Andhra Pradesh

Chittoor-II at triputi

CC/59/2018

B.Yeshaiah, S/o B.Sundara Rao - Complainant(s)

Versus

The Branch Manager, M/s HDFC ERGO General Insurance Company Ltd. - Opp.Party(s)

V.Sreenivasulu

19 Dec 2019

ORDER

                                                                                                     

                                                                                                                                      Filing Date: 17-08-2018                                       Order Date: 19-12-2019

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, CHITTOOR AT TIRUPATI.

 

Present:-  Sri. T.Anand, President (FAC)

      Smt.T.Anitha, Member

 

THURSDAY THE NINETEENTH DAY OF DECEMBER, TWO THOUSAND AND NINETEEN

 

C.C.No.59/2018

Between

Sri. B. Yeshaiah, S/o. B. Sundara Rao,

Christian, aged about 38 years, business,

Residing at House No.22-8-252/1/B1,

Upadyaya Nagar, Near Grand World,

Tirupati, Chittoor District.                                                                  ... Complainant

 

And

1. The Branch Manager, 

M/s. HDFC ERGO General Insurance Company Ltd.,

V.V.Mahal Road,

Tirupati,

Chittoor District.

 

2. The Manager,

Legal Department,

HDFC ERGO GENERAL INSURANCE COMPANY LIMITED

STELLART IT PARK TOWERS – 1,

Fifth Floor,

C-25, SECTOR – 16,

NOIDA – 201301,

Utter Pradesh.                                                                        … Opposite Parties

 

         This complaint coming on before us for final hearing on 11.12.2019 and upon perusing the complaint and other relevant material papers on record and on hearing of Sri.V.Sreenivasulu, counsel for the complainant and Sri.S.M.Jhan, counsel for the opposite parties 1 and 2 having stood over till this day for consideration, the Forum made the following.

ORDER

DELIVERED BY SRI. T.ANAND, PRESIDENT (FAC)

ON BEHALF OF THE BENCH

         Complaint is filed under section 12 of the Consumer Protection Act 1986, alleging as follows:- Complainant had taken Health Suraksha Policy, Silver Plan on 21.11.2009 from opposite parties vide policy bearing No.2952200900490701000 to cover health insurance for himself and his family members. The policy was taken by phone conversation at the time of availing the policy he disclosed all relevant health issues to the officials of opposite parties and after satisfying the information furnished by him the policy was issued. Subsequently his wife Smt. B.Anitha fell sick and had undergone treatment for Bilateral Nasal Polyposis in the year 2013 at Vikram Hospitals, Bangalore. The opposite parties paid the medical expenditure incurred by her basing on the records. Subsequently he renewed the policy from time to time for every two years by paying necessary premium amount. Thus the policy was renewed from 21.11.2015 to 20.11.2017. Once again his wife developed the same problem and got admitted in Sri Ramachandra Medical Centre, Chennai for treatment on 19.08.2016 and surgery namely Functional Endoscopy Sinus Surgery with Polypectomy on General Anesthesia was conducted in the said hospital on 20.08.2016 and the hospital raised bill for Rs.1,91,670/-The complainant brought to the notice of opposite parties by submitting necessary documents like medical records and bills issued by the hospital and requested them to release the amount but the opposite party authorities turned down his request to pay the medical bills by saying that he has concealed the existing disease of Thyroid problem of his wife. He had to pay the amount to the Sri. Ramachandra Medical Centre, Chennai out of his savings and obtained necessary receipts from the hospital and got discharged his wife. Thereafter the complainant has been visiting opposite party’s office for settlement of the claim amount but there was no response from the authorities of opposite party. The risk covered by the policy is Rs.5,00,000/- and opposite party have collected the necessary premium for that. While disclosing the details about himself and his family members over phone, he had clearly informed that, his wife has been suffering from Thyroid problem and thereafter opposite parties obtained his signatures in empty application form by saying that, the information furnished by him has been already recorded in their records when he was disclosing the details over phone to them. In spite of repeated oral remainders and requests the opposite party authorities have not settled the claim and postponing the issue on one pretext or the other. He has been repeatedly sending mails to the authorities of opposite party stating that he did not conceal any information relating to ill health of his wife and the conversation between him and opposite party officials was already recorded to that effect. Taking advantage of non mentioning of the ill health of his wife in the unfilled application which was signed by him, the opposite party authorities have filled the said application subsequently to suit their convenience which amounts unfair trade practice. The complainant has been suffering mental agony due to the acts of the opposite parties. Very purpose of availing health insurance policy is to avoid unnecessary mental torture and agony when ill health issues arise among the family members but, the said purpose has been defeated due to inaction by opposite party. The opposite parties never raised any objection to pay the medical bills when his wife fell sick earlier and took treatment in Vikram Hospital, Bangalore. But now without any reason, the opposite parties are refusing to reimburse the medical expenses incurred by him. Having vexed with the attitude of opposite parties, the complainant issued legal notice dt: 16.04.2018 to the opposite parties and one of the opposite parties received the said notice but failed to settle the claim. Thus there is deficiency of service on part of the opposite parties in not settling the claim. Having renewed the policy from time to time, the opposite parties repudiated the claim without any justification. He had to borrow money from third parties on high rate of interest to pay the medical expenses incurred by him and he is unable to clear the debt so far.

