State Consumer Disputes Redressal Commission
Icici Lombard General Insurance Co. ... vs 1.B. Rajasekhar on 7 August, 2024
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION:HYDERABAD
(ADDITIONAL BENCH)
FA. No. 478/2018
AGAINST ORDERS
IN
CC. No. 147/2016
ON THE FILE OF DISTRICT CONSUMER FORUM-II, HYDERABD
Between :
ICICI Lombard General Insurance Co Ltd,
ICICI Lombard House, 414, Veer SavarkarMarg,
Near SiddiVinayaka Temple, Prabhadevi, Mumbai-25,
Through
Legal Manager, ICICI Lombard General Insurance Co Ltd.,
Osman Plaza, Banjarahills, Hyderabad.
...Appellant/Opposite party No.1
And
B.Rajasekhar S/o Venkaiah,
Aged about 53 yrsOcc: Business,
R/o 16-11-16/V/15, RTA Office Lane,
Moosarambagh, Hyderbad.
Respondent No.1/Complainant
M/S E-Meditek (TPA) Services Ltd, Wellsurance policy, Gurgaon-122016, Rep by its Managing Director ...Respondent No.2/Opposite party No.2 (Respondent No.2/Opposite party No.2 not necessary party) Counsel for the Appellant/Opposite party No.1: M/s. Suri Sravan Kumar Counsel for the Respondent No.1/Complainant : M/s. V.Gourishankar Rao QUORUM: Hon'ble SriK.Ranga Rao, M ember-(J), & Hon'ble Smt.R.S.Rajeshree, M ember (N-J).
WEDNESDAY, THE SEVENTH DAY OF AUGUST, TW O THOUSAND TWENTY FOUR.
Order : (Per Hon'ble SriK.Ranga Rao, M ember -Judicial) ******
1). This appeal is filed by the appellant/Opposite Party No. 1 U/sec.15 of consumer protection Act, 1986, praying this commission to allow the appeal and to set aside the impugned order dt.06.07.2018 passed by the District Consumer Forum-II in CC 147/2016 and consequently to dismiss the complaint.
22). For the sake of convenience, the parties are referred to as arrayed in the complaint. The first Respondent in this appeal was the complainant and the Appellant herein was the first opposite party and second respondent in this appeal was the second opposite party.
3) The brief facts of the complaint are as follows:-
The Complainant submits that the opposite party No.l is engaged in General insurance business, offering different products to the consumers. In the said process, the opposite party No. 1 launched "ICICI Lombard Health Insurance Policy" under the name and style "Healthcare Plus Policy and issued colorful broachers. Being induced by the representations made by the opposite party No.1 and their marketing agents, the complainant has taken the ICICI Lombard Health care policy bearing No.4034/FNP/02414044/00/000 for a sum of Rs.3,00,000/- for a period of one year commencing from 20-7-2007 to 19- 07-2008 by paying a total premium of Rs.10,868/- The policy covered with the risk of the complainant and his wife, he continuously renewed from time to time. In the said process the complainant obtained ICICI Lombard complete Health Insurance Policy bearing No.4128i/HPR/82342314/00/000 dt.28-08-2013 for a period of 2 years from 16-8-2013 to 15-08-2015 by paying insurance premium of Rs.34,122/-. The policy covers the risk of the complainant and his wife for an assured sum of Rs.5,00,000/-
On 24-2-2014 the complainant was admitted in Sunshine hospitals Secunderabad, with the complaint of pain in left hip. The consultant Orthopedic and Joint replacement Surgeon Dr.AVGurava Reddy diagnosed that the complainant was suffering from "Avascular Necrosis of left hip with arthritis and suggested the complainant to undergo primary left total hip replacement.
