Tamil Nadu

North Chennai

104/2014

R.Mathiivanan,S/o.Ramalinam - Complainant(s)

Versus

Rep by its Managing Director, Star Health and Allied Insurance Co Ltd, - Opp.Party(s)

Mr.Karunakaran

01 Aug 2016

ORDER

 

                                                            Complaint presented on:  28.05.2014

                                                                Order pronounced on:  28.09.2016

 

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

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

WEDNESDAY THE 28^th  DAY OF SEPEMBER 2016

 

C.C.NO.104/2014

 

 

R.Mathivanan,

S/o.Ramalingam,

12/4, Kasipuram ‘B’ Block,

2^nd Street, Royapuram,

Chennai 600 013.

                                                                                               ..... Complainant

 

..Vs..

	Star Health and Allied Insurance Co.Ltd., Represented by its Managing Director, No.1, New Tank Street, Valluvarkottam High Road,   Chennai 600034.
	.....Opposite Party

Date of complaint                                  04.06.2014

Counsel for Complainant                      : M/s.R.Karunakaran

Counsel for opposite party                       : N.Vijayaraghavan

 

 

 

 

 

O R D E R

 

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

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

1.THE COMPLAINT IS IN BRIEF:

          The Complainant has taken Family Health Optima Insurance Policy from the Opposite Party in the year 2009 and it has been renewed periodically. The last renewal of policy was on 11.10.2012 vide policy No.P/111114/01/2013/004251 valid from 12.10.2012 to 11.10.2013. The Complainant under went right pneumonetomy for lung abscess at Ezhil Hospital. Tondiarpet, Chennai – 600 081. The duration of the hospitalization i.e., inpatient was for a period of one month from 10.09.2012 to 10.10.2012. The Complainant spent more than Rs.2,50,000/-  for the treatment and medicines. The Opposite Party repudiated the claim on the ground that Kidney disease is pre-existing prior to inception of the policy and the Complainant has not disclosed the same in the proposal form and further the reimbursement claimed in June 2010 for the medical expenses already repudiated by the Opposite Party on 29.08.2010 for the same reason.  The Complainant claimed reimbursement for the treatment of lung abscess. The Opposite Party has unilaterally and arbitrarily cancelled the remaining period of the policy and sent a demand draft for Rs.7,012/- to the Complainant which poured oil on the fire. The Complainant sent a legal notice dated 03.10.2013 to the Opposite Party calling upon the Opposite Party to reconsider the claim of reimbursement and revoke the cancellation of policy. The Complainant suffered mental agony due to the Deficiency in Service of the Opposite Party. Hence the Complainant filed this Complaint for reimbursement of the medical expenses of Rs.2,43,761/- and compensation for mental agony with litigation expenses.

2. WRITTEN VERSION OF THE OPPOSITE PARTY IN BRIEF:

          The Complainant has availed a Family Health Optima Insurance Policy No.P/111114/01/2012/0049 for the period from 12.10.2011 to 11.10.2012 with the Opposite Party covering the Complainant herein, his wife and two children. The Complainant made a claim for reimbursement of hospitalization expenses for his treatment for Right Lower lung abscess, diabetes mellitus, Coronary artery disease (CAD), old anterospetal infraction, chronic kidney disease (CKD) – post Renal Transplant at Ezhil Hospital on 25.09.2012. The Opposite Party perused the claim records relating to the Complainant’s claim for reimbursement. The Complainant is not entitled for the claim for non disclosure of pre-existing disease as per exclusion clause 1 & 7 policy   as the Complainant has not disclosed material facts about the pre-existing disease,  the Opposite Party forced to cancel the policy issued to him and a premium of Rs.7,012/- was refunded to him by way of demand draft and that was acknowledged by the Complainant. The policy was issued in good faith to the Complainant on the basis of disclosure made by him in his proposal form. There is no cause of action for the Complaint and the Complaint is not maintainable for non disclosure of pre-existing disease and therefore prays to dismiss the Complaint.

3. 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 relief?

 

 

4. POINT NO :1

          It is an admitted fact that the Complainant availed a Family Health Optima Insurance Policy for the period 12.10.2011 to 11.10.2012 under Ex.B1 policy with terms and conditions and the Complainant took treatment as inpatient for the period of one month from 10.09.2012 to 10.10.2012 for lung abscess at Ezhil Hospital Tondiarpet and during that period Ex.A1 to A13 prescriptions, investigation reports and cash bill receipts issued by the Opposite Party and the Complainant made  Ex.B2 medical claim for  reimbursement of the amount spent by him and the said claim was repudiated by the Opposite Party under Ex.B6 and hence the Complainant filed this Complaint for claiming reimbursement of the amount spent by him.

          5. According to the Complainant he spent more than Rs.2,50,000/- for treatment and medicines and during with such treatment period the insurance is in force and further the Dr. of Ezhil Hospital issued Ex.A13 that lung abscess can  occur in people without pre-existing condition such as CKD  and hence the patient is entitled for insurance cover.

          6. The Opposite Party contended that the Complainant suppressed the pre-existing disease which has been revealed from his own documents and therefore  he is not entitled for maintain the claim and further his early claim in the year  2010 was rejected and therefore he prays to dismiss the Complaint.

          7. The present claim has been made for treatment of lung abscess disease. Ex.B3 is the discharge summary issued to the Complainant and the disease diagnosed is “Right Lower Lobe Lung Abscess /Diabetes Mellitus” and in Ex.B4 discharge summary it is mentioned as renal transplant done last year. Ex.B5 dated 06.10.2012 is the medical certificate  issued to the Complainant that is suffering with Hypertension since  10 years and diagnosed chronic kidney disease  on 20.01.2010 and under gone with medical management and on 28.02.2010  Arterio  Venous Fistula procedure  was done  and continued with medicines. Ex.B5 medical certificate clearly reveals that the Complainant suffering with chronic kidney disease. Admittedly the Complainant did not disclose this fact in his proposal form at the inception of policy. However the Complainant further contends that his first claim was repudiated on 29.08.2010 and even after such repudiation the Opposite Party renewed the policy and therefore having paid premium he is entitled for the present claim. The Complainant filed documents dated 10.09.2012 to 28.01.2013. He had not filed the first repudiation was made on 28.09.2008 to accept that he made the 1^st claim.

          8. Admittedly the present claim is within the period insurance coverage. Ex.B5 medical certificate of the Complainant and other discharge summary disclosure that he is suffering with chronic kidney disease deducted on 20.01.2010 certainly he should have been suffered with such a chronic kidney previously few years i.e on the date of inception of policy he is suffering with chronic kidney disease is accepted.

          9. The Complainant made claim only for lung abscess and not for any chronic kidney disease . The Opposite Party specifically chronic kidney disease should have been disclosed to the Opposite Party, either he should have collected higher premium or even refused to renew the policy because non disclosure of such chronic kidney disease.  In Ex.B1 terms and conditions of the policy as per execution clause 1 to 7 if pre-existing disease has not been disclosed the insured is not  entitled for claim. The Ex.B6 & Ex.B7 repudiation was done by the Opposite Party on the ground of non disclosure of pre-existing disease and therefore in view of above discussion, the repudiation of claim done by the Opposite Party is sustainable and therefore the Opposite Party has not committed any Deficiency in Service.

 10. POINT NO: 2

          Since the opposite party has not committed any Deficiency in Service, the Complainant is not entitled for any relief in this Complaint and the Complaint is liable to be dismissed without cost.

          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 28^th  day of  September  2016.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 10.09.2012	Requisition Form of Ezhil Hospital
Ex.A2 dated 10.09.2012	C.T.Chest Report
Ex.A3 dated 10.09.2012	Sankar Netharalaya
Ex.A4 dated 10.09.2012	Prescription of Ezhil Hospital
Ex.A5 dated 10.09.2012	Receipt
Ex.A6 dated 10.09.2012	Prescription of Ezhil Hospital
Ex.A7 dated 11.09.2012	Cash Bill No.10671 of Ezhil Priya Medicals
Ex.A8 dated 10.09.2012	Prescription of Ezhil Hospital
Ex.A9 dated 12.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A10 dated 12.09.2012	Hibeam Diagnostic Research Foundation Pvt.Ltd.Receipt
Ex.A11 dated 12.09.2012	Cash Bill No.10709 of Ezhil Priya Medicals
Ex.A12 dated 13.09.2012	Prescription of Ezhil Hospital
Ex.A13 dated 13.09.2012	Cash Bill No.10749 of Ezhil Priya Medicals
Ex.A14 dated 14.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A15 dated 14.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A16 dated 14.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A17 dated 14.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A18 dated 14.09.2012	Investigation result issued by Anderson Diagnostics & Labs
Ex.A19 dated 14.09.2012	Prescription of Ezhil Hospital
Ex.A20 dated 14.09.2012	Cash Bill No.10811 of Ezhil Priya Medical
Ex.A21 dated 15.09.2012	Prescription of Ezhil Hospital
Ex.A22 dated 15.09.2012	Receipt (Biosquare Lifesciences)
Ex.A23 dated 15.09.2012	Prescription of  Ezhil Hospital
Ex.A24 dated 15.09.2012	Cash Bill No.10914 of Ezhil Priya Medical
Ex.A25 dated 15.09.2012	Prescription of Ezhil Hospital
Ex.A26 dated 15.09.2012	Cash Bill No.10916 of Ezhil Priya Medical
Ex.A27 dated 15.09.2012	Prescription of  Ezhil Hospital
Ex.A28 dated 15.09.2012	Cash Bill No.10928 of Ezhil Priya Medical
Ex.A29 dated 15.09.2012	Prescription of Ezhil Hospital
Ex.A30 dated 15.09.2012	Cash Bill No.10933 of Ezhil Priya Medical
Ex.A31 dated 15.09.2012	Requisition Form of Ezhil Hospital
Ex.A32 dated 15.09.2012	Out-patient Bill – Apollo Hospital
Ex.A33 dated 15.09.2012	Department of Bio-Chemistry, Apollo Hospital
Ex.A34 dated 15.09.2012	Report of Department of Haematology
Ex.A35 dated 16.09.2012	Prescription of  Ezhil Hospital
Ex.A36 dated 16.09.2012	Cash Bill No.10949 of Ezhil Priya Medical
Ex.A37 dated 17.09.2012	Prescription of  Ezhil Hospital
Ex.A38 dated 17.09.2012	Cash Bill No.11015 of Ezhil Priya Medical
Ex.A39 dated 17.09.2012	Prescription of  Ezhil Hospital
Ex.A40 dated 17.09.2012	Cash Bill No.11025 of Ezhil Priya Medical
Ex.A41 dated 17.09.2012	Prescription of  Ezhil Hospital
Ex.A42 dated 17.09.2012	Receipt
Ex.A43 dated 17.09.2012	Final Report of VRF Referral Laboratory
Ex.A44 dated 19.09.2012	Prescription of  Ezhil Hospital
Ex.A45 dated 17.09.2012	Cash Bill No.11171 of Ezhil Priya Medical
Ex.A46 dated 20.09.2012	Prescription of  Ezhil Hospital
Ex.A47 dated 20.09.2012	Cash Bill No.11175 of Ezhil Priya Medical
