Karnataka

Bangalore 4th Additional

CC/15/1326

R V Krishna Rao - Complainant(s)

Versus

The Manager. Star Health and Allied Insurance Company Limited, - Opp.Party(s)

02 Apr 2018

ORDER

Complaint filed on: 16.07.2015

                                                      Disposed on: 02.04.2018

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

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

 

 

CC.No.1326/2015

DATED THIS THE 02^nd APRIL OF 2018

 

PRESENT

 

 

SRI.S.L.PATIL, PRESIDENT

SMT.N.R.ROOPA, MEMBER

 

Complainant/s: -                           

R.V.Krishna Rao,

No.403, Oxford College

Staff Quarters,

Bommanahalli,

Bengaluru-68.

 

Inperson     

 

V/s

Opposite party/s

Respondent/s:-

1. The Manager,

Star Health and Allied

Insurance co., ltd.,  

D-Block, 1^st floor,

Basava Sadana,

Nehru Road,

Shimoga-577201

 

2. The Manager

Zonal Office,

Star Health and Allied

Insurance co., ltd.,

Esteem Towers, 3^rd floor,

71, Railway Parallel road,

Kumar Park West,

Bengaluru-20.

Next to Murugan Temple Arch

 

By Adv.Sri.Y.P.Venkatapathi

PRESIDENT: SRI.S.L.PATIL

 

 

            This complaint is filed by the Complainant against the Opposite party no.1 & 2 (herein after referred as Op.no.1 & 2 or Ops) seeking issuance of direction to pay medical expenses of Rs.72,361/-, compensation of Rs.50,000/-, legal expenses of Rs.10,000/- & Travelling cost of Rs.10,000/-.

 

          2. The brief facts of the case of the Complainant are that, he had obtained “Senior Citizens Red Carpet insurance policy” (hereinafter referred as the said policy) from Op.no.1 on 03.01.11 by paying annual premium of Rs.9,326/- and the sum insured for Rs.2 lakhs. Subsequently, he renewed the policy for second year and then for third year. It is the case of the Complainant that, on 05.07.14 evening, he slipped down while waking on the foot path and his left knee rotated, resulting in severe pain.  On 07.07.14, he visited Sanjay Gandhi Institute of Trauma & Orthopedic Center at Bengaluru and the Orthopedic Surgeon Dr.Reddy after examination advised him for x-ray. After reading x-ray report, he prescribed medicines and advised for physiotherapy exercises. As the pain did not subsided, again he visited Sanjay Gandhi hospital and the Dr.Y.S.Shivakumar after examining advised him for MRI investigation. After going through the MRI report, the said doctor advised him to undergo arthroscopic surgery for medical meniscus tear and rupture of the medal ligament. As per his advice, he admitted at Manipal hospital on 31.07.14 and underwent all the investigations and operation was performed on 01.08.14 and he was discharged on 02.08.14 with advice for rest for 10 days.  During that period, his left leg was immobilized with pad and after four days he was advised to use walker. During the period, he was under the medication with analgesics and antibiotics. After 15 days he reviewed and removed the clips and prescribed pain killers. The Complainant further submits that, as per the conditions of Op, Op was intimated immediately after admitting to the hospital on 31.07.14. But Op denied to reimburse the hospital bill and the medical expenses of Rs.70,958/- and asked him to submit fresh claim form and to resubmit all the bills. In this context, he issued legal notice but Op not settled his claim. Hence prays to allow the complaint.

 

