IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present:
Sri. Bose Augustine, President
Smt. Renu P. Gopalan, Member
CC No. 51/16
Friday the 29th day of December, 2017
Complainant : Joseph Philip
Punnasseril House,
Veloor PO, Kottayam.
Pin 686003.Now residing at
Kovoor House, Amalagiri PO,
Kottayam-686561.
(Adv. K. Karjet)
Vs.
Opposite parties : 1) Star Health & Allied Insurance
Co.Ltd, Zonal Office, 4th Floor,
Carmel Towers, Cotton Hill PO,
Vazhuthacadu, Thiruvananthapuram- 695 014
Rept.by its Vice President
2) Branch Manager,
Star Health & allied Insurance
Co.Ltd. 11nd Floor,
Puthenpurackal Complex, MC Road, Kottayam- 686013
(Adv.T.J. Lakshmanan)
O R D E R
Sri. Bose Augustine, President
The case of the complainant filed on 29/1/16 is as follows.
The complainant is a holder of Family Health Optima Insurance policy of the opposite parties. The said policy gives insurance coverage for hospitalization to the complainant and his wife for any illness and can be treated at any hospital and no bill is to be paid for the expenses incurred at the hospital. The said health insurance policy was taken on 2-3-12 and it is renewed every year, lastly renewed on 2-2-15 for the period from 2-3-15 to 1-3-16. The complainant remitted Rs.20764/- as premium amount and the sum assured is Rs. 3 lakhs. On 5-8-15 the complainant’s wife Ramani Jacob was admitted at KIMS Hospital, Kudamaloor and underwent total Knee replacement surgery. The KIMS Hospital authority had sent a proposal to the opposite parties vide claim intimation No.CLI/2016/181113/0120814 for getting preauthorization for reimbursement of the hospital expenses of the above surgery for Rs.2,29,508/- from the opposite parties under the medi claim scheme provided by the opposite parties. But the said request was denied by the opposite party vide letter dated 10-8-15 without having any valid reason. So the hospital authorities insisted for cash payment. But the complainant has another policy with National Insurance Company and an amount of Rs.95,250/- has been sanctioned by the National Insurance Company. The balance amount of Rs.1,31,258/- had been paid by the complainant in cash at the time of discharge on 18-8-15. Thereafter on 10-9-15 the complainant sent a letter to the 2nd opposite party for sanctioning the above amount along with the pre hospitalization charge of Rs.2250/- and post hospitalization charge of Rs.56750/-. But they repudiated the claim by their letter dated 28-9-15 stating that the illness has commenced prior to the date of inception of the policy, it is not disclosed in the proposal form and it falls under Exclusion clause. Then on
12-10-15 again the complainant submitted claim for reconsideration along with the certificate of the doctor who had conducted surgery. It was also denied by the opposite party vide letter dated 20-11-15. According to the complainant his wife had no previous diagnosis of Osteo Arthritis of knee or she had any pre-existing condition ailment or injury or related condition and had signs or symptoms of the disease and that she was not diagnosed or received medical advice of treatment for the same. According to the complainant the act of opposite parties in repudiating the claim of the complainant on baseless allegations amounts to deficiency in service. Hence this complaint filed for the order directing the opposite parties to pay Rs.1,34,075/- the amount remitted to the hospital by the complainant for the treatment.
Opposite parties filed version admitting the issuance of the policy to the complainant and his wife for the period from 2-3-15 to 1-3-16. According to the opposite parties they granted the insurance coverage subject to the terms and conditions of the policy and it is a settled law that the parties to the insurance contract are bound by the terms and conditions of the policy. The proposal form is the basis of insurance contract, on which the policy is issued. In the proposal from, both the insured declared that they have not suffered any illness except high B.P and heart disease. It is also declared that if after the insurance policy is effected any particulars stated in the proposal form are found incorrect, the insurance company would incur ‘no liability’ under the policy. According to the opposite parties the insured Mrs. Ramani Jacob was diagnosed with bilateral severe Osteoarthritis Knees. And the insured through the hospital submitted a request form for cashless hospitalization benefit. After receiving the same the insurance company made a query on the said request and call for the copies of first consultation and duration of said diagnosis. The hospital authorities provided the medical records and as per the medical records of KIMS hospital, the insured is having the bilateral knee pain for the last 7 years. And the investigation of the opposite party it is revealed that the insured/patient was treated for OA Knee bilateral in 2010 at SH Medical Center, Kottayam. The commencement of policy is only from 2-3-12 and the history of treatment is not disclosed by the insured in the proposal form. So the claim of the insured was repudiated vide letter dated 28-9-15 on the ground of the pre-existing disease and suppression of material facts. According to the opposite parties, there is no deficiency in service on the part of them and they prayed for dismissal of the complaint with cost.
Points for considerations are:
- Whether there is any deficiency in service on the part of opposite parties?
- Relief and costs?
Evidence in this case consists of the proof affidavit of the complainant and Ext.A1 to A8 documents from the side of the complainant and Exts. B1 to B3 and X1 documents from the side of opposite parties.
Point No.1
The crux of the complainant’s case is that opposite party had illegally repudiated his medi claim with regard to the treatment of his wife Ramani Jacob. After admitting at KIMS hospital, he had sent a proposal to the opposite parties for getting pre authorisation for reimbursement of the hospital expenses of the surgery. But it was repudiated by them. According to the complainant he had another policy with National Insurance Company, they had sanctioned Rs.95250/- and he had paid Rs.1,31,258/-, the balance amount, to the hospital. Thereafter he submitted claim to the opposite parties. But it is also repudiated by them. The repudiation letter produced by the complainant is marked as Ext. A5. In Ext. A5 the reasons for repudiation is stated that the treatment records clearly reveal that the patient was suffering from Bilateral Knee pain since 7 years. So the existing illnesses suppressed while taking policy by the complainant. In the proposal form complainant revealed Hypertension and cardio vascular disease as pre-existing health related complaints. So according to opposite party obtaining a policy without disclosing the full facts on health of a person would make the insurance policy void ab initio. Furthermore from the medical records from the KIMS hospital, where the patient was treated, it is found that the insured is having the bilateral knee pain for the last 7 years. And on the investigation it is also revealed that the insured / patient was treated for OA Knee bilateral in 2010 at SH Medical Center, Kottayam and the said fact was not disclosed by the insured in the proposal Form. So they had repudiated the claim of the insured on the ground of pre-existing disease and suppression of material facts, which falls under the exclusion clause. Ext. A6 is a certificate issued by Dr. O.T. George, Senior consultant, Orthopaedics, who was treated the patient at KIMS Hospital. In Ext. A6, the doctor certified that the patient had knee pain in 2009. But there is no evidence of osteoarthritis of knee during the following years. The doctor opined that she was diagnosed to have osteoarthritis of knee only after. She had knee pain and difficulty in walking for the last 6 months. So from Ext. A6 certificate it can be inferred that the complainant had no pre-existing disease at the time of inception of policy.
In our view the act of opposite parties, repudiating the claim of the complainant on flimsy ground, amounts to deficiency in service. Opposite party has not disputed the claim amount. Due to the said act of opposite parties complainant had suffered much mental pain and suffering. Point No.1 is found accordingly.
Point No.2
In view of the findings in Point No.1 complaint is allowed.
In the result,
- The opposite parties are ordered to pay Rs.1,34,075/- the claim amount, with 9% interest from the date of complaint till realization, to the complainant.
- Since interest is allowed no cost is ordered.
- The opposite parties are ordered to pay Rs.5000/- as cost of litigation to the complainant.
The Order shall be complied with within 30 days from the date of receipt of copy of the order.
Pronounced in the Open Forum on this 29th day of December, 2017
Sri. Bose Augustine, President Sd/-
Smt. Renu P. Gopalan, Member Sd/-
Appendix
Documents of complainant
Ext.A1-Insurance policy No.P/181113/01/2015/004998
Ext.A2-Copy of statement of account with medical bills
Ext.A3-Copy of Denial letter of cashless payment dtd 10/8/15
Ext.A4-Copy of letter dtd 10/9/15
Ext.A5-Copy of repudiation letter dtd28/9/15
Ext.A6-Copy of certificate issued by Dr. OT.George dtd.12/10/15
Ext.A7-Copy of letter No.ZO/CLAIMS/2015/655 dtd 20/11/15
Ext.A8-Photocopy of Request for Pre under writing Medical Examination
dtd 2/3/11 (Medical Examination Report) of Bharat hospital
Documents for the opposite parties
Ext. B1-copy of proposal form
Ext. B2- copy of insurance policy with terms and conditions
Ext. B3- copy of discharge summary with medical records of the insured
Ext. X1- treatment record of the insured from SH Medical centre
By order,
Senior Superintendent
