Complaint filed on: 31.12.2012                                                     Disposed on: 13.01.2017

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

CC.No.2578/2012

DATED THIS THE 13^th JANUARY OF 2017

PRESENT

SRI.H.Y.VASANTHKUMAR, PRESIDENT

SRI.D.SURESH, MEMBER

SMT.N.R.ROOPA, MEMBER

Complainant: -                     

Mr.Sainuddeen Vm

Edu world Bangalore,

2^nd Floor,

Above Syndicate bank,

Sanjaynagar,

Near police station,

Bengaluru-560094

By Inperson

V/s

Opposite parties:-    

1. The Manager

Star Health and Allied Insurance co. ltd.

Corporate office: No.1

New tank Street,

Valluvar Kottayam

High Road

Nungambakkam

Chennai-600034.

2. The Manager

Bengaluru office:

Star Health and Allied Insurance Co. Ltd.,

No.221, 1^st Floor, Opp. to National co-operative bank, 9^th main road,

Jayanagar 5^th block

Bengaluru-560041.

3. The Manager

Bangalore Baptist Hospital

Hebbal Bellary Road

Bengaluru-560024

For Opposite parties No.1 & 2

By Adv. Sri.Y.P.Venkatapathi

For Opposite party No.3

By Adv. Sri. K.Arunkumar

ORDER

Under section 14 of consumer protection Act. 1986.

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

            The Complainant has prayed for direction to the Opposite parties to pay the bill amount of Rs.22,510/- with interest along with compensation of Rs.1 lakh, by alleging the deficiency for repudiating medical insurance claim.

          2. The case of the Complainant in brief is that he being the holder of the insurance policy of Opposite parties No.1 & 2 after taking treatment at Opposite party No.3 hospital on 16.11.2012, submitted the claim form and it was repudiated by the Opposite parties No.1 & 2 on 20.11.2012. He being the insured has full right to access all medical treatments and the insurance company cannot take arbitrary/capricious attempt towards covering the insurance coverage. The detailed full investigation is required by the forum to stop such exploitation. Hence this complaint.

          3. The Opposite parties No.1 & 2 together Opposite party No.3 filed their separate version. The Opposite party No.3 hospital contends that on 16.11.2012, when the Complainant came to hospital with the history of giddiness and loss of consciousness for few minutes and vomiting, his blood pressure was showing high and hence he was admitted to ICU for monitoring and observation. He was diabetic patient and also was suffering from hypertensive and was on Ayurvedic treatment.  The CT scan of his brain showed high blood pressure, four vessel doppler test of the carotids showed the known complication of diabetes and hypertension, ECHO test showed his known case of loss of consciousness. He also underwent 1) HbA1C, 2) Sugar monitoring, 3) Lipid profile, 4) Creatinine, 5) Sodium, potassium, 6) Urine routine, 7) ECG, 8) Chest x-ray and 10) TSH. He was seen by ophthalmologist for his retinopathy disease. His dispute is with the insurance company but unnecessarily he impleaded the hospital out of spite. He cannot take the benefit of the test and later claim them to be unnecessary. There is no cause of action against the hospital. The complaint is liable to be dismissed with costs.

          4. The Opposite parties No.1 & 2 denied all the allegations made against them contending that they rightly repudiated his claim in terms of the policy. The evaluation of giddiness is beyond the scope of the policy, since only the investigations were done and not active line of treatment was given. The exclusion clause no.13 of the policy does not empower to submit claim petition. The Complainant has suppressed the material facts about pre-existed disease. His allegations have no force. The complaint is not maintainable. There is no deficiency in their part. The contractual obligations of the Complainant makes his case liable to be dismissed with costs for filing it on false grounds.

          5. The Complainant and witnesses of the Opposite party No.3 and Opposite parties No.1 & 2 filed their affidavit evidences relying on Ex-A1 to Ex-A8 and Ex-B1 to Ex-B3 documents respectively. Written arguments were filed by Opposite party No.3 with supported decisions. Arguments of Opposite party No.3 were heard. Perused the records.

          6. The consumer disputes that arise for consideration are as follows:

1. Whether the Complainant establishes the alleged deficiency in service against the Opposite parties No.1 & 2 in repudiating his medical insurance claim ?
2. To what order the parties are entitled ?

7. Answers to the above consumer disputes are as under:

1) Negative

2) As per final order – for the following      

REASONS

          8. Consumer Dispute No.1: The undisputed facts reveal that the Complainant was admitted to Opposite party No.3 Baptist hospital on 16.11.2012 and got discharged on 20.11.2012 as supported by Ex-A1 final bill, Ex-A2 IP settlement voucher, Ex-A3 laboratory results, Ex-A4 discharged summary, Ex-A7 & A8 ECG report. He being the policy holder of Opposite parties No.1 & 2/insurance company submitted claim form/pre-authorization request form as per Ex-A6 and it was denied by the Opposite parties No.1 & 2 through Ex-A5 authorization rejection letter on the grounds that his hospitalization was related to the evaluation and management of an ailment which is not covered in the policy.

          9. It is also undisputed that his treatment is supported by Ex-B1, Ex-B3 hospital documents furnished by Opposite party No.3 hospital. Opposite parties No.1 & 2 relying on exclusion clause no.13 of their insurance policy, contended that the investigations and administrations supported by produced medical bills would have been done without getting admitted to the hospital as inpatient and for such occasions the insurance company shall not be liable to make any payments. In respect of any such expenses whatsoever incurred at hospital or nursing home primarily for diagnostic, x-ray or laboratory examinations not consistent with or incidental to diagnosis and treatment of the positive existence or presence of any ailment sickness or injury.

          10. It is not stated in the final diagnostic summary that the ailment is of particular kind. There is no nexus of the said ailment to the alleged claim ailment. The suppression of facts has influenced them in accepting the proposal for insurance policy and it amounts to suppression of facts and absence of consensus ad idem which makes his complaint not maintainable. He being the patient of diabetics, Hypertension, dyslipidemia has taken the policies by suppressing the same. Evaluation of giddiness for which he was admitted is beyond the scope of the policy.

11. The Complainant in his complaint has requested the forum to investigate the matter instead of establishing the facts against the Opposite parties. He has not produced the needful documents to rebut the contention of the Opposite parties. Thereby the Complainant failed to establish which of the terms & conditions of the insurance policy are violated. It is not his case that he has not possessed the policy and was unable to produce the same. It shows that he had failed to produce the available evidence with him before the forum against the Opposite parties. He has claimed the relief against the Opposite parties No.1 & 2 but has unnecessarily impleaded Opposite party No.3. Thereby he has failed to prove the Consumer Dispute No.1. Accordingly the Consumer Dispute No.1 is answered in the negative.

          12. Consumer Dispute No.2: In view of the finding of Consumer Dispute No.1 the Complainant deserves to get the following:

ORDER

          The Complaint of the Complainant is here by dismissed. No order as to costs.

          Supply free copy of this order to both the parties. 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 13th day of January 2017).

Documents marked on behalf of Complainant:

Documents produced on behalf of Opposite party No.3