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.

   27^th DAY OF JANUARY 2021

ORDER

SMT.PRATHIBHA. R.K., PRESIDENT

This complaint is filed by the complainant against the Opposite Party (hereinafter called as OP) under section 12 of the Consumer Protection Act, 1986.  The complainant prays to direct the OP to clear and reimburse the legitimate claim of Rs.1,04,000/-, to pay Rs.50,000/- towards mental agony, trauma & hardship, to pay Rs.25,000/- towards cost of the proceedings, to pay interest on Rs.1,79,000/- @ 16% p.a from the date of repudiation and pass such other reliefs.

2.      The brief facts of complaint is as under:

Complainant submitted that, she obtained Happy Family Floater-2015 insurance policy bearing No.421703/48/2017/358 from OP.  Complainant paid a premium amount of Rs.16,958/- to the OP for the said policy.  The said policy was valid from 30.08.2016 to 29.08.2017.

Complainant further submitted that due to her health issue she admitted to Bhagwan Mahaveer Jain Hospital, Millers Road, Bangalore on 18.08.2016.  Complainant took treatment in the said hospital for a period of 5 days as inpatient and surgery was made to the complainant.  That at the time of admitting to the hospital, complainant had intimated the OP with regard to the admission and medical claim for her treatment.

Complainant further submitted that after the treatment she was discharged from the hospital on 23.08.2016 and approached the OP Branch Office for medical claims.  Complainant had submitted all the medical bills, bill summary along with claim form to the OP on 25.08.2016.  That after submitting the claim form to the OP along with all the relevant documents, OP did not honor the medical claim and postponing to pay the claim amount to the complainant and turn down the same by stating false reasons that policy is not continuous period of four years.

Complainant further submitted that, she waited for payment of claim amount but OP did not paid the claim amount to the complainant.  OP failed to pay the medical claim amount as per the terms and conditions of the policy.  The insurance for the medical claim is covered for the ailment stated by the complainant and the OP is bound to honor the claim as an insurer and the policy being in force.

Complainant further submitted that she had never admitted in the hospital earlier to the admission and no such ailment earlier to her admission.  Due to the deficiency of service rendered by OP, the complainant got mental stress and after submitting all the documents to the OP delaying to release the claim amount to the complainant and even did not properly replied to complainant.  The officials of OP without verifying these aspects and without releasing the claim amount, they are postponing to release the same.  OP did not comply the demands for reimbursement of legitimate medical claim amount ought to be within the covering period of the policy.  OP did not comply the demands of the complainant even after several requests.  Complainant was made to run from pillar to post to the OP for reimbursement of the claim amount as per the policy and due to in differential attitude and non-complying the claim of the complainant by the OP, she had suffered great hardship and inconvenience.

Complainant further submitted that she had sent several e-mails to the OP with regard to the claim amount on several dates.  Complainant has also issued legal notice dated 17.07.2017 calling upon OP to pay the legitimate claim.  OP replied untenably and rejected the claim of the complainant.  Complainant felt deficiency in service and negligence on the part of OP.  Left with no other option complainant filed this complaint.

3. In response to the notice issued, OP appeared through their advocate and filed their version in brief as under:

OP submitted that the complaint filed by the complainant is not maintainable and same is liable to be rejected in limine.  This complaint is made only to make unlawful gain.  The complaint is liable to be dismissed for non-joinder of necessary party i.e., M/s Raksha TPA (IRDA Recognized Third party administrator), which is the agent of OP insurance company.  Complainant has taken health insurance policy from OP under Happy Family Floater-2015 bearing policy No.421703/48/2017/2918/358, which is valid from 30.08.2016 to 29.08.2017.

OP further submitted that the complainant was admitted to Bhagwan Mahaveer Jain Hospital on 18.08.2017 and she was discharged after 5 days.  Complainant had taken treatment and surgery was also made to the complainant at the said hospital.  That M/s.Raksha TPA, IRDA Recognized and the third party administrator which is the agent on behalf of OP insurance company, which scrutinizes the claim papers and recommends to the company for either settlement or rejection of claim.  As per the letter dated 28.09.2016, M/s.Raksha TPA, after scrutiny of all the relevant papers and the policy condition was opined that claim of the complainant was non-tenable for the following reason.  The same reads here as under:

Observation and Opinion

Kindly Note :- As per policy sub limits, pre existing diseases and their related complications are covered after 4 years continuous renewal of policy (refer clause no.4.1) hence claim is rejected, p212a2 with perimenopausal state with abnormal uterine bleeding with fibroid uterus since 4 years with k/c/o htn since 2 years for tah.

Clause 4.1: Claim is recommended for Non-pay as per clause 4.1 which states that Any ailment/disease/injuries/ health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 4 years of this policy being in force continuously.  This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries.  Such complications shall be considered as a part of the pre-existing health condition or disease.

OP further submitted that the claim is excluded as per clause 4.1 of the insurance policy.  Claim was not tenable as per clause 4.1 of the insurance policy in question, since the claim arose on account of pre-existing disease and 4 years of continuous term from the date of first policy had not been completed hence the claim was rightly rejected.  That the repudiation of the claim in question is based on the recommendations TPA based on thorough scrutiny of documents through panel experts and doctors, which is in order.  There is no deficiency of service on the part of OP.  There is no cause of action for the complainant.  Rest of the allegations made by the complainant is denied by OP.  Hence OP prayed for dismissal of the complaint with exemplary costs.

