Complaint filed on: 15-10-2011
Disposed on: 21-05-2012
BEFORE THE BANGALORE IV ADDITIONAL DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM,
BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052
C.C.No.1888/2011
DATED THIS THE 21st MAY 2012
PRESENT
SRI.J.N.HAVANUR, PRESIDENT
SMT.ANITA SHIVAKUMAR.K., MEMBER
Complainant: -
Sri.Arul Prakash.A.P.,
S/o. Narayan,
Aged about 54 years,
No.6, 6th cross, 10th main,
Maruthinagar, Malleshpalya,
Bangalore - 75
V/s
Opposite parties: -
1. The Manager,
The Health Administration team,
Bajaj Allianz Insurance Company
Ltd, 2nd floor, Bajaj Fineserv
Building, Survey no.208/B-1,
Behind Weikfield IT park,
Off nagar road, Viman nagar,
Pune-14
2. The Manager,
Bajaj Allianz General Insurance
Company Ltd,
Regd. Office, GE plaza,
Airport road, Yerwada,
Pune-06
3. The Manager,
Bajaj Allianz General Insurance
Company Ltd,
No.31, TBR tower, JC Road,
New Mission Road,
Adjacent to Jain College,
Bangalore - 27
ORDER
SRI.J.N.HAVANUR, PRESIDENT
This is a complaint filed by the complainant against the OPs, under section 12 of the Consumer Protection Act, 1986, praying to pass an order, directing the OP to reimburse the medical claim of Rs.38,281.27 covered under the medical claim, to pay a sum of Rs.1,00,000=00 towards the loss, injury and damage, to pay a sum of Rs.1,00,000=00 towards damages for mental agony, and to pay a sum of Rs.10,000=00 towards costs of the present case in the interest of justice and equity.
2. The brief facts of the complaint can be stated as under.
The complainant is a Mediclaim policyholder under the Ops vide medical claim of policy no.OG-10-1721-6003-00000001 and under the said policy, the complainant was covered and protected by the Ops in event of his hospitalization. On 7-3-2010, the complainant was admitted as in patient at Chinmaya Mission hospital, Bangalore due to health problem and he was treated for the accelerated hypertension with left Hemi paresis, and after he was discharged from the hospital on 11-3-2010, he paid all medical expenses, and after his discharge from the hospital, he also paid the medical expenses for further treatment. After discharge from the hospital, the complainant approached the Ops and requested for the re-imbursement of medical expenses and he was instructed by the Ops to submit the copies of indoor case papers for hospitalization in Chinmaya Mission Hospital, Bangalore. Thereafter, the complainant sent the indoor case papers like discharge summary, indoor case patient and clarification from treating doctor to the OP along with covering letter dated 26-10-2010 by RPAD and the OP have received the same. On 29-11-2010 the complainant received intimation from the OP no.1 stating that after initial scrutiny they found the copies of indoor case papers for hospitalization in Chinmaya Mission Hospital from 7-3-2010 to 11-03-2010 are missing. The complainant got surprised and shocked after receiving the letter and however he decided to send the required documents again and on 16-12-2010 the complainant replied to the letter dated 29-11-2010 intimating the OP that he has already sent the documents, again he sent the indoor case papers to the Ops along with covering letter by RPAD and the Ops received the same. On 2-2-2011 the complainant received intimation through letter dated 12-1-2011 from the 1st OP with the same earlier statement that after initial scrutiny they found copies of indoor case papers for hospitalization in Chinmaya Mission Hospital are missing. This was same reason mentioned in their earlier letter the complainant was surprised and shocked after receiving the letter. Thereafter, he made phone calls to the Ops and informed that he has sent all the documents and the office executives of Ops who attended the call of the complainant assured him that his claim for reimbursement is under process and would be settled soon. That on 9-2-2011 the complainant received a phone call from the office of the OP no.1 that office has received all the required documents submitted by him. Since the complainant has lost faith and doubting the credibility of the Ops towards settling his demand for reimbursement of medical expenses has finally decided to send legal notice and accordingly the complainant sent legal notice to OP no.1 and 2 on 21-2-2011 demanding for reimbursement of medical claim of Rs.38,281.27, and to pay Rs.1,00,000=00 towards the loss, injury and damage within 15 days from the date of receipt of the legal notice. The notice sent by the complainant was duly served on the Ops, the 3rd OP gave its reply dated 5-5-2011 repudiating the claim made in the legal notice, the Ops failed to discharge their obligations in terms of the guarantee given to the complainant. The Ops have acted in most negligent manner while dealing with the request of the complainant and due to the act and attitude of the Ops, the complainant was humiliated and embarrassed and hence liable for compensation. So the present complaint is filed.
