By Sri. Chandran Alachery, Member:-
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite Party to pay Rs.36,981/- as treatment expenses to the Complainant and otherwise to return Rs.14,771/- being the amount received from the Complainant, to pay Rs.5,000/- as compensation and Rs.1,000/- towards cost of the proceedings.
2. Complaint in brief:- The Complainant took a medi-claim policy from the Opposite Party named Senior Citizens Red Carpet Policy and its coverage is from 29.04.2016 to 28.04.2017. A sum of Rs.14,771/- is paid by the Complainant as premium and service charge. On 20.09.2016, the Complainant got admitted at Martin Hospital, Ambalavayal for fever and cough. On 21.09.2016, he was discharged and a sum of Rs.3,698/- is spend for medical expenses. The Opposite Party refused the cashless benefit stating that there is supression of material facts. The act of Opposite Party is deficiency of service from their part. Hence the complaint.
3. On receipt of complaint, notice was issued to Opposite party and the Opposite Party appeared before the Forum and filed version. In the version of Opposite Party, the Opposite party admitted the taking of policy by the Complainant and the period of policy is on 30.03.2015 to 29.04.2016 it was renewed up to 28.04.2017. The contract of insurance is a contract of uborime fide. The policy is issued strictly as per terms and conditions of policy. The Complainant is bound to give proper information regarding health conditions. The Opposite party received a pre-authorisation request for cashless benefit from St.Martins Hospital, Ambalavayal in which it was stated that the Complainant was admitted on 29.09.2016 and provisionally diagnosed with COPD and CA HD (Chronic Obstructive Pulmonary Disease and Coronary Atherosderotic Heart Disease). In pre-authorisation request, the treating doctor had recorded the nature of illness disease with presenting complaints as “Known case CAHD/Post PTCA to KCA in 2010 with COPD”. Also in the past history column the duration of IHD/CAD was shown as “6 years”. The policy commences from 30.03.2015. The Complainant not stated anything about his previous treatment details in the proposal form at the time of entering into the contract. Hence the cashless benefit is denied on the suppression of material facts. After discharge, the Complainant not submitted any document to this Opposite Party till this date for processing a claim. There is no deficiency of service from the part of Opposite Party.
4. On perusal of complaint, version and documents, the Forum raised the following points for consideration.
1. Whether there is deficiency of service from the part of Opposite Party?
2. Relief and costs.
5. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents are marked as Exts.A1 to A4. The Opposite Party also filed proof affidavit and is examined OPW1 and Exts.B1 to B6 is marked. Ext.A1 is the Discharge card, Ext.A2 is the rejection letter of pre-authorisation for cashless treatment. Ext.A3 is the policy, Ext.A4(1) is the cash bill, Ext.A4(2) is also a bill, Ext.B1 is the policy schedule, Ext.B2 is the copy of proposal form, Ext.B3 is the copy of request for cashless treatment, Ext.B4 is the copy of treatment records, Ext.B5 is the rejection of pre-authorisation for cashless treatment. Ext.B6 is the authorisation letter.
6. Admittedly, the policy is a senior citizens Red Carpet Policy in which no medical check up is necessary before joining the policy. In the proposal form the Complainant not stated any existing disease. In the medical history column, the answer given is 'No'. But the case of Complainant is that the proposal form is filled by the agent of the Insurance company and the Complainant had disclosed every thing to the Agent. The proposal form is in English and the Agent not explained anything to the Complainant. On perusal of Ext.A1 Discharge card, it is seen that the Complainant went to the Hospital and got treatment for fewer, cough and wheeze. The medicines prescribed are moxikind, paracip, nasal drops etc which are meant for fewer cough and wheeze. When patient is diagnosed, the treating doctor diagnosed CAHD/post PTCA, COAD. But the admission and treatment given are not for CAHD & COPD as per discharge card. The Complainant should disclose all existing illness and diseases in the proposal form. But in this case, the agent filled the form and did not state all facts disclosed by the Complainant to the agent. On perusal of treatment records, the Forum found that the treatment availed by the Complainant is not for any pre-existing disease like CAHD/COPD. Since it is senior citizen Red Carpet Policy in which medical checkup is not necessary the opposite party should expect such diseases in an aged person and should take much care in issuing policy. On perusal of entire evidences, the Forum is of the opinion that the Complainant is entitled to get the treatment expenses from the Opposite Party. According to the Forum, the Opposite Party should take lenient view in senior citizens policy. Non-granting of cashless benefit to the Complainant is a deficiency of service from the part of Opposite Party. Point No.1 is found accordingly.
7. Point No.2:- Since point No.1 is found in fvour of Complainant, the Complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the Opposite party is directed to pay Rs.3,698/- (Rupees Three thousand Six hundred and Ninety Eight) only towards the treatment expenses to the Complainant. The Opposite Party is also directed to pay Rs.1,000/- (Rupees One thousand) only as compensation and Rs.1,000/- (Rupees One thousand ) only as cost of the proceedings. The Opposite Party is directed to comply the order within 30 days from the date of receipt of this order failing which the Complainant is entitled to get 12% interest for whole sum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Forum on this the 22nd day of March 2017.
Date of Filing:06.10.2016.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witnesses for the complainant:
PW1. Issac Complainant.
Witness for the Opposite Party :
OPW1. Balu. Executive, Legal, Star Health Co. Pvt Ltd.
Exhibits for the complainant:
A1. Discharge Card.
A2. Copy of Letter. dt:21.09.2016.
A3. Senior Citizens Red Carpet Health Insurance Policy.
A4(1) Bill dt:21.09.2016.
A4(2) Bill. dt:21.09.2016.
Exhibits for the opposite Party:
B1. Copy of Senior Citizens Red Carpet Health Insurance Policy.
B2. Copy of Senior Citizens Red Carpet Insurance – Proposal Form.
B3. Copy of Request for Cashless Hospitalisation for Medical Insurance Policy.
B4. Copy of Treatment Records.
B5. Copy of Rejection of Pre-Authorization for Cashless Treatment. dt:21.09.2016.
B6. Authorisation Letter. dt:19.01.2017.
