Karnataka

Chitradurga

CC/162/2018

T.K.Nagarajarao - Complainant(s)

Versus

The Authorised Sinatory, - Opp.Party(s)

Sri.C.M.Veeranna

11 Jan 2019

ORDER

COMPLAINT FILED ON:21.08.2018

DISPOSED  ON:11.01.2019

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA.

 

CC.NO:162/2018

 

DATED:  11^th JANUARY 2019

PRESENT :-     SRI.T.N.SREENIVASAIAH :    PRESIDENT                            B.A., LL.B.,

                        SMT. JYOTHI RADHESH JEMBAGI:

BSc.,MBA., DHA.,                LADY MEMBER

 

……COMPLAINANT	T.K.Nagarajarao, Aged about 65 years, Achyutha, 2nd Cross, JCR Extension Chitradurga.   (Rep by Sri.C.M. Veeranna, Advocate)
V/S
…..OPPOSITE PARTIES	The Authorized Signatory, Medicare Insurance TPA Services Pvt Ltd., Paul Mansion, NO.68,Bishop Lefory road, Kolkata 700020.   The Authorized Signatory, SBI General Insurance Co. Ltd., Ground and 1st floor, Rukmini Towers,Railway Platform road, Approach road,     The Branch manager, SBI General Insurance Co ltd., MRP Lodge Complex, VP Extension, Chitradurga   (Rep by Sri.B.M. Ravichandra, Advocate for OP No.2 and OP No.1 and 3 ex-parte)

ORDER

SRI. T.N. SREENIVASAIAH:   PRESIDENT

The above complaint has been filed by the complainant u/Sec.12 of the C.P Act, 1986 for the relief to direct the OPs to pay Rs.59,235/- with nominal interest, Rs.2,00,000/- towards damages, mental agony, loss of time and energy and cost.  

2.     The brief facts of the case of the above complainant is that, he has obtained insurance policy from the OP No.2 bearing No.0000000003505552-02 valid for the period from 07.11.2017 to 06.11.2018 for a sum of Rs.4,00,000/- and paid regular premiums to the OPs.  The complainant has undergone treatment for Coronary Angiography at Fortis Hospital Ltd., Bangalore during January 2018 and incurred medical treatment expenses of Rs.59,235/-.  After that, the complainant has submitted all the required documents including Doctor Certificate for the cause of disease and also document pertaining to the claim of the complainant have been sent to the OPs.  But the OPs have not settled the genuine claim of the complainant.  In this regard, the complainant has approached the OPs and demanded somany times through e-mail/letter correspondence, but the OPs have given evasive replies and not paid the claim amount to the complainant.  The complainant has transacted with the OPs insurance company by availing health insurance from SBI General Life Insurance Ltd., on 08.11.2013 for Rs.5,00,000/- and regularly paid the premium since from 2013 without fail.  Due to delay in settling the mediclaim of the complainant, the complainant is suffering from mental agony, torture and financial crisis, prima-facie shows that the OPs are intentionally and willfully delaying in settling the actual claim of the complainant which leads to deficiency in service, dereliction of duties in rendering their esteemed customers.  Finally, on 30.05.2018, the complainant has issued legal notice calling upon the OPs to settle the claim amount within 15 days from the date of receiving the legal notice.  For this OPs have replied by denying all the allegations made in the notice and not refunded the claim amount to the complainant.  On 14.06.2018, the complainant has written a letter to OPs’ Mumbai Office by clarifying that all the relevant documents have been sent and requested to settle the claim immediately.  The cause of action for this complaint arose at Chitradurga within the jurisdiction of this Forum on 17.01.2018 when the complainant has sent all the relevant documents to OP No.1 and on 30.05.2018 when the legal notice was duly served to the OPs within the jurisdiction of this Forum and prayed for allow the complaint.   