Ex.A48 dated 20.09.2012	Prescription of  Ezhil Hospital
Ex.A49 dated 20.09.2012	Cash Bill No.11176 of Ezhil Priya Medical
Ex.A50 dated 21.09.2012	Prescription of  Ezhil Hospital
Ex.A51 dated 21.09.2012	Cash Bill No.11291 of Ezhil Priya Medical
Ex.A52 dated 21.09.2012	Requistion Form.
Ex.A53 dated 21.09.2012	Bill –Hitech Diagnostic Centre
Ex.A54 dated 21.09.2012	Test Report-Hitech Diagnostic Centre
Ex.A55 dated 21.09.2012	Prescription of  Ezhil Hospital
Ex.A56 dated 21.09.2012	Receipt
Ex.A57 dated 21.09.2012	Requisition Form
Ex.A58 dated 21.09.2012	C.T.Chest Report
Ex.A59 dated 21.09.2012	Receipt
Ex.A60 dated 21.09.2012	Prescription of  Ezhil Hospital
Ex.A61 dated 21.09.2012	Cash Bill No.11292 of Ezhil Priya Medical
Ex.A62 dated 22.09.2012	Prescription of  Ezhil Hospital
Ex.A63 dated 22.09.2012	Cash Bill No.11339 of Ezhil Priya Medical
Ex.A64 dated 23.09.2012	Requisition Form
Ex.A65 dated 23.09.2012	Elector Cardiogram
Ex.A66 dated 23.09.2012	Echocardiography Report
Ex.A67 dated 23.09.2012	Receipt No.120
Ex.A68 dated 23.09.2012	Prescription of Ezhil Hospital
Ex.A69 dated 23.09.2012	Cash Bill No.11383 of Ezhil Priya Medicals
Ex.A70 dated 23.09.2012	Prescription of  Ezhil Hospital
Ex.A71 dated 23.09.2012	Cash Bill No.11381 of Ezhil Priya Medicals
Ex.A72 dated 23.09.2012	Prescription of  Ezhil Hospital
Ex.A73 dated 23.09.2012	Cash Bill No.11382 of Ezhil Priya Medicals
Ex.A74 dated 23.09.2012	Pulmonary Function Test Report
Ex.A75 dated 24.09.2012	Ezhil Hospital Report
Ex.A76 dated 24.09.2012	Prescription of Ezhil Hospital
Ex.A77 dated 24.09.2012	Receipt
Ex.A78 dated 24.09.2012	Prescription of  Ezhil Hospital
Ex.A79 dated 24.09.2012	Cash Bill No.11426 of Ezhil Priya Medicals
Ex.A80 dated 24.09.2012	Cash Receipt No.003
Ex.A81 dated 24.09.2012	Cash Receipt No.215
Ex.A82 dated 24.09.2012	Cash Receipt No.610
Ex.A83 dated 24.09.2012	Cash Receipt No.987
Ex.A84 dated 24.09.2012	Cash Receipt No.1970
Ex.A85 dated 24.09.2012	Cash Receipt No.1309
Ex.A86 dated 24.09.2012	Cash Receipt
Ex.A87 dated 24.09.2012	Requisition Form
Ex.A88 dated  25.09.2012	Investigation Report
Ex.A89 dated  25.09.2012	Investigation Report
Ex.A90 dated  25.09.2012	Investigation Report
Ex.A91 dated  25.09.2012	Investigation Report
Ex.A92 dated  26.09.2012	Prescription of Ezhil Hospital
Ex.A93 dated  26.09.2012	Cash Bill No.11597&11598 of Ezhil Priya Medicals
Ex.A94 dated  26.09.2012	Cash Bill No.11600 of Ezhil Priya Medicals and Requisition Form- Ezhil Hospital
Ex.A95 dated  26.09.2012	Cash Receipt No:C13335.
Ex.A96 dated  27.09.2012	Cash Receipt No:C13344.
Ex.A97 dated  27.09.2012	Final Report by VRF Referral Laboratory.
Ex.A98 dated  27.09.2012	Cash Bill Nos.11634 & 11636
Ex.A99 dated  28.09.2012	Requisition Form
Ex.A100 dated  28.09.2012	Out –Patient Bill- Appollo Hospital
Ex.A101 dated  28.09.2012	Out –Patient Bill- Appollo Hospital
Ex.A102 dated  28.09.2012	Requisition Form (2 Nos) & Cash Memo
