Complaint filed on: 31.07.2012

                                                      Disposed on: 03.02.2017

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

CC.No.1564/2012

DATED THIS THE 3^rd FEBRUARY OF 2017

PRESENT

SRI.H.Y.VASANTHKUMAR, PRESIDENT

SRI.D.SURESH, MEMBER

SMT.N.R.ROOPA, MEMBER

Complainant: -                     

Sri.B.V.Shesha Chalapathi

Aged about 38 years

s/o late Sri.B.Ramarao

Residing at #6/1,

Pipeline Road,

Near Srinivasa Kalyana Mantapa, Mathikere, Bengaluru-54

    By Adv. Sri.M.V.Anoopkumar

V/s

Opposite parties:-    

1. M/s. Star health & Allied Insurance co. ltd.

No.6^th floor, KRM centre,

No.2, Harrington Road, Chetpet, Chennai-600301

2. The Grievance

Redressal officer,

M/s.Star health & Allied Insurance co. ltd.

Corporate office:1,

New Tank street, Valluvarkottam High road, Nungambakkam,

Chennai-600034

3. The Branch Manager

M/s.Star health & Allied Insurance co. ltd.

Branch office code No.141124, No.3, 3^rd floor, JV Towers, 8^th Main Road, Sampangi Rama Nagar, Bengaluru-560027

By Adv.Sri.Y.P.Venkatapathi

ORDER

Under section 14 of consumer protection Act. 1986.

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

            The Complainant has been alleging the deficiency in service in repudiating two insurance claims by the Opposite parties and thereby has claimed the amount of Rs.26,760/- and Rs.16,597/- towards the same along with compensation amount of Rs.15 lakhs.

          2. The case of the Complainant in brief is that he being the proposer as per Ex-B2 got “senior citizens red carpet insurance policy” in the name his father B.Ramrao as per Ex-B3 policy and Ex-A1/B1 schedule and identity card Ex-A16. It was the year ending on 26.07.2012 by paying premium as per Ex-A2. His father Ramrao aged 61 years was hospitalized on 22.12.11 at Saint Marthas Hospital after he fell down from 15 stairs from the first floor. The offered cashless facility was denied by the Opposite parties and he was asked to seek the reimbursement facility after submitted with medical records with discharge summary. He submitted the claim from dtd.09.01.12. Accordingly the second time hospitalization of his father also ended with same response of the Opposite parties and their non-compliance. The said 2 claims for Rs.26,760/- & Rs.16,597/- submitted wide claim forms Ex-A6 of February & Ex-B6 of March, were not settled as promised by the Opposite parties for different reasons. Hence he got issued the legal notice dtd.20.04.12 as per Ex-A7 and he received the reply notice dtd.21.05.12 as per Ex-A10/B4 only on 05.06.12 as per Ex-A11 & A12. The alleged non-disclosure of the facts as per the condition no.7 of the policy was ruled out by him. He received refund of Rs.9,326/- through DD on 27.06.12 as per Ex-A15 and it was against the terms of policy and for the reasons not stated earlier for his 2 claims. The alleged parkinsonism was not in existence at the time of subscribing to the policy. The unilateral conclusion of pre-existence of Parkinson became very much center point for contest. No proper reasons were offered by the Opposite parties while repudiating the claims on 23.02.12 & on 20.03.12 and their act amounts to deficiency in their service. Thereby this case is filed.

          3. The Opposite parties have filed common version, contending that the Opposite party No.2 is not the proper and necessary party and the complaint filed in the present form is not maintainable and that they have not violated any terms & conditions of the policy and discharged their obligations in accordance with the contractual obligations and the repudiation of his claims is also in accordance with law. However they contended that without prejudice they evaluated the claims as per annexed separate lists and ready to pay Rs.14,549/- and Rs.9,735/-, if the Complainant comes forwarded for settlement. They further contend that as per the policy conditions the Complainant had to bear 50% of the amount as co-pay that owing 50% of the obligations in respect of pre-existing diseases and 30% in respect of other claims and such benefit is also given and before arriving the settlement amounts. The Complainant had not disclosed the pre-existing diseases and also about previous sufferance of the RTA and parkinsonism and thereby made the contractual obligations voidable/ab-initio and thereby it was cancelled by them. The above stated 2 amounts were calculated as per the insurance laws and terms & conditions of the policy. The other allegations made by the Complainant being in correct, they fight for and they contest the same. The complaint becomes liable to be dismissed.

          4. The Complainant and one witness of the Opposite parties filed their affidavit evidences relying on Ex-A1 to A16 and Ex-B1 to B7 documents respectively. They filed the written arguments and advanced their arguments relying on the reported decisions.

          5. The consumer disputes that arise for consideration are as follows:

1. Whether the Complainant establishes the alleged deficiency in service by the Opposite parties relating to repudiation of his two insurance claim amounts towards the treatment of his late father ?
2. To what order the parties are entitled ?

6. Answers to the above consumer disputes are as under:

1) Affirmative

2) As per final order – for the following       

REASONS

          7. Consumer Dispute No.1: The undisputed facts reveal that the Complainant being the proposer as per the proposal form Ex-B2 got the “star senior citizens red carpet insurance policy”/Ex-B3 in the name of his father B.Ramrao, aged 61 years, as per schedule particulars Ex-A1/B1. The said policy of one year was ending on 26.07.2012.

          8. It is also undisputed that his father B.Ramrao was hospitalised twice, in between January & February of 2012 and died in the Saint Marthas hospital on 10.02.12 as per the death certificate of the hospital Ex-A4. In the death certificate the cause of death is mentioned as a) Metabolic Encephalopathy [due to or as a consequence of] b) Parkinsonism [due to or as a consequence of] c) Thrombocytopenia.

          9. The Complainant submitted the claim forms towards the medical expenses as per Ex-A3 dtd.11.02.12 and as shown in Ex-B6 and both the claim amounts were repudiated by the Opposite parties through Ex-A6 letter dtd.23.02.12 and 20.03.12, on the grounds that toes of left foot found amputated 8 years earlier in RTA and also was suffering from parkinsonism and both informations were not furnished earlier and that it amounts to suppression and non-disclosure of material facts.

          10. Hence the Complainant got issued the legal notice Ex-A7 dtd.20.04.12 and it was replied by the Opposite parties on 21.05.12 as per Ex-A10/B4 and it was delivered to the Complainant in June 2012 as per Ex-A11 & A12 cover. The Opposite parties had denied all the allegations made against them in the reply notice. Later the Opposite parties on the ground of non-disclosure of material facts (about the existence of pre-existence diseases), sent Ex-A13 cancellation letter dtd.02.07.12 for the policy with DD Ex-A15 dtd.25.06.12 for Rs.9,326/-. The policy was cancelled from inception.

11. Thereafter this complaint was filed on 31.07.12. During the pendency of this complaint, the Opposite parties offered the settlement on 10.12.12 with 50% co-pay under the said policy. On the basis of the medical experts opinion, they later considered 30% as co-pay basis. Accordingly the bills of the Complainant for Rs.26,760/- and Rs.16,597/- were settled as here under with clarification that the charges related to diabetic and thyroid investigation are not payable and hence were disallowed as per the conditions of Ex-B3 policy and shown the calculations in separate sheets annexed to Ex-B7 and they contend that they have given maximum benefits of 30% co-pay benefit.

          12. The facts above stated disclose that the Opposite parties in their repudiation letters Ex-A6 & B6 raised the grounds about the alleged pre-existed diseases and the amputation of toe of left foot because of road traffic accident. The alleged parkinsonism as the pre-existed disease/complaint was not established by the insurance company. The insurance company is under the obligation to prove and establish the said facts and also to prove that they were not disclosed in the proposal form. The Opposite parties relied on number of reported decisions and contended that the insurer/Complainant also has to act strictly in accordance with statutory limitations or terms of the policy (Manu/SC/0495/1999/para16) and the said terms are to strictly interpreted to give natural meaning without the outside aid [appeal(civil)6277/2004(supreme court)-DD date 24.09.04, pages 5 & 6], the deliberated wrong answer lead to the act of fraud which becomes grounds to repudiate the policy [appeal(civil)5322/2007-DD date20.11.07], the proposal form which goes to the root of the contract has to be properly appreciated to know the act of the suppression made by the Complainant (civil appeal no.2776/2002-DD date 10.07.09).

13. In the instant case amputation of toe about 8 years earlier to the date of insurance cannot be considered as the pre-existed disease or sufferings, which effects his life span. The parkinsonism cannot be accepted to be in existence earlier to the date of the policy unless the Opposite parties establish with cogent evidence. The Complainant has stated that the parkinsonism started subsequent to the date of taking policy and it was not the pre-existed disease and the same is not rebutted by cogent medical evidence. The Opposite parties have failed to establish the ground of the second repudiation letter. It was because of the same reasons, the Opposite parties while filing version itself, tried to report settlement saying that with all full benefits under the policy, they are ready to issue the cheques as calculated above. Their act itself shows that there was no sufficient grounds so as to repudiate any of both the claims of the Complainant. The grounds alleged in the repudiation letters had no basis and it was evidenced through subsequent settlements supported by Ex-B7 calculated sheets.  The said inconsistent contentions are sufficient to show that there was deficiency in issuing the repudiation letters by the Opposite parties. Accordingly the Consumer Dispute No.1 is answered in the affirmative.  

          14. Consumer Dispute No.2: The Opposite parties during the pendency of this case came forward and settled the amount of the claim forms by giving maximum benefit of the policy and expressed readiness to issue cheques on the basis of 30% co-pay by the Complainant. The calculations shown in the above mentioned table are morefully described in two calculation sheets annexed to Ex-B7. The heads of deducted amount were also properly described and there is no reason to disbelieve the said calculation sheets. Thereby it has to be resumed that the Opposite parties have considered the claim forms during lis-pendence but not at the earlier stage. Such delayed act of the Opposite parties made the Complainant to suffer with mental agony and made him to issue legal notice and the reply there on again made him to approach this forum seeking justice. Such sufferings of the Complainant and the expenses incurred by him towards the litigation has to be counted and the Opposite parties definitely become liable to pay the same. The compensation has to be estimated on the basis of the claim amount. Accordingly the compensation in this case is estimated Rs.20,000/- and litigation charges is estimated Rs.5,000/-. Accordingly the Complainant deserves to get the following:

ORDER

          The Complaint of the Complainant allowed partly. The Opposite parties have directed to disburse the policy amount of Rs.14,549/- and Rs.9,735/- respectively with interest at 12% p.a. from the date of this order.

          2. The Opposite parties are also directed to pay the compensation of Rs.20,000/- and also litigation charges of Rs.5,000/- within a month and in default to pay the same they are directed to pay the same with interest at 12% p.a.

          Supply free copy of this order to both the parties. 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 3^rd day of February 2017).

Copies of Documents marked on behalf of Complainant:

Documents marked on behalf of Opposite parties