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KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE.
Ravishankar, Presiding Member & Mrs. Smt. Sunita Channabasappa Bagewadi Member
Sri. Syed Peer – Appellant
Versus
The Manager, (Health Insurance) LIC of
India & Anr. – Respondents
First Appeal No. A/1412/2011 with Appeal No.1412/2011
(Arisen out of Order Dated 30/11/2010 in Case No. CC/131/2010 of District Shimoga)
Decided on 17.6.2021
Consumer Protection Act, 1986 – Section 15 (Consumer Protection Act, 2019 – Section 41) – First Appeal - Against Order dt. 30.11.2010 passed by Distt. Forum - Complainant took family health insurance policy on 08.02.2008 by paying Rs.12,500/- premium per month, term 16 yrs. from 06.02.2008 to 2021 – Complainant had heart problem in Dec. 2008, was admitted from 19.12.2008 to 25.12.2008- Took further treatment at a hospital in Bangalore and underwent angioplasty - Was in Hospital again from 04.02.2009 to 08.02.2009, incurred medical expenses of around Rs.1,15,000/- - Filed a claim before the Respondent for reimbursement - Respondents repudiated the claim on the ground that the claim is barred by time and ailment falls under pre-existing disease – Distt. Forum dismissed Complaint – Hence, the Appeal – Not barred by time - No history of hypertension mentioned in discharge summary of the first hospital - Hypertension is a lifestyle disease, easily controllable with medicines and not a fatal disease- Rejection of Appellant’s/complainant claim by Respondent/LIC of India is not sustainable - Mediclaim cannot be denied only on technical ground.
Held: After going through the various judgments of Hon’ble National Commission, the Commission observed that hypertensive is a life style disease and easily controllable with medicines to alternative system. It may occur in many persons at any time. The blood pressure increases or decreases with aging process. But it can be treatable and can keep under control and person can out live his normal life. It is not a fatal disease to say, it was material fact that was suppressed by the complainant at the time of filling of the proposal form. In the present case on 04.02.2008 the proposal for obtaining policy was submitted by the complainant and for contained questions with respect to his health, medical history, the complainant had answered these questions in Negative. That not means the complainant had intentionally suppressed the material facts.
In discharge summary of Hegde Health Complex Hospital shows the complainant was a known case of hypertensive since years on medications. But there is nothing on the file to show that prior to this, the complainant ever took treatment for hypertension from any hospital. Moreover, hypertension is decreased and increased as per the life style and may be, it was under control at the second time of hospitalization of the complainant and may be this is the reason that the Jayadeva Hospital not mentioned about the hypertension in their discharge summary. Hence, in our opinion rejection of the claim of the complainant by LIC of India is not sustainable. Moreover, the complainant has taken the health policy. A contract of insurance policy is one of utmost good faith for both insurer and insured person. Hence, Medi claim cannot be denied only on technical ground. Hence, in our opinion as per the terms and conditions of policy, the complainant is entitled to daily cash benefit and also Rs.1,00,000/- towards Major surgical benefit with compensation. (Paras 11 & 12)
Result: Appeal allowed. Respondents/OPs directed to pay Rs.1,00,000/- to the Appellant/Complainant, pay daily Cash Benefit to complainant per terms and conditions of the policy within 30 days from the date of this order along with 6% interest from 25.02.2009 when claim was rejected by OPs., further directed to pay Rs.25,000/- towards compensation.
ORDERS
Smt. Sunita C. Bagewadi, Member—This appeal is filed by the appellant/complainant being aggrieved by the order dated: 30.11.2010 passed by Shimoga District Consumer Commission in C.C.No.131/2010.
2. The parties to the appeal shall be referred to as complainant and Opposite Parties respectively as per their rankings before the District Commission.
3. The brief facts of the complaint is that:-
The complainant has taken health insurance policy on 08.02.2008 by paying Rs.12,500/- premium Per Month for his family members including the complainant. The term of the policy is 16 years and the same will be in force from 06.02.2008 to 2021. The complainant further submits that there is no default in payment of premium till today. The complainant has suffered heart problem during December 2008. The complainant has got admitted at Hegde Health Complex, Shivamogga from 19.12.2008 to 25.12.2008 and has taken treatment in the said hospital. Subsequently on the advise he has taken treatment at Jayadeva Hospital, Bangalore. After check-up, the complainant was suffered severe heart ailment. Accordingly, the complainant has got admitted at Jayadeva Hospital, Bangalore and he has undergone with Angio-plasti operation and consequential follow-up treatment has taken from the above said hospital. The complainant further submitted that he was in Hospital from 04.02.2009 to 08.02.2009 and he has incurred medical expenses nearly about more than Rs.1,15,000/-. The complainant further submits that in terms of the policy, after discharge from the hospital, within time, he has filed a claim before the Respondent for reimbursement. After securing all the information, the Opposite Parties/Respondents repudiated the claim on the ground that the claim is barred by time and ailment falls under PED. Hence, the complaint.
4. The Opposite Parties appeared before the District Commission and filed their objections. The Opposite Parties contended that it is true that the complainant has obtained a policy under LIC health Plus Plan bearing No.625363734 dated:06/02/2008 for Rs.12,500/- P.A. and also contended that the policy term was 16 years and the Opposite Parties denied that as per the policy conditions, the opponents to bear all medical expenses and as per the policy conditions whenever the members insured or other insured persons got medical treatment as inpatient in any hospital, a daily hospital cash benefit at the rate of Rs.500/- Per Day is payable for the period of treatment excluding first two days in case of any one of the 49 major surgeries listed in the policy condition is undergone, a Major Surgical Benefit of Rs.1,00,000/- (200 times of daily cash benefits choosen by the member insured) is payable.
4(a) The Opposite Parties further contended that the complainant was admitted to Hegde Health Complex Hospital, Shimoga during the period 19/12/2008 to 25/12/2008 with final diagnosis as AWM1/2 HTN. As per the discharge summary, it is recorded that the complainant was a known case of Hypertensive since years on medications. This fact was not disclosed in the proposal form by the complainant. hence, the claim was rejected on 28.02.2009 by Third Party Administrative (TPA) on behalf of LIC of India giving reason as ‘Pre existing disease’. The Opposite Parties further contended that neither the claim made by the complainant is in respect of his hospitalization for the period from 04/02/2009 to 08/02/2009 at Jayadeva Institute of Cardiology, Bangalore. As per the clinical diagnosis and report, the complainant was diagnosed to be a patient of IHD (Ischemic Heart Disease) recent AWMI, CAD-SVD.
4(b) The Opposite Parties further contended that as per the discharge summary, Jayadeva Institute of Cardiology past history was not known case of D.M./H.T.N./COPD Asthama/ Any drug allergy. The complainant had a surgery PTCA with stent to LAD done on 05/02/2009 in Jayadeva Hospital, Bangalore. But the history was not correctly recor
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