IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM.
Dated this the 22nd day of February, 2021
Present: Sri. Manulal V.S., President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
CC No.232/17(filed on 24/10/17)
Complainant : Vijayan K.
S/o Madhava Menon,
Residing at No.13, Divanpuram
Housing Colony, Moolavattam PO,
Kottayam.
(Adv. Dominic Sebastian)
Vs.
Opposite parties : 1) Star Health & Allied Insurance
Co.Ltd., KRM Centre, 6th Floor
No.2, Harrington Road, Chetpet
Chennai-600 031
2) Star Health & Allied Insurance
Co.Ltd., 2nd Floor, Puthenpurackal
Complex, M.C. Road, Kodimatha,
Kottayam-686 013.
(Ops.Adv. Avaneesh.V.N )
Sri. Manulal V.S., President
This complaint is filed under Section 12 of the Consumer Protection Act 1986.
Case of the complainant is as follows:
The complainant availed a health insurance policy bearing No. P/181113/01/2016/000784 from the opposite parties. The opposite parties undertook to reimburse the complainant for all medical expenses for a period of 25/5/15 to 24/5/16 upto an amount of Rs.3,00,000/-. During November 2015 the complainant was diagnosed as having non functioning pituitary macro adenoma and was advised for immediate surgery. The complainant had no sort of information about this disease earlier. This policy was taken based on an understanding with the opposite parties and Swal Corporation were the complainant was working. The complainant underwent inpatient treatment at Amrita Institute of Medical Sciences and Research Centre, Kochi from 3/11/15 to 10/11/15. The complainant had undergone a surgery for non functioning pituitary macro adenoma. The complainant had spent Rs. 2,43,497/- for his treatment. The claims submitted by the complainant was repudiated by the opposite parties stating that the complainant concealed the disease. In fact the complainant was not aware of any major problem for his eyes other than slightly diminished eye sight which was considered as related to age. The complainant has slight hyper tension and diminished vision which was revealed to the opposite parties. The complainant has not concealed any material facts from the opposite parties and the opposite parties are bound to reimburse the expense met by the complainant for the treatment. The opposite parties have committed deficiency in service by repudiating the genuine claim of the complainant.
Upon notice from this commission the opposite parties appeared before the commission and filed version contending as follows:
It is admitted by the opposite parties that the complainant took a Senior Citizen’s Red Carpet insurance policy for a sum insured of Rs.3,00,000/- commencing from 25/5/15 to 24/5/2016. At the time of issuing the policy the complainant was supplied with the terms and conditions of policy and the same was explained to the complainant at the time of proposing the policy. In case of Senior Citizen Red Carpet Insurance Policy medical examination is not required as the insured must be above 60 years of age. As per terms and conditions of the policy only those pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy. It is compulsory that the information regarding the health must be provided in the proposal form, for the opposite party to provide coverage with suitable co-payment that is 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured.
The complainant was admitted at Amrita Institute of Medical Sciences and Research Centre, Kochi on 3/11/2015 for the treatment of non functioning of Pituitary Macro adenoma and after the treatment he was discharged on 10/11/15. The discharge summary of the hospital clearly reveals that the complainant had a history of diminished vision in both eyes since 8 months and history of alopecia present since 1 year as on 3/11/2015. As per the records from Bharath Hospital, Kottayam, the complainant was consulted for visual disturbances that is blurring of vision on 16/8/2014 and the case sheet records dated 11/2/2015 noted “MRI/adenoma-? Pituitary Adenoma”. Based on the available records, it is confirmed that the ailment for which the complainant has undergone treatment is pre-existing. Since the ailment is pre-existing, the opposite party rejected the claim based on exclusion No.1 of the policy. It is alleged in the version that the complainant has not furnished any details regarding his health condition in the proposal form despite specific question to this effect. Hence it amounts to suppression of material facts which makes the contract void ab initio. As per the contract of insurance the insured has to furnish true and correct facts in the proposal form for issuing the policy. The opposite party had rightfully denied the claim of the complainant as per the terms of the policy and there is no deficiency of service or negligence on the part of the opposite parties.
Evidence in this case consists of deposition of PW1 and Exts. A1 to A5 on the side of the complainant. One Padma Prabha P, who is the Chief Manager –Legal, filed proof affidavit for and on behalf of the opposite parties and Ext.B1 to B9 were marked.
On evaluation of the complaint, version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice from the part of the opposite party?
- If so what are the reliefs and costs?