4) The opposite party No.2 is TPA (Third Part Agency) of the opposite party No.1 as such the complainant submitted cashless authorization request note through the opposite party No.2 to the 3 opposite party No.1 and enclosing necessary papers for cashless facility.On 19-2-2014 the opposite party. No. 1 refused to provide cashless facility to him on the ground that he has not disclosed his total hip replacement in the year 2005, in the policy of inception No other alternative, the complainant was constrained to undergo the surgery by spending his own money with liberty to claim for reimbursement subsequently Accordingly, left total hip replacement surgery was done at Sunshine hospitals on 24-02-2014 and discharge on 28-2-2014. The complainant incurred a sum of Rs.3,53,190/- out of that Rs 96,000/- was claimed by GHPL as such, the opposite party No.1 has to pay the balance amount of Rs.
2,57,190/- On 6-3-2014, the complainant submitted the insurance claim form to the opposite party No 2 along with hospital bills, discharge summary, investigation reports, operation notes and insurance policy details etc by RPAD. There was no response from them. On 21-4-2014, the complainant submitted another representation to the opposite partyNo.2 along with the previous claim settlement details and invoices of THR implant and requested to speed up the reimbursement process.
On 28-04-2014 the opposite party No.1 issued termination notice of thehealth policy alleging that the complainant has not disclosed Right primary left total hip replacement undergone in the year 2005 at policy inception opposite party No.1 alleged that in the voice recording of the complainant confirmation call for MALADSP21DATIMS21180412319956A. the complainant has not declared or disclosed the said material facts and hence proposed terminate the insurance policy pursuant to clause 1 of part III of the policy wording. The opposite party No.1 further stated the policy shall stand cancelled after 15 days from the date of the said notice and the premium shall refunded in full to the complainant. Even the premium is not yet refunded.
The action of opposite party No 1 in not providing cashless facility was arbitrary, unreasonable, unjust and illegal. The rejection of the claim and termination of the policy not only amounts to gross negligence and deficiency in service but also amounts to unfair trade practice on the part of the opposite parties 4 The opposite party No.1 has not supplied a copy of proposal form to go through the contents/statements made by the complainant The first sugery was performed to the complainant in the year 2005 whereas the present surgery to the left THR was done on 24-02-2014 i.e. after a period of about 9 years. They have no nexus with each other. As per the broacher issued by the opposite party No.2 "pre-existing diseases can be covered after 4 continuous year of coverage with the company. The first policy was taken from the opposite party No.1 in 2007,whereas the subject surgery was performed on 24-2-2014, as such as per the benefits of the policy even if the said complaint was existing even from 2007, since 4 years continuous period was completed, the said risk is deemed to have been covered. Hence filed the present complaint for claiming compensation andcosts.
Version of the opposite party No.1 in brief: The opposite party No.1 submitted that allegations of the complainant requires elaborate trail which cannot be decided summarily under the provisions of C.P.Act. as such the complaint is liable to be dismissed.
The complainant has taken ICICI Lombard Health Insurance Policy from Mumbai office of opposite party No.1 on 20 th July, 2007 to 19th July 2008 for sum assured of Rs.3.00 lakhs covering the complainant and his wife. Before issuingthe policy the complainant was informed about the policy details, terms and conditions through Tele conversation and the same was recorded with the permission of the complainant. It was clearly mentioned in the policy certificate as under:
Important: Insurance benefit shall become voidable of the option of the company, in the event of any untrue or incorrect statement misrepresentation, non description or non-disclosure of any material particular in the proposal form/personal statement, declaration and connected documents or any material information has been withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance benefit. Please note that any claims arising out of pre - existing illness/injury/symptoms is excluded from the scope of this 5 policy subject to applicable terms and conditions. Refer to attached part II and III of the schedule for the terms and conditions. All disputes are subject to the jurisdiction of Mumbai High Court only It is true that the complainant renewed the policy for a period of 2 years from 16/8/2013 to 15/8/2015: The annual sum insured was Rs5 Lakhs and the additional sum insured was Rs.90,000/- with the same conditions except jurisdiction of Mumbai High Court which was modified to jurisdiction of competent Courts of India .
