CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD

Dated this the   27^th   day of  February   2017

PRESENT  : SMT. SHINY.P.R, PRESIDENT                    

                         : SMT.SUMA K.P, MEMBER                                        Date of filing: 18/01/ 2016

                  : SRI.V.P.ANANTHA NARAYANAN, MEMBER         

                             CC/03/2016                                          

            Binumol.M,

            W/o.Sajikumar,

            Mammilikad House,                                                                       : Complainant

            Palathully, Peruvamba P.O,

            Palakkad, Kerala.

            Pin-678 531.                                                                                  

                                                                        Vs

1. Star Health and allied Insurance Company Ltd.

  Registered Corporate Office 1,

  New Tank street, ValluvarKottam High Road,

  Nungambakkam, Chennai 600 034.

2. The Branch Manager,

    Star Health and Allied Insurance co.Ltd.,                                : Opposite Parties

    Branch Office, Palakkad, Fine centre, 4^th Floor,

    T.B Road Palakkad. Pin 678 014.

3. N.S Arunachalam agent (Star Health and allied Insurance , Co.Ltd)

     SM Office, Sonu Complex,

     Main Road Chittur,

    Palakkad, Pin code-678 101.     

O R D E R

By Smt. Shiny. P.R, President

Complainant had taken a health plan policy from the opposite parties for himself and his family. The total coverage of the policy was Rs.7,50,000/-and the sum insured was Rs.5,00,000/-.  The validity of the policy was from 27/01/2014 to midnight of 26.01.2015.  The policy was a renewal policy the date of inception of first policy on 25/1/2013 with the same insurance company Ltd.  The scheme of description is that 2A+2c the sum insured at the relevant time.  The schedule policy No/181214/01/2014/003563 was issued to the complainant.

The complainant had a small pain in the neck region.  The complainant along with her husband consulted the doctor and after taking scan and other medical checking, they referred her to LAKESHORE HOSPITAL, Ernakulam for better treatment.  After examination of the complainant the doctors advised her to admit in the hospital.  The Complainant was admitted at Lakeshore Hospital on 18.5.2015 after informing 2^nd and 3^rd opposite parties and discharged the complainant on 23/5/2014, with follow up treatment.

Approval of insurance claim sanctioned by the opposite parties 1 to 3 to the hospital authorities treated the complainant under the policy condition after completing the complaint’s operation on 22/5/2014.  Complainant submitted that the company withdrew the authorization letter without any basis and stating that the present hospitalization is for the management of an ailment which is related to pre-existing condition clause. This is against the policy conditions and violation of the agreement at the time of taking policy. There was deficiency in rendering the service and comply contractual obligation to indemnify the insured. The act of rejection of sum offered by the hospitalization expenditure would causes very much mental sock and agony to petitioner. Complainant prays for an order directing opposite parties to pay Rs.80,983/-towards treatment expenses , Rs.5,00,000/- towards the sum assured with interest and Rs.2,50,000/- for mental agony and difficulties suffered by the complainant.    

          Complaint was admitted and issued notice to all opposite parties. All Opposite parties entered appearance and  filed version. The opposite parties contended that the complaint is not maintainable before the forum. There is neither cause of action for the complaint nor there was any deficiency in the service on the part of the opposite parties as the sickness for which the complainant was admitted in hospital was for a pre existing disease which is clear from the anesthesiology chart of the hospital. The complaint has been filed by suppressing material facts.  The complainant after knowing the benefits and the terms and conditions of the policy had of her own choice had taken policy of opposite party styled as ‘Star Comprehensive Insurance policy’ for the period from 25/01/2013 to 24/01/2014 vide policy No.P/181214/01/2013/004630 covering 4 persons for a sum insured of Rs.5,00,000/-which was further renewed up to 26/01/2015.

          In the proposal form, the insured has specifically declared that the complainant was not suffering from any disease or ailment at the time of submitting the proposal form or any point of time earlier and that her health condition was good in all respects.  In the proposal form, the complainant further declared that if after the insurance policy is effected any particulars stated in the proposal form are found correct the insurance company would incur ‘no liability’ under the policy.

          At the time of admission, the opposite party received a request for cashless treatment from the hospital in which the treating doctor, Dr.Idicula Mathews had stated that duration of the present ailment as 6 months.  Hence this opposite party had sent a query dated 19/5/2014 to the hospital directing them to submit a copy of first consultation reports, copy of case sheets and positive investigation reports supporting diagnosis.  In reply to the said queries, the hospital had submitted a consultation sheet dated 14/5/2014.  Hence based on the documents submitted by the hospital, the opposite party had approved a preliminary amount of Rs.50,000/-.  Later after verifying case sheets from the hospital by the opposite party’s filed visit staff, it is confirmed that the patient had history of 6 years for thyroid swelling.  As the disease was pre existing condition, the opposite party had withdrawn the authorization vide letter dated 22/5/2014.

          The duration of 6 months as stated in the discharge summary was on the basis of collusion made between the complainant and treating doctor only for the purpose of getting the claim and to cause illegal gain.  Even though the insured has not taken any treatment for the illness of goiter, it was an existing illness before the inception of policy and hence it comes under the definition clause of pre-existing disease.  As per the definition clause, it is immaterial that whether the patient had takes treatment or not for her illness. 

          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 48 months of continuance coverage have elapsed, since inception of the first policy with any India Insurance company”.

          Moreover the complainant has not furnished any details regarding her 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.  It is submitted that insurance contracts are “contracts of uberime-fide”. The insured person is not subjected to any medical examination by the opposite party.     The complainant is not entitled for any reliefs as claimed in the complaint.  It is the opposite party who is entitled for cost and compensatory cost from the complainant for having lodged such false and frivolous complaint.        The above complaint is liable to be dismissed.

          Opposite parties filed additional version. It is submitted that after discharge from the hospital, the complainant had submitted claim form for the reimbursement of Rs.83,370/-.  As per the policy terms and conditions, an amount of Rs.8884/- will be deducted from the claimed amount (Diet Charges:-Rs.2115/- Excluded Expenses No.108, Admission Fee:-Rs.250/-Excluded Expenses No.73, Consumables:-Rs.2126/-, Cardiology:-Rs.180/-.  Excluded expenses No.75, Injection:-Rs.320/-Excluded Expenses No.106, Miscellaneous:-Rs.300/-Histopathology:Rs.610/-(Non submission of report), Room luxury Tax Rs.800/-Excluded Expenses No.99, Less Medicine return:-Rs.868/-, New

Registration: Rs.150/-Excluded expenses No.73, Laboratory Charges:- Rs.1165/-(Non submission of reports)  and total amount payable will comes to Rs.74,486/-only.  Therefore it is also submitted that even if this Hon’ble Forum finds any liability upon this opposite parties, then the liability of the opposite parties may be limited to Rs.74,486/-.

Complainant and opposite party filed their respective chief affidavit. Ext.A1 to A12 marked on the side of complainant. Ext B1 to B13 marked from the side of the opposite parties.

The following issues are considered

1. Whether there is deficiency in service on the part of opposite parties?
2. If so, what is the relief?

Issues 1 and 2

          Both parties heard. We have perused the documents filed before the forum.  Opposite party admitted the policy and hospitalization of the complainant. Opposite parties contended that complainant has not furnished any details regarding her health condition in the proposal form despite specific question to this effect. Complainant had history of thyroid swelling since 6 years.  Hence it amounts to Suppression of Material Facts which makes the contract void an initio.

          It is true that as per Ext .B5 the Anesthesiology plan, the complainant herself had given a statement to the Anesthetist that she had history of thyroid swelling since 6 years. But In Ext. B3 discharge summary issued by the hospital states that the complainant had a neck swelling of 6 months duration.  In Ext. B4 certificate issued by the treating doctor, Dr. Idicula Mathews, it is mentioned that complainant has noticed enlargement of the neck mass for the last six months. It is also mentioned that she has had a small neck swelling for about six years which did not need any treatment possibility a  physiologic goiter which had not completed receded. She sought treatment for the same when it showed recent enlargement in size which is a common occurrence in thyroid glands.  Opposite party further contended that as per the definition clause, it is immaterial that whether the patient had takes treatment or not for her illness. On the perusal of definition clause of Ext.B9  nowhere it is mentioned that   it is immaterial that whether the patient had takes treatment or not for her illness. The burden is upon on the opposite parties to prove that the insured has fraudulently suppressed material fact. In the present case we are of the view that the opposite parties have failed to prove that the material facts are suppressed by the complainant at the time of taking of policy. The examination of a doctor who treated the patient, prior to the obtaining of the policy in question,   treatment papers, prescription etc. should have been produced. There is no evidence

which may go to show that she had ever consulted doctor for taking treatment for thyroid swelling since 6 years. Repudiation of the claim amounts to deficiency in service on the part of opposite parties.  Complainant submitted that she had spent an amount of Rs. 80,983/- for the treatment. But opposite parties filed additional version stating that there are some deductions from treatment expenses. On verifying the policy terms and conditions we noticed that there are some excluded expenses.  After deducting that expenditures we are of the view that complainant is entitled to get a claim of Rs.74,486/- from the opposite parties.

 In the above circumstances the complaint is partly allowed. Opposite parties are jointly and severally liable to pay the claim amount of Rs. 74,486/-(Rupees seventy four thousand four hundred and eighty six only) along with 9% interest from the date of repudiation till realization along with cost of  Rs.2,000/- (Rupees Two thousand only) as cost of proceedings to the complainant within one month from the date of this order.  

Pronounced in the open court on this the 27^th   day of February2017.

                      Sd/-

Shyni.P.R

President

    Sd/-

Suma. K.P                         Member

                                                                                                          Sd/-        

          V.P.Anantha Narayanan

                    Member

A P P E N D I X

Exhibits marked on the side of complainant

Ext.A1- Discharge summary of complainant on 23/5/2014

Ext.A2- Investigation Results From 18/05/2014 to 23/05/2014

Ext.A3- Discharge bill of complainant on 23/5/2014

Ext.A4 series- Discharge bill of complainant on 23/5/2014(8 Nos.)

Ext.A5 series- OP pharmacy Cash bill(3 Nos.)

Ext.A6 series- Star Comprehensive Insurance Policy Schedule

Ext.A7- Representation by the complaint to get Medical Expenses on 31/10/2014

Ext.A8 series-Postal Receipt(2 Nos.)

Ext.A9- Estimate copy  

Ext.A10- Withdrawal of Authorization letter dated 22/5/2014

Ext.A11-patient type of Registration dated 14/5/2014

Ext.A12-bystander pass, date of issuew from 18/5/2014 to 28/5/2014.

Exhibits marked on the side of Opposite party

Ext.B1-The copy of the Pre-Authorization Letter

Ext.B2-The copy of the denial of pre-authorization letter dated 22/5/2014

Ext.B3-The copy of the Discharge summary

Ext.B4-The copy of the certificate issued by Dr.Idicula Mathews. Dated on 23/5/2014.

Ext.B5-The copy of the anesthetist report

Ext.B6-The copy of the repudiation letter dated 5/7/2014

Ext.B7-The copy of the policy schedule

Ext.B8-The copy of the proposal form

Ext.B9-The copy of policy condition

Ext.B10-The copy of letter dated 11/5/2015

Ext.B11-The authorization letter

Ext.B12-Documents submit wanted to complainant dated 26/09/2014

Ext.B13-Return back complainant’s original documents dated on 22/09/2014

Witness marked on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost Allowed

2000/-