THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 17th DAY OF JUNE 2021
PRESENT
SRI RAVI SHANKAR – JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI - MEMBER
APPEAL NO.1412/2011
Sri. Syed Peer,
S/o Syed Imam Sab,
Aged about 51 years,
Agriculturist and Businessman,
R/o Holaluru,
Village and Post:Holaluru,
Shivamogga Taluk and District.
……….Appellants.
(By Shri/Smt. Chandru & S.Shekar, Adv.,)
-Versus-
1. The Manager, (Health Insurance)
LIC of India, Divisional Office,
KSSIDC Building, Sagar Road,
Shivamogga.
2. The Manager, (Health Insurance)
LIC of India, Divisional Office,
Jeevan Prakash, No.4-1,-899, Oasis Plaza,
Thilak Road, Abids, Hyderabad.
(By Shri/Smt. Prashanth .T Pandith, Adv.,)
:ORDERS:
BY SMT. SUNITA C. BAGEWADI - MEMBER
This appeal is filed by the appellant/complainant being aggrieved by the order dated:30.11.2010 passed by Shimoga District Consumer Commission in C.C.No.131/2010.
2. The parties to the appeal shall be referred to as complainant and Opposite Parties respectively as per their rankings before the District Commission.
3. The brief facts of the complaint is that:-
The complainant has taken health insurance policy on 08.02.2008 by paying Rs.12,500/- premium Per Month for his family members including the complainant. The term of the policy is 16 years and the same will be in force from 06.02.2008 to 2021. The complainant further submits that there is no default in payment of premium till today. The complainant has suffered heart problem during December 2008. The complainant has got admitted at Hegde Health Complex, Shivamogga from 19.12.2008 to 25.12.2008 and has taken treatment in the said hospital. Subsequently on the advise he has taken treatment at Jayadeva Hospital, Bangalore. After check-up, the complainant was suffered severe heart ailment. Accordingly, the complainant has got admitted at Jayadeva Hospital, Bangalore and he has undergone with Angio-plasti operation and consequential follow-up treatment has taken from the above said hospital. The complainant further submitted that he was in Hospital from 04.02.2009 to 08.02.2009 and he has incurred medical expenses nearly about more than Rs.1,15,000/-. The complainant further submits that in terms of the policy, after discharge from the hospital, within time, he has filed a claim before the Respondent for reimbursement. After securing all the information, the Opposite Parties/Respondents repudiated the claim on the ground that the claim is barred by time and ailment falls under PED. Hence, the complaint.
4. The Opposite Parties appeared before the District Commission and filed their objections. The Opposite Parties contended that it is true that the complainant has obtained a policy under LIC health Plus Plan bearing No.625363734 dated:06/02/2008 for Rs.12,500/- P.A. and also contended that the policy term was 16 years and the Opposite Parties denied that as per the policy conditions, the opponents to bear all medical expenses and as per the policy conditions whenever the members insured or other insured persons got medical treatment as inpatient in any hospital, a daily hospital cash benefit at the rate of Rs.500/- Per Day is payable for the period of treatment excluding first two days in case of any one of the 49 major surgeries listed in the policy condition is undergone, a Major Surgical Benefit of Rs.1,00,000/- (200 times of daily cash benefits choosen by the member insured) is payable.
4(a) The Opposite Parties further contended that the complainant was admitted to Hegde Health Complex Hospital, Shimoga during the period 19/12/2008 to 25/12/2008 with final diagnosis as AWM1/2 HTN. As per the discharge summary, it is recorded that the complainant was a known case of Hypertensive since years on medications. This fact was not disclosed in the proposal form by the complainant. hence, the claim was rejected on 28.02.2009 by Third Party Administrative (TPA) on behalf of LIC of India giving reason as ‘Pre existing disease’. The Opposite Parties further contended that neither the claim made by the complainant is in respect of his hospitalization for the period from 04/02/2009 to 08/02/2009 at Jayadeva Institute of Cardiology, Bangalore. As per the clinical diagnosis and report, the complainant was diagnosed to be a patient of IHD (Ischemic Heart Disease) recent AWMI, CAD-SVD.
