Complaint filed on: 02/02/2009<br /> Disposed on: 09/02/2010<br /> <br /> <br /> BEFORE THE BANGALORE IV ADDITIONAL DISTRICT<br /> CONSUMER DISPUTES REDRESSAL FORUM, BANGALORE<br /> URBAN DISTRICT NO.8, SAHAKARA BHAVAN<br /> CUNNINGHAM ROAD, BANGALORE – 560 052<br /> <br /> COMPLAINT NO.295/09<br /> <br /> <br /> DATED THIS THE 9th FEBRUARY 2010<br /> PRESENT<br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT<br /> SRI. GANGANARASAIAH, MEMBER<br /> SMT. ANITA SHIVAKUMAR. K, MEMBER<br /> <br /> <br /> Complainant:<br /> <br /> <br /> Sri. Udaya Sudan<br /> S/o Raju<br /> Aged about 32 years<br /> Residing at No.212<br /> Bellary Road<br /> Nikhi Motors<br /> Sadashivanagar<br /> Bangalore-560 080<br /> <br /> <br /> V/s<br /> <br /> <br /> <br /> <br /> Opposite Parties:<br /> <br /> <br /> 1. The Manager<br /> Royal Sundaram Alliance<br /> Insurance Company Ltd.,<br /> Sundaram Towers<br /> No.46, White Rod<br /> Chennai-600 014<br /> Registered Office<br /> At No.12, Patuallas Road<br /> Chennai-600 002<br /> <br /> <br /> <br /> 2. The Branch Manager<br /> Royal Sundaram Alliance<br /> Insurance Co. Ltd.,<br /> Sree Balaji Sovereign, 2nd Floor<br /> No.132, Brigade Road <br /> Bangalore-560 025<br /> <br /> <br /> O R D E R<br /> <br /> <br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT:<br /> <br /> <br /> The grievance of the complainant in brief against the Ops is that he had availed an insurance policy called Health Shield Insurance from the Ops. The policy was in force from 08/01/2008 to 07/01/2009 taken for Rs.1.00 lakh which covers the complainant and also his mother for meeting medical expenses. That his mother was hospitalized in Mallya hospital on 17/04/2008 as she had chest pain, she was treated there and when they made claim for reimbursement of hospital expenditure with the Ops, Ops refused to reimburse on the ground that the complainant’s mother had pre-existing disease. He had spent Rs.1,24,000/- as medical expenditure and chest pain was not pre-existing disease and thereby contended that Ops have rejected the claim in order to avoid insured amount. Therefore prayed for direction to Ops to refund Rs.1.00 lakh covered under the policy, award Rs.50,000/- as damages with other reliefs claimed.<br /> <br /> Ops have appeared through their advocate and filed common version. It is stated that the complaint is not bona-fide, Ops have admitted that the complainant had medical insurance for Rs.1.00 lakh and the policy covered mother of the complainant. It is stated further when the mother of the complainant was admitted and they diagnose Ischemic Heart Disease/two vessel coronary artery disease along with hypertension and was treated between 17/04/2008 to 28/04/2008. The Ops further contending that the complainant was suffering from Heart disease along with hypertension and stated that heart ailment along with hypertension is excluded under the policy coverage. Therefore, justifying their act of repudiation of the claim have prayed for dismissal of the complaint.<br /> <br /> In the course of enquiry into the complaint, complainant and one G.Vinaya Prakash of Ops have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. Complainant along with the complaint has produced a copy of the policy which contains conditions and explanations with some other hospital records. The counsel for the complainant has filed written arguments. We have heard the counsel for Ops and perused the records.<br /> <br /> On perusal of the materials placed before us, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that the Ops have caused deficiency in their service by repudiating mediclaim benefits of the policy.<br /> 2. To what order the complainant is entitled to?<br /> <br /> Point No.1 : In the affirmative<br /> Point No.2 : To see the final order.<br /> <br /> Answer on point No.1: The complainant in his affidavit evidence and by producing the documents has referred to availment of Health Shield Gold Insurance Policy for Rs.1.00 lakh and stated that his mother due to health problem was admitted to Mallya hospital for treatment and she was discharged on 28/04/2008. She was diagnised Ischemic Health Disease/two vessel coronary artery disease and hypertension was treated and thereafter when he made a claim with Ops for reimbursement of the medical expenditure by limiting it to Rs.1.00 lakh as provided under the conditions of the policy.<br /> <br /> The Ops have not at all disputed these facts as narrated by the complainant. However, they have repudiated the claim of the complainant for reimbursement on the ground that the deceased had taken treatment for the pre-existing disease, therefore relying upon the terms and conditions of the policy justified the repudiation.<br /> <br /> We have by referring to conditions of the policy found that the mother of the complainant is also covered under the policy to the extent of Rs.1.00 lakh she was admitted to Mallya hospital for treatment and she was discharged later. These facts are also not denied by the Ops but the Ops have refused to reimburse the insurance amount on the ground that the complainant was suffering from heart related disease and hypertension even prior to inception of the policy and therefore have said that they are not liable to reimburse the complainant.