CC No.1222.2015

Filed on 29.06.2015

Disposed on 30.06.2017

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU – 560 027.

DATED THIS THE 30^th DAY OF JUNE 2017

CONSUMER COMPLAINT NO.1222/2015                                                                                                                                                                                                                                                   

PRESENT:

    Sri.  H.S.RAMAKRISHNA B.Sc., LL.B.

            PRESIDENT

                 Smt.L.MAMATHA, B.A., (Law), LL.B.

                          MEMBER

                                            V/S

ORDER

BY SRI.H.S.RAMAKRISHNA, PRESIDENT

1. This Complaint was filed by the Complainant on 29.06.2015 U/s 12 of the Consumer Protection Act, 1986 and praying to pass an Order directing the Opposite Party to pay claim amount of Rs.25,855/-plus medicine and travelling cost, to pay compensation of Rs.4,80,000/-, to pay a sum of Rs.5,000/- towards cost and other reliefs. 

2. The brief facts of the complaint can be stated as under:-

In the Complaint, the Complainant alleges that the Complainant husband took Care Cover Type Floater Health Insurance Policy bearing Policy No.10037156 from the Opposite Party commencing from 29^th August 2013 for one year and renew by making one time payment of premium of Rs.79,702/- for three years on 16^th September 2014 till 15^th September 2017.  In the month of March 2015, the Complainant got ill and having chest pains, as per doctor’s advice, he got admitted for the treatment in Narayana Hrudalaya Whitefield, Bengaluru.  Since it is being cashless policy, the Complainant filled the form of the Opponents at the time of getting admitted to hospital.  However, at the time of discharge, the Opposite Party denied the payment to hospital and he was forced to pay the hospital bill.   After getting discharge, the Complainant approached the Opposite Party’s representative and produced all the relevant documents and claimed for Rs.25,855/- plus the expenses on medicine and travelling.  The Opposite Party No.1 had given the notice for cancellation of the policy on 11.05.2015 and they did it vide letter dt.01.06.2015, also asked the Complainant to surrender the original certificate of the policy to their local office at Koramangala Bangalore.  Mr.Rudresh N. representative of Opposite Party No.1 never explained the Complainant about the terms and conditions of the policy before purchasing the same.  He only explained about the amount covered and the bonus of 10% in addition of covered amount in case of no claim made at the time of renewing the policy.  The Complainant had made the payment and purchased the policy, the policy was posted to the Complainant after the medical test were performed by their representative. The Opposite Parties rejected the Complainant’s request on phone stating that he is suffering from Asthma which is not declared in the declaration form at the time of purchasing the policy, which is very disappointing.  The Complainant then immediately discussed the matter with the representative, namely, Mr.Rudresh N, and showed him the doctor certificate stating that there are 9 blockages in the body but it is not Asthma but he was just given false assurances by the Opposite Party’s representative, Mr.Rudresh N.  The Complainant then asked to talk to higher management which Mr.Rudresh N could not do it.  The representative Mr.Rudresh N. came to Complainant’s residence after three days and advised him to remove his name from the policy or surrender his policy in whole by which the company may consider to refund part of premium amount paid in advance for the balance period, which was not acceptable.  The Complainant tried to resolve the dispute amicably be sending a letter dt.29^th April 2015 to the Opposite Parties but not avail.  Hence this complaint.

3. In response to the notice, the Opposite Parties put their appearance through their counsel.  The Opposite Parties have filed their common version, in the version pleaded that the complaint is false, malicious, the complaint is neither maintainable in law nor on facts that there has been no negligence or deficiency of service on the part of the Opposite Parties.  The complaint is based on mere surmises.  The Complainant’s wife has approached the Opposite Party to obtain the Health Insurance Policy covering both husband and wife submitted the Proposal Form to obtain the insurance policy.  Upon their instruction the Opposite Party has provided a general brief about the health policy.  The Opposite Party had precisely explained the standard terms and conditions and key features of the Opposite Party insurance Company.  The Proposal Form was duly filled and signed by the Complainant after going through the “Key Feature Documents” and understanding the scope, meaning and contents of the Proposal Form and the Policy Terms and Conditions.  The Complainant has breached the most fundamental principle of insurance namely Utmost Good Faith.  The Complainant should have disclosed the material information before taking the policy not providing the information led to the violation of not only the terms of the contract but also the basic principles of insurance. Hence the complaint is liable to be dismissed.  A Medi claim Health Insurance Policy was issued vide Policy bearing Number 10037156 on 29.08.2013 covering both the husband ie., the Complainant and his wife 1^st and 2^nd Complainant and the sum assured was Rs.4,00,000/-.  The policy was issued based on the declarations provided by the Policy Holder in his proposal Form and the Pre-policy medical examination report. While taking the policy, the Complainants have furnished the details of their Health Condition in the proposal form.  Based on the above said declaration provided in the Proposal Form, this Opposite Party has issued the policy covering the hospitalization expenses to the tune of Rs.4,00,000/- as a sum assured value.  On 28.03.2015, the Complainant has requested the Opposite Party for cashless facility for the treatment at Narayana Hrudayalaya and has submitted the Pre-authorization form.  Immediately, this Opposite Party has requested the Complainant to provide the additional information in order to process the claim. Ongoing through the medical records, it is observed that the Complainant was a regular smoker since 30 years and it has also been admitted by the Complainant in the questionnaire filled and signed by him that he was an asthmatic since the last 30 Years and was on regular medication.  In view of the same, the Opposite Party has denied the Cashless facility vide letter dt.30.03.2015 on the basis of non-disclosure of material fact at the time of proposal of the policy.  The complaint filed by the Complainant seeking relief as sought in the complaint is not maintainable either in law or on facts.  Hence, prays to dismiss the complaint.     
4. The Complainant, Sri.Mukesh Balkishan Misra has been filed his affidavit by way of evidence and closed his side.  On behalf of the Opposite Parties, the affidavit of Ms.Ramnique Sachar has been filed.  Heard the arguments of both parties.

