BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 153/2005 Filed on 12.05.2005

Dated : 30.06.2011

Complainant :

K.B. Madhusoodanan Nair, Santhasree, Kankathumukku, Thirumullavaram P.O, Kollam-691 012.

(By adv. Kamaleswaram S. Manikantan Nair)

Opposite parties :

1. Bajaj Allianz General Insurance Company Ltd., Policy issuing office, T.C 28/222(5), Anugraha II Floor, Pazhavangadi, Thiruvananthapuram.

    

2. Bajaj Allianz General Insurance Company Ltd., Registered and Head Office, GE Plaza, Airport Road, Yerwada, Pune-411 006.

    

   (By adv. Sreevaraham G. Satheesh)

    

3. The Paramount Health Services Pvt. Ltd., II Floor, Gurukripa Buildings, Subhash Chandra Bose Road, Chettichira, Vyttila P.O, Kochi.

This O.P having been taken as heard on 26.05.2011, the Forum on 30.06.2011 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

Complainant in this case is an advocate. He is an insured under the Health Guard Policy issued by the 2^nd opposite party, the policy No. being 0G-05-1601-8401-00000031. The policy is valid from 02.06.2004 to 01.06.2005. As per the terms and conditions of the policy, the opposite parties are bound to indemnify the complainant and the other insured persons to the extent of Rs. 50,000/- each of the medical expenses incurred for the treatment of illness or accidental bodily injury sustained or contracted by them during the validity period of the policy including ambulance expenses and expenses for medical checkup. The complainant never had heart problems till 15.01.2005. Due to the sudden exertional chest discomfort at 8 a.m on 16.01.2005, the complainant was taken to Upasana Hospital, Kollam. After necessary check up there, he was found to have positive Tread Mill Stress stage-I. Due to the seriousness of his illness he was referred for expert management. Therefore the complainant was admitted at KIMS on 17.01.2005. The investigation therein revealed Left Middle Coronory Artery short vessel severely stenosed and contained thrombus, that the stenosis involved the bifurcation and the origin of Left Circumflux. So he had to undergo open heart surgery at KIMS on 18.01.2005 and was discharged on 30.01.2005. The medical bill issued from KIMS was for Rs. 1,69,760/-. When the doctors at KIMS recommended operation as an emergency procedure, the complainant through the hospital, sent a request to the opposite parties for cashless hospitalization based on policy coverage terms and conditions. But it was turned down by the 2^nd opposite party on the ground that suspected chronisity of the ailment, without prejudice to the right of the complainant to claim reimbursement of medical expenses. Thereafter as required by the 2^nd opposite party the complainant submitted duly filled claim form and submitted the same to the 2^nd opposite party along with originals of the relevant documents for processing the claim. But to the utmost surprise of the complainant, he received a letter dated 28.02.2005 from Paramount Health Services Private Ltd., Cochin stating that the claim is not admissible as the policy excludes coverage for ailments that existed at the time of commencement of the cover for the first time. The complainant states that till the commencement of the policy or upto 15.01.2005 the complainant had no sort of heart ailment. In fact before issuing the policy the complainant, his wife and children were got examined by a panel doctor of the 2^nd opposite party. If as a matter of fact, the complainant was suffering from any sort of heart ailment that would have been detected by the panel-doctor of the 2^nd opposite party and would not have effected the policy. The complainant submits that since the claim of the complainant is turned down by the 3^rd party administrators of the 2^nd opposite party without any basis, the complainant is entitled to get interest on the insured amount of Rs. 50,000/- from the date of rejection of the claim till payment.

In this case 1^st and 2^nd opposite parties filed version. In the version they stated that in this case the Paramount Health Services Ltd. is a necessary party. But the complainant not made the Paramount Health Services Pvt. Ltd. as a party in this case. Hence they prayed for the dismissal of the case for non-joinder of necessary party. After this version, the complainant impleaded the Paramount Health Services Ltd. as the additional 3^rd opposite party. The 3^rd opposite party accepted notice from this Forum, but not turned up to contest the case. Hence additional 3^rd opposite party remained exparte. In the version 1^st and 2^nd opposite party admitted that the complainant is an insured under Health Guard policy and a claim was submitted by the complainant for medical expenses for the treatments undergone by him for Coronory Artery disease. The claim was processed by the Paramount Health Service Pvt. Ltd. and from the medical records it was revealed that the disease was pre-existing. As per exclusion clause 4.1 of the policy, the coverage for ailments that exists at the time of commencement of the policy are excluded. This fact was informed to the complainant by the Paramount Health Services Pvt. Ltd by its letter dated 28.02.2005. The medical records clearly shows that the complainant was having the ailment even before the commencement of the policy. In that circumstances the claim is not payable as per the policy conditions. The claim is legally not payable and hence the same was repudiated. The opposite parties submit that the complainant was having heart problem for the last more than 17 years. The averment that he never had any sort of heart problems till 15.01.2005 is against the medical reports submitted by the complainant himself. The complainant was having the heart ailment even before the commencement of the policy. There was no medical examination as alleged. Even such an examination may not be helpful in finding out any symptoms or causes which existed earlier and subsided on treatments. There is no deficiency of service on the part of the opposite parties. Repudiation of the claim was based on genuine and lawful reasons. The opposite parties only acted in terms of the policy conditions, rules and regulations . Hence they pray for the dismissal of the complaint.

In this case complainant and opposite parties filed proof affidavits in lieu of evidence. From the complainant's side 8 documents were marked as Exts. P1 to P8 series. Opposite parties produced 4 documents which were marked as Exts. D1 to D4.

Points to be ascertained :

1. Whether the repudiation of the claim by the opposite parties is valid or not?

2. Whether the complainant is entitled to get the policy benefit as per the terms and conditions of policy?

3. Reliefs and costs.

Points (i) to (iii):- Complainant is an insured under the policy No. 0G-05-1601-8401-00000031. The policy is valid from 02.06.2004 to 01.06.2005. The opposite party produced the policy copy and its conditions which is marked as Ext. D3. There is no dispute regarding the policy and its validity. As per this policy the opposite parties are bound to indemnify the complainant and other insured persons to the extent of Rs. 50,000/- each of medical expenses incurred for the treatment of illness or accidental bodily injury sustained during the validity of policy period. During this period, i.e; on 18.01.2005 due to sudden chest pain the complainant had to undergo Coronary bypass surgery at KIMS Hospital on an urgent basis. Ext. P1 is the treatment records to prove that diagnosis. In that situation the complainant sent a request for cashless hospitalization based on policy coverage terms and conditions, the same was turned down on the ground of suspected chronicity of the ailment without prejudice to the right to claim reimbursement of medical expenses. Ext. P3 is that letter sent by the 3^rd opposite party to the complainant. Thereafter the complainant submitted claim form along with relevant documents for processing the claim to the 2^nd opposite party. But the complainant received a letter from the Paramount Health Services Pvt. Ltd stating that the claim of the complainant is not admissible as the policy excludes coverage for ailments that existed at the time of commencement of the cover at the first time. Complainant argued that he never had any symptoms of coronary artery disease, cardiac problem or any sort of exertious chest discomfort. To prove that contention he has produced the medical certificate dated 01.01.2006 issued by KIMS Hospital which is marked as Ext. P6. Ext. P6 proves that the contention of the complainant is true. Complainant paid an amount of Rs. 1,69,760/- for his treatment. The medical bills produced by the complainant are marked as Ext. P7 series. As per Ext. P7 the complainant had paid an amount of Rs. 1,69,760/- to the KIMS Hospital for his treatment. In this case the 1^st and 2^nd opposite parties filed proof affidavit and examined the Assistant Manager, Bajaj Allianz General Insurance company as DW1. From the opposite parties' side 3 documents were marked as Exts. D1 to D3. The opposite parties' argument is that as per Ext. D1 medical report issued by the KIMS hospital it can be seen that the complainant was having hypertension for the past 15 years, Dyslipidemia and TIA for last 17 years. As per Ext. D1 the argument of the opposite party is found correct. Opposite parties further argued that the present ailment of coronary artery disease is a known complication of Hypertension and Dyslipidemia. Clause C1 of the policy (Ext. D3) excludes all ailments that exists at the time of commencement of the policy. Therefore from the medical records it is very clear that the present ailment was a pre-existing one. Thus they rejected the claim. But the opposite parties did not prove that the present ailment of coronary artery disease is the complication of hypertension and Dyslipidemia. It is the duty of the opposite parties to prove that contention by medical evidence. The opposite parties failed to prove that the present ailment was a pre-existing one. Moreover by Ext. P6 the complainant did not have any symptoms of coronary artery disease before 15.01.2005. The opposite party never challenged that statement. Another contention of the opposite parties is that in the proposal form he has given false statement regarding his health conditions and that there is suppression of material facts. That the complainant had given the answer as “No” in question No. 4 of the proposal form. That as per Ext. D1 medical report that answer is wrong, on that ground they rejected the claim. But at the time of cross examination of DW1 it was stated that in case of persons below 45 years medical examination was not insisted. In this case the complainant was 55 years old at the time of taking policy. Therefore the complainant should have definitely undergone medical examination and on the basis of that medical report the opposite parties issued the policy to the complainant. Hence that contention of the opposite parties are not sustainable. In this case the opposite parties have not taken any steps to prove their contentions for rejecting the claim. From the above mentioned discussions, we find that the complainant was not having pre-existing disease at the time of issuance of health insurance policy. Hence the complainant is entitled to get the benefits under the policy and opposite parties have the liability to pay the same.

In the result, the opposite parties 1 & 2 are directed to pay Rs. 50,000/-, the insured amount, along with 9% annual interest from 28.02.2005 i.e; from the date of repudiation. The opposite parties shall also pay Rs. 2,000/- as costs to the complainant. The 1^st and 2^nd opposite parties are jointly and severally liable to pay the amounts to the complainant. Time for compliance one month from the date of receipt of the order, otherwise 12% annual interest shall be paid for the above mentioned amount till the date of realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 30^th day of June 2011.

Sd/- BEENAKUMARI. A : MEMBER

Sd/-

G. SIVAPRASAD : PRESIDENT

Sd/-

S.K. SREELA : MEMBER

jb

C.C. No. 153/2005

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - K.B. Madhusoodanan Nair

II COMPLAINANT'S DOCUMENTS :

P1 - Treatment records

P2 - Copy of denial of cashless access.

P3 - Letter sent by the 3^rd opposite party to complainant dated

16.02.2005.

P4 - Copy of letter dated 03.02.2005 issued to 2^nd opposite party.

P5 - Status of insurance claim

P6 - Medical certificate dated 01.01.2006 issued by KIMS

Hospital.

P7 - Medical bills produced by the complainant.

P8 - Postal receipts.

III OPPOSITE PARTY'S WITNESS :

DW1 - Ashok Kumar. A

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Copy of medical report from KIMS Hospitalization

D2 - Original Health Guard proposal form.

D3 - Copy of policy schedule.

Sd/-

PRESIDENT