Complaint filed on: 24-11-2022
Disposed on: 09-05-2023
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 9th DAY OF MAY, 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.178/2022
Sri Lokesh G.R. S/o Rudrappa,
Aged about 45 years,
Business in occupation,
Resident of Gularave Village,
Palasandra Post,
Tumkur Taluk and District.
……………….Complainant/s
(By Smt/Sri. Srinivasa Murthy N.H., Adv.)
V/s
The Manager,
Reliance General Insurance Co. Ltd.,
Office at No.28, 5th Floor, Southren
Portion, Centernary Building,
MG Road, Bangalore-560 001.
……………….Opposite Party/s
(By Sri/Smt. H.K.Ramamurthy, Adv.,)
:ORDER:
BY SRI.KUMARA.N. - MEMBER
The complainant has filed this complaint against the OP U/s 35 of the C.P.Actwith a prayer to direct the OP to pay reimbursement amount with interest and also damages of Rs.2,85,000/- and other incidental charges of Rs.1,00,000/-.The complainant further prays to direct the OP to pay Rs.2,00,000/- as damages for suffering mental shock and agony along with cost and other incidental charges as this Hon’ble Commission deems fit to grant.
2. In this case, Opposite party was /is, The Manager, Reliance General Insurance Co. Ltd., Office at No.28, 5th Floor, Southren Portion, Centenary Building, MG Road, Bangalore-560 001, hereinafter called as insurance company.
3. It’s a case that the complainant has obtained medi claim insurance policy from the Insurance Company for himself and dependent family members i.e. his wife and children namely Jayalakshmi, Tejas and Chaithra by paying premium of 16,291-00. The Insurance Company at the time of issuing said policy assured the complainant that, medical claim up to Rs 500000=00 to the complainant and his family members in case of medical treatment and services and issued the policy bearing No.141522028280002289 on 21.10.2021 and the said policy was valid from 21.10.2021 to 20.10.2022. It is further case of the complainant that the complainant suffered ill health due to chest pain, cardialic attack on 07.06.2022 admitted to Siddartha Advanced Health Center as in patient from 07.06.2022 to 16.06.2022 and taken treatment and undergone heart bypass surgery and spent nearly Rs.2,85,000/- since said hospital not having cash less services / scheme. The complainant paid the entire bill to the hospital as there was no cash less scheme in the hospital. After the discharge, the complainant informed the same to insurance company by way of filled claim form by producing all original medical bills and relevant documents. Thereafter the insurance company assured that they will reimburse the entire medical expenditure and other expenses, but till today the insurance company failed to do so for the reasons best known to the insurance company. Hence, the complainant issued legal notice on 23.09.2022 calling upon the insurance company to pay the amount of Rs.2,85,000/- with interest, damages and other incidental charges, but the insurance company did not pay the said amount in spite of receipt of legal notice. Hence, without any alternative, the complainant has filed this complaint.
4. The complaint registered and commission notice issued to the insurance company, after the notice served, by this Commission, the insurance company appeared through its counsel and filed its version contending that the policy was issued in favour of complainant in respect of medi-claim policy for the period from 21.10.2021 to 20.10.2022 and the liability of the Insurance company, if any is in accordance with the terms and conditions of the policy. The Insurance company further contended that the complainant was admitted in Sidhartha Health Centre at Tumkur on 07.06.2022 and discharged on 16.06.2022 for cardiac arrest treatment, which is known complication of diabetes. As per the discharge summary issued by Siddartha Advanced Heart Center at Tumkur, the complainant suffering from DM type 2 on regular treatment since last 15 years and he was under medication since 15 years and hence all pre-existing disease are excluded under the policy, hence, the complainant is not entitled for the said claim. It is further contended that the complainant suffering from diabetes prior to inception of the policy and for that, he was under treatment and medication, the expenses for the said ailment was excluded under the policy and hence the claim of the complainant is not payable and thereby the insurance company has rightly repudiated the claim of the complainant on 04.08.2022. The Insurance company further contended that as per the policy terms and conditions in Para No.6.1 “Benefits for pre-existing diseases will not be available for any condition(s) as defined in the policy and hence the present complaint is not maintainable. On these among other grounds, the OP prays to dismiss the complaint.
5. The Complainant has filed his affidavit evidence and also marked the documents at Ex.P1 to P23. On behalf of OP, one Mr.Vijaykumar, Legal Manager, has filed his affidavit evidence. The OP produced two documents which are marked at Ex.R1 & R2.
6. We have heard the arguments from both sides counsels.
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 OP?
2) Is complainant entitled to the reliefs sought for?
