BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT
SHRI. P. SUDHIR : PRESIDENT
SMT. SATHI. R : MEMBER
SMT. LIJU B. NAIR : MEMBER
C.C.No: 269/2010 Filed on 21/08/2010
Dated: 31..07..2015
Complainant:
Sujith. C.V., S/o Chandran, Pottanvila Veedu, TC.28/2725, Near old GPO, Thiruvananthapuram.
(By Adv. T.A. Harisankar)
Opposite party:
M/s. Star Health & Allied Insurance Co. Ltd., No.1 New Tank Road, Valluvarkottam High Road, Nungambakkam, Chennai – 39. Represented by the Branch Manager, Star Health & Allied Insurance Co. Ltd., Chandrabhaga, TC.4/8, Plamoode Junction, Pattom, Thiruvananthapuram – 4.
(By Adv. Mann Janarddanan)
This C.C having been heard on 15..07..2015, the Forum on 31..07..2015 delivered the following:
ORDER
SMT. R. SATHI, MEMBER:
The case of the complainant is that he had taken a medi claim policy with the opposite party on 24/10/2008 and continuously renewed the same. Before issuing the policy the complainant was examined as per rules and regulations in the policy agreement by the doctor of the opposite party. The complainant renewed this policy with the opposite party on 25/10/2009. On 19/03/2010 the complainant was admitted in the PRS Hospital, Thiruvananthapuram and was continued inpatient for 3 days and discharged on 22/03/2010. The admission of the complainant was also informed to the opposite party by the hospital authorities. At the time of discharge the hospital authorities gave a bill of Rs. 11,911/- to the complainant and this was informed to the opposite party. But the opposite party did not gave the claim amount. On 29/04/2010 the complainant received a letter from the opposite party that his claim was rejected as pre-existing disease. The complainant contacted the opposite party but no response was made by the opposite party. There is deficiency of service on the part of the opposite party and the failure of the opposite party to settle the claim caused mental pain and agony to the complainant. Hence complainant filed this complaint to pass an order to direct the opposite party to pay a sum of Rs. 11,911/- to the complainant with 18% interest from the date of complaint till the realization of the amount with Rs. 5,000/- as compensation.
2. The opposite party entered appearance and filed version:
The opposite party in their version admits the policy of the complainant. The opposite party also admits that the complainant was admitted in the PRS Hospital on 19/03/2010 and intimation over phone has been received by the Company. On 20/03/2010 opposite party received a pre authorisation request from Dr. Geetha M. Nair consultant nephrologist of PRS Hospital. In it clinical findings blood pressure has been found recorded and concluded that the admission was mainly meant for investigation and evaluation. Hence cashless facility has been denied and the same was intimated to the insured through hospital on 20/03/2010. Later insured submitted completed claim form with medical certificate, discharge summary bills for Rs. 11,910/- and lab reports on 01/04/2010. In the medical certificate dated 24/03/2010 complainant’s records were palpitation heart burns and giddiness. The details furnished in the claim form were substantially different from the details in the preauthorization request, treatment details from the case sheet were obtained. To find the actual cause for admission as inpatient, an expert opinion was sought and the opinion was that the admission is for evaluation of hypertension only. All the results are negative and no illness warranting admission as inpatient has been detected. The case sheet confirm that the insured was suffering from APD before the date of inception of the policy. The document from the hospital itself shows that the complainant was on medicines for APD for a sufficient long period and the same was concealed by the insured from the opposite party intentionally. The claim of the complainant was hit by exclusion clauses which reads as benefits will not be available for pre-existing disease. Hence the claim was rejected and the same was intimated to the insured on 29/04/2010 itself. The opposite party rejected the claim based on suppression of material facts and there is aspects of pre-existing disease. Hence complaint is only to be dismissed.
Complainant filed affidavit and Exts. P1 to P5 marked. Opposite party filed affidavit and marked Exts. D1 to D4.
Issues:
(i) Whether there is any deficiency of service on the part of opposite party?
(ii) Whether complainant is eligible for the reliefs as sought for?
3. Issues (i) & (ii): The case of the complainant is that his claim was rejected as per Ext. P4 letter on the ground of pre-existing disease. The complainant has stated that he has taken the medi claim policy from the opposite party on 24/10/2008 and is continuously renewed till 24/10/2010 and it was only on 19/03/2010 that he was admitted in the PRS Hospital and was under treatment for 3 days. He has also stated that he had to pay Rs. 11,911/- towards the treatment charges in the hospital. His further complaint is that his claim was rejected by letter dated 29/04/2010 on the ground of pre-existing disease. His case is that the rejection is on untenable ground and he is entitled to get the amount of Rs. 11,911/- with 18% interest, compensation of Rs. 5,000/- and costs.
4. On the other hand the opposite party contends that as per the case records the complainant was under homoeo treatment for many years and he was taking medicines for BP and APD for 4 years. They have also stated that they have obtained an expert medical opinion from one Dr. Rajeev who has given an opinion that the admission of the complainant in the hospital was only for evaluation of hypertension and the investigation and tests were to confirm this point. It is also seen that the complainant had no serious illness warranting admission as inpatient in the hospital.
5. On a careful reading of the pleadings on both sides and on perusal of records, it is found that the opposite party relies on the case records produced as Ext. D3 to show that complainant was taking medicines for so many years. They have also a contention that the complainant was admitted in the hospital for treatment of hypertension and allied diseases. On a perusal of Ext. D3 it is noted that hypertension was detected only 1 ½ months back (page 1 of Ext. D3) and the date of examination was on 17/03/2010. Hence at no stretch of examination it can be concluded that the complainant had hypertension at the time of taking the policy on 25/10/2008. Though the opposite party would say that one Dr. Rajeev had given the opinion that the admission of the complainant was unnecessary, the said doctor has not been examined before this Forum to establish that the complainant had no illness warranting admission as an inpatient. Moreover it is also noted that the opposite party is relying on the opinion of the doctor that the admission is for evaluation of hypertension only. Considering all these circumstances we are of the opinion that the rejection of the claim was unjustifiable and against natural justice. The opposite party has committed deficiency in service and the complainant is entitled to get the claim amount of Rs. 11,911/- as per Ext. P3 with interest, compensation and costs.
In the result, the complaint is allowed thereby the opposite party is directed to pay Rs. 11,911/- with 9% interest per annum from the date of complaint with compensation of Rs. 3,000/- and costs of Rs. 2,000/- within two months from the date of receipt of this order, failing which the amount of Rs. 11,911/- shall carry interest at the rate of 12% from the date of default till payment with compensation and costs as ordered above.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 31st day of July, 2015.
Sd/- R. SATHI : MEMBER
Sd/- P. SUDHIR : PRESIDENT
Ad. Sd/- LIJU B. NAIR : MEMBER
C.C. No: 269/2010
APPENDIX
I. Complainant’s witness : N I L
II. Complainant’s documents:
P1 : Copy of Star Health & Allied Insurance Co. Ltd Medi Classic Individual policy Schedule Policy No. P(181111/01/2010/005407)
P2 : Copy of Discharge Summary dated 22/03/2010
P3 : Copy of cash bill for Rs. 11,911/-
P4 : Copy of Claim rejection letter dated 29/04/2010 issued by the opposite party
P5 : Copy of Medical records of Sri. Sujith. C.V of PRS Hospital.
III. Opposite party’s witness : N I L
IV. Opposite party’s documents:
D1 : Copy of pre-authorisation request form of Sujith C.V
D2 : Claim Form for medical insurance of Sujith C.V
D3 : Out patient ticket of Sujith C.V of PRS Hospital
D4 : Medi classic proposal Form of Sujith. C.V
Sd/-PRESIDENT
Ad.
