Tamil Nadu

South Chennai

CC/210/2013

V.Sekar. - Complainant(s)

Versus

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

V.S.Mannarsamy

14 Mar 2019

ORDER

                                                                        Date of Filing  : 20.06.2013

                                                                          Date of Order : 14.03.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP. : MEMBER

 

C.C. No.210/2013

DATED THIS THURSDAY THE 14^TH DAY OF MARCH 2019

                                 

V. Sekar,

S/o. Mr. Vasu,

No.24, First Street,

Govindasamy Nagar,

Kandanchavadi,

Chennai – 600 096.                                                     .. Complainant.                                                           ..Versus..

 

1. The Manager,

M/s. Star Health and Allied Insurance Company Limited,

No.1, New Tank Street,

Valluvarkottam High Road,

Chennai – 600 034.       

 

2. The Manager,

M/s. Star Health and Allied Insurance Company Limited,

Branch Office,

Panna Plaza,

New No.137, Old Nos.73 & 74,

2^nd Floor, Arcot Road,

Kodambakkam,

Chennai – 600 024.                                                 ..  Opposite parties.

          

Counsel for the complainant                  : M/s. A. Ramesh Manikandan

                                                                   & another

Counsel for the opposite parties 1 & 2 : M/s. N. Vijayaraghavan &

                                                                  another

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 & 2 under section 12 of the Consumer Protection Act, 1986 prays to pay a sum of Rs.80,279/- towards the surgery expenses for acute appendicitis as agreed by the 1^st opposite party in his authorization letter dated:23.01.2013 with interest at the rate of 12% p.a. and to pay a sum of Rs.7,00,000/- towards compensation for mental agony with cost to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he is a medical policy holder in the name of Family Health Optima Insurance Policy under the opposite parties vide policy No.P/1111160/01/2012/009484 for the period from 29.03.2012 to 28.03.2013 on proper renewal.    The complainant submits that he availed such policy for the assured sum of Rs.4,00,000/- to his entire family.  On 23.01.2013 at about 05.00 A.M., he developed acute lower abdomen pain and was taken to Fortis Malar Hospital, Adyar, Chennai – 600 020 and got admitted.  After required test, and medical examination, the complainant was diagnosed with acute appendicitis and due surgery was performed on the same day 23.01.2013 at about 07.00 P.M. Due intimation to the opposite parties was given and the opposite parties had accepted for cashless treatment and due authorisation letter dated:23.01.2013 was issued by the opposite parties and paid a sum of Rs.20,000/- as advance.   After surgery, the Fortis Malar Hospital, Adyar issued Discharge Summary along with impatient bill for a sum of Rs.70,279/- deducting the advance amount of Rs.10,000/- after due surgery and before the discharge of the complainant from the hospital. The complainant submits that the claim was made through the hospital authorities.  The opposite parties instead of paying / settling the hospital expenditure, issued withdrawal authorisation letter dated:25.01.2013.   The complainant submits that on 02.02.2013, the policy was duly renewed and thereafter on 15.02.2013, the complainant issued legal notice dated:15.02.2013 claiming reimbursement of the medical expenses.   The complainant submits that due to the sudden withdrawal of the authorisation letter and repudiation of medical claim to secure the amount for settling the medical expenses, the complainant and his entire family was put to great hardship.  The act of the opposite parties amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

2.      The brief averments in the written version filed by opposite parties 1 & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and puts the complainant to strict proof of the same.    The opposite parties 1 & 2 state that the complainant has availed Family Health Optima Insurance Policy vide policy No.P/1111160/01/2012/009484 for the period from 29.03.2012 to 28.03.2013 after due renewal.    Immediately after admitting in Fortis Malar Hospital, Adyar on 23.01.2013, the complainant has lodged the claim on cashless basis.  On a bonafide trust and reason the opposite parties issued authorisation and paid a sum of Rs.20,000/-. After careful scrutiny of the medical reports forwarded from Fortis Malar Hospital, the expert house medical doctors of the opposite parties reported that the claim is ‘Not Admissible’.  Hence, the opposite parties had withdrawn the initial authorisation for settlement of medical expenses on cashless basis.  The opposite parties 1 & 2 state that the complainant was suffering from pre-existing physical condition and specific facts as renal stone removal, seizure disorder, Apical Hypertrophic Cardio Myopathy were not disclosed in the proposal.   The opposite parties 1 & 2 state that the contract of insurance is ‘Uberrimae Fidei’ issued only on the basis of good faith.  Therefore, there is no deficiency in service on the part of the opposite parties 1 & 2 and hence, the complaint is liable to be dismissed.

3.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A11 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and documents Ex.B1 to Ex.B5 are marked on the side of the opposite parties 1 & 2.  

 

 

4.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.80,279/- towards the surgical expenses from the opposite parties with interest at the rate of 12% p.a. as prayed for?
2. Whether the complainant is entitled to a sum of Rs.7,00,000/- towards compensation for mental agony with cost as prayed for?

5.      On point:-

Both parties filed their respective written arguments. Heard the complainant’s Counsel also.  Perused the records namely the complaint, written version, proof affidavits and documents.  The complainant pleaded and contended that he is a medical policy holder in the name of Family Health Optima Insurance Policy under the opposite parties vide policy No.P/1111160/01/2012/009484 for the period from 29.03.2012 to 28.03.2013 as per Ex.A1 to Ex.A3 on proper renewal.  Further the contention of the complainant is that he availed such policy for the assured sum of Rs.4,00,000/- to his entire family.  On 23.01.2013 at about 05.00 A.M., he developed acute lower abdomen pain and was taken to Fortis Malar Hospital, Adyar, Chennai – 600 020 and got admitted as per Ex.A4.  After required test, and medical examination, the complainant was diagnosed with acute appendicitis and due surgery was performed on the same day 23.01.2013 at about 07.00 P.M.   While admitting the hospital for treatment, the complaint has paid a sum of Rs.10,000/-.  Due intimation to the opposite parties was given and the opposite parties had accepted for cashless treatment and due authorisation letter dated:23.01.2013 as per Ex.A5 was issued by the opposite parties and paid a sum of Rs.20,000/- as advance.   After surgery, the Fortis Malar Hospital, Adyar issued Discharge Summary as per Ex.A7 along with impatient bill for a sum of Rs.70,279/- deducting the advance amount of Rs.10,000/- after due surgery and before the discharge of the complainant from the hospital.  Due claim was made through the hospital authorities. The opposite parties instead of paying / settling the hospital expenditure issued withdrawal authorisation letter as per Ex.A9 stating that “NON DECLARATION OF HOCM, RENAL DISEASE, SEISURE DISORDER, PRIOR TO INCEPTION OF POLICY, CASHLESS CANCELLED.  Hence, authorization is withdrawn and stands null and void”. On the basis of the entry in the Discharge Summary vide Ex.A7 that “Known to have Apical hypertrophic. Cardiomyopathy with normal LV function.  Has seizures disorder”.    But neither the Doctor who treated the complainant/ patient nor the opposite parties has not produced any document / medical documents to prove such known factors.  Even at the time of surgery also, they have not experienced any reflections on the alleged known factors. 

6.     Further the complainant contended that on 02.02.2013, the policy was duly renewed as per Ex.A10 and thereafter on 15.02.2013, issued legal notice as per Ex.A11 claiming reimbursement of the medical expenses.   Further the contention of the complainant is that due to the sudden withdrawal of the authorisation letter and repudiation of medical claim to secure the amount for settling the medical expenses, the complainant and his entire family was put to great hardship which amounts to deficiency in service.  Equally, admitting the subsistence of policy and sanctioning the cashless treatment and sudden withdrawal without any basis by the opposite party amounts to unfair trade practice.  The complainant is claiming reimbursement of medical expenses amounting Rs.80,279/- and a compensation of Rs.7,00,000/- towards mental agony.   But the complainant has not adduced substantial for such huge claim.

7.     The learned Counsel for the opposite parties 1 & 2 would contend that admittedly, the complainant has availed Family Health Optima Insurance Policy vide policy No.P/1111160/01/2012/009484 for the period from 29.03.2012 to 28.03.2013 after due renewal.  Ex.B1 is the copy of Insurance policy with terms and conditions.  Immediately, after admitting in Fortis Malar Hospital, Adyar on 23.01.2013, the complainant has lodged the claim on cashless basis as per Ex.B3, claim form.  On a bonafide trust and reason the opposite parties issued authorisation and paid a sum of Rs.20,000/-. After careful scrutiny of the medical reports forwarded from Fortis Malar Hospital, the expert house medical doctors of the opposite parties reported that the claim is ‘Not Admissible’.  Hence, the opposite parties had withdrawn the initial authorisation for settlement of medical expenses on cashless basis.  The opposite parties had filed Ex.B2 in detail showing the pre–existing nature of the disease of the complainant.  But on a careful perusal of Ex.B7, it is apparently clear that the report of the house expert medical doctors is invented self serving document without medical literature and passed history on the basis of medical records which amounts to deficiency in service and unfair trade practice.   Further the contention of the opposite parties 1 & 2 is that the complainant was already suffered from history of seizure disorder and had undergone renal stone removal 8 years back and affected with Apical Hypertrophic Cardio Myopathy.   To prove such volumes of disease, the opposite parties has not taken any steps to produce past medical records also.    Further the contention of the opposite parties 1 & 2 is that the contract of insurance is ‘Uberrimae Fidei’ issued only on the basis of good faith.   In this case, the complainant suppressed the above said renal stone removal etc for availing policy.  But the opposite parties has not produced any details of such treatment or disorder undergone by the complainant in order to repudiate the claim.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 shall pay a sum of Rs.70,279/- towards medical expenses incurred by the complainant with 9% interest p.a. from the date of complaint to till the date of this order and shall pay a compensation of Rs.25,000/- for mental agony with cost of Rs.5,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.70,279/- (Rupees Seventy thousand two hundred and seventy nine only) being medical expenses incurred by the complainant with interest at the rate of 9% p.a. from the date of complaint (i.e.) 20.06.2013 to till the date of this order (i.e.) 14.03.2019 and to pay a sum of Rs.25,000/- (Rupees Twenty five thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 14^th day of March 2019. 

 

MEMBER                                                                  PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	28.03.2009	Copy of Policy Number P/11111/01/2009/003758
Ex.A2	26.03.2010	Copy of Policy Number P/11111/01/2010/006826
Ex.A3	20.03.2012	Copy of Policy Number P/11111/01/2012/009484
Ex.A4	23.01.2013	Copy of the receipt issued by the hospital
Ex.A5	23.01.2013	Copy of the authorization letter issued by the opposite party to the hospital to claim insurance
Ex.A6	23.01.2013	Copy of inpatient bill summary
Ex.A7	23.01.2013	Copy of Discharge Summary
Ex.A8	25.01.2013	Copy of Denial of cashless letter
Ex.A9	25.01.2013	Copy of withdrawal of authorization letter
Ex.A10	02.02.2013	Copy of renewal policy notice
Ex.A11	15.02.2013	Copy of legal notice to the opposite party with acknowledgement due

 

OPPOSITE PARTIES 1 & 2 SIDE DOCUMENTS:-

Ex.B1		Copy of insurance policy with terms and conditions
Ex.B2	23.01.2013	Copy of Field Report
Ex.B3	23.01.2013	Copy of Claim Form
Ex.B4	23.01.2013	Copy of initial examination medical sheet of the complainant
Ex.B5	27.03.2013	Copy of Proposal Form

 

 

MEMBER                                                                  PRESIDENT