           Hence it is prayed to allow the application by directing the opposite parties to pay Rs.1,91,670/- with interest @ 24% p.a. from the date of bill to Sri. Ramachandra Medical Centre, Chennai till the realization of the amount, to pay Rs.1,00,000/- towards damages and deficiency of service, to pay Rs.2,00,000/- for indulging in unfair trade practice, to pay costs of the litigation.

           2.The opposite party No.2 filed written version and same was adopted by opposite party No.1 by filing memo which is part and parcel of the written version of opposite party No.2. They contended as follows:-  At the outset, the complaint averments are denied. The complainant has approached the forum with unclean hands by suppressing the pre-existing disease of his wife. The claim was repudiated for the reason of concealment of past medical history and disclosure of material facts relating to the illness of his wife in the member form. It is admitted that, complainant has taken policy bearing No.2952200900490701000 in the name of Health Suraksha Policy, Silver Plan on 21.11.2009 to cover health insurance for himself and his family members over telephone conversation but it is denied that the complainant informed all the necessary details to the opposite party and officials over phone with regard to the health issues. The apex court judgment reported in SC 2776 of 2002 between Satwant Kaur Sandhu Vs. New India Assurance Company Ltd., has been referred in the written version. The complainant is called upon to prove that his wife fell sick and underwent treatment for Bilateral Nasal Polyposis in the year 2013 at Vikram Hospitals, Bangalore and at that time the opposite parties have paid the medical expenses incurred by her and subsequently the policy was also renewed from time to time by paying necessary premiums and lastly the policy was renewed for two years with effect from 21.11.2015 to 20.11.2017. While denying the averments in the complaint, the opposite parties stated that complainant did not disclose the Thyroid problem of his wife at the time of taking policy. He also did not disclose that his wife has history of Hypothyroidism since 10 years.

     3. The opposite party basing on the proposal made by complainant has issued the policy by capturing pre-existing basis as “No” and same was accepted by the complainant without any objection. During the process of renewal also the complainant did not disclose material facts of ill health problems of his wife and so, the opposite parties rightly repudiated the claim of the complainant. The opposite parties did not accept cashless facility of the complainant while his wife was taking treatment at Sri Ramachandra Hospital, Chennai. The opposite parties denies that the complainant voice was recorded during telephone conversation and the voice record is with them. The complainant has violated the terms and conditions of the policy hence the complainant is not entitled for any claim. The opposite parties would have reassessed the risk and would have decided whether to give policy or not. The well settled law in the field of insurance is that, every material fact must be disclosed at the time of taking policies by the insured. It is a contract of utmost good faith. Person who desires to have a policy must disclose fully all the particulars relating to preexisting health issues voluntarily. It is denied that the opposite parties indulged in unfair trade practice or committed deficiency of service as alleged by the complainant. Hence, it is prayed to dismiss the complaint.

           4. The complainant filed chief evidence affidavit as PW-I and got marked Ex:A1 to A17 whereas for the opposite parties one Aneesh Bhaskaram, S/o. Late M.V.Bhaskaran, working as Manager (Legal Claims) with the opposite party No.2 filed his filed his chief affidavit as RW-1 and got marked Ex:B1.

          5. Now the Point for consideration is:-

               Whether the opposite parties committed deficiency of service and unfair trade practice? If so, to what extent, the complainant is entitled for the reliefs claim in the complaint?

           6. Point:- In  the written arguments the complainant argued that, he availed Health Suraksha Policy, Silver Plan which is marked as Ex:A1 on 21.11.2009 to cover health insurance for himself and for  his family members and at the time of availing the policy he had disclosed all the information pertaining to the health issues of his family members and after satisfying with the information given by him, the policy was issued and subsequently his wife fell sick and had taken treatment for Bilateral Nasal Polyposis in the year 2013 at Vikram Hospitals, Bangalore and the opposite parties paid the medical expenditure amount basing on the medical records of Vikram Hospital. It is further argued that he renewed the policy for a period of two years commencing from 21.11.2015 to 20.11.2017 and during that period, his wife again developed the same problem and was admitted in Sri. Ramachandra Medical Centre, Chennai on 19.08.2016 and surgery was conducted namely Functional Endoscopy Sinus Surgery with Polypectomy on General Anesthesia on 20.08.2016 and bill was raised for Rs.1,91,670/-. Ex:B4 is bunch of photo copies of prescriptions on different dates issued by Sri Ramachandra Medical Centre, Porur, Chennai dt:16.08.2016. Ex:A5 is bunch of photo copies of investigation reports on different dates issued by same hospital dt:16.08.2016. Ex:A6 is photo copy of discharge summary issued in favour of complaint’s wife B.Anitha issued by the same hospital dt: 22.08.2016. Ex:A7 is photo copy of inpatient bill details for an amount of Rs.81,903.44Ps issued by the same hospital in favour of B.Anitha. Ex:A8 is photo copy of medical pharmacy bill for an amount of Rs.2024.23 issued by the same hospital in favour of B.Anitha. Ex:A9 is photo copy of surgical pharmacy bill for an amount of Rs.2143.98 issued in favour of B.Anitha by the same hospital. Ex:A10 is of theatre pharmacy bill (Xerox copy) for an amount of Rs.10,567.89Ps issued by the same hospital in favour of B.Anitha. Ex:A11 is bunch of medical bills (Xerox Copies) for an amount of Rs.11,488/- issued by the same hospital in favour of B.Anitha. Ex:A12 is photo copies of bunch of receipts for an amount of Rs.85,268/- issued by the same hospital in favour of the B.Anitha. These documents are marked in order show that, the complainant’s wife underwent above said surgery in Sri Ramachandra Medical Centre, Chennai during August, 2016.

          7.   It is the contention of complainant counsel that, when the bills were presented, surprisingly opposite parties refused to reimburse medical bills as per terms and conditions of the Ex:A1 on the ground that the complainant suppressed the preexisting disease of his wife. It is the argument of complainant counsel that the repudiation of claim is not justify, since the opposite parties settled the previous claim of complainant with regard to the same treatment of his wife in 2013 when the previous policy was in force. In order to prove the said fact, the complainant has filed photo copy of discharge summary issued in favour of B. Anitha by Vikram Hospital Private Limited, Bangalore dt: 09.05.2013 which is marked as Ex:A14. In Ex:A14, it is clearly mentioned that, the patient was suffering from Bilateral Nasal Polyposis. The patient i.e. B.Anitha had undergone B/I Middle Meatal Antrostomy with Bilateral Fronto-Spheno-Ethmoidectomy under GA on 10.05.2013 and patient was discharged in stable condition. The counsel for complainant on the basis of Ex:A14 argued that, when there was no objection by the opposite party to reimburse the medical expenses incurred by him for the treatment of his wife in Vikram Hospital in 2013, there is no justification for the opposite party to repudiate the claim of the complainant when his wife again got admitted Sri Ramachandra Medical Centre for the same problem and incurred expenditure of Rs.1,91,670/- for the surgery.

           8. The counsel for the opposite parties filed Ex:B1 in order prove that, the complainant suppressed the preexisting disease of his wife and played fraud on the opposite parties and got health insurance. But as per documentary evidence, the opposite parties cannot not deny the fact that on the previous occasion they reimbursed the medical expenditure incurred by the complainant with regard to the treatment of his wife for the same problem in 2013 as per Ex:A14. The complainant stated that the opposite party authorities turned down his request to pay the claim amount under the policy. This fact was not disputed by opposite party in the written version. At Para No.4, the opposite parties stated that, the claim made by complainant was repudiated by the opposite parties for the reason of concealment of past medical history and not disclosing material fact by the complainant in the member form. As per Ex:A15 the complainant issued legal notice requesting to reimburse the medical expenses incurred by him and also demanded compensation of Rs.2,00,000/- each for deficiency of service and for undergoing mental agony respectively for which there was no response from opposite parties. Though complainant has not filed any repudiation letter, the admission of opposite parties in written version shows that they have repudiated the claim of the complainant.

            Hence we are unable to accept the contention of opposite parties that the complainant deliberately suppressed the Nasal disease of his wife and got the insurance renewed by playing fraud on opposite parties. Hence we are of the view that, the repudiation of claim by the opposite parties is not justified. Accordingly we allow this complaint.

          9. In the result,  complaint is allowed in part, directing the opposite parties to pay Rs.1,91,670/- (Rupees one lakh ninety one thousand six hundred and seventy only) with interest @ 9% p.a. from the date of the bill till realization. The opposite parties are further directed a sum of Rs.10,000/- (Rupees ten thousand only) towards compensation due to deficiency of service on their part and sum of Rs.3,000/- (Rupees three thousand only) towards litigation expenses.  The order shall be complied within eight (8) weeks failing which the compensation amount of Rs.10,000/- (Rupees ten thousand only) shall carry interest @ 9% p.a. from the date of this order till realization.

         Dictated to the stenographer, transcribed and typed by her, corrected and pronounced by me in the Open Forum this the 19^th day of December, 2019.

            Sd/-                                                                                                             Sd/-

   Lady Member                                                                                           President (FAC)

APPENDIX OF EVIDENCE

 

Witnesses Examined on behalf of Complainant/s.

 

PW-1: Sri B. Yeshaiah (Chief affidavit filed).

 

Witnesses Examined on behalf of Opposite PartY/S.

 

RW-1: Sri Aneesh Bhaskaram (Chief affidavit filed).

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT/s

 

Exhibits (Ex.A)	Description of Documents
	Photo copy of HEALTH CARD issued in favour of Smt B. Anitha W/o. Sri B. Yeshaiah with Ref No. 2952200900490701000 issued by the opposite parties for a period of 21.11.2015 to 20.11.2017.
	Self attested photo copy of HEALTH CARD issued in favour of Sri B. Yeshaiah with Ref No: 2952200900490702 issued by the opposite parties for a period commencing from 22.11.2017.
	Photo copy of Covering Letter along with the policy addressed to the complainant herein sent by the opposite parties. Dt: 13.11.2015.
	Bunch of photo copies of PRESCRIPTIONS on different dates issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai (Six in Number). Dt: 16.08.2016.
	Bunch of photo copies of INVESTIGATION REPORTS on different dates issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai (Seven in Number). Dt: 16.08.2016.
	Photo copy of DISCHARGE SUMMARY issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai (Four in Number). Dt: 22.08.2016.
	Photo copy of IN PATIENT BILL DETAIL for an amount of Rs.81,903.44 issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai. Admission Dt: 19.08.2016 Discharge Dt: 22.08.2016.
	Photo copy of MEDICAL PHARMACY BILL for an amount of Rs.2024.23 issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai.
	Photo copy of SURGICAL PHARMACY BILL for an amount of Rs.2143.98 issued in favour of smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai.
	Photo copy of THEATRE PHARMACY BILL for an amount of Rs. 10567.89 issued in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai.
	Photo copy of Bunch of MEDICAL BILLS for an amount of Rs.11,488/- issued in favour of Smt B. Anitha issued by issued by Sri Ramachandra Medical Centre, Porur, Chennai (Nine in Number).
	Photo copy of Bunch of RECEIPTS for an amount of Rs.85,268/- in favour of Smt B. Anitha issued by Sri Ramachandra Medical Centre, Porur, Chennai (Four in Number).
	Photo copy of Bunch of E-MAIL CORRESPONDENCES between the complainant and opposite parties (Four in Number).
	Photo copy of DISCHARGE SUMMARY issued in favour of Smt B. Anitha W/o. Sri B. Yeshaiah issued by Vikram Hospital Private Limited, Bengaluru. Admission Dt: 09.05.2013 Discharge Dt: 12.05.2013.
	Office copy of the REGISTERED LEGAL NOTICE Dt: 16.04.2018 sent to the opposite parties along with postal receipts 2 in number.
	Served Acknowledgement Card.  Dt: 02.05.2018.
	Self attested photo copy of the HDFC ERGO General Insurance Company Limited policy issued by the 2nd opposite party. Dt: 13.11.2015.

 

EXHIBITS MARKED ON BEHALF OF THE OPPOSITE PARTY/s

 

Exhibits (Ex.B)	Description of Documents
	Memo filed by the opposite party No.2 along with C.Ds 2 in Number.

 

                                       Sd/-

                                        President (FAC)

 

// TRUE COPY //

// BY ORDER //

 

 

 

Head Clerk/Sheristadar,

Dist. Consumer Forum-II, Tirupati.

 

Copies to:  1) The Complainant, 

                   2) The Opposite parties 1 and 2.