Complaint filed on: 21-02-2023
Disposed on: 20-07-2023
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 20th DAY OF JULY, 2023
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER
CC.No.22/2023
Sri.K.Sannareddy S/o Rudrumuniyappa,
Aged about 39 years,
R/at Uddaneshwara layout,
Haralur Post, Guluru Hobli,
Tumakuru.
……………….Complainant/s
(By Sri. T.H. Lokesh., Adv.)
V/s
1. The Manager,
Star Health and Allied Insurance Company Limited,
No.15, Sri. Balaji Complex, 1st Floor,
Whites Lane, Royapettah, Chennai-600 014.
Branch Officer address
2. The Manager,
Star Health and Allied Insurance Company Limited,
1st Floor, 4th Cross, M.G.Road, Tumkur Town.
……………….Opposite Party/s
(By Smt. K.P.Mamatha, Adv.,)
:ORDER:
BY SRI.KUMARA.N., MEMBER
This complaint filed by the complainant U/s 35 of the Consumer Protection Act 2019 with a prayer to direct the OPs to settle the Medi-claim amount of Rs.2,53,287/- and further prays to direct the OPs to pay Rs.50,000/- towards damages and Rs.25,000/- towards other damages.
2. In this case opposite parties were /are, Manager, Star Health and Allied Insurance Company Limited, No.15, Sri.Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600 014 and Manager, Star Health and Allied Insurance Company Limited, 1st Floor, 4th Cross, M.G.Road, Tumkur Town (here in after called as OPs)
3. It is the case of the complaint, that the complainant obtained Medi-claim policy bearing No.P/141131/01/2023/002141 from OPs on 13.08.2020. The complainant paid premium of Rs.5,815/- regularly and get it renewed up to date. The complainant further submitted that the policy is in active, on 02.10.2022, he got admitted to Center for Kidney and Diabetes Hospital, Yelahanka Old Town, Bangalore as inpatient for the period 02.10.2022 and 07.10.2022 and undergone surgery of his right finger. The complainant on 02.10.2022 informed the same to the OPs in order to claimant of medi-claim and as per the direction of OPs, the complainant taken treatment. After the treatment, as per the OPs direction and instruction in Email dated 17-10-2000,the complainant submitted claim form with original documents to the OPs on 21.10.2022. On 04.11.2022 the complainant received email acknowledgment for receipt of original documents along with claim form.. Again, on 08.11.2022, the OPs sought further clarification & information from the complainant, accordingly the complainant submitted the required documents on 22.1.2022. In spite of the complainant submitted all the required documents to the OPs. In spite of submitting all required documents, on 02.12.2022, the OPs repudiated the claim stating that all the documents are not submitted along with the application, in turn the complainant on 07-12-2022 submitted the required information along with documents to the OPs. In spite of repeated calls / requests and legal notice served on :07.01.2023, the OPs have not responded. Hence, this complaint.
4. After the case registered, the OPs counsel appeared and filed their version by admitting the fact that the complainant had obtained the said policy bearing No P/141131/01/2023/002141 from the OPs, which valid for the period 13.08.2022 to 12.08.2023. The OPs have contended that the complainant was suffering from Hypertension, but the same was not disclosed by the complainant at the time of obtaining the policy i.e. failure to inform pre-existing disease, amounts to concealment of material fact and multiple tamper of documents resulted in OPs came to conclusion that the said claim was false. Hence, they repudiated the claim of the complainant.
5. The Complainant has filed his evidence by way of affidavit and marked the documents at Ex.C1 to C13. One Mr.Manjunath T.L., Branch Manager has filed his evidence by way of affidavit on behalf of OPs. The OPs marked the documents at Ex.R1 to R12.
6. We have heard the arguments from both side counsels. Both parties also files written their arguments.
7. The points that would arise for determination are as here under:
1) Whether the complainant proves the deficiency in service on the part of OPs?
2) Is complainant entitled to the reliefs sought for?
8. Our findings on the aforesaid points are as follows:
Point No.1: Partly Affirmative
Point No.2: In the partly affirmative for the below
:R E A S O N S:
9. The complainant counsel argued that the complainant informed the OPs well in advance regarding complainant treatment in Center for Kidney and Diabetes Hospital, Yelahanka Old Town, Bangalore and as per the advice and instructions of the OPs, the complainant taken treatment and after taking treatment, the complainant submitted all required original documents along with claim form to the OPs and initially, the OPs assured to settle the claim, later, the OPs seeks clarification and advised the complainant to submit additional documents. Accordingly, the complainant submitted all the required documents in original, in spite of it, the OPs not settled. Hence, the complainant’s counsel prays to allow the complaint. The complainant’s counsel produced the documents as Ex.C1/Insurance policy, Ex.C2/Copy of email sent by respondent to the complainant, Ex.C3/copy of respondent directed to complainant to submit the relevant documents dated:17.10.2022, Ex.C4/copy of the application along with documents submitted by the complainant dated:21.10.2022, Ex.C5/copy of email sent by OPs dated:21.10.2022, Ex.C6/copy of email received from the OP dated:08.11.2022. Ex.C7/copy of documents submitted by complainant to OP dated:22.11.2022, Ex.C8/copy of repudiation letter issued on 02.12.2022, Ex.C9/copies of further documents sent by complainant to OPs on 07.12.2022, Ex.C10/copy of legal notice, Ex.C11/RPAD receipt, Ex.C12/RPAD acknowledgment and Ex.C13/letterhead of center for kidney and diabetes dated:18/10/2022.
