Tamil Nadu

North Chennai

CC/74/2017

Mr.K.Radhakrishnan - Complainant(s)

Versus

M/s.Star Health and Allied Insurance company limited Represented by its Managing Director - Opp.Party(s)

S.Shalni

13 Feb 2019

ORDER

 

                                                            Complaint presented on:  07.06.2017

                                                                Order pronounced on:  13.02.2019

 

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

 

WEDNESDAY  THE 13^th   DAY OF FEBRUARY 2019

 

C.C.NO.74/2017

 

Mr.K.Radhakrishnan,

No.1B, 8^th Cross Street,

New Colony, Chromepet,

Chennai – 600 044.

                                                                                               …..Complainant

 

 ..Vs..

M/s.Star Health and Allied Insurance Company Limited,

Represented by its Managing Director,

No.1, New Tank Street,

Valluvar Kottam High Road,

Nungambakkam, Chennai – 600 034.

.....Opposite Party

Date of complaint                                 : 23.06.2017

Counsel for Complainant                      : M/s.S.Shalni, V.Subramaniyam,

                                                                    Uma Subramaniyam

 

Counsel for  Opposite Party                     : N.Vijayaraghavan

 

 

 

 

 

 

O R D E R

 

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

          This complaint is filed by the complainant  to direct the opposite party to pay a sum of 1,08,291/-entire medical expenses with interest @24% and  also  to pay a sum of Rs. 5,00,000/- towards the damages for breach of terms of the policy and also to pay a sum of Rs.1,00,000/- towards compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant is a businessman and that he is sole breadwinner of his family. The opposite party is a Insurance company providing services of health insurance. The complainant originally took the first Mediclassic Insurance Policy bearing policy No.P/121317/01/2015/001610 with the opposite party in the year 2015 for a sum of Rs.2,00,000/- from 18.03.2015 to 17.03.2016. The complainant further states that he has accordingly issued a cheque dated 16.03.2015 drawn on Indian Bank for a sum of Rs.7,070/- towards payment of premium of the opposite party. The complainant renewed the same policy for the second year by making payment of the premium amount of Rs.6,756/- on 25/03/2016 by way of cheque bearing No.8880200 drawn on Indian Bank in favour of the opposite party and he was issued the policy bearing No.P/121317/01/2016/001571 for the period of second year from 30.03.2016 to 29.03.2017. The complainant once again renewed the same policy for the third year by making payment of the premium amount of Rs.7,235/- on 05.04.2017 by way of cheque bearing No.381145 drawn on Indian Bank in favour of the opposite party and he was issued year the policy bearing No.P/121317/01/2017/001810 for the period of third year from 11.04.2017 to 10.04.2018. Then the complainant visited MIOT International Hospital on 10.04.2017 for the complaint of joint pain in his left knee. The doctor after due examination advised him to undergo a surgery for the purpose of “Left knee arthroscopic loose body removal” and prescribed certain tests before the said surgery. Accordingly he underwent all the preoperative investigations and consequently incurred pre-hospitalization expenses to tune of Rs.8011/-. He was informed that the surgery would cost Rs.95,000/- and therefore on being admitted to the hospital on 18.04.2017 he raised a claim for pre-authorization for cashless treatment. The opposite party had repudiated his valid and genuine claim for baseless and unfounded reasons. He underwent Left Knee Arthroscopic Removal of Loose Bodies and Chondroplasty of Retropatellar Chondral Surface on 19.04.2017. He is the breadwinner of his family and his family members suffered with mental agony because they had not made any prior arrangements to mobilize funds for the hospital payment and faced with health crisis. The complainant had incurred a total expenditure of Rs.1,08,291/-. He had renewed the policy strictly in accordance with the clause 8 of the policy document in the genuine belief that he would have insurance coverage at all times. The complainant states that he had paid the premium as early as 05.04.2017 and therefore according to clause 8 of the policy the actual period of coverage began under the renewed policy from 05.04.2017 which is the date of payment of premium. He had paid the premium amount by way of cheque dated 05.04.2017 and the opposite party had issued the policy only after a delay of 6 days on 11.04.2017. The opposite party always considers only the date of the cheque issued towards payment of premium as the date of payment of premium. Therefore the complainant states that the period of actual cover of the renewed policy according to clause 8 has commenced on 05.04.2017 itself. The complainant states opposite party has made a mockery of clause 8 of the policy document by repudiating his valid claim and the said repudiation is a deliberate act by the opposite party to escape its liability to reimburse the medical expenses covered under the policy. The complainant had caused the legal notice dated 10.05.2017 to be issued to the opposite party. The opposite party had received the legal notice as early as 12.05.2017 and opposite party has neither redressed his grievance by complying with the notice nor has the opposite party replied to the legal notice. In such circumstances he is left with no other efficacious remedy other than to file the present complaint before this Hon’ble Forum.

