DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the  14^h   day of November 2017

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P. Member                                                      Date of filing:  28/03/2014

               : Sri.V.P.Anantha Narayanan, Member

                                                              (C.C.No.50/2014)

P.C.Narendran,                                                                                   - Complainant

S/o Chami,

Kuruvakkattu Parambil,

Kallippadam P.O,

Shornur  1, Ottappalam,

Palakkad.

(Advs.K.Sujith Kumar & Shine Francis)             

                                                                            Vs

Star Health Allied Insurance Company,                                             -  Opposite party

Represented by its Branch Manager, Branch Office,

Palakkad Fine Centre, 4^th Floor, T.B.Road,

Palakkad 678 014.                 

(Adv.A.R.V.Sankar)

O R D E R

By Smt.Shiny.P.R, President ,

Brief facts of the complaint

Complainant had taken Family Health Optima New Insurance having No. P/181214/01/2013/002890 for the period from 30-10-2012 to 29-10-2013  from opposite party. Sum assured was Rs.3,00,000/-. On 03-09-2013 complainant was admitted at Jubilee Mission Medical College Hospital, Thrissur for the treatment of right CP angle Tumour-Vestibular Schwannoma. The surgery was conducted on 06-09-2013. After treatment he was discharged on 17-9-2013. The complainant has incurred an amount of Rs.1,30,000/- for treatment.  Then the complainant submitted a claim form along with medical bills and records before the opposite party.  Complainant submitted that opposite party is liable to pay Rs.1,30,000/- to complainant.  Even though the complainant has submitted the entire documents connected with her disease, hospitalization and expenses, they have repudiated the claim without any reasons.  The act of opposite party amounts to deficiency of service and unfair trade practice.  Hence the complaint. Complainant prays for an order directing opposite party to pay Rs.1,30,000/- along with 12% interest from 17-9-2013, Rs.1,00,000/- for the compensation for mental agony suffered  and also to pay cost of proceedings to the complainant.  

Complaint was admitted and notice was issued to opposite party. Opposite party filed version contending the following:-

The opposite party admitted that the complainant had taken Family Health Optima New Insurance from the opposite party for the period from 30-10-2012 to 29-10-2013 which has been further renewed up to 29-10-2014.  As per the contract of insurance the insured has to furnish true and correct facts in the proposal form for issuing the policy.  The policy is issued strictly according to the terms and conditions of the policy.  The policy issued to the complainant being a health policy, the complainant is bound to give proper information regarding his present and past health status at the time of filling the proposal which are material for proper underwriting of the proposal.  The policy is issued after accepting the facts in the proposal form on utmost good faith.  The insured person was admitted on 03-09-2013 at Jubilee Mission Medical College Hospital, Thrissur for the treatment of Right CP angle Tumour-Vertibular Schwannoma and underwent treatment for Right Retromastoid Craniectomy and Microscopic excision of Tumor.  After treatment, he was discharged on 17-09-2013.  It is admitted that after treatment, the insured had submitted a claim form along with medical bills and lab reports to the opposite party.  In the discharge summary and in the claim form, symptoms of hearing loss and swaying while walking were recorded.  The opposite party had conducted in investigation and collected OP/IP case sheet copies from Jubilee Mission Medical College Hospital, Thrissur. The case sheet reveals that the complainant was suffering from hearing loss since 1 year form 17-10-2009 and was under medications for Vertigo (Tablet-Zevert) since 15-09-2010.  Based on the available records, the opposite party obtained an Expert Independent Medical Opinion which confirmed that hearing loss and vertigo are typical signs and symptoms of Vertibular Schwannoma.  It is submitted that the complainant had not mentioned any diseases in the health history column of the proposal form.  Based on the declaration of the complainant and believing his declaration, the policy was issued to him.  In the proposal form the complainant further 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.  If the insured person discloses the facts of pre-existing disease, a decision will be taken by the opposite party whether to accept or reject the proposal.  But in this case the insured has not informed about the pre-existing disease in the proposal form though he had knowledge about his previous illness of vertigo & hearing loss for which he was under treatment.  Since 2009, so he suppressed material facts of the pre-existing disease of hearing loss & vertigo at the time of taking the policy.  If there is suppression of material facts, then the insurance contract becomes void from the beginning and the company is not liable to indemnify the insured.  As the insured had suppressed the material facts of the pre-existing vertigo & hearing loss, which are the typical symptoms of the present illness, the opposite party had rejected the claim of the complainant & informed the same to the insured on 08-02-2014.  Thereafter the complainant request to return all original documents on 05-12-2013 & the opposite party had sent the same on 19-04-2014.  It is submitted that there is no deficiency in service form the part of this opposite party.  The claim was repudiated based on the terms & conditions of the policy. 

Opposite parties filed additional version stating  that as per the policy terms and conditions, an amount of Rs.19,787/-will be deducted from the claimed amount of Rs.1,33,053/-,   (Documentation charge Rs.200/-, Excluded expenses No.117, ECG Report Rs.110/- Report Not enclosed, Glucometer Rs.400/-, Rs.13,000/- Condition No.17 (80% of package charges applied), Pulse Oxymeter Rs.210/-, Excluded Expenses No.140, Bystander room rent Rs.3,400/- Consumables Rs.2,388/-, Return Rs.79/-) and total amount payable will comes to Rs.1,13,266/- only.  They also submitted that even if this Hon’ble Forum finds any liability upon this opposite party, then the liability of the opposite party may be limited to Rs.1,13,266/-. 

Both parties filed their respective chief affidavit. Exts. A1 to A3 marked from the side of the complainant and Exts. B1 to B10 marked from the side of the opposite party. Complainant was examined as PW1.

The following issues are taken into consideration.

1. Whether there is any deficiency of service from the part of opposite party?
2. If so what are the relief and cost?

 Issues No. 1 & 2

We have perused the documents and affidavits filed before the Forum. Opposite parties admitted the policy and treatment taken by the complainant. Opposite  parties contended that the complainant was suffering from hearing loss since 1 year form 17-10-2009 and was under medications for Vertigo (Tablet-Zevert) since 15-09-2010. The insured has not informed about the pre-existing disease in the proposal form though he had knowledge about his previous illness of vertigo & hearing loss for which he was under treatment. In order to prove suppression of pre-existing disease opposite parties did not adduce any evidence before the Forum. It is evident from the perusal of Ext B6 case sheet that on 15-9-2010 the patient had no vertigo. From this it is revealed that the contentions taken by the opposite parties are false. It is true that in the discharge summery it is mentioned that the patient has the history of hearing loss since 2 years and it is associated with tendency to fall while walking since 5 months. Opposite party contended that based on the available records, the opposite party obtained an Expert Independent Medical Opinion which confirmed that hearing loss and vertigo are typical signs and symptoms of Vertibular Schwannoma. If so, burden of proof is upon opposite party to establish with sufficient evidence that claim submitted by the complainant is pertaining to pre-existing disease. To prove the above contention opposite party should have to produce the report of expert or examine the expert before the Forum. Opposite party is failed to prove their case.

 In the above circumstances we are of the opinion that the repudiation of claim by the opposite party is unjustifiable and without any cogent reason and they have committed deficiency in service. Hence complainant is entitled to get the claim of Rs 1,30,000/-. Opposite party filed additional version stating that even if this Hon’ble Forum finds any liability upon this opposite party, as per the policy terms and conditions, an amount of Rs.19,787/- (Documentation charge Rs.200/-, Excluded expenses No.117, ECG Report Rs.110/- Report Not enclosed, Glucometer Rs.400/-, Rs.13,000/- Condition No.17 (80% of package charges applied), Pulse Oxymeter Rs.210/-, Excluded Expenses No.140, Bystander room rent Rs.3,400/- Consumables Rs.2,388/-, Return Rs.79/-) is to be deducted from the claimed amount of Rs.1,33,053/-, and then the liability of the opposite party may be limited to Rs.1,13,266/-.   But opposite party has not produced the terms and conditions of the policy before the Forum to show that on what basis the above deductions are to be made from the actual expenses incurred by the complainant. So the above deductions cannot be allowed. In   the above circumstances we partly allow the complaint and direct the opposite party to pay Rs.1,30,000/- (Rupees one lakh thirty thousand only) towards the claim amount, Rs.5,000/- (Rupees five thousand only) as compensation for  mental agony and Rs.2,000/- (Rupees two thousand only) as cost of proceedings.

This order shall be executed within one month from the date of receipt of this order; failing which the complainant can also realize from the opposite party interest at 9% p.a on the total amount due to him from the date of this order till realization. 

Pronounced in the open court on this the 14^th  day of November 2017.

    Sd/-                   Shiny.P.R.

                                   President 

                                       Sd/-

                               Suma.K.P.

                                 Member

                     Sd/-

    V.P.Anantha Narayanan

                                Member

Appendix

Exhibits marked on the side of complainant

Ext.A1  -  Family Health Optima Insurance Policy Schedule issued by Star Health and Allied

                Insurance Company Limited dated.30.10.2012

Ext.A2  – Discharge Summary issued by Jubilee Mission Medical College, Thrissur

                dated.17.09.2013

Ext.A3  –  Repudiation of claim letter dated.08.02.2014 issued by Star Health and Allied

                Insurance Company Ltd to the complainant.

Exhibits marked on the side of Opposite parties

Ext.B1 -  Claim Form of Medical Insurance

Ext.B2 -  Discharge Summary issued to the complainant by Jubilee Mission Medical College,

               Thrissur dated.17.09.2013

Ext.B3 -  Inpatient Record of Jubilee Mission Medical College, Thrissur

Ext.B4 - CT Scan Report of the complainant dated. 22.08.2013

Ext.B5 -  MRI Brain (Plain +contrast) Report dated. 29.08.2013

Ext.B6 -  Out Patient Record of Jubilee Mission Medical College, Thrissur

Ext.B7 -  Repudiation of claim letter dated.08.02.2014 issued by Star Health and Allied

                Insurance Company Ltd to the complainant

Ext.B8 -  Request letter sent to the complainant to opposite party for returning him to

               The scan & x-ray Film.

Ext.B9 -  Authorization Letter of Star Health and Allied Insurance Co.Ltd

Ext.B10 series - Medical Bills

Witness examined on the side of complainant

PW1    -  Narendran

Witness examined on the side of opposite party

Nil

Cost   

            Rs.2,000/-