5.      The points that arise for consideration are:-

1. Whether the Complainant has proves the alleged deficiency in service by the Opposite Parties ?
2. If so, to what relief the Complainant is entitled?

6.     Our findings on the above points are:-

                POINT (1):- Affirmative

                POINT (2):- As per the final Order

REASONS

7. POINT NO.1:- By looking into the averments of the Complaint and also version of the Opposite Party it is not in dispute that the Complainant had taken Care Cover Type Floater Health Insurance Policy bearing Policy No.10037156 from the Opposite Party with effect from 29^th August 2013 for one year and renewed the same by paying premium amount of Rs.79,702/- for three years on 16^th September 2014 till 15^th September 2017. Further in support of this, the Complainant in his sworn testimony, reiterated the same and produced the Health Insurance Policy Certificate.  By looking into this document, it is in the name of Ms.Kusum Mukesh Misra Floater Health Insurance Policy bearing Policy No.10037156 and policy is for period 29.08.2013 to 28.08.2014.  Under this policy, the Complainant Sri.Mukesh Balakrishnan Misra and his wife Ms.Kusum Mukesh Misra have sum assured is Rs.4,00,000/- and also produced the renewal of Policy No.10037156, by looking into this document, it is clear that the Complainant had paid a sum of Rs.79,702/-, renewed the said policy from 16.09.2014 to 15.09.2017.  This evidence of the Complainant remains unchallenged, therefore, it is proper to accept the contention of the Complainant. 
8. It is further case of the Complainant, in the month of March 2015, the Complainant got ill and having chest pains, as per doctor’s advice, he got admitted for the treatment in Narayana Multispeciality Hospital, Whitefield.  Since the policy is cashless, the Complainant filled the form of the Opposite Party at the time of getting admitted to hospital.  However, at the time of discharge, the Opposite Party denied the payment to hospital and he was forced to pay the hospital bill.  After getting discharge, the Complainant approached the Opposite Party’s representative with relevant documents and claimed for a sum of Rs.25,855/-.  The Opposite Party No.1 had given the notice for cancellation of the policy on 11.05.2015 and they did it vide letter dt.01.06.2015, also asked the Complainant to surrender the original Certificate of the policy.   In order to substantiate this, the Complainant in his sworn testimony, reiterated the same and produced the Discharge Summary issued by the Narayana Multispeciality Hospital.  As looking into this document, it is in the name of the Complainant and reveals that the Complainant taken treatment as an inpatient from 30.03.2015 to 31.03.2015 for Chest Pain and also bill cum receipt issued by the Narayana Multispeciality Hospital.  By looking into this document, it clears that the Complainant spent for medical treatment a sum of Rs.15,355/- and also produced request for Cashless Hospitalization for Medical Insurance Policy for a sum of Rs.18,300/- but the Opposite Party rejected the cashless Facility.  This evidence of the Complainant remains unchallenged.  Therefore, it is proper to accept the contention of the Complainant that the Complainant as an inpatient taken treatment in Narayana Multispeciality Hospital on 30.03.2015 to 31.03.2015 for Chest pain by incurring a sum of Rs.15,355/- his request for cashless facility was refused.  Further it is coming the evidence of the Complainant that after discharge from the Hospital the Complainant presented the claim form along with documents, but the Opposite Party refused to honour the claim of the Complainant. 
9. It is further case of the Complainant that the Opposite Party No.1 had given the notice for cancellation of the policy on 11.05.2015 and cancellation of policy vide letter dt.01.06.2015 and also asked the Complainant to surrender the original certificate of the policy, the Opposite Party representative Mr.Rudresh N. never explained the Complainant about the terms and conditions of the policy before purchasing.  The Opposite Parties rejected the Complainant’s request and ground that he is suffering from Asthma which is not declared in the declaration form at the time of purchasing the policy.  The Complainant then immediately discussed the matter with the representative, namely, Mr.Rudresh N, and showed him the Doctor Certificate stating that there are 9 blockages in the body but it is not Asthma.   To substantiate this fact, the Complainant in his sworn testimony, reiterated the same and produced Notice issued by the Opposite Party to the Complainant for cancellation of policy dt.11.05.2015.  By looking into this document, it is addressed to the Complainant wife Ms.Kusum Mukesh Misra, the Opposite Party issued this notice to the Complainant at the time of obtaining the policy in the Proposal Form nondisclosure of Material Facts Pre-Existing Ailments has known case of Asthma since 30 years and smoking since 30 years for member Sri.Mukesh Balkishan Misra and also produced the notice dt.01.06.2015 cancelling the policy issued in favour of the Complainant bearing No.10037156 and further produced the Certificate issued by the doctor in Narayana Multispeciality Hospital dt.31.03.2015 clearly mentioned that the Complainant had been hospitalized in view of Chest Discomfort with positive TMT test, for elective coronary Angiography.  Even though he has been known asthmatic, this condition has no relationship with his asthma ailment.  He has three vessel disease which require treatment.  Even this evidence also not been challenged by the Opposite Party.  Therefore, it is proper to accept the contention of the Complainant that the Complainant had taken a treatment in Narayana Multispeciality Hospital for his chest pain and the said disease is not connected with Asthma, in spite of that the Opposite Party without honouring the claim of the Complainant rejected the claim of the Complainant, on the ground that the Complainant is known case of Asthma since 30 Years.  This ground of rejecting the claim of the Complainant is not proper and in accordance with procedure and also absolutely there is no evidence to show that the Complainant has suppress this fact at the time of taking policy. As the evidence produced by the Complainant, it clearly reveals that the Complainant is suffering from Diabetic but he has not mentioned that suffering from Asthma and before issuing policy in favour of the Complainant.  The Opposite Party conducted a Medical examination of the Complainant, if the Complainant was known Asthma patient since 30 Years, the Opposite Party would have rejected to issue policy in the name of the Complainant, at that stage itself, on the other hand, Dr.Sridhar of Opposite Party examine the Complainant on 06.09.2013 before issuing policy he never reported that the Complainant is suffering from Asthma, thereby it is not proper to believe the defence taken by the Opposite Party that the Complainant is known as Asthma patient since 30 Years and on that ground the claim of the Complainant was repudiated and also the notice issued for cancellation of the policy in favour of the Complainant is uncalled for and also unreasonable and furthermore the Opposite Party in support of their defence has not placed any evidence that the Complainant was known as Asthma patient since 30 Years.  Except on the basis of the Discharge Summary issued by the Narayana Multispeciality Hospital that the Complainant was known as Asthma patient.  On that ground the Opposite Party repudiated the claim of the Complainant, it is unreasonable one also cancelling the policy is uncalled for the reason assigned by the Opposite Party for repudiating the claim of the Complainant is totally bad in law.  On the other hand, the Opposite Party ought to have honour the claim of the Complainant since during policy is in force the Complainant hospitalization for chest discomfort.  Furthermore, the Complainant placed relevant evidence i.e., Doctor Certificate who treated the Complainant, as a result of the Chest Discomfort and there is three vessels, thereby, the repudiation of the claim of the Complainant amounts to deficiency of service and also adopting unfair trade practice by the Opposite Parties.  Hence, this point is held in the Affirmative.    
10. POINT NO.2:- In the result, for the foregoing reasons, we proceed to pass the following order:

