CC No:521/2014

 Filed on 18.03.2014

Disposed on 20.02.2016

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

BANGALORE – 560 052

DATED THIS THE 20^th DAY OF FEBRUARY 2016

CONSUMER COMPLAINT NO.521/2014

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 is a complaint filed by the Complainant against the Opposite Parties under Section-12 of the Consumer Protection Act, 1986, praying to pass an order directing the Opposite Party No.1 to pay Rs.2,49,934/- along with interest at 18% p.a. from the date of hospitalization and Rs.7,00,000/- as damages for the mental agony suffered by the Complainant.

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

The Complainant alleged that he took the medical insurance policy covering the family of the Complainant covering up to Rs.3 lakhs.  The premium is Rs.5,730/- per year commencing from 18.07.2013 and valid upto 17.07.2014.  The policy was renewed on 18.07.2014 for a further period of on year.  On 26.08.2013, the wife of the Complainant fell ill and she was taken to the Elbit Medical Diagnosis Limited, Bangalore for treatment.  The doctor diagnosed that she was suffering from hypertension.  The ECG was conducted.  The doctor of Elbit Medical Diagnosis Limited informed the wife of the Complainant to approach Dr. Charit Bhograj of Vikram Hospital.  Smt. Asha Chandrashekar visited the Vikram Hospital for further check-up on 26.08.2013.  On checkup doctor found that mid left anterior descending (LAD) has minor irregularity.  Distal LAD has 99% sub occlusive stenosis with distal trickle.  The doctor of Vikram Hospital opined that there is regional wall motion abnormality.  On 29.08.2013 Smt. Asha Chandrashekar was discharged from Vikram Hospital.  The insurance policy prescribes that in the event of hospitalization of the insured person, intimation should be given to the company immediately however within 24 hours from the time of admission.  Accordingly, the intimation of the admission of Smt. Asha Chandrashekar was given on 26.08.2014 to the Opposite Party by the Vikram Hospital, Bangalore.  Unfortunately a day before to the discharge of Smt. Asha Chandrashekar, the Vikram Hospital received a letter from the Opposite Party that intimating the withdrawal of the authorization for non-disclosure of the major of the PED-DM and HTN and that cashless authorization cannot be taken.  The Complainant therefore forced to make the payment towards the bills raised by the Vikram Hospital.  They refused to settle the hospital bill by the Opposite Party has resulted in great mental agony and tension to the Complainant.  All of a sudden, the Complainant was informed by the hospital that the Opposite Party has refused to settle the bills.  The Complainant was attending on his wife and he has to approach his relatives to raise the huge amount of Rs.2,49,000/- which has resulted in mental agony and tension.  After settling the bill and on going through the medical prescription, the Complainant found that the doctor has wrongly mentioned the period of hypertension as two to three years instead of three months.  The Complainant brought this mistake to the notice of the hospital and the doctor.  Immediately the Elbit Medical Diagnosis Limited issued a clarification that Smt. Asha Chandrashekar was referred to Vikram Hospital and she was wrongly deducted to hypertension since last 3 months.  The Vikram Hospital also clarified that Smt. Asha Chandrashekar detected with hypertension recently and the duration of hypertension has been wrongly documented in the case records as hypertension 2-3 years instead of 3 months.  The Opposite Party declined to release the amount by its letter dt.29.01.2014.  Hence, this complaint.

