Tamil Nadu

South Chennai

349/2010

Ramanathan Vellayan - Complainant(s)

Versus

M/s.Royal Sundaram Allianace Insurance Co. Ltd - Opp.Party(s)

K.V.Sundararajan

15 Nov 2018

ORDER

                                                                        Date of Filing  : 31.08.2010

                                                                          Date of Order : 15.11.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

                 TMT. K. AMALA, M.A., L.L.B.                                : MEMBER-I

 

C.C. No.349/2010

DATED THIS THURSDAY THE 15^TH DAY OF NOVEMBER 2018

                                 

Ramanathan Vellayan,

S/o. Mr. Rm. Vellayan,

No.4-b, Bhattacharjee Street,

Virugambakkam,

Chennai – 600 092.                                                        .. Complainant.                                                      

 

                                                                                                   ..Versus..

 

M/s. Royal Sundaram Alliance Insurance Co. Ltd.,

Represented by its Manager,

Sundaram Towers,

Nos.45 & 46, Whites Road,

Royapettah,

Chennai – 600 014.                                                   ..  Opposite party.

          

Counsel for complainant     :  M/s. S. Ramesh & others

Counsel for opposite party :  M/s. M.B. Gopalan & others

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 praying to pay a sum of Rs.1,41,613/- towards the hospital charges with interest at 24% p.a. from the date of submission of the claim till payment and to pay a sum of Rs.3,00,000/- towards compensation for mental tension, agony and deficiency in service with cost to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he has availed Health Insurance Policy from the opposite party for himself and his family members in the year 2005 and was renewed year after year till the impugned policy of the year 2009 – 2010.  The complainant submits that on 14.05.2009, the complainant’s father complained of vomiting and loss of appetite and showing the science of giddiness, disorientation in terms of time and place and incontinence of urine.  Hence on 16.05.2009, the complainant’s father was taken to Sooriya Hospitals.  On the advice of the Doctor the complainant’s father was admitted in Sooriya Hospital on 17.5.2009 and undergone treatment till 21.05.2009.  The complainant has expended a sum of Rs.35,615/- on 21.05.2009.   The complainant submitted the claim for sum of Rs.35,615/- dated:09.06.2009.  The complainant submits that on 25.05.2009, once again the complainant’s father was admitted in the same hospital and undergone treatment till 14.06.2009 and discharged.  The complainant has expended a sum of Rs.1,06,000/- towards treatment.  The complainant submitted the claim form claiming a sum of Rs.1,06,000/-.  

2.     The complainant submits that the complainant requested the opposite party to reconsider the claim since there is no response.   The complainant addressed the letters dated:07.12.2009 & 24.02.2010 to the Insurance Ombudsman to reconsider the claim for which, the complainant was directed to contact the opposite party, M/s. Royal Sundaram Alliance Insurance Co. Ltd.   The complainant also contacted the opposite party.  The Ombudsman after hearing about the same passed an award and rejected the claim but the Ombudsman awarded a sum of Rs.25,000/- as Ex-gratia payment.  The complainant submits that on 05.08.2008 and 23.04.2009, the complainant’s father had undergone cataract surgery.  At that time, there was no disease of hypertension to the complainant’s father. The complainant’s mother gave a statement that for mild hypertension the complainant’s father taken a tablet of Losar 25 1 od – 4 years alone.   The complainant availed the family health Insurance policy right from 2005.   The complainant submits that even after knowing fully well that the complainant availed Family Health Insurance Policy of the opposite party from 2005 to 2010, rejected the claim without any substantial reason and without conducting any enquiry regarding the hypertension and without taking consideration of the complainant’s mothers evidences.   In discharge summaries for the cataract surgery, there is no mentioning of hypertension.  The act of the opposite party caused great mental agony.    Hence, the complaint is filed.