2. WRITTEN VERSION OF THE  OPPOSITE PARTY IN BRIEF:

          The complainant had availed Mediclassic Individual Insurance Policy with this opposite party for a sum insured of Rs.2,00,000/- under the following policy No.’s

P/121317/01/2015/001610 from 18/03/2015 to 17.03.2016

P/121317/01/2016/001571 from 30.03.2016 to 29.03.2017

P/121317/01/2017/001810 from 11/04/2017 to 10/04/2018 (Which is after a break of 13 days during the grace period)

It is specifically stated that the complainant has renewed the policy for third year after a break of 13 days during the grace period. The policy renewed is contractual in nature and claims arising under the policy is subject to the terms and conditions contained therein. A claim was reported by complainant during the third year of policy for hospitalization and expenses incurred for his treatment at MIOT Hospital on 18.04.2017 diagnosed as left knee pain. The complainant raised a pre-authorization request to avail cashless facility. On the perusal of the claim documents submitted by the treating hospital, the following were observed. As per Dr.Billy Paul Wilson Consulation slip dated 10.04.2017, the insured has consulted for his complaints in Left Knee which falls during the break period. The previous policy of the complainant expired on 29.03.2017 and has been renewed after a break of 13 days from the date of expiry of the policy and the complainant was diagnosed during break-in period which is on 10.04.2017. The opposite party submits that as per the policy condition No.8, claim is not covered for any treatment undergone during the break period. The complainant has submitted Good health declaration on 10.04.2017 suppressing the material facts i.e., the complainant/Insured has consulted Dr.Billy Paul Wilson on 10.04.2017 with the complaints in Left knee but the same was not disclosed at the time of renewal of policy. Pre-authorization was rejected and the same was informed to the complainant/insured vide letter dated 18.04.2017. The cheque dated 05.04.2017 towards premium along with Good Health declaration dated 10.04.2017 was received by the insurer only on 11.04.2017 and the policy was renewed on the same day (i.e.11/04/2017). Thus it is specifically stated that the insurer has not committed any delay in renewing the policy. The complainant aggrieved against the rejection of claim has issued legal notice to the opposite party on 10.05.2017 (received on 16.05.2017) and the same were duly replied by the insurer on 05.06.2017. The complainant herein has wantonly omitted to state about the consultation with Dr.Billy Paul Wilson on 10.04.2017 with his complainants in left knee in his good health declaration which was submitted to the insurer. The conduct of the complainant will reveal that the complainant has not acted in good faith and misrepresented the material facts for the purpose of compensation under the policy which is not otherwise payable. The complaint regarding nature of hospitalization and expenses incurred to an extent of Rs.8,011/- and Rs.95,000/- is specifically denied and complainant is put to strict proof of the same through proper documentary evidence. The allegation that the complainant was the breadwinner of his family and his family suffered for mobilizing funds for complainant’s treatment are mere exaggerations for the purpose of the complaint and same is denied that  complainant has incurred a total sum of Rs.1,08,291/- towards medical expenses and the same is covered under the policy is false and denied. The repudiation is subject to policy terms and conditions. The averment that the complainant has paid premium as early as 05.04.2017 is denied. The complainant though has issued cheque dated 05.04.2017 towards premium, he has submitted the cheque along with Good Health declaration only on 10.04.2017 and the same was received by the isurer only on 11.04.2017. The policy was renewed on the same day (i.e. 11.04.2017). Hence the payment and policy was renewed only on 11.04.2017 and not on 05.04.2017 as alleged by the complainant. 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. The allegation of the complaint that insurer has not replied to legal notice is false. The opposite party received the legal notice on 16.05.2017 and the same was duly replied by the insurer on 05.06.2017.The complaint is to be dismissed.

3. The complainant and the opposite party had come forward with their respective proof affidavit and documents. Ex.A.1 to A.12 were marked on the side of the complainant and the opposite party proof affidavit and documents Ex.B1 to Ex.B7 were marked on the side opposite party.

