Tamil Nadu

North Chennai

CC/80/2015

M/s.A.Parthasarathy - Complainant(s)

Versus

The Branch Manager, The Management, Star Health and Allied Insurance Company Ltd., - Opp.Party(s)

M/s.C.Russel Raj

24 Oct 2017

ORDER

                                                            Complaint presented on:24.04.2015 

                                                                Order pronounced on:24.10.2017 

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

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

 

         PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,       PRESIDENT

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

TUESDAY  THE 24^th DAY OF OCTOBER 2017

 

C.C.NO.80/2015

 

A.Parthasarathi,

S/o. G.Arulanandam,

Plot No.138, 7^th Street,

Kumaran Kudil (Extension),

Metukuppam,

Chennai – 97.

                                                                                ….. Complainant

 

   ..Vs..

1.The Branch Manager/The Management,

Star Health and Allied Insurance Company Limited,

K.M.R., Centre, 6^th Floor,

No.2, Harrington Road,

Chetpet, Chennai – 31.

 

2.The Management,

Grievance Department,

Star Health and Allied Insurance Company Limited,

No.1, New Tank Street,

Valuvarkottam High Road,

Nungambakkam, Chennai – 600 034.

 

3.The Branch Manager/The Management,

No.1, New Tank Street, Valluvar Kottam High Road,

Nungambakkam, Chennai – 34.

.....Opposite Parties

Date of complaint                                 : 22.05.2015

Counsel for Complainant                      : C.Russel Raj

Counsel for Opposite Parties                 : N.Vijayaraghavan

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant claiming medical expenditure, compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant family has taken family health Optima Insurance Policy for the period from 24.03.2014 to 23.03.2015 for the sum insured of Rs.5,00,000/- + Bonus Rs.5,00,000/-, Totally Rs. 10,00,000/-. The complainant was hospitalized on 15.01.2015 at Global Health City, Chennai and after treatment, he was discharged on 17.01.2015. Based on the bill issued to the complainant, he made a claim for a sum of Rs.2,30,519/- on 25.01.2015 along with relevant documents. The 1^st opposite party sent a notice on 24.02.2015 that he is not liable to pay the claim and rejected the same for the reason of non disclosure of material fact.

          2. The complainant sent notice dated 12.03.2015 to the opposite party and he replied dated 24.03.2015. The complainant had taken treatment in the year 2015 before he had consulted a doctor S.S.Ayyer in the year 2010. The treatment taken in the year 2015 is not a pre-existing one. There is no defect in the policy and if there is any defect the insurance company has power to cancel the policy. The policy was renewed for the further period of 24.03.2015 to 23.03.2016. Therefore the opposite party committed deficiency in service in repudiating the claim of the complainant. Hence the complainant filed this complaint claiming medical expenditure, compensation for mental agony with cost of the complaint.

3. WRITTEN VERSION OF THE  OPPOSITE PARTIES 1 to 3 IN BRIEF:

          The complainant has availed Family Health Optima Insurance Policy No.P/111113/01/2014/013749 with the opposite parties for the period 24.03.2014 to 23.03.2015 in respect of medical and hospitalization expenses incurred during the policy period. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy.  The complainant made a claim for reimbursement of hospitalization expenses of Rs.2,30,519/- incurred towards his medical treatment and hospitalization for Single Vessel Coronary Artery disease, primary PCI with stunting to RCA at Global Hospitals, Chennai. The opposite parties on receipt of claim papers filed by the complainant scrutinized the same.  The opposite parties rejected pre-authorization request for cashless treatment

1. complainant/Insured patient has hypertension for the past 4 years with history of (R)  MCA (Middle Cerebral Artery Stroke) for the past four years and is on treatment.
2. As per the consultation report dated 27.01.2010 of Fortis Malar Hospital the complainant had stroke right MCA in fact one year back.

 

The afore said medical records of the complainant were present even prior to the inception of medical insurance policy, which were not disclosed by the complainant to the insurer while availing the policy.

          The Policy condition No.7 clearly stipulates as follows:

          “If there is any misrepresentation/non disclosure of material fact 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 such claim.

The complainant /patient have hypertension for the past four years with history of MCA. The consultation report dated 27.01.2010 Fortis Malar Hospital the complainant had stroke on right MCA one year back.  Such diseases is pre-existing to the complainant in the year 2010 itself. The said fact was suppression of material facts and thereby violated the policy terms.

          4. The claim arising under the policy is payable subject to the terms and conditions attached therein. The complainant incurred hospitalization expenses of Rs.2,30,519/-. The complainant nowhere deny that the treatment records issued by the Fortis Malar Hospital which details medical history of him. The complainant ought to have cancelled the policy for the defect but has renewed the policy for the further period 24.03.2015 to 23.03.2016 which shows that the insurer has no specific stand is frivolous and absurd. Repudiation of a claim for breach of policy terms does not ipso-facto lead to cancellation of policy. The cancellation of policy is at the discretion of the company depending on various factors. Mere renewal of the policy does not imply that the repudiation of claim by the insurer is improper. The complainant having sought for renewal of policy even after the repudiation of his earlier claim cannot take it as defense to validate its earlier claim. The opposite parties have not committed any act of Professional negligence as alleged by the complainant.  Hence the opposite parties have not committed any deficiency in service and prays to dismiss the complaint with cost.

5. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          It is an admitted fact that the complainant family had taken Optima Insurance Policy for him and his family members and the opposite party issued Ex.A1 Ex.A2 policy to them and during the policy in force, the complainant was admitted on 15.01.2015 at Global Health City Chennai and procedure was done to him was “Primary PCI and Stunting to RCA” and he was  discharged  on 17.01.2015 and Ex.A3 is the discharge summary issued to him and Ex.A4 is the bill issued to the complainant for his treatment and based on the bill the complainant made a claim to the opposite parties and the said claim was  repudiated on the ground that the complainant suppressed the material fact that he had hypertension for four year and his report Ex.B4 dated 27.01.2010 of Fortis Malar Hospital reveals that he had stroke right MCA 1 year ago and the repudiation  of claim  dated 24.02.2015 is marked as Ex.A7.

          7. The complainant would contend that the Ex.B4 report issued by the Malar Hospital has nothing to do with the treatment undergone at the Global hospital and therefore there is no suppression of material fact by the complainant and hence the opposite parties have committed deficiency in rejecting his claim.

8. The counsel for  opposite parties argued that Ex.B4 proves that the complainant had stroke – right MCA  and facial – brachial weakness  in the year 2010 and this fact was suppressed by the complainant is a material fact and thereby violated terms of the policy and hence the rejection  of the claim done  by the 1^st opposite party is sustainable.

9. On the date of admission of the complainant and during the course of treatment at Global Health City Hospital, Chennai the policy issued by the opposite parties is in force.  There is no dispute that the complainant underwent “Primary PCI and Stunting to RCA procedure on 15.01.2015”.  For such procedure of treatment the complainant incurred an expenses of Rs.2,30,519/- as per the bills filed in Ex.A4.

10. The complainant had treatment in the year 2010 itself as per Ex.B4 for the ailment of stroke – right MCA on left facio – brachial weakness fully recovered. The Ex.B4 reveals that the complainant had treatment for nerve diseases and such diseases also fully recovered as per the document. The nerve disease has nothing to do with the treatment taken by the complainant at the Global City Hospital. The complainant had treatment at the Global City Hospital for Renal Coronary Artery Ailment. Further the opposite party themselves filed Ex.B3 dated 05.08.2014 medical summary of the complainant. The nerve disease mentioned in Ex.B4 in the year 2010 was not mentioned in Ex.B3 in the year 2014. Even in Ex.B4 itself the diseases mentioned therein was suffered by him 1 year ago.  The complainant took the policy in the year March 2013 after 3 years of issuance of Ex.B4 Prior to 1 year of Ex.B4. The complainant had stroke as per the contents of that document. It means the complainant had stroke in the year 2009 only. No documents filed by the opposite party to establish that the complainant was suffering with stroke on the date of Ex.B1. Therefore, absolutely there is no evidence on behalf of the opposite party that the complainant was suffering with any pre-existing diseases at the time of Ex. B1 proposal form was signed by the complainant.

11. The opposite party relied on a judgment of the Supreme Court in  SATWANT KAUR SANDHU VS NEW INDIA ASSURANCE COMPANY LTD dated 10.07.2009 in support of their case. The facts in that case is that at the time of taking out  the mediclaim policy, the policy holder was suffering from Chronic diabetic and renal failure was a material fact and non disclosure of this fact in the proposal form is suppression and the repudiation of the claim was justified in law.  Further in that case he was undergoing haemodialysis. Whereas in the case in hand there is no evidence that on that date of proposal form furnished to the opposite parties, the complainant was suffering from any pre-existing diseases. Therefore, the above judgment referred by the opposite parties is not applicable to the facts of the case in hand.

12. This complainant underwent treatment for coronary artery disease. The treatment given for the disease in Ex.B4 is a different disease than the coronary artery disease. Therefore the 1^st opposite party repudiated claim made by the complainant for his medical expenditure is not sustainable and therefore we hold that the opposite parties 1 to 3 have committed deficiency in service.

13. POINT NO:2

          Since the opposite parties have committed deficiency in service in repudiating the claim of the complainant, the complainant is entitled for a sum of Rs.2,30,519/- from the opposite parties towards the medical expenses incurred by him. Due to repudiation of the claim made by the opposite parties, the complainant suffered with mental agony is accepted and for the same it would be appropriate to award a compensation of Rs.50,000/- to the complainant besides a sum of Rs.5000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 to 3 jointly or severally are  ordered to pay a sum of Rs.2,30,519/- (Rupees two lakhs thirty thousand five hundred and nineteen only) towards medical expenses  to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 24^th day of October 2017.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 04.03.2013                   Family Health Optima Insurance Policy

 

Ex.A2 dated 24.03.2014                   Family Health Optima Insurance Policy Renewal

 

Ex.A3 dated 17.01.2015                   Global Health City – Discharge Summary

 

Ex.A4 dated 17.01.2015                   Global Health City – Discharge Summary in-

                                                      patient sash bill

 

Ex.A5 dated 17.01.2015                   Report of X-ray and other details by Global Health

                                                     City

 

Ex.A6 dated 23.01.2015                   Letter sent the opposite partY for renewal of

                                                     Policy

 

Ex.A7 dated 24.02.2015                   Letter from the 1^st opposite party for denial of

                                                     Claim

 

Ex.A8 dated 12.03.2015                   Advocate notice to first and second opposite

                                                     parties

 

Ex.A9 dated 24.03.2015                   Reply from the opposite party.

 

Ex.A10 dated NIL                             Family Health Optima Insurance Policy Renewal

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES :

 

Ex.B1 dated NIL                     Proposal Form signed by the complainant

 

Ex.B2 dated NIL                     Insurance Policy with terms and conditions

 

Ex.B3 dated NIL                     Medical Summary of the complainant dated

                                                    05.08.2014 issued by Fortis Malar Hospital

 

Ex.B4 dated NIL                     Consultation Report of complainant dated

                                                    27.01.2010 Fortis Malar Hospital

 

Ex.B5 dated NIL                     Repudiation Letter dated 24.02.2015

 

 

 

MEMBER – I                                                               PRESIDENT