3.      The brief averments in the written version filed by the  opposite party is as follows:

The opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.  The opposite party states that the complainant availed Health Insurance Policy of the opposite party since 29.12.2005 and was renewed from time to time till 2010.  A claim was lodged for hospitalisation of Mr. Vellayan aged 73 on 17.05.2009 along with the Discharge Summary of Soorya Hospital reveals that the history as “known case of hypertension on Tab Losar 25 one 1 od- 4 years”.   Hence after perusal of the claim form and the medical records, this opposite party repudiated the claim on the ground of pre-existing hypertensive condition which was totally suppressed at the time of availing the policy.  As per the terms and conditions of the policy clause D which reads as follows:

EXCLUSIONS

The Company shall not be liable under this Policy for any claim in connection with or in respect of:

1. a) Pre Existing Disease and any disease, illness, medical condition, injury which is a complication of a Pre Existing Disease”.   

Hence, this opposite party rightly repudiated the claim.   Therefore, there is no deficiency in service on the part of the opposite party.  Hence the complaint is liable to be dismissed.

4.    To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A22 are marked.  Proof affidavit of the opposite party is filed and documents Ex.B1 to Ex.B7 are marked on the side of the opposite party. 

5.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.1,41,613/-  paid towards medical expenses with interest as prayed for?

2. Whether the complainant is entitled to a sum of Rs.3,00,000/- towards compensation for mental agony, deficiency in service etc with cost as prayed for?

6.      On point:-

Both parties filed their respective written arguments.  Heard the Counsels also.  Perused the records namely the complaint, written version, proof affidavits and documents.  The learned Counsel for the complainant contended that he has availed Health Insurance Policy from the opposite party for himself and his family members in the year 2005 and was renewed as per Ex.A1 year after year till the impugned policy of the year 2009 – 2010 is admitted.  Further the contention of the complainant is that on 14.05.2009, the complainant’s father complained of vomiting and loss of appetite and showing the science of giddiness, disorientation in terms of time and place and incontinence of urine.  Hence on 16.05.2009, the complainant’s father was taken to Sooriya Hospitals.   On the advice of the Doctor the complainant’s father was admitted in Sooriya Hospital on 17.5.2009 and undergone treatment till 21.05.2009.  Ex.A2 is the Discharge Summary.  The complainant has expended a sum of Rs.35,615/- as per Ex.A3.   The complainant submitted the claim for sum of Rs.35,615/- as per Ex.A3.   Further, the complainant contended that on 25.05.2009, once again the complainant’s father was admitted in the same hospital and undergone treatment till 14.06.2009 and discharged. Ex.A5 is the Discharge summary.  The complainant has expended a sum of Rs.1,06,000/- towards treatment.  The complainant submitted the claim form Ex.A6 claiming a sum of Rs.1,06,000/-.   But the opposite party has rejected both the claims as per Ex.A4 & Ex.A7 stating that

“The Company shall not be liable under this Policy for any claim in connection with or in respect of Pre Existing Disease and any disease, illness, medical condition, injury, which is a complication of a Pre Existing Disease”.

7.     Further the contention of the complainant is that as per Ex.A8 & Ex.A9, the complainant requested the opposite party to reconsider the claim  since there is no response.   The complainant addressed the letters to the Insurance Company as per Ex.A10 & Ex.A14 to the Insurance Ombudsman to reconsider of the claim for which, the complainant was directed to contact the opposite party, M/s. Royal Sundaram Alliance Insurance Co. Ltd.   The complainant also contacted the opposite party.  The Ombudsman after hearing about the same passed an award as per Ex.A17 and rejected the claim.  Anyhow, the Ombudsman awarded a sum of Rs.25,000/- as Ex-gratia payment.  The rejection of the claim by the opposite party and the Ombudsman is solely based on the pre-existing disease of hyper tension for 4 years. 

8.     The learned Counsel for the complainant further pleaded and contended that on 05.08.2008 and 23.04.2009, the complainant’s father had undergone cataract surgery.  Ex.A18 & Ex.A19 are the Discharge Summaries.  At that time, there was no disease of hypertension to the complainant’s father.  On 21.05.2009, when the complainant’s father was taken to the hospital the Doctor made a note in the Discharge Summary as per Ex.A2 that known case of hypertension for the past 4 years is not correct.  The complainant’s mother gave a statement that for mild hypertension the complainant’s father taken a tablet of Losar 25 1 od – 4 years alone.  The complainant availed the family health Insurance policy right from 2005.  It was renewed from time to time till 2010.  The exclusion clause shall not be counted for more than 2 years.    Thereby, the complainant is entitled to reimburse the amount expended towards medical treatment and compensation.   Further the contention of the complainant is that even after knowing fully well that the complainant availed Family Health Insurance Policy of the opposite party from 2005 to 2010, rejected the claim without any substantial reason and without conducting  any enquiry regarding the hypertension and without taking consideration of the complainant’s mothers evidences.  In discharge summaries Ex.A18 & Ex.A19 for the cataract surgery, there is no mentioning of hypertension; amounts to deficiency in service. 

9.     The learned Counsel for the opposite party contended that admittedly, the complainant availed Health Insurance Policy of the opposite party since 29.12.2005 and was renewed from time to time till 2010.  A claim was lodged for hospitalisation of Mr. Vellayan aged 73 on 17.05.2009 along with the Discharge Summary of Soorya Hospital reveals that the history as “known case of hypertension on Tab Losar 25 one 1 od- 4 years”.  Hence after perusal of the claim form and the medical records, this opposite party repudiated the claim on the ground of pre-existing hypertensive condition which was totally suppressed at the time of availing the policy.  As per the terms and conditions of the policy clause D which reads as follows:

EXCLUSIONS

The Company shall not be liable under this Policy for any claim in connection with or in respect of:

1. a) Pre Existing Disease and any disease, illness, medical condition, injury which is a complication of a Pre Existing Disease.

    b) Any heart, kidney and circulatory disorders in respect of insured Persons suffering from pre-existing Hyper tension / diabetes”.

Hence, this opposite party rightly repudiated the claim.  But on a careful perusal of records, as per Ex.A18 & Ex.19 the complainant’s father Mr. Vellayan has no hypertension of any kind.   The policy was right in force from 2005 to 2010.   Hence, such pre-existing disease of hypertension has nothing to do with the claim.    Considering the facts and circumstances of the case this Forum is of the considered view that the opposite party shall pay a sum of Rs.1,41,613/-  with  a compensation of Rs.30,000/- and cost of Rs.5,000/-.

In the result, this complaint is allowed in part.   The opposite party is  directed to pay a sum of Rs.1,41,613/- (Rupees One lakh forty one thousand six hundred and thirteen only) being medical expenses incurred and to pay a sum of Rs.30,000/-  (Rupees Thirty thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 15^th day of November 2018. 

 

MEMBER –I                                                                      PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:

		Copy of Insurance policy for the year 2009 to 2010
		Copy of Claim HR 52349- Discharge Summary
		Copy of Claim HR 52349- Claim form for Rs.3,35,615/-
		Copy of Claim HR 52349- Rejection letter
		Copy of Claim HR 3962 – Discharge Summary
		Copy of Claim HR 3962 – claim form for Rs.1,06,000.18
		Copy of Claim HR 3962 – Rejection letter
		Copy of request to reconsider both the claims
		Copy of rejection of reconsideration request
		Copy of complaint to insurance Ombudsman
		Copy of letter by Ombudsman to contact Royal Sundaram
		Copy of reconsideration request to Royal Sundaram
		Copy of rejection by Grievance Cell, Royal Sundaram
		Copy of complaint to Insurance Ombudsman
		Copy of minutes of hearing at Insurance Ombudsman
		Copy of response of corrections etc. to the minutes
		Copy of award of Ombudsman
		Copy of Discharge Summary after 1st Cataract Surgery
		Copy of Discharge Summary after 2nd Cataract Surgery
		Copy of Indicating letter
		Copy of renewal of policy No.HS00039287000105
	26.12.2011 to 24.03.2012	Copy of E-mails correspondence

 

OPPOSITE  PARTY SIDE DOCUMENTS:-

Ex.B1		Copy of policy
Ex.B2		Copy of Discharge Summary
Ex.B3	06.06.2009	Copy of claim form
Ex.B4		Copy of Discharge Summary
Ex.B5	29.06.2009	Copy of repudiation letter
Ex.B6	29.10.2009	Copy of repudiation letter
Ex.B7	31.05.2010	Copy of Ombudsman Order

 

 

 

MEMBER –I                                                                      PRESIDENT