          4. The written arguments of the complainant and the opposite party were filed and the oral arguments of the both were heard

 

 

5. POINTS FOR CONSIDERATION:

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

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

6. POINT NO :1 

The Complainant had taken a Mediclassic Insurance policy  with the opposite party   in the year 2015 for a sum of Rs.2,00,000/-. The complainant issued Indian bank cheque dated 16.03.2015 for Rs.7,070/- towards premium  and the coverage period was from 18.03.2015 to 17.03.2016 and the policy document is Ex.A1 and it was renewed by the complainant  for the second year  by making payment of premium amount of Rs.6,756/- by way of Indian bank cheque dated  25.03.2016 and the complainant was issued the policy covering the period from 30.03.2016 to 29.03.2017 which is marked as Ex.A2. Again there  was a renewal of  the same policy for the third year by making payment of Rs.7,235/- by way of Indian bank cheque  dated 05.04.2017 and the acknowledgement is Ex.A3 subject to realization of the cheque it was received, but the date of receipt do not find place in Ex.A3. The policy for the third year was issued on 11.04.2017 vides Ex.A5. The complainant  visited  MIOT International Hospital  for the complaint of joint pain in his left knee on 10.04.2017. It is said by the complainant that  he was advised to undergo surgery namely “Left Knee Arthroscopic Loose Body Removal”  and hence pre-operative tests were done and incurred expenses as per Ex.A7.  The complainant was admitted in the hospital on 18.04.2017 and the claim was raised for pre-authorisation cashless treatment and it was repudiated by the opposite party   for the reason that it was during the break period.  The complainant underwent the surgery regardless of the repudiation and according to the complainant since no prior arrangements for money was made. Hence his family suffered mental agony. Hospital records are filed as Ex.A7,Ex.A9 and Ex.A10. The Complainant’s pass book entries copy is Ex.A6. Letter of rejection by opposite party is Ex.A8. Legal notice was issued by the complainant to opposite party and proof of delivery is Ex.A11 and Ex.A12.

 7. The claim was reported by the complainant during the third year of policy for hospitalization at MIOT Hospital on 18.04.2017. The renewal of policy of the complainant is admitted by the opposite party but according to opposite party, it was after a break period of 13 days of its original renewal date. Proposal from and Insurance policy with terms and conditions are marked as Ex.B1 & Ex.B2. Good Health Declaration letter dated 10.04.2017 was submitted to opposite party vide Ex.B3. Pre-authorisation Form dated 18.04.2017 is Ex.B4. Complainant had consulted one Dr. Billy Paul Wilson of MIOT Hospital, and the slip is marked as Ex.B5. Cashless rejection letter is Ex.B6. Notice sent by the complainant in Ex.A11 was replied in Ex.B7.

8. The opposite party would contend that the complainant has suppressed the material fact i.e. the complainant’s consultation with the Dr. Billy Paul Wilson which happened on 10.04.2017 and this fact was not disclosed at the time of renewal of policy in the grace period.  Even though the cheque towards premium is dated to 05.04.2017, it was sent along with Good Health declaration form dated 10.04.2017  and  received by  the opposite party  only on 11.04.2017 and was renewed on the same day, therefore insurer has not committed any delay  in renewing the policy  and no negligent on their part and also the same was duly replied to the complainant  and also condition no.7 of the terms and conditions have not been followed by the complainant, which all resulted in rejecting the claim.

9. Under Ex.A3 Cheque dated 05.04.2017 was received by the authorized person, but the date of receipt is not mentioned in Ex.A3.  Good Health declaration letter is dated as 10.04.2017 vide Ex.B3. The complainant had stated in the complaint that opposite party  would always consider only the date of cheque issued towards the payment of premium and hence the actual cover of the renewed policy according to clause 8  has commenced on 05.04.2017 itself  but for the previous years, earlier  two payments for the year 2015 to 2016  & 2016 to 2017, the date of issue of cheque varies from the date of premium  and also to condition No.8, sets out, when the policy is renewed  within 30 days of its grace period, the continuity benefit is allowed.    The opposite party  contends that  the complainant though issued a cheque dated  05.04.2017 towards premium, he has submitted the cheque along with Good Health declaration form and the same was received by the insurer only on 11.04.2017 and further contends that the complainant admittedly approached the Dr. Billy Paul Wilson on 10.04.2017 for his ailment and on that day itself  it was decided to undergo surgery  following which the complainant was admitted in the hospital and having consulted the doctor and after fixing  for Surgery, the complainant has given  Good Health  declaration letter suppressing  the fact of his consultation with the Dr. Billy Paul Wilson. The reply to the legal notice issued by the complainant is also suppressed in the complaint. On perusal of Ex.A3 , it is noticed that there is no date of receipt is mentioned and hence it ought to have submitted along with Good Health declaration letter dated 10.04.2017 vide Ex.B3 and hence the opposite party’s version regarding the above said facts  has to be accepted as true. Ex.B3 letter which is addressed by the complainant to opposite party dated 10.04.2017 reveals the admission of the policy expiry date as 29.03.2017, and he has accepted regarding no liability attached to the insurer in respect of any accident or diseases contacted by the insured persons during the break period.

10. Condition No .7 in Ex.B2 is pointed out by opposite party and it reads as follows;-

“ The company shall not be liable to make payment under the policy in respect of any claim is in any manner fraudulent or supported by any  fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf”.

 The Insured/complainant is expected to declare  in the proposal  form/ good health declaration about the details of ailments/ sickness in good faith and past medical history if any so that it will help the insurer to evaluate the  material facts  and to decide whether to accept  the proposal or not and the premium rate. In this case the complainant has given the good health declaration on 10.04.2017  revealing his health as completely  alright even after his  consultation  with  doctor  and hence the policy is renewed without disclosing the material fact  to the Insurer and the claim is also lodged during the break period  i.e. between 29.03.2017 to 11.04.2017.

            11. The policy was issued on the date of the receipt of the cheque and also good Health declaration letter i.e. on 11.04.2017 is considered as true in view of the documents in Ex.B3 and its contents and there is no proof filed by the complainant that the cheque dated 05.04.2017 was received by the opposite party on that day itself or earlier to 10.04.2017, hence it is to be accepted that there is no delay on the part of opposite party as alleged by the complainant. There is a breach of policy and terms and conditions on the part of the complainant. Paragraph 3 of Clause 8 of the policy is quoted by the complainant and it reads:

 

 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 benefit 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.

 When the clause is read in entirety, it reveals that the continuity of benefit is available during the grace period is subject to the condition that no claim will be payable during break period. Therefore, the said benefit is also not available to the complainant. The complainant having availed the policy is bound by its terms and conditions. The repudiation by the opposite party is based on the policy terms only and once it is based on terms and conditions there cannot be any unfair trade practice by opposite party.

             12. Since the repudiation of claim by the insurer  based on the ground that the claim is received during the break period and non- disclosure of material fact and misrepresentation,  is in accordance with policy terms and opposite party / Insurer. The opposite party cannot go beyond the contractual terms therefore the opposite party cannot be held liable for deficiency in service. In conclusion we are of the opinion that there is no deficiency in service and unfair trade practice on the part of the opposite party, therefore point No1 is answered against the complainant.

13. POINT NO:2

             In view of the findings in point No1, the complainant is not entitled to any relief as prayed for and is also not entitled for any reimbursement of money for the medical expenses and any compensation. Therefore the complaint fails and to be dismissed and this point is also answered against the complainant.

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

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 13^th  day of February 2019.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 18.03.2015         Medi classic insurance policy document bearing policy number P/121317/01/2015/001610

Ex.A2 dated 30.03.2016         Medi classic insurance policy document bearing policy number P/121317/01/2015/001517

Ex.A3 dated 05.04.3027         Acknowledgement Receipt issued by the authorized representative of the opposite party

Ex.A4 dated 10.04.2017         Hospital records and medical bills of the complainant

Ex.A5 dated 11.04.2017         Medi classic insurance policy document bearing policy number P/121317/01/2015/001810

Ex.A6 dated 13.04.2017         Bank pass book entries pertaining to the complainant’s account maintained with Indian Bank

Ex.A7 dated 13.04.2017         Medical bills of the complainant pertaining to preoperative tests

Ex.A8 dated 18.04.2017         Letter of rejection of pre-authorization for cashless treatment given by the opposite party

Ex.A9 dated 18.04.2017         Hospital bills for surgery

Ex.A10 dated 20.04.2017       Discharge summary and hospital bill issued by MIOT international hospital

Ex.A11 dated 10.05.2017       Legal Notice issued by the complainant

Ex.A12 dated 12.05.2017       Online proof of delivery of notice to the opposite party        

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY:

 

Ex.B1 dated NIL                     Proposal Form

 

Ex.B2 dated NIL                     Insurance Policy with terms and conditions

 

Ex.B3 dated 10.04.2017                   Good Health Declaration letter dated 10.04.2017

 

Ex.B4 dated 18.04.2017                   Pre-Authorization Forum

 

Ex.B5 dated 10.04.2017         Complainant’s Consultations slip with Dr.Billy Paul Wilson, Miot Hospital      

 

Ex.B6 dated 18.04.2017         Cashless Rejection letter

 

Ex.B7 dated 05.06.2017         Reply to the legal notice

                                                                  

 

                                               

MEMBER – I                                                               PRESIDENT