Karnataka

Belgaum

CC/865/2013

Mohanlal S Shah - Complainant(s)

Versus

The Manager of Oriental Insurance Cmpy Ltd. - Opp.Party(s)

R.R. Joshi

11 Jan 2017

ORDER

                 

ADDITIONAL  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BELAGAVI

C.C.No.865/2013

 

                       Date of filing: 27/12/2013

 

                                                                                                                 Date of disposal:11/01/2017

 

P R E S E N T :-

	(1)	Shri. A.G.Maldar, B.Com,LL.B. (Spl.) President.
	(2)	Smt.J.S. Kajagar, B.Sc. LLB. (Spl.)  Lady Member.

 

 

COMPLAINANT        -

Shri.Mohanlal Sheshmal Oswal @ Shah, Age: 59 Years, Occ: Business, R/o: Mahaveer Nivas, Bhagyalaxmi Nagar, K.C. Road, Chikodi, Tq: Chikodi, Dist. Belgaum.                             (Rep. by Sri.R.R.Joshi, Adv.)

- V/S -

 

OPPOSITE PARTIES  -

1.           2.             3.

The Manager, The Oriental Insurance Co. Ltd., Branch Nippani, Tq: Chikodi, Dist. Belgaum.                   (Rep. by Sri.V.B.Malannavar, Adv.)   The Head Office, The Oriental Insurance Co. Ltd., Oriental House, P.B.No.7037, Asaf Ali Road, New Delhi – 110002.                                         (Ex-parte)   The Manager, TPA MD India Health Care Services (P) Ltd., Reimbursement and Cashless Claims and General Enquiries, S.No.46/1, E-Space,  A2 Building, 3rd Floor, Pune Nagar Road, Wadagoan Sheri, Pune – 411014. (Maharashtra).                 (Rep. by Sri.V.B.Malannavar, Adv.)

JUDGEMENT

 

By  Sri.A.G. Maldar, President.

 

 

1.      This is a Complaint filed by the complainant under Section 12 of the Consumer Protection Act, 1986 (herein after referred to as Act) against the Opposite Parties (in short the “Ops”) directed them to pay remaining claim amount of Rs.1,94,556/- with interest @18% p.a. and Rs.1,00,000/- towards compensation for mental agony and Rs.5,000/- towards cost of the proceedings etc.,

2.      The facts of the case in brief are that;

 

          The case of the complainant is that, the complainant has subscribed the health insurance policy in his daughter Ku.Seema Mohanlal Oswal, since the last 5 years from the OP.No.1 under the scheme Happy Home Family Floater Policy and the insurance policy bearing No.472502/48/2013/1222 for the period from 18.10.2012 to 17.10.2013, it covers under the family members of the complainant and further the said policy covering for sum assured of Rs.5,00,000/- and covers towards the critical illness of heart deceases etc., and complainant has fulfilling all the terms and conditions of the policy and paying the installments regularly to the Op.No.1.

 

          It is further case of the complainant that, the complainant suffering from illness from 13^th to 26^th February 2013 and he was admitted to the KLEs Hospital, Belgaum and complainant was underwent open heart surgery and for said surgery including medical bill, the complainant was incurred an amount of Rs.2,66,928/- and further the said surgery was carried out during the force of above said policy.

 

It is further case of the complainant that, after admitting the hospital, the complainant has approached to the Ops for the approval of cashless settlement. On the request of the Ops, the complainant alongwith the Mediclaim letter dtd:23.07.2013, the complainant was submitted all the necessary documents to the OPs i.e. Discharge Summary, Operation Note, Patient Final Bill,  Coronary Angiography Report, Coronary Angiogram Report, In Patient Department Receipt of Rs.1,50,000/- and Rs.44,556/- accordingly, to pay the entire claim amount of Rs.2,66,928/- to the complainant.

 

But, the OPs were given approval and authorization for Rs.1,00,000/- only and paid only Rs.72,372/- towards the claim amount by the complainant, instead of Rs.2,66,928/- towards the medical bills and operation and further the policy is cover to the extent of Rs.5,00,000/- and complainant spent total an amount of Rs.2,66,928/- for his open heart surgery.