5) The complainant submitted cashless authorization request through Sunshine hospital for Rs.2Lakhs. In the past history column of the request letter it was clearly mentioned (R) THR in 2005. The opposite party No.1 sought discharge summary of the said treatment and informed the same to Sunshine hospitals. The hospital authorities furnished the discharge summary of the complainant to opposite party No.1 on 28/2/2014 From the discharge summary it reveals that the complainant had consulted Dr.A.V.Guruva Reddy for pain in both hips which he was suffering since 11 years. He was admitted in hospital on 5/1/2006 and discharge on 11/1/2006. He was treated for (Rt) Articular resurfacement done with Depuy ASR The opposite party No.1 denied preauthorization request and informed the same to the Sunshine hospital through letter dated 28/2/2014. The hospital authorities also clarified through letter dated 28/2/2014 that the final bill amount was Rs.3,45,490.25.
The allegation of the complainant he incurred an amount of Rs.3.53,190/- is false and the same is denied. The complainant for the reasons best known to him did not file the in-patient final bill. The advance receipt dated 24/2/2014 for Rs.50,000/- and another advance receipt dated 28/2/2014 forRs.2,07,190 are printed on 1/3/2014 whereas the complainant was discharge on 28.2.2014. This clearly shows to prove that they are created for the purpose of this case only. The bill of invoice dated 24/2/2014 issued by Global surgical pertains to sunshine hospital only. The opposite party No. 1 does not admit that the ref name and IP no mentioned are of the complainant and the description of the goods was used for the purpose of the complainant only 6 The opposite party No.1 submitted that the in-patient final bill dated 28/2/2014 for Rs.3,45,490.25 issued by hospital bears the name of the organization as United India InsuranceCo.Ltd, and TPA name as GHPL, employee no GHUJAB00229785 and medical card No.GHULAB00229785.It clearly shows to prove that the complainant also lodged claim with United India Insurance Co.Ltd for the same period and received the payment. The complainant managed the hospital authorities and obtained letter dated 19/4/2014 in his favour. The opposite party No. 1 did not receive any such letter from the hospital as such they do not admit the contents of the letter.
6) The complainant did not lodge any claim with opposite party No.1 and they had no idea about the representation dated 21/4/2014 said to have been sent by the complainant. The complainant did not file any proof to substantiate it.
It is true that opposite party No. 1 issued letter dated 28/4/2014 informing about termination of the policy within 15 days and also about refund of the premium. The complainant did not send any notice denying the contents of the letter. The premium amount was refunded to the complainant on 21/05/2014 and he received the same The complainant failed to state how the action of opposite party No.1 is unjust and illegal in rejection of the claim and termination of the policy. The complainant has nowhere stated or alleged in the complaint that he informed about his previous surgery in the year 2005 and the opposite party No.1 is know about it. The proposal is the basis of the contract and the policy represents the contract between the insured and the insurer. The complainant for the reasons best known to him did not disclose his previous left hip replacement in 2005 at the time of taking the policy on 18/4/2012. Had he disclosed about it the opposite party No.1 would have think about issuing the policy. Since he failed to disclose it the contract became void and the opposite party No.1 informed the same to the complainant. The policy was cancelled due to non-disclosure of material facts at the time of taking the 7 policy on 18/4/2012. The complainant misunderstood the cancellation as pre-existing disease and seeking relief from this Forum on thatground. The complainant was given 15 days notice by way of letter dated 28/4/2014 before cancellation of the policy. The contents of the letter is respipsaloquitor to justify the action of opposite party No.1.
7) The opposite party No.1 once again reiterates that the complainant did not lodge any claim with opposite party No.1 for the treatment at Sunshine Hospital. The hospital bill for Rs.3,45,490.25 was raised in the name of United India Insurance Co.Ltd as such this opposite party No.1 is not liable to pay any amount and there was no deficiency in service on their part. Hence prayed to dismiss the complaint against them.
Version of the opposite party No.2 in brief: The present complaint is not maintainable against the opposite party No.2 as there is no privity of contract between the complainant and opposite party No.2 as neither any premium was charged by opposite party No.2 nor there is any contract of insurance entered between the complainant and opposite party No.2, who is merely a third party administrator.
The opposite party No.2 has no pecuniary/financial interest in any of the claims whatsoever as such we only process/settle the claim on behalf of insurance companies as per the guidelines and the final call of the insurance company to reimburse the claims to the insured or not. The entire payments liabilities are of the insurance company.
