Date of filing:26.7.2013
Date of Disposal:2.4.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II::
VIJAYAWADA, KRISHNA DISTRICT.
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER
WEDNESDAY, THE 2ND DAY OF APRIL, 2014.
C.C.No.138 OF 2013.
Between :
Balantha Raja Ratnam, S/o Venkata Ratnam, Hindu, 39 years, O/o A.G.K.MPL High School, Gudiwada, Krishna District, Andhra Pradesh State.
….. Complainant.
And
1. The Branch Manager Star Health and Allied Insurance Co., Ltd., Branch Office, D.No.40-1/1-17, Adarsh Nagar, Opp:Chennupati Petrol Bunk, Moghalraj Puram, Vijayawada, Krishna District.
2. The Managing Director, Star Health and Allied Insurance Co., Ltd., KRM Centre, VI Floor, No.2, Harington Road, Chetpet, Chennai – 600 031.
…..Opposite Parties.
This complaint is coming before us for final hearing on 20.3.2014 in the presence of Sri B.Devadas, Counsel for complainant and Sri N.Sridhar, Counsel for opposite parties and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Smt N. Tripura Sundari)
This complaint is filed under Section 12 of the Consumer Protection Act, 1986.
The averments of the complaint are in brief:
1. The complainant obtained family health optima insurance policy from the 1st opposite party for himself, his wife and two children for a sum of Rs.2,00,000/- on 27.6.2011 and the said policy was renewed 2012, 2013 and it is valid from 27.6.2013 to 26.6.2014. While so on 15.4.2013 the complainant was admitted in Narayana Super Specialty Hospital Nellore as an inpatient “Chronic Pancreatic status sphincterotomy with chronic cholecystitis”. The complainant underwent surgery in the said hospital on 16.4.2013 for his ailment and discharged from the hospital on 22.4.2013. The complainant incurred an expenditure of Rs.49,820/- towards surgery and medicines. The complainant informed the said fact to the opposite parties and submitted claim form along with necessary documents. The opposite parties repudiated the claim made by the complainant vide their letter dated 21.6.2013 stating that the ailment suffered by the complainant is pre-existing and claim is not payable. The repudiation made by the opposite parties is illegal and without any basis. The opposite parties with a view to avoid the claim made baseless allegations and violated the terms of the policy which amounts to deficiency in service. Hence the complainant is constrained to file this complaint against the opposite parties praying the Forum to direct the opposite parties to reimburse the medi-claim amount of Rs.49,820/- along with interest from the date of surgery i.e., 16.4.2013 to the complainant and to pay costs.
2. The 2nd opposite party filed its version and the 1st opposite party adopted the same.
The version of the opposite parties is in brief:
The opposite parties denied all the allegations of the complaint and submitted that the complainant obtained health insurance policy from the opposite parties for himself, to his wife, to his daughter and to his son on 27.6.2011 and the said policy was renewed 2012, 2013 and it is valid from 27.6.2013 to 26.6.2014. The complainant as an educated can understand the terms and conditions of the proposal and other stipulations incorporated therein. In response to the replies furnished by the insured to the questions under medical history the complainant answered as no to each of the questions of the proposal form and stated that the statements answers and particulars stated in the proposal form, and other questions are not incorrect or untrue in any respect and if they are incorrect or untrue the insurance company incurs no liability under this policy and signed on the same proposal form. During the coverage of the policy the complainant admitted in Narayana Super Specialty Hospital, Nellore on 15.4.2013 as inpatient with Chronic Pancreatic status sphincterotomy with chronic cholecystitis and undergone surgery on 16.4.2013 and discharged on 22.4.2013. The complainant incurred an amount of Rs.49,820/-. The complainant also submitted various bills, papers, documents and discharge summary of the hospital to the opposite parties for reimbursement. Basing on that submitted documents pre-authorization request form (specialty) the opposite parties scrutinized the records and submitted rejection letter dated 25.6.2013 stating that the treatment of ailment is pre-existing disease and not covered under family health optima insurance policy. The opposite parties team observed from the discharge summary of Andhra Hospital for admission from 15.6.2011 to 16.6.2011 and the complainant was hospitalized for a chronic Calcific pancreatitis CBD structure which was prior to instruction of medical insurance policy. At the time of obtaining the first policy on 27.6.2011 the complainant has not disclosed the above mentioned medical history which amounts to misrepresentation and 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 material facts whether by the insured person and any other person acting on his behalf the opposite party is not liable to make any payment in respect of any claim. As per condition No.11 of the policy is also liable to be cancelled. As per the contents of the discharge summary it clearly reveals that “HISTORY AND EXAMINATION: H/O COLICKY PAIN ON & OFF SINCE 7 YEARS, PAIN IS OF SHORT DURATION, IN THE EPIGASTRIC REGION, NO RADIATION, H/O JAUNDICE FOR ONE DAY WITH PAIN 1 YEAR BACK. PATIENT UNDERWENT CBD STENT FOLLOWING JAUNDICE. PATIENT HAS INCREASED PAIN THE LAST 3 MONTHS. HE IS NON ALCOHOLIC & NON SMOKER, NO H/O DIABETES. PATIENT IS ON PANCREATIC ENZYME SUPPLEMENTATIONS FOR THE PAST 1 MONTH”. So the opposite parties rejected the policy. So the opposite parties are not liable to pay the bill amount much less compensation requested by the complainant. Therefore there is no deficiency in service on the part of opposite parties towards the complainant in repudiating the claim of the complainant and prayed to dismiss the complaint with costs.
3. On behalf of the complainant he gave his affidavit and got marked Ex.A.1 to Ex.A.10 and on behalf of the opposite parties the 1st opposite party Sri C.Krishna Sagar gave his affidavit and no documents were filed by the opposite parties.
4. Heard and perused.
5. Now the points that arise for consideration in this complainant are?
1. Whether there is any deficiency in service on the part of the opposite parties
towards the complainant in repudiating the claim of the complainant?
2. If so is the complainant entitled for any relief?
3. To what relief the complainant is entitled?
POINTS 1 AND 2:
6. On perusing the material on hand the complainant obtained family health optima insurance policy from the opposite parties on 27.6.2011 to cover himself, his wife, his daughter and his son for an amount of Rs.2,00,000/-. He renewed the same in the year 2012 and 2013 valid from 27.6.2013 to 26.6.2014 under Ex.A.1, Ex.A.2 and Ex.A.3. on 15.4.2013 the complainant was admitted in Narayana Super Specialty Hospital, Nellore as inpatient with Chronic Pancreatic status sphincterotomy with chronic cholecystitis and after investigations he underwent surgery in the said hospital on 16.4.2013. He spent Rs.49,820/- towards surgery and medicines. The complainant informed the said fact to the opposite parties and submitted claim form under Ex.A.5 along with necessary documents. On receiving the claim form from the complainant the opposite parties sent a request letter Ex.A.7 to Narayana Hospital Authorities to handover related documents of the complainant. Again the opposite parties sent a request letter Ex.A.8 to Narayana Hospital Authorities. (1) to provide the discharge summary investigation report and treatment details for sphincterotomy (2) As per discharge summary history of jaundice CBD stunt provide treatment details for the same (3) Histopathology report (4) copies of indoor case papers. The Narayana Hospital Authorities sent the medical record of the complainant to the opposite parties. After verifying the hospital record of the complainant the opposite parties sent repudiation of the claim letter Ex.A.6 dated 21.6.2013 to the complainant stating that the present ailment is pre-existing and he has not disclosed the above mentioned medical history of the insured person which amounts to misrepresentation-non discloser of material facts. Hence the claim is not payable. On receiving the repudiation letter the complainant sent a letter to opposite parties on 26.6.2013 stating that he had taken treatment for gallbladder stones but not for chronic Pancreatic.
7. The opposite parties say that the complainant was admitted in Narayana Super Specialist Hospital on 15.4.2013 as inpatient with Chronic Pancreatic status sphincterotomy with chronic cholecystitis and underwent surgery on 16.4.2013 and discharged on 26.4.2013 and he incurred an amount of Rs.49,820/-. The complainant submitted claim form along with hospital record and after verifying the record the opposite parties repudiated the claim of the complainant as the treatment of the ailment is pre-existing disease and does not cover under family health optima insurance policy. The complainant disclosed the material facts.
8. We the Forum noticed the contents of discharge summary History and examination: H/o colicky pain on & off since 7 years, pain is of short duration, in the epigastric region, no radiation, h/o jaundice for one day with pain 1 year back. patient underwent CBD stent following jaundice. patient has increased pain the last 3 months. he is non alcoholic & non smoker, no h/o diabetes. patient is on pancreatic enzyme supplementations for the past 1 month”. o/e: no pallor / No icterus/ no pedal colema. Abdomen: soft, no tenderness no guardane. No pulpable mass. We find no abnormality in the said above contents of discharge summary. This history not related to prior to take health insurance policy. The pain is only in short duration but not for long time. Admission in Andhra Hospital from 15.6.2011 to 16.6.2011 with pain may be due to gastric problem. The findings in the discharge summary are in positive. The doctor stated that no stent was found in gallbladder. The complainant underwent only lap.cholecystectomy due to stones that is not pre-existing disease as the 1st policy was taken on 27.6.2011. The present insurance policy is only for coverage of health not for life. Hence we are not agreeing with the submissions of the opposite parties. We hold that there is deficiency in service on the part of the opposite parties towards the complainant in repudiating the claim of the complainant. The complainant is entitled to get relief from the opposite parties. Accordingly these points are answered.
POINT No.3:-
9. In the result, the complaint is allowed in part and the opposite parties jointly and severally are directed to pay medi-claim insurance amount of Rs.49,820/- (Forty nine thousand eight hundred and twenty rupees only) along with interest at the rate of 9% per annum from the date of operation i.e., 16.4.2013 till realization and to pay Rs.2,000/- (Two thousand rupees only) towards costs to the complainant. Time for compliance one month. Rest of the claim of the complainant are dismissed.
Dictated to the Stenographer K.Sivaram Prasad, transcribed by him, corrected by me and pronounced by us in the open Forum, this the 2nd day of April, 2014.
PRESIDENT MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant: For the opposite parties:-
P.W.1 B.Raja Ratnam None.
Complainant
(by affidavit)
On behalf of the Complainant:
Ex.A.1 27.06.2011 Photocopy of Proposal Form.
Ex.A.2 . . Photocopy of Customer Identity Card issued by opposite
party.
Ex.A.3 . . Photocopy of insurance policy.
Ex.A.4 14.05.2013 Renewal notice.
Ex.A.5 . . Letter from the complainant to the Claims Department of the
opposite party along with photocopy of claim form for
medical insurance.
Ex.A.6 21.06.2013 Letter from the opposite party to the complainant.
Ex.A.7 . . Status of intimation.
Ex.A.8 11.06.2013 Photocopy of Remainder for intimation.
Ex.A.9 . . Photocopy of discharge bill.
Ex.A.10 . . Photocopy of Discharge summary.
For the opposite parties:-
Nil.
PRESIDENT
