Complaint filed on: 09-08-2011
Disposed on: 15-05-2012
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.1532/2011
DATED THIS THE 15th MAY 2012
PRESENT
SRI.J.N.HAVANUR, PRESIDENT
SRI.GANGANARASAIAH, MEMBER
SMT.ANITA SHIVAKUMAR.K., MEMBER
Complainants: -
1. T.Sridhar S/o. Thimmappa,
2. Smt.Usha Rani w/o. T.Sridhar,
Aged about 41 years, Both resident of No.232/19, 4th main, 13th cross, Vyalikaval, (Between Rajesh Hotel and Vyalikaval Police Station) Bangalore-03
V/s
Opposite parties: -
1. The Manager,
ICICI Lombard Health Insurance
Also known as ICICI Lombard
Health Care, Having office at
“Zenith House” Keshavrao Khade
Marg. Mahalakshmi, Mumbai
2. The Manager,
ICICI Lombard Health Insurance
# 89, SVR complex 89,
Hosur Main Road, Madivala
Koramangala, Bangalore
ORDER
SRI.J.N.HAVANUR, PRESIDENT
This is a complaint filed by the complainant against the OPs, under section 12 of the CP Act, praying to pass an order, directing the OPs to pay damages of Rs.2,00,000=00 for wrongful unilateral termination of health care policy, and to pay Rs.1,00,000=00 towards the litigation expenses.
2. The brief facts of the complaint can be stated as under.
The complainant was admitted to Mediclaim policy of OP in the year 2006 and as on date, the policy was in vogue until 20-4-2011, and the policy numbers and details as under:
a. Policy no.4034/FNP/015924332/00/000
b. Policy no.40341/CHI/05646163/00/000
c. Policy no.4034/HIR/04133672/00/000
The insurance is regularly renewed with OP, the OP issued Mediclaim policy as stated above. The insurance coverage is upto Rs.2,00,000=00 PA. The complainant was admitted into the ICICI health care policy of Ops on 14-12-2006, the policy was renewed as and when it fell due without default. The complainant was diagnosed for renal failure and underwent dialysis for the first time in the year 2007 and on 1-9-2006 he never hospitalized or diagnosed at Apollo RM Hospital for dialysis as asserted by the OP in the termination letter. The record reveals that the OP is liable to make reimbursement of medical expenses met by the complainant vide policy clause no.3.3 of the OP, the OP has indulged in Reprobatory act. The complainant claimed reimbursement, expenses etc under the Mediclaim and the same was rejected by the OP on the ground that the complainant was suffering from pre existing disease and the same is contrary to the terms of policy and the policy was terminated on 20-4-2011. The OP has terminated the policy unilaterally without any authority when the matter was pending before the II Addl. Consumer Forum, Bangalore. The OP cannot indulge in such Reprobatory acts as such they are liable to honour the claim of the complainant. Under the policy, the Ops are liable to honour the commitments and meet the medical claims of the complainant from 14-12-2010. As per the policy even if there was any pre-existing disease as asserted by the Ops under the clause 3.1 and 3.3 of the terms and conditions of the policy, the Ops are bound to honour the claims made by the complainants, but to surprise of the complainants the Ops are making an attempt to terminate the policy unilaterally without any authority. The Ops had no authority to terminate the policy as per clause 1 of part-3 of the policy. The subject matter of the claim is pending before the II Addl. Consumer Forum, Bangalore and notice has been caused to Ops. So the present complaint is filed stating that the complainants are consumer and they are entitled for the medical reimbursement. So the complaint of the complainant be allowed and pass an order as prayed in the complaint.
3. After service of notice, the Ops have appeared through their counsel and filed version, contending inter-alia as under:
The policy was issued in favour of complainant’s family in respect of health care policy for the period from 14-12-2006 to 13-12-2008 and the liability of this OP if any is in accordance with the terms and conditions of the policy of policy. The complainant seeking compensation of Rs.3,00,000=00 and other relief is not maintainable either in law or on the facts. The complainant had obtained policy declaring him self in the proposal form stating that he is not suffering from any pre existing disease and under the policy of insurance all the pre existing disease have been excluded. The present treatment is taken for pre existing disease and hence the said diseases are excluded under the policy of insurance and hence the OP is not liable to pay any compensation under the policy of insurance issued. The discharge summary issued by the hospital authority clearly reveals that the complainant was suffering from the said disease prior to inception of the policy and for that he was on medication and the said fact has been admitted by the complainant. So the OP has rightly repudiated the claim of the complainant and the said repudiation has been challenged by the complainant herein before II Addl. Consumer Forum, Bangalore in complaint no.482/2011 and on hearing the same on merits, the district forum dismissed the complaint on merits. The complainant was suffering from the said disease for long time prior to inception of this policy and for that now he has taken treatment and hence as per the policy terms and conditions 3.1 all pre existing disease are not covered under the policy of insurance, and accordingly, the claim of the complainant is repudiated. So the complaint is not maintainable and as per the discharge summary issued by the hospital, the complainant has undergone treatment for renal failure and acute onset of dysonea grade IV associated with Orthoponea and PND due to earlier disease and the same is not covered as per the policy terms and conditions, the claim of the complainant is not payable. The discharge summary given by the hospital authority clearly discloses that the complainant was suffering from the said disease prior to inception of the policy and the same was not disclosed at the time of taking the policy and non discloser of the material facts amounts to fraud and hence the claim of the complainant is not payable. There is no deficiency of service on the part of this OP, since the OP acted as per the terms and condition of the policy. So it is prayed to reject the complaint with cost.
