Tamil Nadu

South Chennai

CC/185/2018

R Thiagarajan - Complainant(s)

Versus

SBI Insurance & Another - Opp.Party(s)

Party in Person

24 Jun 2022

ORDER

Date of Complaint Filed : 09.04.2018

Date of Reservation      : 01.06.2022

Date of Order               : 24.06.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

PRESENT:    TMT. B. JIJAA, M.L.,                                                 : PRESIDENT

                       THIRU. T.R. SIVAKUMHAR, B.A., B.L.,                 :  MEMBER  I 

                       THIRU. S. NANDAGOPALAN., B.Sc., MBA.,          : MEMBER II

 

CONSUMER COMPLAINT No.185/2018

FRIDAY, THE 24^th DAY OF JUNE 2022

1. R.Thiagarajan,

   S/o.K.Ramalingam

 

2. T.Chandra,

    W/o. Thiagarajan,

 

Both are residing at No.4/14,

Perundevi Ammal Street,

Hasthinapuram, Chennai-600 064.                                                                                                                              ... Complainants                               

..Vs..

1.The Managing Director,

   SBI General Insurance Company Limited

   Corporate Office,

  "Nataraj", 101, 201, & 301,

   Junction of express highway,

   Andheri Kurla Road,

   Andheri East, Mumbai -400 069.

 

2.The SBI General Insurance Company Limited,

    Rep. by its Authorised Signatory,

    New No.64, Old No. 149,

    Ground and Mezzanine Floor,

    Greens Road,

    Chennai-600 006.                                                                                                                                                   ...  Opposite Parties

 

******

Counsel for the Complainant            : Party in Person

Counsel for the Opposite Parties       : M/s. M.B. Gopalan Associates

 

        On perusal of records and after having heard the oral arguments of the Complainant in person and Counsel for the Opposite Parties, we delivered the following:

ORDER

Pronounced by the President Tmt. B. Jijaa, M.L.,

1.      The Complainant has filed this complaint as against the Opposite Parties under section 12 of the Consumer Protection Act, 1986 and prays to pay a sum of Rs.5,00,000/- towards  mental agony, pain, damage caused to them, because of the deficiency in service committed by the Opposite Parties and direct the Opposite Parties to reimburse the cataract operation expenses of Rs.36,747/- and to pay a sum of Rs.50,000/- being the cost incurred by the Complainants.

2.     The averments of Complaint in brief are as follows:-

The Complainants had taken SBI General Group Health Insurance Policy bearing No.0000000003629429-02 and had paid three premiums for 3 years. The Policy period was in force from 30.11.2017 to 29.11.2018 for a period of one year. The Policy was given as family floater for two adults and the total sum assured was Rs.3 lakhs. The premium was collected on 04.09.2017 for a sum of Rs.16,300/- and issued a receipt No.6621514 dated 21.11.2017. The Opposite Parties are fully aware of the age factor and health conditions of the Complainant and they were informed that the pre-existing elements or disease and any health complaints / accident / treatment taken / hospitalization are not applicable to the insured persons. The Opposite Parties agreed to take care of the risk and cover of the Complainants after verifying the documents submitted by the Complainants and confirmed that the documents are in order and awarded the Policy and Customer ID 0000000005358950. The 2^nd Complainant was admitted in Sankara Nethralaya (Unit of Medical Research Foundation) on 07.02.2018 for cataract treatment and made request to the Opposite Parties through their agency Paramount Health Services and Insurance TPA Pvt. Ltd., for cashless treatment, but the said request was denied for the reason that the 2^nd Complainant was having pseudophakia since 9 years in her eye.  But whereas in the terms and conditions supplied along with the policy Clause 3 exclusions applicable for the first year of cover from commencement of policy for the following diseases, illness and its related complications wherein in sub clause VI cataract is indicated. Cataract is not pre-existing disease, according to medical report over a period of time and of age factor the said cataract will develop. The Opposite Parties concluded that the cataract developed 9 years back. The purpose of availing Group Health Insurance from the Opposite Parties is to use the same according to their requirement if any arises in future. There is total negligence in service on the part of the Opposite Parties in evading to honour the claim made by the Complainants. The Opposite Parties evaded to comply with the demand for the expenses incurred on the cataract operation of the right eye and committed deficiency of service. Hence the complaint.