Ex.A103 dated  28.09.2012	Prescription of  Ezhil Hospital
Ex.A104 dated  28.09.2012	Cash Receipt
Ex.A105 dated  28.09.2012	Cash Receipt Nos. 292960
Ex.A106 dated  28.09.2012	Cash Bill Nos. 11733 & 11734
Ex.A107 dated  28.09.2012	Cash Bill Nos. 11735,11741 & 11742
Ex.A108 dated  28.09.2012	Cash Bill Nos. 11743
Ex.A109 dated  28.09.2012	Electrocardiogram
Ex.A110 dated  29.09.2012	Requisition Form
Ex.A111dated  29.09.2012	Out –Patient Bill- Appollo Hospital
Ex.A112 dated  29.09.2012	Investigation Report
Ex.A113 dated  29.09.2012	Investigation Report
Ex.A114 dated  29.09.2012	Bill Nos.11797&11798
Ex.A115 dated  29.09.2012	Bills Nos.11799,11800,11805 & 11806
Ex.A116 dated  29.09.2012	Bills Nos. 11807,11808,11809 & 11810
Ex.A117 dated  29.09.2012 &                                    30.09.2012	Bills Nos. 11811,11812,11841 & 11843
Ex.A118 dated  30.09.2012	Bill No.11842
Ex.A119 dated  01.10.2012	Investigation Report
Ex.A120 dated  01.10.2012 &                            02.10.2012	Bills Nos.11929,11930,12003 & 12004
Ex.A121 dated  01.10.2012	Bill No.11931
Ex.A122 dated  03.10.2012	Investigation Report
Ex.A123 dated  03.10.2012, 04.10.2012 & 07.10.2012	Bills Nos. 12098,12100,12101,12416
Ex.A124 dated  05.10.2012,       08.10.2012 & 09.10.2012	Bills Nos. 12275,12276,12505,12581
Ex.A125 dated  04.10.2012,      06.10.2012 & 07.10.2012	Bills Nos. 12162,12353,12354,12415
Ex.A126 dated  25.09.2012,                           10.10.2012	Report (7 Sheets)
Ex. A 127 dated 10.10.2012	Cash Receipt No.2164
Ex. A 128 dated 10.10.2012	Cash Receipt No.428 & Requisition Form
Ex. A 129 dated 10.10.2012	Cash Receipt No.006 & 217
Ex. A 130 dated 10.10.2012	Final Receipt of Ezhil Hospital
Ex. A 131 dated 10.10.2012	Medical Certificate
Ex. A 132 dated 10.10.2012	Receipt No.1457 of Ezhil Hospital
Ex. A 133 dated 26.11.2012	Repudiation of claim letter of Opposite Party
Ex. A 134 dated 04.04.2013	Doctor’s Certificate
Ex. A 135 dated 11.09.2012	Renewal Notice
Ex. A 136 dated 13.06.2013	Reply of Opposite Party
Ex. A 137 dated 16.07.2013	Notice  of cancellation of policy by Opposite Party
Ex. A 138 dated 03.10.2013	Legal Notice of Opposite Party
Ex. A 139 dated 28.11.2013	Reply of Opposite Party

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY:

Ex.B1 dated NIL                        Insurance policy with terms and conditions

Ex.B2 dated NIL                        Claim Form

Ex.B3 dated 24.09.2012                      Discharge Summary

Ex.B4 dated 10.10.2012                      Discharge Summary

Ex.B5 dated 06.10.2010                      Medical Certificate issued by Dr.Balaraman

                                                       along with claim form dated 04.08.2010

Ex.B6 dated 26.11.2012                      Repudiation Letter

Ex.B7 dated 13.06.2013                      Repudiation Letter     

 

 

 

MEMBER – II                                                               PRESIDENT