CC No: 873/2014

 Filed on 14.05.2014

Disposed on 22.03.2016

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

BANGALORE – 560 052

DATED THIS THE 22^nd DAY OF MARCH 2016

CONSUMER COMPLAINT NO.873/2014

PRESENT:

Sri. H.S.Ramakrishna,  B.Sc., LL.B.

                                    PRESIDENT

                        Smt. L. Mamatha, B.A., (Law), LL.B.

                        MEMBER

                                                        V/S

ORDER 

BY SRI H.S. RAMAKRISHNA, PRESIDENT

1.         This is a complaint filed by the Complainant against the Opposite Party under Section-12 of the Consumer Protection Act, 1986, praying to pass an order directing the Opposite Party to pay Rs.2,50,000/- along with Rs.10,00,000/- as compensation towards hardship and trauma undergone.

2.         The brief facts of the Complaint can be stated as under:

In the complaint the Complainant alleged that the Complainant and his family members were covered by company’s corporate medical insurance from Bajaj Allianz since June 2010 for a sum assured of Rs.2,50,000/- p.a.  In addition to this, the Complainant took an additional insurance from Star bearing policy No.P/141111/01/2012/009843 dt.22.03.2012 for a sum assured of Rs.3,00,000/-.  Incidentally an inconspicuous swelling was noticed in June and further tests were carried out.  Biopsy and PET CT revealed it to be NHL Stage II Low grade (SLL) and 6 cycles of Chemotherapy and maintenance cycles thereafter was advised.  His first cycle cost came up to Rs.91,635/-.  The claim was submitted to Star vide cashless claim No.0045137 dt.06.07.2012.  Initially an amount of Rs.40,000/- was pre-approved orally.  An additional expenses of Rs.37,535/- had also been incurred.  At the time of billing, after waiting for more than 3 hours for the approval, the total claim was disapproved based on some flimsy reason and finally the bill amount was settled by the Complainant and the amount was claimed by Bajaj and the same has been approved and received by the Complainant.  The amount received from Bajaj Rs.1,30,353/-.  Similarly, the 2^nd, 3^rd, 4^th cycles have been claimed from Bajaj and have been approved and received. Amount received from Bajaj Rs.72,262/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2082930-Bajaj Allianz G on 10.08.2012.  Amount received from Bajaj Rs.6,666/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2114784-Bajaj Allianz G on 03.09.2012.  Amount received from Bajaj Rs.35,293/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2155605-Bajaj Allianz G on 01.10.2012.  Amount received from Bajaj Rs.1,005/- vide Ref.No.00000  SCBL0036001 ref. NEFT CR-SIN 00043Q2179775-Bajaj Allianz G on 22.10.2012.  Amount received from Bajaj Rs.3,967/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SCBL 0036001-Bajaj Allianz G on 10.08.2012.  The total amount received from Bajaj Allianz Rs.2,49,546/-.  After exhausting the eligibility from Bajaj, the Complainant submitted the 5^th cycle claim vide No.95965 dt.28.09.2012 for a sum of Rs.35,863/- and 6^th cycle claim vide No.106517 dt.18.10.2012 for Rs.35,357/- to Star.  An additional expenditure of Rs.22,000/- has been incurred on 01.12.2012 towards follow-up PET CT scan as per doctor’s advice.  Even this bill has been submitted to Star.  After more than 7-8 weeks of follow ups and furnishing all the requisite documents, there didn’t seem to be any claim settlements being initiated.  Request for additional document claim No.95965 received from Star dt.25.10.2012.  All documents furnished as requested.  Again request for the same additional document claim No.95965 received from Star dt.15.11.2012.  All documents furnished as requested.  Again request for the same additional document claim No.95965 received from Star dt.06.12.2012.  Request for additional document claim No.106517 received from Star dt.12.12.2012.  All documents furnished as requested.  Request for additional documents claim No.95965 received from Star dt.13.12.2012.  All documents furnished as requested.  Again request for the same additional documents claim No.6517 received from Star dt.28.12.2012.  All documents furnished as requested.  Again request for the same additional document claim No.95965 received from Star dt.29.12.2012.  All documents furnished as requested.  Repudiation of claim No.106517 dt.03.01.2013 vide No.CLI/2013/141111/ 0106517 citing “Pre-existing disease”.  Repudiation of claim No.95965 dt.17.01.2013 vide No.CLI/ 2013/141111/0095965 citing “Pre-existing disease”.  All bills and reports returned by Star.  The original of PET CT scan report, PET CT bill etc, are found to be missing among the documents.  Policy renewed vide. P/141111/01/2013/010126 valid till 21.03.2014 for a sum assured of Rs.3,75,000/-.  The Complainant resigned from the job with effect from 01.03.2013, hence, no longer being covered under corporate insurance.  The Complainant frustrated by their laxity.  Every time follow-up it amounts to a STD call to Chennai, but yields no results.  The Complainant don’t get any responses from Star except for asking for the same documents over and over again which appears to be just some sort of delaying tactics.  Hence, this complaint.

