BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.354/2018

DATED ON THIS THE 9^th May, 2019

      Present:  1) Sri. C.V.Maragoor

B.Com., L.L.M., - PRESIDENT   

                     2) Sri. Devakumar.M.C.           

                                        B.E., LLB., PGDCLP   - MEMBER

Sri C.V.MARAGOOR,

President

1.          This complaint is filed by Mr.V.N.Srinath S/o V.S.Nagarajan aged 43 years resident of Mysuru against the Branch Manager, M/s Star Health and Allied Insurance Company Limited, Mysuru to set aside the repudiation of claim dated 10.08.2018 and to direct the opposite party to make reimbursement of medical expenses of Rs.1,02,000/- with interest at the rate of 18% p.a. from 20^th July 2018, a sum of Rs.20,000/- towards mental agony, hardship etc., and Rs.10,000/- towards cost of the litigation.
2.           The complainant had taken policy in the name of his mother Smt.Saroja and paid premium amount to the Senior Citizen Red Carpet Health Insurance policy for Rs.3,00,000/.  The policy period is from 23.05.2018 to 22.05.2019.  The mother of the complainant was hale and healthy at the time of subscribing to the above medical policy i.e. in the month of May, 2018.
3.           It is further case of complainant that on 17.07.2018 the insured i.e. mother of complainant felt uneasiness, as such she was taken to JSS Hospital, Mysuru and thereafter she was shifted to BGS Apollo Hospital, Mysuru for further treatment.  The insured was admitted as in-patient and diagnosed as Type 2 respiratory failure, Acute on Chronic bronchitis, Obstructive Sleep Apnea PAH, Cor Pulmonale, diabetes mellitus and hypertension.  The insured took treatment from 17.07.2018 to 20.07.2018.  After admitting the insured as in-patient, the complainant had informed the opposite party to provide for cashless medical facility, but the opposite party refused the request.  Thereafter, the complainant has submitted claim to the opposite party for Rs.94,900/-, but the opposite party has repudiated the claim on false and frivolous ground.  Hence, this complaint.
4.           The opposite party after the service of notice put in appearance through its learned counsel and filed written version admitting that the complainant has proposed insurance policy in favour of his mother, a senior citizen health policy.  The opposite party has denied that it has repudiated the claim on false and frivolous ground.  The complainant has failed to furnish the report from the doctor who treated the insured and previous treatment records.  There is no deficiency in service or negligence on the part of opposite party.  The opposite party has repudiated the claim since the complainant has failed to furnish the required information. Apart from that the complainant is not entitled to claim amount since she has undergone treatment within twelve months from the date of taking health policy.
5.           The complainant filed his affidavit in lieu of evidence and produced some documents.  On behalf of opposite party, one Upendra Kumar Nayak S/o Shivaram Nayak, Branch Manager filed affidavit in lieu of evidence and produced relevant documents. 
6.          We heard the arguments advanced by learned counsel for both the sides in addition to written arguments submitted by them.  On perusal of the records, the points that would arise for determination are as under:-   

1. Whether the complainant proves that the act of opposite party in repudiating the claim of his mother amounts to deficiency in service?
2. Is complainant entitled to the relief sought for?
3. What order?

7.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the affirmative;

Point No.2 :- In the partly affirmative;

Point No.3 :- As per final order for the below

:: R E A S O N S ::

8.         Point Nos.1 to 3:- The learned counsel for the complainant submitted that the insured i.e. mother of complainant aged 74 years has suddenly had breathing trouble as such she was compelled to go to hospital for treatment.  The complainant has not suppressed pre-existing deceases of the insured.  As against this, the learned counsel for the opposite party urged that the complainant has failed to provide the necessary information with regard to previous treatment taken by the insured.  Further their submission that the insured has taken treatment within twelve months from the date of issue of health policy, as such she is not entitled for claim amount.
9.         The opposite party has not disputed subscribing or proposing Senior Citizen Red Carpet Health Insurance policy by the complainant in the name of his mother Smt.Saroja aged 74 years.  The opposite party has produced original proposal form submitted by the complainant.  The complainant has disclosed pre-existing illness i.e. B.P. and diabetes and insured has been taking medicine for the last ten years.  The opposite party even in the policy have mentioned the pre-existing diseases of the insured i.e. diabetes and hypertension and their complications.  The policy has been issued on 23.05.2018 and it covered the health risk of the insured for one year. 
10.      The complainant has produced discharge summary issued by B.G.S. Apollo Hospital, Mysuru.  According to discharge summary, the date of admission of insured was on 17.07.2018 and date of discharge on 20.07.2018.  The discharge summary indicates that the insured has Type 2 diabetes mellitus/hypertension presented with c/o cough with scanty whitish sputum since 15-20 days C/o breathlessness on exertion since 15 days.  History of drowsiness and increased sleepiness during day time since 20 days.  It is further recorded that Type 2 diabetes mellitus/Hypertension on treatment.  The doctor diagnosed Type 2 respiratory failure acute on chronic bronchitis, obstructive sleep apnea PAH, cor pulmonale diabetes mellitus and hypertension.  The complainant has disclosed the pre-existing diseases of diabetes mellitus and hyper tension of the insured for the last 10 years and she has been under medication.  The diagnosed made by the doctor i.e. Type 2 respiratory failure due to old age.  The opposite party has repudiated the claim for non-furnishing the information i.e. letter from the treating doctor with regard to exact duration of pulmonale, obstructive sleep previous history of similar complaints in the past and past hospitalization records, such as discharge summary and investigation reports.  In discharge summary, it is clearly mentioned that the insured has been suffering from the above problems for the last 15-20 days.  If the insured had similar problems earlier to 20 days, she would have disclosed before the doctor.  Therefore, the information sought by the opposite party is not new, but it is already in the discharge summary.  Therefore, repudiation of the claim made by the opposite party amounts to deficiency in service, since the insured has already disclosed pre-existing diseases in the proposal form as she has been under medication for the diabetes and hypertension for the last 10 years.
11.         The learned counsel for the opposite party highlighted the policy condition i.e. exclusion clause, the company shall not liable to make any payments under the policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of pre-existing disease as defined in the policy until 12 consecutive months of continuous coverage for elapsed since inception of the first policy with any independent insurer.  The above exclusion clause is nothing but an unfair trade practice.  If said exclusion clause is applied, the purpose of taking health policy for the first year will not help the insured or serve any purpose.  The insured has taken treatment for respiratory failure due to old age and it is not in connected with the pre-existing diseases of diabetes mellitus and hypertension.  Therefore, the opposite party is liable to pay medical expenses incurred by insured at BGS Apollo Hospital, Mysuru and JSS Hospital, Mysuru a total sum of Rs.1,02,000/- with interest at the rate of 10% p.a. from 20^th July 2018 till payment.  Apart from that the opposite party is liable to pay a sum of Rs.10,000/- for mental agony and sufferings and Rs.10,000/- towards litigation costs.  In the result, we  proceed to pass the following:-

:: O R D E R ::

1. The complaint filed by Sri V.N.Srinath, S/o V.S.Nagarajan is partly allowed directing the opposite party to pay a sum of Rs.1,02,000/- with interest at the rate of 10% p.a. from 20^th July 2018 till its payment.
2. In addition to that the opposite party is directed to pay Rs.20,000/- towards mental sufferings and costs of this litigation to the complainant within two months from the date of order.   Otherwise, it carries interest at the rate of 10% p.a. from the date of filing the complaint till payment.
3. Furnish the copy of the order to the complainant and opposite party at free of cost.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 9^th May, 2019)