<br /> <br /> As found from the defense of the Ops, the Ops have not controverted any of the statements made by the complainant including hospitalization and expenses incurred. It is also not in dispute that the policy in question was valid as on 17/04/2008 on which date the complainant’s mother was admitted and treated. Ops who have taken a contention that the mother of the complainant was suffering from breathlessness and hypertension even prior to the inception of the policy dated 08/01/2008, but has not produced any documents or adduced oral evidence to substantiate their contention that the mother of the complainant had pre-existing disease. Further, the opponents by relying the discharge summary of Mallya hospital where the mother of the complainant underwent treatment and corrective measures. In this discharge summary, the doctors of Mallya hospital on examination found that mother of the complainant had breathlessness problem with other observations and back pain. It is further stated that there was no history of chest pain, PND sweating, syncope or vomiting. In this discharge summary, under the head, Past History it is written as known case of hypertension on treatment. Hence it is clear that the Ops by relying upon a sentence in the discharge memo that mother of the complainant was known case of hypertension and on that basis disallowed the claim of the complainant. Even otherwise, it is not clear as to who told the doctors of Mallya hospital that mother of the complainant had hypertension for recording. It is not known whether the mother of the complainant gave the past history or any attendants or whether the doctor himself stated as known case of hypertension of his own. Added to this neither the Ops have produced any documents nor the doctor of Mallya hospital is examined before us to know the basis for it. Mallya Hospital has recorded as known case of hypertension and on treatment. We do not understand as how and from where he got that information. The Ops also have not produced any piece of evidence to prove that mother of the complainant was on treatment for hypertension and she had knowledge of ailment.<br /> <br /> The Insurance Company who takes a shelter under pre-existing disease duty cast on them to prove the pre-existing disease and in the absence of such proof the contention of the Ops can not be believed. In this regard, counsel representing the complainant relied upon a decision of Andhra Pradesh Consumer Disputes Redressal Commission reported in II (2008) CPJ 262. <br /> <br /> In this decision, it is held “Discharge summary neither discloses positively time period to show that complainant has been suffering from severe diabetes which led to hospitalization – Burden of proof is on insurer to establish that materials facts suppressed by insured – Complainant aware of symptoms of disease prior to taking of policy not proved hold Insurer is liable under the Policy”. <br /> <br /> The said decision in our view apply to the facts of the case. With this, we hold that the Ops have not proved with any case history or through any means that mother of the complainant was suffering from such disease, was on treatment and have suppressed the facts. The Ops in our view are not justified in taking such defense, simply by relying upon the observations made regarding breathlessness and hypertension in a discharge summary. Apart from this, we shall also bear in our mind, that even assuming that the mother of the complainant was known case of hypertension but the Ops are required to convince this forum by proof that the mother of the insured had knowledge of her ailments and she has suppressed such disease while filling up the application for taking a policy. Examining this case from any angle, we cannot imagine that the mother of the complainant or the complainant had knowledge of ailment, treatment and have suppressed those facts and obtained policy. Hence, we reject the claim of the Ops and hold that the complainant is entitle for relief for reimbursement of medical expenditure to the extent of Rs.1.00 lakh. Hence, we answer point No.1 in the affirmative and pass the following order.<br /> <br /> O R D E R<br /> <br /> Complaint is allowed. Ops are jointly and severally held as liable to pay Rs.1.00 lakh which is the limit fixed under the policy and direct them to reimburse Rs.1.00 lakh with interest @ 9% p.a from date of receipt of the claim application and that amount shall be paid within 60 days from the date of this order.<br /> <br /> Ops shall also pay Rs.5,000/- to the complainant towards hardship, mental agony and for uncertainty.<br /> <br /> Ops shall also pay Rs.1,000/- towards cost to the complainant. <br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the Open forum on this the 9th February 2010.<br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />