Andhra Pradesh

East Godwari-II at Rajahmundry

CC/40/2015

Mrs. Panangipalli Syamala Subbarao - Complainant(s)

Versus

M/s. Star Health & Allied Insurance Co. Ltd - Opp.Party(s)

E.M.Sreedhar Babu

26 Apr 2016

ORDER

 

                                                                                                       Date of filing:   03.07.2015

                                                                                                       Date of Order: 26.04.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

                           PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

                   Tuesday, the 26^th day of April, 2016

 

 

C.C.No.40 /2015

Between:-

 

Mrs. Panangipalli Syamala Subbarao, W/o. P.V. Subbarao,

Doctor, D.No.75-6-11/9, Flat No.302, Suseela Shelters,

Prakashnagar, Rajahmundry.                                                                     …        Complainant

 

                                    And

 

1)  M/s. Star Health & Allied Insurance Co. Ltd.,

      Rep. by its CMD., Regd. & Corporate Office, 1,

      New Tank Street, Valluvar Kottam High Road,

      Nungambakkam, Chennai – 600 034.

 

2)  The Branch Manager, Branch office,

      M/s. Star Health & Allied Insurance Coc. Ltd.,

      D.No.46-7-27/2, Opp: Green Park Hotel,

      Danavaipeta, Rajahmundry.                                                         …        Opposite parties

 

 

            This case coming on 13.04.2016 for final hearing before this Forum in the presence of Sri E. Murali Sreedhara Babu, Advocate for the complainant and Sri S.S. Chalam, Advocate for the opposite parties, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.H.V. Ramana, President(FAC)] 

This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties to pay a sum of Rs.1,93,957/- with subsequent interest      @ 24% p.a. from the date of complaint till the date of their payment; to pay a sum of Rs.25,000/- towards damages and award costs of the complaint.

2.         The case of the complainant is as follows:-  It is submitted that basing on the advertisement and information given by the 2^nd opposite party, the complainant had taken the said Star Senior Citizens Red Carpet Insurance Policy for the 1^st time in the year 2013 covering the period from 14.12.2013 to 13.12.2014, and in continuation of the said policy, a renewed policy was taken by the complainant by paying a sum of Rs.14,494/- towards premium for the renewed policy for the period commencing from 14.2.2014 to 13.12.2015, same is paid to the 2^nd opposite party, under Receipt No.11-01/167002229 and the opposite parties issued policy bearing No.P/131124/01/15/002167, the policy is subsisting till 13.12.2015. While so, the complainant had fallen bed while getting down, due to that fall, she fractured her neck of left femur. Immediately, she was taken to the hospital Sai Multi Specialty Hospitals, Rajahmundry on 10.4.2015, by doing operation of “un/cemented HIP Replacement by Bipolar Hemiarthoplasty and she was discharged on 21.4.2015 and the hospital had raised bill for Rs.1.50 lakhs in respect of the operation conducted by them to the complainant. Thereafter, on 28.4.2015, the complainant was once again admitted in the above hospital, due to breathlessness associated with fever. The doctors opined that, she showed Pulmonary Oedema, gave treatment to her and discharged the complainant on 4.5.2015. The hospital had raised a bill for Rs.20,000/- for the above treatment. Besides that, for both the treatments, the hospital had claimed a sum of Rs.21,917/- towards medicine expenses. The complainant submits that the hospital where the complainant had taken treatment is recognized hospital of opposite parties. The complainant submits that, on both the occasions of her admitting in the hospital and the treatments to be given to her, was intimated to the opposite parties. The complainant submits that when she was admitted in the hospital on 9.4.2015, for treatment, the opposite party sent a letter dt.10.4.2015, addressed to the hospital, stating that, the claim of the complainant is inadmissible. The complainant submits that, as the opposite parties denied the claim, the complainant had paid the bills amount to the hospital by herself.  After second admission in the hospital, the complainant had intimated the same to the opposite parties, and paid the bill amount to the hospital at the time of discharge. Thereafter, the 1^st opposite party sent a letter dt.5.5.2015 to the complainant where under it is stated that, as per Clause No.11 of the Policy, as the complainant did not disclose her earlier disease more particularly that she was treated CA Breast in 2008, basing on that, the opposite parties informed that the policy is cancelled. Though under the letter dt.5.5.2015, the opposite parties denied their liability, but the 1^st opposite party sent 1^st reminder dt.25.5.2015 to the complainant where under, it had demanded the complainant fulfill certain formalities in respect of the claim made by her more particularly demanding to submit certain documents for settling her claim. The complainant had complied the formalities required by the opposite party by submitting all relevant documents demanded by the opposite parties from her. By sending 1^st reminder dt.25.5.2015 to the complainant, the opposite parties, have admitted their liability. After receipt of the above reminder and submission all papers by the complainant, the complainant was under the impression that, she would be paid the bills amounts incurred by her during the period of her hospitalization by the opposite parties. But, to the surprise of the complainant, the opposite parties sent a letter dt.6.6.2015 repudiating the claim of the complainant, on the same reason which they have mentioned in their earlier letter dt.5.5.2015, thereafter on 12.6.2015 the opposite parties refunded a sum of Rs.7,227/- to the complainant and informed to the complainant that the policy is cancelled and the cancellation of the policy by the opposite parties is illegal and arbitrary. The complainant submits that, she received the amount sent by the opposite parties along with the letter dt.12.6.2015, without prejudice to her rights and contentions and with a right to claim the amount, which she is entitled to under the policy. Hence, the complaint.  

