By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get reimbursement of the hospital bill.
2. Brief of the complaint:- The complainant is a valid policy holder of opposite parties Wide Policy No.P/18315/01/2015/001015 since 2012 onwards. While so on 14.05.2015 she was admitted at Baby Memorial Hospital, Calicut due to heart disease and angioplasty was done and discharged on 16.05.2015. Immediately after admission in the hospital the complainant contacted the opposite parties and intimated about the hospitalization. So as immediately after the discharge from the hospital complainant submitted claim form before opposite party in order to get reimbursement of the hospital bill. But this claim was rejected on the ground of “suppression of material facts” at the time of joining the policy. But complainant alleged that she was not aware of the pre-existing disease and she was never treated for any pre-existing disease. Complainant alleged that the repudiation of the claim by the opposite parties is clear case of deficiency of service. Hence filed this complaint to get reimbursement of the claim amount with cost and compensation.
3. On receipt of notice opposite party appeared and version filed stating that the complainant was admitted at Baby Memorial Hospital, Calicut on 14.05.2015 and was diagnosed with CAD, EVOLVED ASMI, DOUBLE VESSEL DISEASE, HYPERTENSION, IMPAIRED FASTING GLUCOSE for which Angioplasty was done and was discharged on 16.05.2015. Thereafter the complainant had submitted completed claim form with medical bills and lab reports to the opposite party. It is submitted that on scrutiny of the treatment records of the hospital, it was revealed that the complainant was having known case of hypertension since ten years. Hypertension and chest pain are closely related to cardiac ailment. Even though specific columns are provided in the proposal form to fill up the details of existing ailments, the complainant had not mentioned anything about the hypertension while submitting the proposal form. This amounts to willful suppression of material facts. Had this information regarding her hypertension since the last several years been given in the proposal form, the insurance company would have issued the policy to the complainant only after incorporating the necessary exclusions. So the claim was repudiated by the opposite party on the ground of suppression of material facts based on the available records and had informed the complainant on 30.06.2015. After the repudiation of the claim, the complainant had preferred a petition to the grievance cell of the opposite party for reconsidering the claim. After processing the petition, even though the policy obtained by the complainant by violating the conditions, this opposite party, on maintaining the customer relationship and for goodwill basis, decided to settle the claim on merits. In this case, from the treatment records, it is clear that the complainant is a known case of hypertension for 10 years which has not been declared in the proposal form. Even though the complainant may claim that the hypertension is not the direct cause of CAD it is definitely one of the pre-disposing factor for CAD. Despite this violation, with considering customer relationship and as a goodwill gesture, this opposite party had decided to settle the claim for an amount of Rs.1,54,964/- as per the terms and conditions in the policy. The complainant had accepted the offer of settlement and accordingly this opposite party had settled the claim vide DD No.561642 dated 27.01.2016 in full and final settlement of the claim. After accepting the claim amount without any objection this complaint was filed. Once the complainant has received the amount unconditionally and has also got the cheque encashed, she ceases to be consumer as per Consumer Protection Act 1986 privity of contract between parties if any, came to an end the amount the petitioner accepted the claim amount unconditionally and also got the cheque encashed. There is malafide intention on the part of complainant to file such a complaint and prayed to dismiss the complaint.
4. Complainant filed affidavit and examined as PW1. Ext.A1 to A5 documents were marked. Ext.A1 is the copy of the policy from 11.07.2012 to 10.07.2013. Ext.A2 is the copy of the policy from 13.07.2014 to 12.07.2015. Ext.A3 is the copy of policy from 28.07.2015 to 27.07.2016. Ext.A4 is the copy of Discharge summary. Ext.A5 is the copy of Claim Repudiation Letter dated 30.06.2015. Opposite party adduced evidence as OPW1. Ext.B1 to B5 documents were marked. Ext.B1 to B3 documents were confronted and marked through PW1. Ext.B1 is the copy of Proposal Form. Ext.B2 is the request submitted by opposite party dated 04.12.2015. Ext.B3 is the discharge summary given by the treating doctor. Ext.B4 is the Acknowledgment card. Ext.B5 is the Authorization letter.