4. On the above 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, as per the policy even if there is any pre-existing diseases under the clause no.3.1 and 3.3 of terms conditions of the policy, the Ops are bound to honour their claim and the Ops are making an attempt to terminate the policy unilaterally without any authority.
2. If point no.1 is answered in affirmative, whether the complainant is entitled to claim the amount 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.2: For the following order
REASONS
6. So as to prove the case, Smt.Usha Rani who being the complainant no.2 has filed her affidavit by way of evidence, and produced 8 documents. On the other hand, one Jayant Inamdar, who being the Manager Legal working in OP Company has filed his affidavit and produced one order copy of the 2nd Addl. Consumer Forum, Bangalore. We have heard the arguments of both sides. We have gone through the oral and documentary evidence of both parties meticulously.
7. By reading the averments of the complaint of the complainant, version of the Ops and evidence of both parties scrupulously. It is an admitted fact between the parties that, the complainant has taken Mediclaim policy from OP bearing No.4034/FNP/01592432/00/000, No.40341/CHI/05646163/00/ 000, and No.4034/HIR/04133672/00/000 in the year 2006. That policy was renewed from time to time, the renewed policy number is 4034/HIR/04133672/00/000 and that policy was in force upto 14-12-2012. The 1st complainant was admitted to the hospital on 3-8-2007 and he was diagnosed for renal failure disease, diabetic retinopathy and hypertension, and the discharge summary was issued to the complainant, when the complainants made claim with the OP, their claim was rejected, on the ground that, the 1st complainant has dialysis on 1-9-2006 for pre existing disease. Now we have to verify the relevant documents, and also relevant terms and conditions of the policy to know whether the complainants are entitled to get relief as prayed in the complaint. The complainants have produced discharge summary issued by Narayana Hrudayalaya in the name of the complainant no.1. As per the said document, the complainant no.1 was admitted on 3-8-2007 and discharged on 7-8-2007 and the complainant was suffering due to sever renal failure, diabetes and Hypertension. The complainants have produced copies of ICICI Lombard Health Care Insurance policy issued in the name of the complainants for a period from 14-12-2006 to 13-12-2007, so also another copy of ICICI health care insurance policy is produced for a period from 14-12-2008 to 13-12-2009 issued in the name of the complainant. The complainants have produced one more copy of policy issued by the OPs in the name of the complainants for a period from 14-12-2011 to 13-12-2012. At this stage, it is relevant to cull out the important portion of clause no.3.3 of the policy condition for the sake of conditions as under:
“In case the above illness are not pre-existing at the commencement of this policy, then this exclusion shall cease to apply if the insured has taken a healthcare policy from the company without a break for a period of two consecutive years immediately preceding the period of insurance”
“In case the above illness are pre-existing at the commencement of this policy then this exclusion shall cease to apply if the insured has taken a healthcare policy from the company without a break for a period 4 consecutive years immediately preceding the period of insurance”.
8. If we read the discharge summary and policy condition no.3.3 conjointly, it is made clear that, the complainant no.1 has been suffering due to Diabetes mellitus and Hypertension since 3 years and is having sever renal failure and he took treatment for this disease in Narayana Hrudayalaya from 3-8-2007 to 7-8-2007, and all these diseases were not disclosed by the complainant at the time of renewal of the policy, and all diseases namely Diabetic, Hypertension and severe renal failure were pre-existing diseases for which the treatment was taken. As per the terms and conditions of the policy issued by the OPs, it is made vivid clear that any claim arising out of pre-existing illness is excluded from the scope of policy, subject to applicable terms and conditions, since the complainant has taken treatment in the hospital for pre-existing disease namely Diabetes, Hypertension and sever renal failure and these diseases have been excluded from the scope of the insurance policy. So the complainants are not entitled to claim any relief as prayed in the complaint. So, viewing the terms and conditions of the policy taken by the complainants and discharge summary issued by the hospital, we are inclined to come to an irresistable conclusion that what ever the treatment taken by the complainant no.1 was for pre-existing disease and the said ailments are excluded from the scope of the insurance policy, and accordingly the Ops have rightly repudiated the claim of the complainants. The Ops have produced one order copy of the 2nd Addl. Consumer Forum, Bangalore passed in the complaint no.482/2011 and that order copy goes to show that, the complaint was filed by the complainant against the OP and that complaint came to be dismissed as the policy does not cover pre-existing disease. When once health insurance policy has been taken by the complainant agreeing to terms and conditions of the policy, both the complainant and Ops shall act as per the terms and conditions of the policy. That apart no iota of documentary evidence is produced by the complainant to demonstrate before the forum that, the Ops are making attempts to cancel the health care policy without any authority. The material evidence in this regard is totally lacking on the part of the complainants. So, viewing the case of the complainants, on the back ground of terms and conditions of the health care policy taken by the complainant and discharge summary issued by the Narayana Hrudayalaya together with treatment taken by the complainant no.1 for a particular ailments or disease, we are of the considered opinion that, the complainants who come to forum seeking relief under section 12 of the CP Act have failed to prove this point by placing believable and trust worthy material evidence, and as such, we are declined to grant any relief to the complainants as prayed in the complaint. So in view of the discussion made hitherto, we answer this point in a negative.
9. In view of the negative finding on point no-1, the complainant is not entitled any relief as prayed in the complaint. So we answer this point in a negative. In the result, for the forgoing 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 15th day of May 2012.
MEMBER MEMBER PRESIDENT
