Date of Filing:29.11.2021

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 complainants files a complaint with this Commission under Section 35 of the Consumer Protection Act of 2019 with a direction to OP to OP to reimburse total hospitalization bill  amounting to Rs.37,39,7467/- with interest at 24% p.a. from the date of admission to the hospital i.e. 09.08.2021 and such other reliefs.

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

The complainant has availed insurance policy from the OP company by paying the premium of Rs.11,352/- and it is a policy in the name of Diabetic Safe Insurance policy to the limit of sum assured of Rs.3,00,000/-. The said policy covers all the related ailments of Diabetic problems and also General Health problems and hospitalization charges. The policy is issued by OP company bearing no.18030V041819 Annual policy no. P/141127/01/2019/005356, it valid from 13.03.2019 to 12.03.2020. After availment of the policy, the policy was renewed for the 2^ndtime during the year 2020 and annual premium is also paid and accordingly the policy issued by OP bearing no. P/141127/01/2020/006700 and it is valid from 13.03.2020 to 12.03.2021 by paying premium of Rs.11,352/- and sum assured of Rs.3,00,000/- andagain the said policy was renewed for 3^rd annual year on receipt of the premium of Rs.11,352/- for a sum assured Rs.3,00,000/-. The OP have issued the policy bearing No.P/141127/01/2021/010493 and it is valid from 13.03.2021 to 12.03.2022. It is the case of the complainant on 09.08.2021 the complainant got admitted to the Apollo Hospital for swelling of left leg knee of the complainant and also suffered other diabetic related issues. The hospital authorities have kept on observation and all the tests done for 4-5 days. Since there is no alternative to save the life of the complainant and finally the Doctors have decided to amputate and finally amputated the left upto leg knee on 14.08.2021. Further the hospital authorities have also informed complainant parents stating that after healing of the wound for about 60-70 days they suggest to conduct plastic surgery to the amputated left leg knee and they have submitted the hospital bills of Rs.8,02,298.33p. During the stay in the hospital when the complainant contacted the OP company for benefits of cashless benefit. The OP Company refused to give the facility and suggested to submit final bills along with all the records. There after when the complainant submitted all the relevant documents along with claim form, the OP Company have refused to settle the claim of the complainant for one or the other reason and also dodge the same for some time. Aggrieved by the act of the OP, complainant was forced to initiate present complaint and sought the reliefs of insurance claim amount along with other reliefs for which he is entitled.

3. Notice to OP-duly served, represented by counsel, filed written version and affidavit in support of their defence and also filed chief examination affidavit.

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

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

6.  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?

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

Point No.1               :       Affirmative

Point No.2               :       As per final order

REASONS

8. POINT NO.1:-  That the complainant has availed insurance policy from the OP company by paying the premium of Rs.11,352/- and it is a policy in the name of Diabetic Safe Insurance policy to the limit of sum assured of Rs.3,00,000/-. The said policy covers all the related ailments of Diabetic problems and also General Health problems and hospitalization charges. The policy is issued by OP company bearing no.18030V041819 Annual policy no. P/141127/01/2019/005356, it valid from 13.03.2019 to 12.03.2020. After availment of the policy, the policy was renewed for the 2^nd  time during the year 2020 and annual premium is also paid and accordingly the policy issued by OP bearing no. P/141127/01/2020/006700 and it is valid from 13.03.2020 to 12.03.2021 by paying premium of Rs.11,352/- and sum assured of Rs.3,00,000/- and  again the said policy was renewed for 3^rd annual year on receipt of the premium of Rs.11,352/- for a sum assured Rs.3,00,000/-. The OP have issued the policy bearing No.P/141127/01/2021/010493 and it is valid from 13.03.2021 to 12.03.2022. It is the case of the complainant on  09.08.2021 the complainant got admitted to the Apollo Hospital for swelling of left leg knee of the complainant and also suffered other diabetic related issues. The hospital authorities have kept on observation and all the tests done for 4-5 days. Since there is no alternative to save the life of the complainant and finally the Doctors have decided to amputate and finally amputated the left leg upto knee on 14.08.2021. Further the hospital authorities have also informed complainant parents stating that after healing of the wound for about 60-70 days they suggest to conduct plastic surgery to the amputated left leg knee and they have submitted the hospital bills of Rs.8,02,298.33p. During the stay in the hospital when the complainant contacted the OP company for benefits of cashless benefit. The OP Company refused to give the facility and suggested to submit final bills along with all the records. There after when the complainant submitted all the relevant documents along with claim form, the OP Company have refused to settle the claim of the complainant for one or the other reason and also dodged the same for sometime. Aggrieved by the act of the OP, complainant was forced to initiate present complaint and sought the reliefs of insurance claim amount along with other reliefs for which he is entitled.

9. The OP filed written version and they have taken up the contention that even though they admitted issuance of the policy to the complainant and it is valid as on the date of the complainant admission to the said hospital. Their only contention for rejection of the complainant claim is that since the complainant was known patient of Diabetic, as it was not disclosed at the time of availment of the policy and also assigned some other reasons as stated that the complainant has failed to produce all the required documents pertaining to his hospital treatment. By assigning all these reasons the OP has prayed for dismissal of the complaint as it is a clear violation of the insurance contract by the complainant.  on this ground they pray for dismissal of complaint as they are not liable to pay the insurance claim.