That it was held by Hon'ble Supreme Court of India in case Prem Nath Motors Vs. Anurag Mittal reported in AIR 2009 SC 567, wherein it was held as under:
Held, that Section 230 of the Contract Act categorically makes it clear that an agent is not liable for the acts of a disclosed principal. Hence prayed to dismiss the complaint against them.8
8) During the course of enquiry before the District Forum, to prove his case, the complainant filed his evidence affidavit and got marked Ex. A1 to A16. On behalf of opposite parties 1,One K.Amith Reddy, who is the legal Manger of ICICI Lombard General Insurance Coltd, filed his evidence affidavit and got marked Ex.B1 to B6.
9). The District Forum after considering the material available on record, allowed the compliant in part, holding as follows:
"In the result, Compliant of complainant is allowed in part directing the opposite party No.1 (i) To pay Rs.2,57,190/ - (Rupees Two lakhs fifty Seven Thousand one Hundred and Ninety only) to the complainant with interest @ 9% p.a. w.e.f. 19.02.2014 i.e. form the date of Denial of cashless Access under Ex.B3 till its realization. (ii) To pay costs of Rs.10,000/- towards costs. Time FOR compliance is 30 days from the date of receipt of this order.
Rest of the claim of the complainant is dismissed.
Aggrieved by the above order the appellant/opposite party preferred this appeal vide FA.No.478/2018 with the following grounds:-
.The order of the District forum-II Hyderabad in CC 147/2016 is unjust contrary to law and materials on record.
. The District Forum-II Hyderabad erred in allowing the complaint but it ought to have dismissed the complaint.
. The District Forum-II Hyderabad failed to see the objection raised by the Appellant for not making Andhra Bank as well as United India Insurance Co Ltd as proper and necessary parties as the Complainant has taken Andhra Bank Aarogyadaan policy vide policy no 050400/48/13/41/00000429 valid from 9/6/2013 to 8/6/2014 and lodged claim with them that the Respondent. No.1/Complainant did not lodge any claim with Appellant.
. The District Forum failed to see that policy was terminated and the premium amount was refunded to the Complainant as such the 9 Complainant ceases to be a consumer within the meaning of C.P.Act and ought to have dismissed the complaint.
.The District Forum-II Hyderabad failed to see EX.A9and EX.B3 especially the important clause properly wherein it was clearly stated that denial of authorization does not imply denial of the treatment and does not in any way prevent the insured from seeking necessary medical attention or hospitalization/claiming for reimbursement issues.
.The District Forum-II failed to see that the Complainant did not lodge any claim for reimbursement of medical bills after discharge from the hospital.
.The District Forum-II Hyderabad failed to see the contents of EX.A11 dated 19/4/2014 properly as the letter was addressed by Sunshine Hospitals to Opposite Party No.2with regard to settlement of the claim of the Complainant with TATA AIG only.
.The District Forum-II Hyderabad failed to see the pleadings of the Complainant made in para 6 of his complaint wherein he clearly stated that he submitted claim form along with Hospital bills, discharge summary, investigation reports, operations notes, insurance policy details etc by RPAD to Opposite Party No2 and also about the representation dated 21/4/2014 sent to Opposite Party No2.
.The District Forum-II Hyderabad failed to see that there is no relationship between Appellant and Opposite Party No2 as Opposite Party No.2 is not TPA of the Appellant. In fact the Appellant has separate claims dept at Gachibowly, Hyderabad to deal the claims under the policy.
10. The District forum-II went beyond the terms and conditions of policy in granting relief to the Complainant.
11. The District Forum-II Hyderabad also erred in awarding Interest 9% PA from the date of denial of cashless till realization and Rs10,000/- costs Awarding interest as well as compensation amounts to double relief which is not permissible under law.
10) With the above grounds, the appellant/opposite party prayed this commission to allow the appeal and to set aside the impugned order of the District Forum and consequently to dismiss the complaint.10
11) Heard arguments of both sides The Point that arises for consideration is :-
(i) Whether the impugned order dt.06.07.2018 passed by the District Forum-II, Hyderabad in CC 147/2026, suffers from any error or irregularity or whether it is liable to be set aside, modified or interfered with, in any manner?