8. Our findings on the aforesaid points are as follows:
Point No.1: Partly affermative
Point No.2: In the partly affirmative for the below
:R E A S O N S:
Point Nos.(1) & (2):-
9. The complainant counsel argued that the complainant, obtained medi claim policy from the Insurance company by paying premium of Rs 16291=00 on 21-10-2021, which was in force from 21-10-2021 to 20-10-2022 and the sum assured was Rs 500000=00, the insurance company assured the complainant that, the complainant and his family members covered by the said policy and the said policy support the medical treatment expenses including cash less services / schemes in the hospitals or reimburse the medical bills up to Rs 500000=00. The complainant due to heart attack on 07-06-2022, hospitalized and undergone surgery and taken treatment from 07-06-2022 to 16-06-2022 in Sri Siddartha Advanced Heart Center at Tumkur, as there was no cash less scheme in the said hospital, the complainant paid medical bill of Rs 285000=00 and discharged. The complainant submitted the claim form along with necessary documents and bills to the insurance company, but the insurance company not settled the claim and repudiated the claim by telling non disclosure of material facts that, the complainant suffering from DM type 2 since 15 years. The Complainant further argued that the insurance company at the time of issuing the policy not given any information on this, i.e. pre existing diseases, the proposal form and the insurance policy did not define the terms “preexisting disease,” “pre existing ailment,” “preexisting condition”, “disease” or “illness.”. Since the complainant not aware of all and the insurance company assured to give medical support up to Rs 500000=00, the complainant paid the premium and obtained the said policy and prayed to allow the complaint and award compensation. The complainant produced EX P1, copy of the PAN card, Ex P2, copy of the reliance health gain policy schedule, Ex P3, copy of TRANS THORAC ECHO Report, Ex P4, copy of Coronary angiogram Report, Ex P5, copy of IP cash bill, Ex P6 , copy of Tax Invoice, Ex P7 copy of discharge summery, Ex P 8, copy of health claim form, Ex P9, copy of legal Notice Dated 23-09-2022, Ex P10, postal acknowledgement, Ex P11, postal receipts, (Ex C1 to Ex C20 were original documents of Ex P1 to Ex P8) Ex C21 doctor prescription, Ex C22 crossed cheque of complainant, Ex C23, Copy of Complainant bank pass book.
10. The counsel for the insurance company argued that, admitted the facts that the complainant obtained medi claim policy bearing number 141522128280002856 on 21.10.2021 and the said policy was valid from 21.10.2021 to 20.10.2022 and the complainant submitted claim for Rs 285000=00 along with documents, said claim repudiated, from the record its revels that the complainant suffering with DM Type 2 on regular treatment since last 15 years, but has not disclosed the same at the time of inception of the policy reliance general insurance. The policy cancelled as per clause 6.1 of the policy, as policy holder not disclosed material fact or misrepresented or non disclosed the existence disease. The counsel of the insurance company prayed to dismiss the complaint. The Insurance company counsel produced Ex R1, reliance health gain policy schedule and Ex R2,, copy of the reliance health gain policy schedule words.
11. The Complainant not aware of the facts that to fill the proposal form with respect to prevailing diseases or any diseases and the insurance company not informed nor not raised issues. The complainant left the column blank. Failure to fill in all the queries in the proposal form cannot be termed as suppression or misdeclaration vide Canara Bank v. United India Insurance Co. (2020) 3 SCC 455.
12. The non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
13. The Hon’ble Delhi State Consumer Disputes Redressal Commission in the case between Biral Sun life Insurance Company Ltd., and Ors Vs. Harish Grover on 24 March, 2023, held as under:-
“Services – Insurance – Medical pre-existing illness – patient not suffering at the time of issuance of policy – no proof that patient had medical history – From the aforesaid settled law, it is clear that the common lifestyle disease like diabetes and hypertension, cannot be treated as pre-existing diseases, therefore, cannot be a ground of repudiation of the claim by the Insurance Companies”.
14. The Hon’ble SUPREME COURT OF INDIA, in the case between Manmohan Nanda vs United India Insurance Co. Ltd. on 6 December, 2021, opinioned that,
Therefore, it is observed that any complication which would arise from diabetes mellitusII was also within the consideration of the insurer. Despite the aforesaid facts regarding the medical record of the insured, the insurance company decided to issue the policy to the appellant. The aforesaid clause has to be read against the respondent insurer by applying the contra proferentem rule against it. Otherwise, the very contract of insurance would become meaningless in the instant case. Hence, in our considered view, the respondent insurance company was not right in repudiating the policy in question.
15. In the above discussion, in this case, The complainant paid premium of Rs 16291=00,& obtained medi claim policy reliance health gain policy from the Insurance company, bearing number 141522128280002856 on 21.10.2021 and the said policy was valid from 21.10.2021 to 20.10.2022 and the complainant on 07-06-2022 due to heart attack undergone surgery and taken treatment from 07-06-2022 to 16-06-2022 in Sri Siddartha Advanced Heart Center at Tumkur, as there was no cash less scheme in the said hospital, the complainant paid medical bill of Rs 285000=00 and discharged and submitted the claim of said bills to the insurance company along with documents is an admitted facts, not disputed. Only dispute is the insurance company repudiated the said claim, by the reason of the complainant suffering with DM Type 2 on regular treatment since last 15 years, but has not disclosed the same at the time of inception of the policy, reliance general insurance. it is clear from the para 11,12,13 & 14,of the above, that the common lifestyle disease like diabetes and hypertension cannot be treated as pre- existing diseases, therefore, cannot be a ground of repudiation of the claim by Insurance company. The Insurance company before issuing the policy should have examined the person through medical tests in order to check whether the person is suffering from any pre- existing diseases like DM Type 2.hence insurance company is liable to pay the claim amount to the complainant. In the above discussion this commission is in the opinion of awarding Rs.10,000-00 towards mental agony /compensation and litigation cost of Rs.10, 000-00 to the complainant. Accordingly, we proceed to pass the following;
:ORDER:
The complaint is allowed in part.
The insurance company is directed to pay the claim amount of Rs.2,85,000=00 with interest @ 8% pa from 04-08-2022 i.e. repudiation date to till the date of realization to the complainant.
The OP is further directed to pay 10,000-00 towards mental agony/compensation to the complainant.
The OP is further directed to pay litigation cost of Rs.10,000-00 to the complainant.
The OP is further directed to comply the above order within 45 days from the date of receipt/knowledge of the order. Otherwise it carries fine of Rs 150 per day.
Furnish the copy of order to the complainant and opposite party at free of cost.
