Karnataka

Kolar

CC/34/2017

Smt.R.Sugunamma, W/o. V. Ramaiah, - Complainant(s)

Versus

United India Insurance Company, - Opp.Party(s)

Sri.Ganesh.N

04 Jan 2018

ORDER

Date of Filing: 19/04/2017

Date of Order: 04/01/2018

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, D.C. OFFICE PREMISES, KOLAR.

 

Dated: 04^TH DAY OF JANUARY 2018

PRESENT

SRI. K.N. LAKSHMINARAYANA, B.Sc., LLB., PRESIDENT

SMT. A.C. LALITHA, BAL, LLB.,  ……  LADY MEMBER

 

CONSUMER COMPLAINT NO. 34 OF 2017

Smt.R.Sugunamma,

W/o. V. Ramaiah,

Aged 55 Years,

No.110, Bale Bazaar,

Behind Dharmaraiah Temple,

Kattaripalya, Kolar-563 101.                               ….  COMPLAINANT.

(Rep. by Sri. Ganesh.N & D.V. Lakshminarayan, Advocates)

 

- V/s -

1) United India Insurance Company,

Bank Insurance Division, 2^nd Floor

IML Building, N.R. Square,

Bangalore-560 002.

(Rep. by Sri. K.P. Ramesh, Advocate)

 

2) The Manager,

Vijaya Bank, Near KSRTC Bus-stand,

Kolar .

(Rep. by Sri. S.N. Mallikarjuna Swamy, Advocate)

                                                               …. OPPOSITE PARTIES.

 

-: ORDERS:-

BY SMT. A.C. LALITHA, LADY MEMBER

01.   The complainant having submitted this complaint on hand as envisaged Under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred in short as “the Act”) against the opposite parties has sought issuance of directions to make payment of health insurance policy vide No.072600/28/15/P1/11147397 claim dated: 05.03.2016, a sum of Rs.1,69,000/- along with interest at the rate of 18% per annum and compensation of Rs.20,000/- towards mental agony and Rs.5,000/- towards expenditure spent and any other reliefs as the forum to deem fit.

 

02.   The facts in brief:-

(a)    It is the contention of the complainant that, she has purchased an health insurance policy vide No.072600/28/15/P1/11147397 on 22.12.2015 from OP No.1 through OP No.2 which is valid from 22.12.2015 to 21.12.2016.

 

(b)    It is further contended that, she had treated as in-patient at SITA BHATEJA HOSPITAL for back pain and medicine expenses from 24.02.2016 to 02.03.2016 total expenditure towards treatment spent was a sum of Rs.1,69,000/-.

 

(c)    It is contention of complainant that, on 05.03.2016 she was submitted claim No.12701696 to OP No.1 for a sum of Rs.1,69,000/- towards her medical expenses but the OP No.1 repudiated her claim.  So contending, the complainant has come up with this complaint on hand by seeking above set-out reliefs. 

 

03.   In response to notice issued with regard to the case on hand by this forum Ops have put in appearance through their said learned counsel and submitted written version.

 

(a)    OP No.1 in its written version stated as the complainant had obtained a fresh V. Arogya (Group Health Insurance Scheme) Insurance Policy No. 072600/28/15/P11/1147397 covering the period from 12:09 hours of 22.12.2015 to Midnight of 21.02.2016 through the OP No.2 bank.

 

(b)    The main contention of OP No.1 is that, while sending proposal for Health Insurance Policy to complainant itself OP No.2 explained about clause No.4 of the said policy as the claim for the pre-existing ailments prior to policy shall not be admissible.

 

(c)    It is contention of OP No.1 that, the said claim repudiated as per clause No.4 of said insurance policy and also relied on the Discharge Summary of complainant issued by the Sita Bhateja Hospital about history of the ailment of the complainant. Complainant admitted as she has been suffering from L4 L5 Grade II Spondylosis with canal Stenosis and low back ache radiating to left lower limb since 01 years 02 months and this is a known case of hypertension and IHD since 5 years and a case of bilateral knee osteoarthritis since one year.  So prayed for dismissal of the complaint, cost has been sought. 

