Complaint filed on: 01.03.2016
Complaint Disposed on:07.07.2017
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.15/2016
DATED THIS THE 7th DAY OF JULY 2017
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
Hemaraju M.A,
S/o Late Annappa Shetty,
Aged about 51 years,
Presently R/at Near Govt.
Polytechnic, Rathnagiri Road,
Chikmagalur.
(By Sri/Smt. K.M.Abdul Jabbar, Advocate)
V/s
OPPONENT/S:
1.The Manager,
Indus Ind Bank,
Chikmagalur Branch,
M.G. Road, Chikmagalur.
2.M/s Religare Health Insurance
Company Limited, 14-2-104/31,
Shop No.31, 3rd floor, City light
Building, Balmatta Road,
Hampanakatta, Mangalore.
Also available at GYS Global
Plot No.A3,A4,A5 Sector-125,
Noida, Uttar Pradesh State-201301.
(OP No.1 By Sri/Smt. Udayanarayan, Advocate)
(OP No.2 By Sri/Smt. T.R.Harish, Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos.1 & 2 alleging deficiency in service in not settling the medical claim of the complainant. Hence, prays for direction against Op Nos.1 & 2 to settle the medical claim to the tune of Rs.2,50,000/- along with compensation of Rs.1,00,000/- for deficiency in service.
2. The brief facts of the complaint is that:
The complainant had obtained health insurance policy from Op No.2 through Op No.1 and the details are below:
a) Group Policy holder Name :Indus Ind Bank Limited
b) Group Policy No. :10087119
c) Certificate of Ins. No. :10211428
d) Plan Name :GroupCare(Scheme2IIB)
e) Cover Start Date :00:00 hrs 14 Feb-2015
f) Cover end Date :Midnight 13-Feb-2016
g) Premium Paid :Rs.7,606/-
h) Premium Payment mode :Single premium
Such being the case, on 02.06.2015 complainant admitted to Vikram Hospital, Yadavagiri, Mysore for Renal transplantation and after surgery he was discharged on 10.06.2015. During the surgery the wife of the complainant Smt.Sujatha donated her kidney after obtaining the due permission from competent authority and complainant spent nearly Rs.5,00,000/- towards transplantation of the kidney. There afterwards the complainant claimed medical reimbursement as he is the policy holder to the policy issued by Op No.2. The claim made by complainant was repudiated by citing the reason that, “CARE 6-1 FOR NON DISCLOSURE OF HYPERTENSION SINCE 15 YEARS AND CKD SINCE SEPTEMBER 2014”, but the repudiation made by Op No.2 on the above grounds is illegal and unjust. The complainant duly filled the claim application along with required documents and he was replied all the queries made by Op No.2, even then the Op No.2 had repudiated the claim on false and untenable grounds. Further, Op No.2 in his repudiation has contended that the complainant was suffering from hypertension since 15 years and CKD since September 2014 in order to avoid the repayment of medical claim. As per the policy the complainant is eligible for reimbursement of Rs.2,50,000/-, the said amount was not given by Op No.2. Hence, Op No.1 and 2 rendered deficiency in service.
Therefore, complainant filed this complaint and prays for direction against Op No.1 and 2 to pay the eligible reimbursement of Rs.2,50,000/- along with compensation of Rs.1,00,000/- for deficiency in service as prayed above.
3. After service of notice Op No.1 and 2 appeared through their counsel and filed version.
4. Op No.1 in his version has contended that, the 2nd Op had created group care (scheme 2-IIB) for their customers and this Op is a master policy holder. The master policy document forms part and parcel of the policy terms and the 2nd Op had issued a policy based on the information provided by policy holder in the proposal form and the said information forms basis for issuance of the insurance policy. This Op is only responsible for providing details about the policy, collecting documents/premium amount and submitting to the Op No.2 (Insurance Policy). This Op’s responsibility ends once the policy is issued and there after the group policy holders are at free will to go through the policy terms and are entitled to return the policy within 15 days from the date of receipt of the policy, if the policy terms are not agreeable to them or the terms are different to that have been explained by this Op (Master policy holder). In this instant case the complainant had not raised any grievances during free look period and had accepted the policy terms and agreed to abide policy terms and conditions and after lapse of free look period this Op does not have any role in the claims that will be lodged by insured and this Op do not know about the claim made by complainant and also repudiation of the Op No.2. The complainant made this Op as unnecessary party to this complaint and there is no cause of action arose against this Op and also no deficiency in service on the part of this Op in issuing the policy to the complainant. Hence, prays for dismissal of the complaint.
5. Op No.2 in his version has contended that, they have issued a group policy bearing No.10087119 (group care) (scheme -2 IIB) with certificate of insurance No.10211428 for the period from 14.02.2015 to 13.02.2016 and the liability of this Op is subject to terms, conditions, exception and limitation of the policy. The sum insured under the policy is Rs.2,50,000/- only.
The complainant made a reimbursement claim on 18.08.2015 for medical expenses with respect to the treatment taken by complainant from 02.06.2015 to 10.06.2015. On perusal of the claim documents received from complainant this Op observed that the complainant is suffering from Hypertension past 15 years and Chronic Kidney Disease since September 2014 which is before the issuance of the policy. Considering the pre existing disease the claim of the complainant was rejected on 12.10.2015 as per the policy terms and conditions and on the basis of non-disclosure of the said ailments as under clause 9 of the policy, which reads as follows:
“Disclosure to information Norm
If any untrue or incorrect statement are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld in the proposal form or accompanying documents or if a claim is fraudulently made or any fraudulent means or device is used by the insured member or any one acting on his/their behalf. The company shall have no liability to make payment of any claims and the premium shall be forfeited to the company”.
