Karnataka

Bangalore 4th Additional

CC/2127/2017

Hemanth Kumar K.S, - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd., - Opp.Party(s)

31 Dec 2018

ORDER

Complaint filed on: 26.07.2017

                                                      Disposed on: 31.12.2018

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

 

 

CC.No.2127/2017

DATED THIS THE 31^st DECEMBER OF 2018

 

PRESENT

 

 

SRI.H.Y.VASANTH KUMAR, PRESIDENT

SMT.N.R.ROOPA, MEMBER

 

Complainant/s: -                           

Hemanth Kumar K.S.

S/o Shivaram K.C.,

Aged about 29 years,

126, 7^th Cross, KR Layout,

Puttenahalli Main Road,

6^th Phase, JP Nagar,

Opposite to Inchara Restaurant, Bangalore-78.

 

By.Adv.Sri.K.C.Manjunath

 

V/s

Opposite party/s:-    

1. Star Health and Allied

Insurance co.,

No.15, Sri Balaji Complex,

1.  

Rep. by its Authorized Signatory

 

2. Star Health and Allied

Insurance Co. Ltd.,

Branch Office: 8^th Floor,

Palm Court, Maharana

Pratap Circle,

•  

Rep by its Authorized Signatory

 

By Adv.Sri.Y.P.Venkatapathi

 

3. Customer Relationship Team Policy Bazaar.Com

Plot No.119, Ground

Floor, Sector-44,

•  

Rep by its Authorized Signatory.

By.Adv.Sri.S.Guru Prasanna

 

  

ORDER

 

Under section 14 of consumer protection Act. 1986.

 

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

 

            The Complainant has alleged the deficiency in service by Op.1, 2insurance company and OP-3/TPA, in repudiating his health insurance claim and also for cancelling of his health policy and has prayed for direction against the Ops for the payment of Rs.1,58,014/- with interest and compensation amount of Rs.2 lakhs.

 

          2. The case of the Complainant in brief is that, he got ‘Diabetes Safe Insurance Policy’ of Op.1 & 2 through Op.3/TPA with effect from 16.10.14 for a sum of Rs.10 lakhs and got it renewed every year till 2017. On 08.05.17 he was admitted to ‘Dr.Malathi Manipal Hospital, Bengaluru’ with an history of fever with chills, breathlessness, swelling of lower limbs and anasarca from two months and sought for preliminary amount of Rs.15,000/- towards estimated cost of Rs.65,000/-. The Op.1 approved vide letter dtd.11.05.17. Then the Op.1 through letter dtd.23.05.17 rejected the cashless benefits and also cancelled the policy with effect from 02.08.17 on the ground of alleged ‘non-disclosure’ of material facts. He had checked his health vide lab reports dtd.16.09.14 to 26.12.14 which show normal health.  He has spent Rs.1,58,014/- towards hospital bills. The rejection of his insurance claim by the Ops amounts to deficiency in service. Hence, he issued legal notice dtd.31.05.17 and it was replied by Op.3 only and not by Op.1 & 2 and hence this complaint is filed.

 

          3. The Op.1 & 2 together and Op.3 separately filed their versions. Op.3 has contended that, there is no cause of action against him to seek the remedy as prayed for in the complaint. He being facilitator and IRDA, accommodated the Complainant and Op.1 & 2 relating to the insurance policy and compliance of the requirements of both the sides. He has coordinated and communicated the messages and nothing can be considered as lapses on his parts. The complaint becomes liable to be dismissed against him.

 

          3a. The Op.1 & 2 commonly contended that, non-disclosure of the particulars in the proposal form disqualifies the complainant for continuation of the policy, after coming to know about the existing facts. The policy was from 16.10.14 and was renewed yearly and the claim is on the third year policy. The said policy is only for ‘Diabetes Safe Insurance’ but not for any other health complaints. That the Complainant was found advised for avoiding the Nephrotoxic drugs and for Serum Creatinine, albumin Creatinine ratio and it shows that at Karnataka Institute of Diabetology, Bengaluru on 16.09.14 and on 05.04.14, he had taken such advice and it was not disclosed in the proposal form of the first policy. It shows that, he was suffering from Diabetic Nephropathy prior to first policy inception and the same was suppressed. It is against the policy condition which amounts to misrepresentation/non-disclosure of the material facts and hence, the claim was repudiated, though initial cashless benefit to the tune of Rs.15,000/- was allowed based on the limited documents then produced. It was without prejudice to his right of proving extent of risk and amount un-payable. Since he failed to produce the original documents for scrutiny even after giving opportunity, the repudiation letter was sent and thereby there is no deficiency on their part. The complaint becomes not maintainable. There is no cause of action for filing the complaint. The legal notice dtd.31.05.17 was duly replied on 14.05.17. As the Complainant himself is the reason for repudiating the claim, he cannot raise grouse against them. The fact of renal problem/diabetic nephrology though was in existence, not filled in the proposal form. Hence, complaint becomes liable to be dismissed with cost.

 

          4. The Complainant, Op.3 and Op.1 & 2 filed their affidavit evidences relying Ex-A1 to A13, Ex-B1 and Ex-B2 to B6 documents respectively. Written arguments filed by Complainant only. Arguments were heard.                    

 

                   

          5. The consumer disputes that arise for consideration are as follows:

 

1. Whether the complainant establishes the deficiency in service against the Opposite parties in repudiating his insurance claim and terminating the policy with effect from 02.08.17 ?
2. Whether the Complainant is entitled to get relief as prayed for ?    
3. To what order the parties are entitled ?

 

6. Answers to the above consumer disputes are as under:

1) Negative

2) Negative

3) As per final order – for the following      

 

REASONS

 

          7. Consumer Dispute No.1: The undisputed facts reveal that, the Complainant got the insurance policy named  “Diabetes Safe insurance policy” started from 16.10.14 for a sum of Rs.10 lakhs. He got the policy renewed and such third policy is Ex-A1 for the period 16.10.16 to 15.10.17.

 

          8. It is also undisputed that, on 08.05.17, he was admitted to Dr.Malathi Manipal Hospital, Bengaluru with an history of fever with chills, breathlessness, swelling of lower limbs from two months. He applied for cashless treatment benefit vide Ex-A2 dtd.11.05.17 and accordingly got Rs.15,000/- as preliminary amount vide letter dtd.11.05.17 of the Op.1.

 

          9. On 15.05.17, the Op.1 sent Ex-A3 letter refusing to enhance the payment on the ground that, submitted ICP dtd.16.10.14 shows the Diabetic Nephropathy first diagnosed and hence all previous consultation papers, Serial creatinine levels and USG done prior to 16.10.14 were required for further processing.  On 23.05.17, the Op.1 rejected the pre-authorization for cashless treatment through Ex-A5/letter with an opinion that the claim is not admissible, as the patient had NPDR and elevated micro albumin/creatinine ratio as per consultation report dtd.05.04.14 and was found advised to avoid Nephro Toxic drugs, which indicated that he has renal complications prior to policy inception and this material facts were not disclosed at the time of policy inception.

 

          10. The Complainant produced Ex-A12 dtd.16.09.14 and Ex-A13 dtd.26.12.14 lab reports which show normal level of Serum Creatinine, Serum Potassium and they were the reports of Haematology issued by United Labs and on the basis of such lab reports, the Complainant got issued legal notice/Ex-A7 dtd.31.05.17 claiming the amount of Rs.1,58,014/- spent by him towards medical treatment and it was served on the Ops vide postal acknowledgement/Ex-A8 & A9 and Op.3 only sent reply Ex-A10/B1 dtd.19.06.17 denying its liability in the absence of his role relating to the remedy he claimed.

 

          11. The Op.1 & 2 had produced the copy of proposal form/Ex-B2 with terms & conditions/Ex-B6 of such policy contending that, the Complainant has violated the terms & conditions of the policy which was issued specifically for ‘Diabetes Safe insurance’ and other health complaints do not cover under the policy.

 

          12. Op.1 & 2 furnished Ex-B3/Nephrology consultation sheet issued by “Karnataka Institute of Diabetology, Bengaluru” and another such follow up sheets/Ex-B4 & B5 having observation dtd.16.09.14, 14.10.14, 26.12.14. On 05.04.14 as mentioned in Ex-B3 sheet, the Complainant was advised to avoid Nephrotoxic Drugs. The contention of Op.1 & 2 that, the Complainant was advised for “Serum Creatinine, albumin Creatinine ratio” as mentioned in Ex-B3 to B5 cannot be ruled out in the absence of rebuttal evidence by the Complainant. Ex-B3 & B4 are the medical opinions obtained on 05.04.14 and 16.09.14 to prove that, he was suffering from ‘Diabetic Nephropathy’ and such ill health was in existence prior to first policy inception i.e. prior to 16.10.14 and the same was not disclosed in the proposal form/Ex-B2.

 

13. In Ex-B2, the Complainant who was shown as “Salaried person having annual income of Rs.5 lakhs” filled up the columns and in front of column no.6c “Any problem relating to Kidney”, he has mentioned “No”. As the title of the insurance policy itself discloses that it is meant only for ‘‘Diabetes Safe Insurance’ and not for any other ill health. Other Ill health problems are mentioned as ‘Nil’ and thereby as rightly contended by Op.1 & 2, the Complainant who was having Nephropathy problem even earlier to the date of policy enforcement as supported by Ex-B4 & B5, not disclosed the same and his act amounts to non-disclosure of material facts to get the insurance policy.

 

14. Insurance policies are issued on the basis of utmost good faith believing the furnished details of the policy holder.  The Ops were deprived of the opportunity to know the existence of the Nephropathy problem before accepting and issue the policy and thereby, they get every right to repudiate the insurance claim for the reasons stated in the repudiation letter and hence, their act does not become the deficiency in service. Accordingly Consumer Dispute No.1 & 2 are answered in the negative.

15. Consumer Dispute No.3: In view of findings of the Consumer Dispute No.1 & 2, the Complainant deserves to get the following:

 

ORDER

 

          The CC.No.2127/2017 filed by the Complainant is hereby dismissed. No order as to costs.

 

          Supply free copy of this order to both the parties. 

 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 31^st December of 2018).

 

 

 

 

(ROOPA.N.R)     MEMBER

(VASANTH KUMAR.H.Y)  PRESIDENT

                                                                        

Copies of Documents marked on behalf of Complainant/s:

 

Ex-A1	Insurance policy
Ex-A2	Authorization for cashless treatment of the insured dtd.11.05.17
Ex-A3	Query letter for enhancement authorization dtd.15.05.17
Ex-A4	Denial of pre-authorization for cashless treatment dtd.18.05.17
Ex-A5	Rejection of pre-authorization for cashless treatment dtd.23.05.17
Ex-A6	Manipal hospital bills receipts and acknowledgements
Ex-A7	Legal notice dt.31.5.2017
Ex-A8	Postal receipts
Ex-A9, A9a	Returned postal acknowledgements
Ex-A10	Reply notice dt.19.6.2017 by Op.3
Ex-A11	Reply issued to Complainant by Op.1 dtd.nil
Ex-A12 & 13	United lab report dt.16.9.2014, 26.12.2014

 

Copy of Document marked on behalf of Opposite party no.3

 

Ex-B1

Reply notice dt.19.6.2017 by Op.3

 

 

Copies of Documents marked on behalf of Opposite party no.1 & 2

 

Ex-B2	Proposal form
Ex-B3 to B5	Follow up sheet dt.5.4.14,16.9.14, 14.10.14, 26.12.14
Ex-B6	Original terms and conditions

 

 

 

 

(ROOPA.N.R)     MEMBER

(VASANTH KUMAR.H.Y)  PRESIDENT