3. After service of notices, the OPs have appeared through their counsel and filed version, contending inter-alia as under:
The complaint is not maintainable either in law or on facts, the complainant by not disclosing the material facts has breached the fundamental concept of the contract of insurance, this complaint is liable to be dismissed. The contents of the complaint are bereft of the exact facts and the complainant has not approached this forum with clean hands. The complainant had been admitted to Chinmaya Mission Hospital, Indira nagar, Bangalore for accelerated hyper tension with left hemisparesis and the complainant dully filled in a claim form and submitted to Ops on 22-3-2010 for reimbursement of medical bills that were received by the Ops on 26-3-2010. The OPs immediately on 29-3-2010 requested the complainant seeking medical certificate mentioning the duration of Hyper tension from the doctor treating the complainant along with the breakup of the medicines mentioned in the final bill. As the Ops did not receive any reply from the complainant a reminder letter was sent to the complainant which was replied by the complainant wherein only the breakup of medical bills were received by the Ops. Subsequently the Ops repudiated the claim on 20-5-2010 for the reasons that the complainant was suffering from Hypertension since 10 years and material facts were suppressed in the proposal form while availing the health insurance from the Ops. The complainant in an afterthought on 22-6-2010 requested the hospital authorities to issue a corrigendum that the complainant was suffering from hypertension since 10 months and not 10 years and he was wrongly mentioned in the discharge summary earlier. The complainant reissued letter dated 26-10-2010 for reconsideration of the claim by annexing an overwritten discharge summary wherein it has been over written as 1 year 4 months. The Ops on many occasions requested the complainant to submit the indoor case papers and even on 29-11-2010 when the Ops requested the complainant to submit the indoor case papers the complainant replied that the indoor case papers were already submitted, as per the exclusions and declaration in the health insurance policy the complainant ought to have disclosed the pre existence of hypertension. The question of reimbursement of medical expenses is governed by the terms and conditions and exclusion of the policy. If all the conditions, terms and exclusion are satisfied then the claim becomes payable. The complainant got issued the Ops with a legal notice and the same was replied with clarification. As per the conditions, terms and exclusion under the policy were breached the claim fell outside the scope of the policy. So the Ops repudiated the claim of the complainant as there was concealment of material facts and non production of indoor case paper by the complainant. The Ops were constrained to repudiate the policy. Repudiation of the claim by the Ops was done only after applying their mind and through investigation and as such it cannot be said to be unfair or unjust. There is no deficiency of service rendered to the complainant. The Ops are liable to pay a sum of Rs.38,281.27 to the complainant along with Rs.1,00,000=00 towards loss and damage, and Rs.1,00,000=00 towards damages for mental agony and cost. Hence, it is prayed to dismiss the complaint of the complainant.
4. So from the averments of the complaint of the complainant and objection of the OPs, the following points arise for our consideration.
1. Whether the complainant proves that, the Ops did not take any effective steps to settle his legal demand for reimbursement and they are liable for breach of contract and there is deficiency in service on the part of the Ops and they are liable to compensate to him for loss and injury?
2. If point no.1 is answered in favour of the complainant, whether the complainant is entitled to claim the relief as prayed in the complaint.
3. What order?
5. Our findings on the above points are;
Point no.1: In the Negative
Point no.2: In the Negative
Point no.3: For the following order
REASONS
6. So as to prove the case, the complainant has filed his affidavit by way of evidence, and produced 17 documents with list. On the other hand, one Shankaraiah has filed his affidavit on behalf of the OPs. We have heard the arguments of both sides. We have gone through the oral and documentary evidence of both parties meticulously.
