Date of Filing:10.01.2022

Date of Disposal:29.04.2023

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

ORDER

SRI RAMACHANDRA.M.S,  PRESIDENT

1. The complainant files a complaint against the OP with this Commission under Section 35 of the Consumer Protection Act of 2019 for deficiency of service to direct the OP to reimburse total hospital bill  amounting to Rs.2,02,187/- with interest at 18% p.a. from the date of discharge and such other reliefs.

2.   The following are the complaint's key facts: 

This is the case of the complainant that the complainant has taken Health Insurance Policy for his parents from the OP company covered from 20.08.2019 to 19.08.2020 bearing policy no.141113/01/2020/006128 by paying premium of Rs.30,685/-. 2^nd policy takenfrom the OP company covered from 20.08.2020 to 19.08.2021 in policy bearing no.P/141142/01/2021/000752 by paying premium of Rs.35,978/-.3^rdpolicy taken by the complainant has taken health care policy covered from 20.08.2021 to 19.08.2022 bearing policy No.P/141142/01/2022/002194 by paying premium of Rs.40,616/-. The said policies are continued from 20.08.2019 to 19.08.2022 covering heath care of the parents of complainant and the OPrepresentatives haveassured for better coverage to provide treatment to his parents.

3. It is further  case of the complainant that complainant father Chikkabettaiah as he fell sick with difficulty in breathing and got admitted to Anupama Hospital in BEL layout, Bengaluru on 13.07.2021 for treatment and he was diagnosed as Acute Exacerbation  of Chronic Obstructive Pulmonary Disease and upon given treatment he was discharged on 18.07.2021. At the time of discharge the complainant has paid a total sum of Rs.73,000/- and later when  the claim was raised for the said amount and OP has failed to reimburse the said amount, which is covered under the said policy and even after several approaches the OP has failed to settle the claim of the complainant.

4. Further case of the complainant that the complainant father was again fell sick on 2^nd week of September 2021 for the shortness of breathing problem, Head ache and complainant father was admitted to the Chord road hospital, Basaveshwaranagar, Bengaluru on 14.08.2021 around 12.PM and on the  same day he was referred to higher centre at Apollo Hospital, Sheshadripuram, Bengaluru and wherein he was admitted on 15.09.2021 and he was diagnosed as Acute Exacerbation of Chronic Obstructive Pulmonary Disease with inspection to lower respiratory tract. In addition he was diagnosed for Hyper tension, Rheumatoid Arthritis and Wedge compression fracture of D5 & D8 and on extending effective treatment by expert doctor, the complainant father was discharged on 21.09.2021 with follow up advise. In that context, the complainant have renewed the previous policy, secured continued Health Insurance Policy  for his parents covering for the period from 20.08.2021 to 19.08.2022 in policy no.P/141142/01/2022/002194. The complainant has intimated the OP to reimburse the insurance claim amount. The complainant has spent huge amount towards bills of Apollo hospital amounting to Rs.1,55,000/- and bill of Chord road hospital amounting to Rs.14,925/-. When the said claim was raised before the OP Company, the OP has examined the claim of the complainant and they have refused to settle the claim of the complainant for reimbursement of the complainant father’s policy. The complainant has totally spent amount of Rs.2,02,187/- for the treatment of his father. When there is valid policy existing as on the date of treatment of the complainant father when it is covered  for his father’s claim also. The rejection of the complainant claim by assigning the reason that the previous ailments and treatments have not been intimated to the insurance company by the complainant father at the time of availment of the policy. Since, this amounts to violation of terms and conditions of the policy, the question of settling the claim does not arise as the liability on the company cannot be fixed for the above reasons. By contending the same OP has refused to settle the claim of the complainant. Aggrieved by the act and action of the OP company, the complainant has no other alternative other than filing present complaint and sought for the settlement of the insurance claim which is covered under the said policy.

5. Notice to OP  duly served. OP represented by the counsel and filed version along with affidavit and also produced relevant documents in support of their contention.

6.  The complainant filed chief-examination affidavit along with annexure documents in support of his contention.

7.  Heard arguments. The matter is reserved for order.

8.  The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency of service on the part of the OPs as alleged in the complaint and thereby prove that he is entitle for the relief sought?
2. What order?

