Date of filing:      29.03.2019

                                                                                                                                 Date of disposal : 31.10.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                 .…. PRESIDENT

                 THIRU.P.MURUGAN,M.Com.ICWA(Inter),B.L.,                                        ....MEMBER-II

 

RBT/CC. No.78/2022

THIS MONDAY, THE 31st DAY OF OCTOBER 2022

(CC.No.68/2019 sent from DCDRC, Chennai North)

 

Mr. P.Sivaprasad, S/o.Late S.Prathap Singh,

Flat No.5, Ashtalakshmi Flats,

No.12, Teachers Colony,

Adyar, Chennai 600 020.                                                                  ……Complainant.     

                                                                          //Vs//

M/s.Chola MS General Insurance Company Limited,

Rep. by its Manager (Head of Claims),

New No.319, Shaw Wallace Building, 

2nd Floor, Thambu Chetty Street,

Chennai 600 001.                                                                        .......Opposite party. 

 

Counsel for the complainant                                           :   Mr.D.Kumar, Advocate.

Counsel for the opposite party                                       :   M.B.Gopalan Associates.

                         

This complaint has been filed before DCDRC, Chennai (North) as CC.No.68/2019 and transferred to this commission by the order of the Hon’ble State Consumer Disputes Redressal Commission, Chennai and taken on file as CC.No.127/2022 and this complaint coming before us on various dates and finally on 07.10.2022 in the presence of M.B.Gopalan Associates counsel for the opposite party and upon perusing the documents and evidences of of both parties, this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

 

This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service in repudiating the insurance claim along with a prayer to pay a sum of Rs.5,00,000/- with 18% interest per annum from the date of complaint and to pay a sum of Rs.50,000/-towards compensation for the mental agony caused to the complainant along with cost of the proceedings to the complainant. 

Summary of facts culminating into complaint:-

 

It was the case of the complainant that he has taken Health Insurance Policy with the opposite party for a sum of Rs.5,00,000/- named as CHOLA SWASTH PARIVAR INSURANCE-ROYAL, vide policy No.2856/00150113/000/00 and Customer ID No.101823153748.   The policy was taken on 29.04.2017 and was  periodically renewed upto 28.04.2018.  At the time of taking policy on 29.04.2014 one Mr.P.S.Lakshiminarayanan who was the inter-mediatory of the opposite party verified all the medical records of the complainant and satisfied himself to the effect that the complainant was not having any pre-existing illness and insured the complainant.  Originally there were no exclusions for the complainant which fact was specifically mentioned by the opposite party in the first policy and also in the renewal policies issued to the complainant. The complainant was admitted in Prashanth Super Speciality Hospital at Velachery for Coronary Angiogram on 15.01.2018 and got discharged on the same day vide Discharge Summary issued by the hospital.  The complainant had subsequently undergone a treatment for Coronary Artery Disease-double Vessel Disease PTCA with stent to LAD done, for which he was admitted in Fortis Malar Hospital on 17.01.2018 and got discharged on 20.01.2018 and he was again admitted on 21.01.2018 and discharged on 25.01.2018.  For the above said two medical treatments and procedures, he made the payments to Fortis Malar Hospital on his own.  When the complainant had submitted for claim reimbursement for the above said treatments one Mr.Babu of the opposite party’s office enquired about the mentioning of the 3 to 4 years Diabetic and B.P. for 4 years ago in the discharge summary of Prashanth Super Speciality Hospital. It was satisfactorily explained in detail supported by Doctor’s certificate. Since the opposite party had taken a long period to consider the complainant’s claim the complainant had sent an email on 08.05.2018 to the opposite party for which the opposite party issued a reply mail stating that they have rejected the complainant’s claim for the reason that the said ailment was the complication of existing longstanding illness of hypertension and diabetes which was termed pre-existing as per the terms.  The opposite party has sent a second detailed rejection order dated 09.05.2018 for both claim Nos.2856012978 & 2856012979 in respect of both the claims which were received by the complainant on 14.05.2018.  The opposite party has reiterated that the present ailment (Coronary Artery Disease) is a complication attributable to Hypertension and Diabetes which were existing since 14 years in relation to HTN and 3-4 years related to diabetes which is prior to the inception of the policy dated 29.04.2014.  It is stated as present ailment was considered as pre existing disease and hence the claim was inadmissible as per General Exclusion clause C-3 which reads as No indemnity is available or payable for claims directly or indirectly caused by or arising out of or connected to any pre-existing condition as defined in the policy, until 48 consecutive months of continuous coverage. Thus aggrieved by the act of the opposite party the present complaint was filed for the following reliefs as mentioned below;

To pay a sum of Rs.5,00,000/- with 18% interest per annum from the date of complaint;

 To pay a sum of Rs.50,000/-towards compensation for the mental agony caused to the complainant along with cost of the proceedings to the complainant.

