Vrs.
- The Branch Manager,
Star Health and Allied Insurance Company Limited,
-
Sambalpur-768001 .…....……….Opp. Party
Counsels:-
- For the Complainant :- Sri. P.K.Nath & Associates
- For the O.P. :- Sri.B.K.Purohit, Adv.
Date of Filing:12.02.2024, Date of Hearing :01.07.2024, Date of Judgement :06.08.2024
Presented byDr. Ramakanta Satapathy, PRESIDENT
- The case of the Complainant is that the Complainant obtained a family Health optima Insurance policy No. P/19121/01/2022/005118 for the period 14.02.2022 to 13.03.2023 under 2 adults scheme with a limit of Rs. 6,20,000/-, paid premium of Rs. 23,612/-. The Complainant on 10.07.2022 felt sevior pain in abdomen and went to Life Care Hospital, Sambalpur for treatment, Dr. T.K. Karmakar, General and Laparoscopy Surgeon checked. On 12.07.2022 all types of blood and abdominal tests done and detected stone in Gallbladder and advised for surgery to remove stone. Complainant requested to cashless to the hospital with hospital authority. The O.P. said to submit all documents.
The Complainant admitted in Life Care Hospital, Sambalpur on 19.07.2022, undergone operation by Dr. T.K.Karmakar and discharged on 22.07.2022. Complainant spent Rs. 1,06,554/- as O.P. not provided cashless facility. Claim No. CIR/2023/191214/0472888 was made but it was repudiated on 25.08.2022 on the ground that the treatment of the Complainant was started from 10.02.2023 during break in policy period.
The Policy is continuing from 30.10.2017 and unfortunately not able to renew for the period 23.12.2021 to 13.02.2022. The Complainant submitted his explanation to the O.P. along with report of doctor dated 10.07.2022 but the O.P. repudiated the claim. Being aggrieved complaint has been filed.
- The O.P. in reply submitted that the policy was valid for the period 14.02.2022 to 13.02.2023. Complainant was admitted at Life Care hospital on 19.07.2022 and discharged on 22.07.2022 for treatment of CHOLECYSITIS. Cashless request denied as the treatment was started frm 10.02.2022 during break in policy period. Complainant felt sever pain in abdomen on 10.07.2022. Annexure-2 is false and denied. As per prescription the insured was under the treatment of Life Care Hospital on 10.02.2022 which was the onset of CHOLECYSTITIS. Cashless was denied. Complainant is not entitled for the claim of Rs. 1,06,554/-. The Complainant has violated condition No.10 of the policy. The policy was discontinued from 23.12.2021 to 13.02.2022 and during that period only the disease was diagnosed on 10.02.2022.
- Perused the documents filed by the Complainant:
- Copy of policy No. P/191214/01/2022/005118.
- Copy of discharge note of the care Hospital.
- Letter of the O.P. dated 25.08.2022.
- Mail dated 07.11.2022 of the son of Complainant.
- Prescription dated 10.07.2022 of the Life Care Hospital.
- Certificate issues by life care Hospital and report.
The O.P. has filed the following documents:-
- Copy of policy renewed from 14.02.2022 to 13.02.2023.
- Prescription dated 10.07.2022 of Life Care Hospital.
- After perusal of the documents and contentions of the parties following issues are framed:
ISSUES
- Whether the Complainant was diagnosed CHOLECYSTITIS on 10.02.2022 or 10.07.2022?
- Whether the Complainant violated condition No. 10 of the policy and repudiation of claim by O.P. is proper?
- What relief the Complainant is entitled for?
Issue No.1:- Whether the Complainant was diagnosed CHOLECYSTITIS on 10.02.2022 or 10.07.2022?
It is admission of both the parties that policy No. P/191214/01/2022/005118 was in force for the period 14.02.2022 to 13.03.2023. The O.P. submitted that annexure-2 filed by the Complainant is not acceptable as the disease CHOLECYSTITIS was detected on 10.02.2022 and during that period the policy was not in existence.
In the other hand the Complainant to substantiate his case stated that the annexure 2 is dated 10.07.2022 and policy was in existence. The O.P. treated the date 10.07.2022 as 10.02.2022 and repudiated the claim. The Complainant submitted discharge note of Life Care Hospital dated 22.07.2022. The Complainant admitted in hospital on 19.07.2022 and discharged on 22.07.2022. Dr. T.K. Karmakar clarified that the prescription issued to the Complainant is dated 10.07.2022. It is further supported by 2 DEcho & Doppler report dated 14.07.2022 issued by Dr. Laxmiprasad Dash and Lab Care Diagnostic dated 21.07.2022.
The O.P. treated the date of diagnosis as 10.02.2022 instead 10.07.2022 and repudiated the claim. The issues is answered infavour of the Complainant.
Issue No.2:- Whether the Complainant violated condition No. 10 of the policy and repudiation of claim by O.P. is proper?
The O.P. submitted that ‘Coverage is not available during the grace period”. The Complainant violated condition No.10 of the policy. As discussed Supra the disease was diagnosed on 10.07.2022 during the subsistence of the policy, violation of condition No.10 is not acceptable. As the policy has been continued by the O.P. w.e.f. 14.02.2022, premium of Rs. 23,612 has been received by the O.P. the repudiation of claim No. CIR/2023/191241/0472888 is not proper.
The issue is answered infavour of the Complainant.
Issue No.3:- What relief the Complainant is entitled for?
As discussed Supra the Complainant is entitled for the relief claimed for. The Complainant has spent Rs. 1,06,554/- to-wards treatment. Further non allowing the cashless facility and further repudiation of claim amounts to deficiency in service on the part of the O.P.
Accordingly following order is passed:-
ORDER
The complaint is allowed on contest against the O.P. The O.P. is directed to pay Rs. 1,06,554/- with 7% interest per annum from the date of repudiation of claim. For deficiency in service the O.P. is liable to pay compensation of Rs. 50,000/- and litigation expenses of Rs. 10,000/- within one month of this order amount will carry 12% interest P.A. from date of repudiation of claim till realisation.
Order pronounced in open court on 6th day of August, 2024.
Supply free copies to the parties.
