Tamil Nadu

North Chennai

CC/68/2015

G.Edwin Sundara Selvan - Complainant(s)

Versus

Manager, Star Health and Allied Insurance Co Ltd - Opp.Party(s)

S.Natarajan

15 Jun 2017

ORDER

 

                                                            Complaint presented on:  23.02.2015

                                                                Order pronounced on:  15.06.2017

 

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

 

THURSDAY THE 15^th DAY OF JUNE 2017

 

C.C.NO.68/2015

 

 

G.Edwin Sundara Selvan,

#:50 Second Main Road,

VGP Layout Part I,

Palavakkam Chennai – 41.

                                                                                    ….. Complainant

 

..Vs..

 

Manager,

Star Health and Allied Insurance Co Ltd.,

#:2 Gee Gee Universal 1^st Floor,

Mc Nichols Road Chetpet Chennai – 31.

 

.....Opposite Party

Date of complaint                                 : 22.04.2015

Counsel for Complainant                      : S.Natarajan

Counsel for Opposite Party                      : N.Vijayaraghavan

 

         

 

 

 

 

O R D E R

 

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

          This complaint is filed by the complainant to direct the Opposite Party to pay the hospital expenses and also compensation for mental agony to unfair trade practice with cost of the Complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant is a policy holder of Family Health Optima Insurance Policy issued by the Opposite Party for him and his wife for the sum insured for Rs.3,00,000/-.  The said policy is valid for the period from 13.04.2013 to 12.04.2014. The annual premium payable is at Rs.10,280/-. The Complainant is a tennis coach and did not undergo any medical tests despite his readiness for tests.

          2.  On 30.09.2013, world Heart Day, the Complainant underwent tread mill test and showed “Positive for inducible myocardial ischemia”. On 09.10.2013 he was admitted and underwent varied tests at Apollo Hospital, Greams Road, Chennai and he was diagnosed Coronary Artery Disease (CAD) and advised CABG surgery. A surgery was done on 14.10.2013 and discharged on 21.10.2013.

          3. The Complainant made claim for pre-authorization for cashless treatment was denied by the Opposite Party by his letter dated 13.10.2013 that due to non-disclosure of Diabetes Mellitus (DM). Against such rejection, the Complainant approached the Insurance Ombudsman and he had also dismissed the claim of the Complainant confirming the repudiation of the Opposite Party. The rejection of the claim is not sustainable and hence the Complainant filed this Complaint to direct the Opposite Party to pay the hospital expenses and also compensation for mental agony and unfair trade practice with cost of the Complaint.

4. WRITTEN VERSION OF THE  OPPOSITE PARTY IN BRIEF:

          The Opposite Party admits that the Complainant availed a Family Health Optima Insurance Policy from him for the period 13.04.2013 to 12.04.2014. The policy specifically excludes pre-existing diseases. The Opposite Party received a pre-authorization request from the Complainant’s hospital for cashless treatment of the Complainant. The Diagnosis mentioned in the pre-authorization request was “Coronary Artery Disease (CAD).”  Further the CAD Report of the Complainant indicated that severe lesion in all major coronary arteries indicated a long standing CAD. The medical reports disclosed that the Complainant is a known case of Diabetes Mellitus for the past 15 years. Hence the medical panel of the Opposite Party concluded that the ailment of the Complainant could not have developed within a short span of 6 months (from the policy commencement) indicating a long standing CAD. Further the Complainant has not disclosed Diabetes Mellitus in the Proposal form, though Diabetes Mellitus is a major risk factor of CAD. Therefore the request for cashless treatment was declined by the insurer dated 13.10.2013 on the ground of pre-existing disease. The policy availed by the Complainant was taken only on 13.04.2013 and it has run only 5 months since  the commencement of the policy and the insurer was therefore constrained to repudiate the claim by letter dated 05.02.2014.The other averments made in the Complaint are denied. This Opposite Party has not committed any Deficiency in Service and he prays to dismiss the Complaint with costs.

 

 

5. 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 extent?