3.         The 2^nd opposite party filed its written version and the same was adopted by the        1^st opposite party and denied all the allegations made by the complainant and the complaint is not maintainable either under law or on facts. It is true that the complainant took senior citizen Red carpet insurance policy for the 1^st time in the year 2013 covering the period from 14.12.2013 to 13.12.2014 and in continuation of the said policy the premium amount was paid for renewal and hence a new policy bearing No.P/131124/01/15/002167 was issued and the same is subsisting till 13.12.2015. Averments regarding the treatment undergone by the complainant in the hospital within the period of subsistence of the policy is also true and correct. Mere asking certain documents related to previous medical history by the opposite party in its reminder dt.25.5.2015 does not mean that the opposite party admitted its liability. This opposite party submits that on scrutiny of the claim records, it is observed from the medical records that the complainant who is the insured patient is a known case of parkinsonism since 13.11.2013. As per the discharge summary of Krishna Medical Institute of Medical Sciences limited dt.21.5.2008, the complainant is a known case of C A breast since 2008. It is also submitted by the opposite parties that the O P D papers dt.13.11.2013 stated that the insured is a know case of Parkinsonism. This opposite party submits that at the time of inception of policy that is from 14.12.2013 to 13.12.2014 or at the time of renewal, the complainant has not disclosed the above medical history/health details of the insured person in the proposal from which amounts to misrepresentation/non disclosure of material facts. This opposite party submits that as per condition 7 of the said policy, if there is any misrepresentation/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the opposite party company is not liable make any payment in respect of any claim. Hence, the opposite party right by repudiated the claim of the complainant and communicated to her vide letter dt.6.6.2015. The repudiation of the claim by the opposite party in this case appears bonafide being based on the history in the discharge card of the hospital and that therefore there is no deficiency of services on the part of the opposite party insurance company. This opposite party submits that as per the condition 13 of the policy insurance company rightly cancelled the policy on 14.6.2015 and in order to show the bonfies the opposite party refunded the premium amount of Rs.7,227/-.  Therefore, the opposite party prays the Hon’ble Forum to dismiss the complaint with costs.  

4.         The proof affidavit filed by the complainant and Exs.A1 to A14 have been marked for the complainant. The proof affidavit filed by the 2^nd opposite party and Exs.B1 to B9 have been marked for the opposite parties. Written arguments filed on behalf of the opposite parties.

5.         Heard both sides.

6.         Points raised for consideration are:

 

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

            2. Whether the complainant is entitled for the reliefs asked for?

            3. To what relief?

 

7.  POINT Nos.1 & 2:  The admitted facts of the complaint are that the complainant is a doctor by herself and she took the policy from the opposite parties bearing No.P/131124/10/ 2015/002167 vide Ex.A1. The name of the said policy is Star Senior Citizens Red Carpet Insurance Policy. For the first time, she took the policy in the year 2013 covering the period from 14.12.2013 to 13.12.2014 and in continuation the said policy was renewed by paying a sum of Rs.14,494/- as premium vide Ex.A2 & A3. The complainant was fallen from bed, due to that  the left femur of her neck was fractured and immediately, she was taken to Sai Muti Specialty Hospital, Rajahmundry on 9.4.2015 and a surgery was conducted on her on 10.4.2015. The said operation was done as “un-cemented hip replacement bipolar Hemiartoplasty and she was discharged on 21.4.2015 and the discharge summary is herewith marked as Ex.A4 = Ex.B5. The hospital had raised a bill for Rs.1.5 lakhs vide Ex.A6 in respect of the operation conducted by them on the complainant. Again, the complainant was admitted in the hospital on 28.4.2015 due to breathlessness associated with fever. The doctors gave treatment and discharged her on 4.5.2015 and the discharge summary is marked as Ex.A5 = Ex.B6. Again, the hospital raised a bill for Rs.20,000/- vide Ex.A7 for the above treatment. The complainant also spent Rs.21,917/- towards medical expenses and a consolidated bill along with the above expenses is herewith marked as Ex.A8. The complainant was addressed a letter by the 1^st opposite party dt.10.4.2015 vide Ex.A9 stating that her claim is inadmissible due to non-disclosure of pre-existing diseases. The 1^st opposite party wrote another letter vide Ex.A10 stating that they may cancel the policy due to non-disclosure of material facts. They also wrote another letter to the complainant for sending the documents such as discharge summary etc. vide Ex.A11. The 2^nd opposite party wrote another letter dt.6.6.2015 vide Ex.A12 and stated that they repudiated the claim by not disclosing the medical history of the complainant. The opposite parties refund half of the premium amount of Rs.7,227/- to the complainant vide Ex.A14.

The opposite parties also filed the proposal form vide Ex.B1 and the policy schedule with terms and conditions vide Ex.B2 and also filed Histopathology report issued by Krishna Institute of Medical Sciences Limited (KIMS) vide Ex.B3. They also filed physicians assessment of the complainant issued by Neuro Krish vide Ex.B4 and copies of discharge summary reports. The opposite parties field visit report of the opposite parties medical officer vide Ex.B7 and filed query on pre-authorization vide Ex.B8. An authorization letter given by the complainant to the opposite parties vide Ex.B9.                   

The main contention of the complainant is that the opposite parties has to pay the claim amount and damages for mental agony and deficiency in service. The complainant contended that the opposite parties failed to reimburse the amount incurred by her for medical treatment even inspite of giving the claim form. She further contended that she has taken Star Senior Citizens Red Carpet Insurance Policy in the year 2013 and the same is renewed in the year 2014. She also contended that by the date of her surgery, the policy was in force. The complainant further submitted that the opposite parties repudiated the claim basing on clause 11 of the policy that she has not disclosed the earlier ailments. Again, they sent a reminder to the complainant to fulfill certain formalities and to file some documents in respect of the claim made by her vide Ex.A11. After submission of all the papers by the complainant, the opposite parties sent a letter by repudiating the claim vide Ex.A12. The  complainant also contended that the opposite parties mentioned in Ex.A10 that non-disclosure of pre-existing diseases and later vide Ex.A14, they refunded an amount of Rs.7,227/- as part of the premium to the complainant and cancel the policy. The complainant contended that the opposite parties without settling the claim, they cancel the policy and sent the half of the premium amount to the complainant and the same was received by her without prejudice to the rights. She also contended that the opposite parties denied the payment of the claim amount without any valid reasons and further contended that the opposite parties illegally, un-authorizedly repudiated her claim which amounts to deficiency in service.

The main contention of the opposite parties is that the complainant concealed the fact in Ex.B1 and gave false declaration. They also contended that as per the medical records such as Ex.B7, Ex.B8 & Ex.B9, the complainant is a known case of CA Breast since 2008 and the same is supported by the discharge summary i.e. Ex.B3 of Krishna Institute of Medical Sciences. They also contended that the complainant is a known case of Parkinson disease since 13.11.2013 vide Ex.B4, but the complainant in her declaration i.e. Ex.B1, she fully suppressed her medical history and wrongly declared in the proposal form. They also contended that as per condition 7 of the policy i.e. under Ex.B2, if there is any misrepresentation of the material facts, they are not liable to make any payment in respect of the claim. Hence, they contended that they repudiated the claim of the complainant. They further submitted that if the complainant disclosed her ailments in the proposal form, the opposite parties ought not to have issued the policy to the complainant as it is a declined risk. The opposite parties sent the premium amount of Rs.7,227/- by way of D.D. to the complainant vide Ex.A13. The main contention of the opposite parties is that violation of the terms and conditions by the complainant and the opposite parties expressed their intention for cancellation of the policy as per Condition No.11.