(ii)If so to what relief?
To decide the points for consideration we have carefully examined the whole material borne by record i.e. the averments of the complaint, the evidence affidavit of the complainant and Ex.A1 to A16 which are marked on behalf of the complainant, and the evidence affidavit of Rw1 and Ex.B1 to B6 which are marked on behalf of opposite parties and the same would manifest that it is the specific case of complainant that he obtained Ex.A1 ICICI Lombard health care policy from opposite party No.1 vide policy bearing No.4034/FNP/02414044/00/000 for a sum of Rs.3 lakhs for a period of one year commencing from 20.07.2007 to 19.07.2008 by paying the total premium of Rs.10,868/- The policy covers the risk of the complainant and his wife. The complainant renewed the policy from time to time.
It is also the case of the complainant that he obtained Ex.A5 ICICI Lombard Complete health insurance policy from opposite party No.1 vide policy bearing No.4128i/HPR/82342314/00/000 dt.28.08.2013 for a period of 2 years from 16.08.2013 to 15.08.2015 by paying insurance premium of Rs.34,122/-. The policy covers the risk of the complainant and his wife for an assured sum of Rs.5 lakhs.
On 24.02.2014 the complainant was admitted in Sunshine Hospital, Secundered with the complainant of pain in left hip. The Consultant Orthopaedic and Joint Replacement Surgeon Dr. A.V. Gurava Reddy Diagnosed that the complainant was suffering from "Avascular Necrosis of Left hip with Arthritis" and suggested to the complainant to undergo primary left total hip replacement.
11In view, of the same since opposite party No.2 is TPA (Third Party Agency) of opposite party No.1, the complainant submitted Ex.A8 cashless Authorization request note to opposite party No.1 through opposite party No.2, by enclosing necessary papers for cashless treatment.
On 19.02.2014 Opposite party No.1 refused to provide cashless facility to him under Ex.B3 on the ground that he has not disclosed his total hip replacement in the year 2005, at the inception of the policy. As there was no other alternative, the complainant was constrained to undergo the surgery by spending his own money, so as to claim reimbursement of the same subsequently. Left total hip replacement surgery was done to the complainant at Sunshine Hospital on 24.02.2014 and was discharge on 28.02.2014 as seen from Ex.A10 discharge summary issue by Sunshine Hospital as seen Ex.A12 to A14, the complainant incurred a sum of Rs.3,53,190/- out of which Rs.96,000/- was claimed by THPL as such, the opposite party No.1 has to pay the balance amount of Rs.2,57,190/-.
On 06.03.2014 the complainant submitted the insurance claim form to opposite party No.2 along with Hospital Bills, discharge summary, investigation Reports, operation notes along with insurance policy details by Registered post with acknowledgment due. But there was no response from the opposite parties. On 21.04.2014 the complainant submitted another representation to opposite party No.2 along with pre vious claim details and invoices of THR implant and requested to speed up the reimbursement process.
12) On 28.04.2014 opposite party No.1 issued Ex.B6 termination notice of the health policy alleging that the complainant has not disclosed Right Primary left total hip replacement undergone by him in the year 2005, at the policy inception. The opposite party No.1 alleged that in the voice recording of the complainant confirmation call for MALADSP 21 DATIMS 21180412319956A, the complainant has not declared or disclosed the said material facts and hence proposed to terminate the insurance policy in pursuance of clause 1 of part III of the 12 policy wording. The opposite party no.1 further stated that the policy shall stand cancelled after 15 days from the date of the said notice and premium shall be refunded in full to the complainant. The complainant submits that even premium is not yet refunded.
It is the further case of the complainant that the opposite party No.1 has not supplied the copy of the proposal form to go through the contents/statements made by the complainant.
The first surgery was performed in the year 2005, whereas the present surgery to the left THR was done on 24.02.2014 i.e. after a period of about 9 years. The said two surgeries have no nexus with each other.
