Tamil Nadu

North Chennai

CC/146/2015

V.Kannan - Complainant(s)

Versus

N.Dillip Kumar - Opp.Party(s)

party in person

11 Apr 2018

ORDER

                                                            Complaint presented on:  29.09.2015

                                                                Order pronounced on:  11.04.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

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

 

        PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

WEDNESDAY THE 11^th   DAY OF APRIL 2018

 

C.C.NO.146/2015

 

 

V.Kannan,

110/70. V.V.Koil Street,

Choolai,

Chennai – 600 112.

                                                                                    ….. Complainant

 

..Vs..

1. N.Dilip Kumar,

Maxbupa Insurance Agent,

No.9, N.No.17, 1^st Floor,

Perumal 2^nd Street, Purasaiwalkam,

Vepery, Chennai – 600 084.

 

2. The Branch Manager,

Maxbupa  Health Insurance Co.Ltd.,

Ampa Manor, 2^nd Floor,

107/2, Nelson Manickam Road,

Aminjikarai, Chennai – 600 029.

 

3. The Manager,

Maxbupa Health Insurance Co.Ltd.,

B-1/1-2, Mohan Co. Operative Industrial Estate,

Mathur Road, New Delhi – 110 044.

 

.....Opposite Parties

Date of complaint                                 : 12.10.2015

Counsel for Complainant                       : Party in Person

Counsel for 1^st & 2^nd Opposite Parties     : Ex-parte (on 13.11.2015)

 

Counsel for 3^rd opposite party               : M.B.Gopalan Associates,

                                                                   N.Vijayaraghavan, M.B.Raghavan

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant to direct the opposite parties to pay the claim amount of Rs.1,04,786/- with 24% interest and also to pay compensation for deficiency in service and mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant was having policy with Star Health Insurance for the period 2007 to 2012 and thereafter he migrated to the opposite parties availing Family Floater Policy through portability on 23.09.2012 and continuously renewed the policy with the opposite parties for three years from 2012 to 2015. For the year 2014 to 2015 he paid annual premium of Rs.12,414/- to the opposite parties.

2. The complainant wife K.Lalitha was hospitalized on 06.10.2014 and sought pre-authorization. The opposite parties sanctioned a sum of Rs.50,000/- as pre-authorization. On 17.10.2014 she under gone surgery and on 18.10.2014 and final bill was sent for approval. The final bill was rejected and Rs.50,000/- approval was also cancelled. On 29.12.2014 the claim was rejected on the ground of non-disclosure of pre-existing deseases.

3. The said Lalitha was already undergone treatment in Apollo Hospital for urinary infection before porting and the complainant also claimed the said expenses that time with Star Health Insurance. The opposite parties cancelled the pre-authorization and also rejected the claim of the complainant is deficiency on their part.  The complainant is continuously having the policy from 2007 to till date. Hence the complainant filed this complaint to direct the opposite parties to pay the claim amount of Rs.1,04,786/- with 24% interest and also to pay compensation for deficiency in service and mental agony with cost of the complaint.    

4. WRITTEN VERSION OF THE 3^rd  OPPOSITE PARTY IN BRIEF:

The complainant is guilty of suppression of material fact that she had treatment on earlier occasion. She did not disclose medical history in clause 6 & 7 of the proposal form dated 25.08.2012. The sum insured policy was Rs.3,00,000/- for the period 23.09.2012 to 22.09.2013. The said policy was renewed subsequently for the period till 22.09.2015.

5. The complainant was hospitalized on 16.10.2014 and was discharged on 18.10.2014 and this opposite party was intimated on 14.11.2014 with a delay of one month. This opposite party admits that the sum of Rs.50,000/- approved  was cancelled vide letter dated 18.09.2014, since the patient was suffering with pre-existing disease. At the time inception of the policy, the complainant failed to disclose the medical treatment which she had in the year 2012 at the Apollo First Med Hospital and filed claim with Star Health Insurance. The other averments made in the complaint are denied. This opposite party has not committed any deficiency in service and prays to dismiss the complaint with costs.

6. 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?

7. POINT NO :1 

          The admitted facts are that the  complainant was having Ex.A5 policies  with Star Health Insurance for the period 2007 to 2012 and thereafter he migrated to the opposite parties  availing Family Floater Policy through portability on 23.09.2012 and Ex.A4 is the policy issued by the opposite parties for the period 23.09.2012 to 22.09.2013 and  renewed Ex.A6  policy  for the  period 23.09.2013 to 22.09.2015 with the  opposite parties and he paid an annual premium of Rs.12,414/- to the opposite parties and the complainant’s wife K.Lalitha was hospitalized on 06.10.2014 and sought pre-authorization and the opposite parties approved a sum of Rs.50,000/- and  on 17.10.2014 she under gone surgery and on 18.10.2014 final bill  was sent for approval and the final approval was rejected and Rs.50,000/- pre-authorization  approval was also cancelled under Ex.B4 and the claim was rejected in Ex.B8 letter dated 15.06.2015 by the opposite parties  on the ground of non disclosure of  pre-existing  diseases.

          8. The complainant would contend that he was having the policy from the year 2007 onwards till 2012 and thereafter due to portability was issued with Family Floater Policy for the year 2012-2013 and subsequently it was renewed upto 22.09.2015 and hence the complainant is having the policy continuously from 2007 to 2015 and further the agent only filled the proposal form and since he is continuously having the policy for nearly 8 years and the claim was rejected non- disclosure of pre-existing decease as per clause 4(a) of the policy is not sustainable and prays to allow the complaint.

          9. The opposite party would contend that the complainant was specifically asked to provide medical history in the proposal form and he has not intentionally disclosed the material facts and there by committed breach of policy conditions and further the complainant submitted a letter dated 24.08.2012 to the insurer that at the time of availing policy has stated that ‘No claim’ was preferred which is blatant lie and therefore the complainant has not approached this forum with clean hands and prays to dismiss the complaint with costs.

          10. According to the complainant he availed the policy with the opposite party through portability for better service. The complainant submitted Ex.B7 portability form to the opposite parties to avail policy from them from 23.09.2012 and accordingly Ex.A4 policy issued by the opposite parties. In Ex.B7 the complainant clearly stated the reasons for portability for better service. The sum proposed insured increased to Rs.3,00,000/- with that of Rs.2,00,000/- from the previous insurer. Further the particulars of previous insurance policies from 2007 onwards filled in the said form with other required particulars. Therefore the opposite parties accepting the continuance of policies issued by the previous insurer, they have issued the policy under portability.

          11. The opposite parties made clear in their written argument that the waiting period of 48 months would not be applicable to the case of the complainant, since he had been covered under other health insurance policies from September 2007 onwards for nearly 5 years. When the waiting period of 48 months is not applicable to the complainant in respect of the pre-existing condition, the contention of the opposite parties that the complainant suppressed the pre-existing decease and the claim made with the previous insurer cannot hold good in view of that waiting period of 48 months was expired before claim made by the complainant to the opposite parties.

12. The complainant would contend that the agent of the opposite parties only filled the proposal form and he was not aware anything excepting signing the form and handed over the certain documents to him. In view of the waiting period already over the non-disclosure of the previous treatment had by the complainant wife and claim made for medical expenses, becomes immaterial. Further the very object of moving through portability, the insured would be entitled to all benefits what she had earlier. The 3^rd opposite party pleaded in the written argument that the complainant in his letter dated 24.08.2012 he has informed that ‘No claim’ was preferred with the previous insurer is a blatant lie. The said letter dated 24.08.2012 is marked as Ex.B7, which is nothing but portability form. Nowhere in that form had he stated that ‘No claim’ was preferred by him and hence such a contention is rejected. The object of moving through portability for better service and for more benefits and the same is not available with new insurer the complainant could have continued with his previous insurer itself. Therefore considering the facts and circumstances of the case, the non-disclosure of pre-existing decease is not applicable to this case and hence the opposite parties repudiated the claim as per clause 4(a) under Ex.B8 is not sustainable and hence we hold that the opposite parties 1 to 3 have committed deficiency in service in rejecting the claim of the complainant.

