Tamil Nadu

North Chennai

CC/08/2016

M/s.Srinivasan - Complainant(s)

Versus

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

M/s.M.Mohan Kumar and Others

10 Feb 2020

ORDER

 

                                                            Complaint presented on:  29.12.2015

                                                               Order pronounced on:  10.02.2020

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT:  TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL -  PRESIDENT

 

TMT.P.V.JEYANTHI B.A., MEMBER - I

 

MONDAY THE 10^th   DAY OF FEBRUARY  2020

 

C.C.NO.08/2016

 

Mr.S.Srinivasan,

Flat No.5A,F2, Harini Flats,

First Street, Arunachalam Nagar,

Porur, Karambakkam,

Chennai – 600 116.

 

                                                                                     …..Complainant

 ..Vs..

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

Represented by its Authorized Signatory,

No.1, New Tank Street,

Valluvarkottam High Road,

Nungambakkam, Chennai – 600 034.

 

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

Represented by its Authorized Signatory,

KRM Centre, VI Floor,

No.02, Harrington Road, Chetpet,

Chennai – 600 031.

.....Opposite Parties

Counsel for Complainant                         : M/s.M.Mohan Kumar, S.Manjula,

                                                                      G.Srinivasan

 

Counsel for  opposite parties                      : Mr.N.Vijayaraghavan,

                                                                     M.B.Raghavan

                                                                      

ORDER

 

BY PRESIDENT TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          On 26^th December 2011,  complainant applied for insurance for his father Mr.Subramania Bharathi, aged about 68 years the medical insurance policy “Senior Citizens Red Carpet Insurance Policy” .The 1^st opposite party approved the policy on 27^th December 2011 and issued the policy certificate to the complainant bearing  policy No.P/700001/01/2012/007085 for a sum assure Rs.3,00,000/- on payment of the insurance premium amount of Rs.14,229/- per annum commencing from 26^th December 2011 to midnight of 25^th December 2012. On 13^th January 2015, the insured person was admitted in Sri Ramachandra Medical Centre for complaints of Right Leg Ulcer. The complainant has spent a sum of Rs.33,582.53/- towards pre-hospitalization bills, Rs.25,350.38/- towards post hospitalization bills, Rs.4,848/- towards pharmacy bills and Rs.710/- towards test reports dated 15^th , 16^th, 17^th & 21^st January 2015, respectively. All totally amounting to a sum of Rs.64,490.91/-. The opposite parties approved a preliminary amount of Sri Ramachandra Medical Centre  denying the request for authorization for cashless treatment of the  insured person.  The complainant caused a legal notice dated 18^th May 2015 to the opposite parties. Hence this complaint.

 

 

2. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

          Based on the treatment records the 2^nd opposite party approved a preliminary amount of Rs.20,000/- towards treatment of the complainant’s father for “Carbuncle Right LL”.  The medical panel of the opposite party on scrutinizing the medical records found that the patient was a known case of epilepsy for 30  years and Chronic Kidney Disease  known case of psychotic illness and on Olazepine and nitrazepam  which was not disclosed at the time of inception of policy. Hence the cashless authorization was denied and the same was communicated to the treating hospital and insured by letter dated 19.01.2015.The complaint may be dismissed.

3. POINTS FOR CONSIDERATION:

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

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO :1 

          The complainant had availed Senior citizen Red carpet Insurance  Policy No.P/700001/01/2012/007085 for the period from 26.12.2011 to 25.12.2012 for a sum of Rs.3,00,000/- covering his father with the opposite parties  and it was renewed periodically for the term commencing from 26.12.2014 till 25.12.2015. Insurance  premium was Rs.14,229/- per annum The complainant’s father  was admitted in Sri Ramachandra  Medical Centre for complaints of right leg ulcer and  as per the  complaint, the complainant spent  a total amount  of  Rs.64,490.91/-. The opposite parties  have approved Rs.20,000/- as a preliminary amount on 14.01.2015. Ex.A1 to Ex.A4 and  Ex.A11 to Ex.A13,  Ex.A15, Ex.A16, Ex.A18 and A22 are record of the hospital with respect to the Complainant’s treatment and Ex.A5,Ex.A14,Ex.A17 and Ex.A21 are the discharge summaries from the hospital. Insurance policies from 22.11.2012 to 10.11.2014 are Ex.A6 to Ex.A9. Insurance policies are not disputed. Preliminary amount for cashless treatment of Rs.20,000/- was permitted under Ex.A10 for the diagnosis namely “Carbuncle Right LL-Surgical management”.

             05.  On 19.01.2015 under Ex.A19 queries on pre-authorisation was sent to the hospital and after the receipt of communication with respect to the quries 2^nd opposite party had  denied the pre-authorisation for cashless treatment vide its letter in Ex.A20. Patient got discharged on 21.01.2015 and the discharge summary is Ex.A21. Then claim form was submitted by the complainant on 22.01.2015 for the paid amount of Rs.64,490.91 to the hospital vide Ex.A23 for reimbursement. On 24.01.2015 and on 27.01.2015 there was a corresponding letter sent by the 2^nd opposite party in Ex.A24 & Ex.A25 requesting the complainant to send the documents mentioned in the above said letters. First reminder under Ex.A26 was issued to the complainant on 12.02.2015 by the 2^nd opposite party for the earlier request. Ex.A27 is the letter of repudiation of claim by grievances department of opposite parties. Ex.A28 is the final reminder sent by the opposite parties again for submission of the requested records. Ex.A29 is the letter sent by the opposite parties   to the complainant by drawing the attention of the complainant  on the point of decision of cancellation of policy on grounds of non-disclosure of material fact or non-cooperation by the insured person. Ex.A30 is the letter sent by the opposite parties intimating the closure of the reimbursement claim and Ex.A31 is the cancellation of the policy Ex.A32  is cancellation of the policy. Ex.A33 is the legal notice from complainant, Ex.A34 is the reply from opposite parties.

                      06. Repudiation of claim by opposite parties  is based  on non-disclosure of the existing  previous disease at the inception of policy. The discharge summary of Sri Ramachandra Medical centre dated  08.08.2011 vide Ex.A5 which is submitted by the complainant at the request of the opposite parties reveals that insured patient has the past  known history of  Chronic Kidney Disease (for the past one year)  and known case of psychotic illness and an olazepine and nitrazepam. But at the time of inception of policy, i.e. 0n 26.12.2011 the complainant did not disclose Chronic Kidney Disease and psychotic illness in the proposal form in Ex.B2. Insurance Policy with terms and conditions are marked is Ex.B3.

Condition 7 of the policy reads as:

          “If there is any misrepresentation/nondisclosure of material facts whether by the insured person or any other acting on his behalf, the company is not liable to make any payment in respect of any claim”.

             07. On perusal of records it is noticed that the insured/complainant  had not disclosed the above said illness on the date of inception of   policy  and also  not furnished the bills for the hospitalization of the complainant’s father  discharge summary and investigation reports  even after the  repeated reminders/letters for processing the claim. Even though those documents are filed before this forum no proof  is shown by the complainant to have submitted the same before the opposite parties. No other disease is shown in the form by the complainant during the time of availing policy except diabetes. Hence the policy would have been issued in good faith by the opposite parties   based on the representation  and disclosure made by the complainant .

08. As per condition 13 of the policy  non-disclosure of material fact or non-cooperation by the insured person in submitting the essential records as and when called for by the Insurer resulted in cancellation of the policy.

 

Condition 13 of the policy reads as:

          “The company may cancel this policy on the grounds of non-disclosure of material fact or non-co-operation by the insured person by ending the insured 30 days notice by registered letter at the insured person’s last known address.”

As per the above stated condition the Insurance company by their letter dated 06.03.2015 under Ex.B6 sent a notice for cancellation and also refunded the premium on pro-rata basis for the remaining period of policy by way of DD 131470 dated  08.04.2015 for a sum of Rs 10,126/- to the complainant. Under these circumstances the complainant has no locus standi to file the complaint also. Therefore this forum is of the view that there is no deficiency on the part of opposite parties and point No1 is answered accordingly.

