BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD : THIRUVANANTHAPURAM

PRESENT

SHRI. P. SUDHIR                                :         PRESIDENT

SMT. SATHI. R                                   :         MEMBER

SMT. LIJU B. NAIR                            :         MEMBER

                                              C.C.No: 283/2013     Filed on 26/06/2013   

                                            Dated: 16..03..2017

Complainants:

1 Confederation of Consumer Vigilance Centre, Sreekovil, Kodunganoor-P.O., Vattiyoorkavu, Thiruvananthapuram, represented by its General Secretary.

2. C.K. Vijayan Nair, Kalindam, Chennilode, Kannammoola, Medical College-P.O., Thiruvananthapuram – 695 011.

                              (Party in person)

Opposite parties:

1. The Cholamandalam MS General Insurance Company, Hari Nivas Tower, 2^nd Floor 163, Thambu Chetty Street, Parry’s Corner, Chennai – 600 001, Tamil Nadu.

                    (By Adv.  V. Manikantan Nair)

          2. M/s. South Indian Bank Ltd., Chakka Branch, Thiruvananthapuram.

                              (By Adv. S. Williams)

This C.C having been heard on 31..01..2017, the Forum on 16..03..2017  delivered the following:

ORDER

SMT. LIJU B. NAIR, MEMBER:

          Complainants’ case is that the 1^st complainant is a consumer organization working for the welfare of the consumers. The 2^nd complainant had taken a Health Insurance Policy No.HWT-00003874-000-00 covered under Group Health Master Policy from the 1^st opposite party through the 2^nd opposite party on 20/10/2010 and the same was renewed valid upto 28/10/2012. The policy is issued in the name M/s. South Indian Bank Ltd., the 2^nd opposite party and the insured as the complainant, C.K. Vijayan Nair and his spouse Sumom S.P. On 04/02/2012 the 2^nd complainant was admitted to KIMS Hospital, Thiruvananthapuram with symptom of acute chest pain and an angioplasty was done and spent Rs. 2,50,000/-. After discharge the 2^nd complainant claimed the amount spent in the hospital, limited to policy sum assured Rs. 2,00,000/- from the 1^st opposite party as per claim application dated 15/02/2012. But the 1^st opposite party vide repudiation letter dated 24/05/2012 denied 2^nd complainant’s legitimate right for the claim under the policy citing some lame excuses. The action of the 1^st opposite party is against the terms and conditions of the policy and therefore the 2^nd complainant requested the 1^st opposite party to re-consider the issue based on the medical report of doctor who treated him, by sending a registered letter dated 28/06/2012. According to 1^st opposite party the claim was inadmissible as the treatment done was on the outcome of 2^nd complainant’s hypertension. But 2^nd complainant’s hypertension exited since 25 years. The hypertension is caused by coarctation of aorta and it is congenital deformity. Since the hypertension is treated and controlled it is not any way a reason for 2^nd complainant’s present ailment. The 1^st opposite party would have conducted a medical examination before issuing the policy if hypertension is a ground for rejection of the policy. The 2^nd complainant has not suppressed the fact that he is having hypertension at the time of issuing insurance policy. No medical examination conducted at the time of issuing the policy. If hypertension had been a ground for rejection of policy, the 1^st opposite party would not have issued the policy. The rejection of claim after receiving the premium of policy and renewal of policy is a clear violation and abuse of law and natural justice. The reason adduced for rejection of insurance claim has no support of any valid medical certificate issued from a competent doctor and the same is on the own inference of the 1^st opposite party. The 2^nd complainant’s problem of acute myocardial infarction is not directly related to hypertension as certified by Dr. V. Ramakrishna Pillai, M.D, Senior Consultant and Cardiologist of the KIMS Hospital. But the 1^st opposite party tried to evade and escape from the liability under the policy claim. The act of the opposite party in not allowing the legitimate claim under the policy is a total violation of law and natural justice and that amounts to deficiency in service on the part of opposite party. Opposite party did not come forward to discharge his liability to the 2^nd complainant in spite of request made to the 1^st opposite party. On 10/10/2012 the complainant sent a legal notice through his lawyer calling upon the 1^st opposite party to allow the claim under the policy. But the 1^st opposite party has not allowed the claim under the policy, which account for deficiency of service on the part of 1^st opposite party and hence this complaint.

          2. The 1^st opposite party Cholamandalam MS General Insurance Company filed version that para 4 of the complaint is admitted regarding the submission of claim form and regarding the repudiation letter dated 24/05/2012. But the 1^st opposite party is denying the averment that this opposite party repudiated the 2^nd complainant’s legitimate claim citing lame excuses.  The issuance of registered letter by the 2^nd complainant to 1^st opposite party is admitted. But this opposite party vehemently denying the averment that the 2^nd complainant’s hypertension is caused by coarctation of aorta and it is congenital deformity and since the hypertension is treated and controlled, it is not in any way a reason for 2^nd complainant’s present ailment. It is submitted that this opposite party repudiated the claim vide letter dated 24/05/2012 stating that “On perusal of the documents it is observed that the present ailment (ACS / myocardial infarction / CAD) is a complication of hypertension which is existing since 25 years, which is prior to the inception of the policy (29/10/10), hence present ailment is considered as pre-existing disease and the claim is inadmissible as per General Exclusion Clause C1 which read as “No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following: 1) any pre-existing condition benefits will not be payable for any condition(s) as defined in the policy under 24 consecutive months of coverage for the insured person have elapsed, since inception of the first policy with the insurer”. There is no deficiency of service on the part of 1^st opposite party and the 2^nd complainant is not entitled to get any relief as claimed, from 1^st opposite party.

          3. 2^nd opposite party filed version contenting that the 2^nd opposite party is a Banking Company registered under the Company’s Act 1956. The complainant is an account holder with the 2^nd opposite party. With the good intention to assist it’s customers for having insurance coverage, helped the 2^nd complainant in taking health insurance with the 1^st opposite party. The 2^nd opposite party provided its assistance to its customers as a welfare step to its customers. The 2^nd complainant availed the insurance policy from the 1^st opposite party at his own free will. The allegation that the insurance policy is issued in the name of the 2^nd opposite party is false and not true to real facts. The 2^nd opposite party is not having any liability to redress the grievance of the 2^nd complainant herein, since the insurance policy was availed by him on his free will. The insurance policy was issued by the 1^st opposite party directly to the 2^nd complainant. The terms of the insurance policy were reduced to in writing. As seen from the policy certificate, the terms are binding on both the partis ie, 2^nd complainant and first opposite party. The settlement of claim is absolutely an internal business of the 1^st opposite party with the 2^nd complainant, over which the 2^nd opposite party has no role at all.  The 2^nd opposite party have no knowledge relating to the illness and the hospitalisation of the 2^nd complainant with KIMS Hospital, Thiruvananthapuram. The 2^nd opposite party neither received any claim from the 2^nd complainant nor rejected any of his claim. The 2^nd opposite party have no knowledge relating to any claim raised by the 2^nd complainant before the 1^st opposite party. On going through the complaint it is revealed that neither any deficiency of service alleged nor any claim is raised against the 2^nd opposite party. In the circumstances the 2^nd opposite party is only an unnecessary party and it be deleted from the party array.

          4. Issues raised:

          (i) Whether the repudiation is justifiable?

          (ii) If not, what are the reliefs for which the complainant is eligible?

          5. Issues (i) & (ii):  Complainant filed affidavit along with 6 documents which were marked as Exts. P1 to P6. She was examined as PW1. 1^st opposite party filed affidavit with 6 documents which were marked as Exts. D1 to D6. No affidavit or document is seen filed by 2^nd opposite party. Perused the documents and gone through the arguments of both sides. This is a complaint regarding repudiation of a medical claim by the 1^st opposite party. 2^nd opposite party is only a formal party in this proceedings. No relief is claimed against them. 1^st opposite party repudiated the claim on the ground that the illness for which the claim was raised was a pre-existing one. As per Ext. D6 “On perusal of the documents it is observed that the present ailment (ACS/myocardial infarction/CAD) is a complication of the hypertension which is existing since 25 years, which is prior to the inception of the policy (29/10/2010), hence present ailment is considered as pre-existing disease and the claim is inadmissible as per General Exclusion clause C-1 which reads as “No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following: 1)Any Pre-Existing Condition Benefits will not be payable for any condition (s) as defined in the policy, until 24 consecutive months of coverage for the insured person have elapsed, since inception of the first policy with the insurer”. Complainant in his deposition also admits that he is having hypertension for the past 30 years. He produced a letter which is marked as Ext. P6 with objection by the opposite party, that it is subject to proof. But no steps were taken by the complainant to prove the veracity of Ext. P6, which was the only evidence from their side to prove that the present illness was not due to hypertension. So we are of the considered view that the repudiation done by the 1^st opposite party is as per terms and conditions as per the available records and the complainant failed miserably to establish his case which is only to be dismissed.

                    In the result, complaint is dismissed.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 16^th day of March, 2017.

                   Sd/- LIJU B. NAIR :         MEMBER

                     Sd/- P. SUDHIR            :         PRESIDENT

Ad                 sd/- R. SATHI                :         MEMBER

C.C.No: 283/2013

APPENDIX

  I.  Complainants’ witness         :         Vijayan Nair

II.  Complainants’ documents:

P1      :  Copy of Certificate of Insurance of Cholamandalam MS General Insurance

P2      :  Copy of Certificate of Insurance of      ..do..            ..do..

P3      :  Copy of Health Claim Form

P4      :  Copy of Repudiation Letter dated 24/5/2012 of 1^st opposite party

P5      :  Copy of letter dated 28/6/2012 from the complainant to the 1^st opposite party

P6      :  Copy of Treatment Certificate of Mr. Vijayan Nair issued by KIMS Hospital dated 15/3/2012.

III. Opposite parties’ witness     :         N I L

IV. Opposite parties’ documents:

          D1      :  Attested copy of Health Insurance Policy of C.K. Vijayan Nair

          D2      :  Attested copy of Health Insurance policy terms and conditions

          D3      :  Copy of Health Claim Form

          D4      :  copy of Discharge Summary of Mr. Vijayan Nair

          D5      :  copy of Inpatient Medical Record of Mr. Vijayan Nair

D6      :  Copy of Repudiation letter

Sd/-PRESIDENT

    Ad.