            3.         In response to the notice, Opposite Party put their appearance and filed their version.  In the version Opposite Party pleaded that the complaint is not maintainable either in law or on facts.  The Complainant supposed to make the Head Office of the company as party to the proceedings, as per the terms of the policy.  Hence, the complaint is bad for mis-joinder of necessary and proper party.  The Complainant had taken the alleged policy bearing No.P/141111/01/2012/009843 subsequently renewed the same for the period from 22.03.2013 to 21.03.2014 subject to the terms and conditions stated therein.  The Complainant complaint is vague.  The Complainant has not produced full text of the policy and has been attempting to mislead the Forum, in seeking the claimed relief, for which he is not entitled from the Opposite Party.  The Opposite Party perused the claim records seeking reimbursement of Rs.35,863/- towards Chemotherapy cycle 1 to 5 underwent by the Complainant on 16.10.2012 for the treatment of low grade non-hodgkinslympohoma and Rs.35,683/- for the treatment of NHL stage second low grade at Apollo Hospital, Bangalore on 26.09.2012.  On scrutiny of the claim records it is observed that the Complainant availed policy on Bajaj Alliance Insurance Company.  Hence, the Opposite Party have called for the following documents vide letter dt.25.10.2012, 15.11.2012 & 13.12.2012, which are mandatory to process the claim.  The Complainant had not disclosed the previous policy with Bajaj Insurance Company to the Opposite Party in the proposal form at the time of inception of the policy.  As per Condition-8 of the policy, if at the time when any claim arises under this policy, thee is in existence any other insurance whether it be effected by or on behalf of any Insured Person/s in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the company will not be liable to contribute more than a ratable proportion of such cost and expenses.  Inspite of repeated reminders, the Complainant had not submitted the claim records to enable the Opposite Party to process the claim.  As per Condition-5 of the policy, the insured shall submit the bills, receipts and other documents upon which a claim is based and also give the Company such additional information and assistances the company may require in dealing with the claim.  The Complainant not submitted the particularly that were not furnished, it is the obligations and responsibility of the Opposite Party to seek such documents and particulars from the Complainant, in the process of scrutiny of the claim.  If there are two policies simultaneously, it is necessary to furnish the copy of the policy of other company to the company with whom the claim is subsequently made.  The insurance security of an individual is only for getting the reimbursement of the expenses because of the unforeseen ill health consequences and not for making profit or getting profit out of it.  Hence, it is necessary to verify the claims under all the angles when the claims of this kind are made by the insured persons and processing of such claims will take little time for want of full particulars.  The claim documents of the Opposite Party for perusal, based on the documents available, the Opposite Party have evaluated the claim and observed that (i) as per first consultation report, the insured complained of swelling in the neck two weeks prior to first consultation on 19.06.2012,      (ii) The discharge summary for the admission on 06.07.2012 states that the insured had loss of appetite, weight loss and swelling left side of the neck since two weeks and on examination both neck and axilla palpable lymph nodes are present, (iii) HPE report dt.22.06.2012 states low grade lymphoma and stage-II as per PET scan.  Thus the present hospitalization is for the management of pre-existing disease, which existed much prior to the inception of the policy on 22.03.2012.  As per Exclusion No.1 of the policy, the company is not liable to make any payment in respect of expenses for the treatment of pre-existing diseases until 48 months of continuous coverage has elapsed, since inception of the first policy with the company.  Hence, the claim was repudiated and the same was communicated to the insured vide letter dt.03.01.2013.  The Complainant approached the Hon'ble Ombudsman, on receipt of notice from Hon'ble Ombudsman on 19.04.2012, the Opposite Party have evaluated the claim documents and considered the claim for settlement for Rs.70,259/- and the same was settled vide DD.No.853065/ 07.10.2013 and the complaint before the Hon'ble Ombudsman was closed.  The Complainant had already moved the Insurance Ombudsman.  The Opposite Party accepted and admitted the relief’s granted and satisfied it as well.  Hence, as per the said Redressal of Public Grievance Rules, under which the Insurance Ombudsman is constituted, there is full satisfaction of the award and order.  If so, the cause of action no longer survives for the Complainant.  It is understandable if the complaint was dismissed by the Insurance Ombudsman and the Complainant approached this Hon'ble Forum.  The Complainant sought a remedy, got the benefit of it and still has chosen to file a consumer complaint.  The cause for this complaint being one and the same and the insurer having satisfied the relief’s already granted, there is no further cause of action surviving and available to the complaint to file this consumer complaint.  Hence, the complaint deserves to be dismissed and prays to dismiss the complaint.

4.         In support of the complaint, the complainant has filed his affidavit by way of evidence.  For the Opposite Party one Sri John Nosonha, Asst. Vice President has filed his affidavit by way of evidence.  Heard the arguments of both the parties.

5.         Now the points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Party?
2. If so, to what relief the Complainant is entitled?

6.         Our findings on the above points are:-

                        POINT (1):-  Negative

                        POINT (2):-As per the final Order

REASONS

7.         POINT NO. 1:-         As looking into the averments of the complaint and the version filed by the Opposite Party, it is not in dispute that the Complainant took a Star Insurance Policy bearing No.P/141111/01/2012/ 009843 dt.22.03.2012 for a sum assured of Rs.3,00,000/-.  The Policy renewed vide No.P/141111/01/2013/010126 valid till 21.03.2014 for a sum assured of Rs.3,75,000/-.  In order to substantiate this, the Complainant filed his affidavit and in the sworn testimony reiterated the same.  In support of his contention, he produced the requirement of additional documents/details dt.25.10.2012 and 13.12.2012.  Under these documents, the Star Health Allied Insurance Policy requested the Complainant to produce the additional documents/details as mentioned in these letters with respect to the Claim Intimation No.CLI/2013/141111/95965 filed by the Complainant with the Opposite Party.  So in these documents, it is also mentioned that the Complainant had a policy bearing No.P/141111/01/ 2012/009843 Family Health Optima – New and also produced reminders dt.29.12.2012.  Even by looking into this document also, it is clear that the Opposite Party requested the Complainant to produce the originals for his Claim Intimation No. CLI/2013/141111/95965.  In this document also, it is clearly mentioned that the Complainant is having a policy bearing No. P/141111/01/2012/009843.  This evidence of the Complainant remains unchallenged and there is no contra evidence to disbelieve the version of the Complainant.  Therefore, it is proper to accept the contention of the Complainant that the Complainant had an additional insurance from Star Health and Allied Insurance Policy bearing No. P/141111/01/ 2012/009843.