ORDER

The complaint is partly allowed holding that there is deficiency in service by the Opposite Parties No.1 & 2.

The Opposite Parties No.1 & 2 are directed to reimburse the Medical expenses of Rs.15,855/- and also directed to pay a sum of Rs.10,000/- as compensation for causing mental agony to the Complainant.

The Opposite Parties No.1 & 2 are directed to pay sum of Rs.2,000/- as cost.

Supply free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, 30^th day of June 2017)

         MEMBER                                            PRESIDENT
 

LIST OF WITNESSES AND DOCUMENTS

 Witness examined on behalf of the Complainant:

1. Sri.Mukesh Balkishan Misra, who being the Complainant has filed his affidavit.

 List of documents filed by the Complainant:

1. Copy of Insurance Policy and Renewal of Policy
2. Discharge Report
3. Hospital Bills
4. Letter to Religare Health Insurance dt.29^th April 2015,
5. Brochure Showed Before Purchasing the Policy
6. Premedical Report
7. Report of Test Performed by Hospitals
8. Request for Cashless Hospitalisation to Religare Health Insurance
9. Dr.Ashwin M.Daware’s Certificate
10. Notice for Cancellation of Policy dt.11^th May 2015
11. Complaint receiving Letter dt.14^th May 2015.
12. Policy 10037156 Cancellation Letter dt.1^st June 2015.

Witness examined on behalf of the Opposite Party:

1. Ms.Ramnique Sachar, the Manager Legal of the Opposite Party.

List of documents filed by the Opposite Party:

                                -NIL-

     MEMBER                                             PRESIDENT