2022, the OPs revert the premium paid amount to the complainant account on 04.08.2022, without giving proper reasons and violated the contract, and made the complainant to suffer, hence prayed to allow the complaint and award compensation. The Complainant counsel produced Ex P1/copy of Insurance, Ex.P2/copy of premium paid receipt, Ex.P3/copy of legal notice, Ex P4/copy of postal receipt, Ex P5/copy of postal acknowledgment, Ex.P6/copy of Endorsement dates: 11.05.2022, Ex P7/copy of claim form dated:29.04.2022, Ex P8/copy of discharge summary dated:18.07.2022, Ex P9/copy of 05 medical bills, Ex P10/copy of ECG, Laboratory report, Radiology Report, Ex P11/copy of in-patient bill (2 time) dated:18.07.2022, Ex P12/copy of discharge summary, Dt:18.07.2022 , Ex P13/copy of Laboratory report, Ex P14/copy of 07 bills.
10. The OPs counsel argued that, as per the policy, the complainant need to disclose the pre existing diseases of insured persons at the time of obtaining health insurance policy, but the complaint fails to disclose the same, as his son Master Pariani gowda S, who is insured in the policy, suffering from SEIZURE disease. The complainant son admitted to the People Tree Hospital, Goragunte Palya, Bengaluru on 04.04.2022,after the treatment to seizure disease, discharged on 06.04.2022 and in discharge summery, narrated as, diagnosis - UNPROVOKED SEIZURE - SEIZURE DISORDER and in history shows that child was apparently well / child presented with complaints of abnormal movements, unrolling of eyes, tonic position for 2-3 minutes, but unrolling of eyes continues, which lasted for 15-20 minutes followed by post ictal drowsiness and 1 episode of vomiting. No history of fever, trauma. Further, in past history - Similar 3 episodes in past 3 years, not on any medications, hence the medical claim rejected due to violation of terms and conditions of the policy by the complainant, and health insurance policy, Young Star insurance bearing No.P/141131/01/2022/001327 not renewed and the complainant paid the premium of amount Rs 13919.00 revert back to his SB account, hence the OPs counsel prayed to dismiss the case with costs. The OPs counsel produced, Ex R1/Copy of request for cashless hospitalization, Ex R2/Copy of request for cashless hospitalization, Ex R1/Copy of request for cashless hospitalization, Ex R2/Copy of Aadhar of complainant’s son, Ex R3/copy of letter of approved amount of Rs.10,000-00, Ex R4/Copy of letter of approved amount of Rs.10,000-00provided to complainant’s son dated:05.04.2022 from OP, Ex R5/Copy of the claim form, Ex R6/Copy of discharge summary of People tree hospital w.r.t. complainant’s son, Ex R7/Copy of final bill of people tree hospital, Ex R8/Copy of receipt issued by People tree hospital for Rs.28,104-00, Ex R9/Copy of ECG, Ex R10/Copy of Laboratory investigation report, Ex R11/Copy of radiology report, Ex R12/Copy of repudiation of claim dated:12.05.2022, Ex R13/Copy of customer information sheet, Ex.R14/Copy of terms and conditions, Ex.R15/Copy of letter dated:06.07.2021 issued by OP and statement along with policy i.e. 1st year renewal copy with declaration.
11. The Complainant not aware of the facts that to fill the proposal form with respect to prevailing diseases or any diseases and the insurance company not informed nor not raised issues. The complainant left the column blank. Failure to fill in all the queries in the proposal form cannot be termed as suppression or misdeclaration vide Canara Bank v. United India Insurance Co. (2020) 3 SCC 455.
12. The fundamental principle is that insurance is governed by the doctrine of uberrima fidei. This postulates that there must be complete good faith on the part of the insured. This principle has been formulated in MacGillivray on Insurance Law12 succinctly, thus:
―[Subject to certain qualifications considered below], the assured must disclose to the insurer all facts material to an insurer’s appraisal of the risk which are known or deemed to be known by the assured but neither known or deemed to be known by the insurer. Breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms…‖
The relationship between an insurer and the insured is recognized as one where mutual obligations of trust and good faith are paramount.