 

The complainant has further asked to Ops to pay the remaining balance amount of Rs.1,94,556/- inspite of several request and demand, the Ops have not paid the remaining balance amount and not given any reply to the same, then ultimately, the complainant has issued two letters dtd:07.07.2013 and 29.07.2013 asked the Ops to pay the remaining balance amount of Rs.1,94,556/-, but OPs were not paid, finally the complainant has issued a legal notice through his counsel dtd:26.10.2013 asking the Ops to pay the remaining balance amount of Rs.,1,94,556/- the said notice received by the OPs and has given a false reply and avoid to pay the remaining claim amount, this act of the OPs its clearly shows that, there is a deficiency in service on the part of the OPs. Hence, the complainant is constrained to file this complaint.

 

3.      After issue of notice to the Opponents, the OP.No.1 & 3 has appeared through his counsel and OP.No.3 has neither appeared nor filed any version, inspite of giving sufficient time. The Hon’ble Forum considered the OP.No.3 is placed Ex-parte and OP.No.1 & 3 contended that, the complainant has filed this false complaint only to harass the OPs and the Ops have denied all the averments made by the complainant.

 

          It is case of the OP.No.1 & 3 that, the complainant had obtained individual mediclaim policy up to the year 2007-08 for a sum assured of Rs.1,00,000/- in respect of one individual from 2008-09 onwards, the complainant has opted for Happy Home Family Floater Mediclaim Insurance Policy alongwith other family members, the said policy was in force and further the documents produced by the complainant in particular “Patient History” discloses that, “as per patient known case of hypertension since 15 years” and the condition i.e. unstable angina encountered by complainant is nothing but the outcome of hypertension i.e. Pre-existing Disease and the surgical procedures undergone by complainant is to nullify the effect of unstable angina. Therefore, OP was constrained to calculate the sum assured relating to the individual mediclaim policy which was in force, 4 years prior to the date of claim maximum of Rs.1,00,000/- it is further submitted that, similarly if the sum assured is enhanced subsequent to the inception of the policy the exclusions (vide Sl.No.4.1, 4.2 & 4.3 of the model Happy Family Floater Policy which forms part and parcel of the main policy) as per the terms of the policy will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

 

          Further it is OP.No.1 & 3 contended that, the OP was under obligation to cover the medical expenses as per existing policy only, after completion of four policy, i.e. 2012-13 which came to end on 17.10.2013, the insurer will be under obligation to cover the pre-existing disease, in the present case, four years prior to the date of raise of claim on 13.02.2013, the individual medical policy was in force which gave Rs.1,00,000/- per person coverage and further contended that, the OP is liable to cover the risk of complainant as provided under individual mediclaim policy and offered to settle the claim of Rs.1,00,000/- in total and out of which Rs.72,372/- has already been approved for cashless hospitalization and further the OP is ready to settle the claim to the balance amount of Rs.27,628/- and accordingly, OP company has through its counsel made it clear in the reply notice to accept the amount as per the terms of insurance.

 

It is also further case of the OP that, the complainant is trying to put up claim based on the subsequent insurance policy, whereas his risk is covered under the previous policy and he has malafidely obtained the subsequent insurance policy under family floater category in order to cover up the earlier disclosures about the hypertension and further the complainant is not entitled to succeed in his attempts to dupe and defraud the OP company. It is pertinent to note that, there was no deficiency of service on the part of OPs and further the OP Company even till today is ready to settle the claim of the complainant in terms of the previous policy. On this count also the complaint of the complainant is liable to be rejected and there is no negligence or deficiency in service on the part of the OPs and prayed for dismissal of the complaint.

 

 

4.      Both the parties have filed their affidavits in support of their case, the complainant has produced 33 documents which were marked as Ex.P-1 to Ex.P-33, and on behalf of the OP.No.1 & 3 has also filed 11 documents and same are marked as Ex.R-1 to Ex.R-11, for sake of our convenience, marked as P & R series. Both parties have filed their written arguments and heard the arguments on both sides.

 

 

Now, on the basis of these facts, the following points arise for our consideration:

 

1. Whether the complainant has proved that, there is deficiency of service on the part of the OPs for not reimbursing the insurance mediclaim amount?

