Tamil Nadu

North Chennai

204/2013

L.Veera Raghavan,H/o.Muthulaxmi - Complainant(s)

Versus

The Original Insurance Company Ltd.,(A Govt of India Undertaking) - Opp.Party(s)

A.Gunasekaran.

30 Mar 2017

ORDER

 

                                                            Complaint presented on:  23.10.2013

                                                                Order pronounced on:  30.03.2017

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

THURSDAY THE 30^th DAY OF MARCH 2017

 

C.C.NO.204/2013

 

 

L.Veera Ragahavan,

H/o.Muthulakshmi,

No.1, 3^rd Main Road, (Extension),

Kurinji Nagar,

Old Perunkalathur,

Chennai – 600 063.

                                                                                    ….. Complainant

 

..Vs..

1.The Oriental Insurance Company Ltd.,

Rep. by its Sr.Divisional Manager,

Luck man Manzil, 3^rd Floor,

Old No.130, New No.258,

Angappan Naicken Street,

Chennai – 600 001.

 

2.M/s. MD India Health Care Services Pvt. Ltd., (TPA)

Rep by its  Claim Manager,

Third  Party Administrator, Old No.702, New No.260/16,

3^rd Floor, Mount Casa Blanca,

Anna Salai, Chennai – 600 006.

 

.....Opposite Parties

Date of complaint                                 : 25.10.2013

Counsel for Complainant                      : S.Gunasekaran, S.Ravichandran,

                                                                    S.Rajesh, D.Ramesh

 

Counsel for 1st Opposite Party                : M.B.Gopalan, N.Vijayaraghavan,

                                                                 M.B.Raghavan

 

Counsel for 2^nd opposite Party                       : Dismissed (21.04.2014)

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant to pay a sum of Rs.2,41,005/- towards the Happy Family Floater Policy claim amount and to pay a sum of Rs.1,00,000/- towards compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant’s wife has taken Health Insurance Policy from the 1^st opposite party under the plan Happy Family Floater Policy for the period from 10.05.2010 to 09.05.2011. The said policy was renewed periodically till 09.05.2014 by paying the premium. The policy is covered for all the family members. The Complainant was admitted on 23.09.2012 for the treatment of diabetic of Sebaceous Abscess at Dr.Mohan Diabetes Specialties Centre Chennai-86. The Complainant was aged 61 years and he was discharged on 26.09.2012. The Complainant made claims to the TPA(2^nd opposite party ) for reimbursement. The TPA refused the claim for the reason of pre-existing disease is not applicable for re-imbursement, as per clause 4.1 of the terms and conditions of the policy. The Complainant spent a sum of Rs.46,005/-.

          2. On 29.08.2013 the Complainant had severe heart attack and he was admitted at 11.15 a.m Deepam Hospital, G.S.T Road Chrompet, Chennai-44 an Angioplasty treatment was given to him and he was discharged on 31.08.2013 at 4.30 p.m. The treatment comes to Rs.1,80,000/- and the medicine bills  comes to Rs.15,000/- and thus a total sum of Rs.1,95,000/- was incurred for the treatment of Angiogram. While the Complainant was in admission in the hospital, he made claim to a TPA and the claim was refused on 30.08.2013 for the reason that the cashless hospitalization is denied under exclusion clause 4.1, as the pre-existing illness cannot be covered under the policy. The denial of both the aforesaid claims is not justified, since the Complainant has made claims during the valid period of policy.   The Complainant had heart attack only on 29.08.2013 for the first time. There is no question of pre-existing ailment of heart disease by refusing the claim by the 1^st opposite party and he has committed deficiency in service. Hence the Complainant filed this Complaint  for re-imbursement of Rs.2,41,005 and compensation for mental agony with cost of the complaint.            

3. THE COMPLAINT AGAINST THE 2^ND OPPOSITE PARTY WAS DISMISSED AS STEPS NOT TAKEN.  WRITTEN VERSION OF THE 1^ST OPPOSITE PARTY IN BRIEF.

          The Complainant was suffering from diabetes for 26 years and Systemic Hypertension, which were material facts. But without disclosing the same in the Proposal Form, he took the policy is suppression of material fact in the proposal. The materiality of the ailments is clear in the specific questions given in the proposal, to which the Complainant had not given the true answers and disclosed the same. Thus the contract was vitiated by suppression of material facts and hence no benefit can be claimed under the same by the Complainant. The contract of insurance itself is void for non-disclosure and suppression of facts. The Complainant reported two claims during the 3^rd year of insurance. The discharge summary for the first treatment from 23.09.2012 to 26.09.2012 revealed the complaints were primarily related to Diabetes Mellitus for 26 years and systemic Hypertension complications of the same which were pre-existing and clearly excluded by clause 4.1 of the policy.

4. The Complainant sought to make a claim for cashless facility even prior to the treatment from 29.08.2013 to 31.08.2013 for AWMI and diabetes at Deepam Hospital. In view of the treatment being related to the pre-existing diabetes, the cashless facility was declined. However, the Complainant was informed to complete the treatment and lodge a claim with the opposite party. The Complainant has not done so. The complaint is therefore premature and unsustainable.  The policy was issued based on proposal submitted by the Complainant. If facts were not truly and fully disclosed, the opposite party was justifiable entitled to deny liability. The Complainant having obtained the policy without disclosing facts cannot take merely reply upon payment of premium and thereby taking advantage of his own suppression. The opposite parties are not aware of the expenses incurred for the treatment as no bills have been submitted for the same. The opposite parties deny that the expenses for second treatment was for Rs.1,95,000/- or that the same was payable under the policy in as much as no such bills have been submitted to the opposite party. There is no cause of action for the Complaint against the opposite party and hence prays to dismiss the same with cost.

           

5. POINTS FOR CONSIDERATION:

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

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          The admitted facts are that the Complainant’s wife availed Ex.A1 Happy Family Floater Policy  from  the 1^st opposite party for the period 10.05.2010  to 09.05.2011 and as per the policy family members are fully covered including the Complainant who is husband of the policy holder and the said policy was renewed till 09.05.2014 through Ex.A2 to Ex.A4 by paying required premium to the 1^st opposite party and the Complainant was admitted on 23.09.2012 for the treatment of diabetic of Sebaceous  Abscess and discharged on 26.09.2012 and the said discharge summary is marked as Ex.A5 and the said hospital issued treatment bill and medicines bill for a sum of Rs.46,005/- which is evidenced under Ex.A6, Ex.A7 and thereafter again the Complainant was admitted at Deepam Hospital, Chennai – 44 on 29.08.2013 due to sudden heart attack and where he had undergone angiogram treatment and he was discharged on 31.08.2013 at 4.30 p.m and the discharge summary is marked as Ex.A12 and the Complainant made claim for a sum of Rs.1,95,000/- to the TPA and both the aforesaid claims were rejected by the opposite parties and hence the Complainant filed this complaint for the claim of  the amounts incurred by him for treatment.

          7. The Complainant made two claims and the 1^st claims for a sum of Rs.46,005/- for treatment of diabetic. The opposite parties rejected the claims on the ground that the Complainant suppressed the pre-existing disease of diabetes for the past 26 years and further the Complainant took treatment for the said diabetic diseases and hence the claim was rejected under Ex.A11. Admittedly the Complainant took treatment for diabetic disease. Ex.B1 is the proposal form given by the Complainant to the opposite party. In Ex.B1 page 3 column 13 with regard to furnish information in respect of diabetic or any urinary diseases the Complainant replied as no. It means the Complainant has not disclosed about that he  suffered diabetic for the past 26 years.  Therefore the non disclosure of diabetic in Ex.B1 proposal form is considered as suppression of material fact and therefore the 1^st opposite party rejected the claims of Rs.46,0005/- under Ex.A1 is justified.

          8. The Complainant made 2^nd claim by way of cashless service to undergo angioplasty while he was in patient during the period of 29.08.2013 to 31.08.2013. The said claim  was rejected by the TPA under Ex.A14 that cashless service for hospitalization is denied under exclusion clause 4.1 as pre-existing illness and further stated that denial of authorization for cashless access is no way to be construed as denial of treatment and the policy holder after obtaining treatment he can file his claims for the re-imbursement and MD India will furnish the claims as per the terms and conditions of the policy.

          9. The Complainant contended that the heart attack comes only for first time on 29.08.2013 and there is no question of pre-existing ailment of heart diseases. Further the Complainant had only pre-existing diseases of diabetic and hypertension only for the opposite party specifically stated in Ex.A14 denial authorization letter that is no way construed as denial of claim for reimbursement and after obtaining treatment he can file his claim for re-imbursement and MD India will process it. The Complainant did not avail the opportunity to make a claim to the 1^st opposite party as per Ex.A14 letter and without availing the opportunity given in the Ex.A14 the letter of the 1^st opposite party, it cannot be construed that the 1^st opposite party denied the cashless service claim of the Complainant. In such circumstances it cannot be held that the 1^st  opposite party has committed any deficiency in service to the Complainant in respect of the claim made by him for his heart ailment.

10. POINT NO:2

          The Complainant has filed this complaint without making claim to the 1^st opposite party for the heart ailment treatment of Rs.1,95,000/- to this forum, this complaint is not maintainable in this forum and the same is liable to be dismissed. Further in respect of the other reliefs and the claim in respect of the treatment taken at the  Dr.Mohan diabetic specialty hospital, the Complainant is not entitled for any relief and the complaint is liable to be dismissed. However, in view of Ex.A14 the Complainant can be given a liberty to make a claim to the 1^st opposite party in respect of the expenses incurred by him for undergoing angioplasty treatment.

          In the result the complaint is dismissed with liberty that the Complainant can make claim to the 1^st Opposite Party  in respect of the expenses incurred by him for the treatment of angioplasty within two months from the date of this order and the same shall be considered by the 1^st Opposite Party and pass orders on merits within two months from the date of receipt of  the claim from the Complainant. No costs.  

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this  30^th day of March 2017.

 

MEMBER – II                                                               PRESIDENT

 

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 11.05.2010                   Happy Family Policy & Receipt

Ex.A2 dated 02.05.2011                   2^nd Premium Receipt & Policy

Ex.A3 dated 09.05.2012                   3^rd Premium Receipt & Policy

Ex.A4 dated 06.05.2013                   4^th Premium Receipt & Policy

Ex.A5 dated 26.09.2012                   Discharge Summary

Ex.A6 dated 26.09.2012                   IP Bill & Receipt Rs.35,920/-

Ex.A7 dated 21.09.2012                   Medicine Bills Rs.10.085/-

               To 01.10.2012

 

Ex.A8 dated 03.10.2012                   Claiming Request Letter to Opposite Party

 

Ex.A9 dated 08.10.2012                   Condonaton of Delay Letter

 

Ex.A10 dated 12.12.2012                 Legal Notice to 1^st  Opposite Party

 

Ex.A11 dated 26.12.2012                 Reply notice from 1^st Opposite Party

 

Ex.A12 dated 31.08.2013                 Discharge summary of Angioplast

 

Ex.A13 dated 31.08.2013                 Treatment & Medicine Bills total Rs.1,95,000/-

 

Ex.A14 dated 30.08.2013                 Claiming Denial letter of 2^nd Opposite Party

 

Ex.A15 dated NIL                             Floater policy’s website advrt of Opposite Party

 

 

 

 

 

 

LIST OF DOCUMENTS FILED BY THE  1^st OPPOSITE PARTY :

 

Ex.B1 dated 10.05.2010                   Proposal for insurance

 

Ex.B2 dated NIL                     Policy for the period from 10.05.2010 to

                                                    09.05.2011

 

Ex.B3 dated NIL                     Policy for the period from 10.05.2011 to

                                                    09.05.2012

 

Ex.B4 dated NIL                     Policy for the period from 10.05.2012 to

                                                    09.05.2013

 

Ex.B5 dated NIL                     Policy for the period from 10.05.2013 to

                                                    09.05.2014

 

Ex.B6 dated NIL                     Terms and conditions of the policy

 

Ex.B7 dated NIL                     Request for cashless facility for treatment in 2013

 

Ex.B8 dated 30.08.2013                   Letter of rejection of cashless facility

 

 

 

MEMBER – II                                                               PRESIDENT