CONSUMER DISPUTES REDRESSAL FORUM

Palakkad, Kerala

Dated this the 18^th day of September 2014

CC.NO.209/2013

PRESENT : SMT. SEENA. H, PRESIDENT                Date of filing: 09/12/2013

                 : SMT. SHINY.P.R ,MEMBER

       : SMT. SUMA K.P, MEMBER

N.K.Kalyanaraman,

S/o.Late.Dr.N.P.Venkiteshwara Iyyer,

Residing at “Geethanjali”,

Chinmaya Mission Road,

Palat Road,  Ottapalam Taluk,                                   :        Complainant

Palakkad District.    

(By Adv. K.K.Thankappan) 

                                                            Vs

1.The New India Assurance Co.Ltd.,

   Divisional Office, Kollannur Buildings,

   Palace Road, Thrissur – 680 020

2. Medi Assistant Pvt.Ltd.

    No.406, Chandralayam,

    Ravipuram, Kochi-682 015                                   :        Opposite parties  

3. The New India Assurance Co.Ltd.,

    Branch Office,

    Near Mission High School,

    Palakkad – 678 001.

   (By Adv.P.R.Hariharan)

O R D E R   

By Smt. Shiny . P. R.  Member.

Brief facts of the case:-  The complainant had taken a C.S.B Health Care support Insurance Policy from the 1^st opposite party on 01-8-2008 for the period from 1-8-2008 to 31-7-2009 and the policy number is 760300CSBIISO 808 1526, the Floater Policy number is 76030034088700000329. At the time of taking policy opposite parties had assured to give health coverage to the complainant and his family consisting of his wife and 2 children as per Plan C3 thereon and complainant had paid Rs.3944/- as premium. As per the said plan, the medi claim sum assured is Rs.2,00,000/- and the PA Sum assured is Rs.1,00,000/-. Complainant has continuously insured under the 1^st opposite party since 2002 and is continuing till this date without any lapse. In the year 2007, the complainant has triple vessel disease and stinting was done in CMC Hospital Vellore. Since complainant had incurred an expense of Rs.2,98,233/-, he claimed only Rs.2,00,000/- from the opposite parties. 1^st opposite party repudiated the same on the ground the complainant’s disease is a pre-existing disease. Then the complainant had to prefer C.C.89/08 before this Hon’ble forum. On 2-6-2009 the complainant encountered severe chest pain and got admitted in Christian Medical College Vellore. The complainant had undergone Angioplasty, and was advised for Coronary Artery Bypass Grafting on 8-6-2009 and he was discharged on 15-6-2009. Complainant had to incur an amount of Rs.1,56,186/- for the surgery. Immediately after the discharge complainant had submitted a claim form to the opposite parties with all original bills and receipts issued from the hospitals along with necessary particulars of the claim form. Since there was no response from the opposite parties, the complainant had to make several enquires and continuous reminders. On 30-9-2009 the 2^nd opposite party communicated to the complainant via an email that the complainant‘s claim has been repudiated on the ground that the disease is a pre existing one, and as per the provision 4.1 of the policy, the complainant is not entitled for the claim amount. Opposite parties has repudiated the claim without any valid reason. The complainant submitted that the coronary artery disease was first identified in the complainant on  23-10-2007 when he was admitted in CMC Vellore  for severe chest pain and stinting was done on the complainant on 1-11-2007 . All these aspects were intimated to the company soon after his discharge. Being fully aware of the disease of the complainant, the opposite parties knowingly issued the policy again on 1-8-2008 without making any exclusion for any particular disease of the complainant. Hence the complaint. Complainant prays for the direction to pay Rs.1,56,186/- being the amount payable for meeting the claim of the complainant under the health care policy issued by the opposite parties along with Rs.50,000/-  as compensation towards mental agony.   

           Complaint was admitted and issued notice to opposite party and they entered appearance and filed their version. 

The contention in their version is that complainant has not come with clean hands before this forum. The complainant had already filed C.C.89/08 before this forum for the claim of Rs.2,00,000/-, and after considering the evidence and available records, this Hon’ble forum was pleased to award an amount of Rs. 2,00,000/- as compensation. Against the award passed by the Hon’ble District forum  the opposite parties preferred an appeal before the Hon’ble State Commission and reduced the amount to Rs.50,000/- with interest @ 12% per annum from the date of complaint till  realization. As per    Ext.A1 clause 4.1 of the Medi claim policy limits the liability of the claim to “all diseases/insured which are pre existing when the cover incepts for the 1^st time. For the purpose of applying the condition the date of inception the initial medi claim policy taken from any of the Indian insurance companies shall be taken, provided the renewals have been continuous without any break. If the policy is to be renewed for enhanced sum insured then the restriction as applicable to a fresh policy will apply  additional sum insured as of a separate policy has been issued for the difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy period. The opposite parties further submitted that the insured is a known case of hypertension diabetes, sarcoidosis patient before the inception of the 1^st policy itself. Hence the opposite parties have rightly repudiated the claim and complaint is liable to be dismissed. The complainant has suppressed material information regarding the settlement of medi claim of          Rs. 61,436/-  during July 2013.    

          Both parties filed their chief affidavit.  Ext. A1 to A9 marked from the side of complainant. Ext. B1 marked on the side of opposite parties. Complainant is examined as PW1.

The following issues are considered. 

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

2.       If so what is the relief and cost?

 ISSUES 1 & 2

Both parties heard: - We have perused the documents on record.    Ext.B1 is the  terms and conditions of the Medi Claim Policy of 2007. So it is not applicable to the policy during the year 2008. The present policy is for the period from 1-8-2008 to 31-7-2009. Opposite parties not produced any documents to prove their contentions. Being fully aware of the disease of the complainant, the opposite parties knowingly issued the policy again on 1-8-2008 without making any exclusion for any particular disease of the complainant. Hence Opposite parties are liable to pay Rs.1, 56,186/- to the complainant being the amount covered under the said policy. Repudiation of the claim of the complainant could not be justified. Customer avails mediclaim policy with the hope that medical treatment expenses will be reimbursed by insurer.  Act of Opposite party is unjust and unfair towards complainant.   

            In view of the above discussions, we are of the opinion that repudiation of the claim amounts to  deficiency in service from the part of opposite parties.  Hence complaint is partly allowed.  All the Opposite parties are jointly and severally liable to pay Rs. 1,56,186/-(Rupees One lakh fifty six thousand one hundred and eighty six only) with 12% interest from the date of repudiation till date of order with cost of Rs.1000/- (Rupees One Thousand Only).

          Ordered amount shall be paid within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest for the whole amount from the date of order till realization.

          Pronounced in the open court on this the 18^th day of September 2014    

                                                                                                   Sd/-

                                                                                        Smt. Seena. H

                                                                                            President

 Sd/-

                                                                                        Smt. Shiny. P.R

                                                                                            Member

Sd/-

                                                                                      Smt.Suma K.P                                                                                                              Member

APPENDIX

 Exhibits marked on the side of the complainant

Ext.A1 -    Copy of CSB Health Care Support Group Insurance Certificate issued by

                the 1^st opposite party to the complainant dtd. 01/08/2008.

Ext.A2   -   Copy of the letter sent by the 2^nd opposite party  to the complainant 

                Intimating the repudiation of Complainant’s claim dtd. 30/09/2009.

Ext.A3   -   Copy of the claim form submitted by the complainant to the 1^st opposite   

                party dtd.30/07/2009.

Ext.A4   -   Copy of the letter sent by the complainant  to the 1^st opposite party

                Dtd.09/07/2009

 Ext.A5  -   Copy of the reply letter sent by the complainant.

 Ext.A6  -   Copy of the remainder letter sent by the complainant dtd.09/11/2009.

Ext.A7   -   Copy of medical bills dtd.18/06/2009.

Ext.A8   -   Copy of the discharge summary issued from CMC Vellore dtd.15/06/2009.

Ext.A9   -   Copy of the lawyer notice issued to the opposite parties.

Exhibits marked on the side of the opposite parties

Ext.B1- Mediclaim Policy (2007) of 1^st opposite party                  

Witness examined on the side of complainant

PW1 – Kalyanaraman.N.K

Witness examined on the side of opposite parties

Nil 

Cost allowed

Rs. 1,000/- (Rupees One Thousand only) allowed as cost of the proceeding