BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT
SHRI. G. SIVAPRASAD : PRESIDENT
SMT. SATHI. R : MEMBER
SMT. LIJU B. NAIR : MEMBER
C.C.No: 13/2011 filed on 20/01/2011
Dated: 30..11..2013
Complainant:
Viswanathan, S/o Kunjan, Janaki Bhavan (Anoor), Murukkumpuzha – P.O., Thiruvananthapuram.
(By Adv. S. Krishna Kumar)
Opposite parties:
- Star Health & Allied Insurance Co. Ltd, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600 034.
- Branch Manager, Star Health & Allied Insurance Co. Ltd., Chandrabhaga, Plamoodu Junctionm, Thiruvananthapuram.
(By Adv. K.S Radhika Devi)
This O.P having been heard on 11..11..2013 , the Forum on 30..11..2013 delivered the following:
ORDER
SHRI. G. SIVAPRASAD, PRESIDENT:
The facts leading to the filing of the complaint are that, complainant is a senior citizen and he was the holder of the health insurance scheme named as “Star Senior Citizen Red Carpet Insurance Policy” of the opposite party Star Health & Allied Insurance Co. Ltd, that the 1st opposite party is the registered corporate office of the Star Health & Allied Insurance Company and 2nd opposite party is its branch at Thiruvananthapuram, that on the basis of the promises assured by the opposite parties, complainant joined in the opposite parties Star Senior Citizen Red Carpet Insurance Policy, that opposite parties issued the insurance policy vide policy No. P/181111/01/2010/002022 which is valid from 24/06/09 to 23/06/2010, that the sum insured of the policy is Rs. 1,00,000/-, that opposite parties agreed and undertook that if the complainant contract any disease or suffer from any illness or sustain from any body injury through accident and if such disease or injury shall require any such person and inpatient treatment on the company will pay to the insured person the amount of expenses incurred for hospitalisation and treatment, that complainant herein on 03/05/2010 suffered from fever and cellulitis and sought medical treatment in the Kerala Institute of Medical Sciences (KIMS), Anayara and admitted the insured in the hospital as inpatient till 08/05/2010, that immediately after the admission, the matter was informed to opposite parties and opposite parties directed the complainant to submit claim form after completion of treatment, that complainant submitted claim form along with treatment details, discharge summary and entire bills signed by the Medical Officer of the KIMS Hospital to the opposite parties, that complainant incurred the total amount of Rs. 27,109/- for the treatment, that even after repeated request opposite party delayed the same saying flimsy reasons, that at last complainant constrained to issue Advocate notice, that thereafter complainant received a repudiation letter from the Area Office of the opposite parties, opposite parties repudiated the claim on flimsy ground, that the action of the opposite parties amounts to deficiency in service. Hence this complaint to direct opposite parties to settle the claim for an amount of Rs. 27,109/- along with compensation of Rs. 50,000/- and cost.
2. Opposite parties entered appearance and filed version contending inter alia that the complainant had taken a fresh policy of Star Senior Red Carpet Policy from the opposite party for the period of 24/06/2009 to 23/06/2010, that the proposal form is the basis and part of the contract upon which the policy is issued, that opposite party received a pre authorization request from the hospital for extending the cashless facility to the client for his admission, that in the preauthorization request complainant shows fever one day and leg pains, further under clinical findings blood pressure has been recorded and the insured has been suffering from diabetes since 2o years, that since the information furnished is not revealed in the proposal form there is violation of the principle of utmost good faith, that the medical certificate showing the past history of disease in the discharge summary diagnosis noted are cellulitis with streptococcal bacteremia, that opposite party sought an expert medical opinion from Dr. Rajeev. A., Consultant Physician, that his opinion the patient has been suffering from DM & HTN for the past 25 years, that the opposite parties rejected the claim based on the ground of suppression of material facts and the same was intimated to the insured on 03/07/2010 itself, so there is no deficiency of service from the opposite parties. Hence opposite parties prayed for dismissal of the complaint.
3. The points that arise for consideration are:
(i) Whether repudiation of the claim is justifiable?
(ii)Whether there is deficiency in service on the part of opposite parties?
(iii) Whether the complainant is entitled to any of the reliefs as prayed for?
In support of the complaint, complainant has filed proof affidavit and has marked Exts. P1 to P6. In rebuttal, the Legal Officer of the opposite parties has filed proof affidavit and has marked Exts. D1 to D10.
Points (i) to (iii): Admittedly, complainant is a senior citizen and had taken a medi claim insurance policy named as “Star Senior Citizen Red Carpet Insurance Policy” from the opposite parties vide policy No. P/181111/01/2010/002022 which was valid from 24/06/2009 to 23/06/2010. It has been the case of the complainant that on 03/05/2010 complainant suffered from fever and cellulitis and sought medical treatment in KIMS Hospital, Anayara, Thiruvananthapuram and as advised by the Doctor concerned complainant was admitted in the hospital and treated there as inpatient till 08/05/2010. The very case of the complainant is that he had to spend a sum of Rs. 27,109/- for the treatment, that though complainant submitted claim, opposite parties had not made communication. At last, the complainant issued an Advocate notice and thereafter a claim repudiation letter was issued to the complainant stating suppression of material facts. According to complainant, opposite parties purposely repudiated the claim. Complainant has led evidence by way of proof affidavit and Exts. P1 to P6. Ext. P1 is the copy of the Star Senior Citizens’ Red Carpet Insurance Schedule. A perusal of the policy reveals that the policy is valid for a period of 24/06/2009 to 23/06/2010. As per Ext. P1 the total sum insured is Rs. 1,00,000/-. Ext. P2 is the claim repudiation letter dated 03/07/2010 issued by the opposite party to the complainant. The claim is seen repudiated on the ground of “suppression of material facts:- Various existing illness suppressed while taking policy. The claim, therefore falls outside the scope of the policy and under the said circumstances opposite parties expressed their inability to consider a claim”. Ext. P3 is the visit card of Health Insurance Advisor Smt. Umadevi. S of Star Health and Allied Insurance Co. Ltd. Ext. P4 is the visit card of Health Insurance Advisor Smt. Mini. G. Nair of Star Health and allied Insurance Company Ltd. Ext. P5 is the brochure issued by Star Health and Allied Insurance Co. Ltd. Ext. P6 is the Star Senior Citizens’ Red Carpet Insurance Policy terms and conditions. Opposite party has led evidence by way of proof affidavit of the Legal Officer of the opposite party and Exts. D1 to D10. Ext. D1 is the policy terms and conditions. Ext. D2 is the copy of Star Senior Citizens’ Red Carpet Insurance Proposal of the insured K. Viswanathan. Ext. D3 is the copy of Star Senior Citizens’ Red Carpet Insurance Schedule. Ext. D4 is the copy of the preauthorization request. Ext. D5 is the copy of the denial of cashless letter dated 6th My, 2010 issued by the Star Health and Allied Insurance Co. Ltd. Ext. D6 is the copy of the Claim form for Medical Insurance. Ext. D7 is the copy of the bills issued by KIMS. Ext. D8 is the copy of the discharge summary issued by KIMS. Ext. D9 is the copy of the Inpatient Record. Ext. D10 is the copy of the claim repudiation letter. The stand of the opposite party is that the history of DM, CAD & HTN are not revealed in Ext. D2 Proposal form. According to opposite party in a contract of insurance any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a material fact. Opposite party has cited the decision of Hon’ble Supreme Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd 2009 KHC 4898. Relying on the said decision opposite party contends that if the proposer has knowledge to the material fact, he is obliged to disclose it to insurer while answering questions in the proposal form. Any inaccurate answer to said questions will entitle the insurer to repudiate the liability under the policy. Since complainant has not revealed the information in the proposal form, according to opposite party, there is violation of the principle of utmost good faith and the contract itself is void from the very beginning and due to the non disclosure of the pre existing disease, during the inception of the policy, cashless facility was denied and the same was intimated to the insured through the hospital by a letter. According to complainant this insurance policy is available to persons between the ages 60 years and 69 years. Renewals of this insurance can be made up to 85 years. The policy schedule and any endorsement are to be read together the terms and conditions and exceptions that appear in the policy or in any endorsement are part of the contract and must be complied with. To this effect there is a condition numbered as 20 heading as ‘Important Note’ in Ext. P6 terms and conditions of the policy. According to complainant it is the settled position of law that Insurance Company must investigate health issues before issuing insurance policy as it is laid down by the Hon’ble National Commission in Life Insurance Corporation of India Vs. Smt. Sudesh reported in 2012(1) CPR 391 (NC). In this case no such investigation done by the opposite party before issuing the policy to the complainant. In Ext. P5 it is stated that medical check up is not required for Senior Citizens’ Red Carpet Insurance Policy. According to complainant as the scope of the policy is for senior citizens of age group 60 to 69 and renewal is provided for age up to 85 and benefit is covered to persons of pre existing illness, the company avoided medical check up. Complainant has argued that Ext. D6 medical certificate filled in by the treated Doctor in which to question No. 8 whether the present ailment is a complication of pre existing disease, the doctor answered as “No”. To question No. 9 whether the disease / disorder is congential in nature, the Doctor answered as “No”. Thus evidently by Ext. D6 the treated ailment was not due to the complication of pre-existing illness and hence opposite parties are liable to pay the amount incurred for the treatment. Complainant has relied on the decision of National Commission in New India Assurance Company Ltd. Vs. Harinder Paul Singh 