            8.         In the complaint, it is further alleged that in the month of June, the Complainant noticed swelling and further tests were carried out.  Biopsy and PET CT revealed it to be NHL Stage II Low grade (SLL) and 6 cycles of Chemotherapy and maintenance cycles thereafter was advised.  His first cycle cost came up to Rs.91,635/-.  The claim was submitted to Star vide cashless claim No.0045137 dt.06.07.2012.  Initially an amount of Rs.40,000/- was pre-approved orally.  An additional expenses of Rs.37,535/- had also been incurred.  At the time of billing, after waiting for more than 3 hours for the approval, the total claim was disapproved based on some flimsy reason and finally the bill amount was settled by the Complainant and the amount was claimed by Bajaj and the same has been approved and received by the Complainant.  The amount received from Bajaj Rs.1,30,353/-.  Similarly, the 2^nd, 3^rd, 4^th cycles have been claimed from Bajaj and have been approved and received.  Amount received from Bajaj Rs.72,262/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2082930-Bajaj Allianz G on 10.08.2012.  Amount received from Bajaj Rs.6,666/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2114784-Bajaj Allianz G on 03.09.2012.  Amount received from Bajaj Rs.35,293/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2155605-Bajaj Allianz G on 01.10.2012.  Amount received from Bajaj Rs.1,005/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SIN 00043Q2179775-Bajaj Allianz G on 22.10.2012.  Amount received from Bajaj Rs.3,967/- vide Ref.No.00000 SCBL0036001 ref. NEFT CR-SCBL 0036001-Bajaj Allianz G on 10.08.2012.  The total amount received from Bajaj Allianz Rs.2,49,546/-.  After exhausting the eligibility from Bajaj, the Complainant submitted the 5^th cycle claim vide No.95965 dt.28.09.2012 for a sum of Rs.35,863/- and 6^th cycle claim vide No.106517 dt.18.10.2012 for Rs.35,357/- to Star.  An additional expenditure of Rs.22,000/- has been incurred on 01.12.2012 towards follow-up PET CT scan as per doctor’s advice.  Even this bill has been submitted to Star.  After more than 7-8 weeks of follow ups and submission of the requisite documents did not settle the claim requesting for additional documents and all the documents furnished as requested.  Instead of settling the claim, the Opposite Party repudiated the Claim No.106517 dt.03.01.2003 vide No.CLI/2013/141111/ 0106517 citing “Pre-existing disease”.  Repudiation of claim No.95965 dt.17.01.2013 vide No.CLI/2013/141111/0095965 citing “Pre-existing disease”.  The Policy renewed vide No.P/141111/01/2013/010126 valid till 21.03.2014 for a sum assured of Rs.3,75,000/-.  Inspite of that Opposite Party fails to settle the claim and repudiate the claim.  To establish this fact, the Complainant in his sworn testimony reiterated the same and also produced the award passed by the Insurance Ombudsman.  As looking into this award, the complaint No. I.O.(HYD)G-11.44.263/2013-14 filed by the Complainant against the Star Health and Allied Insurance Company Ltd., passed an Order stating that insurer settled the claims of the Complainant and there was no dispute on the settled claim amount.  The Complainant was seeking compensation for the delay and mental agony.  During the hearing, it was explained to him and observing this complaint as treated as allowed.  But by looking into this Order, the Ombudsman have not passed any award in favour of the Complainant since the claim settled by the insurance company and also produced the reminder dt.29.12.2012.  Under this reminder, the Opposite Party requested the Complainant to submit the originals for settle the claim with respect to the policy No.P/141111/01/2012/009843 Claim Intimation No. CLI/2013/ 141111/95965 and also requirement of additional documents/details dt.25.10.2012 and 13.12.2012.  Under these documents, the Star Health Allied Insurance Policy requested the Complainant to produce the additional documents/details as mentioned in these letters with respect to the Claim Intimation No.CLI/2013/141111/95965 filed by the Complainant with the Opposite Party.  So in these documents, it is also mentioned that the Complainant had a policy bearing No.P/141111/01/ 2012/009843 Family Health Optima – New and also produced reminders dt.29.12.2012.  Even by looking into this document also, it is clear that the Opposite Party requested the Complainant to produce the originals for his Claim Intimation No. CLI/2013/141111/95965.  In this document also, it is clearly mentioned that the Complainant is having a policy bearing No. P/141111/01/2012/009843 and also repudiation of claim No.106517 dt.03.01.2013 vide Policy No. CLI/ 2013/141111/0106517 claiming reimbursement of Rs.35,357/- towards the Chemotherapy cycle on the ground of existing disease which is existing much prior to the inception of the policy dt.22.03.2012.  Another repudiation claim dt.17.01.2013 with respect to the Claim Intimation No.95965 of the Complainant with respect to Policy No.CLI/2013/141111/0095965 dt.22.03.2012 and also produced the Discharge Voucher dt.07.10.2013.  As looking into this document, this Discharge Voucher is with respect to Claim No. CLI/2013/141111/0095965 and No. CLI/2013/141111/0106517 of the Policy No.P/141111/01/2012/009843 in the name of the Complainant as per the complaint No. I.O.(HYD)G-11.44.263/2013-14.  The Complainant received a sum of Rs.70,529/- as full and final settlement of the claim from Star Health and Allied Insurance Company Ltd., arising out of the hospitalization to the Apollo Hospital, Bangalore for the admission on 26.09.2012.  So from this document also as per the Order passed by the Ombudsman, the Star Health and Allied Insurance Company Ltd., has paid a sum of Rs.70,529/- and the Complainant received this amount as full and final settlement.  Inspite of receiving the said amount, the Complainant again filed this complaint on false grounds and apart from that, the Opposite Party has repudiated the claim on the ground that there is a pre-existing disease.  Thereby, the Complainant has failed to prove that there is a deficiency of service on the part of the Opposite Party and also the Complainant fails to produce the original bills, receipts and other documents in support of his claim, for that reason, they have not able to honour the claim of the Complainant.  Therefore, there is no deficiency of service on the part of the Opposite Party.  Hence, this point is held in the negative.

9.         POINT NO.2:-          In view of the finding on Point No.1, we proceed to pass the following;

ORDER

The Complaint is dismissed. No 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 22^nd day of March 2016).

       MEMBER                                                                               PRESIDENT

CC. NO.1763/2014

LIST OF WITNESSES AND DOCUMENTS

Witnesses not examined, but affidavit of the witnesses is filed, as follows;

1. Sri Vainik Shetty has filed his affidavit for Complainant.
2. Sri John Nosonha, Asst. Vice President filed his affidavit for the Opposite Parties.

List of documents filed by the Complainant :

1. Copy of the Order of Insurance Ombudsman.
2. Copy of the repudiation of claim.
3. Copy of the reminder – 1.
4. Copy of the requirement of additional documents/details.
5. Copy of the discharge voucher.

List of documents filed by the Opposite Parties :

1. Copy of the Proposal Form for insurance.
2. Copy of the Order of Insurance Ombudsman

MEMBER                                                                               PRESIDENT