6. POINT NO :1 

          The admitted facts are that the Complainant is a policy holder of Family Health Optima Insurance Policy issued by the Opposite Party for himself and his wife for the sum insured is at Rs.3,00,000/- and the said policy is valid for the period from 13.04.2013 to 12.04.2014 and the annual premium payable is at Rs.10,280/- and the policy issued by the Opposite Party is marked as Ex.A1  and the premium payment receipt marked as Ex.A2 and the Complainant was admitted in the Apollo Hospital on 09.10.2013 and they have conducted various tests and diagnosed that he was suffering with  Coronary Heart Diseases (CAD) and advised him to  undergo surgery  and accordingly a surgery was done on 14.10.2013 for the said disease and discharged on 21.10.2013 and the discharge summary is marked as Ex.A4 and while the Complainant was inpatient, he made claim for pre-authorization for cashless treatment and the same was denied by the Opposite Party under Ex.A6 letter dated 13.10.2016, due to non disclosure  of diabetes Mellitus and also the report shows severe lesion in all major coronary artery and the Complainant also approached the insurance ombudsman and the insurance ombudsman also rejected  the claim of the Complainant by his order Ex.A11 dated 25.10.2014 and hence the Complainant had filed his Complaint for appropriate relief.

          7. The case of the Complainant is that the Complainant is a tennis coach and hence no medical tests was conducted on him   for issuance of the said policy and on 13.09.2013 world heart day, to know his heart condition he underwent a treadmill test and the result shows inducible  myocardial ischemia, then he was admitted in the Apollo Hospital and under gone treatment, the Opposite Party had not obtained any proposal form from the Complainant in issuance of the policy and the signature found in Ex.B2 proposal form not signed by him and the signature of the Complainant found in the said form is  different from that of his signature available in his vakalat, Complaint and his proof affidavit and hence the said Ex.B2 proposal form was created by the Opposite Party only for the purpose of the case and by excluding the said proposal form, the Complainant is entitled for the claim made by him.

          8. The Opposite Party would contend that he had submitted Ex.B3 proposal form and in the said form he had clearly stated that he was not suffering with any disease and based on such form the Complainant was issued with Ex.A1 & Ex.B1 Insurance Policy with terms and conditions to the Complainant  and when this Opposite Party received a cashless treatment request from the hospital, in the pre-authorization request the disease diagnosed was mentioned as “Coronary Artery Disease (CAD)  and the medical reports also shown as he was a known case of diabetes mellitus for the past 15 years and therefore this Opposite Party had rightly denied the pre-authorization under Ex.B5 and also repudiated the claim under Ex.B6 dated 24.12.2013 and hence by rejecting the claim of the Complainant as stated above this Opposite Party has not committed any Deficiency in Service.

          9. The Complainant specifically pleaded in his Complaint that the Opposite Party issued medi claim policy without proposal from to the Complainant and he was also a tennis coach and hence he did not undergo any medical tests despite his readiness to undergo such tests. However, the Opposite Party has stated in his written version that only after obtaining proposal form from the Complainant only he had issued that policy to him. The proposal form alleged to have furnished by the Complainant is marked as Ex.B2. In Ex.B2 at page 15 & 17 of typed set of documents of the Opposite Party the proposer signature was obtained. As contended by the Complainant the signature in the Ex.B2 proposal form is compared with the signature of the Complainant available in his vakalat, Complaint and his proof affidavit, the signature found in Ex.B2 proposal form  entirely differs and not tallies with the Complainant signature. Especially the signature in the proposal form, the style and the way of writing of the signature is entirely differs from the Complainant’s admitted signature found in vakalat, Complaint and his proof affidavit. Therefore as contended by the Complainant the signature found in the Ex.B2 proposal form is not that of the Complainant and the same will conclude that the Opposite Party only created Ex.B2 proposal form only to defeat the claim of the Complainant.

          10. The Opposite Party would contend that as per the terms of the policy exclusion clause 3(1) after 48 consecutive months from the date of inception of the policy only the Complainant is entitled for claim in respect of pre-existing service. The Complainant also is the first policy holder and further as per Ex.A4 discharge summary, the Complainant is a known diabetes since 15 years and therefore the claim of the Complainant was rejected under Ex.A7 in view of exclusion clause 3(1) and further the report of the Complainant also shows severe lesion and the pre-authorization was also rejected under Ex.A6 is also sustainable and therefore prays to reject the claim of the Complainant.

          11. We have already decided above that the proposal form was not submitted for issuance of policy and terms and conditions by the Opposite Party. The terms and conditions of the policy only accompany the policy issued to the Complainant. Before issuance of policy the terms and conditions was not known to the Complainant. Since, we have already held that no proposal form was submitted by the Complainant, we hold that the Opposite Party issued medi claim policy only without proposal to the Complainant as the Complainant is a tennis coach. Since the Complainant is not aware of the terms and conditions of the policy and he had also received the same only along with the policy, the terms and conditions of the policy will not apply to this Complainant in the peculiar circumstances of the case. Hence the exclusion clause will not apply to this case. Therefore in such circumstances the Opposite Party rejected the pre-authorization and the claim made by the Complainant is deficiency on its part on the part of the Opposite Party  and therefore, we hold that the Opposite Party has committed Deficiency in Service in rejecting the claim made by the Complainant.  

12. POINT NO:2

          Having the Opposite Party committed Deficiency in Service, he is liable to pay the claim made by the Complainant. The Complainant filed Ex.A5 series expenses bill from pages 37 to 41 of the typed set of the Complainant. At page 41 from the date of admission 09.10.2013 to till the date of discharge 21.10.2013 a comprehensive bill amount was arrived at Rs.3,42,404/- including surgery and other expenses. Out of the said amount in the same final interim bill the Complainant already deposited a sum of Rs.2,90,000/-. In the same bill paid an outstanding amount of Rs.52,404/- was shown. However, the Complainant had not filed any proof to show that he had paid aforesaid outstanding amount to the hospital. However, in Ex.A5 at page 37 prior to admission the Complainant underwent  a test on 07.10.2013, as he was admitted on the same day and discharged on the same day and for that day expenses the Complainant paid a sum of Rs.18,000/-. This amount of Rs.18,000/- is added  with the already paid amount of Rs.2,90,000/-. The Complainant had totally paid a sum of Rs.3,08,000/-. However, as per the policy the sum insured is only at Rs.3,00,000/-. Therefore, the Complainant is entitled only a sum of Rs.3,00,000/- towards the expenses in the hospital from the Opposite Party. Due to rejection of pre-authorization and the claim made by the Complainant he had suffered with mental agony is accepted and for the same it would be appropriate to direct the Opposite Party to pay a sum of Rs.50,000/- towards compensation for Deficiency in Service and mental agony, besides a sum of Rs.5,000/- towards litigation expenses. The Complaint in respect of the other relief is liable to be rejected.

         In the result the Complaint is partly allowed. The Opposite Party is ordered to pay a sum of Rs.3,00,000/- (Rupees three  lakhs  only) towards the medical  expenses amount to the Complainant and also to pay  a sum of Rs.50,000/- (Rupees fifty  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. The Complaint in respect of the other relief is liable to be rejected.

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 15^th day of June 2017.

 

MEMBER – II                                                               PRESIDENT

 

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated  13.04.2013                  Policy issued by Opposite Party

Ex.A2 dated Nil                      Receipt for payment of premium

Ex.A3 dated NIL                     Venkateswara hospital details

Ex.A4 dated NIL                     Discharge summary

Ex.A5 dated NIL                     Bills

Ex.A6 dated 13.10.2013                   Opposite Party’s letter

Ex.A7 dated 05.02.2014                   Repudiation letter

Ex.A8 dated 18.01.2014                   Complainant’s letter

Ex.A9 dated 14.03.2014                   Complainant’s letter

Ex.A10 dated NIL                             Complainant’s letter

Ex.A11 dated 25.10.2014                 Ombudsman’s award

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated 19.04.2013                   Insurance Policy with terms and conditions

 

Ex.B2 dated 12.04.2013                   Proposal Form signed by the Complainant

 

Ex.B3 dated NIL                     Discharge Summary of the Complainant

 

Ex.B4 dated 25.06.2014                   Order copy of Insurance Ombudsman

 

Ex.B5 dated 13.10.2013                   Cashless denial letter

 

Ex.B6 dated 24.12.2013                   Repudiation letter

 

Ex.B7 dated 02.10.2013        

& 07.10.2013                          CT Angiography Report of the Complainant

 

Ex.B8 dated 30.09.2013                   TMT Report

 

Ex.B9 dated 16.12.2013                   Specialist Opinion of Doctor

 

 

 

MEMBER – II                                                               PRESIDENT