Tamil Nadu

North Chennai

221/2013

N.Rajan,S/o.Mr.Narayanan, - Complainant(s)

Versus

Appollo Munich,Health Insurance Co ltd,Family Health plan(TPA) Ltd, - Opp.Party(s)

N.A.Kareem

25 Jan 2017

ORDER

                                                            Complaint presented on:  11.11.2013

                                                                Order pronounced on:  25.01.2017

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

WEDNESDAY  THE 25^th  DAY OF JANUARY 2017

 

C.C.NO.221/2013

 

N.Rajan,

S/o.Mr. Narayanan,

No.595, 3^rd Block, Pugazhenthi Salai,

Mogappair East, Chennai – 37.

 

Change of Address:

2/557, Seethakathi Salai,

Mogappair west,

Chennai – 37.

                                                                                    ….. Complainant

 

..Vs..

1. Appollo Munich,

Health Insurance Co Ltd.,

Family Health Plan (TPA) Ltd.,

10^th Floor, Tower – B,

Building No.DLF,Cyber City,

DLF, City Phase – II, Gurgaon,

Haryana – 122 002.

 

2. Appollo Munich Health Insurance Co. Ltd.,

No.4, Old No.319, Near Harrison Hotel,

Valluvarkottam High Road,

Chennai – 600 034,

Ms. Angayarkanni (Authorized Agent)

.....Opposite Parties

Date of complaint                                 : 18.11.2013

Counsel for Complainant                      : N.A.Kareem

Counsel for Opposite Parties                  : Mrs.Elveera Ravindran, K.Vinod

                                                                 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant availed a medical insurance from the Opposite Parties for himself and his family members in the scheme of Easy Health Individual Standard and the policy was issued to them for the period 24.05.2010 to 23.05.2011 and the sum assured was Rs.1,00,000/- each. The above said policy was renewed by the Opposite Parties for the period 24.05.2011 to 23.05.2012 and subsequently for the period 24.05.2012 to 23.05.2013. The Complainant paid a sum of Rs.7,935.11/- towards premium for Easy Health plan for the period 24.05.2012 to 23.05.2013. On 10.09.2012 around 2.00 p.m at Shanthi Colony, Anna Nagar, Chennai – 40 while the Complainant was crossing the road a SUV Motor Vehicle driven negligently hit him and sped away. The Complainant sustained fracture on his right hand and he rushed to a nearby SMF Hospital and after first aid  he was admitted in MN Orthopaedic Hospital, Kilpauk Chennai -10.  The Complainant submitted all the documents through the hospital to claim medical coverage for treatment. The Hospital also received a pre-payment sanction of Rs.35,000/- dated 11.09.2012.  A surgery was conducted in that hospital for fracture and he was discharged after 3 days. AT the time of discharge, the hospital received a mail from the Opposite Parties  that the approval was cancelled by them and the claim was  not covered  as per their terms and conditions. Hence the Complainant with great difficulty paid the amount at the hospital. The Complainant incurred treatment expenses of Rs.72,000/-. Thereafter the Complainant issued a legal notice to settle the amount and however the Opposite Parties have terminated the policy and also refunded the sum of Rs.7,937/- towards renewal premium paid by the Complainant. The Complainant’s claim for the total payment of Rs.1,32,000/- paid by him.  Hence the Complainant filed this Complaint for the premium insured amount of Rs.1,00,000/-  and Rs.50,000/- towards compensation for loss in business and mental depression and with cost of the Complaint.

2. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

          The Opposite Parties admits that the Complainant and his family members insured the policy plan easy health individual standard for the period stated by him. The said policy was issued to him without medical examination. The insured while applying for the policy bound to disclose all the facts. On 09.09.2012 on behalf of the Complainant a pre- authorization form along with documents for cashless request was received from MN Orthopedic Hospital alleged to have sustained fracture of right shaft humorous in a road accident, with approximate expenses of Rs.50,000/- for 3 days for the treatment of open reduction  and internal fixation.  In the pre-authorization form, the Complainant was stated to be a non-diabetic and non-hypertensive.   As per further request of Opposite Parties the treating hospital submitted a certificate that the Complainant was not under the influence of alcohol at the time of accident. The Opposite Parties approved a sum of Rs.35,000/-  in good faith for surgical management vide their letter dated 11.09.2012. Later the treating hospital submitted discharge summary and final bill for payment, where it is transpired that the Complainant is suffering from diabetics for 5 years. This fact was not disclosed by the Complainant in his medical history deliberately at the time of cashless request. Therefore the Opposite Parties denied cashless benefit due to non-closure of DM since 5 years for treatment and previous approval stands null and void, vide their letter dated 12.09.2012.  The Opposite Parties denied the facilities due to suppression of disease and also cancelled the Complainant policy and also refunded the premium amount of Rs.7,937/-  paid by the Complainant. Therefore, the Complainant is not entitled for his claim and the Complaint is liable to be dismissed with cost.

3. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO :1

          It is an admitted fact that        the Complainant  availed medical insurance policy from the Opposite Parties for himself and his family members in the scheme of Easy Health Individual Standard and the policy was issued to them for the period 24.05.2010 to 23.05.2011 and the sum assured was a sum of Rs.1,00,000/- each and the said policy was renewed by the Opposite Parties  for the period 24.05.2011 to 23.05.2012 and subsequently for the period 24.05.2012 to 23.05.2013 and the Complainant also paid premium for  Easy Health  plan for the period  24.05.2012 to 23.05.2013 and  on 10.09.2012 around 2.00 p.m at Shanthi Colony, Anna Nagar, Chennai – 40 while the Complainant was crossing the road, he  met with an accident and the Complainant sustained fracture on the right hand and he was admitted as an inpatient at  MN Orthopaedic Hospital, Kilpauk Chennai -10 on 09.09.2012 and surgery  was conducted on 10.09.2012 for fracture of humorous bone and he was discharged from  the said hospital  on 12.09.2012.

          5. The Complainant submitted all the documents through the hospital to the Opposite Parties for cashless treatment and the Opposite Parties also  gave pre-authorization of Rs.35,000/- for treatment and subsequently  when the final bill submitted, the Opposite Parties denied the cashless service under Ex.B10 that the Complainant due to non-disclosure of DM (Diabetic Mellitus), since 5 years.

          6. According to the Opposite Parties while submitting Ex.B4 for pre-authorization form by the Complainant, he furnished that he was not suffering from diabetic and hyper-tension. However, in Ex.A8 discharge summary issued by the hospital where the Complainant undergone surgery, it has been clearly stated that “a known DM past 5 years”. This disease DM was not disclosed by the Complainant either in Ex.B1 proposal form or in Ex.B4 pre-authorization form and therefore the Opposite Parties denied cashless service to the Complainant on receipt of final bill.

          7. The Complainant sustained fracture of injury in his right hand due to accident and to prove the same Ex.A3, FIR copy is filed. The Opposite Parties also have not denied the accident and injury sustained by the Complainant. Even assuming that the Complainant has not dis-closed the disease DM, the same has nothing to do with the injury sustained in the accident and the treatment of surgery taken by the Complainant.  In such circumstances, it is pertinent to mention that the non-disclosure of disease diabetic and hyper-tensive has no relevance for the treatment taken by the Complainant at MN Orthopedic Hospital.

          8. It is relevant to refer the order of the Hon’ble National Commission reported in III (2012) CPJ 322 (NC) (National Insurance Co., Ltd., & anr., Vs. Girin R. Shah). The Hon’ble National Commission held in paragraph 7 as follows:

The respondent Insurance Company has not produced the affidavit of the doctor, documentary medical evidence or other evidences in support of their say that the abscess in the anus had occurred due to diabetes and, therefore, the say of the opponent that the deceased insured was sufferings from pre-existing disease cannot be accepted. We hold that the policy Condition No.4.1 cannot be applied and by disallowing the claim for the expenses for the treatment, the Insurance Company has shown deficiency in service.