4(b) The Opposite Parties further contended that as per the discharge summary, Jayadeva Institute of Cardiology past history was not known case of D.M./H.T.N./COPD Asthama/ Any drug allergy. The complainant had a surgery PTCA with stent to LAD done on 05/02/2009 in Jayadeva Hospital, Bangalore. But the history was not correctly recorded in respect of AWMI/2 HTN with hypertensive since years on medications in discharge summary of Jayadeva Hospital, Bangalore.
4(c) The Opposite Parties further contended that the complainant in respect of the 2nd hospitalization has been sent to the TPA by the Opposite Parties on 25/02/2009 which is belated claim also as per the terms and conditions agreed to under the policy of insurance. The Opposite Parties further contended that the claim forwarded by the complainant has been sent to the 3rd party Administrator (TPA). After going through the hospital papers and other documents submitted by the complainant, the claim was rejected vide letter dated:10.04.2009 for the reason “Claim submitted after 15 days from the date of discharge from the hospital and pre existing disease”.
4(d) The Opposite Parties further contended that according to the complainant as answered by him question in No. 2 & 6 he has suffered from hyper tension and that he was not taking any medication for it, but this statement was false to his own knowledge. The complainant has suppressed these material facts that was vital for the Opposite Parties to know to assess the risk he is going to undertake in issuing a policy to the complainant and decide about accepting or otherwise of the risk involved. Thus, the complainant has committed a serious breach of trust by suppressing material facts which he was bound to disclose and fraudulently induced the Opposite Parties to accept the risk on his life and on the life of his family members.
4(e) The Opposite Parties further contended that the surgical operation that the complainant underwent is “PTCA with stent to LAD done on 05.02.2009 – 2.75 X 25 mm PROLINK stent used (Lot No-K080806020404) – Cath No – 14826/1”) which is no included in the 49 Major Surgical Benefit covered under the policy. Thus, even if the Opposite Parties have taken decision to condone the delay in submission of the claim by the complainant, the complainant would not have been eligible for Major Surgical Benefit (MSB). However, he is eligible for Hospital Cash Benefit (HCB) only. Hence, prays to dismiss the complaint.
5. After trial, the District Commission, Shimoga dismissed the complaint.
6. Being aggrieved by the said order, the appellant/complainant is in appeal on various grounds.
7. We have heard the arguments of respondents. In spite sufficient opportunities, the appellant did not address his arguments. Hence, the argument of the appellant is taken as heard.
8. Perused the order passed by the District Commission, Shimoga and materials on record, we noticed that it is an admitted fact that the complainant has obtained a policy under LIC Health Plus Plan bearing policy No.625363734 dated:06.02.2008 for 16 years with the premium of Rs.12,500/- PA. The policy covered lives of member insured, his wife and two children. It is also an admitted fact that the complainant was admitted to Hegde Health Complex Hospital during 19.12.2008 to 25.12.2008 with final diagnosis as AWMI /2 HTN and the complainant forwarded the claim to the LIC of India for that hospitalization. But the same was rejected on 28/12/2009 by TPA on behalf of LIC of India giving reason as “Pre existing disease”, because as per the discharge summary of Hegde Health Complex Hospital, it is recorded that the complainant was a known case of Hypertensive since years on medications. This rejection of claim has been not questioned by the complainant.
9. Here dispute is only in respect of alleged second hospitalization of the complainant for the period from 04.02.2009 to 08.02.2009 at Jayadeva Institute of Cardiology, Bangalore and as per the discharge summary of Jayadeva Institute of Cardiology, past history was not known case of D.M./H.T.N./COPD Asthama/Any Drug allergy. The history was not correctly recorded in respect of AWMI/2 HTN with hypertensive since years on medications. The complainant had a surgery PTCA with stent to LAD done on 05/02/2009 at Jayadeva Institute of Cardiology, Bangalore. This claim also rejected by the TPA for the reason “Claim submitted after 15 days from the date of discharge and “Pre Existing Disease”.