3. On receipt of the notice, Op.no.1 & 2 did appear and filed common version admitting that Complainant has obtained the said policy and submits that the claims arising therein are subject to the terms & conditions forming part of the policy.  Ops further submit that, the Complainant though had gone to hospital as intimated, as per submitted documents, the medical team opined that the admission is for Pre-Existing Condition which was not disclosed at the time of inception of policy. Hence, the cashless facility was not allowed and asked the Complainant to approach with claim form and along with supporting documents, for consideration of the claim, as per the terms & conditions of the policy. The Complainant have approached for reimbursement along with the bills, on receipt of the said bills Op raised a query to submit (1) the first consultation report when chronic obstructive pulmonary disease, hypertension, deep vein thrombosis was first diagnosed with all investigation reports including pulmonary functions tests, chest x-ray, ECHO, ECG, Doppler limbs, MRI spine and all other reports with treatment details taken till the date of admission (ii) previous hospitalization discharge summary with reports. The Complainant since failed to produce the reports and necessary documents, the Op could not process the claim. Therefore on seeing the past history since the facts found otherwise than what is stated in the proposal and other documents by the Complainant, the cash less facility was first rejected and then he was asked to submit all the documents for further scrutiny. According to discharge summary he was diagnosed as suffering with COPD since 7 years, Hypertension since 12 years, DVT since 2 years and he had suffered fracture of his femur bone several times since childhood. Hence the Op has called for the above said documents which are mandatory to process the claim but the Complainant has not submitted the same, without which the Op could not process the claim. The Op further submits that, as per condition no.4 “the insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require the dealing with the claim. The Op further submits that, the Op is guided/obligated to process the claim subject to scrutiny of the documents that will be furnished by the insured, the claim will be examined accordingly, and if payable, it will be paid and if, the claim falls under any exclusion clauses of the contract, the decision will be taken accordingly. As per the contents of the hospital documents, the claim of the Complainant is not allowable. However, he is at liberty to approach the Op for getting clarifying the Op and get relief, if it is payable as per contract. Hence, Op is unable to pay the amount as per policy, while working as juristic person, without proper support of the documents and furnishing of the documents and particulars. Hence the complaint deserves to be dismissed with costs for want of cause of action. Hence, prays to dismiss the complaint.

         

          4. The Complainant to substantiate his case filed affidavit evidence and produced 23 documents. Joint Vice President of Op insurance co., filed affidavit evidence and none of the documents been produced. Complainant filed written arguments. Heard.  

  

5. The points that arise for our consideration are:

1. Whether is there any deficiency of service on the part of Ops, if so, whether the Complainant entitled for the relief sought for ?  
2. What order ?

         

           

 

6.  Our answers to the above points are as under:

 

Point no.1: In the Affirmative  

Point no.2: As per the final order for the following

 

REASONS

 

          7. Point no.1:  We have briefly stated the contents of the complaint as well as the version filed by Op.no.1 & 2. The undisputed facts which reveals from the pleadings of the parties goes to show that, Complainant had availed the “Senior Citizens Red Carpet insurance policy” (hereinafter referred as the said policy) for a sum of Rs.2 lakhs. The Complainant has renewed the said policy by paying the stipulated premium of Rs.9,500/- per year i.e. from 03.11.11 to 02.01.15, which can be seen at page 2 of the complaint. It is also an undisputed fact that, he was suffering from twisting injury on his left knee since few months for which he took treatment at Sanjay Gandhi Hospital on 07.07.14 on OPD basis and later on he was admitted on 31.07.14 at Manipal Hospital for further treatment since there was a severe pain in his left knee and was unable to walk for long distance. After thorough investigation in the said hospital it was diagnosed that he had Partial tear posterior horn of medial meniscus left knee and grad 3 chondral damage medial femoral condyle, grade 2 lateral femoral condyle. As per the doctor’s advice he underwent Arthroscopic partial Menisectomy of left knee on 01.08.14 and discharged on 02.08.14. In this context, Complainant has spent an amount for the hospitalization at Manipal Hospital. We also noticed that, at the time of underwent for the operation for the above disease, the said policy was in force. The injury so sustained by the Complainant was on account of “twist injury in foot path while walking six months back” which can be seen at red ink page 000026. He sought for the reimbursement of the hospital expenditure for an amount of Rs.59,333/- (document no.13 Inpatient detailed bill - red ink page 000027). In this context, authorized signatory of Ops wrote a letter dtd.02.08.14 (document 4 red ink page 000013) to the Manipal Hospital, Bengaluru stating that “On a scrutiny of the details furnished by you, we are of the opinion that the claim of insured-patient is not admissible under the above insurance policy issued to him for the following reasons – There is nondisclosure of pre-existing disease during inception of the policy. Hence, your request for authorization for cashless treatment of the above insured-patient is denied.” By assigning these reasons, the claim has repudiated. The Complainant vehemently urged before us stating that, the injury so sustained by the Complainant was due to twist injury in foot path while walking six months back, hence, it is not pre-existing disease. When such being the fact, the question of suppressing alleged pre-existing disease does not arise, so the claim repudiated by the Ops is totally illegal and also as against the settled principal of law. In support of his arguments, he placed reliance on the following decisions.

