Karnataka

Bangalore 4th Additional

CC/15/810

Mrs. Rukmani Harigopal - Complainant(s)

Versus

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

In Person

02 Nov 2018

ORDER

Complaint filed on: 23.04.2015

                                                      Disposed on: 02.11.2018

 

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.810/2015

DATED THIS THE 2^ND NOVEMBER OF 2018

 

PRESENT

 

 

SRI.S.L.PATIL, PRESIDENT

SMT.N.R.ROOPA, MEMBER

 

Complainant/s: -                           

Mrs.Rukmani Harigopal,

Aged about 75 years,

W/o Late Mr.Harigopal,

R/at no.873, 3^rd cross,

7^th main, HAL II stage, Indiranagar,

Bengaluru-38.

 

By Adv.Sri.Ravi Jagan     

 

V/s

Opposite party/s

Respondent/s:-

 

Star Health & Allied

Insurance co., ltd.,

No.01, New Tank Street, Valluvarkottam High Road, Nungambakkam,

Chennai-600034

 

By Adv.Sri.Y.P.Venkatapathi

 

 

PRESIDENT: SRI.S.L.PATIL

 

 

            This complaint is filed by the Complainant against the Opposite party (herein after referred as Op) seeking issuance of direction to pay Rs.71,530/- being the sum incurred on account of her hospitalization with interest at 12% p.a. from the date of repudiation till the date of payment. Further direct Op to pay compensation of Rs.2 lakhs, cost of Rs.10,000/- and to grant such other reliefs deem fit for which the Complainant is entitled to.

 

          2. The brief facts of the case of the Complainant are that, Sri.Sunil Harigopal is the son of the Complainant has proposed the Complainant for insurance cover with Op. The Complainant is a home maker. The objective behind seeking the insurance cover was to cover the Complainant’s health-meaning to cover eventualities and expenses that would be incurred in the event of her suffering an illness requiring medical treatment and hospitalization. Accordingly, during 19.10.13, the Complainant had approached the Op and sought to take out a “Senior Citizens Red Carpet Insurance”.  The Complainant further submits that, as a precursor, she and her proposer were required to fill out a proposal form. The proposal form amongst other things, required the Complainant to disclose various details, pertinent amongst such details disclosed were:

Medical history:

Preceding 12 months from the date of the proposal: infection near the right ankle. Treatment complete.

Beyond preceding 12 months, date of proposal: Giddiness/BP in 1999, under medication.

Additional questions: CVA/Brain stroke: Yes/No. The Complainant had answered as No.

The Complainant had thus disclosed truly and faithfully her medical history/ailments and record of hospitalization since 1999. A good 14 years prior to 2013. The Complainant further submits that, thereafter upon the request of Op, the Complainant had attached alongwith email dtd.31.10.13 sent by the proposer, the discharge summary of the Complainant relating to her hospitalization during 2013, on account of ‘infection near right ankle’. Op after due verification and satisfaction, had accepted the proposal of the Complainant and had issued a ‘Senior Citizen Red Carpet Insurance policy.’ The Complainant had paid the Op the premium prescribed under the policy. The Complainant further submits that, she had suffered an injury to her right leg, which required hospitalization and treatment between 12.07.14 and 18.07.14 at the Manipal hospital, Bengaluru. The diagnosis and treatment administered was for ‘Cellulitis Right Leg’.  At the inception of the aforesaid hospitalization, the Complainant reasonable assumed that being covered under insurance by Op, she was entitled to cashless treatment and accordingly sought the pre-authorization for cashless treatment from Op. The Complainant was dismayed when the aforesaid request was rejected by the Op by its letter dtd.17.07.14 addressed to the said hospital. The reason assigned by Op for such rejection was ‘All pre-existing disease/conditions………preceding 12 months from the date of proposal. The Complainant further submits that, after settling the hospital bill of Rs.71,530/- took up this matter with the Op. And upon further persuasion the Op agreed to reconsider the claim of the Complainant and required her to submit her claim, which the Complainant did. The Complainant further submits that, Op by its letter dtd.08.08.14 required the Complainant to provide to it, further documents/details as found in the aforesaid letter. The Complainant through her son, under email dtd.16.08.14 had sent Op, her discharge summary pertaining to her hospitalization during 1999. Op by its letter dtd.13.09.14 informed the Complainant that not only was it rejecting her claim for reimbursement of Rs.71,530/- but it was also canceling her insurance policy on account of ‘non-declaration of pre-existing disease and misrepresentation/non-disclosure of material facts’ in her proposal form. Hence prays to allow the complaint.

