BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 15th day of October 2016
Filed on : 03-07-2015
PRESENT:
Shri. Cherian K. Kuriakose, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
CC.No.436/2015
Between
1. M.R. Muraleedharan, : Complainants
S/o. Ramakrishnan Nair, ( By Adv. Tom Joseph, Court road,
Muthayil (Karthika) House, Muvattupuzha)
Kadathy East, Market P.O.,
Muvattupuzha-686 673.
2. Sunitha Muraleedharan,
W/o. Late Muraleedharan Nair,
Muthayil, (Karthika) house,
Kadathy East, Market P.O.,
Muvattupuzha.
3. Sruthi M. Nair,
D/o. Late Muraleedharan Nair,
Muthayil, (Karthika) house,
Kadathy East, Market P.O.,
Muvattupuzha.
4. Sreelakshmi Nair, (Minor)
D/o. Late Muraleedharan Nair,
rep. by her Mother Sunitha
Muraleedharan,
Muthayil (Karthika) house,
Kadathy East, Market P.O.,
Muvattupuzha.
And
Branch Manager, : Opposite party
M/s. Star Health & Allied
Insurance Company Ltd.,
Branch Office,
Door No. 33/19/D-15,
1st Floor, Ammu Arcade,
Civil Lane Road,
Padivattom, Kochi-24.
O R D E R
Cherian K. Kuriakose, President.
1. Complainant's case
2. The complainant took mediclaim policy with the opposite party from 06-01-2014 onwards. Prior to that he had mediclaim policy with M/s. National Insurance Company Ltd. During the 2nd year of the policy the opposite party M/s. Star Health & Allied Insurance Company Ltd, the complainant was admitted in Amrita Hospital from 03-04-2015 till 13-04-2015 for a diagnosis of Liver Metastasis. He had spent an amount of Rs. 2,03,760/- towards treatment expenses. Request for cashless facility with the opposite party was denied. Later request for reimbursement was also rejected on the ground that the claim was for pre-existing disease since 10-01-2014. It was also alleged that the patient was diagnosed with Carcinoma prior to the inception of the policy. Aggrieved by the above said act of the opposite party the complainant had approached this Forum alleging deficiency in service and unfair trade practice.
3. Notice was issued to the opposite party. The opposite party was served and they did not appear to contest the matter. Meanwhile, the original complainant died and his legal heirs were pleaded as additional complainants 2 to 4, as per order in I.A. 182/16 on 23-03-2016.
4. When the matter came up for complainant's evidence the original complainant's wife Smt. Sunitha filed an affidavit in support of the allegations in the complaint. Exbts. A1 to A3 documents were marked. Exbt. A2 is the copy of the policy issued by the opposite party covering a period from 06-01-2014 to 06-01-2015. It is seen from Exbt. A2 that the proposal was made on 06-01-2014 and the policy had commenced from the same day. It was a new policy. Premium of Rs. 11,340/- excluding the service tax and stamp duty is seen to have been paid by the original complainant in order to cover the whole family including his wife and the two girl children, Sruthi and Srilakshmi , aged 18 and 14 years respectively. The policy taken was “Family Health Optima Insurance Plan”. Exbt. A1 dated 12-06-2015 is the copy of the letter repudiating the claim on the ground that the treatment record revealed that the original complainant was diagnosed with villous adinoma showing carcinoma in situ since 10-01-2014 and that the policy commenced from 16-01-2014. According to the opposite party as per Exbt. A1 since the illness has commenced prior to the date of inception of the policy, it falls under exclusion clause No. 1 i.e. pre-existing disease. It was also alleged, as a ground for repudiation, that the treatment records had shown that the complainant was diagnosed with villus adinoma showing carcinoma since 10-01-2014and that fact was suppressed by the complainant at the time of taking the policy.
5. Exbt. A3 is the discharge summary pertaining to the original complaint issued on 13-04-2015. In the discharge summary it is seen shown that he suffered liver metastasis and that the original complaint was a known case of carcinoma rectum. Left Hepatectomy was done on 04-04-2015. He had the past history of Ileostomy Closure on 11-06-2014. At the time of discharge the general condition was fair and all other systems were within normal limits.
6. From the above data available in this case it is clear that the complainant had taken the original policy with the opposite party on 06-01-2014. He was diagnosed with villous adenoma showing carcinoma in situ at a later date i.e. 10-01-2014. The policy commenced from 06-01-2014 but it is seen wrongly stated in Exbt. A1 that it commence from 16-01-2014 in order to repudiate the claim. On 06-01-2014 when the complainant had taken the policy there was no information for him that he was a patient of villous adenoma. Since the diagnosis of the disease was effected subsequently the issuance of the policy we find that the allegations of the opposite party in Exbt. A1 to repudiate the claim was deliberate, misleading and would amount to unfair trade practice. It is pertinent to note that the opposite party did not appear to contest the matter.
7. In the above circumstances, we find that the complainants have proved a clear case of deficiency in service on the part of the opposite party coupled with commission of unfair trade practice, by mis-stating relevant facts to he prejudice of the consumer in order to make wrongful gain. We find that the complainants have succeeded in their litigation.
8. In the result, the complaint stands allowed
i. directing the opposite party to reprocess the claim of the complainants within a period of one month from the date of receipt of a copy of this order on the assumption that the complainants are entitled to get the whole admissible claims as per the policy.
Directing the opposite party to pay a compensation of Rs,. 25,000/- towards the unfair trade practice committed and towards deficiency in service rendered to the complainants
The complainants are entitled to realize the costs of the litigation from the opposite party which we quantify at Rs. 5,000/- .
iv. the delayed reprocessing of the claim as afore directed, if any, would entitle the complainants to claim interest @ 12% p.a. on all the payments as aforesaid from the date of filing of this complaint (24-06-2015) till the date of realization.
Pronounced in the open Forum on this the 15th day of October 2016
Sd/-
Cherian K. Kuriakose, President.
Sd/-
Sheen Jose, Member.
Sd/-
Beena Kumari V.K., Member.
Forwarded/By Order,
Senior Superintendent
APPENDIX
Complainants Exhibits
Exbt. A1 : True copy of repudiation letter
dt. 12-06-2015
A2 : True copy of family Health
Optima Insurance
Policy-schedule
A3 : True copy of discharge summary
dt. 13-04-2015
Opposite party's Exhibits: Nil
Copy of order despatched on :
By Post: By hand:
