Orissa

Sambalpur

CC/34/2021

Subhransu Prasad Acharya - Complainant(s)

Versus

Branch Manager, Star Health and Allied Insurance Limited - Opp.Party(s)

Sri. B.K.Shroff & D.Shroff

30 Aug 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No- 34/2021

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

 

Subhransu Prasad Acharya,

S/O-Late Banka Bihari Acharya,

R/O-At Radharani Vihar, Khajurtika, Ward No-08,

Po/Dist-Bargarh,

At Present Resident of A/302, Greenpark Residency,

Near Mahila Ps, Laxmi Talkies Chowk,

Dist-Sambalpur, Odisha,768001.                                  ...………..Complainant

                                                Versus

Branch Manager, Star Health and Allied Insurance Limited,

Office at 2^nd floor, Quality Mansion,

Nayapara, Sambalpur, Odisha 768001                                   …………...Opp.Parties

 

Counsels:-

1. For the Complainant                   :-Sri. B.K.Shroff & Associates
2. For the O.P.                                  :- Sri. B.K.Purohit, Advocate

 

DATE OF HEARING :26.07.2022, DATE OF JUDGEMENT : 30.08.2022

           Presented by Dr. Ramakanta Satapathy, PRESIDENT,

1. The Complainant is insured under family Health Optima Insurance plan of the O.P. having Policy No. P/191214/01/2021/004734 for the period 26.12.2020 to 25.12.2021 MN., paid Rs. 29,695/- to-wards renewal policy premium and since 26.12.2018 policy is continuing. In 2016 the Complainant has undergone Pre-Existing Disease(PED) eye operation and declared it. On 11.02.2021 for cataract in left eye operated in L.V. Prasad Eye Institute, Bhubaneswar and applied for cashless transaction. The Complainant on 13.02.2021 admitted in Hospital, got operated and discharged. Claim was filed with O.P. The O.P. on 05.03.2021 repudiated the claim on the ground that:

“As per Exclusion No.(1) PED-Code Excl. 01 (D) of the policy issued to you, the coverage under the policy after the expiry of 48 months for any PED is subject to the same being declared at the time of application and accepted by the insurer. We are therefore unable to settle you claim under the above policy and we hereby repudiate you claim.”

On 16.03.2021 the Complainant wrote a letter to reconsider his claim as his right eye was operated in 2016 and policy started since 26.12.2018. The O.P. remained silent. Being agrieved the complaint was preferred.

2. The O.P. in its version submitted that the policy coverage was for Rs. 5.00 lakhs for the period 26.12.2018 to 25.12.2016 and renewal has been made from time to time till 25.12.2021. The O.P. on 10.12.2021 received a pre-authorisation request of the Complainant for his surgery of left eye (cataract) in phacoemulidication with foldable Intraocular lens (Mono focal), claimed Rs. 43,790/-. The O.P. requested to provide documents details. In reply letter dated 11.02.2021 L.V.Prasad Institute provided medical report dated 16.06.2016 dated 12.12.2019, discharge summary dated 18.12.2019 of the left eye operation. The O.P. vide letter dated 11.02.2021 rejected the authorisation for cashless treatment. The consideration letter of Complainant dated 11.02.2021 was rejected vide letter dated 12.02.2021 on the same ground.

The Complainant has undergone treatment of cataract which is incorporated in the policy as one of the P.E.D. at the time of inception of the medical policy. The latest admission and treatment of the insured is for the PED. Basing on Exclusion No.(1) PED-code Excl.01 (D) the coverage under the policy after the expiry of 48 months for any PED is subject to the same being declared at the time of application and accepted by the insurer. The Claim was not settled.

The insured had undergone treatment for EPD in the 3^rd year policy, the claim is not payable as per waiting period Ex cl. No. 3 (iii) and the insurer is not liable to make payment o f the expenses incurred as a PED as per policy terms. The Complainant has concealed the material facts in first policy dated 26.12.2018. The Complainant declared that he was suffering from DM-2 since two years and suffering from cataract on one eye, through there was SANILE CATARACT for both eyes as on 16.06.2016 as per the report of the L.V. Prasad Institute. The O.P. has rightly repudiated the claim and the Complainant is not entitled for any relief.

3. Perused the documents filed by the Complainant, complaint and version of the O.P. and the following issues are framed:
103606587.  

1. Whether the O.P. rightly repudiated the claim of the Complainant?
2. Is the O.P. deficiency in its service?
3. What relief the Complainant is entitled to get?

Issue No.1 Whether the O.P. rightly repudiated the claim of the Complainant?

          The Complainant has paid Rs. 29,695/- to-wards renewal policy premium for the period 26.12.2020 to 25.12.2021 MN to the O.P. The Complainant also declared the previous history at the time of renewal and submitted relevant papers before the O.P. The Complainant applied for cashless transaction for operation in his left side cataract on 11.02.2021 but the O.P. repudiated the claim intimation CIR/2021/191214/2243951. Again on 16.03.2021 the complainant requested for reconsideration of the claim.

          The ground of repudiation of the policy is that the coverage under the policy after expiry of 48 months for any PED is subject to the same being declared at the time of application and accepted by the insurer. While taking the policy first time on 26.12.2018 the Complainant has declared that he was suffering from D.M.2 since two years and suffering from cataract at one eye on 16.06.2016. The ground taken by the O.P. about suppression of fact is not acceptable as clearly the Complainant has declared about his eye conditions and operation undergone. The O.P. accepted the proposal and time to time renewed the proposal, accepted payment of premium. At the sweet will of the O.P. Company the insured can not take up any operation and as per advise of the treating physicians the operation was made although the left eye was affected in 2016 but the cataract was not matured which was operated in 2021. As the insurer accepted the premium after first operation in 2016, the repudiation made is not proper and accordingly it is set aside.

          The issue is answered in favour of the Complainant.

Issue No.2 Is the O.P. deficiency in its service?

          The repudiation of the claim by the O.P. is not proper and accepting premium made repudiation of the claim amounts to deficiency in service.

          Accordingly, the issue is answered.

Issue No.3 What relief the Complainant is entitled to get?

          The Complainant has made expenditure of Rs. 43,790/- to-wards surgery, Rs. 500/- to-wards Patho-lab testing and consultation fees of Rs. 400/- which are recoverable from the O.P.

          It is ordered:

ORDER

The complaint is allowed on contest. The O.P is liable to pay Rs. 44,690/- with 12% interest P.A. from the date for repudiation till payment. The O.P. is directed to pay Rs. 20,000/- compensation and litigation expenses of Rs. 10,000/- within one month failing which the entire amount will carry 12% interest P.A. till realisation.

          Order pronounced in open court on this 30^th day of August, 2022.

          Supply free copies to the parties.