            3.         In response to the notice, the Opposite Parties 1 & 2 put their appearance through their counsel and filed their common version.  In the version, the Opposite Parties pleaded that the complaint is not maintainable either in law or on facts.  The Complainant has taken a policy for a period subject to the terms and conditions stated therein to the respective policy.  The policy covered the risk of the Complainant and his dependants as shown in the policy.  The Complainant has not produced all the related documents and has not even mentioned the source of the documents where they can be got and has not produced the full text of the policy and has been attempting to mislead this Hon'ble Forum in seeking the claimed relief for which he is not entitled from the Opposite Party.  The wife of the Complainant is stated as undergone treatment for the alleged heart related ailment.  On her admission to the Vikram Hospital on their intimation seeking cashless facility to the patient, the wife of the Complainant by the said hospital and the Complainant as per procedure, the field inspection doctor was asked to visit the hospital and get the full particulars including the identification of the patient with reference to the photograph furnished to the company.  As per the consultation report of treating doctor dt.09.10.2009 reveals that the patient had BP 170/90.  As per the CAG report dt.26.08.2013 which forms part of the claim form states that the insured patient had double vessel coronary artery disease adequate LV function.  The patient hospitalization is for the management of an ailment which was related to a pre-existing condition.  At the time of incepting of the first policy, which incepted from 18.07.2012, the insured have not disclosed the above mentioned medical history of health details of his wife in the proposal form which amounts to misrepresentation/non-disclosure of material facts.  Therefore, the report also substantiate that the insured wife had the pre-existing diseases and he has not disclosed them and obtained the policy.  Hence, the policy is void and non-enforceable.  After preliminary particulars collected, the Opposite Party obligated to allow cashless facility subject to scrutiny of the said documents and the documents that will be furnished by the hospital authorities.  The case will be examined accordingly and if payable, the cashless facility will be allowed and if the claim falls under any exclusion clauses of the contract, the decision will be taken accordingly.  Thus in the case of complaint, the cashless has been denied as the claim pertain to the non-disclosure of material facts-ailments and the disease is pre-existing disease related with other disease at the time of policy inception and as related with condition to the pre-existing disease.  As the said ailment has been a chronic conditions of pre-existing stage of the state to the policy period the Complainant is not entitled for even for reimbursement.  Hence, the Opposite Parties are not bound to pay the amount as per policy, hence, the complaint deserves to be dismissed.  There is no deficiency of service rendered by the Opposite Party, as to invoke the provisions of Consumer Protection Act.  The claim of the Complainant has been repudiated after due application of mind and following the due procedures as per the Contract of Insurance, immediately and that too within short span after getting the copies of the documents and the claim being made by the Complainant herein.  Hence, it will not amount to deficiency of service.  The facts and circumstances of the transaction does not attract the jurisdiction of this Hon'ble Forum for adjudication and for want of deficiency of service.  Hence, prays to dismiss the complaint. 

            4.         In support of the complaint, the complainant has filed his affidavit by way of evidence.  For the Opposite Party one Mr.R. Rengaraj has filed his affidavit by way of evidence.  Heard the arguments of both the parties.

5.         Now the points that arise for consideration are:-

1. Whether the Complainant has proved 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:-         It is the case of the Complainant that he took medical insurance covering the family for a sum of Rs.3 lakhs from the Opposite Parties.  The policy commenced from 18.07.2013 and valid up to 17.07.2013 and he paid a premium of Rs.5,730/-.  The policy was renewed on 18.07.2013 for further period of one year up to 17.07.2014.  This fact has not been denied by the Opposite Parties.  Further, to establish this fact, the Complainant in his sworn testimony reiterated the same and also produced the copy of the Family Health Insurance Policy.  By looking into this document, the insurance policy is in the name of the Complainant bearing policy No.P/141121/01/2013/000860.  This policy covers from 18.07.2012 to 17.07.2013 and premium amount is Rs.5,730/- and limit of coverage is Rs.3 lakhs.  Under this policy, the Complainant himself and his family members Smt. Asha Chandrashekar – wife, Vikram and Vishal his children.    Further the Complainant also produced the renewed policy.  By looking into this, it is clear that the Complainant renewed the policy from 18.07.2013 to 17.07.2014.  This evidence of the Complainant remains unchallenged.  Thereby it is proper to accept the contention of the Complainant that the Complainant has taken life insurance policy from the Opposite Party.

            8.         Further it is the case of the Complainant that on 26.08.2013, the wife of the Complainant fell ill and she was taken to Elbit Medical Diagnosis Limited, Bangalore for treatment.  The doctor diagnosed that she was suffering from hypertension.  The doctor at Elbit Medical Diagnosis Limited informed the wife of the Complainant to approach Dr. Charit Bhograj of Vikram Hospital.  Smt. Asha Chandrashekar visited the Vikram Hospital for further check-up on 26.08.2013.  On checkup doctor found that mid left anterior descending (LAD) has minor irregularity.  Distal LAD has 99% sub occlusive stenosis with distal trickle.  The doctor of Vikram Hospital opined that there is regional wall motion abnormality.  On 29.08.2013 Smt. Asha Chandrashekar was discharged from Vikram Hospital.  The Opposite Party has not disputed this fact.  Further, to substantiate this fact, the Complainant produced the medical report of Elbit Medical Diagnosis Limited.  By looking into this document, it is dt.26.08.2013 and this document is referred to Smt. Asha Chandrashekhar and complaint of Mid LAD has minor irregularities.  Distal LAD has 99% sub occlusive stenosis with distal trickle.  D1 is normal.  D2 has ostial irregularities.  On 29.08.2013 Smt. Asha Chandrashekar was discharged from Vikram Hospital.  The Opposite Parties have not disputed this fact.  Further, to substantiate this fact, the Complainant produced the medical report of Elbit Medical Diagnosis Limited. By looking into this document, it is dt.26.08.2013 and this document is referred to Smt. Asha Chandrashekar and complaint of pain in left upper limb, mild left sided chest pain, BP 140/80, weight-49 kgs and also ECG report and later doctor of Elbit Medical Diagnosis Limited advised to consult cardiologist Dr. Charith Bhograj.  This evidence also remains unchallenged.  Therefore, it is proper to accept the contention of the Complainant that on 26.08.2013 the Complainant’s wife Smt. Asha Chandrashekhar had some health problem, for that reason, she was taken to Elbit Medical Diagnosis Limited.  On examination, she had heart ailments, for that reason, doctor of Elbit Medical Diagnosis Limited advised the Complainant’s wife Smt. Asha Chandrashekhar to consult the Cardiologist Dr.Charith Bhograj of Vikram Hospital.

            9.         Even the Complainant in his affidavit reiterated that on 26.08.2013 his wife Smt. Asha Chandrashekhar visited to Vikram Hospital and on check-up doctor found that Mid LAD has minor irregularities.  Distal LAD has 99% sub occlusive stenosis with distal trickle.  D1 is normal.  D2 has ostial irregularities and she was discharged on 29.08.2013.  This fact is also has not disputed.  To substantiate this, the Complainant produced Coronary Angiography Report issued by the Vikram Hospital.  From this document, it reveals that on 26.08.2013 the Complainant’s wife Smt.Asha Chandrashekhar was under treatment and on examination clinical diagnosis – acute anterior wall M1 and also produced Echocardiography Report.  By looking into this, it reveals that Complainant’s wife Smt. Asha Chandrashekhar had Ischaemic heart disease, regional wall motion abnormality.  To disbelieve this version of the Complainant, there is no contra evidence.  So from this material evidence placed by the Complainant clearly goes to show that the Complainant’s wife Smt. Asha Chandrashekhar was suffering from ischaemic heart disease, regional wall motion abonormality and also from the discharge summary, it is further clear that Smt. Asha Chandrashekhar was suffering from ischaemic heart disease and Smt. Asha Chandrashekhar discharged on 29.08.2013.

            10.      The Complainant informed the hospitalization of Smt. Asha Chandrashekhar through Vikram Hospital.  But the Opposite Parties fails to provide cashless facility.  This fact is reiterated in the sworn testimony of the Complainant and also to substantiate this fact, the Complainant produced a letter issued by the Opposite Parties.  By looking into this document it is dt.28.08.2013 addressed to the Vikram Hospital.  Under this document, the Opposite Party informed non-disclosure of major PED-DM and HTN.  Hence, cashless authorization cannot be given.  So from this evidence, it is very clear that the Opposite Party has refused to give cashless authorization as per the terms and conditions of the policy on the ground that non-disclosure of pre-existing disease.  So for that reason, the Complainant has to pay medical bill of Vikram Hospital.  To substantiate this, the Complainant has paid the entire medical bill of Vikram Hospital.  He produced the receipt issued by the Vikram Hospital.  By looking into this document, it is dt.29.08.2013 and under this receipt the Complainant has paid Rs.2,49,934/-.  This evidence is also remains unchallenged.  Therefore, it is proper to accept the contention of the Complainant that he has made payment of Rs.2,49,934/- to Vikram Hospital towards the payment of his wife Smt. Asha Chandrashekhar.  After discharge of his wife Smt. Asha Chandrashekhar from the hospital, the Complainant applied for reimbursement of the medical bill, but the Opposite Parties refused to settle the hospital bills.  The Complainant suppressed the pre-existing disease of his wife at the time of inception of the policy even though doctor has wrongly mentioned the period of hypertension as 2-3 years, instead of 3 months in the discharge summary.  To substantiate this fact, the Complainant in his sworn testimony reiterated the same.  Nodoubt as looking into the discharge summary, in the discharge summary clearly mentioned that the Complainant’s wife Smt. Asha Chandrashekhar is known case of hypertension since 2-3 years, known case of diabetes mellitus since 2 months.  At the time of inception of the policy the Complainant has not disclosed these facts.  But the contention of the Complainant is that the doctor of Vikram Hospital wrongly mentioned in the discharge summary as 2-3 years instead of 3 months.  To substantiate this fact, the Complainant produced the letter issued by Elbit Medical Diagnosis Limited.  By looking into this document, it is dt.02.10.2013.  In this letter the doctor has clearly mentioned that Smt. Asha Chandrashekhar come to their diagnostic centre on 26.08.2013 with a complaint left side chest pain since morning, ECG was referred to Vikram Hospital.  She was recently detected to hypertension since last 3 months.  Further to substantiate this fact, the Complainant also produced the letter issued by the Vikram Hospital.  This letter is dt.03.12.2013 issued by Dr. Charit Bhograj.  By looking into this document, it is clear that Smt. Asha Chandrashekhar recently detected hypertension since last 3 months and diabetes mellitus since last 2 months and was admitted to our hospital on 26.08.2013 with acute interior wall MI.  Duration of hypertension has been wrongly documented in the discharge summary as hypertension 2-3 years instead of 3 months.  The Complainant along with claim application produced all these documents inspite of it, the Opposite Parties reimburse the medical expenses as per the terms and conditions of the policy refused the same and repudiate the claim as per their letter dt.29.01.2014 on the ground that insured patient is known case of hypertension from past 2-3 years, thereby the repudiation of the claim of the Complainant by the Opposite Parties is not proper and in accordance with law.  The Opposite Parties ought to have considered the claim petition of the Complainant and to reimburse the same to the Complainant as per the terms and conditions of the policy.  Thereby the repudiation of the claim of the Complainant by the Opposite Parties amount to deficiency of service on the part of the Opposite Parties.  Hence, this point is held in the affirmative.

11.      POINT NO.2:-          In view of the finding on Point No.1, we proceed to pass the following;

ORDER

The complaint is allowed holding that there is deficiency of service by the Opposite Parties.  The Opposite Parties are directed to pay a sum of Rs.2,49,934/- to the Complainant and also to pay a compensation of Rs.1,00,000/- towards mental agony.  The Opposite Parties are granted 30 days time from this date to comply this Order.  Failing which, the aforesaid amount shall carry interest at 18% p.a. from the date of this Order, till the date of realization. 

Supply free copy of this order to both the parties.  

(Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 20^th day of February 2016).

       MEMBER                                                                               PRESIDENT

CC. NO.521 /2014

LIST OF WITNESSES AND DOCUMENTS

Witnesses not examined, but affidavit of the witnesses is filed, as follows;

1. Sri V.S. Chandrashekaran has filed his affidavit for Complainant.
2. Sri R. Rengaraj Thomas has filed his affidavit for Opposite Party.

List of documents filed by the Complainant:

1. Copy of the insurance policy.
2. Copy of the renewed insurance policy.
3. Copy of the medical report from Elbit Medical Diagnosis Ltd.
4. Copy of the ECG report.
5. Copy of the letter dt.26.08.2013.
6. Copy of the Coronary Angiography report, Echocardiography report, Biochemistry report, Echocardiography report from Vikram Hospital
7. Copy of the discharge certificate.
8. Copy of the letter dt.28.08.2013 from the Opposite Party.
9. Copy of the bill payment receipts.
10. Copy of the clarification letter issued by Elbit Medical Diagnosis Ltd and Vikram Hospital.
11. Copy of the letter dt.29.01.2014.

List of documents filed by the Opposite Parties:

1. Copy of the proposal form.
2. Copy of the claim for medical insurance.
3. Copy of the Star medical officer FVR (PAN INDIA) revised.
4. Copy of the discharge summary.
5. Copy of the clause No.1.0(A) of the policy stands as amended.

MEMBER                                                                               PRESIDENT