Andhra Pradesh

East Godwari-II at Rajahmundry

CC/5/2016

Anil Kumar Javvar - Complainant(s)

Versus

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

P.N.N.Tagore

21 Dec 2016

ORDER

                                                                                                                                                         Date of filing:   11.01.2016

                                                                                                                                                         Date of Order: 21.12.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAMAHENDRAVARAM

 

                                             PRESENT:  Smt. D. Leelavathi, B.Sc., B.L.               PRESIDENT

                            Smt H.V. Ramana, B.Com., L.L.M.,          MEMBER

                

                   Wednesday, the 21^st day of December, 2016

 

 

C.C.No.5 /2016

Between:-

 

1)  Anil Kumar Javvar, S/o. Bala Kishan Javvar,

      Hindu, aged 42 years, R/o. Door No.9-25-31,

      Business, Gunduvari Street, Rajamahendravaram,

      E.G. District, A.P., India.

 

2)  Manju Javvar, W/o. Anil Kumar Javvar,

      S/o. Bala Kishan Javvar, Hindu, aged 42 years,

      R/o. Door No.9-25-31, Business, Gunduvari Street,

      Rajamahendravaram, E.G. District, A.P., India.                                                                                      …        Complainant

 

                                    And

 

1)  The Manager, Star Health & Allied Insurance Co. Ltd.,

      Door No.46-7-27/2, Opp: Green Park Hotel,

      Danavaipeta, Rajamahendravaram-533103, E.G. District,

      A.P., India.

 

2)  The authorized Signatory, Star Health & Allied Insruance

      Co. Ltd., 1, New Tank Street, Valluvan Kottam High Road,

      Nungambakkam, Chennai, Tamilnadu, India.                                                                                         …        Opposite parties

 

 

            This case coming on 06.12.2016 for final hearing before this Forum in the presence of Sri P.N.N. Tagore, Advocate for the complainants and Sri S.S. Chalam, Advocate for the opposite parties, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.D. Leelavathi, President] 

This is a complaint filed by the complainants U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties to pay Rs.1,30,000/- to the 1^st complainant towards medical policy reimbursement of his wife 2^nd complainant of his claim with interest @ Rs.1/- per hundred from the date of complaint; award Rs.1,00,000/- towards compensation for damage and mental agony and award Rs.5,000/- towards costs of the complaint.

2.         The case of the complainants is as follows:-  It is submitted that the 1^st complainant obtained Family Health Optima Insurance Policy from the opposite parties and the Policy No.P/131124/2010/000303 is given to the complainant and period of insurance commenced from the year 2009 and the net premium was Rs.2,234/- inclusive of service tax. As per policy, the coverage is there for 1^st complainant, his wife and their two children and the floater sum insured Rs.1,00,000/-. Subsequent to the insurance policy referred above, about one year after it commencement, the company has been enhanced to Rs.2,00,000/- and addressed letter informing the complainant about the same and the complainant received Rs.30,000/- towards bonus till date. The 2^nd complainant Smt. Manju Javvar, who is the wife of the 1^st complainant started complaining fatigue and severe neck pain and sometimes, she used to fall down to the earth suddenly while attending to household work. This problem started about one year ago. The 1^st complainant took her to Kranti Nursing Home, where scanning was done and the report revealed that normal. Even though she took medicines as prescribed by the Kranti Nursing Home, the pain was not subsided. But there was no relief to 2^nd complainant from pain and suffering, the complainant went to Ganga Hospital, Coimbatore and got the treatment given there. The disease/problem had come to complainant knowledge only doctors at Coimbatore hospital diagnosed after conducting many tests, processes etc. and named the disease as “Arnold Chiari Malformation” and the 2^nd complainant as advised had undergone operation. The complainant spent Rs.4,00,000/- and odd towards operation, hospitalization, nursing, transportation etc. The 2^nd complainant was admitted in the hospital on 5.6.2014 for operation and discharged on 28.6.2014. On 20.5.2014, the hospital claim department had sent the pre-authorization request for cashless facility and the opposite parties had approved only cashless treatment amount of Rs.1,00,000/- instead of Rs.2,00,000/-. However, the opposite parties paid only a sum of Rs.1,00,000/- while repudiating the claim of complainant for the balance amount. The complainant has not availed the bonus of Rs.30,000/- and balance coverage of Rs.1,00,000/-. Then the complainant got issued a legal notice dt.31.10.2015 to the opposite parties. The opposite parties were received the notice. The 2^nd opposite party issued the reply with false grounds without any settlement of complainant claim. Hence, the complaint.

