BEFORE THE DAKSHINA KANNADA DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH,                                                                                             MANGALORE

Dated this the 6^th December 2016

PRESENT

SRI. VISHWESHWARA BHAT D         : HONBLE PRESIDENT

SRI. T.C. RAJASHEKAR                      : HONBLE MEMBER

ORDER IN

C.C.No.57/2013

(Admitted on 25.2.2013)

Mrs. Dorathy Pinto,

W/o Richard Pinto,

Aged about 40 years,

Residing at Classique Villaments,

Flat No.401, Kankanady Bypass Road,

Pumpwell, Mangalore  5757 002.      

                                                         ….. COMPLAINANT

(Advocate for the Complainant: Smt. MNA)

VERSUS

1. M/s. Star Health & Allied Insurance,

     Company Ltd.,

    KRM Centre, VI Floor, No.2,

    Harrington Road, Chetpet,

    Chennai  600 031.

    Represented by its Authorized Signatory

2. M/s. Star Health & Allied Insurance,

    Company Ltd.,

    City Light Complex, Balmatta Road,

    Balmatta Road Mangalore  575 001,

    Represented by its Authorized Signatory

                                                                  ......OPPOSITE PARTIES

 (Advocate for the Opposite Parties No.1 & No.2: Sri. AKK)

ORDER DELIVERED BY HONBLE PRESIDENT

SRI. VISHWESHWARA BHAT D:

I.       1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against claiming certain reliefs. 

The brief facts of the case are as under:

     The complainant contends since last 3¹/₂ years he availed in policy issued by opposite party with the latest policy with valid from 4.6.2012 to 3.6.2013. On 6.8.2012 when complainant approached Dr. Muneer Ahmed ENT with blockage/running nose and headache since 15 days he underwent treatment as impatient of Unity Health Complex and was discharged on 9.8.2012.  When the complainant sought reimbursement of the amount of Rs.41,965/ being the medical expences along with CT Scan and medicines expenditure totalling Rs.43,962.18/ the opposite party repudiated the claim as the disease is pre existing.  Hence seek the relief as mentioned in the complaint.

II.     Opposite party in the objection admits the Insurance Policy issued to claimant and denied the treatment and medical expenditure as claimed.  The opposite parties contend that they observed from the records the complainant had history of alleged complaints since about 3 to 4 years which is prior to inception of the policy and that the being under pre existing disease exclusion clause No.1. 

     2.     In support of the above complainant Mrs. Dorathy Pinto filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked as Ex.C1 to C6 detailed in the annexure here below.  On behalf of the opposite party Mr. Melwin D Souza (RW1) Branch Manager, Star Health & Allied Insurance Co. Ltd., Mangalore also filed affidavit evidence and answered the interrogatories served on him.

III.     In view of the above said facts, the points for consideration in the case are:

1. Whether the Complainant is a consumer and the dispute between the parties?
2. If so, whether the Complainant is entitled for any of the other reliefs claimed?
3. What order?

      We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:         

               Point No. (i): Affirmative

              Point No. (ii): Affirmative

              Point No.(iii): As per the final order.                  

REASONS

IV.   POINTS No. (i):  The complainant contends she as under treatment as impatient at Unity Health Complex for nasal blockage, running nose.  That complainant had purchased Medi Family Package Plan No.P/141211/01/2013/001308 is undisputed.  When complainants claim is she avails insurance policy for more than 3¹/₂ years.  As opposite party repudiated the claim of complainant alleging it was pre existing basis.  There is a dispute between complainant the consumer and opposite party the service provider as contemplated the under C P Act.  Hence we answer point No.1 in the affirmative.

POINTS No.(ii):   The complainant getting treatment for the ailment as mentioned in the complaint for nose blockage, running nose  is not disputed by opposite party.  Ex.C2 the copy of discharge summary mentions complaints of nasal block, running nose, headache since 15 days.  It also mention as to final diagnosis Chronic Rhino Sinusitis.  There is no mention that the complainant suffering from this for 3 to 4 years as alleged by the opponent.  There are no documents produced by opposite party to sustain such claim.  Hence opposite party failed to establish that the disease for which the complainant was treated was pre-existing for 3 to 4 years.  Hence we are left with what is mentioned at Ex.C2 as mentioned above.  It is dated Ex.C2 6.8.2012.

     2.  The copy of the medi claim is an policy individual produced in the case mentions at 3.0 the exclusion.  But as seen from the Exclusion 3.0 at 1 as to Pre Existing Disease what is mentioned as defined in the policy, until 48 months of continuous coverage have elapse, since inception of the first policy is with the company.  As seen from Ex.C1 the copy of the Insurance Policy for the period from 4.6.2012 to midnight of 3.6.2013 mention the Renewal Year as third year.  Infact at Ex.C1 the date of first policy inception date is shown as 4^th June 09 and Ex.C1 is issued by opposite party Star Health and Allied Insurance Company Limited.   Hence the claim made by opposite party is false.  Hence the ground urged for repudiating the claim of the complainant is unjustified.

     3.  The opposite party has not disputed the amount of expenditure incurred by complainant mentioned in the complaint.  As such the complainant proved the expenditure incurred by the complainant for the treatment and as such complainant is entitled for medical expences of Rs.43,962.18/ with interest at 9%.  Further towards mental agony and inconvenience of complainant due to unjust rejection of claim of complainant a sum of Rs.30,000/ and towards legal notice cost Rs.1,000/- and cost of the proceedings at Rs..5,000/   in our view it is just and proper. Hence we answer point No. 2 in the affirmative.

      POINTS No. (iii): Wherefore the following Order:

                                                                                                             ORDER

     The complaint is allowed.  Opposite party is directed to pay Rs.43,962.18/ (Rupees Forty Three thousand and Nine hundred Sixty Two and Eighteen paisa only) with interest at 9% per annum till the date of payment. Opposite party shall also pay towards mental agony and inconvenience of complainant due to unjust rejection of claim of complainant a sum of Rs.30,000/(Rupees Thirty thousand only)  and towards legal notice cost Rs.1,000/ (Rupees thousand only) and cost of the proceedings at Rs.5,000/ (Rupees Five thousand only) in our view it is just and proper. Payment shall pay within 30 days from the date of receipt of copy of this order.

     Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.

     (Page No.1 to 6 directly dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 6^th December 2016)

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 Mrs. Dorathy Pinto

Documents marked on behalf of the Complainant:

Ex.C1:                   : Insurance Policy with conditions               

Ex.C2:  9.9.2012     : Discharge summary

Ex.C3: 31.08.2012  : Repudiation letter

Ex.C4: 12.10.2012   : Office copy of the legal notice

Ex.C5:                    : Postal receipt

Ex.C6: 15.01.2013   : Letter by Post Master

Witnesses examined on behalf of the Opposite Party:

RW1: Mr. Melwin D Souza, Branch Manager, Star Health & Allied

         Insurance Co., Ltd., Mangalore.

Documents marked on behalf of the Opposite Party:

Nil 

Dated:  06.12.2016                                         PRESIDENT