 

3. On receipt of the notice, Op did appear and filed version denying the contents of the complaint. The sum and substance of the version of the Op are that, the complaint filed by the Complainant is not maintainable either in law or on facts, hence liable to be dismissed.  The Op further submits that, claim of the Complainant falls within 8 months of the very first policy. The policy was issued for the alleged period subject to and with presumption that, the insured will disclose all the facts without suppressing anything about the past and present health condition of himself/insured and there will be no suppression or and misrepresentation of facts by the insured. However, the Complainant has not acted accordingly. The policy was obtained for the period from 31.10.13 to 30.10.14, subject to terms & conditions. The Op further submits that, on receipt of the intimation of claim for cashless facility, from the hospital, Op scrutinized the claim records as provided by the hospital and found that, the insured patient was admitted for treatment of right leg cellulites which is suffered from the period even prior to the inception of the policy, which is the very first policy. Hence, the Op denied the cashless authorization and the same was communicated to the Complainant through the letter dtd.01.08.14. However, it was asked the insured to produce the documents and come for reimbursement, if permitted, to consider claim, under the policy. On producing certain documents seeking reimbursement, it was asked the insured to produce further documents, as the Complainant had many health problems as per the particulars gathered and there was need for further scrutiny of the documents and ascertaining of the facts. On producing the discharge summary dtd.23.07.1999 to 27.07.1999, she was treated for left cerebral infarct, which she had not disclosed in the proposal form and also even in the additional questionnaire, the ailment was incepted even prior to inception of first policy. The Op further submits that, the discharge summary dtd.09.10.12 to 15.10.13 states that the Complainant was admitted for treatment of Osteomyelitis of right lateral malleolus. Although the present admission of the insured was for the treatment of right leg cellulites, it can be observed from the discharge summary of Mallya hospital for the admission from 12.10.13 to 15.10.13, the insured patient is a case of Osteomyelitis right lateral malleolus, from the outpatient records of the above hospital states that the insured is an old case of CVA and the discharge summary of Mallya hospital for the admission for the insured patient from 23.07.1999 to 28.07.1999, states that, she has been treated for left cerebral infarct. All these are prior to the inception of the first policy and not disclosed at the time of the execution of the proposal form. On perusal of the proposal form, the Complainant had not stated or disclosed the said past health history. The act amounts non-disclosure of material facts. As per condition no.7 of the policy issued to the Complainant “if there is any misrepresentation/non-disclosure of the material facts, whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.” Hence, thus and based on the above, for non-disclosure of material facts, the claim was repudiated and the same was communicated on 30.09.14. The Op has repudiated the claim for valid and tenable reason. Without prejudice and assuming that, the Complainant proves her eligibility for the claim, the claim is governed by the policy terms & conditions and exclusion clauses. As per exclusion no.5, 50% of each and every claim out of all pre-existing diseases and 30% in case of all other claims which are to be borne by the insured. There is not truthfulness in the claim made. Hence, the claim and claimed amounts to be proved by the Complainant. Hence on these grounds and other grounds prays for dismissal of the complaint.

         

          4. The Complainant to substantiate her case filed affidavit evidence and got marked the documents as Ex-A1 to A14. The Joint Vice President of Op filed affidavit evidence and got marked the documents as Ex-B1 to B7. Written arguments filed by Complainant only. Heard both side.

  

5. The points that arise for our consideration are:

1. Whether is there any deficiency of service on the part of Op, if so, whether the Complainant entitled for the relief sought for ?  
2. What order ?

 

           

 

6.  Our answers to the above points are as under:

 

Point no.1: In the Affirmative   

Point no.2: As per the final order for the following

 

REASONS

 

          7. Point no.1:  We have briefly stated the facts of the complaint and also version filed by the Op. The undisputed facts which reveal from the pleadings of the parties goes to show that, Complainant has availed the health insurance policy named as “Senior Citizens Red Carpet Insurance” (hereinafter referred as the said policy). As a precursor, the Complainant and her proposer were required to fill out a proposal form. The proposal form amongst other things, required the Complainant to disclose various details. Accordingly, she disclosed her details as:

Medical history:

Preceding 12 months from the date of the proposal: infection near the right ankle. Treatment complete.

Beyond preceding 12 months, date of proposal: Giddiness/BP in 1999, under medication.

Hence, she has disclosed truly and faithfully her medical history/ailments and record of hospitalization since 1999.  

Thereafter upon the request of Op, she had attached alongwith email dtd.31.10.13 sent by the proposer, the discharge summary of the Complainant relating to her hospitalization during 2013, on account of ‘infection near right ankle’ which can be seen on going through the contents of email dtd.31.10.13 marked as Ex-A2. Op after due verification and satisfaction, had accepted the proposal of the Complainant and had issued the said policy on 31.10.13 which is marked as Ex-A3.

