DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 27th day of February 2018
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 22/09/2016
: Sri.V.P.Anantha Narayanan, Member
(C.C.No.142/2016)
Unus Salim,
S/o Moideen,
Priyadarshini-Kunnath House,
Kottapuram (PO),
Ottapalam Taluk,
Palakkad, Kerala. - Complainant
(By.Adv.K.K.Sreenivas)
V/s
The Star Health & Allied - Opposite party
Insurance Co.Ltd,
VILCO Centre, 1st Floor, Subhash Road 8,
Near Garware House,
Vile parle (e),
Mumbai – 400 057.
(By Adv. A.Raji Vijaya Sankar)
O R D E R
By Sri. V.P.Anantha Narayanan, Member
Brief facts of the case.
With the opposite party health insurance company, complainant has taken a Senior Citizen Red Carpet Health Insurance Policy, as per policy number P700002/01/2016/021479 for a period from 30.08.2015 to 29.08.2016 in continuation of previous policy No. P700002/01/2015/013280 to cover the medical expenses of his father and mother. All the health details of his father and mother were handed to opposite party and after verifying all the records, opposite party has issued the policy after receiving premium of Rs.10,146/-. As per the terms of the policy, opposite party is liable to pay the medical expenses of the father and mother of the complainant and opposite party’s officials at the time of issuing the policy assured the complainant that all the medical expenses of his father and mother would be issued to him by the opposite party without delay. On 14.11.2015 complainant’s father Mr.Kunnath Moideen was admitted in the Moulana Hospital, Perinthalmanna and discharged on 25.11.15. Complainant paid the bill of Rs.35,143.46/-. Complainant claimed the bill amount from the opposite party but opposite party allowed only Rs.3,000/- to the complainant. As per the terms of the policy, opposite party has to pay the entire medical expenses of his father incurred in the hospital, pleaded by the complainant. The opposite party denied the entire amount on silly grounds by violating the conditions of the opposite party’s insurance scheme. Complainant’s father was again admitted in Mother Care Hospital, Vattambalam from 29.11.2015 to 08.12.2015 where the complainant paid medical bill of Rs.33,615.94/-. This claim was also rejected by the opposite party as per the letter dated.30.11.2015 stating the reason of non disclosure of material facts during inception of the policy. According to the complainant, no material facts were suppressed by him; if he suppressed any material facts, then opposite party should have rejected his claim, but opposite party paid Rs.3,000/- only and rejected other claims which shows that no material facts were suppressed. For covering the medical expenses of his aged father and mother complainant has taken policy from opposite party insurance company; but opposite party has not complied the conditions and denied the policy benefits to him. This act of opposite party is highly illegal and amounted to gross dereliction of service to the customers. According to the complainant, he suffered much financial loss and mental agony. Complainant also sent a lawyer notice to the opposite party on 12.12.2015 claiming Rs.1,30,000/- for the losses and damages suffered by him. The opposite party received the notice but they have not paid any amount nor sent any reply. Complainant pleads that as per the terms of the policy issued by the opposite party they are liable to pay all the treatment expenses of his father and the opposite party denied his claim without any basis. Hence, the complainant prays to the Hon’ble Forum to pass an order against opposite party to pay Rs.1 lakh to the complainant for the treatment expenses of his father as per the terms of the policy with 12% interest, and to pay Rs.30,000/- to the complainant towards mental agony and other damages caused to him and to allow such other reliefs which are proper and fit in the interest of justice.