5. On perusal of complaint, affidavit, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and Cost.
6. Point No.1:- Complainant's case is that opposite party repudiated her claim for reimbursement of hospital bill on the ground of pre-existing disease, but this complainant has not aware of the history of any pre-existing disease. Hence there is no suppression of material facts on the part of her at the time of taking the policy. This complainant was admitted in the hospital for angioplasty on 14.05.2015 and was discharged on 16.05.2015. There she spent an amount of Rs.1,63,822/- as treatment expenses being a valid insurance policy holder, she submitted claim form before opposite party to get reimbursement of the hospital bill but opposite parties repudiated the claim. After repudiation of the claim (Ext.A5) this complainant submitted a request to reconsider the claim before opposite party and finally on 22.01.2016 complainant filed this complaint before this Forum. Thereafter on 27.01.2016 she received a DD of Rs.1,54,964/- from the opposite party. After the receipt of claim amount this complainant proceeded with this complaint to get compensation for the sufferings caused to her due to the deficient act of opposite party.
7. Perusal of records produced by opposite party it appears that this complainant had past history of hyper tension since 10 years. But the complainant had not mentioned anything about it while submitting the proposal form. On perusal of second page of Ext.B1, complainant answered “NO” in all the columns in “Details of Health”. So the opposite party repudiated the claim on the ground of suppression of material facts based on the available records and informed the complainant on 30.06.2015 through Ext.A5. After the repudiation of the claim this complainant had preferred petition to grievance cell for reconsideration of the claim. Request to reconsider the claim was submitted by the complainant to the opposite party on 04.12.2015 (Ext.B2). In it complainant request to reconsider her claim and stated that separate bill for stent is not available and price but was included in the previous bill. Opposite party resisted the complainant relaying this Ext.B2 that only on 04.12.2015 the complainant submitted Ext.B2. Based on this document opposite party reconsidered the claim and sanctioned an amount of Rs.1,54,964/- to the complainant. This complainant was filed on 22.01.2016 and the date of 1st appearance of opposite party was on 22.02.2016, summons to opposite party despatched on 06.02.2016. In the meanwhile based on Ext.B2 request opposite parties reconsidered the claim and sanctioned an amount of Rs.1,54,964/- to the complainant. On 27.01.2016 the complainant received the claim amount by way of DD without any objection and encashed. Before getting notice from the Forum opposite parties settled the claim and complainant accepted the DD without any protest and proceeded with the matter till the end in order to get compensation from the opposite party.
8. On an overall evaluation of the pleadings and records we are of the opinion that the repudiation of the claim by opposite party was in for reasonable ground, even though they settled the claim before getting notice of this complaint in order to maintain customer relationship and good will. Here the complainant accepted the amount without protest as final settlement of the claim. Hence we cannot attribute any deficiency of service on the part of opposite party and the complainant is not entitled to get compensation from opposite parties. The Point No.1 is found accordingly.
8. Point No.2:- Since the Point No.1 is found against the complainant, No Order as to cost and compensation.
In the result, the complaint is dismissed. No Order as to Cost and Compensation.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 14th day of November 2016.
Date of Filing: 22.01.2016.
PRESIDENT :Sd/-
MEMBER :Sd/- MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Santhakumari. Housewife.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Junior Executive, Star Health, Trivandrum.
Exhibits for the complainant:
A1. Copy of Family Health Optima Insurance Policy schedule from 11.07.2012 to
10.07.2013.
A2. Copy of Family Health Optima Insurance Policy schedule from 13.07.2014 to
12.07.2015.
A3. Copy of Family Health Optima Insurance Policy schedule from 28.07.2015 to
27.07.2016.
A4. Copy of Discharge Summary.
A5. Copy of claim Repudiation Letter. Dt:30.06.2015.
Exhibits for the opposite parties:-
B1. Copy of Proposal Form. Dt:09.07.2012.
B2. Copy of Request Letter. Dt:04.12.2015.
B3. Copy of Discharge Summary.
B4. Acknowledgment Card.
B5. Authorization Letter. Dt:01.07.2016.
Sd/-
PRESIDENT, CDRF, WAYANAD.
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