3.         The 1^st opposite party filed its written version and the same was adopted by the          2^nd opposite party. This opposite party denied the main and material allegations made in the complaint is not maintainable either under law or on facts. This opposite party submits that it is true that the complainants had availed Family Health Optima New Insurance Policy No.P/131124/01/ 2014/001793 for the period from 26.12.2013 to 25.12.2014. Whereas the averments that the claim made by the complainant No.2 stating that the period of insurance was fixed from 12.12.2009 to 11.12.2018 for the policy No.P/131124/2010/000303 is not true and correct and the same is denied. It is also admitted that a claim was submitted by the complainants to the opposite party for reimbursement of medical expenses for the treatment of Arnold Chiari Malformation/S/P foramen magnum decompression with wound/CSF leak at Ganga Medical Center and Hospitals Pvt. Limited, Coimbatore on 5.6.2014 with claim No.CLI/2015/131124/0049787. The opposite parties herein submits that on scrutinizing the claim records, it is observed that the onset of disease to the insured patient was 5 years back that is prior to inception of this policy and hence, the claim was settled as per the applicable insured of Rs.1,00,000/- which is maximum amount payable as per the terms and conditions of the policy. Therefore, the question of payment of Rs.1,30,000/- including the bonus as alleged in the complaint does not arise. This opposite party also submitted that as per the Medical records, the insured patient had symptoms of neck pain and back pain since five years and on the basis of the said ailment, the insured patient was diagnosed and treated and the said ailment existed prior to the inception of the policy and the same was not disclosed in the proposal form and such non-disclosure of pre-existing disease amounts to violation of terms and conditions of the policy. This opposite party also submitted that the increased sum insured will not be applicable for the above said ailment. The sum insured existing in the 1^st year of policy is Rs.1,00,000/-. As such, under claim No.CLI/2015/131124/0034860, the claim of the insured patient was settled for Rs.1,00,000/- through NEFT on 11.6.2014 which is the maximum amount payable by the opposite party as per the terms and conditions of the policy.

            The opposite parties herein submitted as per condition No.8 Renewal: “The policy will be renewed except on ground of misrepresentation/Fraud committed. A grace period of 30 days from the date of expiry of the policy is available for renewal. If renewal is made within this 30 days period the continuity of benefits will be allowed. However, the actual period of cover will start only from the date of payment of premium. In other words, no protection will be available between the date of expiry of policy and the date of payment of premium for renewal.”  However, in respect of disease/sickness/illness the sum insured will be restricted to the sum of the policy insured when the signs or symptoms was diagnosed/ received medical advice/treatment. In view of the aforesaid aspects, the insured patient in the present case at any cost is not entitled for more than the amount insured much less the claim amount of Rs.1,30,000/- and Rs.1,00,000/- by way of damages and costs etc. as claimed in the complaint.  Hence, there is no deficiency of service on the part this opposite party and the complaint is liable to be dismissed with costs.  

4.         The proof affidavit filed by the 1^st complainant and Exs.A1 to A12 have been marked for the complainants. The proof affidavit filed by the 1^st opposite party. There is no documentary evidence adduced by the opposite parties.  

5.         Heard. Written arguments filed on behalf of the complainants and written arguments not filed by the opposite parties.

 6.        Points raised for consideration are:

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

            2. Whether the complainants are entitled for the reliefs as prayed for?

            3. To what relief?

 

7.  POINT Nos.1 & 2:  Admittedly, the 1^st complainant had obtained Family Health Optima Insurance Policy from the opposite parties vide Policy No.P/131124/2010/000303 and the period of insurance commenced from the year 2009 and the net premium was Rs.2,234/- inclusive of service tax. As per policy, the coverage is there for 1^st complainant, his wife Manju Jawar and their two children namely Dev Jawar and Anmol Jawar and the floater sum insured is Rs.1,00,000/-.

It is also not in dispute that subsequent to the insurance policy referred above, the floater sum insured has been enhanced to Rs.2,00,000/- and the bonus amount is Rs.30,000/- and the limit of coverage is Rs.2,30,000/- vide Ex.A2. The policy is still existing and the complainant has been paying the premium without any default and the policy has been renewing every year.

The proof affidavit of the 1^st complainant discloses that the 2^nd complainant who is the wife of the 1^st complainant started complaining fatigue and severe neck pain and sometimes she used to fall down to the earth suddenly while attending to household work. This problem started about one year ago. The 1^st complainant took his wife to Kranti Nursing Home, where scanning was done and the report revealed that normal. Even though the 2^nd complainant took medicines as prescribed by Kranti Nursing Home, the pain was not subsided. On the advice of the doctor, MRI scanning was done by Dr. Aravindam of Rajamahendravaram, who told her that it was a case of nervous problem. As pain was not got rid of, the 2^nd complainant took treatment at Aushutosh Neuro Surgeon, Rajamahendravaram and KIMS Hospital, Hyderabad etc. As there was no relief to the 2^nd complainant from pain and suffering, both the complainants went to Coimbatore Ganga Hospital and got treated the 2^nd complainant and after conducting necessary tests, processes etc., the doctors at Coimbatore hospital diagnosed and named the disease as “Arnold Chiari Malformation.” The 2^nd complainant as advised had undergone operation for the prolapsed brain above the back side of the neck, at Coimbatore and the 2^nd complainant was in hospital as inpatient for three weeks in the months of May and June, 2014. The 1^st complainant spent a total sum of Rs.4,00,000/- and odd towards operation, hospitalization, nursing and transportation etc. The 2^nd complainant was admitted in Ganga Hospital on 5.6.2014 and undergone surgery and discharged on 28.6.2014. Then a claim was submitted by the 1^st complainant to the opposite parties for reimbursement of medical expenses for the treatment of Arnold Chiari Malformaton at Ganga Medical Center and Hospital Private Limited, Coimbatore on 5.6.2014 with claim No.CLI/2015/131124/0049787. But, the opposite parties had approved only cashless treatment amount of Rs.1,00,000/-, while repudiating the claim of the              1^st complainant for the balance amount. The opposite parties have sent a letter of withdrawal of authorization, rejection of pre-authorization for cashless treatment as the restricted sum insured has been exhausted through the previous claim approval given has been withdrawn and claim has rejected vide Ex.A4.    

The material on record reveals that the 1^st complainant has sent a letter to the opposite parties on 30.8.2014 vide Ex.A8 with forwarding hospital bills for reimbursement of the claim mentioning of all particulars. The same was received by the opposite parties and sent a reply vide Ex.A9 stating that the “condition of the present diagnosis has been experienced even prior to his policy”. Then the 1^st complainant got issued a legal notice dt.31.10.2015 vide Ex.A10 to the opposite parties and it was acknowledged by the 2^nd opposite party on 4.11.2015 vide Ex.A11. The 2^nd opposite party sent a reply notice vide Ex.A12 stating that “the onset of disease to the insured patient was 5 years back i.e. prior to the inception of the policy and hence, the claim was settled as per the applicable sum insured of Rs.1,00,000/- which is maximum amount payable as per the terms and conditions of the policy”. So, it is quite evident that the opposite parties have rejected the balance amount of the 1^st complainant on the sole ground that the condition of present diagnosis has been experienced even prior to the policy.

 

As there is valid medical insurance coverage to the 1^st complainant’s family, the       1^st complainant made a claim application and furnished all the material papers to the opposite parties for payment of claim vide claim dated 18.5.2014 by the hospital for pre-authorization for cashless treatment and again on 11.8.2014 vide claim form – Part B by Ganga Hospital with all relevant material, bills, scanning record, lab reports, advance payments etc., but the opposite parties on the wrong notion denied the claim stating that the complainants have suppressed the said disease under the head pre-existing disease which is named as Arnold Chiari malformation/S/P foramen magnum run decompression with wound/CSR leak. The opposite parties admitted that they have received the claim form submitted by the                 1^st complainant seeking reimbursement hospitalization expenses of Rs.2,13,220/- for the treatment of Arnold Chiari malformation/S/P foramen magnum run decompression with wound/CSR leak. So, the duty is cast upon the opposite parties to make an enquiry through their concerned officer to know whether the insured patient i.e. 2^nd complainant had symptoms of neck pain and back pain since 5 years and on the basis of the said ailment, the insured patient i.e. 2^nd complainant was diagnosed and treated and the said ailment existed prior to the inception of the policy. But, they did not do so for the reasons best known to them.  Further, in Ex.A5 letter issued by the Ganga Medical Center and Hospitals Private Limited, wherein it is clearly mentioned that the 2^nd complainant was admitted in the said hospital as inpatient on 5.6.2014 and was discharged on 28.6.2014. Generally, every hospital will maintain case sheet whenever patient is admitted in the hospital. It is a known fact that in the case sheet, all the particulars and previous history of the alleged disease will be noted by the duty doctor. But, the opposite parties have not taken any pains to get the medical record from the said hospital to substantiate their contention that the condition of the present diagnosis has been experienced even prior to the policy. So, it is vague allegation which is not supported by any scrap of paper produced by the opposite parties.

On perusal of the material available on record, we observed that the opposite parties   1 and 2 have acted in most negligent manner and not complied with terms of contract in reimbursing balance of Rs.1,13,220/- to the complainants and the repudiation of claim of the complainants is also untenable and illegal. The opposite parties also failed to establish their version that the complainants have suppressed the said disease and made the claim without disclosure of the same. Further there is no violation of terms and conditions of the policy.                   So, it amounts to deficiency of services on the part of the opposite parties. The opposite parties cannot refuse the claim of the complainants on the flimsy ground that the present diagnosis has been experienced even prior to the policy, however, they failed to prove the same. 

Therefore, we are of the opinion that the opposite parties are liable to pay the balance claim amount of Rs.1,13,220/-. We are not inclined to grant Rs.30,000/- towards bonus. The complainants also entitled the costs of the complaint.            

 

8.   POINT No.3:  In the result, the complaint is allowed in part, directing the opposite parties to pay Rs.1,13,220/- towards the balance claim amount with interest @ 9% p.a. from the date of complaint i.e. 11.01.2016 till realization to the complainants. We further direct the opposite parties to pay Rs.2,000/- towards costs of the complaint to the complainants. Time for compliance is two months from the date of this order.

 

 

Dictated to the Stenographer, typed to my dictation, corrected and pronounced by us

in open Forum,, on this the 21^st day of December, 2016.

    

                  Sd/-                                                                                                                      Sd/-

              MEMBER                                                                                                         PRESIDENT

         

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANTS:  None.                                                                                     FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANTS:

 

 

 

 

Ex.A1    dt/12.12.2010            Customer Identity card of Star Health and allied insurance

             company limited valid from 12.12.2010 issued by the opposite

             party.

Ex.A2    dt/.                             Family Healthy Optima Insurance Policy for the family

            members of complainant in No.4 issued by the opposite party.

Ex.A3    dt/27.06.2014            Withdrawal of authorization letter by opposite party.

Ex.A4    dt/27.06.2014            Rejection of Pre-authorization for cashless treatment.

Ex.A5    dt/01.07.2014            To whom so ever it may concern letter.

Ex.A6    dt/.                              Drugs used in operation theatre (4) by Ganga Medical Center.

Ex.A7    dt/11.08.2014            Claim form by the complainant to the opposite party.

Ex.A8    dt/30.08.2014            Letter addressed by the complainant to the opposite party with

           postal receipt.

Ex.A9    dt/10.10.2014            Letter to the complainant by the opposite party.

Ex.A10  dt/31.10.2015           Legal notice got issued by the complainant to the opposite

           parties.

Ex.A11  dt/.                             Postal acknowledgements in No.2.

Ex.A12  dt/ .                             Reply given by the opposite party to the complainant’s counsel.      

 

FOR OPPOSITE PARTIES:-    - Nil -

 

                  Sd/-                                                                                                     Sd/-

              MEMBER                                                                                       PRESIDENT