4. In the course of enquiry into the complaint, the complainant and the OP has filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant and OP has submitted written arguments.  Complainant and OP has produced certain documents.  We have heard the arguments of OP and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

5. Based on the above materials, the following points arise for our consideration;  

1. Whether the complainant has proved that there is deficiency in service on the part of the OP, if so, whether complainant is entitled for the relief sought for?

2.  What order?

6. Our findings on the above points are as under:

Point No.1:  Affirmative in part

Point No.2:  As per the order below

REASONS

7. Point No.1:- On perusal of the pleadings, evidence and documents produced by both the parties, it is an admitted fact that, the complainant obtained Happy Family Floater Policy – 2015.  The said policy was renewed by paying an amount of Rs.16,958/- to the OP vide policy No.421703/48/2017/358 for the period from 30.08.2016 to 29.08.2017. 

8. The contention of the complainant is that, the complainant admitted to Bhagwan Mahaveer Jain Hospital, Millers Road, Vasanthanagar, Bangalore on 18.08.2016 as an inpatient for 5 days and she has underwent a surgery and discharged from the hospital on 23.08.2016.  After discharge from the hospital the complainant submitted a claim form along with documents before the OP.  But OP illegally rejected the claim of the complainant.  The complainant alleged that the policy was in force at the time of taking the treatment.  Further the complainant was suffering from the above said disease from past 15 months from the date of surgery.  The OP has deliberately repudiated the claim of the complainant.

9. Per contra OP submitted that the complainant suffering from p212a2 with perimenopausal State with abnormal uterine bleeding with fibroid uterus since 4 years with k/c/o htn 2 years for tah.  As per the policy terms and conditions clause 4.1 pre-existing disease and their related complications are covered after 4 years of continuous renewal of the policy.  The complainant has not renewed the policy continuously for 4 years.  Hence OP has repudiated the claim of the complainant.  

10. On perusal of the repudiation letter dated 28.09.2016 issued by OP which reads here as under:

Observation and Opinion

Kindly Note :- As per the policy sub limits, pre existing diseases and their related complications are covered after 4 years continuous renewal of policy (refer clause no.4.1) hence claim is rejected, p212a2 with perimenopausal state with abnormal uterine bleeding with fibroid uterus since 4 years with k/c/o htn since 2 years for tah.

11. Further on perusal of the terms and conditions of clause 4.1 which reads here as under:

Clause 4.1: All Pre-existing Disease (whether treated/untreated, declared or not declared in the proposal form), which are excluded upto 48 months of the policy being in force.  Pre-existing diseases shall be covered only after the Policy has been continuously in force for 48 months.  For the purpose of applying this condition, the date of inception of the first indemnity based health Policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. 

This exclusion shall also apply to any complication(s) arising from pre-existing diseases.  Such complications will be considered as part of the pre-existing health condition or disease.

12. On perusal of the discharge summary/Ex-A6 the chief complaints which reads here as under:

Chief complaints: Complaints of excessive menstrual bleeding since 1¼ years.

Past History:

K/C/O Hypertension since 2 years on Tab Metoprolol 50mg and Tab Amlodipine 2.5mg.

History of appendicectomy when she was 13 years old.

History of occasional headache.

13. The crux of the matter is that, whether the complainant is suffering from pre-existing disease.  Admittedly the complainant obtained the policy from OP in the year 2013 vide policy bearing No.421703/48/2014/497 valid from 30.08.2013 to 29.08.2014.  The same was renewed for the year 2014-15, 2015-16 & 2016-17 as per Ex-A1.  The complainant admitted to the hospital on 23.08.2016/Ex-A6.  As per the discharge summary the complainant suffering from the above said disease from past 15 months.  The complainant is not suffering from the said disease at the time of inception of the policy.  Further the OP has not produced the medical evidence or proved to show that the complainant had undergone medical treatment for the said disease prior to the date of inception of the policy.  When there is no reliable piece of evidence or proof to show that the complainant has pre-existing disease much prior to the obtaining of the first policy.  The repudiation made by the OP only on the ground that the complainant suffering from pre-existing disease and the same shall be covered only after the policy has been continuously in force for 48 months is illegal and arbitrary.

14.  In view of the facts and circumstances of the case, we are of the opinion that, the complainant is successful in proving the deficiency of service on the part of OP.  Therefore, we feel it appropriate to direct the OP to pay a sum of Rs.1,04,000/- to the complainant being medical expenses incurred to her treatment together with interest @ 9% p.a from the date of repudiation till the date of realization.  OP is further directed to pay compensation of Rs.20,000/- towards mental agony and hardship suffered by the complainant with litigation cost of Rs.10,000/- to the complainant.  Accordingly, we answer the point no.1 affirmative in part.

15. Point No.2: In the result, for the foregoing reasons, we proceed to pass the following order:

O R D E R

The complaint is allowed in part.

OP is directed to pay a sum of Rs.1,04,000/- (One Lakh Four Thousand only) to the complainant towards medical expenses incurred by the complainant together with interest @ 9% p.a from the date of repudiation till the date of realization. 

OP is further directed to pay compensation of Rs.20,000/- towards mental agony and hardship suffered by the complainant together with litigation cost of Rs.10,000/- to the complainant.

This order is to be comply by OP within 45 days from the date of receipt of this order.

Supply free copy of this order to both parties. 

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the open Commission on this 27^th day of January 2021)

Witnesses examined on behalf of complainant by way of affidavit:

Smt.Sangeetha Murugan.

Copies of documents produced on behalf of complainant:

Witnesses examined on behalf of the OP by way of affidavit:

Sri.Noorullah S/o Late P.Abdul Aman

Documents produced on behalf of Opposite Party:

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