2012 (3) CPR 46 (NC) in which it was held that Insurance Company is bound to prove grounds of repudiation of insurance claim. According to complainant in the present case evidently by Ext. P5 & Ext. P6 the pre-existing diseases are also covered by the policy scheme. Complainant has relied on the decision of Kerala State Commission in National Insurance Company Vs. Muttil Valsala 2012 (3) CPR 19 in which it was held that mediclaim cannot be rejected on pretext of pre-existing illness. Further complainant relied on the decision of Kerala State Commission 2012 (2) CPR 190 in which it was held that allegation of suppression of material facts has to be supported by evidence. It is further argued by the complainant that the contention of the opposite parties that the suppression of material facts on the ground that DM, CAD & HTN are not revealed in the proposal form is a case against Ext. P2 claim repudiation letter issued by the opposite parties. No such ground stated in Ext. P2. What Ext. P2 states is that suppression of material facts: various existing illness suppressed while taking policy. According to complainant the words used in Ext. P2 are “various existing illness”. According to complainant it is a general term. Ext. P6 policy does not include various existing illness and as such there is no suppression of material facts. It is argued by the complainant that the decision reported in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd is not applicable in the present case on the ground that in the said case the disease for which treatment expenses claimed was linked with pre-existing illness and the same was not disclosed in the proposal form. In the present case the treating doctor in Ext. D6 certified that the present ailment is not a complication of pre-existing disease. Further complainant is not claiming for the treatment expenses of DM, CAD & HTN. Herein the treatment is for fever and cellulitis. The decision relied by the opposite party is one where the existing illness was never covered under the policy. While in the present policy in dispute pre-existing illness were outside the scope of the policy, at the same time, existing illness are covered under the policy and are within the scope of the policy. It is pertinent to point out that both Ext. P5 & P6 are issued by the opposite parties. As per Ext. P6 terms and conditions of the Policy there is a condition numbered as 20 heading as “Important Note” in which it is stated: This insurance policy is available to persons between the ages 60 years and 69 years. Renewals of this insurance can be made up to 85. The policy schedule and any endorsement are to be read together and any word or such meaning wherever it appears. The terms and conditions and exceptions that appear in the policy or in any endorsement are part of the contract and must be complied with. Failure to comply may result in the claim being denied”. As per Ext. P5 it is clearly stated that this policy is available to the persons in age group 60 – 69 having existing illness and there is no need of medical check up. Further as per Ext. P1 there is a provision for renewability of the policy wherein it is stated cover for pre-existing diseases / conditions would be available, as applicable, if the policy is renewed within a period of 15 days. Considering Exts. P1, P5 & P6 we are of the view that there is no suppression of material fact influencing the mind of insurer in deciding whether to accept or not to accept the risk. Since the insurer has accepted the risk with existing illness by the terms and conditions of the policy by virtue of Exts. P1, P5 & P6 we do not find any merit in the contention of the opposite parties that there is suppression of material facts. Opposite party has failed to establish material suppression by the insured. In view of the evidence available on record we are of the considered opinion that considering the nature of the policy the repudiation of the claim is not justifiable. Complainant is entitled to get the claim amount Rs. 27,109/-. The action of the opposite parties in repudiating the claim of the insured amounts to deficiency in service for which complainant is entitled to get a compensation which we fix at Rs. 5,000/-.
In the result, complaint is allowed. Opposite parties shall settle the claim of the complainant for an amount of Rs. 27,109/- and shall pay Rs. 5,000/- as compensation within 2 months from the date of receipt of this order, failing which Rs. 27,109/- will carry interest @ 8% from the date of receipt of this order. Parties shall bear and suffer their respective costs.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 30th day of November, 2013.
Sd/- G. SIVAPRASAD : PRESIDENT
Sd/- R. SATHI : MEMBER
Ad. Sd/- LIJU B. NAIR : MEMBER
C.C.No: 13/2011 APPENDIX
I. Complainant’s documents:
P1 : Copy of the Star Senior Citizens’ Red Carpet Insurance Schedule
P2 : Claim repudiation letter dated 03/07/2010 issued by opposite
party to the complainant
P3 : Visit card of Health Insurance Advisor Smt. Umadevi
P4 : Visit card of Health Insurance Advisor Smt. Mini. G. Nair of Star
Health and Allied Insurance Co. Ltd.
P5 : Brochure issued by Star Health and Allied Insurance Co. Ltd
P6 : Star Senior Citizens’ Red Carpet Insurance Policy terms and
Conditions
II. Complainant’s witness:
PW1 : K. Viswanathan
III. Opposite parties’ documents:
D1 : Policy terms and conditions
D2 : Copy of Star Senior Citizens’ Red Carpet Insurance Proposal of
the insured K. Viswanathan
D3 : Copy of Star Senior Citizens Red Carpet Insurance Schedule
D4 : Copy of the pre-authorisation request
D5 : Copy of denial of cashless letter
D6 : “ claim form for medical insurance
D7 : “ bills issued by KIMS
D8 : “ discharge summary issued by KIMS
D9 : “ inpatient records
D10 : “ claim repudiation
IV. Opposite parties’ witness : NIL sd/-
PRESIDENT