13. Honorable Supreme court of India, judgment, dated; 6th December,2021 in the case of Manmohan Nanda vs United India Insurance Co. Ltd. in para 6, held that, Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured,
14. Medical assessment means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
15. In this case, the complainant produced, EX p1,which revels that, the complainant, obtained health insurance policy i.e. Young Star insurance Policy from the OPs, where in the complainant paid the premium of Rs 13919.00 to the OPs in turn the OPs issued the said policy, wherein sum assured was Rs 500000.00, for the period 16.07.2021 to 15.07.2022 and insured persons were Sri Somashekar BS, who is the complainant, Smt Manushree, spouse of the complainant, and the nominee to the said policy and Master Pariani gowda S, son of the complainant, which were admitted facts, not disputed by the OPs. The disputes by the OPs were, the complainant son suffering from UNPROVOKED SEIZURE - SEIZURE DISORDER, since last three years, the complainant not disclosed the same at the time of obtained the said insurance policy and violated the policy terms and conditions, but complainant contented that, either the complainant or his wife not having the knowledge of his son having the seizure disease at the time of taking, Young Star insurance Policy from the OPs and his son was active as usual, and never noticed any symptoms of the disease.
16. The object of seeking a health / medi-claim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur on any time or any stage. If the insured / complainant suffer a sudden sickness or ailment or disease, which is not expressly excluded under the policy, a duty is cast on the OPs to indemnify the complainant for the expenses incurred thereunder. If the insured / complainant, had no knowledge of any ailment or diseases, he or his dependents, had, obviously there could be no disclosure of any ailment or sickness or disease, which would require medical attention.
17. In view of the above discussion, (Para 12 & 13) the repudiation of the 1st, medical reimbursement bill of the complainant, for Rs.28,104/-by the OPs was illegal and not in accordance with law, since the complainant paid the premium of Rs 13919.00 to the OPs, in turn the OPs issued the said policy, i.e. Young Star insurance Policy, the sum assured was Rs 500000/-, for the period 16.07.2021 to 15.07.2022, accordingly the complainant son, who was insured in the said policy, due to illness or disease, admitted to the hospital on 06.04.2022 as inpatient, after the treatment discharged on 29.04.2022, which was policy active period and paid the medical bills of Rs 28401/- and same informed by the complainant to OPs and submitted the said medical bills for reimbursement to the OPs on 29.04.2022, which acknowledged by the OPs, accordingly, the OPs are liable to reimburse the said medical bill of Rs 28,401/- to the complainant by considering Regarding 2nd,medical reimbursement bill of the complainant, for Rs 11,978/- the complainant son admitted as inpatient, and taken treatment in JP Hospital Nelamangala, from 18.07.2022 to 20.07.2022, since this treatment period was not prevailed in the said policy active period i.e. 16.07.2021 to 15.07.2022, and the OPs not to renewal the said policy further at that time, and the OPs revert back the renewal premium paid by the complainant to his SB account, the OPs are not liable, since, it’s a contract between the Complainant and OPs. The OPs instead of reimbursing 1st medical treatment bill of Rs 28,401/-, to the complainant, repudiated and compelled the complainant to approach this commission, hence liable to pay the litigation cost of Rs.10,000/- and compensation of Rs.6,000/- to the complainant, accordingly we proceed to pass the order as;
:O R D E R:
Complaint filed by the complainant is allowed in part.
The OPs are ordered to pay, jointly and severely Rs.28,401-00 (Rs.Twenty Eight Thousand Four Hundred One only) along with interest @ 8.00 % p.a from 29-04-2022 to the complainant. It is further ordered that OPs to pay Rs.10,000.00(Rs.Ten Thousand only) towards litigation costs and Rs.6,000.00 (Rs.Six thousand only) towards compensation to the complainant.
The OPs are further directed to comply the above order within 45 days from the date of receipt/knowledge of the order, otherwise, it carries fine of 150/- per day till realization.
Furnish the copy of order to the complainant and opposite party at free of cost.
