Tamil Nadu

North Chennai

191/2013

M.C.Balasubramaniam, - Complainant(s)

Versus

Divisional Manager, The Oriental Insurance Co., Ltd, - Opp.Party(s)

S.Venkatesan

18 Aug 2016

ORDER

                                                                          Complaint presented on:  10.10.2013

                                                                             Order pronounced on:  30.08.2016

 

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

 

TUESDAY THE 30^th    DAY OF AUGUST 2016

 

C.C.NO.191/2013

 

L.N.C.Balasubramanyam,

G2, Saraswathi Block,

SSM Residency, Moppedu Road,

Alapapkka,, New Perungalathur,

Chennai – 600 063.

                                                                                    ..... Complainant

 

..Vs..

Divisional Manager,

The Oriental Insurance Co.Ltd.,

IV Floor, UIL Building,

No.8, Esplanade,

Chennai – 600 108.

	......Opposite Party

Date of complaint                                 : 10.10.2013

Counsel for Complainant                      : M/s.S.Venkatesan

Counsel for   opposite party                    : Mr.N.Maheswaraiah

 

 

 

 

 

 

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 taken a mediclaim policy with the Opposite Party  during 2004 & 2005 and the said policy has been renewed by him periodically and the sum assured is Rs.3,00,000/-. The Complainant has been healthy person and however he could feel some pain in his knee while walking. He consulted a doctor and he was advised to undergo knee surgery. The Complainant is 73 years old and therefore his family members advised him to undergo therapy treatment at Ojus Health Care, Bangalore. He took treatment Ojus Health Care during the period 10.11.2011 to 30.11.2011. The Complainant submitted a claim for a sum of Rs.90,000/- with the Opposite Party for reimbursement spent by him for the treatment at Ojus Health Care.  The Opposite Party rejected the claim on the ground that the material facts about the pre-existing ailment has been suppressed by the Complainant and the hospital from where the treatment was taken by him do not fall under the definition of the hospital. Therefore the Complainant approached the insurance ombudsman who also dismissed the claim on 29.06.2012 confirmed the rejection made by the insurance. The rejection of the claim by the Opposite Party is a clear case of Deficiency in Service.  Therefore the Complainant filed this Complaint to pass an order for the claim made by the Complainant and also compensation for mental agony with expenses and cost of the Complaint.

2. WRITTEN VERSION OF THE   OPPOSITE PARTY IN BRIEF:

          The Opposite Party admits that the Complainant paid a premium of Rs.21,925/- and obtained individual mediclaim policy from the Opposite Party for a maximum sum of Rs.3,00,000/- and the said policy was issued subject to the terms and condition forming part of the policy. The Opposite Party, while acting on the proposal, of the Complainant for a mediclaim policy, had no opportunity to verify the genuiness of the proposal in as much as the proposal was accepted in “Good faith” for the simple reason that the contract of insurance is always based on the principle of “Good faith”. Any reimbursement of medical expenses could be possible only subject to the terms and conditions attached to and forming part of the policy in question. A claim from the Complainant was received by this Opposite Party. The claim lodged by the Complainant was rejected by them on 14.02.2012. The Complainant at the time of making a proposal gave a questionnaire form duly filled and signed by him on 02.03.2011. In the proposal colomn No; 6 contains personal History of the insured. Annexure B it contains in respect of adverse medical history. Complainant deliberately with a view to prompt and mislead the Opposite Party to give a policy to his advantage and to the detriment of Opposite Party, misrepresented in respect of all the questions in column No.6 by giving answers in the negative thereby inducing the Opposite Party to believe that he had no adverse medical history at all, not to mention disease of bones, joints, Arthritis including rheumatic diseases etc. for which a claim has been made by the Complainant. The Mediclaim Medical Report (MMR) issued by the attending doctor of the Complainant was issued on 30.11.2011 by Dr.G.S.Nayar stating that the Complainant is a known case of OSTEOARTHRITAS since 10 – 15 years and hence it is a crystal clear that the Complainant has a knee joint problem since 15 years. The clinical summary issued by the Ojus Health care,it is observed that the Complainant was having chronic kidney disease, chronic obstructive pulmonary disease state III, Hypertension, benign prostatic Hypertrophy. The same was not disclosed by the Complainant at the time of giving proposal for issuing the mediclaim policy. The Opposite Party submits that the Ojus Health Care Pvt Ltd., where the Complainant got treatment which does not comes under the definition of the Hospital/Nursing Home under the policy. Therefore the rejection of the claim made by the Opposite Party and ombudsman is sustainable and prays to dismiss the Complaint with cost.    