3.Written Version filed by the Opposite Parties in brief is as follows:-

         The Complainants were insured under Group Health Insurance Policy for the period 30.11.2017 to 29.11.2018 which was issued subject to terms and conditions as well as exclusions. As per Exclusion 1 of policy terms and conditions pre-existing ailments were excluded for a period of 48 months from commencement of cover. The Complainant's Policy was on its third renewal and 48 months had not expired so as to cover pre-existing diseases. A claim was made for cataract treatment of right eye for 2^nd  Complainant under the above Policy. The claim was processed by Third Party Administrator M/s. Paramount Health Services, who found that the 2nd Complainant was suffering from cataract for 9 years due to pseudophakia left eye before 9 years and hence information regarding first consultation and progress of ailment was sought in regard to right eye, Specific Information was avoided and vague response was provided in regard to the ailment. It was therefore reasonably concluded that the treatment of cataract was on account of the long existing cataract and the claim was declined. Hence the complaint of deficiency in service as against the Opposite Parties is wholly misconceived, unsustainable and liable to be rejected in limine.

The Complainant is making selective reference to the Policy terms by mentioning only exclusion of 30 days, ignoring various other exclusions. The Policy generally excludes pre-existing ailments vide Exclusion 1. In addition, even if not pre-existing Cataract is excluded during first year vide Exclusion 3. The two Exclusions operate independently. In as much as the 2nd Complainant had pseudophakia for 9 years in the left eye it was obvious that she was suffering from cataract for long duration. Clearly the ailment was pre existing. Hence, vide Exclusion 1 the treatment of right eye is not admissible. It is an absurd interpretation. The Opposite Parties submit that cataract develops bilaterally and the Complainant who had admittedly undergone pseudophakia 9 years back cannot claim that she suffered cataract only after insurance with the Opposite Parties. The treatment after insurance cannot be portrayed as having developed cataract itself after insurance. The Opposite Parties have not committed deficiency in service.  Hence, the complaint is to be dismissed.

4.      The Complainants submitted their Proof Affidavit and Written Arguments. On the side of the Complainants, documents Ex.A-1 to Ex.A-5 were marked. The Opposite Parties submitted their Proof Affidavit and Written Arguments. On the side of the Opposite Parties documents Ex.B-1 to Ex.B-6 were marked.    

5.     Points for Consideration

1. Whether there is deficiency in service on the part of the Opposite Party?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

6.    Point No.1:-

The fact that the Complainants were insured under the Group Health Insurance Policy issued by the Opposite Parties for the period from 30.11.2017 to 29.11.2018 is undisputed. On 07.02.2018, the 2^nd Complainant was admitted in Sankara Nethralaya (Unit of Medical Research Foundation) for cataract treatment on the right eye and made a claim to the Opposite Parties through their agency Paramount Health Services and Insurance TPA Pvt. Ltd., under the said policy, but the claim was rejected for the reason that the 2^nd Complainant was suffering from cataract for 9 years due to pseudophakia on left eye, progress of ailment on the right eye was on account of long existing cataract.

As per Ex.B-2, Paramount Health Services (TPA) Pvt. Ltd., considering the claim of the 2nd Complainant had requested Sankara Nethralaya,the hospital where the 2^nd Complainant had taken eye treatment to provide information about the diagnosis and follow up papers, which was duly replied on 03.02.2018, vide Ex.B-3 attaching the details of the 2^nd Complainant along with her case summary, wherein it is mentioned under the head Past Medical History, “Left eye Pseudophakia 9 years”. When additional information was sought from Sankara Nethralaya to confirm the duration of right eye cataract in view of left eye pseudophakia since 9 years vide Ex.B-4, for which SankaraNethralaya as found in Ex.B-5, informed that the “cataract usually starts in one eye. The need for surgery is determined by the vision of the patient at presentation. Even if it occurs in both eyes one eye may progress faster than the other so the difference is in the time of surgery”. Hence on 07.02.2018 vide Ex.B-6, the Opposite Parties had denied the claim of the Complainants as per the terms of the policy on account of pre – existing disease, the Complainant was having pseudophakia since 9 years in left eye, cataract develops bilaterally which caused right eye cataract.

