Complaint filed on: 26-06-2010 Disposed on: 27-11-2010 BEFORE THE BANGALORE IV ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052 C.C.No.1460/2010 DATED THIS THE 27th NOVEMBER 2010 PRESENTSRI.D.KRISHNAPPA, PRESIDENT SRI.GANGANARASIAH, MEMBER SMT. ANITA SHIVAKUMAR. K, MEMBER Complainant: - Mr.Krishnan Kutty G. S/o. G.K.Gangadharan, Aged about 70 years, R/at No.101, Rapsody, Shanthivana, Sahakaranagar, Bangalore-92 V/s Opposite parties: - 1. M/s. Star Health and Allied Insurance co. ltd, No.1, New Tank road, Valluvarkottam, Nungambakam, Chennai-34 Represented by its managing Director 2. Mr. V.Jagannathan, Chairman cum managing Director, M/s. Star Health and Allied Insurance co. Ltd, No.1, New Tank Road, Valluvarkottam, Nungambakam, Chennai-34 3. M/s. Star Health and allied Insurance Co. Ltd, No.S-1 (55) II floor, PSN Plaza, DVG Road, Basavanagudi, Bangalore -04 Represented by its Manager and Authorised Signatory claims. O R D E R SRI. D.KRISHNAPPA., PRESIDENT., The grievance of the complainant against the opposite parties in brief is, that based on the assurance given by the Ops, he availed a insurance policy called “STAR SENIOR CITIZENS RED CARPET POLICY” was issued by the 2nd OP, which was in effect from 3-2-2010 to 2-2-2011. On 17-3-2010 he got admitted with the complaint of breathlessness during night time, irregular bowel movements etc. to the Wockhardt hospital for treatment. He was told that his ailment is covered under the policy and he is having cashless treatment facility. But through the fax dated 20-3-2010, he was denied cashless treatment facility, with a direction to approach the Ops for reimbursement of medical expenditure. Then he after obtaining claim form, made a claim with the 1st OP for reimbursement of expenditure by enclosing all necessary documents, he has incurred an expenditure of Rs.27,700-00 for his treatment. That despite several contracts, the Ops have failed to reimburse the medical expenditure and attributing deficiency in the service of the OP has prayed for a direction to the Ops to reimburse Rs.27,700-00 and to award damages of Rs.2,00,000-00 with cost. 2. Ops No.1 and 3 have appeared through their advocate and filed version by taking contention that, OP No.2 is one of the representative of the 1st OP and 2nd OP is an unnecessary party. Ops No.1 and 3 in their version have contended that the complainant since had pre existing disease has by suppressing the said fact obtained the policy. Therefore they have under the terms and conditions of the policy repudiated the claim which do not amounts deficiency in their service. That the complainant has suppressed the fact of long existing medical problems like diabetes mellitus, hypertension since 15 years bronchial asthma for more than two years peripheral vascular disease since four years etc and obtained the policy by suppressing them. The ailments are not covered under the exclusion clause of the policy, the complainant made a claim within two years of the policy and 24 months have not lost after inception of 1st and 2nd policy period. The insurance is a contract of good faith and pre existing disease are not covered under the policy. The complainant has taken treatment for his pre existing disease as such is not entitled for reimbursement and thereby justifying the repudiation have prayed for dismissal of the complaint. 3. In the course of enquiry into the complaint, the complainant and the Zonal Manger of the Ops have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant alongwith the complaint has produced a copy of the policy, copies of hospital records and copies of bills, besides copies of certain letters he had addressed to Ops. Ops have also produced a copy of policy, copies of claim verification, copy of claim rejection letter, copy of claim form, with discharge summary. Counsel for the complainant has filed written arguments. We have heard the counsel for the Ops and perused the records. 4. On the above materials following points for determination arise. 1) Whether the complainant proves that the OPs have caused deficiency in their service in repudiating his claim for reimbursement of medical expenditure? 2) To what reliefs, the complainant is entitled to? 5. Our findings are as under: Point no.1: In the affirmative Point no.2: See the final Order REASONS 6. Answer on Point No.1: The fact that the complainant is a medical claim policy holder under the scheme “STAR SENIOR CITIZENS RED CARPET POLICY” for a period from 3-2-2010 to 2-2-2011 and he was admitted to Wockhardt hospital on 17-3-2010 discharged on 20-3-2010, that he was diagnosed for chronic bronchitis, hypertension, Dibetic Melitus, Asymptomatic cholelithaisis and Gouty Arthritis etc. and he was treated, there are all not at all in dispute. The complainant though under the policy was entitled for cashless facility, but that facility was denied by the Ops with instruction to the complainant to apply for reimbursement of expenditure after the treatment. Latter on the complainant after dischargel, when applied for reimbursement, Ops through their letter dated 3-6-2010 repudiated the claim of the complainant on the ground that the complainant was a known case of hypertension and diabetic mellitus with history of chronic bronchitis, it was pre existing disease was suppressed at the inception of the policy. Ops for such repudiation of the claim of the complainant have relied upon discharge summary of Wockhardt hospital. In the discharge summary, the complainant has been diagnosed for certain ailment as already stated. Further under heading of history and examination, it is recorded as here under: “Mr.Krishnan Kutty, 70 years old male came with c/o breathlessness since 12-50 days, c/o gastritis on & off since a long time irregular bowel movements, breathlessness during night time, paroxysmal nocturnal dysnoea”. Past history: Known case of hypertension, diabetes mellitus no history of asthma, epilepsy or any drug allergy. The Ops except, this discharge summary have not produced any hospital records, diagnoses report or treatment availed by the complainant for any such ailments. Therefore, it is not understandable as how the Ops have taken the stand that the complainant had pre existing diseases and repudiated his claim. In the discharge summary, we do not find any mention of history of ailment of the complainant either given by the complainant himself or any of his attenders. On seeing the heading history and examination, the doctor who examined the patient himself appears to have recorded the symptoms, he noticed and we do not find any basis on which the said doctor could say that the complainant had ailments from any particular period or the complainant had such ailment prior to inception of the policy and the complainant has suppressed it. The observation of the doctor, who treated the complainant, that patient was having long time irregular bowel movements, breathlessness in the night may be since some time prior to the examination of the complainant by the doctor. Thus it is seen that the Ops interpreting the wording of the doctor recorded in the discharge summary have reached the conclusion, that the complainant had pre existing diseases and he had suppressed those facts, when took the policy. Even assuming that the complainant had hypertension and diabetic mellitus, we do not have any evidence or proof laid by the Ops before us to prove that caused breathlessness to the complainant during night time. 8. In the absence of any proof to show that the complainant had taken any treatment for any ailment earlier to issuance of the policy that he was diagnosed any diseases and he had knowledge of his ailment the complainant can not be condemned to has suppressed those ailments, when he took the policy. We therefore on consideration of entire materials placed before us, we hold that the Ops have not placed any materials to prove that the complainant had knowledge of the diseases, when he got the policy application filled up to hold that he has suppressed the facts, therefore repudiation of his claim, in our view is erroneous and therefore it amounts to deficiency in their service. With the result, we answer point No.1 in the affirmative and pass the following order: ORDER Complaint is allowed. Ops No.1 and 3 are jointly and severally are held has deficient in their service and therefore are directed to reimburse Rs.27,700/- to the complainant within 60 days from the date of this order. Failing which, they shall pay interest at 9% per annum on that amount from the date of this order until that amount is paid. Ops No.1 and 3 shall also pay cost of Rs.1,000/- to the complainant. Dictated to the Stenographer, Got it transcribed and corrected, Pronounced on the Open Forum on this 27th November 2010. Member Member President
| | [HONORABLE Ganganarsaiah] Member[HONORABLE Sri D.Krishnappa] PRESIDENT[HONORABLE Anita Shivakumar. K] Member | |