7. One Arul Prakash, who being the complainant has stated in his affidavit that, he is a Mediclaim policyholder of the Ops and under the said policy he was covered and protected by the Ops in event of his hospitalization. On 7-3-2010, he was admitted as in patient at Chinmaya Mission hospital, Bangalore due to health problem and he was treated for the accelerated hypertension with left Hemi paresis, and after he was discharged from the hospital on 11-3-2010, he also paid all the medical expenses from his pocket, and after discharge from the hospital, he approached the Ops for the re-imbursement of medical expenses, and he was instructed by the Ops to submit the copies of indoor case papers for hospitalization, and on 26-10-2010 he sent the indoor case papers like discharge summary, indoor case patient and clarification from treating doctor to the OP along with covering letter dated 26-10-2010 by RPAD and the OP have received the same. On 29-11-2010, he received intimation from the OP no.1 stating that after initial scrutiny they found the copies of indoor case papers for hospitalization from 7-3-2010 to 11-03-2010 issued by Chinmaya Mission Hospital are missing, he got surprised and decided to send the required documents, again he sent the indoor case papers like discharge summary, indoor case patient and clarification along with covering letter from treating doctor, and the Ops received the same, and again on 12-1-2011 he received intimation letter from OP no.1 with the same earlier statement and thereafter, he made phone calls to the office of the Ops and informed that he sent all the documents as demanded by him. The office executives of Ops assured him that his claim is under process and it will be settled soon. On 9-2-2011, he received a phone call from the office of the OP no.1 that office has received all the required documents and nothing is pending. Since he has lost faith and doubting the credibility of the Ops, so he decided to send legal notice to the Ops and accordingly, on 21-2-2011 he sent legal notice to the Ops, it was sent to them, the 3rd OP gave its reply, he submitted all the documents to the OP on two occasions, the Ops did not take any effective and positive steps to settle his legal demand for reimbursement. The Ops failed to discharge their obligations in terms of the guarantee given to him. The Ops have acted in most negligent manner and due to the act and attitude of the Ops, he was humiliated and embarrassed and he liable to be compensated. Hence, the present complaint is filed praying to pass an order, directing Ops to reimburse the medical claim of Rs.38,281.27, to pay a sum Rs.1,00,000=00 towards the loss and injury and damage, to pay a sum Rs.1,00,000=00 towards mental agony and to pay a sum of Rs.10,000=00 towards the costs. Hence the order to be passed as prayed for.
8. By reading the averments of complaint and evidence of the complainant as mentioned above, it is made explicitly clear that, the complainant has tendered his evidence in accordance with the averments of the complaint. Let us have a look at the relevant documents of the complainant to know whether the oral testimony of the complainant is fortified by the documentary evidence or not. The document no.1 is the copy of Generic Contingency Policy Schedule issued by the OPs in the name of the complainant, and date of policy was 4-9-2009 and the said policy was expired on 30-8-2010 and sum assured was Rs.2,00,000=00. The document no.2 is the copy of Individual personal accident policy issued by the OP. The document no.3 is the copy Health guard policy document of Ops. The document no.4 is the copy letter of the complainant issued to the OPs requesting to settle his claim earlier. The next two documents are the copies of postal acknowledgment cards. The document no.7 is the copy of letter dated 16-12-2010 issued to the OPs by the complainant stating that, he has already submitted the discharged summary; however, he is enclosing herewith one more copy of the discharged summary. The document no.8 is the copy of letter issued by the OP in the name of the complainant dated 12-1-2011 stating that the discharge summary, indoor case papers, clarification from treated doctors are mandatory to decide on the admissibility of a claim and the claim may be closed without payment in case, the same are not available. The document no.9 is the copy of legal notice dated 21-2-2011 issued to the OP by the advocate of the complainant stating that, even though the complainant has submitted all the documents on two occasions, the OPs are not taking any effective and positive steps to settle his legal demand for reimbursement, the Ops are liable to reimburse the medical claim of Rs.38,281.27, to pay a sum of Rs.1,00,000=00 towards the loss, injury along with cost of Rs.1,00,000=00. The document no.10 is the copy of reply given by the OP to advocate of the complainant dated 5-4-2011 stating that the complainant was suffering from hypertension since 10 years, but the material facts was suppressed in the proposal form, hence the repudiation, since the complainant did not provide indoor case papers, hence the claim has been repudiated, so the Ops are not liable to reimburse the bill and not liable to pay any damages, and also cost. The document no.11 is the copy of letter dated 26-10-2010 issued by the complainant to the OPs stating that, he has produced herewith the revised discharge summary issued by the Hospital Authority to settle his claim, so requested to settle the claim and release the amount. The document no.12 is the copy of policy issued by the OPs for a period from 4-9-2009 to 30-8-2010. The document no.13 is the copy of letter dated 22-6-2010 issued by the complainant to the OPs stating that, he is suffering from hypertension for the past 10 months and not 10 years, it is wrongly recorded by the duty doctor as 10 years, hence the due correction is requested in discharge summary and same will be obtained soon and he has not hidden any material information during inception of his first policy, and one receipt copy is produced by the complainant which is issued by the OPs for having received Rs.8,250-00 on 25-8-2010. The next two documents are the copies of two postal acknowledgement cards issued in the name of the OPs by the complainant. The document no.17 is the copy of letter dated 22-6-2010 written by the complainant in the name of the Medical Director, Chinmaya Mission Hospital, Bangalore requesting to issue fresh discharge summary after the due correction of mistake committed by his staff. The document no.18 is the copy of repudiation letter given by the OPs in the name of the complainant stating that, the complainant is suffering due to hypertension since 10 years which is prior to the inception of the policy date. The document no.19 is the copy of discharge summary issued by the Chinmaya Mission Hospital, Bangalore stating in the past history column as known case of hypertension since 1 years and 4 months, on treatment and along with the said document, one certificate of Dr.C.S.Nagaraju is produced stating that, the complainant is known patient of hypertension since 1 year 4 months and he is taking treatment with him. Dr.C.S.Nagaraju who issued certificate is private doctor and he is not working doctor in the Chinmaya Mission Hospital, Bangalore. The document no.20 is the copy of discharge summary issued by the Chinmaya Mission Hospital, Bangalore wherein in the past history column, it is written as known case of hypertension since 10 year and it is corrected and over written as one year, on treatment, and after making correction, small signature is put by mentioning date as 11/3/2010. In the said discharge summary, it is not stated no where that through mistake it was written as 10 years and it is corrected one year etc. The entire discharge summary is silent on this vital aspect, for the reasons best known to the complainant. The remaining documents of the complainant are copies of scanning report, Echocardiography report, ECG report and some radio image graphics reports and one receipt issued by Dr.C.S.Nagaraju and copies of medical bills.
9. On making careful scrutiny of documents of the complainant, it is no doubt true that, the complainant has produced two copies of discharge summary issued by the Chinmaya Mission Hospital, Bangalore, and in one of the discharge summary in the past history column, it is written as known case of hypertension since one year and four months and in the another discharge summary in the past history column, it is written as known case of hypertension since 10 years, it was written first and then made correction as one years and put signature of by somebody by mentioning date as 11-3-2010. It is worthy to be noted that, no wherein any of the discharge summary of Chinmaya Mission Hospital, Bangalore, it is clarified by the hospital authority stating that, through mistake it was written as 10 years with regard to Hypertension problem, instead of one year, and it is corrected accordingly as one year etc. No explanation or any endorsement is made by the concerned doctor who issued the discharge summary. We do not find any consistence between these two discharge summary produced by the complainant. In the absence of explanation by Chinmaya Mission Hospital, it is unsafe and hazard to hold on the basis of these two copies of discharge summary issued by the Chinmaya Mission Hospital that, the complainant is suffering due to hypertension since one years or one year and four months only as stated in the complaint. When the complainant had submitted his claim to the OP claiming reimbursement of the hospital expenses, he must have submitted the discharge summary, wherein it is mentioned as known case of hypertension since 10 years and on making scrutiny of the papers submitted by the complainant, the Ops have rejected the claim of the complainant as he has not disclosed, the said problem prior to inception of the policy. So looking to the terms and conditions of the policy and two discharge summary produced by the complainant and repudiation of claim by the complainant, we are of the considered opinion that, the complainant who comes to this forum seeking relief has failed to prove his case with documentary evidence that, the hospital authorities who issued discharge summary for the first time, have committed mistake by mentioning as 10 years instead of one year or one year and four months and that mistake has been rectified by the hospital authority by giving their explanation particularly. Doctor by name Dr.C.S.Nagaraju who issued certificate produced by the complainant is not a working doctor in the Chinmaya Mission Hospital, and that doctor is a private doctor and his certificate issued in the name of the complainant cannot be taken into consideration. If the complainant had produced the discharge summary issued by the Chinmaya Hospital with explanation in respect of correction made this forum would have accepted the claim of the complainant and granted the relief. Since, the discharge summary produced by the complainant does not contain the explanation with regard to correction made in place of 10 years particularly two discharge summary copies produced by the complainant are unworthy of acceptance. The oral and documentary evidence of the complainant are in-sufficient to hold that the Ops are negligent and there is deficiency in service on the part of the Ops, and he is entitled to relief as prayed in the complaint. So on account of paucity of material evidence of the complainant, we declined to extend any helping hands to the complainant, even though, the complainant took the medical policy of OP and as such, we answer this point in a negative.
10. In view of the negative findings on point no.1, the complainant is not entitled to any relief as prayed in the complaint. So, we answer this point in a negative. In the result, for the foregoing reasons, we proceed to pass the following order.
ORDER
The complaint of the complainant is hereby dismissed. So, under the circumstance, parties shall bear their own cost.
Supply free copy of this order to both parties.
Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open forum on this the 21st day of May 2012.
MEMBER PRESIDENT