As per the broacher issued by opposite party No.2 "pre- existing diseases can be covered after four continuous years of coverage" with the company. The first policy was taken from opposite party No.1 in the year 2007, whereas the subject surgery was performed to the complainant on 24.03.2014, as such as per benefits of the policy, even the said complaint though existing even from 2007, since 4 years continuous period was completed, the said risk is deemed too have been covered. The Act of opposite party in not providing cashless facility was arbitrary, unreasonable, unjust and illegal. The rejection of claim an d termination of policy not only amounts to gross negligence and deficiency in service but also amounts to unfair trade practice on the part of the opposite parties. Hence he filed the complaint for the reimbursement of Rs.2,57,190/- along with interest 18% p.a. from 28.02.2014 till the date of realization and for the compensation of Rs.50,000/- and for cost of Rs.25,000/-.
13) But on the other hand it is the contention of the opposite party No.1. that while processing the pre authorization request note vide No.110100216267 for admission of complainant in Sunshine Hospitals on 28.02.2014 for cashless treatment, it was evident from Ex.A16 discharge summary of KIMS dt.11.01.2006 (Ex.B5 is the equivalent of Ex.A16) that the insured/complainant was diagnosed with Bilateral Avascular Necrosis of Femoral Head and is a case of pain in both hips since 11 years and as per Ex.A10 13 discharge summary of Sunshine Hospitals dt.28.02.2014, the insured/complainant underwent right primary Left Total hip replacement in 2005 which was not disclosed at policy inception i.e.18.04.2012, ( the subject policy is Ex.A3 health care policy for the period from 14.08.2011 to 13.08.2012). It is also the contention of the opposite party that the first health care policy unde r Ex.A1 was taken by the complainant on 20.07.2007 and prior to that the complainant underwent the surgery of right primary left total hip replacement in 2005 which was not disclosed by the complainant at the time of taking Ex.A1 which is for the period from 20.07.2007 to 19.07.2008. Before issuing the policy, the complainant was informed about policy details and terms and conditions and it is clearly mentioned in policy certificate to the affect that "Important:
Insurance benefit can become voidable a t the option of the company, in the event of any untrue or incorrect sta tement, misrepresentation, non disclosure of any material particulars in the proposal form/personal statement, declaration and connected documents or any material information, has been withheld by beneficiary or any one acting on behalf of beneficiary to obtain insurance benefit. Please note that any claim arising out of pre-existing illness/injury/symptoms, is excluded from the scope of the policy subject to applicable terms and conditions. Refer to attached part II and III of the schedule for the terms and conditions." In view of the non disclosure of the pre-existing illness and undergoing of total hip replacement surgery by the complainant, opposite party NO.1 refused for cashless facility under Ex.B3 to the complainant and further issued Ex.B6 termination notice of the policy on 28.04.2014 with a notice of 15 days and the same is legal and sustainable as such opposite party no.1 company is not liable to reimburse the claim amount of the complainant and further as there is no deficiency of service, opposite party No.1 is not liable to pay compensation and costs to the complainant as claimed.
In view of the above revel contentions it is to be seen and examined from the oral and documentary evidence of the complaint that whether he has proved his case and after that it is to be scrutinized whether opposite party No.1 is justified in refusing the cashless facility to the complainant for his treatment and 14 further whether issuing Ex.B6 termination notice of policy to the complainant by opposite party No.1, is legal and sustainable.
To prove his case the complainant filed his evidence affidavit in which he has reiterated his case of what he pressed in his complaint. In support of his oral evidence, the complainant got marked Ex.A1 to A16.
Ex.A1 is Health Care Insurance policy for period 20.07.2007 to 19.07.2008. Ex.A2 is policy for the period from 14.08.2009 to 13.08.2010. Ex.A3 health care policy from the period from 14.08.2011 to 13.08.2012. Ex.A5 is ICICI Lombard complete health insurance policy given by opposite party in favour of the complainant with the coverage for the period from 16.08.2013 to 15.08.2015. Of course issuing of the above polices by opposite party No.1 is not in dispute as the same were admitted by opposite party No.1. Opposite party No.1 who also filed four policy certificates of the complainant under Ex.B1 and the same establish the fact that the inception of the policy was in force w.e.f. 28.7.2007 to 15.08.2017 for a continuous period of 8 years till its Termination Letter dt.28.04.2014 issued by opposite party No.1 under Ex.B6.
Ex.A10 discharge summary of the complainant issued by the Sunshine Hospitals shows that the complainant was admitted in the said hospital on 24.02.2014 at 6.45 AM with the complaint of pain in the left hip, associated with difficulty in daily activities. The consultant Doctor Dr. Gowra Reddy, the consultant orthopaedics and joint replacement surgeon, examined the patient/the complainant and diagnosed that the complainant was suffering from Avasclar Necrosis of left hip with Osteo arthritis. The said discharge summary also shows that after all relevant investigations and PAC, surgery of left total hip replacement was done to the complainant and he was discharge on 28.02.2014 at 1PM.
14) Ex.A8 is cashless authorization request note and the same corroborates the version of the complainant that he submitted the said Ex.A8 to opposite party No.1 through opposite party No.2. Ex.B3 is denial of cashless access/facility which is issued by 15 opposite party No.1. under Ex.B3 (Ex.A9 is equivalent to Ex.B3). A perusal of Ex.B3 shows that opposite party No.1 denied the cashless facility to the complainant for his treatment on the ground that he has not disclosed his undergoing of total hip replacement surgery in 2005 which was prior to policy inception.
In view of the denial of cashless treatment, the complainant underwent treatment with his funds with a view that the amount spent for surgery can be reimbursed from opposite party No.1 subsequently. The complainant incurred a sum of Rs.3,53,190/- for the said surgery. This version of the complainant is buttressed by Ex.A11 to A14. Out of the incurred expenditure of Rs.3,53,190/- a sum of Rs.96,000/- was claimed by GPHL and therefore, the opposite party No.1 by virtue of the insurance policy has to reimburse the balance amount of Rs.2,57,190/-
Ex.B6 is the termination notice of health policy. A perusal of the same shows that Ex.B6 notice was issued by opposite party No.1 to the complainant, wherein opposite party No.1 stated that the complainant has not disclosed his undergoing of surgery of right Primary Left Total Hip Replacement in the year 2005, at policy inception i.e. 18.04.2012 as such opposite party no.1 issued Ex.B6 termination notice to him and Health Care insurance policy shall stand cancelled after 15 days from the date of the said notice and premium shall be refunded in full to the complainant. But as seen from Ex.A1 Health care policy particularly under the head Health Care Plus-Coverage, it is mentioned that " Pre-Existing diseases can be covered after four continuous year of coverage with the company." Admittedly the inception of the policy was w.e.f. 2007as per Ex.B1(Four policy certificates) The complainant sought cashless authorization request note under Ex.B2 in the year 2014 after lapse of seven years from the date of inception of policy. As such the Denial of the Cashless Access under Ex.B3 by opposite party No.1 to the complainant, in our considered view is untenable and further issuing Ex.A15 termination notice of the health policy by opposite party No.1 to the complainant, is not legal and the same amounts to unfair trade practice and deficiency of service on the part of opposite party No.1.
1615) Thus having examined the whole material borne by the record independently and in view of our afore stated discussion, we hold that the complainant by his evidence as PW1 coupled with Ex.A1 to A16 has proved his case as such his complaint deserves to be allowed for the reliefs sought by him in the same. Of course the District Forum rightly allowed the complaint of the complainant in part granting the reliefs mentioned in its order. We have gone through the order of the District Forum passed in CC 147/2016 dt.06.07.2018 and conquer with the reasoning and findings of the District Forum, made in the said order.
Viewed from many angel, nothing appears to us to interfere with well reasoned order of the District Forum as such we hold that this appeal is liable to be dismissed as devoid of merits.
In the result, the appeal is dismissed, conforming the order of the District Forum.
Each party shall bear their own costs.
Typed to the dictation to the Steno on system, corrected and pronounced by us in the open bench on 07.08.2024.
SD/- SD/-
--------------------------------------------- Dated: 07.8.2024.