Before the Consumer Disputes Redressal Forum
Bangalore Urban District
Sri. M.N. Shankar Bhat : President
Sri. Syed Usman Razvi : Member
Complaint NO. 1744 of 2003
Sri. S. Manoharlal Complainant
M/s. United India Insurance Company Limited Opp. Party
O R D E R
The complainant has filed the above complaint to direct the OP to pay a sum of Rs. 1,20,000/- with interest at 18% p.a, from 16.12.2002 and for other reliefs alleging deficiency in service on the part of the OP.
In order to avoid the repetition, the respective contention of the parties shall be adverted to during the course of this order.
1. The complainant has filed his affidavit in support of the averments made in the complaint and produced six documents. The OP has filed the version and on its behalf the Asst. Divisional Manager, Sri. S. Shivamadappa has filed the affidavit. No arguments came to be addressed on behalf of the complainant.
2. The Counsel for the OP while admitting that the complainant is covered by a mediclaim policy referred to in the complaint contended that the claim was rightly repudiated by the OP after taking into consideration all the relevant documents which revealed the complainant was suffering from shortcomings of breath for the last two years prior to his admission to Narayana Hrudayalaya. In that event, it follows that the complainant had cardiac problems even before he obtained the policy for the first time during the year 2001, and as such, he submitted the OP is justified in repudiating the claim and prayed the complaint may be dismissed.
3. We have considered the above arguments. The case of the complainant is that for the first time he obtained a medi claim policy on 23.11.2001 and to evidence the same he has produced the receipt dated 30.11.2001 and this receipt also refers to the policy number, etc. The said policy was got renewed by him for a further period from 23.11.2002 to 22.11.2003. This is also not disputed by the OP. According to the complainant, even at the time of obtaining the 1st policy on 23.11.2001 he had furnished the required particulars in the proposal form. It is his case during the period when the policy was in force, he developed breathlessness and visited Chinmaya Mission Hospital during October and November 2002 and was examined by Dr. Ravi Kishore of the said hospital and the said doctor advised him to consult Dr. Devi Prasad Shetty of Narayana Hrudayalaya. Accordingly, he got himself admitted to Narayana Hrudayalaya on 19.11.2002 and an Angiogram was taken and he was discharged from the hospital on 20.11.2002 and towards the Angiogram he spent Rs. 16,975/-. After going through the angiogram report, Dr. Devi Prasad Shetty advised the complainant to undergo DVR surgery and accordingly he once again got admitted to Narayana Hrudayalaya on 25.11.2002 and underwent surgery on 27.11.2002 and was discharged from the hospital on 16.12.2002 and according to the complainant, towards his treatment he spent a total sum of Rs. 2,21,000/-. To evidence the same he has produced the documents which are at Exs. E to E-4. His grievance is after his discharge, he submitted a claim with the OP claiming a sum of Rs. 1,20,000/- which was the amount covered by the policy. He submitted the claim to the TPA on the advise of the OP. But the TPA namely, Family Health Plan Ltd under a letter dated 29.07.2003 and by another letter dated 27.08.2003 repudiated the claim on the ground the complainant obtained treatment in respect of a pre-existing ailment. According to the complainant, the repudiation of the claim on the said ground is illegal. He came to know of the ailment only after he consulted a doctor not earlier to that, and as such, the complainant has alleged the repudiation of the claim by the OPs is illegal.
4. As stated earlier, the OP has not disputed the fact the complainant was covered by the policy referred to in the complaint but justified the repudiation by referring to the exclusion clause contained in the policy. Therefore, it is necessary to find out whether the OP is justified in repudiating the claim for the reasons stated in the letter of repudiation referred above.
5. In this connection, at first, it is necessary for us to refer to the letter dated 29.07.2003 which is at Ann-F1 addressed by Family Health Plan Ltd to the complainant and in this letter the reason for the rejection of the claim is that the hospitalization for the management of an ailment is related to a pre-existing condition and this opinion is based on the discharge summary issued by Narayana Hrudayalaya dated 12.12.2002 which shows the date of admission as 25.11.2002 and the date of discharge as 16.12.2002 and the patient was admitted to the hospital with severe Aortic Regurgitation, severe mitral stenosis, moderate pulmonary arterial hypertension, sinus rhythm and the history of present illness is stated as follows:-
Presented with C/o shortness of breath class II since 2 years
H/o. Palpitation +
No h/o chest Pain / giddiness / synocope.
The complainant has also produced the discharge summary dated 19.11.2002 issued by the said hospital and at that time after angiogram he was discharged from the hospital on 20.1.2002. Here also there is reference to the chest pain, giddiness, etc., According to us, only on the basis of the above note made in the discharge summary of the hospital, it cannot be said the complainant was suffering from an ailment which is related to a pre-existing condition. The OP before repudiating the claim has not chosen to conduct any enquiry to find out whether the complainant was suffering from any disease prior to the obtaining of the policy on 23.11.2001. The OP has also not chosen to produce the proposal form filled by the complainant at the time of obtaining the medi claim policy. No convincing material is placed before us by the OP that the complainant has suppressed his illness at the time of obtaining the medi claim policy. When the OP repudiated the claim, it is for the OP to conduct thorough enquiry regarding all the aspects to find out whether the complainant had obtained any treatment and undergone any tests before he obtained the medi claim policy. In this case, the OP has not produced any document to show that two years prior to 19.11.2002 the complainant was suffering from chest pain leading to the problems for which he obtained treatment. Strangely enough, the OP asked the complainant to submit a claim to Family Health Plan Limited and the said agency without conducting any enquiry relying on the discharge summary issued by Narayana Hrudayalaya Hospital reached to a conclusion that the hospitalization of the complainant related to a pre-existing condition. This letter is dated 29.07.2003 signed by the Medical Officer of the OP and the said Medical Officer has also not chosen to file any affidavit before us to prove the treatment obtained by the complainant is related to a pre-existing ailment. Basing on the said opinion given by the doctor, the Family Health Plan Limited intimated the complainant under a letter dated 27.08.2003 informing him his claim was rejected as the ailment for which he obtained treatment related to a pre-existing ailment.
6. From the materials placed before us, it is clear the OP has repudiated the claim without bothering to find out whether the claim is genuine or not and the agency appointed by the OP has also repudiated the claim without conducting any investigation. For the reasons stated above, we hold, the repudiation of the claim by the OP is illegal and the same amounts to deficiency in service.
7. In that event, the next point that has to be considered is the nature of relief to which the complainant is entitled to?
8. The complainant has spent more than Rs. 2,00,000/- towards his medical expenditure. But under the medi claim policy he has covered to the extent of Rs. 1,20,000/- only. Therefore, we hold, the OP is bound to pay the said amount. Hence, the
O R D E R
Complaint is allowed directing the Opp. Party to pay a sum of
Rs. 1,20,000/- to the complainant along with interest at 12% from
16.12.2002 till payment with costs of Rs. 10,000/-.
The OP is directed to comply with the order within a period of
Four weeks from the date of communication of this order.