BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

                               BENGALURU – 560 027.

DATED THIS THE 29^th DAY OF OCTOBER, 2021

CONSUMER COMPLAINT NO.2456/2017

PRESENT:                                                          

Sri.C.V.Maragoor, B.com, LL.M.              ….      PRESIDENT

Smt.L.Mamatha, B.A., (Law), LL.B.….    MEMBER

Sri. M.B. Seena, B.A., (Law), LL.B.            ….         MEMBER

Mr.Ranganath R,

S/o Late R.R.Kadam,

Aged about 54 years,

R/at no.34, D.B.Street,

Palace Guttahalli,

(Rep. by Smt. Reshma Thammaiah, Adv)

V/s

OPPOSITE PARTIES:

1. The Original Insurance Company Limited,

Having its registered office

at:Oriental House, P.B.No.7037,

A-25/27, Asaf Ali Road,

New Delhi-110002,

Represented by its Manager,

(Rep. by Sri. Adarsh Gangal, Adv)

Also at:

2. State Bank Building Annexe,
3.  

Bank Street,

Represented by its Manager.

Its Regional Office:

(Rep by Sri.Adarsh Gangal, Adv)

3. 1001/56, Jayalakshmi Mansion,
4.  
4.  
5.  

Rep by its Manager.

(Rep by Sri.Adarsh Gangal, Adv)

4. Raksha TPA Private Limited,

Unit No.2, A Wing

Time square, 3^rd Floor,

Marol, Andheri, Kurla Road,

Rep by its Manager.

******

//ORDER//

SRI.C.V.MARGOOR, PRESIDENT

This complaint is filed u/s 12 of the Consumer Protection Act, 1986 to direct the opposite party no.1 to refund the hospital bills totalling a sum of Rs.4,03,251/- along with interest at the rate of 18% p.a. from the date of complaint, to pay a sum of Rs.75,000/- as compensation for mental agony, harassment and award cost of this litigation. 

 2. It is the case of complainant that he had obtained Health Insurance Policy by name “Happy Family Floater-2015 Policy” for the period from 22.04.2016 to 21.04.2017 by paying premium of Rs.29,146/- on 22.04.2016 insurance covered for a sum of Rs.6,00,000/- to himself, his wife and two children.  The opposite party no.1 is insurer of said health policy and opposite party no.4 is 3^rd party administrator.  The complainant was hospitalized on 06.12.2016 and discharged on 13.12.2016, again on 28.12.2016 at Manipal North side Hospital, Malleshwaram, Bangalore for removal of Kidney Stones and discharged on 01.01.2017.  Again the complainant went to the same hospital for stent removal on 24.01.2017 and discharged on the same day.  The opposite party no.1 to 3 have refused to pay three bills amount of Rs.4,03,251/- and on the contrary repudiated the claim stating that the claim is made within the first two years of the policy.   Hence, this complaint. 

3. Opposite party no.1 to 3 in response to the notice appeared and filed written version admitting that the complainant has obtained Oriental Insurance Company’s Limited Happy Family Floater-2015 policy for the period from 22.04.2016 to 21.04.2017 for himself, his wife and two children for a total sum of Rs.6,00,000/- through insurance agent.  The opposite parties have repudiated the claim of complainant since he has contacted the said disease in the first two years of the policy and declined to release the claims as his claim is against the policy condition clause.   On the amongst other grounds, the opposite parties asked to dismiss the complaint.

4. The opposite party no.4 has filed separate written version contending that this opposite party processed the claim of complainant and not paid in accordance with the policy terms and conditions laid down by the opposite party no.1 as per Clause no.4.3.The complainant has entered into the contract with opposite party no.1 as such this opposite party no.4 is just a 3^rd party administrator who acts on the basis of the policy entered into between the complainant and opposite party no.1.Hence, the opposite party no.4 asked to dismiss the complaint.

5. The complainant has filed his affidavit evidence and got marked Exs.P1 to P11 documents.  On behalf of opposite party no.1 to 3 one Mr.R.S.Arasu, Manager and authorized signatory filed affidavit evidence and produced EXs.R1 to R5 documents. 

          6. We have heard the oral arguments advanced by the leaned counsel for opposite party No.1 to 3, whereas the complainant has submitted written brief and the points that would arise for determination are as under:

i) Whether the complainant proves that repudiation of claim made by opposite parties is improper and illegal ?

ii) Is complainant entitled to the reliefs sought for ?

7.    Our findings on the aforesaid points are as follows:

Point No.1:     In the negative    

Point No.2:     In the negative for the below

REASONS

8. Point No.1 and 2:- The learned counsel for complainant contention is that the complainant has not suppressed material fact with regard to his health condition at the time of obtaining health policy from the opposite parties 1 to 3.   The opposite party no.1 to 3 on false ground has rejected the medical claim of the complainant.  As against this, the learned counsel for opposite party no.1 to 3 submitted that contract between the complainant and opposite parties is on good faith.  The opposite parties have repudiated the claim since the complainant has contacted calculus disease within period of two years from the date of taking health policy as such, the complainant is not entitled for any medical claim. 

9.   The opposite parties 1 to 3 have not disputed issue of “Happy Family Floater 2015 Policy” to the complainant, his wife and two children on 22.04.2016 for one year period till 21.04.2017.  The complainant has produced EX.P3 discharge summary dt.13.12.2016.  The complainant was admitted at Manipal Hospital, Bangalore on 06.12.2016 and discharged on 13.12.2016 and discharge summary final diagnosis of the complainant reads hereunder;

1. UROSEPSIS-AKI WITH SEPTIC SHOCK
2. LEFT STAGHORN CALCULUS
3. LEFT URETHRAL CALCULI
4. HYPOTHYROIDISM
5. HYPERTENSION
6. DIABETES MELLITUS-BORDER LINE (ON DIET CONTROL).

10. Again the complainant was admitted in the same hospital on 28.12.2016 and discharged on 01.01.2017 and discharge summary EX.P4 indicates final diagnosis of the complainant reads hereunder;

1. LEFT URETHRAL CALCULI/LEFT STAGHORN RENAL CALCULUS
2. HYPERTENSION
3. HYPOTHYROIDISM
4. DEPRESSION

11. The 3^rd discharge summary of same hospital dt.24.01.2017 says that the complainant has post left PCNL DJ Stent In-Situ- (2) HTN (3) Hypothyroidism (4) Depression.  The complainant has produced EXs.P6, 7 and 8 medical bills issued by Manipal Hospital for a sum of Rs.4,03,600/-.  EX.P9 is repudiation letter dt.18.04.2017 issued by opposite party no.1 to 3 to the complainant stating that the complainant hospitalized with complaint of post left Penl DJ Stent In Situ with Hypertension Hypothyroidism and underwent treatment for the same, currently the policy is in its first year with date of inception 22.04.2016.  Since policy terms and condition states that the present ailment is non-payable in first two years of policy, this claim stands repudiated under Exclusion Clause-4.3. 
12. The opposite party no.1 to 3 produced EX.R2 “Happy Family Floater Policy-2015” and clause No.4 of the policy says that the General Exclusions: the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of: 4.3 the expenses on treatment of following ailments/diseases/surgeries, if contracted and/or manifested after inception of first policy (subject to continuity being maintained), are not payable during the waiting period specified below.  Under this clause, the table contained 24 ailments/diseases/surgeries and waiting period.  Serial no.17 hypertension waiting period 2 years, serial no.18 diabetes waiting period 2 years and serial no.19 calculus diseases waiting period 2 years. The discharge summary of complainant indicates that he has diagnosed of hypertension, diabetes Mellitus and left urethral calculi/left staghorn renal calculus.  All the three times the complainant diagnosed of same diseases. The complainant has contacted the said diseases in the first year of the policy and as per the terms and conditions of the clause no.4.3 the policy holder is not entitled for claim of the said diseases for a period of 2 years from the date of inception of policy.

13. The learned counsel for complainant has relied upon the case of Tarlok Chand Khanna V/s United India Insurance Company Limited dt.16.08.2011, the Hon’ble National Consumer Disputes Redressal Commission wherein held the onus to prove that the insured had pre-existing medical condition is on the respondent.  In the case on hand, it is not the case of insurer i.e., insurance company that the complainant has suppressed pre-existing disease.  It is the specific case of opposite parties that the complainant has contacted disease in the first year of the policy as such the complainant is not entitled claim as they have excluded under clause no.4.3 of policy and only after two years from the date of taking policy the insurer shall liable to pay the claim amount.  Therefore, above citation is not helpful to the complainant.  The opposite parties 1 to 3 have rightly repudiated the claim as the complainant has contacted three diseases in the first year of obtaining “Happy Family Floater-2015 policy” as such the complainant is not entitled to any medical bills.  In the result, we proceed to pass the following;

ORDER

The complaint is dismissed without costs.

Furnish the copy of order to the complainant and opposite parties at free of cost. 

      (Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 29^th day of October, 2021)                                            

• M.B.SEENA)      (L.MAMATHA)          (C.V.MARAGOOR)                       
  144616126.  

                                 //ANNEXURE//

Witness examined for the complainants side:

Sri.Ranganath R, the complainant has filed his affidavit.

Documents marked for the complainant side:

1. The original policy schedule bearing No.121802/48/2016/2090 issued by Oriental Insurance Company Limited dt.18.03.2016 for the period from 18.03.2016 to 17.03.2017 (3 pages).
2. Premium payment receipt dt.18.03.2016.
3. Discharge summary of complainant dt.13.12.2016 issued by Manipal Hospital (3 pages).
4. Another discharge summary of complainant dt.01.01.2017 issued by Manipal Hospital and one another discharge summary of complainant dt.24.01.2017.
5. The inpatient detailed bill dt.13.12.2016 of Manipal Hospital pertaining to the treatment taken by complainant (in 11 sheets).
6. Another inpatient bill dt.01.01.2017 which is in 7 sheets and one more inpatient bill dt.24.01.2017 both pertaining to complainant and issued by Manipal Hospital.
7. The letter dt.18.04.2017 addressed to complainant by the Oriental Insurance Company Limited, repudiating complainant claim in respect of hospitalization dt.24.01.2017.
8. The copy of the legal notice dt.07.07.2017 got issued by complainant to the opposite parties.
9. Postal acknowledgments.
10.   Postal receipts. 

Witness examined for the opposite party side: 

• Manager and authorized signatory of opposite party has filed his affidavit.

Documents marked for the Opposite Parties side:

1. Copy of the Insurance Policy of Happy Family Floater 2015.
2. Copy of the terms and conditions of the Happy Family Floater 2015 policy.
3. Original Discharge summary dt.13.12.2016 and 01.01.2017.
4. Copy of the letter dt.23.03.2017.

• M.B. SEENA)         (L.MAMATHA)          (C.V.MARAGOOR)    
•