Hence, they have repudiated the claim of the complainant through their letter under clause 6.1 of the policy. After receipt of the claim form they have received information from the treating Dr.Srinivas Nalloor, one who has given information that the complainant has Hypertension/ Blood pleasure since 15 years and Chronic Kidney Disease since September 2014 and the complainant is in regular treatment for both. The complainant has suppressed the pre existing illness while obtaining the insurance policy. The complainant has given negative answers in the proposal form, which requires to say information about the health condition of the proposal. Thus, the complainant has suppressed the pre existing illness during submission of the proposal form.
Op No.2 further contended that, medical insurance policy is a contract of good faith, whereas the complainant had by suppressing the previous illness with malafide intention had obtained a policy from this Op. Hence, the claim made by complainant was rejected as per the terms and conditions of the policy and there is no any deficiency in service on the part of this Op in rejecting the claim. Hence, prays for dismissal of the complaint.
6. Complainant filed affidavit and marked documents as Ex.P.1 and Ex.P.2 and Op No.1 & 2 also filed affidavit and marked documents as Ex.R.1 to Ex.R.5.
7. Heard the arguments.
8. In the proceedings, the following points do arise for our consideration and decision:
- Whether there is deficiency in service on the part of OPs?
- Whether complainant entitled for any relief & what Order?
9. Our findings on the above points are as follows:-
- Point No.1: Negative.
- Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
10. The case of the complainant is that, he had obtained group insurance policy from Op No.2 through Op No.1 and during the policy is in force complainant admitted to Vikram Hospital at Mysore on 02.06.2015, during his hospitalization Renal transplantation was done on 04.06.2015 and subsequently discharged on 10.06.2015. During his hospitalization the kidney was transplanted by donation of wife by obtaining due permission from competent authority. The complainant also spent nearly Rs.5,00,000/- towards transplantation of the kidney. There afterwards being beneficiary of the policy he claimed for reimbursement of the said amount, but the claim made by complainant was rejected by Op No.2 for the reason that he had Hypertension since 15 years and Chronic Kidney Disease since September 2014. But the complainant alleged he had no any such ailment before taking policy and Op No.2 had repudiated the claim ill-legally in order to avoid the reimbursement of the medical expenses. Hence, filed this complaint alleging deficiency in service and prays for reimbursement of the said amount as per the policy terms and conditions.
11. On contrary Op No.2, who had issued a group insurance policy to the complainant had taken a contention that, the complainant has suppressed his pre existing illness at the time of obtaining the policy and he had given no answers with respect to the health condition at the time of proposal. In fact complainant had a Chronic Kidney Disease and Hypertension since 15 years and he is in regular treatment to the kidney disease, which resulted in kidney transplantation after obtaining the policy. Considering all these facts the Op No.2 had repudiated the claim and submits no deficiency in service and expressed his inability to pay the reimbursement to the complainant.
12. On going through the documents produced by both complainant and Ops we noticed that the complainant had given a proposal form to Op No.2 by filling the required columns and we observed in the health column the complainant has stated he had not visited any hospital or he was not under any medication at the time of taking proposal form (Ex.R.2), whereas on 02.06.2015 the complainant admitted to the Vikram Hospital at Mysore for Renal Transplantation, the said Renal Transplantation was performed when the kidney disease was chronic, the Dr.Srinivas Nalloor, who have treated the complainant have expressed in their opinion that the complainant was suffering Chronic Kidney Disease since September 2014 and he is under maintainance of Hemodialysis. The said Dr.Srinivas Nalloor has categorically stated in his questionary that complainant had a Chronic Kidney Disease stage 5 and he is having MHD (Maintenance Hemodialysis). Hence, it is a clear case that the complainant is having a kidney disease since 2014, but the complainant has not disclosed the said information at the time of obtaining the policy. Hence, we are of the opinion that the complainant has suppressed the material facts at the time of taking policy. It is observed that the complainant had taken the policy which covers from 14.02.2015 whereas after lapse of one month he visited the hospital for treatment to the kidney disease. Hence, we found there is no any deficiency in service on the part of this Op in repudiating the claim of the complainant.
13. The learned advocate for complainant had vehemently argued and cited a number of decisions which established that it is the burden on the insurance company to establish the pre existing disease. Here in this case the Op No.2 has established that the complainant had a pre existing disease, the certificate issued by Dr.Srinivas Nalloor with respect to the pre disease of the complainant is sufficient to held that the complainant had pre existing disease which was not disclosed at the time of proposal. Hence, the complainant is not entitled to get any relief as claimed in the complaint and also failed to establish deficiency in service. Hence, the complaint is liable to be dismissed. For the above said reasons, we answer the above point no.1 and 2 in the Negative and proceed to pass the following:-
: O R D E R :
- The complaint filed by the complainant is hereby dismissed. No order as to costs.
- Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by her, transcript corrected by me and then pronounced in Open Court on this the 7th day of July 2017).
(B.U.GEETHA) (H. MANJULA) (RAVISHANKAR)
Member Member President
ANNEXURES
Documents produced on behalf of the complainant/S:
Ex.P.1 - Original Policy.
Ex.P.2 - Claim Rejection letter.
Documents produced on behalf of the OP/S:
Ex.R.1 - Claim form.
Ex.R.2 - Application form.
Ex.R.3 - Discharge summary.
Ex.R.4 - Insurance Certificate.
Ex.R.5 - Entire medical records.
Dated:07.07.2017 President
District Consumer Forum,
Chikmagalur.
RMA