Perused the material on record and observed that the complainant took a Red Carpet Policy from the opposite parties and when she had an injury and the same is operated in Sai Orthopedic Hospital. When the Sai Orthopedic Hospital approached for cashless claim, the opposite parties denied for payment of the amount. The main contention of the opposite parties is that the complainant concealed the material facts of her previous health condition and took the policy.

The complainant relied on the following decisions:-

1. Apollo Munich Health Insurance Co. Ltd., & Anr., Vs. Mrs. Kirti & Anr., II (2014) CPJ 365 (NC), in which it was held that Consumer Protection Act, 1986 – Sections 2(1)(g), 14(1)(d), 21(b) – Insurance (Mediclaim) – Exclusion Clause – Menstrual problems and severe abdominal pain – Surgery conducted – Reimbursement of expenditure denied – Deficiency in service – District Forum dismissed complaint – State Commission – allowed appeal – Hence revision – Medical records, ultrasound report and discharge card show that Insured was treated for fibroid, which was presented with heavy menstrual bleeding and abdominal pain – Patient/complainant was diagnosed as a case of Primary Infertility but she was also diagnosed as having fundal fibroid – Hospital performed diagnostic laparoscopy and then myomectomy – Removal of fibroid was an absolute necessity, for better health of patient – Claim rejected on basis that primary cause for surgery was Primary Infertility – Repudiation of claim under exclusion clause Section 6(e)(ix) is just and arbitrary act – Insurance company cannot assume a reason, for an ailment, according to its own convenience – Repudiation not justified – Punitive costs awarded.
2. New India Assurance Company Ltd., Vs. B.Y. Srikanta: IV (2015) CPJ 380 (NC), in which it was held that Consumer Protection Act, 1986 – Sections 2(1)(g), 14(1), 21(b) – Insurance (Mediclaim) – Medical reimbursement – Concealment of pre-existing disease alleged – Claim repudiated – Deficiency in service – District Forum allowed complaint – State Commission dismissed appeal – Hence revision – Insurance Company has not produced any evidence to show that Parkinson disease is a pre-existing disease and same was not disclosed in proposal form by complainant – Repudiation not justified.
3. National Insurance Co. Ltd. & Anr., IV (2015) CPJ 84 (Punj.), in which it was held that C.P. Act, 1986 – Sections 2(1)(g), 14(1)(d), 15 – Insurance (Mediclaim) – Medical reimbursement – Coverage under policy disputed – Claim repudiated – Deficiency in service – District Forum allowed complaint – Hence appeal – Most illiterate and rustic villagers are not aware about niceties of law and unless and until, terms and conditions of contract of insurance are conveyed to them, they cannot be said to be binding on them – It was duty of empanelled hospitals and insurer to provide cashless treatment to complainant and they committed default therein – Disease is not pre-congenital, so as to be excluded from terms and conditions of policy – Repudiation not justified.
4. Padmavathy Venkatesh Vs. Oriental Insurance Company Ltd., & Anr., IV (2015) CPJ 407 (NC), in which it was held that C.P. Act, 1986 – Sections 2(1)(g), 14(1)(d), 21(a)(i) – Insurance (Mediclaim) – Medical reimbursement – Concealment of previous ailment alleged – Claim repudiated – Deficiency in service – Insurance cover was obtained without medical examination – As per terms of insurance policy, illness of insured was covered to extent of USD 10,000 – More than USD 10,000 were spent on treatment of insured – Repudiation on plea of concealment of fact is not justified.

