IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA
Dated this the 31st day of May 2014
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member-I)
C.C. No. 05/2014 (Filed on 01.01.2014)
Between:
Valsamma Korah @ Valsa Rajan,
Puthenpurackal House, Naranamoozhy P.O.,
Ranni-Perunad, Pathanamthitta. … Complainant.
(By Adv. Anu. T. Thomas)
And:
- Star Health & Allied Insurance-
Co. Ltd., Registered Office,
1, New Tank Street,
Valluvar Kottam High Road,
Nungambakkam,
Chennai – 600 034, represented
By its Managing Director.
- Star Health & Allied Insurance Co.
Ltd., Branch Office, First Floor,
Kannampuram Building,
Opp. CTO, M.C. Road,
Kottayam – 686 001, represented
By its Branch Manager. … Opposite parties.
(By Adv. Lovejith. K. Anand)
ORDER
Smt. K.P. Padmasree (Member):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. Brief facts of the case is as follows: The first opposite party is a registered company engaged in imparting insurance services including health insurance service. The second opposite party is a branch office of the first opposite party operating from Kottayam. The complainant availed a health insurances in the name of “Mediclassic – Individual Policy” scheme of the first opposite party in the year 2011 to 2012 through the agent of the opposite parties for an assured sum of Rs. 1,00,000/-. After the expiry of the same, the said policy was renewed by the complainant vide policy No.P/181113/01/2013/002519. As per the terms of the renewed policy, the period of insurance therein extended from 28.11.2012 to 27.11.2013.
3. As per the policy terms, the first opposite party guarantees, inter alia that if, during the continuance of the policy, the insured person incurs hospitalization expenses for medical/surgical treatment at any hospital/nursing home in India as an inpatient, the first opposite party will reimburse the amount of necessary and reasonable expenses incurred by the insured person.
4. During the continuance of the above said policy, the complainant developed an adverse thyroid condition including swelling of left lobe thyroid. On medical examination, she was advised to undergo hemithyroidectomy for left thyroid gland. The complainant was admitted at the Christian Mission Hospital, Pandalam on 25.07.2013 for pre-operative procedures. She was admitted as inpatient and the surgical treatment was undergone by the complainant on 26.07.2013. The complainant duly notified the concerned authorities of the second opposite party about the facts of admission and scheduled hemithyroidectomy, as required under the terms of the policy.
5. For the above said surgical treatment and incidental treatments, the complainant incurred an expense of Rs. 80,592-09. She preferred a claim before the second opposite party for the reimbursement of the said amount as claim No. 78539 dated 02.08.2013 along with the original I.P. discharge bill from the said hospital. But the first opposite party rejected her claim orally alleging that the complainant’s ailment is a pre-existing disease as she had undergone thyroidectomy before taking the policy. The repudiation was confirmed by the first opposite party vide letter dated 04.12.2013. The first opposite party repudiated the claim by alleging pre-existing disease at the time of proposal by not disclosing the pre-existing disease. Complainant has not suppressed any material fact at the time of entering into the contract with the opposite parties. Complainant issued a legal notice on 07.12.2013 to the opposite parties demanding Rs. 80,500/- which the complainant is lawfully entitled. But there is no response from the opposite parties. The repudiation of claim by the opposite parties is a clear deficiency in service which caused mental agony and hardship to the complainant. Hence this complainant for getting Rs. 80,500/- along with interest @ 12%, along with compensation of Rs. 50,000/-.
6. In this case, opposite parties entered appearance and filed common version with the following main contentions: Opposite parties admitted that the complainant had taken Mediclassic – Individual Insurance Policy for the period from 18.11.2011 to 17.11.2012 which has been further renewed upto 04.12.2014. The policy is issued strictly according to the terms and conditions of the policy. The complainant herein had admitted the terms and conditions and exclusions set in the policy and thereafter had signed in the proposal form of the policy. The policy issued to the complainant being a health policy, the complainant is bound to give proper information regarding her present and past health status at the time of filing the proposal which are mentioned for proper underwriting of the proposal. The insured has not mentioned any disease in the health history column of the proposal form despite specific question. Based on the declaration of the complainant and believing her declaration, policy was issued to the complainant.
7. Complainant had submitted completed claim form with medical bills and lab reports. Opposite parties collected case sheet copy from C.M. Hospital, Pandalam which revealed that the complainant underwent hemithyroidectomy surgery at the age of 32 years and was on medication since then. Moreover, she was on continuous medication for hypertension and dyslipidemia. This fact has not been disclosed by the complainant in the proposal form. The discharge summary and claim form with medical certificate are prepared at a later stage which was silent about past history of the complainant. So the claim falls under the exclusion clause No.1 of the policy.
8. Complainant has not informed about her pre-existing disease in the proposal form at the time of medical examination. So she suppressed material facts of the pre-existing disease at the time of taking the policy which is a suppression of fact and is against policy conditions. So there is no deficiency of service on the part of the opposite parties. With the above contentions, opposite parties prays or the dismissal of the complaint with their costs.
9. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
10. The evidence of this complaint consists of the oral testimony of PW1, Exts. A1 to A10 and B1 and B2. After closure of evidence, both sides were heard.
11. The Point: Complainant’s case is that she had taken a Mediclassic – Individual Insurance Policy for the period from 18.11.2011 to 17.11.2012 which has been further renewed upto 04.12.2014. During the continuance of the policy, complainant developed an adverse thyroid problem and admitted as an inpatient at C.M. Hospital, Pandalam on 25.07.2013 and surgery was done on 26.07.2013 and the complainant remained as an inpatient in the said hospital till 29.07.2013 for post-operative care.
12. For the aforesaid surgical treatment and incidental treatment, the complainant incurred an expenditure o Rs. 80,592-09. She preferred a claim before the second opposite party for the re-imbursement of the said amount. The complainant is fully entitled to receive the expenses incurred by her for the aforesaid hospitalization being a valid policy holder of the opposite parties. But opposite parties rejected the claim alleging the complainant’s ailment as a pre-existing disease and she suppressed the said material facts at the time of taking the policy. The repudiation of the claim by the opposite parties is a clear deficiency in service and the opposite parties are liable to the complainant.
13. In order to prove the complainant’s case, complainant filed proof affidavit along with 10 documents. On the basis of the proof affidavit, complainant was examined as PW1 and the documents produced are marked as Exts. A1 to A10. E xt. A1 is the Mediclassic Health Insurance Policy Schedule dated 28.11.2012 issued by the opposite parties. Ext. A2 is the premium certificate dated 28.11.2012 issued by the opposite parties to the complainant. Ext. A3 is the advance premium receipt dated 28.11.2012 issued by the opposite parties to the complainant. Ext. A4 is the terms and conditions o Mediclassic Insurance Policy of the opposite parties. Ext. A5 is the I.P. discharge bill bearing bill 63250 for an amount of Rs. 80,592-09 issued from C.M. Hospital, Pandalam to the complainant. Ext. A6 is the copy of the claim form by the complainant. Ext. A7 is the repudiation letter of claim issued by the opposite parties on 04.12.2013. Ext. A8 is the copy of lawyer’s notice dated 07.12.2013 issued by the complainant to the opposite parties. Ext. A9 is the postal receipts dated 12.12.2013 of Ext. A8 lawyer’s notice. Ext. A10 is the acknowledgment card of Ext. A8 lawyer’s notice.
14. On the other hand, the contention of the opposite parties is that, policy issued to the complainant is a health policy, which is issued strictly according to the terms and conditions of the policy. Opposite parties collected medical records of the complainant from the hospital and found that the said disease is a pre-existing one. Hence the claim was repudiated based on the terms and conditions of the policy. There is no deficiency in service from the part of the opposite parties.
15. In order to prove the case of the opposite parties, no witnesses were examined on their side. Two documents produced are marked as Exts. B1 and B2. Ext. B1 is the proposal form. Ext. B2 is the case sheet of the complainant from C.M. Hospital, Pandalam.
16. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record and found that there is no dispute that the complainant has a valid policy at the time of treatment. The only dispute is that the treatment undergone by the complainant is pre-existing and as per the terms and conditions of the policy, complainant is not entitled to get the treatment expenses.
17. According to the opposite parties, complainant’s ailment is a pre-existing one and as per the terms and conditions of the policy, pre-existing disease is not covered by the policy. On going through the entire evidence adduced by both the parties, it is clear that the complainant undergone hemithyroidectomy in the year 1981. The contention of opposite parties is that since she was suffering from a pre-existing disease, they are not liable to provide any coverage under the policy. For substantiating this, they are relying Ext. B2 which is the case sheet of the complainant. According to them, the entries seen in Ext. B2 is as follows: “H/o Hemi thyroidectomy in 1981. On Thyroxine (100) since then”. Their argument is that the last 2 words “since then” which means that she was under treatment from 1981 onwards and as such the ailment is a pre-existing disease. But they have not adduced any evidence to show that the last words seen in Ext. B2 is “since then” and she was continuing her treatment from 1981 onwards. Mere production of a document and interpreting indistinct words therein as “since then” without proving the same through the doctor who made it in Ext. B2 cannot be accepted.
18. On the other hand, Ext. A6 which is the claim form submitted by the complainant in which there are specific columns to be filled in by the treated doctor. Columns 6 to 8 are relevant. The entries made by the doctor in columns 6 to 8 in Ext. A6 clearly shows that the complainant’s present ailment is not a pre-existing disease and the complaints is only 12 weeks old. The doctor further given his answer as “No” for the question whether the present ailment is a complication of pre-existing disease (column No.8). From this, it is clear that the present ailment for which the complainant had undergone treatment is not a pre-existing disease. Further nobody can say that left hemi-thyroidectomy done to a patient in the year 2013 is the continuation of right hemi thyroidectomy done 30 years ago unless and until it is proved with cogent evidence. Therefore, we find that the allegation pre-existing disease and suppression of material facts raised by the opposite parties is not sustainable. In the circumstances, the repudiation of the claim by the opposite parties will not stand and it is a clear deficiency in service. Therefore, this complaint is allowable.
19. In the result, this complaint is allowed, thereby the opposite parties are directed to pay an amount of Rs. 80,592-09 (Rupees Eighty thousand five hundred and ninety two and nine paise only) the actual medical expense as per Ext. A5 along with Rs. 2,500/- (Rupees Two thousand five hundred only) as compesation and Rs. 1,000/- (Rupees One thousand only) as cost to the complainant within 30 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with 9% interest per annum from today till the realization of the whole amount.
Declared in the Open Forum on this the 31st day of May, 2014.
(Sd/-)
K.P. Padmasree
(Member-I)
Sri. Jacob Stephen (President) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Valsa Rajan.
Exhibits marked on the side of the complainant:
A1 : Mediclassic Health Insurance Policy Schedule dated 28.11.2012 issued by the
opposite parties.
A2 : Premium certificate dated 28.11.2012 issued by the opposite parties to the
complainant.
A3 : Advance premium receipt dated 28.11.2012 issued by the opposite parties to the
complainant.
A4 : Terms and conditions of Mediclassic Insurance Policy of the opposite parties. A5 : I.P. discharge bill No. 63250 dated 29.07.2013 for an amount of Rs. 80,592-09
issued from Christian Mission Hospital, Pandalam to the complainant.
A6 : Copy of the claim form.
A7 : Repudiation letter of claim issued by the opposite parties on 04.12.2013.
A8: : Copy of lawyer’s notice dated 07.12.2013 issued by the complainant to the
opposite parties.
A9 : Postal receipts dated 12.12.2013 of Ext. A8 lawyer’s notice.
A10 : Acknowledgment card of Ext. A8 lawyer’s notice.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties:
B1 : Proposal form.
B2 : Case sheet of the complainant from C.M. Hospital, Pandalam.
(By Order)
(Sd/-)
Senior Superintendent
Copy to: (1) Valsamma Korah @ Valsa Rajan, Puthenpurackal House, Naranamoozhy P.O.,
Ranni-Perunad, Pathanamthitta.
- The Managing Director, Star Health & Allied Insurance Co. Ltd., Registered
Office,1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai – 600 034.
- The Branch Manager, Star Health & Allied Insurance Co.Ltd., Branch Office, First
Floor, Kannampuram Building, Opp. CTO, M.C. Road, Kottayam – 686 001.
- Stock file.