09. POINT NO.2:

As discussed in point no.1, there is no deficiency in service on the part of opposite parties  and  the complainant had undergone the mental agony and stress cannot be accepted.  The complainant is liable to be dismissed. Accordingly  it is dismissed. No costs.

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

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 10^th day of February 2020.

 

MEMBER – I                                                                PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 28.07.2011                   CT Scan Brain

Ex.A2 dated 28.07.2011                   Report form for Ultra sonogram

Ex.A3 dated 28.07.2011                   Blood Test Reports

Ex.A4 dated 01.08.2011          Report Form for non-invasive imaging and Haemodynamic Laboratory

Ex.A5 dated 08.08.2011          Discharge Summary from Sri Ramachandra Medical Centre

Ex.A6 dated 27.12.2011          Insurance Policy

Ex.A7 dated 22.11.2012          Insurance Policy Renewal

Ex.A8 dated 25.11.2013          Insurance Policy Renewal

Ex.A9 dated 10.11.2014          Insurance Policy Renewal

Ex.A10 dated 14.01.2015        Authorisation for Cashless Treatment sent by the opposite party to the Hospital

Ex.A11 dated 14.01.2015        Investigation Report of Transthoracic Echocardiogram

Ex.A12 dated 15.01.2015        In-Patient Bill

Ex.A13 dated 15.01.2015        Payment Receipts

Ex.A14 dated 16.01.2015        Discharge Summary from Sri Ramachandra Medical Centre

Ex.A15 dated 16.01.2015        Biochemistry Report

Ex.A16 dated 16.01.2015        Report from Clinical pathology & Haemotology

Ex.A17 dated 18.01.2015        Discharge summary from Sri Ramachandra Medical Centre

Ex.A18 dated 18.01.2015        Admission Records

Ex.A19 dated 19.01.2015        Query  on Pre Authorisation sent by the opposite party to the Sri Ramachandra Medical Centre

Ex.A20 dated 19.01.2015        Denial of Pre-authorisation for cashless Treatment

Ex.A21 dated 21.01.2015        Discharge Summary from Sri Ramachandra Medical Centre

Ex.A22 dated 21.01.2015        In-patient bill

Ex.A23 dated 22.01.2015        Claim Form Part-A filed by the petitioner

Ex.A24 dated 24.01.2015        Reimbursement of Medical Claim sent by the opposite party

Ex.A25 dated 27.01.2015        Reimbursement of Medical Claim sent by the opposite party

Ex.A26 dated 12.02.2015        Reminder sent by the opposite party

Ex.A27 dated 24.02.2015        Letter sent by the opposite party

Ex.A28 dated 28.02.2015        Reminder sent by the opposite party

Ex.A29 dated 06.0.2015          Letter sent by the opposite party

Ex.A30 dated 25.03.2015        Letter sent by the opposite party

Ex.A31 dated 06.04.2015        Policy Endorsement Schedule

Ex.A32 dated 08.04.2015        Letter sent by the opposite party

Ex.A33 dated 26.06.2015        Legal Notice sent on behalf of opposite party

Ex.A34 dated 08.07.2015        Reply Notice sent by opposite party

 

LIST OF DOCUMENTS FILED BY THE   OPPOSITE PARTIES:

 

Ex.B1 dated 08.08.2011          Discharge Summary of complainant’s father at Sri-Ramachandra Medical Centre

 

Ex.B2 dated 23.12.2011          Proposal Form along with additional questionnaire

 

Ex.B3 dated NIL                      Insurance Policy with terms and conditions

 

Ex.B4 dated 24.02.2015          Opposite parties repudiating the claim of complainant

Ex.B5 dated 25.03.2015          Letter from opposite parties closing the 2^nd claim of the complainant

Ex.B6 dated 08.04.2015          Letter from opposite parties cancelling the policy of the complainant

 

 

 

MEMBER – I                                                               PRESIDENT