 

 

2. What order?

 

 

5.      Our findings to the above points are as under:

 

                              

1. Partly Affirmative.
2. As per the final order for the following:

 

 

                               :: R E A S O N S ::

 

 

 

6.      POINT NO:1:-  We have perused the pleadings of the parties and the evidence and documents placed on record. It is the case of the OPs that, there is no dispute regarding insurance, and mediclaim policy up to the year 2007-08, the complainant claiming as per policy cover sum assured of Rs.5,00,000/- the policy is cover to the extent of Rs.5,00,000/- and complainant has paid  Rs.2,66,928/- for his open heart surgery which is marked as
Ex.P-19, further the OPs contended that, the OPs have paid MD India Health Care Services Covered Rs.72,372/- only and stated that, there is only a balance amount of  Rs.27,628/- as per policy for a sum assured of Rs.1,00,000/- in respect of one individual from 2008-09 onwards, the complainant has opted for Happy Home Family Floater Mediclaim Insurance Policy alongwith other family members, the said contention contended by the OPs has not established by producing reliable and acceptable affidavit evidence  and relevant material documents in respect of complainant is only entitled an amount of Rs.1,00,000/- as per policy. So, the contention of the OPs have not at all merit for the reason that, the complainant has not substantiate in detail how, the complainant is entitled only for Rs.1,00,000/-, when the  scheme of Happy Home Family Floater Policy for the period from 18.10.2012 to 17.10.2013, it covers under the family members of the complainant and further the said policy covering for sum assured of Rs.5,00,000/- and covers towards the critical illness of heart deceases etc., looking to the above reasons and facts, the contention of the OPs has no merit, so OPs insisting to the complainant to settle for Rs.1,00,000/- by taking remaining balance amount of Rs.27,628/- and attitude of the OPs it amounts to deficiency of service on the part of the OPs and further the complainant has not established as alleged in the written version as well as affidavit evidence in respect of Happy Home Family Floater Policy, when sum assured of Rs.5,00,000/- is admitted and it is evident from the document of complainant produced which is marked as Ex.P-1, the said policy is covered from 18.10.2012 to midnight of 17.10.2013.

 

The complainant was admitted on dtd: 13.02.2013 for suffering from illness and admitted to the KLEs Hospital, Belgaum and complainant was underwent open heart surgery under such circumstance, the complainant has incurred an amount of
Rs.2,66,928/- as per patient final bill produced by the complainant which is already marked as Ex.P-19.

 

More ever, the OPs have not disputed the said bill, the OPs only contended that, the complainant is entitled only for Rs.1,00,000/- and OP was constrained to calculate the sum assured relating to the individual mediclaim policy which was in force, 4 years prior to the date of claim maximum of Rs.1,00,000/-. When, we have gone through the said policy it is revel that, the complainant has admitted in the Hospital for the month of February 2013, not prior to as alleged by the OPs. Therefore, the said Happy Family Floater Policy scheduled i.e. Ex.P-1, it covers personal accidental cover for a sum of Rs.5,00,000/- when, the Ex.P-1 clearly revels that, personal accidental cover happen to be during the enforcement and existence of said policy from 18.10.2012 to 17.10.2013, then how the OPs have taken contention and calculate the sum assured relating to the individual mediclaim policy which was in force, 4 years prior to the date of claim maximum of Rs.1,00,000/- and how the OPs has taken contention that, regarding the “Patient History” discloses that, “as per patient known case of hypertension since 15 years” and the condition i.e. unstable angina encountered by complainant is nothing but the outcome of hypertension i.e. Pre-existing Disease and the surgical procedures undergone by complainant is to nullify the effect of unstable angina. The said contention alleged by the OPs have not been proved and also not detailed explained in respect of alleged contention by producing supporting affidavit evidence and material documents. So, in our consideration that, the OPs have failed to prove his case as alleged in the written version as well as in affidavit evidence.

 

On going through the pleadings of the OP that, the complainant is not entitled to claim reimbursement of medical bills due to suppressing of pre-existing disease and on one breath the OP taken stand, the complainant is entitled for Rs.1,00,000/- only, the both contention taken by the OPs is contradict to each other, which version has to be consider and believable for adjudicate the matter, it creates doubt, therefore we are of the consider opinion that, for sake of argument consider that, there was a Pre-existing Disease and the surgical procedures undergone by complainant is to nullify the effect of unstable angina, then why the OPs have paid and on what basis ?,  it has not clearly explained to this Forum, and no doubt it is true that, the said amount paid to the Hospital by MD India Health Care Services Covered for Rs.72,372 and insisting to take balance amount and settle the matter. By going through, the detail terms and conditions of the insurance policy and pleading of the OPs, it is nothing but harassing the complainant by way of one or the other reason by putting unsustainable grounds to the complainant and demanding to take remaining amount of Rs.27,628/-, which is not proper and justifiable. Apparently, it shows that, there is deficiency of service on the part of the OPs by taking to unsustainable contentions and insisting, demanding complainant to take remaining amount it amounts to deficiency of service on the part of the OPs.  

 

Therefore, the mere alleging untenable contention and insisting complainant to settle and close the claim by receiving balance amount of Rs.27,628/- which is not proper and even he has not substantiate regarding the OPs are liable to pay Rs.1,00,000/- only to the complainant and it is not covered under said policy conditions. Therefore, it is crystal clear that, the OPs are committed deficiency of service on the part of the OPs for not reimbursing as per policy bond and conditions. For that proposition of law, the counsel of the complainant relied revision petition No.558/1997 of National Consumer Disputes Redressal Commission, New Delhi, wherein the Hon’ble National Commission, New Delhi, hold that, repudiation of mediclaim based on the plea that, the deceased was pre-existing is not justified.

 

Further we would like to refer a decision Hon’ble National Commission reported in CTJ 152 (CP) (NCDRC) (1) Wherein it was observe that, the information collected from the Hospital is not primary piece of evidence, but primary piece of evidence would be of the doctor, who recorded the information in the discharge summary and doctor who prepared the discharge summary has not been examined are filed evidence in that case and more or less the same proposition has been laid down by the Hon’ble National commission in the decision reported in II (2012) CPJ 65 (NC), IV 2012 CPJ 2013 (NC) the proposition laid down in the above said decision applied to the instead case with all force, so we are of the consider opinion that, the OPs are failed to discharge burden of proving their case about said allegation by placing cogent, satisfactory and acceptable evidence.  So, it is to be held that, the OPs are not justifiable in not reimbursing bill claim amount of the complainant and such not reimbursing bill claim amounts to deficiency of service on the part of the OPs.

 

Looking to the facts and circumstances of the case, consequently with above observation we are of the consider opinion that, there is a deficiency of service on the part of OPs, in not reimbursing the Medical bill claim amount of the complainant.
So, we award medical bills as per Happy Family Floated Bond Clause 2.3 (A) towards package Coronary Angiography with
non-Ionic (NEW) an amount of Rs.2,50,000/- + Rs.14,000/- = total an amount of Rs.2,64,000/-, it is evident from record produced by the complainant already marked as Ex.P-19 and the said document has not been disputed and challenged by the OPs. Hence, it is deemed that, the said bill is admissible by the OPs. So, the OPs has paid a part of an amount of bill which will be after deducting the amount paid by MD India Health Care Services of Rs.72,372/- i.e. ( Rs.2,64,000 - Rs.72,372) = Rs.1,91,628/-. Therefore, in our consider view, as per medical claim, the complainant is entitled for Rs.2,64,000/- out of which already the OP has paid an amount of Rs.72,372/- and now the complainant is entitled remaining balance amount of Rs.1,91,628/- which is come after deduction, it would meets end of justice.   

 

Now our considered opinion, we have no hesitation to hold that, the insurance company is to be held liable to pay Rs.1,91,628/-  as per medical bill which is not disputed and challenge by the OPs and the complainant is entitled for mental agony and costs of the proceedings for Rs.2,000/-.  Accordingly, we answer Point No:1 in the Affirmative and proceed to pass the following:

 

O R D E R

 

For the reasons discussed above, the complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is hereby partly allowed with costs.

 

           The OPs shall pay a sum of Rs.1,91,628/-  towards medical bills to the complainant.

 

          The OPs shall pay a sum of Rs.2,000/- towards mental agony and cost of the proceedings.

 

          The OPs are granted 8 weeks time for compliance of this order. 

 

 

(Typed to our dictation then corrected, signed by us and then pronounced in the open Forum on this 11^th January -2017).

 

 

 

Sri A.G.Maldar, President

Smt. J.S. Kajagar,                Lady Member.

.