Karnataka

Kolar

CC/56/2018

C.Maniraju - Complainant(s)

Versus

The Manager, Star Health & Allied Insurance Company Limited - Opp.Party(s)

GSR

11 Jan 2019

ORDER

Date of Filing: 11/07/2018

Date of Order: 11/01/2019

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, D.C. OFFICE PREMISES, KOLAR.

 

Dated: 11^th DAY OF JANUARY 2019

PRESENT

SRI. K.N. LAKSHMINARAYANA, B.Sc., LLB., PRESIDENT

SMT. A.C. LALITHA, BAL, LLB.,  ……  LADY MEMBER

 

CONSUMER COMPLAINT NO. 56 OF 2018

Sri. C. Muniraju,

S/o. Late Chikkagiriyappa,

34 Years, Thornahalli Village,

Bhyranahalli Post,

Kasaba Hobli,

Malur Taluk, Kolar District.                                  ….  COMPLAINANT.

(Rep. by Sri. Srinivas.G, Advocate)

 

- V/s -

1) The Manager,

Star Health & Allied Insurance Company

Limited, Kolar Branch,

1^st Floor, New Kolar Nursing Home

Building, Antharagange Road,

Kolar-563101.

 

2) Chief Manager/Managing Director,

Star Health & Allied Insurance Company

Limited, #1, New Tank Road,

Valluvarkottam High Road,

Nungambakkam,

Chennai-600034.

(Both OP Nos.1 & 2 are Rep. by

Sri. G.R. Ramachandra Murthy, Advocate)           …. OPPOSITE PARTIES.

-: ORDER:-

BY SMT. A.C. LALITHA, LADY MEMBER,

01.   The complainant having submitted this complaint on hand as envisaged Under Section 12 of the Consumer Protection Act, 1986 (hereinafter in short it is referred as “the Act”) against the opposite parties has sought issuance of directions to make payment of health insurance policy vide No. P/141119/01/2018/000985 of his daughter M. Gowthami amount spent towards her treatment a sum of Rs.30,340/- + Rs.750/- + Rs.250/- and travelling expenses of Rs.5,000/- as in total sought for compensation of Rs.5,00,000/-.

 

02.   The facts in brief:-

(a)    It is contention of the complainant that, he has availed health insurance policy from OPs on 23.08.2017 vide No. P/141119/01/2018/000985 which is valid from 23.08.2017 to 23.08.2018 for coverage amount of Rs.15,00,000/-.

 

(b)    It is contended that, on 28.11.2017 his daughter Gowthami had suffered fever, stomach ache and rashes on body taken to St. Mary’s Hospital, Malur, and on 30.11.2017 he took her to Manipal Hospital admitted as in-patient after her completion of treatment got discharged on 01.12.2017.  He had paid cash for treatment as, for patient card Rs.250/-, Doctor consultation fee Rs.750/- other expenses of Rs.5,000/-.

 

(c)    It is contended that, his daughter has discharged from the hospital on 01.12.2017 with no any health issues.  He had informed to OPs as his daughter admitted at Hospital through phone.  One of OPs representative visited to hospital and took his signature.  But later on he got letter from OPs as the policy is denied as suppression of pre-existing disease and proposed to submit documents at Kolar Branch Office.  On 05.05.2018 he received another letter from OPs as his daughter was the patient of Liver disease prior to obtaining of the policy, hence refunding premium of Rs.2,892/- cheque.

 

(d)    It is further contended that, his daughter does not had any liver disease prior to policy.  To escape from liability OPs falsely alleged so and in this regard he got issued legal notice to OPs on 21.05.2018 and no reply by OPs.  So contending, the complainant has come up with this complaint by seeking above set-out reliefs.

 

03.   In response to notice issued by this Forum OPs have put in appearance through their said learned counsel and submitted version.