 

(d)    The main contention of OP No.2 is that, the complainant has not claimed any relief against OP No.2 and this OP No.2 is only a formal party and there is no pre-emptive of contract between bank and insurance company i.e., OP No.1 and by relying on documents of complainant OP No.2 submitted as, the claim is not possible for pre-existing ailments as per policy conditions.  So prayed for dismissal of the complaint with costs has been sought.

 

04.   The complainant has submitted her affidavit evidence and also submitted below mentioned documents and citation:-

(i) Pass-Book of complainant.

(ii) News paper edition relating to Supreme Court decision.

(iii) Insurance Policy

(iv) acknowledgment of postal authority

(v) Claim Form of complainant.

(vi) Discharge summary

(vii) Bills of Hospital

(viii) Medicine Bills

(ix) Receipt issued by the Hospital

(x) Another Discharge Summary issued by Hospital

(xi) Letter issued by OP No.1

(xii) Terms and conditions of the Policy

(xiii) List of hospitals

(xiv) Letter issued by OP No.1

(xv) V. Health Care Medicine policy

(xvi) Copy of the Pass-book

(xvii) Certificate of OP No.1.

(xviii) Civil Appeal No.3883 OF 2007

(xix) Civil Appeal No.1156 OF 2008.

 

05.   On behalf of OP No.1 Sri. D. Sundrarajan, Manager, M/s. United India Insurance Company Limited has submitted affidavit evidence and submitted below mentioned documents:-

(i) Original Insurance Policy of the complainant

 

06.   On behalf of OP No.2 Sri. P.Abhilash, Senior Branch Manager, has submitted affidavit evidence and no documents filed by OP No.2.

 

07.   The learned counsel appearing for complainant as well as OP No.1 and OP No.2 have submitted their written arguments and heard oral arguments too.

 

08.   Therefore the points that do arise for our consideration are:-

(1) Whether OP No.2 is a formal party as contended by OP No.2 itself?

 

(2) Whether the repudiation of the claim of complainant by OP No.1 would amount to deficiency in service?

 

(3) If so, to what relief the complainant is entitled?

 

(4) What order?

 

09.   Our findings on the above stated points are:-

POINT (1):-              In the Negative

POINT (2) & (3):-      In the Affirmative

POINT (4):-              As per the final order

        for the following:-

REASONS

POINT (1):-

10.   OP No.2 specifically contended as it is only a formal party to this case and no claim has sought against OP No.2.  Meanwhile OP No.1 in Para-2 of its version contends as OP No.2 Bank being agent of OP No.1 had categorically explained to the complainant that, as stipulated under Clause-4 of the said policy, the claims for pre-existing ailments prior to obtaining the insurance policy shall not be admissible.  It is an admitted fact that, the complainant had obtained the said health insurance policy from OP No.1 through OP No.2 Bank.  Under these circumstances we opined that, being agent of insurance and when there is specific contention by OP No.1 as OP No.2 had given instructions of the policy etc., OP No.2 is a necessary party to this case on hand and accordingly we answered point (1) in the Negative.

 

POINT (2) & (3):-

11.   To avoid repetition in reasonings and as these points do warrant common course of discussion, the same are taken up for consideration at a time. 

 

(a)    Admittedly complainant had availed V. Arogya (Group Health Insurance Scheme) Insurance Policy No. 0726002815P111147397 from OP No.2 Bank being agent of OP No.1 the United India Insurance Company Limited. 

 

(b)    The contention of OP No.2 is on suppression of pre-illness of insured Smt. R. Sugunamma, as per Clause-4 of United Insurance Company Limited conditions and on pre-history of discharge summary of Sita Bhateja Hospital her claim was repudiated. 

 

(c)    Contrary to this complainant sworn in her affidavit as she was hale and healthy at the time of issuance of said policy and in the oral arguments the learned counsel for complainant had relied on the very OP document of attached copy of said insurance policy reads as “No pre-medical check-up is required”.  So the question of suppression of pre-illness does not arise hence complainant is eligible for her claim. 

 

(d)    On perusal of the entire pleadings and documents and affidavit evidence of both parties it is true that as per the said insurance policy no pre-medical check-up is required.  And there is no document with regard to pre-medical check-up was done to the complainant at the time of issuance of proposal form to obtain the said policy and copy of proposal form is also not submitted. 