The Complainant had agreed to the terms and conditions of the Group Health Insurance Policy dated 21.11.2017, Ex.A-1 issued by the Opposite Parties, wherein under the head “Exclusions applicable to T.Chandra” pre -existing disease as defined under exclusions “Point 1” of Policy Wordings is applicable to the 2^nd  Complainant.

The Counsel for Opposite Parties relied on the Order passed by the NCDRC, New Delhi reported in 2017 SCC Online NCDRC 1690, R.P.No.1906 of 2014, Oriental Insurance Co., Ltd., Vs. Priyank Bhadada, wherein it was observed that as per the Exclusion Clause of the Policy the Claim of the Complainant was not reimbursable because the claim was initiated within four years of the inception of policy and the Complainant does not deserve any insurance claim and held that the Opposite Party insurance Company was justified in its repudiation.

Reliance was also placed by the Opposite Parties on Order dated 25.01.2018 passed by NCDRC, New Delhi in Lalit Kumar Gargs United Indian Insurance Co., Ltd., wherein it was held that in any case the pre-existing ailment was excluded under the Exclusion Clause contained in the insurance policy and hence the insurer was wholly justified in repudiating the claim.

The 2^nd Complainant having pseudophakia in the left eye for 9 years,  has the tendency to develop bilaterally according to the opinion given by Sankara Nethralaya and hence the contention of the Complainants that the cataract suffered by the 2^nd Complainant only after taking insurance with the Opposite parties cannot be sustained and as the ailment of the 2^nd Complainant falls under the head of pre-existing disease which is excluded for a period of 4 years from the date of inception of Health Insurance Policy as stipulated under the terms and conditions of the Group Health Insurance Policy dated 21.11.2017. As the Complainants claim fall under the Exclusion Clause of pre existing disease and as 4 years has not expired to cover pre existing disease and the denial of claim is based on the terms and conditions of the Group Health Insurance Policy dated 21.11.2017 (Ex.A-1) accepted and signed by the Complainant, and as the judgment referred by the Opposite Parties is applicable to the present case, we are of the considered view that the Opposite Parties had not committed any deficiency of service to the Complainant.  Accordingly point No.1 is answered against the Complainants.

7.     Point No.2 and 3:-

        As discussed and decided on point No.1, we are considered view that the Complainant is not entitled for reliefs claimed in the complaint or for any other relief. Accordingly point No.2 and 3 are answered against the Complainants.

In the result the Complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on  24^th day of June 2022. 

 

 

S. NANDAGOPALAN                                                 T.R. SIVAKUMHAR                                                       B.JIJAA

         MEMBER II                                                                MEMBER I                                                          PRESIDENT

 

 

List of documents filed on the side of the Complainants:-

 

Ex.A1	21.11.2017	Policy taken in the name of the complainants to the SBI General Insurance Company Ltd.
Ex.A2	01.02.2018	Series of Medical Research Foundation Receipts.
Ex.A3	07.02.2018	Medical Research Foundation, Patient Advance Receipts
Ex.A4	07.02.2018	Denial of cashless access issued by the   Paramount Health Services & Insurance   TPA Private Limited.
Ex.A5	08.02.2018	E-mail sent by the Complainant's son to   the opposite parties.

 

List of documents filed on the side of the Opposite Parties:-

 

Ex.B1	-	Pre authorization request
Ex.B2	03.02.2018	Additional information sought from complainant
Ex.B3	03.02.2018	Reply to the query
Ex.B4	06.02.2018	Additional information sought from complainant
Ex.B5	06.02.2018	Reply to the query
Ex.B6	07.02.2018	Denial of cashless request

 

 

 

 

 

S. NANDAGOPALAN                                               T.R. SIVAKUMHAR                                                               B.JIJAA

         MEMBER II                                                             MEMBER I                                                                   PRESIDENT