13. POINT NO:2

          The complainant made a claim of Rs.1,04,786/- towards medical expenses of his wife K.Lalitha. Since we held above that the opposite parties 1 to 3 have committed deficiency in service by rejecting the claim made by the complainant, they can be directed to pay the said claim amount of Rs.1,04,786/- to the complainant. Further due to the deficiency in service of the opposite parties, the complainant suffered with mental agony is accepted and for the same, it would be appropriate to direct the opposite parties to pay a sum of Rs.50,000/- towards compensation, besides a sum of Rs.5,000/- towards litigation expenses. The complaint in respect of the other reliefs is liable to be dismissed.

          In the result the Complaint is partly allowed. The Opposite Parties 1 to 3 jointly or severally are ordered to pay a sum of Rs.1,04,786/- (Rupees one lakh four thousand seven hundred and eighty six only) towards the medical expenses to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for deficiency in service and mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. The complaint in respect of the other reliefs is dismissed.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said medical expenses and compensation amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 11^th day of April 2018.

 

MEMBER – I                                                                PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 18.10.2014                   Authorization cancellation

Ex.A2 dated 14.11.2014                   Applied for Hospitalization & Prehospitalization

Ex.A3 dated 29.12.2014                   Rejection of claim

Ex.A4 dated 23.09.2012                   Maxbupa Policy through portability

Ex.A5 dated 2007-2012          Policy documents before porting

Ex.A6 dated 2012-2015          Policy documents after porting

Ex.A7 dated 01.01.2015                   Reconsideration request

Ex.A8 dated 20.01.2012                   Authorization for Rs.20,000/-

Ex.A9 dated 07.03.2012                   Cheque for Rs.12,293/-

Ex.A10 dated 27.03.2012                 Cheque for Rs.2,610/-

Ex.A11 dated 14.01.2015                 Rejection of reconsideration request

Ex.A12 dated 09.02.2015                 Complaint Reg.in IRDA (02.15.008662)

Ex.A13 dated 13.02.2015                 Rejection of claim by grievance redressal

Ex.A14 dated 19.02.2015                 complaint e-mailed to G.R.O Maxbupa

Ex.A15 dated 19.02.2015                 Undelivered e-mail

Ex.A16 dated 19.02.2015                 E-mail forwarded to IRDA

Ex.A17 dated 27.02.2015                 Rejection of claim by Grievance redressal

Ex.A18 dated 07.07.2015                 Copy of hearing minutes given by ombudsman of

                                                    Insurance

 

Ex.A19 dated 23.07.2015                 Copy of award passed by ombudsman of insurance

Ex.A20 dated 05.08.2015                 Applied for post hospitalization claim

Ex.A21 dated 01.09.2015                 Copy of notice & proof of delivery                       

LIST OF DOCUMENTS FILED BY THE 3^rd OPPOSITE PARTY :

 

Ex.B1 dated 30.08.2012                   Policy booklet for policy No.30127417201200

 

Ex.B2 dated 19.09.2014                   Policy booklet for policy No.30127417201402

 

Ex.B3 dated NIL                      Claim Form submitted by complainant

Ex.B4 dated 18.10.2014                   Pre-authorization cancellation letter

 

Ex.B5 dated NIL                      Discharge summary of the complainant’s wife

                                                    (16.10.2014 to 18.10.2014) and Discharge

                                                    Summary of complainant’s wife for the period

                                                    17.01.2012 to 20.01.2012)

 

Ex.B6 dated NIL                      Investigation Report

 

Ex.B7 dated 24.08.2012                   Portability Documents

 

Ex.B8 dated 15.06.2015                   Claim Denial Letter

 

 

 

MEMBER – I                                                               PRESIDENT