Tamil Nadu

South Chennai

385/2008

R.Govindarajalu - Complainant(s)

Versus

The Branch manager, Royal sundaram alliance Insurance co. Ltd. & others - Opp.Party(s)

S.Sathya Moorthy

06 Aug 2018

ORDER

                                                                        Date of Filing  : 26.09.2008

                                                                          Date of Order : 06.08.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

 2^ND Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

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

                 TMT. K. AMALA, M.A., L.L.B.                                : MEMBER-I

 

C.C. No.385 /2008

DATED THIS MONDAY THE 06^TH DAY OF AUGUST 2018

                                 

Mr. R. Govindarajulu,

S/o. Mr. Ramasamy,

Flat #:1331, Sri Jaya Apartments,

20^th Main Road,

Anna Nagar West,

Chennai – 600 040.                                                 .. Complainant.                                                       ..Versus..

 

1. The Branch Manager,

Royal Sundaram Alliance Insurance Co. Ltd.,

Sundaram Towers,

Nos.45 & 46, Whites Road,

Chennai – 600 014.

 

2.  The Manager,

Medicate TPA Services (I) Pvt. Ltd.,

No.2, Paul Mansion,

No.6, Bishop Lefroy Road,

Kolkata – 20.                                                   ..  Opposite parties.

          

Counsel for complainant           :  M/s. G. Gopalakrishnan

Counsel for opposite parties    :  M/s. M.B. Gopalan & others

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986 praying to refund a sum of Rs.55,495.95/- expended towards medical treatment and hospitalization with interest, to pay a sum of Rs.4,00,000/- towards compensation for deficiency in service, unfair trade practice, and mental agony with cost of Rs.25,000/- to the complainant.

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

The complainant submits that he is a policy holder of Health Shield Insurance Policy bearing No.HS00042176000102 for an assured sum of Rs.5,00,000/- covering the period from 09.03.2008 to 08.03.2009 for himself and his family consisting of his wife, son and daughter and paid an annual premium of Rs.5,089/-.  Further the complainant submits that on 02.01.2008, the complainant’s wife Mrs. Rajalakshmi suffered sudden severe pain on her left leg pain.   After various tests and diagnosis, she was admitted in Apollo Hospitals, No.21 Greams Lane, Chennai-6 on 02.05.2008 as inpatient for treatment and was discharged on 06.05.2008.  Further the complainant submits that on 13.05.2008, the complainant submitted the claim form to the 1^st opposite party claiming a sum of Rs.55,495.95/- with all required documents.  The 2^nd opposite party by letter dated:24.04.2008 repudiated the claim which was confirmed by the 1^st opposite party in his letter dated:09.06.2008 only on the ground of pre-existing disease which is not covered under the policy.  The complainant submits that till admitting as inpatient, the complainant has not have any knowledge regarding Varicose vein. The complainant’s wife may felt some pain occasionally on the impugned day of admission, she suddenly experienced severe pain which shall not be considered as pre existing disease.   Hence the complaint is filed.

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

The opposite parties specifically deny each and every allegations made in the complaint and puts the complainant to strict proof of the same.    The opposite parties state that the complainant had taken a Health Shield Insurance Policy consisting himself, his wife, son and daughter for the period from 09.03.2008 to 08.03.2009.  Further the opposite parties state that the complainant made a claim for the treatment of his wife related to pain in the left leg from 02.05.2008 to 06.05.2008 at Apollo hospital which was diagnosed as “Varicose Vein.   Further the opposite parties state that the claim form submitted by the complainant was duly repudiated for the simple reason of pre-existing disease.    Further the opposite parties state that even if the medi claim is accepted, the amount admissible is only Rs.38,922/-  as per the policy coverage.   There is no deficiency in service on the part of the opposite parties.  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.A6 are marked.  Proof affidavit of the opposite parties filed and documents Ex.B1 to Ex.B4 filed and marked on the side of the opposite parties.

4.      The points for consideration is:-

1. Whether the complainant is entitled to get refund of a sum of Rs.55,495.95/- expended towards medical treatment and hospitalization with interest as prayed for?
2. Whether the complainant entitled to a sum of Rs.4,00,000/- towards compensation for deficiency in service, unfair trade practise and mental agony with cost of Rs.25,000/- as prayed for?

5.      On point:-

        Both parties filed their respective written arguments.  Heard both sides.  Perused the records namely the complaint, written version, proof affidavits, documents etc.  Admittedly, the complainant is a policy holder of Health Shield Insurance Policy bearing No.HS00042176000102 for an assured sum of Rs.5,00,000/- covering the period from 09.03.2008 to 08.03.2009 for himself and his family consisting of his wife, son and daughter.   Ex.A1 is the Certificate of Insurance.   It is also admitted that the policy is subsisting during the relevant period of treatment.    The learned Counsel for the complainant contended that on 02.01.2008, the complainant’s wife Mrs. Rajalakshmi suffered sudden severe pain on her left leg.   After various tests and diagnosis, she was admitted in Apollo Hospitals, No.21 Greams Lane, Chennai-6 on 02.05.2008 as inpatient for treatment and was discharged on 06.05.2008.  Ex.A3 is the Discharge Summary.   Further the complainant contented that on 13.05.2008, the complainant submitted the claim form to the 1^st opposite party claiming a sum of Rs.55,495.95/- with all required documents as per Ex.A2.  The 2^nd opposite party by letter dated:24.04.2008 repudiated the claim which was confirmed by the 1^st opposite party in his letter dated:09.06.2008 only on the ground of pre-existing disease which is not covered under the policy. Ex.A4 & Ex.A5 are the letters of the opposite parties.  The learned Counsel further contended that till admitting as inpatient, the complainant has not have any knowledge regarding Varicose vein. The complainant’s wife may felt some pain occasionally; on the impugned day of admission, she suddenly experienced severe pain which shall not be considered as pre existing disease.

6.     The learned Counsel for the complainant cited the decision reported in:

CDJ 2008 (Cons.) Case No.105

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION,

NEW  DELHI

Between

New India Assurance Co. Ltd.

-Versus-

Kashinath Balmukund Marwadi

Held that

“The policy which states that it is not material whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the Insurance Company to disown the liability.  If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same.  This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured  under the grab of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company reliefs on their Clause 4.1 of the policy in a malafide manner to repudiate all the claims.  No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps per-existing in the system totally unknown to him which he is genuinely unaware of them..... In any case, it is the contention of the complainant that he was thoroughly checked up by the Doctors who were nominated by the Insurance Company and at that time he was found hale and hearty.  In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease”.

7.     Further the contention of the complainant is that the complainant is claiming a sum of Rs.55,495.95/- towards medical expenses and a sum of Rs.4,00,000/- towards compensation for mental agony, deficiency in service with cost.  But the complainant has not explained the proposition for claiming such huge compensation.

8.     The learned Counsel for the opposite parties would contend that the complainant had taken a Health Shield Insurance Policy consisting himself, his wife, son and daughter for the period from 09.03.2008 to 08.03.2009 in which, the following exclusion clause which reads as follows:

“D. EXCLUSIONS:-

The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by way Insured Person in connection with or in respect of:

Pre-Existing Condition – Such diseases/injury which have been in existence at the time of proposing this insurance.    Pre-existing condition also means any sickness or its symptoms, which existed prior to the effective date of this insurance, whether or not the Insurer Person had knowledge that the symptoms were relating to the sickness.   Complications arising from pre-existing disease will be considered part of that pre-existing condition”.

9.     Further the contention of the opposite parties is that the complainant made a claim for the treatment of his wife, related to pain in the left leg from 02.05.2008 to 06.05.2008 at Apollo hospital which was diagnosed as Varicose Vein.   As per Ex.B3, the Discharge Summary it reads as follows: “Diagnosis: Varicose Vein

Surgery : Left sapheno femoral ligation.  Electrical venous stripping multiple stab ligation.

 

History of Present Illness

 

Chief Complaints: Left leg pain for 2½ years.  She has pain after walking”.

 

 

Course In The Hospital & Discussion

 

39 years old Mrs. Rajalakshmi, came with complaints of left leg pain.  She was diagnosed to have varicose veins.....”

proves that the complainant’s wife was suffering for the past 2½ years which amounts to pre-existing.  But there is no appearance of any Varicose Vein of any nature found. 

10.    Further the contention of the opposite parties is that the claim form submitted by the complainant was duly repudiated for the simple reason of pre-existing disease.  But the opposite parties issued policy after due check-up and health condition is not denied.   Further the contention of the opposite parties that even if the medi claim is accepted, the amount admissible is only Rs.38,922/-  as per the policy coverage.  Considering the facts and circumstances of the case this Forum is of the considered view that the opposite parties shall pay a sum of Rs.38,922/- with interest at the rate of 9% p.a. from the date of complaint with a compensation of Rs.20,000/- and cost of Rs.5,000/-.

  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.38,922/- (Rupees Thirty eight thousand nine hundred and twenty two only) with interest at the rate of 9% p.a. from the date of filing of this complaint i.e. 26.09.2008 to till the date of this order and to pay a sum of Rs.20,000/- (Rupees Twenty 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 06^th day of August 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:

		Copy of Certificate of Insurance
		Copy of the complainant’s claim
		Copy of the discharge summary
		Copy of the 2nd opposite party’s letter
		Copy of repudiation letter
		Copy of bills & reports

 

OPPOSITE  PARTIES SIDE DOCUMENTS:  

Ex.B1	30.05.2008	Copy of the policy with terms
Ex.B2	30.05.2008	Copy of TPA opinion
Ex.B3	05.05.2008	Copy of Discharge Summary
Ex.B4	09.08.2008	Copy of the repudiation letter

 

 

MEMBER –I                                                                      PRESIDENT