BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 5^TH DAY OF JUNE 2023

ORDER

SMT.K.ANITA SHIVAKUMAR, MEMBER

Complainant filed this case, seeking direction to pay sum of Rs.3,98,636/- with interest at the rate of 15% P.A towards insurance amount, to pay Rs.25,000/- towards further cost of surgery and treatment charges, Rs.5,00,000/- towards the damages for mental agony and physical sufferings and cost of proceedings.

2. Brief facts of the case are as follows:-

Complainant filed this complaint U/S 35 of Consumer Protection Act 2019 stated that complainant has obtained medical insurance policy bearing No. 0239095830 for sum insured Rs.5,00,000/- for the period of 1 year, commences from 03.12.2021 to 02.12.2022 from Tata AIG Insurance, who is OP in this case. Complainant stated that one Mr. Damodaran working in Canara Bank took care of all the documentation work and all details pertaining to previous medical medical history. Heart surgery of the complainant was conveyed to Mr. Damodaran and proforma of insurance policy was filled by him. Complainant further stated that premium of Rs.11,372/- was deducted from the complainant’s Canara Bank account on 30.11.2021. On 15.03.2022 Complainant met with an accident near KGA Club parking place, Old Airport Road. He was taken to Manipal Hospital, got admitted to under go surgery in his left hand. Since he has obtained cash less insurance from OP, he has been admitted as cash less insured patient. But the Doctor in Manipal Hospital to check the complainants past ailments, if any enquired with the complainant. Complainant revealed that he had underwent heart surgery in Sagar Apollo Hospital. Complainant further stated that when the hospital updated the health status of complainant to the OP insurance company, OP denied paying insurance amount as the patient did not disclose about the heart surgery in insurance application.

3. Complainant underwent surgery in his left hand and total medical bill of Rs.3,99,027/- in Manipal Hospital. Out of each OP has paid sum of only Rs.391/-, balance amount of Rs.3,98,636/- as paid by complainant. Complainant also submitted that Rs.25,000/- approximately for the cost of surgery and treatment charges for removal of steel rod from his left hand excluding medicines. In view of the above facts complainant submits that he had conveyed the previous history of heart surgery but the same has not been entered in the insurance policy. Complainant stated that it is not deliberately hidden the facts with regard to previous history of the heart surgery in the insurance policy. But on that ground OP repudiated the claim of the complainants and caused deficiency of service, harassment and mental agony to the complainant. Hence complainant approached this commission seeking direction to OP supra.

4. OP represented through its counsel and filed statement of objections. OP stated in his version that insured obtained insurance policy from OP by suppressing the material fact of the conditions of the health, complainant did not disclose the pre-existing ailments. OP also contends that complainant has IHD (Ischemic Heart Disease) since 5 years that is prior to inception of policy whereas policy commences from 03.12.2021. Wherefore the OP rightly denied the cash less facility, the same has been intimated to hospital on 22.03.2022. OP contends that the terms and conditions of the policy are binding on the insurer as well as insured. Only on the ground that complainant has not disclosed the relevant information and suppressed the history of his health is amounts to violation of trust conditions. Hence, OP repudiated the claim of the complainant. OP prays to dismiss the complainant with the exemplary cost.

5. Both parties filed their oral evidences. In support of oral evidences complainant filed 18 documents which are marked as Ex.P.1 to Ex.P.18, one Pruthvi.K, M.T/Legal claims division of OP company filed affidavit on behalf of OP along with 6 documents which are marked as R.1 to R.6. OP also filed certificate U/S 65(B) of Indian Evidence Act. Both the parties reiterated in the affidavit evidence as they stated in their pleadings.

6. On the basis of above pleadings for our consideration are as follows:-

i) Whether the complainant proves the deficiency of services on the part of OP?

ii) Whether complainant is entitled to get the relief as sought?

iii) What order?