9. The findings on the above points are as under:

Point No.1                :       Affirmative

Point No.2                :       As per final order

REASONS

10. POINT NO.1:-  From the perusal of the complainant chief examination, it is found that when the complainant has taken health care policy from the OP covered from 20.08.2019 to 19.08.2020 bearing policy no.141113/01/2020/006128 by paying premium of Rs.30,685/-. 2^nd policy taken  from the OP company covered from 20.08.2020 to 19.08.2021 in policy bearing no.P/141142/01/2021/000752 by paying premium of Rs.35,978/-.  3^rd  policy taken by the complainant has taken health care policy covered from 20.08.2021 to 19.08.2022 bearing policy No. P/141142/01/2022/002194 by paying premium of Rs.40,616/-. The said policies are continued from 20.08.2019 to 19.08.2022 covering heath care of the parents of complainant and the OP  representatives have  assured for better coverage to provide treatment to his parents.

11.   It  is the case of the complainant that complainant father Chikkabettaiah as he fell sick with difficulty in breathing and got admitted to Anupama Hospital in BEL layout, Bengaluru on 13.07.2021 for treatment and he was diagnosed as Acute Exacerbation  of Chronic Obstructive Pulmonary Disease and upon given treatment he was discharged on 18.07.2021. At the time of discharge the complainant has paid a total sum of Rs.73,000/- and later when the claim was raised for the said amount and OP has failed to reimburse the said amount, which is covered under the said policy and even after several approaches the OP has failed to settle the claim of the complainant.

12. Further case of the complainant that the complainant father was again fell sick on 2^nd week of September 2021 for the shortness of breathing problem, Head ache and complainant father was admitted to the Chord road hospital, Basaveshwaranagar, Bengaluru on 14.08.2021 around 12.PM and on the same day he was referred to higher centre at Apollo Hospital, Sheshadripuram, Bengaluru and wherein he was admitted on 15.09.2021 and he was diagnosed as Acute Exacerbation of Chronic Obstructive Pulmonary Disease with inspection to lower respiratory tract. In addition he was diagnosed for Hyper tension, Rheumatoid Arthritis  and Wedge compression fracture of D5 & D8 and on extending effective treatment by expert doctor, the complainant father was discharged on 21.09.2021 with follow up advise. In that context, the complainant have renewed the previous policy, secured continued Health Insurance Policy  for his parents covering for the period from 20.08.2021 to 19.08.2022 in policy no.P/141142/01/2022/002194. The complainant has intimated the OP to reimburse the insurance claim amount. The complainant has spent huge amount towards bills of Apollo hospital amounting to Rs.1,55,000/- and bill of Chord road hospital amounting to Rs.14,925/-. When the said claim was raised before the OP company, the OP has examined the claim of the complainant and they have refused to settle the claim of the complainant for reimbursement of the complainant father’s policy. The complainant has totally spent amount of Rs.2,02,187/- for the treatment of his father. When there is valid policy existing as on the date of treatment of the complainant father when it is covered for his father’s claim also. The rejection of the complainant claim by assigning the reason that the previous ailments and treatment have not been intimated to the insurance company by the complainant father at the time of availment of the policy. Since, this amounts to violation of terms and conditions of the policy, the question of settling the claim does not arise as the liability on the company cannot be fixed for the above reasons. By contending the same OP has refused to settle the claim of the complainant. Aggrieved by the act and action of the OP company complainant has  no other alternative than filing present complaint and sought for the settlement of the insurance claim which is covered under the said policy.

13.  The OP filed written version, they have denied complaint allegations and also denied any deficiency in service on their part during the course of service to the complainant. The specific contention is on the claim of the complainant. Since, the complainant insured the complainant father was suffering from COPD prior to the availment of the said policy. This fact is mentioned in the discharge summary, the discharge summary of the complainant father, medical records which is produced by the complainant. By assigning the said reason this previous diseases which is suffered by the complainant father much prior to the availment of the policy, when they have failed to disclose the same at the time of availing the policy. The act of the policy holder amounts to non-disclosure of the material facts, this being the violation of terms and conditions of the policy and liability cannot be fixed on the OP Company. This amounts to violation of terms and conditions of the policy and  by contending the same they pray for dismissal of the complaint and claim that they are not liable to pay the insurance claim to the complainant.

14.  The complainant filed chief examination  affidavit and reproduced the complaint averments and also produced annexure documents in support of their pleadings. By looking  at contentions of both the parties, it is observed that issuance  of policy from the OP to the complainant father is not at all disputed by the OP. They are also  not disputed the validity of the said policies as on the date of treatment of  the complainant father. The only dispute between the complainant and the OP is that the OP contended that for the violation of the terms and conditions of the policy they are not liable to pay the insurance claim amount and as it is legally  not payable, as there is clear violation from the complainant’s. For the said violation they contended that rejection of the complainant claim is justified in accordance with the terms and conditions of the policy.

15.   The OP contended that  in the discharge summary which is submitted by the complainant pertaining to his father, the treated doctors in the discharge summary they have mentioned that insured patient is know case of COPD. By contending this entry in the discharge summary of the complainant father treated doctor clearly says that the complainant father was a known patient of COPD. When this fact of the previous ailment is not disclosed, the question of paying the insurance claim amount to the insured does not arise, as there is no liability on the part of the OP Company.  Apart from placing the discharge summary which is submitted by the complainant for the settlement of the claim, the OP has not at all made any attempt to produce any documents and also not produced any illness previous  treatment records pertaining to the insured. They merely contented that  insured was suffering from COPD have  not produced any medical records in order to substantiate their contention that the insured was suffering from the COPD much prior to the availment of the policy. The OP has only contended that non-disclosure of the COPD at the time availment of the policy and also made violation of the terms and conditions of the policy, for which they refused to settle the claim of the complainant. The mere contention for refusal to settlement of claim of the complainant for the above reason is not sufficient. The OP is bound to produce relevant documents in support of  their defence. The OP has merely contended  that COPD illness of the insured , but no documentary evidence or any medical records are not produced in order to substantiate their contention that the insured was suffering from COPD much prior to the availment of the policy. It is also bounden duty of the OP company for indemnify of  the insurance contract with the insured. They are bound to honor the legitimate claim of the insured. The contention of the OP for the refusal of the claim of the complainant as it is not proved with relevant documents in support of their contention. The contention of the facts are very stray statement without having any cogent and convincing evidence on the point of defence. The statement of the OP on facts of stray statement and is not evidentiary value in the eye of law. The OP has not relied on and discharge summary which is produced by the insured and he is also relying on the entry of the discharge summary. Apart from this the OP company has not at all produce any annexure document in order to put forth the defence by way of any record.

16.  In view of the above discussion and by observing the contentions of both parties, it is held that the act and action of the OP attracts deficiency of service on their part in refusal of the claim of the complainant amounts to careless and negligent act of the OP company. The rejection of complaint claim is not at all justified under the law as well as insurance contract between the parties. When such being the case the OP is liable to pay the insurance claim amount to the complainant as prayed in the complaint.
17.  In view of the above discussion, the commission has no hesitation to hold that the complaint deserves to be allowed. Accordingly, the Point No.1 we answer in affirmative.

18. POINT NO.2:- In the result, we passed the following:

ORDER

1. Complaint is allowed in part.
2. The OP is directed to pay Rs.2,02,187/- along with 6% interest from 21.09.2021 till payment made to the complainant.
3. The OP is   further directed to pay a sum of  Rs.10,000/- as compensation towards deficiency of service and Rs.5,000/- towards litigation charges. OP fails to comply the order within 45 days from the date of order, compensation amount and cost of litigation shall  carry interest at 6% p.a. for non-compliance of the order.
4. Furnish free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 29^th April 2023)

(RAMACHANDRA M.S.)

PRESIDENT

       (NANDINI H KUMBHAR)             (CHANDRASHEKAR S.NOOLA)       

                 MEMBER                                        MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Sri Girish-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit: Smt.Prema

Documents produced by the OPs: Nil

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*