There is no dispute on the fact that the complainant took a Senior Citizens Red Carpet Insurance Policy from the opposite parties vide Ext.A1 policy certificate. On perusal of Ext.A1 policy we can see that the sum assured is Rs.3,00,000/- and period of coverage was from 25/5/15 to 24/5/16. It is also admitted that the complainant had underwent for the treatment of non functioning Pituitary macro adenoma at Amrita Institute of Medical Sciences and Research Centre, Kochi. The complainant was admitted in the hospital on 3/11/15 and after the treatment he was discharged on 10/11/15. Ext.B3 is the discharge summary issued from Department of Neuro surgery, Amrita Institute of Medical Sciences and Research Centre, Kochi. Ext.B3 proves that the complainant has undergone a navigation assisted extended endoscopic trans nasal trans sphenoidal excision under GA on 4-11-15. According to the complainant he had spent an amount of Rs.2,43,497/- for the treatment.
According to the opposite party the complainant is not entitled for reimbursement of the expenses which had met by him for the treatment. The opposite parties repudiated the claim of the complainant on the ground that as pre-existing diseases are excluded from the coverage of policy. As per the policy pre-existing disease is excluded under exclusion clause No.1 of the policy which states that pre-existing disease as defined in the policy, until 12 months of continuous coverage has elapsed, since inception of the first policy with any Indian Insurance company. Thus any treatment for pre existing disease would have to come under the coverage of the policy after 12 months from the date of inception of the first policy. According to the terms and conditions of policy, pre existing disease means any ailments or injury or related conditions for which the insured person had signs or symptoms and or was diagnosed and or received medical advice or treatment within 48 months prior to insured person’s first policy with the company. On perusal of Ext.B4 we can see that 10/4/13 onwards complainant was under the treatment in Bharath Hospital Kottayam. The opposite party relied on an entry dated 11/2/15 in Ext.B4 to substantiate their contention that the complainant had been under the treatment for which he had undergone from the surgery. It is noted in Ext.B4 on that day as ‘MRI/adenoma? Pituitary adenoma”. On going through Ext.B4 we cannot see before 11/2/15 the complainant had undergone for any treatment for pituitary macro adenoma at Bharath hospital.
A catena of judgments has defined the term pre-disease for the purpose of bringing out more clarity while deciding the insurance case were the claims are repudiated on account of some pre existing disease. In such decisions it was held by the apex fora that the disease should not be only existing at the time of taking the policy but also should have existed in the near proximity. It is further clarified in several decisions that if insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person he cannot be held guilty of concealment of any disease the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy within a few days or months. On perusal of Ext.B3 and B4 it cannot be seen that the complainant had the knowledge that he is suffering from pituitary macro adenoma and he is under the treatment for the same at the time of proposal form on 25/5/15. On perusal of Ext.B2 proposal form we can see that the complainant had disclosed that he was suffering from hyper tension from last 2 years. Ext. B3 proves that only on 3-11-15 the pituitary macro adenoma was diagnosed. Therefore we are of the opinion that the complainant was not in the knowledge that he had pituitary macro adenoma at the time of making Ext.B2 proposal form. Hence the contents of the opposite party cannot be sustainable. Therefore we are of the opinion that the opposite parties had committed deficiency in service by repudiating the claim of the complainant without any valid reasons.
Ext.B3 proves that the complainant had spent Rs.2,19,558/- for the treatment. The opposite parties contented that they are liable to pay 50% of treatment expenses in case of treatment of pre existing disease. But on perusal of terms and conditions of the policy attached to Ext.B1 no such conditions were incorporated in the terms and conditions of the policy. Hence we are of the opinion that opposite parties are liable to pay Rs.2,19,558/- which is the amount incurred by complainant for his treatment. The complainant had suffered much sufferings and hardships due to the act of deficiency in service by the opposite party for which they are liable to compensate the same.
In these circumstances we allow the complaint and pass the following orders.
- We hereby direct the opposite parties to pay Rs. 2,19,558/- to the complainant alongwith 9% interest from 24/10/17, ie the date of filing of the complaint till the date of realization.
The Order shall be complied with within 30 days from the date of receipt of copy of the order.
Pronounced in the Open Commission on this the 22nd day of February, 2021.
Sri. Manulal V.S., President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Witness examined on the side of the complainant
Pw1-K.Vijayan
Exhibits marked on the side of complainant
A1-Copy of policy certificate
A2 Reply Notice dtd 18/8/17
A3-Copy of suit notice dtd 4/8/17
A4-Postal receipts
A5-Copy of discharge summary issued by Amrita institute of Medical sciences
and research centre, Kochi.
Exhibits marked on the side of opposite parties
B1-Copy of policy and original conditions
B2-Proposal form for Senior Citizens Red Carpet Health insurance policy
B3-Copy of discharge summary
B4-Copy of medical records from Bharath Hospital
B5-Copy of medical records from Amrita Institute of Medical Sciences
and Research Centre
B6-Copy of letters dtd 7/3/16, 11/5/16 and 2/8/16
B7-Copy of repudiation letter dtd 29/1/16
B8-Copy of review rejection letter dtd 1/9/16
B9-Copy of reply notice dtd 18/8/17
By Order,
Senior Superintendent.