(a)    The contention of OPs is that, by admitting the issuance of family health optima insurance policy covering complainant, Mrs. Meenakshi spouse, M. Gowthami, vide policy No. P/141119/01/2018/000985 for the period from 23.08.2017 to 22.08.2018 for the floater sum insured of Rs.1,50,000/- for first time.

 

(b)    The contention of OPs is that, it is admitted by the complainant that, his daughter M. Gowthami was admitted to St. Mary’s Hospital, Malur, on 22.08.2017 as she was suffering from bubbles on the body stomach ache and fever and also typhoid.  Without disclosing anything the complainant availed the insurance policy on the next day i.e., 23.08.2017.  From the records submitted by the complainant it was noticed that, M.Gowthami the patient has been on continuous evaluation for liver failure since 2015 which is prior to the inception of the policy and the same was omitted to be disclosed in the proposal form which amounts to non-disclosure of material facts.  The present admission and treatment of the insured patient, the claim is non-payable in view of non-disclosure of pre-existing disease as per the terms and conditions of the policy.  The insured has not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to mis-representation/non-disclosure of the material facts.

 

(c)    As per the contract of insurance it is the duty of the proposer to disclose all the material facts to the insurer, so that the insurer evaluates the material facts and decide whether to accept the proposal or not, as the insurance contracts based on utmost good faith.  In case of health insurance contracts the discloser of health detail or the material facts.  The insured has to disclose all his past medical history in the proposal form which is material fact for issuing medical insurance policy to the insured.

 

(d)    As per condition No.6 of the policy “if there is any misrepresentation/nondisclosure of material facts whether by the insurance person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim”.  Hence the claim was repudiated and communicated to the insured vide letter dated: 28.03.2018.

 

(e)    As per condition No.12 of the policy “the company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non disclosure of material facts as declared in the proposal form/at the time of claim or non co-operation of the insured person”.

 

(f)     The complainant submit that, the policy was cancelled with effect from 8.5.2018 due to non disclosure of PRE-LIVER DISEASE after sending a 30 days notice to the insured and the premium amount of Rs.2,892/- was refunded vide DS.D/No.161439, dated: 4.5.2018 and the same was informed to the insured vide letter dated: 5.5.2018.

 

(g)    The complainant submit that, the claim was reported in the 3^rd month of Medical Insurance Policy from inception.  The insured patient got admitted on 30.11.2017 at Manipal Hospital, Bangalore and discharged on 01.12.2017 and it was diagnosed that, evaluation for Liver failure and evaluation of liver transplant.  The insured has raised a pre-authorization request to avail cashless facility.  On perusal of the claim documents it was observed that, the ailment is suggestive of a long standing disease and the exact chronicity of the ailment cannot be ascertained which is a available documents, cashless authorization was denied and communicated the same to the treating hospital as well as insured vide letter dated: 01.12.2017 and subsequently the insured submitted a claim for reimbursement of medical expenses.  On scrutiny of the claim documents it was observed that, the liver function report dated: 12.09.2015 and 22.08.2017 shows that insured patient has elevated liver enzymes.  Hence, the claim was denied.  Thereafter the insured caused a legal notice which was duly replied.  In spite of it, the insured has approached this Hon’ble Forum by suppressing the facts.  Hence, the relief claimed is not available to the complainant and the complaint needs to be dismissed.  The complainant has falsely stated that, for the purpose of medical expenses, the complainant has made hand loans and has spent more than Rs.25,000/- for conveyance and the family of complainant was put to mental and physical harassment.  So contending the OPs have sought for dismissal of the complaint in the interest of justice and equity.

 

04.   The complainant has submitted affidavit evidence and also submitted below mentioned documents:-

(i) Letter dated: 29.03.2018 issued by OPs to complainant along with copy of claims Medical Rejection dated: 28.03.2018.

 

(ii) Letter dated: 05.05.2018 issued by OPs to complainant

 

(iii) Policy Schedule containing 04 sheets

 

(iv) Manipal Hospital records pertaining to patient (running to 11 sheets)

05.   On behalf of OPs Sri. Kumar.C, Branch Manager, has submitted his affidavit evidence and also submitted the below mentioned documents:-

(i) Proposal form – Annexure-1

(ii) Letter issued by OPs to complainant dt.5.5.18 – Annexure-2

(iii) Policy form – Annexure-3

(iv) Admission request form – Annexure-4

(v) Undertaking forms two in numbers  - Annexures-5 & 6

(vi) Letter issued by OPs to complainant dt.29.3.18 – Annexure-7

(vii) Claims rejection – Annexure-8

(viii) Hospital Lab reports (4 in numbers) – Annexure-9.

 

06.   Heard arguments of both counsel.

07.   Therefore the points that do arise for our consideration are that:-

(1) Whether complainant’s daughter M. Gowthami is the patient of liver disease prior to 23.08.2017?

 

(2) Whether the repudiation of the claim of complainant by OPs would amount to deficiency in service?

 

(3) If so, whether the complainant is entitled for claim as he sought?

 

(4) What order?

 

08.   Our findings on the above stated points are:-

POINT (1):-      In the Negative

POINT (2) & (3):-In the Affirmative

POINT (4):-      As per the final order

for the following:-

REASONS

POINTS (1) to (3):-

09.   To avoid repetition in reasonings and as these points do warrant common course of discussion, the same are taken up for consideration at a time.

 

(a)    It is an admitted fact that, OPs have issued family health optima insurance policy vide No. P/141119/01/2018/000985 to complainant, Mrs. R. Meenakshi spouse, M. Gowthami valid for a period from 23.08.2017 to 22.08.2018 for a sum insured of Rs.1,50,000/- for first time.

 

(b)     OPs have contended that, the claim of complainant has been rejected as per condition No.6 of the policy i.e., mis-representation/non-disclosure of material facts.  Since the claimant M. Gowthami has the patient of liver disease from 12.09.2015 complainant has suppressed this fact and availed policy on 23.08.2017.

 

(c)    Contrary to this complainant pleaded as his daughter M. Gowthami is healthy and never had any such disease prior to the said policy.

 

(d)    On perusal of medical reports submitted by OP and complainant pertaining to treatment of M. Gowthami no document revealed that, the said baby was liver disease from 2015 as contended by OPs. 

 

(e)    On perusal of entire records of the case no premedical check-up was done to the baby before issuance of the policy.  It was the bound duty of insurance company and its agents to have verify the information given in the proposal form by obtaining suitable expert opinion before issuing the policy, but OPs failed to submit any evidence in this regard.

 

(f)     On perusal of medical records of the said baby, the symptoms, conditions so mentioned in the history column does not imply that, the complainant would aware the said symptoms were of serious disease without examination by a Doctor.  So the question of suppression of pre-illness while obtaining policy will not arise at all.  Therefore the OPs rendered deficiency in service by wrongly repudiating claim of complainant on non-disclosure of pre-existing disease.  However OPs admitted policy validity so they are entitled to pay the claim of complainant said policy.  According to Bill dated: 01.12.2017 submitted by complainant total amount spent for treatment of Rs.33,530/- which falls within claim amount of said policy and OPs liable to pay the same to complainant and compensation.

 

POINT (4):-

10.   In view of the above discussions on Point (1) to (3) we proceed to pass the following:-

ORDER

01.   For foregoing reasons the complaint is allowed with cost of Rs.2,000/- as against OPs.

02.   The OPs are herewith directed to pay a sum of Rs.33,530/- of insurance policy vide No. P/141119/01/2018/000985 and compensation of Rs.3,000/- with 9% interest from the date of filing of this case till realization to complainant within 30 days from the date of communication of this order.

 

03.   Send a copy of this order to both parties free of cost.

(Dictated to the Stenographer, transcribed by him, corrected and then pronounced by us on this 11^th DAY OF JANUARY 2019)

 

 

LADY MEMBER                         PRESIDENT