The Hon’ble National Commission clearly held that  suppression of diabetic has nothing to do with the  disease abscess in the anus occurred and therefore the Complainant was suffering pre-existing disease cannot be accepted. Likewise in the case in hand also the treatment had by the Complainant for the fracture sustained by him in the accident, has nothing to do with the pre-existing disease of DM of the Complainant cannot be accepted. Therefore relying on the above ratio of the National Commission and considering the facts and circumstances of the case, the Opposite Parties denied the cashless service to the Complainant is deficiency on their part and hence we hold that the Opposite Parties have committed deficiency in service.

09. POINT NO:2

          Ex.B9, is the final bill  for Rs.51,160/- issued by the MN Hospital filed by the Opposite Parties.  The said bill contains medicines, implants and other charges for surgery.  However, the Complainant filed Ex.A7, Ex.A8 for medicines and implant charges. The charges for medicines and implant included in Ex.B9 final bill itself. Therefore, the final claim amount of the Complainant would be only Rs.51,160/- and for such amount the Complainant is entitled towards insurance claim from the Opposite Parties.  The claim amount of Rs.1,00,000/- though covered under the policy, without proof of document for the same, the Complainant is not entitled as claimed in the Complaint. Due to denial of cashless service, the Complainant suffered with mental agony and for the same, it would be appropriate to order a sum of Rs.25,000/- besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay a sum of Rs.51,160/- (Rupees fifty one thousand  one hundred and sixty only)  towards Mediclaim to the Complainant and also to pay a sum of Rs.25,000/-  (Rupees twenty five thousand only) towards compensation for mental agony, besides a sum of Rs.5,000/- (Rupees five thousand only)  towards litigation expenses.

          The above amount shall be paid to the Complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 25^th day of January 2017.

 

MEMBER – II                                                               PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 23.05.2012                   Renewal of health insurance coverage with

                                                    Customer information sheet

 

Ex.A2 dated 09.09.2012                   MN Hospital admission request Note (family 

                                                    health plan limited) with estimation

 

Ex.A3 dated 10.09.2012                   Accident FIR No.453/A13/2012 on the file of

                                                    Anna Nagar police station

 

Ex.A4 dated 10.09.2012                   Janaki diagnostic centre receipts

 

Ex.A5 dated 11.09.2012                   Authorization letter by family health plan ltd to

                                                    MNO Hospital

 

Ex.A6 dated 11.09.2012                   Sweetha pharmacy credit bill

 

Ex.A7 dated 12.09.2012                   Sweetha pharmacy cash bill

 

Ex.A8 dated 12.09.2012                   MN orthopaedic Hospital implant receipt

 

Ex.A9 dated 30.09.2012                   Legal Notice to Opposite Party by Complainant

 

Ex.A10 dated 07.11.2012                 Legal notice to 2^nd respondents

 

LIST OF DOCUMENTS FILED BY THE  OPPOSITE PARTIES :

Ex.B1 dated 24.05.2010                   Proposal Form

Ex.B1 dated NIL                     Policy Schedule

Ex.B3 dated NIL                     Policy wordings

Ex.B4 dated NIL                     Pre Authorization Form signed by treating doctor

                                                    along with annexures

 

Ex.B5 dated 10.09.2012                   Additional Information Request Form

 

Ex.B6 dated 09.09.2012                   Treating Hospital Letter

 

Ex.B7 dated 11.09.2012                   Authorization Letter

 

Ex.B8 dated 12.09.2012                   Discharge Summary

 

Ex.B9 dated NIL                     Final Medical Bills

 

Ex.B10 dated 12.09.2012                 Denial of cashless service

 

Ex.B11 dated 24.12.2012                 Notice of termination sent to Complainant

 

Ex.B12 dated 25.01.2013                 Letter regarding cancellation sent to complete

                                                    along  with cheque

                  

 

                            

MEMBER – II                                                               PRESIDENT