State Consumer Disputes Redressal Commission
Star Health And Allied Insurance ... vs G. Sumathi on 9 January, 2013
BEFORE THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MADURAI BENCH BEFORE THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MADURAI BENCH. Present: THIRU.A.K. ANNAMALAI, M.A., M.L., M.Phil., Presiding Judicial Member THIRU.S. SAMBANDAM, Member F.A.No.160/2012 (F.A.No.593/2011 on the file of State Consumer Disputes Redressal Commission, Chennai.) (Against the order in C.C.No.153/2010 on the file of DCDRF, Tirunelveli) WEDNESDAY, THE 09th DAY OF JANUARY 2013 1. Star Health and Allied Insurance Company Ltd., Through its Authorized Signatory, Corporate Office, No.1, New Tank Street, Valluvarkottam Highways Road, Nungambakkam, Chennai 600 034. 2. The Area Manager, Star Health and Allied Insurance Company Ltd., Area Office, III Floor, Nellai Plaza, Madurai Road, Tirunelveli District. Appellants/Opposite Parties 1 & 2 Vs G. Sumathi, W/o. Gomathinayagam, No.49-D, Anna Nagar, Alangulam Post, Tirunelveli District. Respondent/Complainant Counsel for Appellants/Opposite parties: Mr. S. Suresh, Advocate. Counsel for Respondent/Complainant : M/s. Jacob & Jacob Associates, Advocates. This appeal having come before us for final hearing on 03.01.2013, upon hearing the arguments of both sides, perused the documents and records as well as the order of the District Forum, this Commission made the following :- ORDER
THIRU.A.K. ANNAMALAI, PRESIDING JUDICIAL MEMBER.
1. The opposite parties are the appellants.
2. The complainant availed mediclaim policy from the opposite parties during the period from 2009-2010 by paying necessary premium and availed treatment of heart ailment in the month of May 2010 and the claim was made for Rs.1,42,000/- for which a guarantee letter was given for Rs.60,000/- on 08.06.2010 and on the basis of the same, the complainant undergone treatment for the ailment and subsequently it was withdrawn by the opposite parties without any prior intimation or notice and thereby the complainant was compelled to pay the entire expenses for the treatment at Madras Medical Mission Hospital at the time of discharge and thereby mental agony and ordeal was caused to the complainant for non payment of claim amount by the opposite parties and thereby came with the consumer complaint before the District Forum at Tirunelveli and the District Forum allowed the complaint which is now assailed by the opposite parties against the impugned order.
3. When the appeal came for hearing before us, the learned counsel for the appellants contended that the District Forum passed an exparte order in the absence of the opposite parties and the opposite parties failed to file a written version and proof affidavit and thereby prayed for remand of the matter for fresh disposal.
Whereas the respondent/complainant argued that the matter was related to the year of 2010 and if once again the matter is remanded for fresh disposal which would cause unnecessary trouble to the complainant/respondent to get the fruits of the award, once again, after more than one year from to-day and thereby prayed for disposal of the appeal on merits from the materials placed before this Commission and hence we are of the view that the appeal could be disposed of on merits and thereby not inclined to remit the matter back for fresh disposal.
4. We have carefully considered both sides arguments and materials placed before us. It is the crucial point to be considered is whether the sudden withdrawal of the guarantee or promise made by the opposite parties while granting a sum of Rs.60,000/- towards the medical expenses on the basis of policy already taken by the complainant. The complainant had undergone medical treatment on the basis. But, it was withdrawn by the opposite parties on the ground that the ailment for which treatment undergone relates to pre-existing disease and thereby the claim was repudiated for which the opposite parties/appellants relied upon the documents of medical reports under Exhibits A-13, A-17 and Ex -A18 which are all medical reports issued by the Madras Medical Mission where the complainant has undergone treatment for congenital heart disease for closure of Atrial Septal Defect which is said to be congenital heart disease suppressed by the complainant while taking the policy.