a. 2010 (2) CPR 443, Uttaranchal State Commission in the case of Mahavanand Joshi vs. Life Insurance Corporation of India and another. Held: Where suppression of material facts is alleged by the insurance company in relation to a mediclaim policy, the insurer is required to prove that life assured was treated or hospitalized for few days before taking the policy.

b. 2012 (1) CPR 391 (NC) in the case of LIC of India vs. Smt.Sudesh, Held: insurance company mut investigate health issues before issuing insurance policy.

c. 2009 (2) CPR 226 (NC) in the case of Bijoy Kumar Chaturvedi vs. United India Insurance co. ltd., Held: onus to prove that there has been a suppression of material facts with regard to the pre-existing disease rests heavily on the insurance company.

d. 2009 (3) CPR 53 in the case of LIC of India and others vs. Kailash Chandra Kar, Held: Consumer Protection Act is a beneficial legislation and it cannot allow insurance company to escape liability on technical grounds to deprive the consumer of benefits to which he was entitled to.

e) SCDRC Page no.1308 LIC of India and others vs. Smt.Usha Rani, Held: the right of repudiation of an insurance claim, it has to be exercised judicially and on sound principles.

f) 2011 (1) CPR 167 (NC) in the case of LIC of India vs. Smt.Rupinder Kaur, Hedl: Repudiation of death claim on the ground of suppression of pre-existing disease- District Forum while holding that there was no attempt by LIC to prove pre-existing disease, directed LIC to pay insured amount along with compensation of Rs.5,0000/-. Upheld the State Commission, Revision dismissed.

g) 2009 CTJ 1187 Supreme Court (CP) Oriental insurance company ltd., vs. Ozma Shipping company and another, Held: insurance companies should not adopt an attitude of avoiding payments of the genuine and bonafide claim of the insured on one pretext or the other. This attitude puts a serious question mark on their credibility and trustworthiness. By adopting an honest, approach, they can save enormous litigation costs and interest liability.

h) 2009 (2) CPR 226 (NC) in the case of Bijoy Kumar Chaturvedi vs. United India insurance company ltd., Held: Onus to prove that there has been a suppression of material facts with regard to the pre-existing disease rests heavily on the insurance company.

i) 2009 (3) CPR 53 LIC of India and others vs. Kailash Chandra Kar, Held: Consumer Protection Act is a beneficial legislation and it cannot allow insurance company to escape liability on technical grounds to deprive the consumer of benefits to which he was entitled to.

j) 2010 (1) CPR 114 National insurance company ltd., vs. Nand Lal, Held: insurance claim must be honestly settled without any delay

k) 2007 (1) AWC 487 in the case of Umesh Narain Sharma vs. The New India Assurance company (Allahabad High court) Held: claim was rejected. High court allowed the writ petition on similar facts and circumstances of this case.

We find there is considerable force in the arguments advanced by the Complainant since injury so sustained by the Complainant was on account of slip when he was walking, but not on account of his alleged pre-existing disease. Hence, the claim repudiated by the Ops is totally illegal.

 

          8. Another contention taken by Ops are that, complaint filed by the Complainant is pre-mature, since they have not received any documents to process the claim. The Manipal hospital authorities have already sent almost all the documents for the refund of the hospital bills, for which Ops wrote a letter dtd.02.08.14 to the Manipal Hospital, Bengaluru, wherein claim has been denied on the ground of non-disclosure of pre-existing disease during the inception of the policy. Except taking this bald allegations nothing is placed on record by filing the affidavit of the concerned Doctor, who examined the Complainant and issued certificate in respect of pre-existing disease. This contention taken by Ops is also no legs to stand.