7.  Our answers to the above points are as follows:-

Point No.1:- In affirmative

Point No.2:- Partly affirmative

Point No.3:- As per the final order

REASONS 

8. Point No.1:- As stated in the complaint, complainant has an account in Canara bank with unique ID No.CANARA2889308758 and officials of Canara Bank offered a medical insurance policy. Complainant agreed and obtained medical insurance policy bearing No.239095830 for sum of Rs.5,00,000/-, for the period of 1 year, commences from 03.12.2021 to 02.12.2021 with TATA AIG insurance, which is not disputed by OP. The said insurance policy details provided in Ex.P.1 and Ex.R.3. As per the very documents Ex.P.1 and Ex.R.3, complainant has insured for Rs.5,00,000/- by paying premium of Rs.11,372/-. For that OP has issued receipt dated 30.11.2021 which is Ex.P.2 and also issued group medicare card in favor of complaint bearing member ID: 0239095830/ CANARA2889308758/01 contains the details of policy number and validity period with the terms and conditions, is also not disputed.

9. As complainant stated that he met with an accident near KGA club parking place, old airport road on 15.03.2022 and was taken to Manipal Hospital. He got admitted in the Manipal Hospital as cash less patient as he got injury on his left arm for which he had to undergo surgery. After going through the documents Ex.P.4, complainant admitted on 15.03.2022 for the treatment and discharged on 24.03.2022.  In the discharge summary, complainant diagnosed as he got closed fracture of ‘ left olecranon ’ and also mentioned that complainant is sustained injury to left elbow and left knee which is at Ex.P.5. In the very document, he also mentioned that past history is ‘ NIL ’. OP has issued interim bill on 24.03.2022 for Rs.3,99,027/-, out of that hospital has given a discount on policy for Rs.391/-. The net amount of a bill for Rs.3,98,636/- and later complainant regularly visited for dressing of wound and spent on consultancy for thrice, approximately Rs.3,000/- on different dates, which is at Ex.P.4.

10. Since complainant has obtained the cash less benefit from OP, he expected the bill amount to be borned by OP Company well within the time of discharge. After verification OP Company has refused to pay directly to the hospital. OP rejected cash less benefit of the complainant by issuing pre-authorized rejection letter dated 22.03.2022 which is at Ex.R.5, stating that ‘as per available information, case been reviewed through that complainant passed medical history and the sum is not favor on this juncture in cash less. Hence the member is requested to come for re-imbursement with all relevant documents’. The final bill issued on 25.03.2022, which are at Ex.P.14 and Ex.P.15, discloses the sum of Rs.3,05,585/- is bill amount. After discount it comes to Rs.2,66,877/-.  Therefore complainant has paid Rs.2,66,877/- to hospital before going to discharge. Later complainant has submitted a proposal form before OP company for the re-imbursement of amount paid to hospital in claim No.2022031700162, as per the documents Ex.R.5. But OP repudiated the claim as he has suppressed the material information while obtaining the insurance policy especially OP relied on the documents Ex.R.4 dated 22.03.2022 issued by doctor of Manipal Hospital, in which he stated the patient had operated for left olecranon fracture and policy metioned that patient has history of ‘ IHD (Ischemic Heart Disease) of 5 years ’. It doesn’t  mean he still persist with heart disease. It is evident through Ex.P.6, report is issued on 15.03.2022 by consultant carialogist of Manipal hospital, which is normal. It shows the complainant has no such heart related diseases as on the date of discharge.

11. The crux of the material here arise with regard to whether the complainant has suppressed the information about his health condition or not? As stated in the complaint and the affidavit of complainant stated that he underwent heart surgey in Sagar Apollo Hospital which is intimated to the one Mr. Damodaran, who is interme diary filled the performa on behalf of complainant. After going through the Para.8 of complaint, complainant himself stated the past ailment in relation to heart and heart surgery, which shows his intention is not to suppress the material facts even before obtaining the policy. Otherwise he could suppressed the same in the complaint also. He might have had an impression that he disclosed the facts and the same has revealed in the complaint. Coming to have more information about IHD, refers to heart weakening caused by reduced blood flow to heart. According to Ex.R.4 Doctor mentioned IHD of 5 years has a history on complainant. Relying on Ex.P.6, shows he is quite normal with heart disease and no complication faced after heart surgery. More so, OP has not placed any congent evidence to prove the same.

12. It is pertinent to note that complainant has under went surgery in connection to left arm when he got injury, after accident and got admitted. The said surgery has no connection to heart problem even it is not related to heart disease. Hence it is not be considered as the suppression of fact, did not caused any inconvenience or financial loss to OP in honoring the claim of complainant and re-imbursement the money he spent on surgery.

13. Subsequently to the discharge, complainant has regularly visited Jayanagar orthopedic centre for examination and dressing. He also done X-ray of his left elbow and spent more than Rs.3,000/- which is at Ex.P.10 to Ex.P.12. Jayanagar arthopadic centre has issued estimated certificate on 23.06.2022 for implant removal treatment of ‘left olecranon’ fracture and the cost of surgery and treatment would be approximately of Rs.25,000/- excluding medicines.

14. The main objet of insurance and obtaining insurance is the purpose of granting security against the loss and damages to the people for unpredictable occurrences in the life. Medical insurance policy also will help to pay for medical emergency, hospitalization, contractions for any reasons and treatment and medicare required in future. Its aim is to reduce financial uncertainity and make accidental loss manageable. Here the complainant obtained medical insurance policy by paying premium and his claim is also well within insured amount and accident occurred within the validity period. Hence OP has no proper reasons to reject the claim of the complainant and made complainant to suffer even financially, along with physical injury. OP has no reason other than nondisclosure of facts from the complainant but it is not agreed by complainant that he disclose his history of health condition to the person who is intermediary between them. Considering the statement of complainant and also he had IHD ‘of 5 years’ not as interpreted as ‘since 5 years’. Hence OP has misinterpreted. OP company has not placed any congent evidence to believe that complainant still persist with heart disease and also commission observed that OP has not conducted medical examination of complainant while issuing insurance policy. Hence the burden of proof entirely lies on OP. Nothing was brought on record by OP, in order to prove complainant has violated terms and conditions of insurance policy on the ground supra. In our considered view the claim of the complainant can be materialized by OP. By considering the claim of the complainant and reimbursement of the amount he paid to Manipal Hospital and also is liable to reimburse the expenditure he made post surgery which should not exceed RS.5,00,000/-.

15. Complainant placed relevant documents with regard to the medical expenditure and the hospital prescription, based on that complainant has proved his case that he paid entire medical expenditure and also paid post surgery treatment. Complainant also produced material documents with regard to the implant removal treatment costs around Rs.25,000/- excluding medicine. Since complainant has insured for Rs.5,00,000/- it is well within the insured amount. Hence OP is liable to reimburse the entire amount of complainant by collecting the new proposal form. It is observed that OP denied the cash less benefit to verify the documents and taken time to take decision, is accepted. But it is not fair in repudiation of reimbursement of claim amount. Hence, OP has caused deficiency of services by repudiating the genuine claim of the complainant and made him to suffer all these days. Hence he has to compensate to complainant by paying compensation. For the above reasons we answer Point No.1 in the affirmative.

16. Point No.2:- Complainant has claimed Rs.3,98,636/- towards medical expenditure but the complainant has paid the amount incurred on surgery of Rs.2,66,877/- as per Ex.P.15 (final bill), Rs.25,000/- towards further cost on surgery and treatment charges. Since the complainant entitle for amount he paid Rs. 2,66,877/- according to which he produced as final bird and Rs.25,000/- to be paid for the removal of implant, OP is liable to reimburse both the amounts. With regard to the interest which the complainant has claimed at the rate of 15% per annum, seems to be exorbitant. Therefore complainant is entitled to get 10% interest on Rs. 2,66,877/-. Complainant has claimed Rs.5,00,000/- as compensation on mental agony and physical sufferings, but it is huge amount to grant. This commission observed to grant Rs.50,000/- towards compensation for the mental agony and physical sufferings he underwent, in the ends of justice. Complainant is entitled to get Rs.10,000/- towards cost of proceedings. For the foregoing reasons we answer Point No.2 in partly affirmative.

17. Point No.3:- In view of the discussion referred above, we proceed to pass the following:-

ORDER

i) Complainant U/S 35 is partly allowed.

ii) OP is directed to reimburse Rs.2,66,877/-with interest at the rate of 10% per annum from date of claim till realization.

iii) OP is further directed to pay Rs.25,000/- towards removal of implant by collecting the proposal form with relevant documents.

iv) OP is directed to pay Rs.50,000/- towards compensation and Rs.10,000/- towards cost of proceedings within 45 days from the date of order, failing which OP is liable to pay interest at the rate of 12% per annum on Award amount from the date of order till realization.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 5^th day of JUNE, 2023)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party No.3– R.W.1;