Crux of the defence put forth by the opposite party:-

 

The opposite party filed version disputing the complaint allegations contending inter alia that the complainant had not filed the policy in full and not filed the terms and conditions containing the relevant exclusion clauses.  It was admitted by the complainant that the policy was issued on 29.01.2014 under the Chola Swasth Parivar Insurance Policy bearing No.2856/00150113/000/03 and undergone treatment for Coronary Artery Disease at Fortis Malar Hospital and Prashanth Hospital. Vide Exclusion No.C-3 the Policies provide coverage subject to certain exclusions, in particular, pre-existing diseases as well as complications arising out of the same for a period of 48 months from the date of initial insurance.  On examination of the medical records it was seen that the complainant suffered Hypertension and Diabetes since 3-4 years and the Coronary Artery Disease was directly related to hypertension and diabetes which is mentioned in the discharge summary of the hospital itself.  Though the complainant obtained certificate subsequently from the Doctor stating that hypertension had occurred 13 years prior to the CAD treatment, the fact remains that it was pre-existing. In the above situation the claim of the complainant was rejected on the ground of the exclusion of pre-existing diseases. Thus the opposite party sought for the complaint to be dismissed.

On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A13 on their side. On the side of opposite party proof affidavit was filed and document Ex.B1 was marked.

 

Points for consideration:

Whether the opposite party had committed deficiency in service in rejecting the medical insurance claim made by the complainant on the ground of exclusion clause found in the policy?

If so to what reliefs the complainant is entitled?

Point No.1:-

The following documents were filed on the side of complainant in support of his contentions;

Bank Statement of the complainant was marked as Ex.A1;

Renewal of policy bearing No.2856/00150113/000/03 dated 29.04.2015 was marked as Ex.A2;

Renewal of policy bearing No.2856/00150113/000/03 dated 29.04.2017 was marked as Ex.A3;

 Discharge Summary of Prashanth Hospital dated 15.01.2018 was marked as Ex.A4;

Discharge Summary of Forties Malar Hospital dated 20.01.2018 was marked as Ex.A5;

Discharge Summary of Fortis Malar Hospital dated 25.01.2018 was marked as Ex.A6;

Claim forms submitted by the complainant was marked as Ex.A7;

Certificate issued by Dr.Srivatsava (Consultant Diabetologist) was marked as Ex.A8;

Email sent by the complainant to the opposite party and reply sent by the opposite party to the complainant rejecting the claim was marked as Ex.A9;

Detailed rejection order sent by opposite party to the complainant for claim No.2856012978 dated 09.05.2018 was marked as Ex.A10;

Detailed rejection order sent by opposite party to the complainant for claim No.2856012979 dated 09.05.2018 was marked as Ex.A11;

Legal notice issued by the complainant to the opposite party dated 30.05.2018 was marked as Ex.A12;

Appeal sent by the complainant to IRDAI with acknowledgement card dated 12.07.2018 was marked as Ex.A13;

On the side of opposite party the following document was filed in support of their defence;

Police terms and conditions was marked as Ex.B1;

 In spite of sufficient notice and opportunities the complainant did not appear to adduce the oral arguments, however he had filed written argument and hence this commission to dispose the case on merits decided to consider the written arguments filed by the complainant as oral arguments.  The learned counsel appearing for the opposite party adduced oral arguments on their side.

The crux of the written arguments made by the complainant is that he had no pre-existing illness at the date of taking of policy.  Before taking the insurance policy the opposite party completely perused the records and after satisfying that the complainant was not having any pre-existing illness, the policy was issued.  The opposite party clearly mentioned in the policy that there is no exclusion for the policy.  It was submitted that he had undergone treatment for Coronary Artery Disease-double Vessel Disease PTCA with stent to LAD done for which he was admitted on 17.01.2018 and discharged on 20.01.2018 and again admitted on 21.01.2018 and discharged on 25.01.2018 respectively.  When clarification was sought for by the opposite party the same was given satisfactorily vide Ex.A8 Doctor Certificate stating that the complainant took treatment for B.P. 14 years ago that too for a period of one year only. Though the complainant took treatment for heart ailment the opposite party rejected the claim stating the reason of diabetes and B.P which is having a waiting period of 4 years which directly or indirectly caused the present heart ailment. It was submitted that the above mentioned illness were not the pre existing illness for the last 4 years as mentioned in the repudiation letter, thus he sought for the complaint to be allowed as prayed for.

On the other hand the opposite party argued that at the time of taking policy no medical examination was made by the complainant to show that he was not suffering any pre-existing illness.  Further when it is established that for the Coronary Artery Disease, Hypertension and diabetes would be the direct cause and when the complainant failed to reveal the same at the time of taking policy vide exclusion clause he is not entitled to the reimbursement of the insurance claim and he sought for the complaint to be dismissed.