On perusal of the policy under Ex A1, we find that the policy was not a new one and it is the renewal of policy and continuation of the policy from the year 2008 and on perusal of the medical report Ex A8 of Meenakshi Medical Mission Hospital in which it is stated that the complainant was having congenital heart disease, SVC type of ASD admitted for Coronary Angiogram and on complaints of recurrent RTI since birth, No Dyspnoea, No cough with expectoration and regarding the past history known case of diabetes mellitus recently detected and not of known case of Hypertension , No history of Bronchial asthma and suggested for closure of Atrial Septal Defect and accordingly under Ex A9 referral slip issued for Kalaignar Insurance Scheme for Life Saving Treatments provisional diagnosis for congenital heart disease and on the basis of the report, it referred to the Madras Medical Mission on 21.05.2010 and under Ex A10, the Madras Medical Mission issued a certificate on 24.05.2010 and advised to undergo open heart surgery (ASD closure) with the expected cost of Rs.1,42,000/- for surgery and Rs.30,000/- approximately for other expenses and thereupon subsequently she had undergone open heart surgery on 08.06.2010 at the Madras Medical Mission for which certificate of discharge was issued under Ex A13 in which also history of the present illness mentioned as having dyspnoea on exertion, Class II since 2 years and progressed to class III since last six months. No complaints of chest pain, palpitation, syncope, PND & detected to have heart disease 6 months back, sinus venosous ASD and advised surgery and she underwent cardiac catheterization at Madurai Meenakshi Hospital and diagnosed for Atrial Septal Defect with left to right shunt and as per the opposite parties letter of authorization under Ex A15, the hospital was authorized on 08.06.2010 for the treatment of ASD with referral shunt guarantee for payment of Rs.60,000/- for the line of treatment to the reference diagnosed. It is said to have been subsequently withdrawn by the opposite parties without any notice to the complainant, being the policy holder, who is entitled to be informed such withdrawal by notice or by intimation and no such thing was happened and not proved by the opposite parties. From the medical reports under Exhibits A8, A9 and A10, even though, it is invariably mentioned that the complainant was having congenital heart disease but nowhere it is stated that the defect was found earlier to the policy taken and the complainant was aware of the same even prior to the policy taken by her and from the above medical reports it is revealed only that congenital heart disease and other defects were found recently detected and six months back alone such heart defects was reported and thereby it is clear that the complainant could not have known and aware of the earlier congenital defect prior to the policy taken in the year 2008-2009 when the policy itself was renewed from the year 2008 and on the basis of renewal of policy only, subsequent claim was made and the opposite parties even though remained absent before the District Forum they would have proved their case by filing necessary documents before this Commission in the appeal to establish their case that they came to conclusion that the complainant was having pre-existing disease which was suppressed while taking the policy and the proposal form or earlier medical reports also not filed by either side and thereby we are of the view that the opposite parties made the complainant to undergo treatment initially and on the basis of their promise or guarantee by assuring the payment of Rs.60,000/- under Ex A15 for the initial expenses towards the surgery and subsequently by withdrawing the same without the knowledge of the complainant and even the hospital authorities have not given any written details by informing the complainant about the withdrawal of the guarantee by the opposite parties which was admitted by the opposite parties in their reply notice under Ex A22 which certainly amounts to breach of trust to the complainant and even if the complainant said to have suppressed the pre-existing disease, which is not proved as that she was already aware of it and estopped him repudiating claim of Rs.60,000/- and at the most could have repudiated the further amount beyond Rs.60,000/- and there was deficiency in service by making the complainant to undergo surgery with false hope and if the same was earlier informed, the complainant would have opted for alternative course under the Kalingnar Insurance Scheme for which also she was entitled as per the letter given under Ex A9. Hence, in view of the above discussion, we are of the view that even though the opposite parties failed to defend their case before the District Forum, on the basis of materials placed before us and on merits of case, we are of the view that the District Forum has passed the award after analyzing the materials placed before it, which is to be accepted except regarding the quantum of compensation alone. Since the complainant or the opposite parties failed to implead the hospital for proper adjudication, we are of the view that as far as the award of compensation alone could be negatived and in other respects the order of the District Forum has to be sustained.
5. In the result, the appeal is allowed in part by modifying the order of the District Forum with the following directions. 1) The order of the payment of compensation of Rs.25,000/- for mental agony and sufferings to the complainant ordered by the District Forum is hereby set aside. 2) The opposite parties are directed to pay medical claim of Rs.1,47,309/- to the complainant as per the policy terms and conditions. 3) The opposite parties are directed to pay a sum of Rs.3000/- to the complainant towards cost of these proceedings. All the directions shall be complied within two months from the date of this order, failing which the complainant is entitled to claim interest at the rate of 9% per annum from the date of default till realization for the amount of Rs.1,47,309/-.
Sd/- S. SAMBANDAM, Sd/- A.K. ANNAMALAI, Member Presiding Judicial Member