KERALA STATE CONSUMER DISPUTES             REDRESSALCOMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.

          APPEAL 740/2011

JUDGMENT DATED 16.11.2011

PRESENT:-

 JUSTICE SHRI.K.R.UDAYABHANU     :       PRESIDENT 

 APPELLANTS

1.     Star Health and Allied Insurance Co.Ltd., KRM Centre,

VI Floor, Harrington Road, Chetpet, Chennai

2.     Star Health and Allied Insurance Co. Ltd.

     BuildingNo. 187(2), Ammus Complex, Kelpetta, Wayanad

               Rep. by the Zonal Manager,

              Star Health and Allied Insurance Co. Ltd.

                                (Rep. by Adv.  P.S. Suresh kumar)

                                        Vs

RESPONDENT

            C. Amina,

            Cheruvil House,

            Naikkaty P.O., Sulthan Bathery,

            Wayanad, Kerala

APPEAL 740/2011

JUDGMENT DATED 16.11.2011

JUSTICE SHRI.K.R.UDAYABHANU      :       PRESIDENT

The appellants are the opposite parties /Insurance Company in C.C. 35/2011 in the file of CDRF, Wayanad.  The appellants are under orders to pay a sum of Rs. 13,126/- to the complainant with interest at 10% from 24.2.2011 till payment and also to pay Rs. 500/- towards cost. 

The complainant who had availed Health Insurance Policy from the opposite parties had claimed the hospital expenses incurred during the period of policy coverage.  She was an inpatient and was subjected to Coronary Angiogram Test.  The claim was repudiated by the opposite parties  on the ground that the tests including Coronary Angiogram were negative.  Hence as per clause 13 of  S.3 Exclusion terms in the policy the expenses incurred primarily for diagnostic examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment for which confinement is required at the hospital is excluded from the coverage.  It is also contended that the claim included expenses incurred for food items amounting to Rs. 2,666/-

The evidence adduced consisted of the testimony of Pw1, the complainant, O.PW1 the Assistant Manager of the opposite party.  Exts. A1 to A3 and B1 to B7.

We find that it is seen from the order of the Forum that the complaint was admitted  in the hospital for chest pain and the tests were conducted  as per the  advice of the doctors.  It is also seen that at the time of discharge, medicines were also prescribed and she was advised appear for review at the department of Cardiology after 3 months.  We find that it can not be held that the complainant was not having any illness.   On account of chest pain, she had to be hospitalized for 3days and that she has been prescribed medicines and directed to attend for review in the department of Cardiology.  It shows that she has having some illness.  Hence we find that Clause 13 of Sec. 3 Exclusions in the policy is not applicable to the instant case.  Hence there is no patent illegality in the order of the Forum.

All the same, as contended by the counsel for the appellant, the amount incurred for food items is not covered by the policy.  Hence the opposite parties/appellant is entitled to exclude the expenses incurred by the complainant in this regard. Rest of the order of the Forum is sustained.  The appellant/opposite party is directed to make the payment ie. Rs. 10,460/- with interest and cost as ordered by the Forum  within 3 months from the date of receipt of this order failing which the complainant will be entitled for interest at 12% from 16.11.2011 the date of this order.

Forward a copy of this order to the Forum.

                JUSTICE SHRI.K.R. UDAYABHANU : PRESIDENT