 

          9. Another contention taken by Ops at para 14 of its version i.e. as an additional pleas states that:

1. This Op further submits that the policy issued to the Complainant under which the dispute has been raised is governed by Limits of liability as per various clauses. That without any prejudice to whatever has been stated earlier in this written statement, even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant – petitioner. It is respectfully submitted that the maximum quantum of liability under the terms of the policy is Rs.40,263/-.
2. As per exclusion no.5: 50% of each and every claim arising out of pre-existing disease as defined and 30% in case of all the other claims which are to be borne by the insured.

 

    10. In this context, we are declined to accept the contention taken by Ops with regard to the limited liabilities, for the simple reasons that those conditions may apply in the event of proving the pre-existing disease. But in the instant case, the Complainant having no any pre-existing disease. The injury so sustained by the Complainant is due to “twist injury in foot path while walking”. Accordingly we come to the conclusion that, while repudiating the claim of the Complainant, Ops have hurriedly without application of mind, come to the conclusion that, the claim is repudiated due to non-disclosure of the pre-existing disease during the inception of the policy. Hence, the medical expenditure as shown in document no.13 Inpatient detailed bill - red ink page 000027 for an amount of Rs.59,333/- dtd.02.08.14 is payable to the Complainant by Op.no.1 & 2 jointly and severally. With regard to the other tests conducted by other than Manipal Hospital are hereby denied. With regard to the compensation is concerned, Complainant has sought for Rs.50,000/-. In our considered view, the said amount is reasonable amount as the claim repudiated by the Ops are on non-application of mind and arbitrary in nature. With regard to the legal expenses are concerned, Complainant has sought for Rs.10,000/-, which appears to be just and proper. With regard to the travelling costs Rs.10,000/- is concerned, the Complainant has not produced any of the receipts. Hence the said claim is denied. In all Complainant is entitled for Rs.1,19,333/-. Accordingly we answer the point no.1 in the affirmative, holding that there is deficiency of service on the part of Op.no.1 & 2 and the Complainant is entitled for the relief sought.   

 

          11. Point no.2: In the result, we passed the following:

 

ORDER

 

          The complaint filed by the Complainant is hereby allowed.  

 

2. Op.no.1 & 2 are jointly and severally liable to pay medical expenditure of Rs.59,333/- and compensation of Rs.50,000/- to the Complainant within six weeks from the date of this order, failing which, the said amounts carried interest at the rate of 6% p.a. from the date of repudiation till the date of realization.

 

3. Ops are also directed to pay cost of litigation of Rs.10,000/- to the Complainant.

 

          Supply free copy of this order to both the parties.

 

          (Dictated to the Stenographer in the open forum and pronounced on 02^nd April 2018).

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT

                                                                        

1. Witness examined on behalf of the complainant/s by way of affidavit:

 

Sri.R.V.Krishna Rao, who being the complainant was examined. 

 

Copies of Documents produced on behalf of Complainant/s:

Doc.no.1	Insurance policy
Doc.no.2	Claim form part B
Doc.no.3	Claim form part A
Doc.no.4	Denial of pre-authorization for cashless treatment dtd.02.08.14
Doc.no.5	Query on pre-authorization
Doc.no.6	Letter dtd.16.10.14
Doc.no.7	Self declaration
Doc.no.8	To Whomsoever it may concern by Manipal hospital
Doc.no.9	Out patient registration
Doc.no.10	Receipt of Sanjay Gandhi Institute of Trauma & Orthopedics dtd.07.07.14
Doc.no.11	Clumax Diagnostics report & bill
Doc.no.12	To Whomsoever it may concern by Manipal hospital
Doc.no.13	Inpatient bills of Manipal hospitals
Doc.no.14	Prescriptions
Doc.no.15	Outpatient record
Doc.no.16	Discharge summary
Doc.no.17	Op bill
Doc.no.18	Manipal hospital bill
Doc.no.19	Op – Senior citizens red carpet insurance policy – schedule and benefit policy
Doc.no.20	Medicine bills
Doc.no.21	Identity card
Doc.no.22	Senior citizens red carpet insurance policy
Doc.no.23	Legal notice dtd.26.09.14

 

2. Witness examined on behalf of the Opposite party/s Respondent/s by way of affidavit:

Sri.John Noronha, who being the Joint Vice President of Op Insurance co., was examined.

 

Copies of Documents produced on behalf of Opposite party/s

NIL  -

 

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT