Date of Filing      : 09.09.2022
                                                                                                                 Date of Disposal: 19.05.2023

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                  .…. PRESIDENT
                 THIRU.P.MURUGAN,.MCom., ICWA(Inter)., B.L.,                                    ....MEMBER-II
 
CC. No.170/2022
THIS FRIDAY, THE 19th DAY OF MAY 2023

Mr.T.Jagadesh, S/o.Tulasinagam,
No.9, Anna Nagar Main Road,
Soranjeri,
Near Bus Stop, Tiruvallur, Chennai,
Tamil Nadu 600 072.                                                                       ........Complainant.

                                                                          //Vs//

1.TATA AIG General Insurance Company Limited,
   Rep. by its Manager,
   2nd Floor, Samson Towers,
   No.403 L Pantheon Road, Chennai 600 008.

2.TATA AIG General Insurance Company Limited,
    Rep. by its Manager,
   Peninsula Business park, Tower A, 15th Floor,
  G.K.Marg, Lower Parcel, Mumbai 400 013.

3.TAGIC Health Claims,
   TATA AIG General Insurance Company Limited,
   Rep. by its Manager,
   5th and 6th floor, Imperial Tower,
   H.No.7-1-6-617/A,
   GHMC No.615, 616, Ameerpet, Hyderabad,
   Telangana – 500 016.                                                                   ...Opposite parties.
 
Counsel for the complainant                            :  Mr.S.Muthukumaravel, Advocate.
Counsel for the opposite parties                     :  Mrs.Latha Maheswari. Advocate.
                        
This complaint is coming before us on various dates and finally on 08.05.2023 in the presence of Mr.S.Muthukumaravel counsel for the complainant  and Mrs.Latha Maheswari counsel for the opposite parties and upon perusing the documents and evidences of both sides, this Commission delivered the following:
ORDER
PRONOUNCED BY THIRU P.MURUGAN, MEMBER-II

This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service in repudiating the claim along with a prayer to direct the opposite parties to pay a sum of Rs.8,90,352 being the expenses for the insured at the hospital due to road traffic accident, to pay a sum of Rs.50,000/- towards compensation for the mental agony and financial loss caused to the complainant and to pay a sum of Rs.50,000/- towards an unjustified repudiation by citing a clause in the contact which is not relevant to the repudiation.
Summary of facts culminating into complaint:-

The complainant has availed a policy from the opposite parties which is Complete Group Medicare Insurance Policy covering self, wife and two daughters in the year 2022-2023 under policy No.0238936811 with certificate No.00967163 and ID 467033197.  The premium for the policy is Rs.15,630/- with IGST of Rs.2,813.40/-totaling Rs.18,443/- paid and the policy came to force for the period 24.03.2022 to 23.03.2023 with the sum insured is Rs.10,00,000/-.  The complainant met with an accident on 11.05.2022 at Hosur and a Police FIR No.136/2022 was filed as the cause of accident as hit and Run case.  The complainant was treated initially at Government Hospital and later shifted to Kavery Hospital, Hosur for treatment.  The due treatment and discharge from hospital made on 03.06.2022.  The expenses for treatment amounting to Rs.8,74,000/- and other expenses like pharmacy bills, post and pre hospitalization charges of Rs.26,352/- totaling to Rs.8,90,352/- met by the complainant. This amount of hospital expenses for the treatment was put forth as claim from the insurance company against the insurance policy taken on 24.03.2022 by the complainant vide claim No.2022060900046-1 on 30.06.2022 which was repudiated by the insurance company on 19.07.2022 vide their email stating that the claim rejection done by the insurance company due to the policy wording as per the general terms and clauses of section 4(7)(i) of policy.  The Section 4(7)(i) is defined as “misrepresentation, or non disclosure of materials fact” challenging this, the complainant has filed this case before this commission praying that direction may be issued to pay a sum of Rs.8,90,352/- being the expenses for insured at the hospital due to road accident, pay a sum of Rs.50,000/- towards compensation for deficiency in service and mental agony and finance loss caused, to pay a sum of Rs.50,000/- for unjustified repudiation by citing a clause in the contract which is not relevant to repudiation and to pay cost of complaint deed fit.
Crux of the defence put forth by the opposite parties:-
On the other hand, the opposite parties have put forth that the insurer was under medical care for the last 25 years as per the medical discharge summary of the hospital and this fact has been suppressed while taking policy by the complainant and the policy clause specifically states that any misrepresentation or non disclosure of material fact does have the impact in disallowing the claim.  Therefore their stand of repudiation is right and correct in dealing of insurance claim by complainant.
On the side of complainants proof affidavit was filed and submitted documents marked as Ex.A1 to Ex.A12 on their side.  on the side of opposite parties proof affidavit was filed and submitted documents marked as Ex.B1 to Ex.B5 on their side.
Points for consideration:-
The complainant’s claim for the reimbursement of hospitalization expenses is in order?  According to the insurance policy where it is based?
Is the repudiation of the claim by the insurance company is correct according to policy agreement?
Point No.1:-
On the side of the complainant the following documents were filed in support of the complaint allegations;
Policy copy of Group Medicate Certificate of Insurance for the year 2022-2023 was marked as Ex.A1;
Copy of FIR dated 11.05.2022 was marked as Ex.A2;
Discharge summary of complainant dated 03.06.2022 was marked as Ex.A3;
Wound certificate dated 16.05.2022 was marked as Ex.A4;
Claim form dated 03.06.2022 was marked as Ex.A5;
Claim repudiated letter dated 30.06.2022 was marked as Ex.A6;
Email sent by complainant dated 20.07.2022 was marked as Ex.A7;
Email sent by opposite parties dated 21.07.2022 was marked as Ex.A8;
Police complaint letter dated 11.05.2022 was marked as Ex.A9;
Medical bill of Rs.8,74,000/- dated 03.06.2022 was marked as Ex.A10;
Medical bills of Rs.15,778/- dated 11.05.2022 was marked as Ex.A11;
TATA AIG Medicare policy wording booklet was marked as Ex.A12;
Email reply given by opposite parties for the section 4(7)(i) was marked as Ex.A13;
Email reply given by opposite parties for the General Terms and clause dated 11.08.2022 was marked as Ex.A14;
Email reply given by the opposite parties to provide the address of complainant and email sent by complainant to opposite parties for sending hard copy of policy wordings dated 14.02.2023 and 15.02.2023 was marked as Ex.A15;
Apology email reply given by opposite parties for sending hard copy of policy wording dated 16.02.2023 was marked as Ex.A16;
On the side of the complainant the following documents were filed in support of their contentions;
Proposal form was marked as Ex.B1;
Policy with terms and conditions was marked as Ex.B2;
Claim form was marked as Ex.B3;
Discharge summary was marked as Ex.B4;
Denial letter was marked as Ex.B5;
This is a case of insurance claim repudiation based on the medical records of the complainant where the facts of the previous medical history suppressed and the policy taken as per opposite party and defended by the complainant putting forth that there is no disease as mentioned in repudiation letter but only treatment for such disorder taken and requested for insurance money.
It is evident that the complainant has taken a policy by paying premium and the same policy was in force when he met with the accident.  The complainant was treated for the injuries and discharged from the hospital namely Kavery hospital, Hosur.  The total medical expenses stood at Rs.8,90,352/- for which the complainant has submitted for reimbursement with the insurance company through proper claim. The insurance company after scrutinizing the discharge summary of the complainant has repudiated the claim based on the fact that the complainant was in treatment for nephritic syndrome and connected treatment for N/K/C/O – DM/IHD/TB/epilephy.
This made the complainant aggrieved and his version of claim of medical reimbursement for the treatment for the accident makes the case.  But whereas the insurance company has put forth that while taking policy the complainant has suppressed the fact of treatment taken earlier and denied the reimbursement citing the insurance policy clause 4(7)(i) which is defined as misrepresentation or non disclosure of material.  The insurance policy is a contract between parties based on belief of statement by both.  Therefore the breach of contract occurs when one of the parties is suppressing the fact and to get the benefit out of it which is against business ethics. In short, the claim is unjustifiable as per insurance company.  It is to decide whether to accept the complainant’s claim or to repudiate the claim.
Although the insurer/complainant has valid policy in his hold and the claim for the reimbursement for the hospital treatment follows, the insurer does have aliments history and was in treatment for many years for diseases like N/K/C/O-DM/IHD/TB/epilepsy. The condition of the insurance policy is that the insurer should disclose the medical treatment history while taking the policy.  In this case, the insurer failed to record the previous case history of his ailment.  That is suppression of materials fact which is against the law of contract of insurance policy.  Though the present accident is not due to any of the ailment mentioned above, the claim of reimbursement could not be done by the insurance company, since the clause of misrepresentation stops them to approve the reimbursement. Had the insured disclosed the previous history of treatment, the stand of the insurance coverage would be different as in the clause.  The insurance company believes facts stated by the insurer and any misrepresentation would be catastrophic effect on business and therefore, the claim of the complainant is not in order based on record.
Point No.2:
Since the claim of the complainant is not in order, the repudiation of the claim by the insurance company is correct before law.  Thus we answer the point accordingly.
In the result the complaint is dismissed.  No order as to cost.

Dictated by the Member-II to the steno-typist, transcribed and computerized by him, corrected by the Member-II and pronounced by us in the open Commission on this the 19th day of May 2023.

    Sd/-                                                                                                                  Sd/-
MEMBER-II                                                                                                     PRESIDENT

List of document filed by the complainant:-

Ex.A1 .............. Policy Copy of Group Medicare Certificate of Insurance for the year 2022-2023 Xerox
Ex.A2 11.05.2022 FIR Copy. Xerox
Ex.A3 03.06.2022 Discharge Summary of complainant. Xerox
Ex.A4 16.05.2022 Would Certificate. Xerox
Ex.A5 03.06.2022 Claim Form. Xerox
Ex.A6 30.06.2022 Claim Repudiation letter. Xerox
Ex.A7 20.07.2022 Email sent by complainant. Xerox
Ex.A8 21.07.2022 Email sent by opposite parties. Xerox
Ex.A9 11.05.2022 Police complaint letter. Xerox
Ex.A10 03.06.2022 Medical bill of Rs.8,74,000/- Xerox
Ex.A11 11.05.2022 Medical bills of Rs.15,778/- Xerox
Ex.A12 ................ TATA AIG Medicare Policy wording booklet. Xerox
Ex.A13 28.07.2022 Email reply by opposite parties for the section 4(7)(i). Xerox
Ex.A14 11.08.2022 Email reply given by opposite parties for the General Terms and clause. Xerox
Ex.A15 14.02.2023
       &
15.02.2023 Email reply given by opposite parties to provide the address of complainant and email sent by complainant to oppostie parties for senting hard copy of policy wordings. Xerox
Ex.A16 16.02.2023 Aplogy email reply given by opposite parties for senting hard copy of policy wordings. Xerox

List of documents filed by the opposite parties:-

Ex.B1 ............... Online Proposal Form. Xerox
Ex.B2 ............. Policy Terms and conditions. Xerox
Ex.B3 ............ Claim Form. Xerox
Ex.B4 03.06.2022 Discharge Summary. Xerox
Ex.B5 05.11.2022 Denial letter. Xerox

    Sd/-                                                                                                                 Sd/-     

MEMBER-II                                                                                                  PRESIDENT