 

(e)    Therefore by this it is clear that no pre-medical check-up was required for issuance of said policy according to the Ops own document.  Accordingly OP No.1 had issued said policy to the complainant which is valid from 22.12.2015 to 21.12.2016.  The Ops relied on Clause-4 of the said policy conditions when complainant approached for her claim.  Based on pre-history of discharge summary of Sita Bhateja Hospital. 

 

(f)     The main point for consideration in this case is, whether there has been suppression of any pre-illness of complainant, while filing of the proposal form submitted to the Insurance Company, which has led to a breach of terms and condition Clause-4 of the said Insurance Policy.

 

(g)    In repudiation letter dated: 25.06.2016, it has been stated as, “the complaints related to surgical procedure of L4-5 Grade II Lytic Spondylolisthesis with canal stenosis.  Essential HTN, IHD are since one year were existing earlier to commencement of policy”.

 

(h)    It was the bound duty of the Insurance Company OP No.1 and Agent Bank OP No.2 to have verify the information given in the proposal form by obtaining suitable expert opinion before taking decision to issue the Insurance Policy, it is a matter of grave concern that the OP No.1 would have done the necessary verification.  But Ops failed to submit any evidence in this regard.  However, when the claim filed by the complainant, minute scrutiny starts at that stage and claim repudiated. 

 

(i)     On perusal of discharge summary of Sita Bhateja Hospital and repudiation letter dated: 25.06.2016, we are of the opinion that, non-disclosure of such conditions in the proposal form cannot be blown out of proportion, so as to disentitle the complainant from the claim amount from the Insurance Company.

 

(j)     The conditions so mentioned in the History Column of said discharge summary do not imply that, the complainant would aware the said symptoms were of any serious disease without examination by a Doctor.  So the question of suppression of pre-illness while obtaining policy will not arise at all and Clause-4 of said policy will not applicable to this case on hand.  Therefore the claim was wrongly repudiated by the OP No.1 on the ground of non-disclosure of pre-illness.

 

(k)    The principle submitted by the complainant enunciated in the citation Civil Appeal No.3883 Of 2007 of Supreme Court of India between National Insurance Company Limited V/s. Hindustan Safety Glass Works Limited.

 

(l)     Civil Appeal No.1156 of 2008 between National Insurance Company Limited V/s. Kanoria Chemicals & Industries Limited since not applicable to the case on hand, hence not considered.

 

(m)   For all aforesaid facts and circumstances we hold that, there is deficiency in service on the part of the Ops in repudiation of the claim of complainant.  Therefore we are of the opinion that, complainant is entitled to the said health insurance policy claim. 

 

(n)    Now we are of fix the liability.  Admittedly OP No.2 is an agent of OP No.1 hence for the negligence and deficiency in service on the part of both the Ops being an Insurance Company OP No.1 is bound to be held as exclusively accountable to pay the said insurance claim of complainant as well as compensation together with interest.

 

(o)    According to discharge summary issued by Sita Bhateja Hospital the total amount incurred towards complainant’s treatment is a sum of Rs.1,60,000/- Bill No.BL16004136, dated: 02.03.2016, Bill No.16003989, Dated: 11.02.2016 Rs.9,000/- in total Rs.1,69,000/- this amount is complainant entitled to recover from OP No.1.

 

POINT (4):-

12.   In view of the above discussions on Point (1) to (3) we proceed to pass the following:-

ORDER

01.   For foregoing reasons the complaint is allowed with costs of Rs.3,000/- as against OP No.1 and the same is dismissed as against OP No.2 with no costs.

 

02.   The complainant is held entitled to claim a sum of Rs.1,69,000/- of health insurance policy vide No. 072600/28/15/P1/11147397 together with interest at the rate of 9% per annum from the date of filing of this complaint till realization and compensation of Rs.20,000/- exclusively from OP No.1 the insurance company. 

 

03.   We grant 30 days time to OP No.1 to comply from the date of communication of this order. 

 

04.   Send a copy of this order to both parties free of cost.

 

(Dictated to the Stenographer, transcribed by him, corrected and then pronounced by us on this 04^th DAY OF JANUARY 2018)

 

LADY MEMBER                                PRESIDENT