3.     On service of notice to the OPs, Sri. B.M. Ravichandra, Advocate appeared on behalf of OP No.2 and 3 and filed version.  According to the version filed by the OPs no doubt the complainant has obtained health insurance policy from OP No.2 and the said health insurance policy is valid from 07.11.2017 to 06.11.2018 covering the total sum insured up to 4,00,000/-.  Further it is submitted that, the complainant has suppressed the material facts in response to the questions in the proposal form, the policy shall become voidable at the option of insurer, in the event of any untrue or incorrect statement, misrepresentation, non description or non discloser in any material particular in the proposal form/personal statement, declaration and connected documents or any material information having been withheld by the insured or any one acting on insured’s behalf.  Any person who knowingly and with intend to defraud the company or any other persons files a proposal for insurance containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the discretion of the company.  It is further submitted that, the complainant had issued a letter to the company through medicare insurance TPS services India Pvt. Ltd., has sent Xerox copy of medical bills, Xerox copy of discharge summary dated 10.01.2018 of Fortis Hospital, Coronary Anzio Report dated 11.01.2018.  After receiving the said documents, the OP No.2 and 3 had issued letter dated 29.01.2018 asking the complainant to give documents like attending doctors has to certify the cause of ischemic heart disease in this case and also needed comment of the doctor regarding that, the associated diabetes, hypertension has any relation to and/or is the causative factor, development of ischemic heart disease to the complainant.  Further it is stated that, the complainant has got admitted to Fortis Hospital from 10.01.2018 to 12.01.2018 for the treatment of ischemic heart disease T2, DM, HTN and underwent CAG with supportive medical management.  As per document submitted, the complainant is suffering from diabetic since from last 15 years which is a risk factor for the development of heart disease.  The said fact has not all been disclosed by the complainant at the time of obtaining the policy and hence the ischemic heart disease is a pre-existing disease and the complainant is suffering from the said disease prior to obtaining the said policy, for non disclosure of material facts by the complainant amounts to violation of policy terms and conditions and hence at this stage the application for payment of compensation to the complainant by the OP No.2 and 3 does not arise and hence prayed for dismissal of the complaint.

4.     Complainant himself has examined as PW-1 by filing affidavit evidence and the documents Ex.A-1 to A-13 got marked.  OPs have examined one Miss. Madhavi Uttam Patil, the Executive – Consumer Litigation as DW-1 and relied on Ex.B-1 and B-6 documents and closed their side.

5.     Arguments heard.

6.     Now the points that arise for our consideration for decision of above complaint are that;

(1)  Whether the complainant proves that the OPs have committed deficiency of service for non settling the medi claim insurance amount and entitled for the reliefs as prayed for in the above complaint?

              (2) What order?

        7.     Our findings on the above points are as follows:-

        Point No.1:- Partly in Affirmative.

        Point No.2:- As per final order.

REASONS

8.     There is no dispute that, the complainant was admitted to the Fortis Hospital, Bangalore from 10.01.2018 to 12.01.2018 for treatment.  The complainant has incurred Rs.59,235/- towards medical treatment.  The complainant has obtained the insurance policy from the OPs and he paid Rs.13,000/- regularly to the OPs since from November 2013 to November 2017.  The above said policy is health insurance policy from SBI Life General Insurance Ltd., for Rs.4,00,000/-.  Accordingly, the complainant has submitted all the documents including discharge summary obtained from the Hospital to the OPs for settlement of the claim, but the OPs have failed to settle the claim of the complainant.  As per the documents produced by the OPs, it clearly shows that, the complainant was suffering from ischemic heart disease and for that he was admitted to the Fortis Hospital, Bangalore for treatment.  Accordingly, he has obtained the treatment from the above said Hospital and incurred Rs.59,235/- towards medical treatment.  But the OPs have taken a main contention that, the complainant has suppressed the material facts in response to the question in the proposal form and further stated that, the complainant was suffering from diabetes since from 15 years, on this ground only, it speaks that, the complainant is suffering from ischemic heart disease.  But the OPs never produced any document before this Forum to show that the complainant was suffering from diabetic since from 15 years and suppressed the material facts at the time of obtaining the insurance policy.  The OPs have failed to disprove the case of the complainant.  In support of his case, the complainant has relied on a decision reported in NSCDRC, New Delhi in the case of Life Insurance Corporation of India Vs. Sarojini and another reported in 2018(2) CPR Page 367, wherein it has been held as under:

“Consumer Protection Act, 1986, - Sections 15,17 and 21 – Insurance – Non-settlement of death claim – Claim repudiated on ground that at time of proposal of policy, life assured was suffering from Idiopathic Dilated Cardiomyopathy – Complaint allowed by For a below – Petitioner has failed to adduce any evidence that deceased was suffering from Idiopathic Dilated Cardiomyopathy since February 2013, and that he was well aware of his disease – Petitioner failed to prove that he had intentionally suppressed his illness which was within his knowledge – Revision Petition dismissed”.

   

        9.     We have gone through the entire documents filed by both parties.  There is no dispute that, the complainant was admitted to the Fortis Hospital, Bangalore during January 2018 for ischemic heart disease and incurred medical expenses of Rs.59,235/- and further the complainant has submitted all the necessary documents to the OPs for settlement of the above said claim.  Further the complainant has obtained health insurance from SBI Life General Insuance Ltd., on 08.11.2013 for Rs.4,00,000/-.  The policy was in force at the time of taking the treatment by the complainant.  The documents produced by the complainant and OPs i.e., Ex.A-1 to A-12 and Ex.B-1 to B-6 clearly shows that the complainant has obtained treatment from the Fortis Hospital, Bangalore.  The OPs have taken only one contention in their version that, the complainant has suppressed the material facts and since from 15 years he was suffering from diabetes and he was suffering from ischemic heart disease.  But the OPs never produced any documents before this Forum to show that, the complainant was suffering from diabetic since from 15 years.  Hence, the OPs have failed to disprove the case of the complainant.  For non settling the claim of the complainant, the complainant has put to great loss and irreparable injury which cannot be compensated by any mode and also the complainant has suffered mental torture and financial loss, hence the OPs are liable to pay the compensation to the complainant.  Accordingly, this Point No.1 is held as partly affirmative to the complainant.

          10.     Point No.2:- As discussed on the above point and for the reasons stated therein we pass the following:-

ORDER

 

The complaint filed by the complainant U/s 12 of CP Act 1986 is partly allowed.

It is ordered that, the OPs are hereby directed to pay a sum of Rs.59,235/- to the complainant along with interest at the rate of 9% p.a from the date of complaint till realization. 

Further it is ordered that, the OPs are hereby directed to pay a sum of Rs.1,00,000/- towards damages, loss of time and energy. 

 It is further ordered that the OPs are hereby directed to pay a sum of Rs.5,000/- towards mental agony and Rs.5,000/- costs of the proceedings.

It is further ordered that, the OPs are hereby directed to comply the above order within 30 days from the date of this order.

            (This order is made with the consent of Lady Member after the correction of the draft on 11/01/2019 and it is pronounced in the open Court after our signatures)     

 

                                     

MEMBER                                                   PRESIDENT

 

-:ANNEXURES:-

Witnesses examined onbehalf of Complainant:

PW-1:  Complainant by way of affidavit evidence.

Witnesses examined on behalf of OPs:

DW-1:  Miss Madhavi Uttam Patil by way of affidavit evidence.

Documents marked on behalf of Complainant:

01	Ex-A-1:-	Letter dated 17.01.2018 from complainant to OP No.1
02	Ex-A-2:-	Grievance letter dated 26.12.2017
03	Ex-A-3:-	Certificate of insurance
04	Ex-A-4:-	GST invoice
05	Ex-A-5:-	Claim form
06	Ex-A-6:-	Claim form Part B
07	Ex-A-7:-	Coronary Angio Report
08	Ex-A-8:-	Test report
09	Ex-A-9:-	Test report
10	Ex.A-10:-	Test report
11	Ex.A-11:-	Test report
12	Ex.A-12:-	Postal receipts and acknowledgements
13	Ex.A-13:-	Legal notice dated 30.05.2018

 

Documents marked on behalf of OPs:

01	Ex-B-1:-	Insurance policy
02	Ex-B-2:-	Discharge summary
03	Ex-B-3:-	Letter dated 14.02.2018
04	Ex-B-4:-	Mandatory Bank details
05	Ex-B-5:-	OPD slip dated 10.01.2018
06	Ex.A-6:-	Prescription slip dated 05.02.2018

 

 

MEMBER                                                   PRESIDENT

Rhr**