Tamil Nadu

North Chennai

CC/170/2015

Mr.Subramani.N - Complainant(s)

Versus

Universal Sompo General Insurance Co Ltd - Opp.Party(s)

J.Chelladurai Caldwell

10 Oct 2017

ORDER

 

                                                            Complaint presented on:  06.10.2015

                                                                Order pronounced on:  10.10.2017

 

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

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

TUESDAY THE 10^th DAY OF OCTOBER 2017

 

C.C.NO.170/2015

 

 

Mr.Subramani.N (Age 63),

No.2C/14, Anbalagan Nagar 4^th Street,

Thiruvika Nagar, Chennai – 600 011.

 

                                                                                    ….. Complainant

 

..Vs..

 

1.Universal Sompo General Insurance Co Ltd.,

Rep by its Manager,

No.102, Door No New 44, Door No.Old 39,

Halls Road, Egmore, Chennai : 600 008.

 

2.Indian Overseas Bank, Perambur Branch,

Rep by its Manager,

75/151, Paper Mills Road,

Perambur, Chennai : 600 011.

 

3.Billroth Hospital,

Rep by its Manager,

 43, Lakshmi Talkies Road,

Shenoy Nagar, Chennai : 600 030.

.....Opposite Parties

Date of complaint                                 : 27.11.2015

Counsel for Complainant                      : J.Chelladurai Caldwell

Counsel for 1^st Opposite Party                 : M/s. R.Vijaya Kamala & Dhanalakshmi

Counsel for 2^nd opposite party                 :  A.Sermaraj (Ex – parte)

Counsel for 3^rd  opposite  party                     : R.Prabhakaran (Ex – parte)

O R D E R

 

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

          This complaint is filed by the complainant to direct the 1^st opposite party to reimburse medical expenses of Rs.1,50,044/- with 2% interest and also directing them to pay 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 is a senior citizen and he has taken Medi Claim Policy for him and his wife. More than 15 years he has taken health care policy and 10 years he was the policy holder of “IOB Health Care plus Policy” without any break. The complainant lived a healthy life and he had no medical complication until 18.05.2015.

          2. The complainant developed Chest heaviness over left mammary region and he was admitted at the Apollo Hospitals, Greams Road, Chennai and he was given first aid in the emergency ward. He paid an amount of Rs.22,585/- in the said hospital. Thereafter on the same day evening he was admitted at the 3^rd opposite party hospital as inpatient for the period 18.05.2015 to 21.05.2015 and the fact of admission in the hospital was intimated to the 1^st opposite party/insurer by the complainant son and they denied the cashless treatment to him.

          3. However, the complainant was billed by the 3^rd opposite party for an amount of Rs.1,27,459/-.      On 02.05.2015 the complainant son submitted claim to the 3^rd party administrator of the 1^st opposite party. The said administrator without making proper enquiry rejected the claim of the complainant that he has not disclosed the ailment of DM and HTN as pre-existing disease. Due to refusal of the claim the complainant forced to lend money from his ex-employer to pay hospital bill and due to the same he suffered with mental agony. Hence the complainant sent legal notice to the opposite parties and thereafter the complainant filed this complaint to direct the 1^st opposite party to reimburse of expenses of Rs.1,50,044/- with 2% interest and also directing them to pay compensation for mental agony with cost of the complaint. 

4. WRITTEN VERSION OF THE   1^st OPPOSITE PARTY IN BRIEF:

          The complainant was discharged from the Apollo Hospital and Billroth Hospital against the medical advice of the said hospitals. The discharge summary of the Apollo Hospital and Billroth Hospital discloses that the complainant was diagnosed with DM and HTM. The complainant underwent surgery for Hydrocele  15 years ago. In respect of the said surgery the complainant had not submitted the medical documents. The complainant claim was denied based on past history.

          5. The complainant submitted proposal form and he had violated clause.2 general condition of the policy. The complainant knowingly violated and failed to disclose that he was suffering from DM and diabetes mellitus only triggered the acute coronary syndrome on 18.05.2016. The complainant had suffered with DM and HTM even early to taking the policy on 15.08.09 which he failed to disclose such pre-existing diseases. Since the complainant had pre-existing, disease he is not entitled for the medical expenses. Therefore the opposite parties have not committed deficiency in service and pray to dismiss the complaint with costs.

6. 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?

7. POINT NO :1 

          It is an admitted fact that the complainant has taken Medi Claim Health Care Policy for himself IOB Health Care Plus Policy  for himself and his wife and the policy copies issued by the 1^st opposite party from the period  of August 2009 August  2015 is marked as Ex.A1 and the said policy is continuously in force without any break and the complainant developed chest heaviness over left mammary region on 18.05.2015 and he was admitted at the Apollo Hospital on the same day and after evaluation he was discharged under Ex.A3 on the same day and thereafter he was admitted in the 3^rd opposite party/ Billroth Hospital and discharged on 21.05.2015 and during that period of treatment at the 3^rd opposite party, on behalf of complainant Ex.A4 cashless claim was sent to the 1^st opposite party and the said claim was rejected under Ex.A5 due to non disclosure in proposal form and thereby violated clause.2 of general condition and thereby the complainant paid Ex.B6 bill for an amount of Rs.1,27,459/-  and discharged under Ex.A7 on 21.05.2015 and after discharge, the complainant made claim to the 1^st opposite party in respect of the expenses incurred at the 3^rd opposite party hospital and the said claim was repudiated under Ex.A8 letter, since the complainant is having diabetic mellitus for 15 years and hyper-tension for 7 years as per general condition clause 2 due to non disclosure of the above ailments and therefore the complainant issued Ex.A9 to Ex.A11 to the opposite parties and the 3^rd opposite party sent Ex.A12 to Ex.A14 reply and then the complainant has filed this compliant to claim the expenses incurred in the hospital.

          8. The complainant alleged deficiency against the opposite parties that the expenses incurred to him at the Apollo Hospital was claimed by him  with the 1^st opposite party and the said claim wrongly rejected by the 1^st opposite party administrator and therefore the complainant is entitled the medical expenses spent by him and compensation for mental agony.

          9. The opposite party’s case is that the complainant has not disclosed that he was suffering from DM for 15 years and HTN for 7 years and as per Ex.A4   such non disclosure  is a pre-existing disease and therefore as per the condition the claim was repudiated is correct and hence the complaint  is also liable to be dismissed.

          10. There is no dispute that the complainant was admitted in Apollo Hospital on 18.05.2015 for chest heaviness over left mammary region and on the day evening itself he was discharged and immediately he was admitted at the 3^rd opposite party hospital and made cashless claim through 3^rd opposite party to the 1^st opposite party under Ex.A4 and the said cashless claim was rejected under Ex.A5 by the opposite parties administrator. According to the 1^st opposite party the mentioning of diabetic and hyper-tension in Ex.A4 was not disclosed in the proposal form and therefore the complainant is guilty of suppression to pre-existing disease.

11. Except this Ex.A4, there is no other document is available to show that the complainant was suffering with diabetic and hyper-tension. According to the complainant he never suffered with any such disease at any point of time. It is the 3^rd opposite party only filled Ex.A4. The complainant further argued even assuming that he had such diseases, as per Ex.A15 policy conditions if any one holding this policy for a continuous period of immediate 36 months from inception and there had been no claim treatment, in relation to such pre-existing condition during the 36 months period such pre-existing disease shall be waived. In this case the complainant is having the policy continuously from the year 2009 to 2015 for 7 years. Therefore even as per the policy condition (Ex.A15) the opposite parties had rejected the claim is not sustainable.

12. The complainant also referred a judgment of the Madurai Bench of the Madras High Court in W.A (MD) No:956 on 2011 dated 30.01.2014 the division bench has held in paragraph 7,8,9 as follows:

          A perusal of the clause 4.1 of the terms and condition of the policy would show that it provides for exclusion in respect of pre-existing diseases.

          It is the admitted case of the petitioner that he is suffering from hypertension and diabetes. If the treatment is relating to hypertension and diabetics, then it is pre-existing disease and no claim can be made. However, in the report, it is stated that the petitioner was suffering from Coronary Artery Disease and surgery was done. Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued. Therefore, the claim apparently is rejected on the misconception. The authority cannot read something more into the terms and conditions of the policy and come to the inference that one disease is relatable to other disease and therefore, medi claim is rejected.

          If the treatment to the appellant/writ petitioner is relating to diabetes or hypertension, then it is a pre-existing disease and he is not entitled to reimbursement in terms of the medi claim policy. Since the nature of the treatment is for Coronary Artery Disease, which is not a pre-existing disease even as per the records, the Insurance  Company cannot dispute the claim by giving another interpretation on the nature of the disease. There may be many reasons for a pre-existing disease or ailment and it is for the Doctors to identify the disease or ailment and provide the treatment. Under the terms of the medi claim policy, interpretation of a particular disease is not permissible. They are strictly bound by the disease or ailment specified in the policy as pre-existing disease. No addition or deletion by way of interpretation can be done, which is what has happened in the present case.

As per the above judgment of the Honourble High Court in the case in hand also the complainant was suffered only his left chest mammary region for the same he took treatment at the 3^rd opposite party hospital. For such treatment, diseases of diabetic and hyper-tension has no nexus and further there is no evidence on behalf of the opposite parties that due to diabetic and hyper-tension the complainant developed diseases on his left chest. Therefore as disclosed above the claim of the complainant was repudiated under Ex.A4 and Ex.A8 are not justified and thereby we hold that the 1^st opposite party has committed deficiency in service.  The 2^nd opposite party is a bank and  the 3^rd opposite party is the hospital. They have no role to play in rejection of the claim of the complainant by the 1^st opposite party or his administrator. Therefore, it is held that the opposite parties 2 & 3 have not committed any deficiency in service.

13. POINT NO:2

          The Apollo Hospital issued Ex.A2 bill for Rs.22,585/- and the 3^rd opposite party hospital issued Ex.A6 bill for Rs.1,27,459/- aggregating a total amount of Rs.1,50,044/-. The 1^st opposite party rejected the claim is not sustainable and therefore the complainant is entitled for the above medical expenses of Rs.1,50,044/- from the 1^st opposite party. Though the complainant claimed compensation from the opposite parties 1 to 3, we held above that the 1^st opposite party only committed deficiency in service. The complainant after repudiation of the cashless service he searched for money to settle the bill amount to the 3^rd opposite party, he had suffered with mental agony is accepted and for the same it would be appropriate to direct the 1^st opposite party to pay  a sum of Rs.50,000/- towards compensation for mental agony besides a sum of Rs.5,000/- towards litigation expenses. The complaint in respect of the opposite parties 2 & 3 is liable to be dismissed.

In the result the Complaint is partly allowed. The   1^st Opposite Party is ordered to pay a sum of Rs.1,50,044/- (Rupees one lakh fifty thousand and forty four only) towards the claim amount of medical expenses to the Complainant with 2% interest from 25.06.2015 to till the date of this order and also to pay a sum of Rs.50,000/- (Rupees fifty  thousand only) towards  compensation for mental agony besides a sum of  Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. In respect of the opposite parties 2 & 3  the complaint is dismissed.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 10^th day of October 2017.

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 19.08.2014                   IOB Health Care plus Policy copies from the   

                                                    August 2009 to August 2015

 

Ex.A2 dated 18.05.2015                   Bill issued by the Apollo Hospitals

 

Ex.A3 dated 18.05.2015                   Discharge Summary issued by the Apollo Hospital

 

Ex.A4 dated                            Copy of the cashless claim form filled by Billroth

                                                    Hospital

 

Ex.A5 dated 21.05.2015                   Reply (Rejection) from the 3^rd party Administrator

                                                   of the 1^st opposite party for the cashless claim form

 

Ex.A6 dated         21.05.2015                   Bill issued by the Billroth Hospital

 

Ex.A7 dated 18.05.2015                   Discharge summary issued by the Billroth Hospital

 

Ex.A8 dated 25.06.2015                   Claim Denial letter from the 1^st opposite party’s 3^rd

                                                    party administrator

 

Ex.A9 dated 25.08.2015                   Notice sent to  1^st opposite party with ack.

 

Ex.A10 dated 18.08.2015                 Notice sent to the 2^nd opposite party with ack.

 

Ex.A11 dated 18.08.2015                 Notice sent to the 3^rd opposite party with ack.

 

Ex.A12 dated 21.08.2015                 Reply notice by 3^rd opposite party

 

Ex.A13 dated 31.08.2015                 Reply sent to the 3^rd opposite party

 

Ex.A14 dated 21.09.2015                 Reply Notice by 3^rd opposite party 

 

Ex.A15 dated NIL                             Policy Instruction Booklet by the 1^st opposite party

 

Ex.A16 dated 30.08.2015                 Recent Sugar taken by the complainant

 

 

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

 

                                        ……. NIL …….

 

 

 

MEMBER – I                                                               PRESIDENT