Tamil Nadu

South Chennai

CC/382/2014

M/s.S.Rajesh - Complainant(s)

Versus

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

M/s.Svaak Legal

08 Aug 2019

ORDER

                                                                  Complaint presented on : 12.09.2014

                                                                    Date of Disposal            : 08.08.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

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

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.382/2014

DATED THIS THURSDAY THE 08^TH DAY OF AUGUST 2019

                                 

S. Rajesh,

S/o. K. Sakthidharan,

No.2/3, V.O.C. Nagar,

2^nd Cross Street, Anna Nagar,

Chennai – 600 102.                                                        .. Complainant.                                

 

                                                                                              ..Versus..

1. Star Health and Allied Insurance Co. Ltd.,

Regd. & Corporate Office,

Rep. by its Manager,

Nos.37 & 38, Venkatnarayana Road,

T. Nagar,

Chennai – 600 017.

 

2. Star Health and Allied Insurance Co. Ltd.,

Corporate Officer Telesales Chennai,

Old No.64-A, New No.2-A,

Ganga Nagar Road,

Kodambakkam,

Chennai – 600 024.                                                ..  Opposite parties.

 

Counsel for the complainant       : M/s. SVAAK LEGAL

Counsel for the opposite parties : M/s. N. Vijayaraghavan

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 & 2 under section 12 of the Consumer Protection Act, 1986 prays to direct the opposite parties to pay the medical expenditure of Rs.95,545.31 incurred by the complainant for his father’s treatment, to pay a sum of Rs.2,00,000/- towards compensation for damages for mental agony, stress, loss, hardship and deficiency in service with cost to the complainant.

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

The complainant submits that his father Mr. K. Sakthidharan availed an insurance policy under the scheme of ‘Senior Citizen red carpet Insurance Policy’ bearing Policy No.P/700001/01/2009/00090, ID card No.440244-1 and the sum assured was Rs.2,00,000/-. The yearly premium is of Rs.9,500/- including service tax was paid by way of cash and from the inception of the policy i.e. on 24.06.2008 the complainant was prompt in paying regular premiums was renewed from time to time.  The complainant submits that on 13.07.2014, Mr. K. Sakthidharan was admitted in Apollo First Med Hospital, Kilpauk Chennai – 600 010 for the treatment of Lung Cancer and he died on 16.07.2014.  At the time of admission, the complainant had informed the above said hospital about the hospitalization benefits policy and the concerned hospital Authority had sent the same for approval of the opposite parties on 13.07.2014 itself through pre-authorization request for cashless treatment claimed to Mr. K. Sakthidharan which was rejected for the reason that the policy was renewed only on 14.07.2014 after admission in the hospital. The complainant submits that the previous policy dated:24.06.2013 and the present policy was taken during the break period as per the permission of the opposite party in accordance with the terms and conditions.  Hence, the complainant issued legal notice dated:25.07.2014 seeking to pay the medical expenditure incurred by the complainant on his father’s treatment and the opposite parties gave an evasive reply dated:05.08.2014 stating that the complainant has not paid his father’s premium for the year 2014-2015 in time.  The opposite parties have not come forward to settle the demands of the complainant.   The act of the opposite parties 1 & 2 amount to deficiency in service and unfair trade practice which caused great mental agony.    Hence, the complaint is filed.

2.      The brief averments in the written version filed by opposite parties 1 & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and put the complainant to strict proof of the same.   The opposite parties 1 & 2 state that the claim for reimbursement of medical expenses incurred by the complainant to his father on 13.07.2014 is not payable for the simple fact that the claim was made during the break period.  The opposite parties 1 & 2 state that there is no valid insurance policy on the date of claim i.e. 13.07.2014 and the insurance policy was availed subsequently with the opposite parties for the period from 14.07.2014 to 13.07.2015 vide policy No.P/700001/01/2015/002797.  The opposite parties 1 & 2 state that the complainant made a claim for hospital expenses incurred for the treatment to his father in respect of lung cancer on 14.07.2014.   On the date of availing the policy, as per the authorization request received from the treating hospital that the insured patient was admitted on 13.07.2014 falls during the break period of the policy. Hence, the cashless authorization was denied.  The opposite parties 1 & 2 state that the contract of insurance is based on utmost good faith.   The opposite parties 1 & 2 is that mere acknowledgement for receiving the premium will not amount to the commencement of policy from the said date. The policy No.P/700001/01/2015/002797 for the year 2014-15 was renewed only for the period from 14.07.2014.  Hence, the opposite parties have not committed any deficiency in service and the complaint is liable to be dismissed.

3.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A10 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and documents Ex.B1 & Ex.B2 were marked on the side of the opposite parties 1 & 2.

4.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.95,545.31 incurred towards medical expenditure as prayed for?
2. Whether the complainant is entitled to sum of Rs.2,00,000/- towards compensation for mental agony and deficiency in service with cost as prayed for?

5.      On point:-

Both parties field their respective written arguments.  Perused the records namely; the complaint, written version, proof affidavits and documents.  The complainant pleaded and contended that his father Mr. K. Sakthidharan availed an insurance policy under the scheme of ‘Senior Citizen red carpet Insurance Policy’ bearing Policy No.P/700001/01/2009/00090, ID card No.440244-1 and the sum assured was Rs.2,00,000/-.  The yearly premium is Rs.9,500/- including service tax and from the inception of the policy i.e. on 24.06.2008 the complainant was prompt in paying regular premiums and as renewed from time to time as per Ex.A1.  Further the contention of the complainant is that on 13.07.2014, Mr. K. Sakthidharan was admitted in Apollo First Med Hospital, Kilpauk Chennai – 600 010 for the treatment of Lung Cancer and he died on 16.07.2014.   Ex.A2 is the Death Certificate.   At the time of admission, the complainant had informed the above said hospital about the hospitalization benefits policy and the concerned hospital Authority had sent the same for approval of the opposite parties on 13.07.2014 itself through pre-authorization request for cashless treatment claimed to Mr. K. Sakthidharan which was rejected for the reason that the the policy was renewed only on 14.07.2014 after admission in the hospital.  Ex.A6  is  the copy of Policy Certificate from 14.07.2014 to 13.07.2015.   Further the contention of the complainant is that the previous policy, Ex.A1 dated:24.06.2013 and the present policy, Ex.A6 was taken during the break period as per the permission of the opposite party in accordance with the terms and conditions.  According to Ex.A10, the rejection of claim of the complainant for the treatment of Mr. K. Sakthidharan on the ground that the policy was availed after the admission; cannot be acceptable since, the opposite parties himself renewed the policy within the permitted stipulated period proves deficiency in service.

6.     The learned Counsel for the opposite parties would contend that the claim for reimbursement of medical expenses incurred by the complainant to his father on 13.07.2014 is not entitled for the simple reason that the claim was made during the break period.  Further the contention of the opposite parties 1 & 2 is that there is no valid insurance policy on the date of claim i.e.13.07.2014 and the insurance policy was availed subsequently with the opposite parties for the period from 14.07.2014 to 13.07.2015 vide policy No.P/700001/01/2015/002797 as per Ex.B2. Further the contention of the opposite parties 1 & 2 is that the complainant made a claim for the hospital expenses incurred for the treatment to his father in respect of lung cancer on 14.07.2014.   On the date of availing the policy, as per the authorization request received from the treating hospital that the insured patient was admitted on 13.07.2014 falls during the break period of the policy. Hence, the cashless authorization was denied. In Ex.A10, rejection letter dated:15.07.2014 it reads as follows:

“As per condition No.9 of the policy, the company is not liable to protect the insured person between the policy expiry date and the date of payment of premium for renewal”. 

7.     Further the contention of the opposite parties 1 & 2 is that the contract of insurance is based on utmost good faith.   In this case, eventhough the complainant’s father availed medical insurance policy previously the renewal of policy No.P/700001/01/2015/002797 has been done within the break period after the expiry of the previous policy which was availed by the complainant’s deceased father Mr. K. Sakthidharan for the period from 24.06.2013 to 23.06.2014.  Further the contention of the opposite parties 1 & 2 is that mere acknowledgement for receiving the premium will not amount to the commencement of policy from the said date. The policy No. No.P/700001/01/2015/002797 for the year 2014-15 was renewed only for the period from 14.07.2014 to 13.07.2015.

8.     As per Ex.B1, Copy of certified copy of Insurance Policy for the period from 24.06.2013 to 23.06.2014, it reads as follows:

8. Renewal:

“A grace period of 30 days from the date of expiry of the policy is available for renewal.  If renewal is made within this 30 days period the continuity of benefits will be allowed.  However, the actual period of cover will start only from the date of payment of premium.   In other words, no protection is  available between the policy expiry date and the date of payment of premium for renewal”.

Considering the facts and circumstances of the case, this Forum is of the considered view that this complaint has to be dismissed.

In the result, this complaint is dismissed.  No costs.

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 08^th day of August 2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of policy Certificate from 24.06.2013 to 23.06.2014
Ex.A2	16.07.2014	Copy of Burial Ground Report of Death of the complainant’s father issued by the Corporation of Chennai – Health Department
Ex.A3	16.07.2014	Copy of Apollo First Med Hospitals Bill
Ex.A4	26.05.2014	Copy of receipt given by the collection representative with ID Proof of representative
Ex.A5	26.05.2014	Copy of cash slip signed by the representative
Ex.A6		Copy of Policy Certificate from 14.07.2014 to 13.07.2015
Ex.A7	25.07.2014	Copy of legal notice with postal receipt
Ex.A8		Copy of acknowledged cards received by the both parties
Ex.A9	05.08.2014	Copy of reply notice
Ex.A10	15.07.2014	Copy of rejection of pre-authorization letter

 

OPPOSITE PARTIES SIDE DOCUMENTS:-  

Ex.B1		Certified copy of Insurance Policy for the period from 24.06.2013 to 23.06.2014
Ex.B2		Certified copy of Insurance Policy for the period from 14.07.2014 to 13.07.2015

 

 

                              

MEMBER                                                                                PRESIDENT