3. POINTS FOR CONSIDERATION:

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

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

4. POINT NO :1

          The Complainant obtained  Ex.A2 mediclaim policy with the Opposite Party for the period 21.03.2011 to 20.03.2012 for the sum insured Rs.3,00,000/-. Ex.A1 is the proposal form submitted by the Complainant to the Opposite Party. The Complainant suffered with knee pain while he is walking and for the same he consulted a doctor, who had advised him to undergo knee surgery and however the Complainant being 73 years old his family members advised him to undergo therapy treatment at Ojus Health Care, Bangalore.  The Complainant undergone the said therapy treatment from 10.11.2011 to 30.11.2011 and thereby he incurred a sum of Rs.90,000/- for such treatment. Ex.A6 & Ex.A7 are the proof incurring expenditure at the Ojus Health Care. Ex.A8 is the clinical summary issued to the Complainant by the said Health Care.

5. The Complainant made a claim for a sum of Rs.90,000/- to the Opposite Party for the expenses incurred by him at Ojus Health Care. The Opposite Party under Ex.A13 letter repudiated the claim on the ground of suppression of material facts that the Complainant was suffering acute osteoarthritis since 10 - 15  years and further the Complainant had not taken treatment at a hospital and the clinic where he took treatment is not a hospital.

6. Ex.A9 mediclaim medical report issued by the doctor who is working as Ojus Health Care centre. In the said report in column 9 duration of disease suffered, it is mentioned as about 10 – 15 years more since one year. In column no.8 the disease diagnosed is arthritis in both knees. Therefore as per Ex.A9 report is clear that the Complainant was suffering arthritis in knees 10 – 15 years. In the proposal form column 6.6 personal history it has specifically asked any disease of bones, joints, arthritis including rheumatic diseases, the Complainant replied as ‘No’. Therefore, according to the Complainant on the date of proposal form submitted by him on 02.03.2011, he was not suffering with any arthritis diseases. Whereas Ex.A9 report is clear that the Complainant was suffering arthritis about 10 – 15 years. Hence Ex.A1 & Ex.A9 establishes that the Complainant suppressed the pre-existing disease of arthritis on both the knees and the same is accepted.

7. Admittedly the Complainant undergone therapy treatment in a clinic and for such a treatment he was not hospitalized. The Opposite Party contended that where he had taken treatment do not fall under the definition of the hospital and therefore on the score also the claim was rejected is sustainable. However the Complainant had not shown any authority to accept that the clinic can be considered as a hospital. Though the Complainant stated that some decisions held that this kind of treatment can be covered under the insurance, however he had not produced any decisions before this Forum to consider the same and hence we reject the contention of the Complainant in this regard. Therefore we hold that the Opposite Party has rightly repudiated the claim of the Complainant and the Opposite Party has not committed any Deficiency in Service.

8. POINT NO :2

          Since the Opposite Party has not committed any deficiency in service, the Complainant is not entitled for any relief in this Complaint and the Complaint is liable to be dismissed.

          In the result the Complaint is dismissed. No costs.     

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 30^th    day of August 2016.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 02.03.2011                   Copy of Mediclaim Insurance Proposal Form

Ex.A2 dated 15.03.2011                   Copy of individual mediclaim policy schedule

Ex.A3 dated 15.03.2011                   Copy of receipt

Ex.A4 dated 10.11.2011                   Copy of receipt issued by Ojus Health Care

Ex.A5 dated 10.11.2011                   Copy of report of Anjana Diagnostics MRI

Ex.A6 dated 16.11.2011                   Copy of invoice issued by Ojus Health Care

Ex.A7 dated 26.11.2011                   Copy of receipt issued by Ojus Health Care

Ex.A8 dated NIL                     Copy of clinical summary

Ex.A9 dated 30.11.2011                   Copy of mediclaim medical report (MMR)

Ex.A10 dated 30.01.2012                 Copy of letter by Oriental Insurance to

                                                Complainant

 

Ex.A11 dated 03.02.2012                 Copy of letter by Complainant to Oriental

                                                Insurance

 

Ex.A12 dated 04.02.2012                 Copy of letter by Complainant to Oriental

                                                Insurance

 

Ex.A13 dated 14.02.2012                 Copy of letter by Oriental Insurance to

                                                Complainant

Ex.A14 dated 23.02.2012                 Copy of letter by Complainant to Oriental

                                                Insurance

 

Ex.A15 dated 23.02.2012                 Copy of letter by Complainant to Oriental

                                                Insurance

 

Ex.A16 dated 29.06.2012                 Copy of award passed by Insurance Ombudsman,

                                                Chennai

 

LIST OF DOCUMENTS FILED BY THE   OPPOSITE PARTY :

                                      …..NIL …..

 

MEMBER – II                                                               PRESIDENT