On appreciation of the documents submitted by the complainant vide Ex.A4 the Discharge Summary we could see that the complainant was diagnosed with Coronary Artery Disease and the Medical History shows that he was suffering with Diabetes mellitus for 3 to 4 years and was found to have high BP 4 years back and took medications for 6 months to 1 years, the letter issued by Dr.K.Chandrasekaran it was certified that the complainant had high BP 4years ago and that he took treatment for 6 month to 1 year and then skipped it. We could also see that vide the Discharge Summary of Fortis Malar Hospital it has been clearly mentioned that the complainant had past history of “Known case of APD/Diabetes mellitus/Hypertension”.  It is seen that vide Discharge Summary the complainant was on medication for Diabetes mellitus/Hypertension.  The claim forms was submitted by the complainant vide Ex.A7.  The detailed rejection letter was issued by the opposite party for both claims dated 09.05.2018 and was marked as Ex.A11.  In the said rejection letter it is seen that the ailment (coronary artery disease) is a complication attributable to hypertension and diabetes which are existing since 14 years in relation to HTN and 3 to 4 years related to diabetes which is prior to the inception of the policy and hence the said disease considered to be pre existing diseases and the claim was inadmissible as the General Exclusion clause C-3 which reads as “No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to any pre-existing conditions(s) as defined in the policy, until 48 consecutive months for continuous coverage have elapsed, since inception of the first policy with us”.  Thus it is evident that even as per the Discharge Summary it was found that the complainant was having a medical history of Diabetes mellitus and high BP.  The policy was taken on 29.04.2014 and the complainant was admitted for Coronary Angiogram with Prashanth Super Speciality Hospital on 15.01.2018 and subsequently admitted in Fortis Malar Hospital on 17.01.2018 for Coronary Artery Disease-double Vessel Disease PTCA with stent to LAD done.  In such scenario, when the exclusion clause provided that no indemnity is available for any disease caused arising out of pre-existing conditions until 48 consecutive months of continuous coverage since the inception of the policy and when the policy was taken on 29.04.2014 and 48 month completed only on 29.04.2018 and even before completion 48 months the complainant had undergone treatment for Coronary Angiogram and Coronary Artery Disease-double Vessel Disease PTCA with stent to LAD the version of opposite party to be accepted.  The contention of the complainant that the policy had no exclusion clause could not be accepted as no insurance policy would be available without exclusion clause.  Further the opposite party had also produced the policy document with complete terms and conditions.  In the facts and circumstances we hold that the opposite party had not committed any deficiency in service in repudiating the medical claim made by the complainant. Thus we answer the point accordingly in favour of the opposite party and as against the complainant.

Point No.2:-

As we have held above that the complainant had failed to prove any deficiency in service on the part of the opposite party, he is not entitled to any reliefs as claimed in the complaint from the opposite party.  Thus we answer the point accordingly.

In the result, the complaint is dismissed.  No order as to cost. 

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 31st day of October 2022.

 

      Sd/-                                                                                                               Sd/- 

MEMBER-II                                                                                                    PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 01.05.2014 Bank Statment of the complainant. Xerox

Ex.A2 29.04.2015 Renewal of policy bearing No.2856/00150113/000/01. Xerox

Ex.A3 29.04.2017 Renewal of policy bearing No.2856/00150113/000/03. Xerox

Ex.A4 15.01.2018 Discharge Summary of Prashanth Hospital. Xerox

Ex.A5 20.01.2018 Discharge Summary of Fortis Malar Hospital. Xerox

Ex.A6 25.01.2018 Discharge Summary of Fortis Malar Hospital. Xerox

Ex.A7 23.02.2018 Claim forms submitted by the complainant. Xerox

Ex.A8 13.04.2018 Certificate issued by Dr.Srivatsava. Xerox

Ex.A9 08.05.2018 Email sent by complainant to the complainant and reply email sent by opposite party to the complainant rejecting the claim. Xerox

Ex.A10 09.05.2018 Detailed rejection order sent by opposite party to the complainant for claim No.2856012978. Xerox

Ex.A11 09.05.2018 Detailed rejection order sent by opposite party to the complainant for claim No.2856012979. Xerox

Ex.A12 30.05.2018 Legal notice issued by the complainant to the opposite party with acknowledgement card. Xerox

Ex.A13 12.07.2018 Appeal sent by complainant to IRDAI with acknowledgement card. Xerox

 

List of documents filed by the opposite party:-

 

Ex.B1 ............... Policy with terms and conditions. Xerox

 

 

   Sd/-                                                                                                                Sd/-

MEMBER-II                                                                                                  PRESIDENT