The complaint was admitted and notice was sent to opposite party to enter appearance and file version. As per the version submitted by opposite party’s authorised representatives, the opposite party denies all the allegations contained in the complaint except to the extent admitted. According to the opposite party, the complaint is not maintainable legally or factually. The complainant has no bonafides in filing this complaint. The complaint is bad for non jointer of necessary parties. The opposite party is not residing nor carrying on any business within the territorial jurisdiction of this Forum. The subject policy has been taken by online and the treatment of the complainant was done at Malappuram. No cause of action has taken place either wholly or partially within the jurisdiction of this Hon’ble Forum at Palakkad, although the complainant resides in Palakkad District. By considering the above facts the opposite party contends that the complaint is not maintainable before this Forum. The complainant has taken a Senior Citizen Red Carpet insurance policy from the opposite party for the period from 30.08.2014 to 29.08.2015 covering his father and mother for a sum assured of Rs.1 lakh each and was further renewed up to 29.08.2016. At the time of taking the policy the complainant was given “terms and conditions of the policy” Opposite party contends that in the case of this policy medical examination is not required as the entry age is more than 60 years. As per the terms and conditions of the policy, only those pre-existing diseases specifically declared by the proposer in the proposal form are covered under the policy and therefore it is compulsory that the information regarding health must be provided in the proposal form which is the basis of insurance contract. On the basis of the proposal form the opposite party provides the insurance coverage. In the proposal form the complainant has specifically declared that his father was not suffering from any disease at the time of submitting the proposal form or earlier and that his father’s health condition was good in all respects. In the proposal form complainant has also declared that if after effecting the insurance policy, any particulars stated in the proposal form are found incorrect, the insurance company would incur “no liability under the policy”. According to the opposite party, the complainant has intimated two claims to the opposite party. In claim no.0240022 complainant’s father was admitted in Moulana Hospital, Malappuram on 14.11.2015 and the opposite party received a pre-authorisation request from the hospital that he was provisionally diagnosed with RTI (Respiratory Tract Infection). On receiving this authorisation, opposite party approved Rs.3,000/- as preliminary amount. Even though the opposite party received discharge bill, the opposite party rejected the enhancement request and informed the hospital on 25.11.2015 because the necessary and reasonable charges for treatment of LRTI were already paid by the opposite party; in claim No.0255629, complainant’s father was again admitted in Mother Care and Health Centre Pvt.Ltd, Vattambalam, on 29.11.2015 and the opposite party company received a pre-authorisation request from the hospital that he was provisionally diagnosed with Basal Vasil Consolidation. In the pre-authorisation request, the duration for Bronchial Asthma was recorded as 3 years which was not disclosed by the insured or the patient at the time of taking the policy. Hence, the opposite party rejected the pre-authorisation request and informed the hospital on 30.11.2015. Opposite party further contends that the cashless facility is extended to those cases where the liability of the insurance company under the policy is established beyond doubt and in other cases the insured has to submit a completed claim form with all supporting treatment documents in order to enable the opposite party to process the claim on merit. According to the opposite party, no documents or original bills were submitted by the complainant to process the claim. As per the condition No.4 of the policy the claim must be filed within 15 days from the date of discharge from the hospital. The insured has not submitted a claim to the opposite party and the opposite party did not get an opportunity to decide on the merits of the claim based on available documents, since the complainant approached the Forum without submitting a claim. Hence, opposite party’s prayer to the Hon’ble Forum to direct the complainant to file the claim form with all necessary documents to the opposite party to process the claim on merits. The opposite party also denies the allegations made by the complainant in paragraphs 1, 2 & 3 of the complaint. According to the opposite party, the insurance company (opposite party) has exercised abundant caution in dealing with the claim by applying all conditions correctly because the opposite party is functioning under the guidelines of IRDA, controlled by the Govt. of India. Therefore the opposite party humbly prays to the Hon’ble Forum that there is no deficiency in service on their part and the complainant has no cause of action and no cause of action has arisen within the jurisdiction of this Forum. Hence this Hon’ble Forum may be pleased to dismiss the complaint with cost to this opposite party.
Complainant & Opposite party also filed affidavit. From the side of the complainant Exts.A1 to A7 were marked and Exts.B1 to B9 were marked on the side of the opposite party.
The following issues are considered in this case.
- Whether the complaint is maintainable before this Forum?
- Whether there is any deficiency in service from the side of opposite party ?
- If so, the relief and cost entitled for the complainant?
Issue No.1,
In this case complainant was treated in two hospitals namely Moulana Hospital, Perinthalmanna, Malappuram District & Mother Care and Health Centre Pvt.Ltd, Vattambalam, Palakkad District. Since he was treated in Palakkad District located hospital also, cause of action has arisen place partially at Palakkad and within the jurisdiction of this Forum. Therefore the issue of jurisdiction is decided in favour of the complainant.
Issues 2 & 3
Complainant took a Senior Citizen Red Carpet Health insurance policy as per policy No.P700002/01/2016/021479 vide Ext.A1 which is a self attested true copy of the policy number mentioned above which indicates policy number, proposer’s name & address, date of inception of the policy, total premium, period of insurance, details of insured persons, details of pre-existing diseases relating to insured persons etc, in continuation of previous policy number No.P700002/01/2015/013280 to cover the medical expenses of the complainant’s father and mother. Self attested true copy of previous policy is marked as Ext.A2 which indicates previous policy number, proposer’s name & address, date of inception of the policy, total premium, period of insurance, details of insured persons, details of pre-existing diseases of insured persons etc. On 14.11.2015 complainant’s father was admitted in Moulana Hospital, Perinthalmanna, Malappuram District and discharged on 25.11.2015. Complainant paid the bill of Rs.35,143.46/- and claimed the bill amount from the opposite party’s insurance scheme. Self attested true copy of medical bill issued by Moulana hospital authorities for treatment of complainant’s father was marked as Ext.A3 which shows details of expenses incurred etc. in the hospital, net amount payable, but the opposite party allowed only Rs.3,000/- to the complainant denying the entire amount of claim. As per Ext.A5 which is a self attested true copy of letter dated.25.11.2015 issued by the opposite party rejecting enhancement request beyond Rs.3,000/- which also shows provisional diagnosis of the patient, name of the insured person, date of admission in the hospital etc. Again complainant’s father was admitted in Mother Care Hospital, Vattambalam, Palakkad District on 29.11.2015 and discharged on 08.12.2015 and complainant paid medical bill of Rs.33,615.94/-. Self attested true copy of medical bill issued by the above hospital authorities for treatment of complainant’s father was marked as Ext.A4 which shows details of medical expenses incurred by the complainant for his father’s treatment, net amount payable, net amount collected, name of doctor etc. This claim is also rejected by the opposite party as per letter dated. 30.11.2015 and self attested true copy of this letter is marked as Ext.A6 which mentions denial of pre-authorization for cashless treatment, diagnosis, non disclosure of material facts during inception of the policy etc. Afterwards the complainant sent a lawyer notice to the opposite party on 12.12.2015 through his counsel claiming Rs.1,30,000/- for the losses and damages caused to him. Self attested true copy of the lawyer notice dated.12.12.2015 issued to the opposite party by the complainant’s counsel is marked as Ext.A7 which asks the opposite party to pay Rs.1,00,000/- as compensation for the loss suffered by the complainant and Rs.30,000/- as compensation for mental agony suffered by the complainant due to the act of the opposite party. The opposite party received the notice, but not paid any amount to the complainant nor sent him a reply to the lawyer notice received by the opposite party.
In the version filed by the opposite party, they deny all the allegations leveled in the complaint except those admitted. According to the opposite party, complaint is not maintainable before this Forum and the complainant has no bonafides, the complaint is also bad for non-jointer of necessary parties and the opposite party is not residing nor carrying on any business within the territorial jurisdiction of this Forum, the subject policy was taken through online, the complainant’s treatment was done at Malappuram and hence no cause of action took place within the jurisdiction of this Forum either wholly or partly. Opposite party also contends that in the proposal form, which is the basis of insurance contract between the complainant and the opposite party and issue of insurance policy, the complainant declared that his father was not suffering from any disease at the time of submitting the proposal form or earlier and complainant’s father also declared that if after effecting the insurance policy any particulars mentioned in the proposal form are found false, the insurance company wood incur “no liability” under the policy. At the time of receiving the policy the complainant was supplied with Ext.B4 which was marked and which shows original terms and conditions of the policy, coverage, definition, exclusions, conditions etc. Attested true copy of the proposal form submitted by the complainant to the opposite party is marked as Ext.B1 which indicates details of proposer, details of plan, details of insured their pre-existing diseases whether occurred or not for past one year, and prior to one year etc. Attested true copy of the policy schedule of policy number 013280 was marked as Ext.B2 and attested true copy of policy schedule of policy No.021479 was marked as Ext.B3 which indicate proposal date, date of inception of the policy, total premium payable, details of insured persons, period of insurance etc. In claim number 0240022 the opposite party approved and paid Rs.3,000/- as the necessary and reasonable charge for treating “LRTI” and rejected the enhancement request. In claim number 0255629 the duration for “bronchial asthma” was recorded as 3 years in the pre-authorization request of the Mother Care Hospital which fact was not disclosed by the insured or the patient at the time of taking the policy, hence opposite party rejected this claim. Attested true copy of pre-authorisation form received from Moulana Hospital Perinthalmanna in claim number 0240022 was marked as Ext.B5 which states name of the treating doctor, date of admission in Moulana Hospital, Declaration by the patient or his representatives, hospital declaration etc. In this claim, complainant’s father was admitted at Moulana Hospital, Perinthalmanna on 14.11.2015 and opposite party approved Rs.3,000/- as the necessary and reasonable charge for LRTI treatment and rejected the enhancement, contended by the opposite party. Attested true copy of authorization for cashless treatment in claim No.0240022 dated.16.11.2015 sent to Moulana Hospital, Perinthalmanna is marked as Ext.B6 which discloses name of the insured patient, date of admission to the hospital, name of policy, policy number, claim intimation number, age of the patient etc. Attested true copy of rejection of request for enhancement of cashless treatment dated.25.11.2015 sent to Moulana Hospital, Malappuram is marked as Ext.B7 which shows name of hospital, name of the insured patient, policy number, claim number, provisional diagnosis, nature of treatment etc. As per claim number 0255629 complainant’s father was admitted in Mother Care and Health Centre Pvt.Ltd. on 29.11.2015 and the opposite party received a pre-authorisation request from the hospital. Attested true copy of pre-authorisation request form in claim number 0255629 is marked as Ext.B8 which indicates name of the hospital, name of treating doctor, details of disease of the patient, particulars of the disease “bronchial asthma” and duration of the same as 3 years etc. As per the pre-authorisation request, the patient was provisionally diagnosed with Basal Vasil Consolidation and the duration of bronchial asthma was recorded as 3 years both of which were not disclosed by the insured/patient at the time of taking the policy. Hence, the opposite party rejected the pre-authorisation request of the hospital. Attested true copy of letter showing denial of pre-authorisation for cashless treatment dated.30.11.2015 sent to Mother Care and Health Centre, Private Limited in claim number 0255629 was marked as Ext.B9 which indicates that request for authorization for cashless treatment of the insured patient in the hospital is denied.
From the affidavits and the documents produced, we understand that although complainant’s father was suffering from Respiratory Tract Infection and Basal Vasil Consolidation, these diseases were not seen disclosed by the complainant in the proposal form submitted by him to the opposite party; also the complainant is found to have concealed from the opposite party in the proposal form submitted to the opposite party, the existence of the disease of Bronchial Asthama for his father at the time of taking the policy and for the last 3 years. We also observe that both these diseases are seen disclosed by the treating doctors of the two hospitals where complainant was treated, in their pre-authorisation request forms sent to the opposite party. We also observe that the complainant has not seen produced before this Forum the discharge summaries issued by Moulana Hospital, Perinthalamanna and Mother Care and Health Centre Private Limited, Vattambalam, Palakkad. We also observe that complainant has been seen to have failed to submit the claim form within the prescribed time and all the necessary documents to the opposite party to prove his case which is compulsory as per the terms and conditions of the Health Insurance Policy issued to the complainant. In the light of all the above we view that grave deficiency and omission have occurred on the part of the complainant. The result is that complaint is dismissed.
Pronounced in the open court on this the 27th day of February 2018.
Sd/-
Shiny.P.R
President
Sd/-
Suma.K.P
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 - Self attested true copy of the policy issued by Star Health and Allied
Insurance Company Limited - No.P700002/01/2016/021479
Ext.A2 - Self attested true copy of the policy issued by Star Health and Allied
Insurance Company Limited - No.P700002/01/2015/013280
Ext.A3 - Self attested true copy of Medical bill dated.25.11.2015 issued by Moulana
Hospital, Perinthalmanna for the treatment of the complainant’s father
Ext.A4 - Self attested true copy of Medical bill dated.08.12.2015 issued by Mother
Care and Health Centre Authorities Perinthalmanna for the treatment of the
complainant’s father
Ext.A5 - Self Attested true copy of rejection of request for enhancement of cashless
amount dated.25.11.2015 issued by the opposite party to Moulana
Hospital, Perinthalmanna
Ext.A6 - Self Attested true copy of denial of pre authorization for cashless treatment
dated.30.11.2015 issued by opposite party to Mother Care & Health Centre,
Pvt, Ltd.
Ext.A7 - Self attested true copy of lawyer notice dated.12.12.2015 issued by the
complainant’s counsel to the opposite party, postal receipt and
acknowledgement card
Exhibits marked on the side of Opposite parties
Ext.B1 - Attested true copy of the filled proposal form submitted by the
complainant
Ext.B2 - Attested true copy of the policy schedule of policy
No.P700002/01/2015/013280 issued by the opposite party to the
complainant
Ext.B3 - Attested true copy of the policy schedule of policy
No.P700002/01/2016/021479 issued by the opposite party to the
complainant
Ext.B4 - Original policy conditions issued by the opposite party to the complainant
Ext.B5 - Attested true copy of filled request form for cashless and hospitalization for
medical insurance policy for claim No.0240022
Ext.B6 - Attested true copy of authorization for cashless treatment in
claimNo.0240022 dated.16.11.2015
Ext.B7 - Attested true copy of rejection of request for enhancement of cashless
amount dated.25.11.2015 on n claim No.0240022
Ext.B8 - Attested true copy of filled up preauthorization request form in
claimNo.0255629
Ext.B9 - Attested true copy of denial of pre-authorization for cashless treatment dated.30.11.2015 in claim No. 0255629
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite party
Nil
Cost
Nil