10. Perused the order passed by the District Commission, Shimoga. The District Commission has not accepted the contentions of the Opposite Parties that the second claim of complainant is beyond the period of 15 days and the complainant is not entitled to such claim. Now only one issue before us for our discussion is that as per the Hegde Hospital discharge summary, the complainant was known case of hypertensive since years on medications and Jayadeva Institute of Cardiology was not correctly recorded in respect of AWMI/2 HTN with hypertensive since years on medications. The complainant was submitted the proposal form on 04.02.2008 and subsequently the policy was issued. After 10 months, the complainant was admitted at Hegde Health Complex Hospital from 19/12/2008 to 25/12/2008, at that time of hospitalization it is recorded as the complainant was known case of Hypertensive since years on medication. Only basing on that discharge summary, the LIC of India rejected the first claim of the complainant. The complainant was admitted second time at Jayadeva Institute of Cardiology, Bangalore from 04.02.2009 to 08.02.2009 and he had surgery PTCA with stent to LAD on 05/02/2009. The complainant was spent Rs.1,15,000/- towards medical expenses and forwarded the claim to LIC of India, but this claim was also rejected by LIC of India on the ground that “Pre existing disease”. However, there was no any history of hypertensive was mentioned in discharge summary of Jayadeva Hospital.
11. After going through the various judgments of Hon’ble National Commission, the Commission observed that hypertensive is a life style disease and easily controllable with medicines to alternative system. It may occur in many persons at any time. The blood pressure increases or decreases with aging process. But it can be treatable and can keep under control and person can out live his normal life. It is not a fatal disease to say, it was material fact that was suppressed by the complainant at the time of filling of the proposal form. In the present case on 04.02.2008 the proposal for obtaining policy was submitted by the complainant and for contained questions with respect to his health, medical history, the complainant had answered these questions in Negative. That not means the complainant had intentionally suppressed the material facts.
12. In discharge summary of Hegde Health Complex Hospital shows the complainant was a known case of hypertensive since years on medications. But there is nothing on the file to show that prior to this, the complainant ever took treatment for hypertension from any hospital. Moreover, hypertension is decreased and increased as per the life style and may be, it was under control at the second time of hospitalization of the complainant and may be this is the reason that the Jayadeva Hospital not mentioned about the hypertension in their discharge summary. Hence, in our opinion rejection of the claim of the complainant by LIC of India is not sustainable. Moreover, the complainant has taken the health policy. A contract of insurance policy is one of utmost good faith for both insurer and insured person. Hence, Medi claim cannot be denied only on technical ground. Hence, in our opinion as per the terms and conditions of policy, the complainant is entitled to daily cash benefit and also Rs.1,00,000/- towards Major surgical benefit with compensation. Accordingly,
:ORDER:
The appeal filed by the appellant/complainant is allowed with no order as to costs.
The order dated:30/11/2010 passed by the Shimoga District Consumer Commission in C.C.No.131/2010 is hereby set-aside and the complaint is allowed.
The Opposite Parties are directed to pay Rs.1,00,000/- to the complainant towards Major Surgical Benefit and also directed to pay daily Cash Benefit to the complainant as per the terms and conditions of the policy within 30 days from the date of this order along with 6% interest from 25.02.2009 i.e. when the claim was rejected by the Opposite Parties.
The Opposite Parties are further directed to pay Rs.25,000/- towards compensation to the complainant.
Return the LCR forthwith to the concerned District Commission.
Send a copy of this order to both parties as well as Concerned District Commission.
Sd/- Sd/-
Member. Judicial Member.
Tss