10. The OPs counsel argued that as per the investigation officer report, due to multiple tampering of documents and not informed the pre-existing disease, they came to conclusion that this is a false claim using fabricated and stereotype documents. Hence, they repudiated the claim and therefore, the OPs counsel prays to dismiss the complaint with costs. The OPs counsel produced documents i.e. Ex.R1/ copy of discharge summary of Adarsha Nursing Home, Tumkur dated:14.07.2022, Ex.R2/copies of medical records regarding treatment of complainant at Dr.Sanjay’s Center for Kidney and Diabetes, Bengaluru from 02.12.2022 to 07.10.2022, Ex.R3/copy of report of Manipal Hospital Neubertent, Ex.R4/copy of health insurance policy during the year 2020 issued by OP No.2, Ex.R5/copy of 2nd year renewal from 13.08.2022 to 12.08.2022 of OP No.2, Ex.R6/cop of terms and conditions of Young Star Health Insurance Policy of Star Health and Allied Insurance Com., Ltd., Ex.R7/copy of claim form Part-A & Part-B, Ex.R8/copy of authorization to Star Health and allied insurance Co., Ltd., by the claimant to seek any information etc., from Dr.Sanjay’s Center for kidney and diabetes, Bengaluru, Ex.R9/copy of letter by Star Health and allied insurance Co., Ltd., to complainant for requirement of additional documents/details dated:23.11.2022, Ex.R10/copy of repudiation of claim by OP No.2 dated:02.12.2022, Ex.R11/copy of repudiation of claim by Star health and allied insurance Co., Ltd., dated:08.02.2023 and Ex.R12/copies of claim verification report.
11. The fundamental principle is that insurance is governed by the doctrine of uberrima fidei. This postulates that there must be complete good faith on the part of the insured. This principle has been formulated in MacGillivray on Insurance Law12 succinctly, thus:
―[Subject to certain qualifications considered below], the assured must disclose to the insurer all facts material to an insurer’s appraisal of the risk which are known or deemed to be known by the assured but neither known or deemed to be known by the insurer. Breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms…‖
The relationship between an insurer and the insured is recognized as one where mutual obligations of trust and good faith are paramount.
12. Honorable Supreme court of India, judgment, dated; 6th December,2021 in the case of Manmohan Nanda vs United India Insurance Co. Ltd. in para 6, held that, Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured,
13. Honorable Supreme court of India, the division bench of Justice Abhay S Oka and Justice Rajesh Bindal, in CIVIL APPEAL NOS. 2769-2770 OF 2023, in the case of Om Prakash Ahuja Vs Reliance General Insurance Co. Ltd, on July 04, 2023, held that, Medical Insurance - Once there is a valid insurance policy in favour of a person, the claim for reimbursement of the expenses incurred must be paid. Once the insurance company has accepted that concealment of a disease at the time of purchasing the policy was not material as it was not related to the disease that caused death, it cannot later refuse further claims or renewal of insurance policy on the same ground.
14. In this case, the complainant produced, EX.P1,which revels that, the complainant, obtained health insurance policy bearing No P/141131/01/2023/002141 from the OPs, where in the complainant paid the premium of Rs 5,815/- regularly to the OPs in turn the OPs issued the said policy, wherein sum assured was Rs 500000.00, which valid for the period 13.08.2022 to 12.08.2023 and insured person is Mr Sanna Reddy, who admitted to the Center for Kidney and Diabetes Hospital, Yelahanka Old Town, Bangalore as a inpatient for the period 02.10.2022 and 07.10.2022 and undergone surgery of his right finger, which is admitted facts, not disputed by the OPs. The disputes by the OPs were / are , the complainant suffering from Nephrotic syndrome, biopsy proven – MG and Hypertension, before inception of the health insurance policy which was not disclosed by the complainant, and the complainant submitted claim form and documents were multiple tampered, and this is false claim using fabricated and stereotyped documents, hence repudiated the claim. by the OPs.
15. Tampering means make unauthorized alterations in the documents, in this case, as alleged by the OPs, the multiple tampering, the question is, who tampered, whether the complainant or the doctor / hospital who treated the complainant, it’s clear that overwriting by the treated Doctor in this case, this commission relied on, the Honorable National Consumer Disputes Redressal Commission (NCDRC), judgment in the case of RAM KARAN CHOUDHARY v. BHANDARI HOPSITAL & RESEARCH CENTRE & ORS dated 04-07-2017. Opinioned that, it was a human error. One, the overwriting is very deliberate and very clear, the kind that is done to correct an error rather than cover track. The overwriting was an error and was rectified by the doctor as soon as he saw it, accordingly in this case overwriting and corrections were happened in Admission record, Operation Notes, Initial assessment and treatment sheet, observation record and nurse daily record, which were hand written and corrected as soon as noticed.