10.  On perusal of the complaint averments as well as the contentions of both the parties, it is crystal clear that the complainant has availed the insurance policy from the OP company and said policy was renewed consecutively for 3^rd year and when the complainant got admitted to the Apollo hospital for his health issues and due to his diabetic issue. The doctors have decided to amputate left leg upto knee of the complainant in order to save the life of the complainant. The complainant was made payment of Rs.8,00,000/- for the treatment availed from the   Apollo hospital, when that claim was raised for reimbursement which is covered in the said policy. Surprisingly, the OP Company have refused to settle the claim of the complainant by assigning one or the other reason. Apart from taking defence of violation of terms and conditions, the OP have failed to substantiate their contention by leading evidence. The repudiation of OP to settle the claim of the complainant is solely for the reason that the complainant was a known patient of diabetic and same was not disclosed by the complainant at the time of availment of the policy as it amounts to violation of terms and conditions and also it amounts non-disclosure of material facts. All these facts disentitle the complainant from getting the benefit of insurance claim amount. For this reasons OP has refused  to honor the legitimate claim of the complainant. On these grounds, the commission observe as follows, the Hon’ble Supreme Court of India and also Hon’ble National Disputes Redressal Commission, New Delhi, in their several verdicts have laid down the ratio which needs to be followed by the company while dealing with such claims. The Apex court of India have held on the fact the judgment rendered by the Hon’ble Supreme court in Civil Appeal No.3397/2020 between the Branch Manager, Bajaj Alliance Insurance Co. Ltd. & others V/s Dalbir Kaur and Hon’ble National Commission, New Delhi, on the point of Hypertension in a case between Mamata Kumar V/s Bharathi Axa Life Insurance Co. , which is alleged in 2016(1) CPJ page 613 insured having an hypertension does not amount to suppression of material facts as it being a life style disease. It is also discussed in the case that it has been clearly mentioned that hypertension and diabetic are lifestyle diseases and it do not amount to suppression of material illness. The principles which is laid down in the judgment is Diabetic and Hypertension cannot be considered  as disease which is held as life style of the people and the insurance company cannot reject any claim of policy for the reasons, that the insured is suffering from diabetic and hypertension.

11. In view of the above discussion and by considering the facts of the complaint and also by taking note of the ratio laid down by the Apex Court of India we have no hesitation to hold that  it is clear case of deficiency on the part of the OP company while dealing with the insurance claim of the complainant, for which liability could be casted upon the company to pay the insurance claim of the complainant along with other reliefs which is granted in the complaint.

12.  The complainant counsel while arguing the complaint on merits has vehemently argued that the complainant is 34 year old young boy and due to the negligence and carelessness and deficiency in service on the part of the OP company while dealing with the claim of the complainant they have acted inhumanly and  when 34 year old young boy when has taken a policy from the OP company he is believed that the insurance company by honoring the insurance contract of indemnity will respond positively at the time of claim for settlement of the insurance amount. The commission observe that even though the policy limit is for a sum of Rs.3,00,000/-. The commission by looking at the age of the insured person and also mental agony and pain and suffering and also  by considering loss of left  leg upto knee due to diabetic, the commission is of the opinion that when the complainant got admitted to Apollo hospital and when the doctors of the hospital have decided to ampute the left leg upto knee of the complainant. The total bill was raised for Rs.8,00,000/-, at that point of time when the claim was raised by the complainant/insured, the OP company knowing the condition of the insurer/complainant, even after knowing that the mental agony and pain suffering and also loss of limb. Even after knowing of his condition of the insured the OP company have negligently and carelessly behaved inhuman manner and when they have refused to settle the claim of the complainant. Due to which the insured was made to undergo trauma, pain and suffering, for which the OP company is to be held liable to pay the compensation for their negligence and carelessness act. Due to the negligent act of the OP company the complainant was made to suffer both financially and mentally and also undergone lot of pain and suffering. The commission can take note of that and also  the age of young boy at the age of 34 years, if he lost his left leg and when raised  to claim of insured amount for the said treatment and amputation of leg and when the insurance company has refused to settle the claim of the complainant at that movement of time even though the company is liable to pay legitimate claim of the insurance amount to the complainant. By this observation and by considering the  condition, pain suffered and hardship which has undergone by the complainant. The commission has no hesitation to hold that the complainant is entitled for the higher rate of compensation and also even if it is awarded and paid for the agony, trauma which is undergone by the complainant/insured  the amount of compensation awarded cannot be subside the pain of the insured.
13.  In view of the above discussion and by considering the facts of the complaint, the commission has no hesitation to held that the complainant is entitled for the relief of insurance claim amount of Rs.3,00,000/- along with higher rate of interest and also with the  relief of higher compensation for alleged deficiency in service of the OP. The OP company is held liable to pay entire amount for their willful and reckless  act and negligent action,  as it amounts to deficiency in service on their part.

14.  In view of the above discussion, the Point No.1 we answer Partly in Affirmative.

15. 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.3,00,000/- along with interest at the rate of 8% p.a. from the date of discharge   till refund is made  to the complainant.
3. The OP is   further directed to pay a sum of  Rs.1,00,000/- as compensation towards deficiency of service and Rs10,000/- towards litigation charges and also to pay Rs.25,000/- towards mental agony, pain and  suffering. 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 Sanjay-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit:    Smt.Prema- Who being the Asst. Manager-Legal  of OP

Documents produced by the OP: Nil

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*