Date of filing: 09.04.2014. Date of disposal: 31.12.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – II:
VIJAYAWADA, KRISHNA DISTRICT
Present: Smt N. Tripura Sundari, B. Com., B. L., President (FAC)
Sri S. Sreeram, B.Com., B.A., B.L., Member
Wednesday, the 31st day of December, 2014
C.C.No.94 of 2014
Between:
Kanneganti Bhavani Prasad, S/o Gopi Chand, Hindu, Aged about 39 years, Business, R/o.D.No.23-20-2B, Subba Rao Street, Satyanarayanapuram, Vijayawada.
…..Complainant.
And
1. The Branch Manager, M/s Vidal Health TPA Pvt., Ltd., Dwaraka Nagar Main Road,Visakhapatnam – 530 016.
2. The Divisional Manager, United India Insurance Co., Ltd., Patamata, Vijayawada–10.
.. … Opposite parties.
This complaint coming on before the Forum for final hearing on 16.12.2014, in the presence of Sri M. Koti Nagaiah, advocate for complainant; Sri N.V.R. Krishna Kumar, advocate for opposite parties; and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Sri S. Sreeram)
This is a complaint filed by the complainant under Sec.12 of Consumer Protection Act against the opposite parties 1 and 2 directing them to pay Rs.2,32,000/- along with interest at the rate of 36% p.a. from 8-1-2014 till the date of payment, to pay Rs.1,000/- towards costs of demand legal notice, to pay Rs.1 lakh towards compensation, Rs.10,000/- towards Advocate fee and for other reliefs.
1. The brief averments of the complaint are as follows:
The complainant is the policy holder of the 2nd opposite party and obtained medical policy card No.VIZ-UI-00000-000-0026912-A and the policy No.151000/48/13/06/00001476, which is valid from 28-12-2013 to 27-12-2014. While so, the complainant suffered from chest pain and underwent coronary angiogram on 8-1-2014 and he also underwent PTCA + gtants to EESXI to ZAD1 (EESX1) to LCX and POBA to RCA (PDA) on 11-1-2014 in Aayush Hospital, Vijayawada and intimated the same to the opposite parties on 27-1-2014 along with original bills and discharge summary for settlement of claim. The complainant in total incurred Rs.2,32,000/- for the surgery. But the 2nd opposite party has repudiated the said claim without bonafide grounds. The repudiation of claim is not valid and the complainant is not a smoker and alcoholic as alleged by opposite parties. The acts of opposite parties 1 and 2 comes under the purview of deficiency of service and the complainant has suffered a lot. The complainant got issued legal notice dt.28-3-2014 to the opposite parties demanding to settle the claim. The opposite parties received the said notice, but of no use. Hence, the complaint.
2. After registering the complaint, notices were sent to the opposite parties 1 and 2. The 2nd opposite party filed its version, which was adopted by the 1st opposite party. The 2nd opposite party while admitting the policy contended that the complainant has suppressed the material facts and got filed the present complaint and that the contract of insurance is based on good faith, but the complainant has not disclosed the real facts and suppressed the same in the proposal form. It is further contended that on the scrutiny of medi claim records of complainant, it is observed that the complainant was a known case of smoker and alcoholic, but on receipt of documents, it was given that the patient is not a smoker and alcoholic. The complainant has managed the hospital authorities and suppressed the material facts. It is further contended that the complainant was having pre-existing ailment and further undergone medical treatment. It is further contended that the alleged medical expenditure to a tune of Rs.2,32,000/- is not genuine. It is further contended that the 2nd opposite party repudiated the claim on bonafide grounds and that there is no deficiency in service on its part and prayed to dismiss the complaint.
3. The complainant filed his chief affidavit reiterating the material averments of the complaint and got marked Ex.A1 to A13 on his behalf. The Deputy Manager of 2nd opposite party filed affidavit as R.W.1 and got marked Ex.B1 to B4 on its behalf and also got examined R.W.2 and 3 on its behalf and got marked Ex.X1 and X2.
4. Heard both sides. Perused the written arguments submitted on behalf of complainant and on behalf of opposite parties. The learned counsel for complainant submitted arguments reiterating the contents of complaint, whereas the learned counsel for opposite parties 1 and 2 submitted arguments reiterating the contents of version.
5. Now the points that stood for consideration are
- Whether there is any deficiency of service on the part of opposite parties 1 and 2 in repudiating the claim of complainant?
- If so, whether the complainant is entitled for any relief?
- To what extent?
Point Nos.1 and 2:
6. The undisputed facts in this case are that the complainant obtained Family Medicare Policy for himself and his family from the 2nd opposite party vide policy No.151000/48/13/06/00001476, which is valid from 28-12-2013 to 27-12-2014 by paying necessary premium. Ex.A2 policy schedule discloses the said fact. Ex.A2 further discloses that the sum assured is Rs.3,00,000/-. In this regard, the opposite parties 1 and 2 also issued a card No.VIZ-UI-00000-000-0026912-A in the name of complainant under Ex.A1. The main grievance of the complainant is that, while the said policy was in existence, he suffered from chest pain and underwent coronary angiogram on 8-1-2014 and also underwent PTCA+ gtants on 11-1-2014 at Ayush Hospital, Vijayawada and spent Rs.2,32,000/- for treatment and that he submitted the claim form under Ex.A3 for settlement of said amount, which was acknowledged by 1st opposite party under Ex.A4. But the opposite party No.2 repudiated the claim under Ex.A10 without any bonafide grounds. The complainant got issued legal notice to the opp.partis under Ex.A11 and the same were received by the opposite parties 1 and under Ex.A12 and A13 postal acknowledgments.
7. As seen from the Ex.A10 repudiation letter, the ground for repudiation is that “the complainant during the pre-auth request, it was given that the patient was a known case of smoker and alcoholic, but on receipt of documents, it was given tat the patient is not a smoker and alcoholic and as there is discrepancies in documents and cash less is rejected as cashless denied as patient is known alcoholic, smoker”. In this case, the opposite parties are solely relying on Ex.B4 which is initial assessment issued by Ayush Hospitals. Perusal of Ex.B4 under the head “History of past illness” discloses that the patient is “Smoker = 6 years and alcoholic – occasional”. Further to substantiate their contention, the opposite parties examined R.W.2 and R.w.3 who are doctors at Ayush Hospital, Vijayawada through whom Ex.X1 and X2 are marked. Ex.X1 is request for cashless hospitalization for medical insurance policy and Ex.X2 is the entire case sheet of complainant.
8. Perusal of Ex.X2 discloses that the complainant joined in the hospital on 7-1-2014 and at the time of joining, the doctors recorded the history of past illness as stated above. Further in the head of personal history also, it is mentioned as – Alcohol – occasional and Tobbaco – smoking. But perusal of Ex.A6 discharge summary issued by Ayush Hosptial which is also part of document in Ex.X2 discloses that the patient is neither a diabetic nor hypertensive. He is not a smoker and not an alcoholic. Admittedly there are discrepancies in the documents Ex.B4 and Ex.A6/Ex.X2. But perusal of said document discloses that the facts mentioned in Ex.B4 are disclosed by the friend of complainant who accompanied the complainant at the time of his joining in the hospital. But the facts mentioned in Ex.A6 discharge summary are clinical summary disclosed by the doctors. As such reliance can be placed on the facts disclosed by the doctors only. In this regard, the contention of the opposite parties is that the complainant managed the hospital authorities. But the said contention cannot be accepted because at the time of discharge, the complainant may not have knowledge that the opposite parties 1 and 2 will repudiate the claim basing on the discrepancies in the documents. Though the opposite parties examined R.W.2 and 3, they could not elicit anything about the discrepancies in the documents. They stated about the contents in the documents. The opposite parties further not elicited from the R.W.2 and 3 that whether the complainant is smoker and alcoholic and due to that only, he suffered from chest pain and under went angiogram. In these circumstances, we have not find any discrepancies in the documents and we would like to rely on the discharge summary under Ex.A6 only which is an authenticated document issued by the doctors after clinical examination and hold that the complainant has not suppressed any material fact at the time of proposal form.
9. Further the complainant filed Ex.A9 bunch of bills in support of his claim of Rs.2,32,000/-. But the said bills are only advanced receipts. But on perusal of Ex.X2, which contains the final bill of Rs.2,27,000/-. As such the complainant is entitled for the said amount. Further perusal of Ex.A5 medical opinion sheet issued by the doctor of 1st opposite party also discloses that the claim can be settled. But in spite of that the repudiation of claim by opposite parties on the flimsy ground that there is discrepancy in the documents is nothing but deficiency in service on the part of opposite parties 1 and 2. Accordingly these points are answered.
10. The opposite parties 1 and 2 in support of their contention relied on the following decisions:
2013 (1) CPR 278 NC between Gian Singh and others Vs. LIC of India, Rohtak and others, wherein it was held that;
“Commission rightly dismissed complaint on account of false declaration about his habits and health”
In the above case, the life assured was addicted to drug (Opium) for last 12 months and admitted in institue and at the time of proposal, though he is having knowledge about the same, not disclosed. But in the case on hand., the past history of life assured was disclosed by the friend of complainant who accompanied him. Further on clinical examination by doctors, they opined that the life assured is not smoker and not alcoholic. As such the said decision is not applicable to the case on hand.
So far as 2nd decision is concerned in 2013 (3) CPR 186 NC between Rajesh Sarma Vs.LIC of India, wherein it was held that “contract of insurance is based on doctrine of utmost good faith”. Admittedly the contract of insurance is based on doctrine of utmost good faith and the life assured has to disclose real and correct facts with regard to past illness or treatments taken by him. But in the case on hand, as stated supra, the past history was disclosed by the friend of complainant.
11. The complainant also in support of his contention relied on the decisions of Hon'ble National Commission reported in 2001(3) CPR 121, wherein it was held that
“Unauthenticated record cannot be relied upon by the company in support of its contention that insured complainant suppressed material facts in the proposal”
The said decision is squarely applicable to the case on hand since the opposite parties repudiated the claim basing on the Ex.B4 initial assessment sheet, which contains the facts disclosed by the friend of complainant and which is unauthenticated document. But the discharge summary under Ex.A6 is issued by doctors which is an authenticated document.
Point No.3:
12. In the result, the complaint is allowed partly directing the opp.aprties to pay Rs.2,27,000/- (as per final bill contains in Ex.X2) to the complainant with interest at 9% p.a. from the date of claim form i.e. 27.1.2014 till realization besides payment of compensation of Rs.5,000/- and costs of Rs.1,000/-. Time for compliance is one month. The other claims of complainant shall stands dismissed.
Typewritten by Steno N. Hazarathaiah, corrected by me and pronounced by us in the open Forum, this the 31st day of December, 2014.
PRESIDENT (FAC) MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite party:
Kanneganti Bhavani Prasad – PW.1 Deputy Manger of 2nd OP - RW.1
(by affidavit) (By affidavit), Dr.K. Kishore Babu – RW.2, Dr.K. Purnachandra Rao
Rao–RW.3 are subjected to cross examine.
Documents marked
On behalf of the complainant:
Ex.A1 Photocopy of medicare card.
Ex.A2 Photocopy of family medicare policy.
Ex.A3 Photocopy of claim form.
Ex.A4 27.01.2014 Photocopy of claim acknowledgement.
Ex.A5 27.01.2014 Photocopy of medical opinion sheet.
Ex.A6 16.01.2014 Photocopy of discharge summary.
Ex.A7 08.01.2014 Photocopy of Coronary Angiogram test issued by Aayush hospitals.
Ex.A8 11.01.2014 Photocopy of Coronary Angioplasty report issued by Aayush hospitals.
Ex.A9 13.01.2014 Photocopy of pharmacy report.
Ex.A10 18.02.2014 Photocopy of letter issued by OP.2 to Divisional Manager, United India Insurance Company Ltd.
Ex.A11 28.03.2014 Copy of legal notice got issued by complainant to Ops.
Ex.A12 Postal acknowledgement.
Ex.A13 Postal acknowledgement.
On behalf of the opposite parties:
Ex.B1 Photocopy of health insurance policy proposal form.
Ex.B2 18.02.2014 Photocopy of letter issued by OP.2 to Divisional Manager, United India Insurance Company Ltd.
Ex.B3 Photocopy of family medicare policy.
Ex.B4 Photocopy of initial assessment issued by Aayush hopsitals.
Ex.X1 Photocopy of request for cashless hospitalisation for medical insurance policy.
Ex.X2 Original admission record issued by Aayush hospitals.
PRESIDENT (FAC).