16. Answering to OPs allegation of false claim using fabricated and stereotyped documents by the complainant, on perusal of the progress record, prescription, and bills, the doctor on 03-10-2022 and 05-10-2022 treated the complainant with TENECTEREL 40 mg injection and EMTUX 500 respectively, wherein Tenecterel 40mg Injection Kit belongs to a group of medicines called thrombolytic agents. It is used in the emergency treatment of heart attack. It helps to dissolve blood clots that have formed in the blood vessels of the heart, here, the treated doctor followed the procedure & protocol before giving to the complainant, by taking Risk conscent for use of TPA, where in the patient name reflected as Sri K, sannareddy i.e. Complainant name and EMTUX 500MG INJECTION given to the complainant on 05-10-2022, which contains Rituximab which belongs to the group of medicines called Anticancer drugs. It is used to treat blood cancer (leukaemia) and lymph cancer (lymphoma). It can also be used to treat various auto-immune disease conditions such as rheumatoid arthritis, granulomatosis with polyangiitis or microscopic polyangiitis (inflammation of blood vessels) and pemphigus vulgaris (severe skin blistering and peeling especially on the mouth, nose, throat, eyes and genitals). Which proves that the complainant taken treatment in the hospital and undergone surgery of his finger. The complainant taken treatment in Center for Kidney and Diabetes Hospital, Yelahanka Old Town, Bangalore as a inpatient for the period 02.10.2022 and 07.10.2022 and produced bill No 02223/00042 Dated 07-10-2022 for Rs 95900.00, bill No 0001301 dated 02-10-2022 for Rs 4725.43, bill No 0001308 & 0001309 dated 03-10-2022 for Rs 5730.21 & Rs 49060.00 respectively, bill No 0001319 dated 04-10-2022 for Rs 3802.93, bill No 0001329, 0001332 & 0001342 for Rs 13877.14, Rs 957.30 & Rs 47160.00 respectively, bill No 0001346 dated 06-10-2022 for Rs 2986.18 and bill No 0001355 dated 07-10-2022 for Rs 2891.11, which totaling to Rs 227090.30 rounded to Rs 227091.00.
17. The object of seeking a health / medi-claim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur on any time or any stage. If the insured / complainant suffer a sudden sickness or ailment or disease, which is not expressly excluded under the policy, a duty is cast on the OPs to indemnify the complainant for the expenses incurred thereunder. If the insured / complainant, had no knowledge of any ailment or diseases, he or his dependents, had, obviously there could be no disclosure of any ailment or sickness or disease, which would require medical attention.
18. In view of the above discussion, this commission relied on the Honorable Supreme court of India, judgment dated 04-07-2023 in the case of Om Prakash Ahuja Vs Reliance General Insurance Co. Ltd, and the Honorable National Consumer Disputes Redressal Commission (NCDRC), judgment in the case of RAM KARAN CHOUDHARY v. BHANDARI HOPSITAL & RESEARCH CENTRE & ORS dated 04-07-2017, this commission is opinioned that, repudiation of the , medical reimbursement bill of the complainant, for Rs.227091/-by the OPs is illegal and not in accordance with law, since the complainant paid the premium of Rs 5,815/- regularly to the OPs, towards health insurance policy bearing No P/141131/01/2023/002141 wherein sum assured was Rs 500000.00, which valid for the period 13.08.2022 to 12.08.2023 and insured person is / was Mr Sanna Reddy,(Ex C1) who admitted to the Center for Kidney and Diabetes Hospital, Yelahanka Old Town, Bangalore as a inpatient for the period 02.10.2022 and 07.10.2022 and undergone surgery of his right finger, and same informed by the complainant to OPs and submitted the said medical claim along with original bills and documents for reimbursement (Ex C3) to the OPs, accordingly, the OPs are liable to reimburse the said medical bill of Rs 227091/- to the complainant and compelled the complainant to approach this commission, by repudiating claim, hence liable to pay the litigation cost of Rs.10,000/- and compensation of Rs.10000 /- to the complainant, accordingly we proceed to pass the order as;
:O R D E R:
Complaint filed by the complainant is allowed in part.
The OPs are ordered to pay, jointly and severely Rs.2,27,091 (Rs.Two lakhs twenty seven thousand ninety one only) along with interest @ 8.00 % p.a from 21-02-2023 to till realization to the complainant. It is further ordered that OPs to pay Rs.10,000.00 (Rs.Ten Thousand only) towards litigation costs and Rs.10,000.00 (Rs.Ten thousand only) towards compensation to the complainant.
The OPs are further directed to comply the above order within 45 days from the date of receipt/knowledge of the order, otherwise, it carries fine of 150/- per day till realization.
Furnish the copy of order to the complainant and opposite party at free of cost.
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