<br /> COMPLAINT FILED: 25.10.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 15th DECEMBER 2008<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.2301/2008<br /> <br /> <br /> COMPLAINANT Sri.K.Ramesh Kumar,S/o Late Ramakrishnan,Aged about 39 years,No.156/6 S, Bhagavathi Layout,Hulimavu, Bannerughatta Road,Bangalore – 560 078.Advocate – Sri.R.Nagendra NaiduV/s.<br /> OPPOSITE PARTIES 1. The New India Assurance Company Ltd.,No.349, II Floor, SVR Complex, Manandi Court, 27th Cross, Jayanagara III Block,Bangalore – 560 011.2. Medi Assist India Pvt. Ltd.,No.49, 3rd Floor,“Shilpa Vidya”, Sarakki Industrial Layout,I Main Road, J.P.Nagara,3rd Stage, Near Oracle Office,Bangalore – 560 078.Advocate – Sri.V.Subramani<br /> <br /> <br /> O R D E R<br /> <br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the insurance claim and pay an amount of Rs.3,00,000/- and a compensation of Rs.1,00,000/- on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> <br /> Complainant took the policy with the OP for Rs.7,00,000/- for the entire family, out of that Rs.3,00,000/- is insured for and on behalf of the complainant towards the hospitalization. Before accepting the proposal and issuance of the policy complainant was subjected to medical examination. OP collected the necessary premium and issued the policy, which is valid from 30.04.2007 to 29.04.2008. On 27.02.2008 complainant felt a chest pain hence he went to Wockhardt Hospital, Bannerghatta Road, Bangalore. Dr.Venkatesh examined him and directed him to undergo “Coronary Angiography”. The said procedure was conducted on 28.02.2008 thereby complainant has spent nearly Rs.4,20,000/-. Before undergoing the said surgery complainant informed concerned hospital about the benefit of the hospitalization policy issued by the OP. With all that OP did not provide him the cashless facility as promised then complainant himself paid the amount. Thereafter claimed the said medical expenses from the OP. Unfortunately OP repudiated the said claim invoking clause.4.1 of the said policy contending that the treatment taken is for pre existing disease, which is not covered under the policy and that there is a suppression of material facts with regard to the ailment and the disease at the time of submission of the proposal. Complainant felt that the repudiation is unjust and improper without due application of the mind. When his repeated requests and demands made to OP to settle the claim and pay compensation went in futile he felt deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the reliefs accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant has suppressed certain material facts which are well within his knowledge. The hospitalization is to take treatment for the pre existing disease. The hospital records themselves goes to show that complainant is suffering from Diabetes Mellitus since 1½ years undergone Coronary Angiography 2 years back and this heart ailment is usual complication of long standing Diabetes. The alleged treatment is mainly for long standing chronic ailments, which was suppressed by the complainant while submitting the proposal. So the repudiation made by the OP by invoking exclusion clause 4.1 is just and proper and after due application of the mind. There is no deficiency in service of any kind on the part of the OP. Complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has Proved <br /> the deficiency in service on the part of <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the relief’s now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainant has taken the said mediclaim policy from OP, which is in force from 30.04.2007 to 29.04.2008. The sum assured as for as complainant is concerned towards the hospitalization is Rs.3,00,000/-. It is contended by the complainant that on 27.02.2008 he experienced the chest pain that is why he got admitted at Wockhardt Hospital. Dr.Venkatesh examined him and advised for “Coronary Angiography”. The said procedure was conducted on 28.02.2008. According to the complainant he has spent nearly Rs.4,20,270/- for the said treatment.<br /> <br /> 7. It is further contended by the complainant that before under going the said surgery he intimated the concerned hospital about the mediclaim policy issued by the OP. Though hospital and complainant requested the OP to extend the cashless facility but it went in vain. Hence complainant is forced to pay medical bills on his own. Thereafter he made the claim to OP to reimburse the medical expenses. Unfortunately the said claim is repudiated by the OP on the flimsy reasons and grounds. Hence complainant felt deficiency in service on the part of the OP.<br /> <br /> 8. The evidence of the complainant which finds corroboration with the contents of the undisputed documents appears to be very much natural, cogent and consistent. As against this unimpeachable evidence of the complainant the defence set out by the OP is that complainant has suppressed certain material facts which are well within his knowledge that too with regard to the pre existing disease. According to the OP complainant had a history of DM since 1 ½ year and undergone Coronary Angiogram about 2 years back prior to submission the proposal and that his heart ailment if any is because of long standing diabetes. As they felt that there is a suppression of material fact by complainant they repudiated claim on the ground that the treatment taken is for the pre existing disease. OP wants to rely on some stray entry made in the hospital record. To rebut the said contention of the OP, complainant filed a certificate issued by treating doctor namely Dr.Venkatesh.<br /> <br /> 9. Of course we have gone through admission history and physical assessment form with respect to the complainant. Who recorded the said information, who furnished it is not known. The said entry further discloses that though complainant is DM since 1 ½ year he is not taking any medication, which is unbelievable. It also discloses that the complainant has undergone CAG 2 years back, but no such report is available. OP would have got investigated the said ailment if at all it is true. On the other hand the discharge summary with respect to the complainant speaks to the past history as a known case of diabetes mellitus since 3 months, no such history of hypertension. The contents of the said discharge summary is not other wise disputed by the OP. What is the basis for the medi assist to come to the conclusion that complainant is DM since 1 ½ year and has also undergone Coronary Angiography about two years back is not known. No supporting documents are produced by the OP.<br /> <br /> 10. The treating doctor has issued a certificate certifying that complainant was admitted in their hospital on 27.02.2008 with a history of diabetes since 3 months. Patient has not had any previous history of coronary artery disease nor has he undergone coronary angiography in the past and in the case file one of the resident doctor wrongly recorded the history. If OP suspects genuineness of the certificate referred to above it would have cross-examined the doctor by summoning him but no such steps are taken. Hence for these reasons we find OP wants to take some undue advantage of stray entry made in the case sheet to avoid its obligation which is not unfair. In our view repudiation is unjust and improper without due application of the mind.<br /> <br /> 11. The fact that OP.2 is a third party administrator for OP.1 and they are bound to provide cashless and reimbursement facility to the policy holder is not at dispute. Unfortunately they have not discharged their obligation. Under such circumstances complainant for no fault of his must have suffered both mental agony and financial loss. Though OP has contended that as per the view of the panel experts the treatment taken by the complainant is for pre-existing disease it is not supported by filing the affidavit of the so called concerned expert on the panel of OP. Hence for this reason also OP defence does not hold much force.<br /> <br /> 12. As already observed by us there is a proof of deficiency in service on the part of the OP. Under such circumstances complainant is entitled for the relief claimed. Though complainant claimed the actual so called hospital expenses of Rs.4,20,000/- and Rs.1,00,000/- compensation. We are of the view that the justice will be met by directing the OP to pay the sum assured that is Rs.3,00,000/- with some litigation cost. With these reasons we answer point Nos.1 & 2 accordingly and proceed to pass the following: <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP is directed to pay the medical expenses in pursuance of the policy issued by them to the tune of Rs.3,00,000/- to the complainant along with litigation cost of Rs.1,000/-. This order is to be complied within four weeks from the date of its communication. Failing in which complainant is entitled to claim interest at the rate of 9% p.a from the date of repudiation till realization along with litigation cost on Rs.3,00,000/-.<br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 15th day of December 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />