Tamil Nadu

North Chennai

136/2013

R.Ranjith - Complainant(s)

Versus

The Manager, Authorised Officer,M/s.Star Health Allied Insurance Co. Ltd, - Opp.Party(s)

S.Senthikumar

28 Apr 2017

ORDER

 

                                                            Complaint presented on:  08.07.2013

                                                                Order pronounced on:  28.04.2017

 

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

                    TMT.T.KALAIYARASI, B.A.B.L.,               MEMBER II

 

FRIDAY  THE 28^th  DAY OF APRIL 2017

 

C.C.NO.136/2013

 

Mr.R.Ranjith,

No. 39/15,

Kothanda Raman Street,

Old Washermanpet,

Chennai – 600 021.

                                                                                       ….. Complainant

 

..Vs..

 

The Manager/Authorized Officer,

M/s. Star Health & Allied Insurance Company Limited,

Area Office, MKM Chambers,

No.42, Old No.54 & 55,

Kodambakkam High Road,

Chennai – 600 034.

 

.....Opposite Party

Date of complaint                                 : 10.07.2013

Counsel for Complainant                      : M/s.S.Senthil Nathan, V.Kirubalini

Counsel for    Opposite Party                   : N.Vijayaraghavan, M.B.Raghavan

O R D E R

 

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

This complaint is filed by the complainant to pay the claim amount of Rs.1,20,000/- and also 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 has insured his family consist of himself, his wife and minor a child aged 4 years under the “Family Health Optima” Insurance Policy bearing No. P/111100/01/2012/006732 for the year 2012-13 having  coverage from 28.02.2012 till midnight of 27.02.2013 against the claim of any medical and hospitalization for all the three members to the extent of any medical and hospitalization for all the three members to the extent of sum of Rs.3,00,000/- and it is relevant to state that the insurance coverage was issued vide policy No P/111100/01/2011/006021 for the previous year also ended with no claim during the currency of the said year. However due to the Complaint of “increased frequency of micturition and incontinence” developed to the child of the Complainant, aged 5 years by name  Baby R.Sruthi was constrained to be admitted in the Hospital known as “Dr.Mehta’s Hospitals having address at No.2, Mcnicholas Road, 3^rd Lane, Chetpet, Chennai – 600 031.

2. The said child of the Complainant was treated as the inpatient from 01.09.2012 till 07.09.2012. The said hospital having cashless treatment facility to the policy holders of the Opposite Party insurance company, as the officers of the insurance company having  network with the said hospital by having office within the precinct of the hospital itself. Therefore upon the admission of the child, Complainant was informed the way of treatment and claim of medical reimbursement was made and the Doctors who are attending also continued the treatment upon hearing the positive node from officers of the Opposite Party upon scrutinizing the policy and medical records. After continuation of treatment for six days all of  a sudden the Complainant was asked to make payment of the medical bills and Opposite Party has rejected the claim and thereby Complainant was constrained to make payment to the hospital to an extent of sum of Rs.50,000/- and thereafter continued the treatment with another hospital and thereby sustained medical expenses and treatment cost crossing a sum of Rs.1,20,000/- which was claimed from the Opposite Party but the same was rejected citing some lame excuses.

3. The policy was in force and conditions of claims are fully satisfied and in fact at the time of admission of the patient to the hospital the Opposite Party admission and continued treatment for six days and thereafter it has rejected the total claim was questioned by the Complainant but the Opposite Party has postponed the reimbursement of the medical claim under one or other pretext without any convincing reasons. In the meantime the terms of the policy got expired during February 2013 and therefore when the Complainant approached the Opposite Party for renewal of the policy and the Complainant was prepared to make payment but was refused to accept his renewal and failed not only to extend the risk coverage and thereby denied his continued medical coverage but also failed and neglecting to reimburse the medical claim. When the policy issued by the Opposite Party was in force and claim made during the currency of the policy, he has no discretion to reject the policy which was continued for two long years. The Complainant legal notice dated 23.03.2013 was issued to the Opposite Party  to settle the claim of the Complainant  within 15 days from the date of receipt of the notice failing which initiating appropriate  remedy under the provisions of Consumer Forum for the deficiency in services was also promptly informed. The Opposite Party had not sent any reply to the legal notice dated neither 23.03.2013 nor settling the claim as per the claim made in the legal notice.   Hence the Complainant filed this Complaint to pay the claim amount of Rs.1,20,000/- and also compensation for mental agony with cost of the Complaint.

4. WRITTEN VERSION OF THE  OPPOSITE PARTY IN BRIEF:

          It is true that the Complainant had availed Family Health Insurance Policy. No. P/111100/01/2012/006732 for the period of 28.02.2012 to 27.02.2013 for the sum insured of Rs.3,00,000/-, which was a renewal of P/111100/01/2011/006021  for the previous year. A claim was made for the treatment availed for minor child R.Shruthi. On scrutiny of medical records, it was found by the expert in house doctors that the child was suffering inadmissible under the contract of insurance and accordingly by letter dated 01.10.2012 the claim was repudiated.  The patient was admitted in Dr.Mehta’s Hospital, Chennai on 01.09.2012. On receipt of the Pre Authorization Request from the treating hospital., the medical team scrutinized the medical records and denied the cashless authorization on the ground that the patient had vesico ureteric reflux with bladder diverticula and increased frequency of Micturation since birth and the same was communicated to the treating hospital vide letter dated 05.09.2012. However, the insurer sent the claim form to the patient to approach them for reimbursement, if any permissible.

          5. On scrutiny of the medical records, the medical team observed that

i. As per the Discharge Summary, the diagonosis was right vesico- ureteric reflux with urinary bladder diverticula.

ii. The patient was admitted with complaints of increased frequency of micturition and incontinence. Known case of developmental delay and speech delay.

iii. The patient was presently admitted with the complaints of burning micturition, fever, pain abdomen.

iv. MCU (Micturating Cysto Urethrogram) dated 01.09.2012 right VUR Grade I with bladder diverticula.

v. IVP lintra Venous Pyelogram) dated 01.09.2012 – urinary bladder diverticula (right lateral valve)

vi. The treating Dr.Vignesh R replied that the patient had increased frequency of micturition from birth, urinary incontinence 3 months and orinary bladder shows multiple out pouching suggestive of diverticula. Reflux of contract seeing in right distal ureter which is non dilated during voiding status.

She is a known case of developmental delay. The claim for treatment and hospitalization was a sequel to the above medical condition. It was clearly found that the patient was suffering from a birth on congenital defect which was pre-existing even prior to inception of the policy for the first time with this insurer on and from 28.02.2011 itself. The said medical condition of the patient was not disclosed by the insured in the proposal form. It is true that cashless benefit was denied by letter dated 05.09.2012 for good and valid reasons. The averments made in paras 2 to 4 have no merit at all. Since the insured was guilty of misrepresentation, the insurer was not under any obligation to offer renewal upon expiry of the policy of insurance. Equally, the claim was found inadmissible and repudiation by letter dated 01.10.2002 was in accord with the medical records and terms and conditions of contract of insurance. The reliefs sought for are not payable. No sum much less the amount claimed is payable. The Complainant is not entitled for any of the reliefs. It is therefore prayed that this Hon’ble Court may be pleased to dismiss the Complaint with costs.

6. POINTS FOR CONSIDERATION:

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

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

7. POINT NO :1 

The Complainant insured for himself, his wife and minor child aged R.Sruthi, 4 years old under the family health optima insurance policy for the period 28.2.2012 to 27.2.2013 against the claim of any medical and hospitalization for them and the said policy is marked as Ex-A2 and health insurance card is marked as Ex-A3. 

8. The child was admitted at Dr. Mehtha’s Hospital on 1.9.2012 for treatment and discharged on 7.9.2012 and the discharge summary marked as Ex-A6.  During the treatment as inpatient the Complainant claimed pre authorization for treatment and the same was denied on the ground that  the child is suffering from congenital disease on 5.9.2012 and further informed the Complainant that after treatment the Complainant can approach the Opposite Party for reimbursement for if any permissible.

          9. The child was diagnosed for the disease “Right vesco ureteric reflex with urinary bladder diverticula” as per Ex-A6 discharge summary and further observed that the child was brought with
C/o increased frequency of micturition and incontinence, known case of developmental delay and speech delay.  N/o c/o burning micturition, fever, pain abdomen. 

10. Ex-B3 copy of the medical records maintained at Dr. Methas Hospital in that record at page 15 observed that recurrent hospitalization.  The child is only 4 years old and treated in the hospital repeatedly as per the record.  The disease which was the child suffering since from her birth as per the case of the Opposite Party.  The records also shows that the child is suffering from congenital disease and therefore the request made by the Complainant for pre authorization is not eligible and the claim rejected is justifiable and therefore the Opposite Party has not committed any deficiency in service.

11. POINT NO:2

Since the Opposite Party has not committed any Deficiency in Service, the Complainant is not entitled for any relief and the Complaint is liable to be dismissed.

          In the result the Complaint is dismissed. No costs.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 28^th day of April 2017.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 28.02.2011                   Health Insurance Policy for 2011-12

Ex.A2 dated 28.02.2011                   Health Insurance Policy for 2012-13

Ex.A3 dated NIL                     Health Insurance Identity card

Ex.A4 dated 02.09.2012                   Test Reports

Ex.A5 various dates                Medical Expenditure and Bills Dates

Ex.A6 dated 07.09.2012                   Discharge Summary

Ex.A7 dated 22.03.2013                   Legal Notice

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated NIL                     Family Health Optima Insurance Policy

 

Ex.B2 dated 28.02.2011                   Proposal Form

 

Ex.B3 dated 01.09.2012                   Medical Records and Test Reports

 

Ex.B4 dated 07.09.2012                   Discharge Summary

 

 

MEMBER – II                                                               PRESIDENT