 

8. As the Complainant had suffered an injury to her right leg, which required hospitalization and treatment between 12.07.14 and 18.07.14 at the Manipal hospital, Bengaluru. The diagnosis and treatment administered was for ‘Cellulitis Right Leg’. In this context, the Complainant placed reliance on the discharge summary marked as Ex-A4. At the inception of the aforesaid hospitalization in the Manipal hospital, the Complainant reasonable assumed that, she being covered under insurance by Op, she was entitled to cashless treatment and accordingly sought the pre-authorization for cashless treatment from Op.  This fact is also not disputed by the Op. But the request of the Complainant for pre-authorization for cashless treatment was rejected by the Op by its letter dtd.17.07.14 addressed to the Manipal hospital. The reason assigned by Op for such rejection was ‘All pre-existing disease/ conditions………preceding 12 months from the date of proposal. The said letter is marked as Ex-A5. Complainant having no other go, settled the hospital bill of Rs.71,530/-. Upon further persuasion, Op agreed to reconsider the claim of the Complainant and required her to submit her claim. Accordingly she submit her claim marked as Ex-A6. Though the Complainant has furnished all the required documents to settle her claim, Op did not consider her request. Hence, Op by its letter dtd.13.09.14 marked as Ex-A10 informed the Complainant that not only was it rejecting her claim for reimbursement of Rs.71,530/- but it was also canceling her insurance policy on account of ‘non-declaration of pre-existing disease. Further the Complainant has sent an email dtd.24.09.14 marked as Ex-A11 and followed it up with a letter dtd.24.09.14 found at inkpage no.37 addressed to Op and protested against the fragrant violations of the covenants of the policy by the Op. In response to it, Op by its letter dtd.30.09.14 marked as Ex-A12, reiterating that the Complainant’s claim of Rs.71,530/- was being rejected/denied on account of her hospitalization between 12.07.14 and 18.07.14 for the reason that it was on account of a ‘pre-existing disease, preceding 12 months from the date of the policy : and the policy was being repudiated/canceled on account of ‘misrepresentation/non-disclosure of material facts’ in her proposal form. Hence, both the reasons assigned are false. Hence, when her claim has been repudiated, she has no other go except to approach this forum to get redress her remedy. Ongoing through the contents of the version, claim has been rejected on account of “pre-existing disease, preceding 12 months from the date of the policy”. With regard to the non-existence of pre-existing disease is concerned, the Complainant has placed reliance on the contents of Ex-A2 which is discharge summary found at inkpage 10, wherein Final Diagnosis mentioned as “Osteomyelitis RT lateral Malleolus Hypertension”, Past history mentioned as “H/o Hypertension – 13 years on treatment. Referring to the said discharge summary, submits that, the claim has been repudiated as per Ex-A10. We placed reliance on the contents of Ex-A10, wherein the reasons assigned for repudiation of claim are as under:

To,

Mr.Rukmani Harigopal

Dear Sir,

Re: Non declaration of pre-existing disease(s): claim no.CLI/2015/700001/0081526A/c.Mr.Rukmani Harigopal Policy no.P/700001/01/2014/005594-(senior citizen)

We refer the letter dtd.01.08.14 from our claims department. We wish to bring your kind attention that during the scrutiny of the above claim papers, we observe that you have not declared the details; “Old CVA since 1999” relating to Mrs.Rukmani Harigopal, which were found to be existing at the time of taking the policy for the first time during the 31.10.2013 to 30.10.2014. This amounts to non-disclosure of material facts.

We draw your attention to condition no.11 in the policy clause which reads as follows.

The company may cancel this policy on grounds of misrepresentation, fraud, nondisclosure of material fact or non-co-operation by the insured person, by sending the insured 30 days’ notice by registered letter at the insured person’s last known address.

Therefore, you are hereby informed that as per the above clause, we intend to cancel the policy in respect of the above person w.e.f.12/10/2014. This letter shall be taken as the notice of cancellation as per the above mentioned condition no.111 of the policy clause.

However, a cheque for refund of premium calculated on prorate basis will be sent shortly.

 

9. As we have already stated above, at the time of availing the policy, Complainant had already stated her detail medical history as described in para 4 of the complaint stating that, Preceding 12 months from the date of the proposal: infection near the right ankle. Treatment complete. Beyond preceding 12 months, date of proposal: Giddiness/BP in 1999, under medication. If these facts are taken in to consideration, Complainant has not suppressed any of the material facts in respect of the alleged pre-existing disease. According to the Complainant, she had suffered an injury to her right leg, which required hospitalization and treatment between 12.07.14 and 18.07.14 at the Manipal hospital, Bengaluru. The diagnosis and treatment administered was for ‘Cellulitis Right Leg’ which can be seen on going through the document discharge summary marked as Ex-A4. As per the terms & conditions of the policy, if the Complainant suppressed any of pre-existing disease, preceding 12 months from the date of the proposal, she is entitle to claim only prorate basis but not as per the sum assured in the policy. But in the instant case, the claim repudiated by the Op alleging that, the Complainant has suppressed pre-existing disease, as the Complainant is an old case of CVA and the discharge summary of Mallya hospital for the admission for the insured patient from 23.07.1999 to 28.07.1999, states that, she has been treated for left cerebral infarct. All these are prior to the inception of the first policy and not disclosed at the time of the execution of the proposal form. Non-disclosure of CVA and the left cerebral infarct are concerned, the Doctor who has examined the Complainant duly appointed by the Op at the time of taking the policy ought to have been traced out.  At the time of availing the policy, the Complainant has specifically stated infection near the right ankle, giddiness/BP in 1999 which are no way concerned to repudiate the claim of the Complainant. Further, the another contention taken by the Op is that, the treatment for left cerebral infarct was from 23.07.1999 to 28.07.1999, but in our considered view this is no way concerned at the time of availing the policy by the Complainant. Further, we noticed that, soon after taking the treatment, Complainant has promptly intimated to the Op for the reimbursement of the said amount, but by one or the other pretext, they are postponing the same. When the alleged disease was not within preceding 12 months, under such circumstances, claim repudiated by the Op is not just and proper in the light of the decisions of Hon’ble National Commission reported in:  

i) 2009 (3) CPR 53 LIC of India and others vs. Kailash Chandra Kar, Held: Consumer Protection Act is a beneficial legislation and it cannot allow insurance company to escape liability on technical grounds to deprive the consumer of benefits to which he was entitled to.

ii) 2010 (1) CPR 114 National insurance company ltd., vs. Nand Lal, Held: insurance claim must be honestly settled without any delay

 

10. In the light of the decisions cited supra, insurance company cannot repudiate the claim on untenable grounds. Hence, we come to the conclusion that, there is a deficiency of service on the part of Op in not honouring the request of the Complainant for processing her medical claim amount. In this context, if we direct the Op to process and pay the medical bill of Rs.71,530/- to the Complainant along with cost of litigation of Rs.3,000/-, we hope ends of justice would met sufficiently. In view of ordering the Op to process the medical bill, we do not find any reason to pay the compensation. Accordingly we answered the point no.1 in the affirmative.

 

           11. Point no.2: In the result, we passed the following:

 

ORDER

 

          The complaint filed by the Complainant is allowed.

 

          2. Op is directed to process and pay the medical bill of Rs.71,530/- to the Complainant.

 

          3. In view of ordering the Op to process & pay the medical bill, we do not find any reason to pay the compensation, but anyhow, Op is directed to pay cost of litigation of Rs.3,000/- to the Complainant.

 

4. Op is also directed to realize the aforesaid amount within six weeks from the date of this order, failing which the Complainant is at liberty to have the redress as per law.

 

          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 2^nd November of 2018).

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT

                                                                        

1. Witness examined on behalf of the complainant/s by way of affidavit:

 

Smt.Rukmani Harigopal, who being the complainant was examined. 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Insurance proposal form
Ex-A2	Email dtd.31.10.13 and discharge summary dtd.15.10.13
Ex-A3	Policy dtd.31.10.13
Ex-A4	Discharge summary dtd.18.07.14
Ex-A5	Letter dtd.17.07.14
Ex-A6	Claim form dtd.20.07.14
Ex-A7	Letter dtd.08.08.14
Ex-A8	Email dtd.16.08.14
Ex-A9	Discharge summary dtd.28.07.99
Ex-A10	Letter dtd.13.09.14
Ex-A11	Email and letter dtd.24.09.14
Ex-A12	Letter dtd.30.09.14
Ex-A13	In-patient final bill for Rs.71530/-
Ex-A14	Credit card statement

 

2. Witness examined on behalf of the Opposite party/s Respondent/s by way of affidavit:

 

Sri.John Noronha, who being the Joint Vice President of Op was examined.

 

Copies of Documents produced on behalf of Opposite party/s

 

Ex-B1	Proposal form
Ex-B2	Email
Ex-B3	Discharge summary dtd.18.07.14
Ex-B4	Discharge summary dtd.28.07.99
Ex-B5	Discharge summary dtd.15.10.13
Ex-B6	Repudiation letter
Ex-B7	Policy and conditions

 

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT