Tamil Nadu

North Chennai

CC/129/2017

M.Madhanan S/o.Muthu perumal - Complainant(s)

Versus

The Regional Manager ,Star Health and Allied Insurance co Ltd - Opp.Party(s)

M/s.Elangovan,V.Asokan

28 Nov 2018

ORDER

                                                             Complaint presented on:  30.08.2017

                                                                Order pronounced on:  28.11.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

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

 

PRESENT: TMT.K.LAKSHMIKANTHAM,B.Sc.,B.L.,DTL.,DCL.,DL &AL  : PRESIDENT

THIRU. D.BABU VARADHARAJAN B.Sc.,B.L.,  :    MEMBER - I

 

WEDNESDAY THE  28^th  DAY OF NOVEMBER 2018

 

C.C.NO.129/2017

 

M.Madhavan,

S/o.Muthuperumal,

Door No.4/234,

M.I.G. Twin House,

Mugappair West,

Chennai – 600 037.

                                                                                     ….. Complainant

 

..Vs..

1. The Regional Manager,

Star Health and Allied Insurance Co. Ltd.,

No.1, New Tank Street,

Valluvar Kottam High Road,

(Regional Office), Nungambakkam,

Chennai – 600 034.

 

2.The Manager,

Star Health and Allied Insurance Co. Ltd.,

No.15, Sri Balaji Complex, 1^st Floor,

Whites Lane, Royapettah,

Chennai – 600 014.

 

….Opposite Parties

Date of complaint                                 : 06.10.2017

Counsel for Complainant                      : M/s.Elangovan.E, V.Asokan

Counsel for   opposite parties                   : N.Vijayaraghavan, M.B.Raghavan

 

O R D E R

 

BY PRESIDENT TMT.K.LAKSHMIKANTHAM,B.Sc.,B.L.,DTL.,DCL.,DL &AL

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant was a policy holder of senior citizens Red Carpet Health Insurance Policy issued by the 2^nd opposite party for the sum insured for Rs.2,00,000/-. On 30.06.2015 the policy was incepted and the annual premium paid as Rs.9,724/- and got the policy through online Registration of the agent of the opposite party. The agent of the opposite party came to his house and appraised the terms and conditions of the insurance policy. At that time, the complainant had disclosed all facts about his health in detail regarding  his admission into Frontier Lifeline hospital on 18.02.2010, and was put into observation for heart problem and later discharged after taking medicine. Further the complainant states that at that time he had not undergone any surgery. The agent  of the opposite parties has not noted about facts given by the complainant in the proposal form as it is covered the pre-existing disease.  On 23.03.2017, he was admitted in the Frontier Lifeline Hospital, Chennai and had undergone various test and was diagnosed with Coronary Artery Diseases (Cardiac) and other problems and was recommended for surgery and surgery was done on 27.03.2017.  At that time of admission in the hospital, he informed a policy in detail about the insurance for cashless treatment under the Senior Citizens Red Carpet Health Insurance Policy issued by the opposite parties. The opposite parties received a pre-authorization rquest from the complainant’s hospital for cashless treatment of the complainant. The opposite party simply rejected the claim by its letter dated 24.03.2017  informing that the complainant was diagnosed with CAD-ACS (STK+) which has not disclosed the above medical history when he took the policy which amounts to non-disclosure of material facts. Since he disclosed his medical history at the inception of policy, he is fully eligible to claim the insured amount as per the terms and condition of the policy. The complainant submits that as he was unable to pay hospital expenses of Rs.3,75,000/- as incurred by way of surgery, the complainant had obtained loan from the 3^rd party and settled the hospital expenses in time. As the opposite party has not settled the hospital expenses, the complainant is put untold hardships and mental agony. The act of the opposite parties in rejecting the legitimate claim made by the complainant amounts to deficiency in service on the part of the opposite parties.

2. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

          Insurance policy is based on good-faith. The complainant is bound to disclose all material facts relating to his health, mental and physical condition including the past medical history at the time of availing the policy    with the opposite party. Non-disclosure of pre-existing disease will amount to misrepresentation and non-disclosure of material facts. A claim was reported by complainant during the second year of policy for hospitalization and expenses incurred for his treatment at Frontier Lifeline Hospital for adequate LV Systolic Function on 24.03.2017.. The complainant  raised a pre-authorization request to avail cashless facility. On perusal of the claim documents submitted by the treating hospital, it is confirmed that the complainant is diagnosed for the CAD – ACS (STK+) prior to the inception of the policy. It is stated that complainant/insured has not disclosed anything in proposal form as pre-existing ailment at the time of availing insurance, other than diabetes. Thus the non-disclosure of CAD prior to policy amounts to non disclosure of material fact.  As per condition No.9, “ the company shall not be liable to make payment under the policy in respect of any claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf”. Hence, the pre authorization was rejected and the same was informed to the complainant/ insured and treating hospital vide letter dated 24.03.2017. The opposite parties thereafter by letter dated 23.06.2017 intimated the complainant, that due to non-disclosure of material facts, the policy expiring on 29.06.2017 will not be renewed and blocked for further renewal. It is further stated that the complainant/Insured is expected to declare in the proposal form/good heath declaration about the details of his ailments/sickness in good faith-past medical history and the reply for the same helps the insurer to evaluate the material facts and to decide whether to accept the proposal or not and the premium rate. The complainant herein has wantonly omitted to state about his pre-existing health ailments which will reveal that the complainant has not acted in good faith and misrepresented the material facts for the purpose of claiming under the policy which is not otherwise payable. The complainant has disclosed all the material facts  relating to his health including his hospitalization on 18.02.2010 is specifically denied. The allegation that agent has not noted the facts in the proposal form is false and without any basis. The policy has been issued based on disclosure made in the proposal form duly signed by complainant. Disclosure of past medical history is material fact which enables the insurer to decide upon the risk to be covered and the premium to be collected. The pre-existing diseases will be automatically covered from second year  is irrelevant when the very disclosure of pre-existing disease has not been made by the complainant in his proposal form at the time of availing policy. The nature of hospitalization is specifically denied and complainant is put to strict proof of the same through proper documentary evidence.  The policy issued on the basis of proposal form signed by the complainant discloses insured was only diabetic. The other pre-existing ailments were not disclosed in the proposal form only prove that contention of complainant is false.  The complainant has incurred a total sum of Rs. 3,75,000/- towards medical expenses by availing loan is false and mere exaggeration. The complainant is bound to prove the medical expenses through proper bills. Complainant has not filed any medical bills to prove his expenditure to an extent of Rs.3,75,000/-. It is also submitted that the complainant has not even filed discharge summary to prove his hospitalization and surgery underwent. The opposite parties have not committed any deficiency in service as alleged by the complainant. Not-withstanding the non disclosure of material fact, the complainant has not proved his hospitalization, treatment and expenses incurred for claiming the sum insured under the policy. Further claim of Rs.2,00,000/- towards deficiency in service and mental agony is unreasonable and without any basis.  

3. 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?

04. POINT NO :1

           The Complainant is a senior citizen and a holder of “Senior Citizen Red Carpet Insurance Policy” issued by 2^nd opposite party  for the insured sum of Rs.2,00,000/- Annul premium of Rs.9,724/- was paid by the complainant. The complainant contends that he disclosed all the facts about his health in –detail including his earlier observation at Front-line Hospital for his heart problem but the agent has not filled the form disclosing all the facts. The inception of policy was on 30.06.2015 and it was renewed again for the period 30.06.2016 to 29.06.2017. On 23.03.2017, the complainant got admitted in the Frontier Lifeline Hospital  and as per the advice of the Doctors surgery was performed. The complainant informed about the policy and the opposite parties  have received the pre-authorization request from the complainant’s Hospital for cashless treatment for the complainant. Subsequently the claim was rejected by the opposite parties   for non-disclosure of material facts and the complainant had settled the amount to the Hospital by obtaining loan from the third party. The opposite parties rejection of the claim amounts to deficiency in service hence the complaint is filed by the complainant.

05. Policy taken by the complainant  from the opposite parties  is Ex.A1 Premium of Rs.9,724/- was paid by the complainant and the receipt is Ex.A2. Rejection letter by the opposite parties  is Ex.A3. Legal notice issued by the complainant’s Advocate is Ex.A4 and the reply  is Ex.A5 . The letter by the opposite parties  to the complainant is Ex.A6. Copy of the Hospital Bills, Discharger Summary, Adult follow up case records are marked as Ex.A7 to Ex.A10.

         06.  The availing of Senior Citizens Red Carpet Insurance policy  by the complainant  for a assured sum of Rs.2,00,000/- with the opposite parties and its renewal and its existence at the time of claim are all admitted facts. The claim of the complainant was reported by the complainant  during  the second year of the policy for hospitalization. Proposal form is Ex.B1. Insurance policy with terms and conditions  are marked as Ex.B2 Pre-authorization form is Ex.B3. This pre-authorization was raised by the complainant  to avail cashless facility. It was rejected and the information was given to the complainant vide letter Ex.B7.

07. The opposite parties  would contend that  the complainant is expected to declare regarding his good health declaration   and previous medical history, here in this case the previous medical history was not disclosed voluntarily by the complainant, which resulted in the rejection of the claim as per the policy. The column in Ex.B2 regarding the question of pre existing disease is filled up as “Diabetic” only. Ex.B3, Pre authorization form  reveals that the complainant was admitted for chest discomfort.  Adult follow up case record  in Ex.B4 dated 18.12.2010 discloses that the complainant was diagnosed with CAD-ACS (STK+) Killip class I , Mild LV dysfunction, DM Type II,FC II. Even in Ex.B5- Adult Follow up records dated 15.05.2010, the diagnosis was recorded as ACS-STEMI (STK+), KILLIP CLASS I, MILD LV DYSFUNCTION, TYPE II DM, at Dr.K.M.Cherian’s FRONTIER LIFELINE HOSPITAL CHENNAI, DEPARTMENT OF CARDIOLOGY, Ex. B6 enclosures also reveals that the complainant is  known case of CAD, STEIWMI (STK+), Mild LV dysfunction.

             08.   It is  contended by the complainant that  he had an history of admission in the hospital for observation only disease and  according to him this particular  policy covers the pre existing disease  and STK is indicated only for taking medicine as precaution, and he has not undergone any surgery earlier, the fact of earlier medial history was intimated to the agent at that time of taking policy , and also the complainant had not taken treatment  for heart-ailment from 2010 till the operation was done in 2017.  Hence  the rejection of the claim by opposite parties  is incorrect.

         09.  Adult follow up records  of the Complaint  discloses medications to be followed for months together and his allegation of  revealing the history to the agent, is not incorporated in the policy hence the point raised by the complainant   will not hold good . The complainant has to check the contents incorporated in the policy are correct while signing the proposal form, if found incorrect,  he should have informed the Insurance company immediately the complainant failed  to do so. STK may indicate the caution, but the case of CAD, STEIWMI is a disease and the rejection by the opposite parties is not based on the complainant had undergone surgery or not pre-existing disease will be covered from the second year is also is irrelevant at this juncture  during the previous admission. The opposite parties stresses upon the point that  the Cardinal principle of the Insurance contract is based  in the Good faith. One must act in good faith  making the full declaration of all material facts in the insurance proposal.  Condition No. 9 of the policy  is pointed  by the opposite parties  and it reads as “The company shall not be liable to make any payment under the policy is respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf”. As per the said condition the complainant  has not disclosed the material fact of pre existing disease, and failed to represent the same at the time of availing insurance. As per records also he has disclosed only Diabetes, not other than that.

10. As argued by the learned counsel for opposite parties, if the disclosure had made at the inception of policy,   it would have helped the insurer to  evaluate material facts of medical history  and to decide   either to accept the proposal or not, thereby the complainant had not acted in good faith, and misrepresented  for the purpose of claiming under the policy, which is  not otherwise payable.  It is not denied by opposite parties that Pre existing diseases will be covered from the second year of the policy provided the disclosure of the same for the insurer to decide upon the feasibility of issuing policy.  The complainant had the knowledge about his earlier medical records but when answering in the proposal form, he failed to disclose the same. All information sought for in the proposal form is no doubt, material for the purpose of entering into contract which is based on the principle of Good faith. Therefore the opposite parties are right in repudiating the claim and there is no deficiency in service on the part of opposite parties. 

11. POINT NO:2

          As per the discussions held  by us, the opposite parties  had not committed any deficiency in service and the complainant is not entitled to get any amount from the opposite parties  and the complaint is to be dismissed.

          In the result, the complaint is dismissed. No costs.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 28^th  day of November 2018.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated NIL                     A policy form of Senior Citizen Red Carpet Health

                                                Insurance Policy by the opposite parties

Ex.A2 dated 07.02.2017                   Receipt of payment of premium Rs.9,724/-

Ex.A3 dated 24.03.2017                   Rejections Letter by opposite parties

Ex.A4 dated 26.04.2017                   Legal Notice issued by complainant advocate

 

Ex.A5 dated 17.05.2017                   Reply on advocate notice

Ex.A6 dated 23.06.2017                   Rejection on claim sent by opposite parties

Ex.A7 dated 03.04.2012                   A copy of Hospital Bills for Rs.3,25,930/- dated

                                                   03.04.2017

Ex.A8 dated 03.04.2017                   A copy of the Discharge Summary dated

                                                    03.04.2017

Ex.A9 dated 18.12.2010                   Copy of Adult follow up case record

Ex.A10 dated 18.12.2010                 Copy of Adult New Case Record

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES :

 

Ex.B1 dated NIL                     Copy of Proposal Form

Ex.B2 dated NIL                     Copy of Insurance Policy with terms and

                                                    conditions

Ex.B3 dated 23.03.2017                   Copy of Pre-authorization Form

Ex.B4 dated 18.12.2010                   Adult follow-up case record of complainant in

                                                    Frontier Lifeline Pvt.Ltd., Chennai

Ex.B5 dated 15.05.2010                   Adult follow-up case record of complainant in

                                                    Frontier Lifeline Pvt.Ltd., Chennai

Ex.B6 dated 23.03.2017                   Complainant initial evaluation record at Frontier

                                                    Lifeline Pvt.Ltd., Chennai

Ex.B7 dated 24.03.2017                   Copy of Rejection of Pre-authorization form

 

         

 

 

MEMBER – I                                                                PRESIDENT