 

 

As per the documents filed by the both parties, it is observed that in Ex.B1, the complainant gave a declaration that she is not having cancer, chronic kidney disease, CVA/Brain Stroke, Alzheimer disease and Parkinson’s disease, but as per Ex.B3 that the complainant was suffering from CA Breast since 2008 and it is also clearly mentioned that in Ex.B4 that she is suffering from Parkinson’s disease. The said information was written in discharge summary i.e. Ex.A4 stating that the complainant taking treatment for Parkinson’s disease since 18 months and also mentioned about breast cancer. As per these documents, it is clearly shows that the complainant has not declared correct information while taking the policy from the opposite parties.

            The complainant filed four citations, which are not applicable in the present case on hand.  It is clearly established that the complainant misrepresented and violated the terms and conditions of the policy. Therefore, the opposite parties has a right to cancel the policy on the ground of misrepresentation, fraud etc. under Condition No.13.

            With the discussion held supra and the facts and circumstances of the case, the opposite parties rightly repudiated the claim of the complainant as the complainant has not disclosed her previous medical history while taking the policy. Therefore, there is no deficiency in service on the part of the opposite parties and the complainant is not entitled for any claim as prayed and the complaint is liable to be dismissed.   

 

8.   POINT No.3:  In the result, the complaint is dismissed without costs.

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the 26^th day of April, 2016.

    

                 Sd/-xxx                                                                                  Sd/-xxx

              MEMBER                                                                              PRESIDENT(FAC)

 

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANT: None.                                         FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

 

Ex.A1     dt/05.12.2014    Senior Citizens Red Carpet Insurance Policy issued by the opposite parties in favour of the complainant.           

Ex.A2     dt/05.12.2014    Premium paid receipt issued by the 1^st opposite party.

Ex.A3     dt/05.12.2014    Hospitalization benefit policy issued by the opposite parties to the

               complainant.

Ex.A4     dt/21.04.2015    Discharge summary issued by Sai Super Specialty Hospitals,

                       Rajahmundry, for the 1^st operation.

Ex.A5     dt/04.05.2015    Discharge summary issued by Sai Super Specialty Hospitals,

               Rajahmundry, for the 1^st operation.

 

 

Ex.A6     dt/                 Duplicate in patient bill issued by Sai Super Specialty Hospitals,

                    Rajahmundry, for the 1^st operation.

Ex.A7     dt/               Duplicate in patient bill issued by Sai Super Specialty Hospitals,

          Rajahmundry, for the 2^nd operation.

Ex.A8     dt/               All bills summary issued by Sai Super Spcialty Hospitals,

                  Rajahmundry, for both operations, including medicines.

Ex.A9     dt/10.04.2015    Letter addressed by the 1^st opposite party to Sai Orthopedic

                                       Trauma and General Hospital and a copy sent to the complainant.

Ex.A10  dt/05.05.2015     Cancellation letter addressed by the opposite party to the

                        complainant.

Ex.A11  dt/26.05.2015     1^st reminder addressed by the opposite parties to the complainant

              demanding submission of certain documents.

Ex.A12  dt/06.06.2015     Repudiation letter sent by the opposite parties to the complainant.

Ex.A13  dt/12.06.2015     Letter addressed by the opposite parties to the complainant while

                      refunding the premium amount.

Ex.A14  dt/05.06.2015     Endorsement schedule sent by the opposite parties to the

                complainant.

 

 

FOR OPPOSITE PARTIES:-  

 

Ex.B1     dt/14.12.2013     Proposed form duly signed by the complainant.

Ex.B2     dt/14.12.2013     copy of the policy schedule along with terms and conditions.

Ex.B3     dt/04.06.2008     Discharge summary along with Medical report of Krishna

                                           Institute of Medical Sciences Limited, Secunderabad.

Ex.B4     dt/13.11.2013    Treatment record of Neuro Krish, Chennai.

Ex.B5     dt/09.04.2015    Discharge summary of Sai Hospital, Rajahmundry.

Ex.B6     dt/28.04.2015    Discharge summary of Sai Hospital, Rajahmundry.

Ex.B7     dt/10.04.2015    Field visit report of Star Health Insurance Medical Officer.

Ex.B8     dt/09.04.2015    Query on pre authorization of Star Health & Allied Insurance

     Company Limited.

Ex.B9     dt/09.04.2015    Authorization given by the complainant to Star Health & Allied 

                                       Insurance Company Limited.

 

                  Sd/-xxx                                                                                        Sd/-xxx

              MEMBER                                                                              PRESIDENT(FAC)