Chanthiathil House, Moolankave Post, : Complainant.
Kuppadi Village, Sulthan Bathery Taluk, :
Wayanad. 673592. :
1. Mr. Legil, Manayath House, :
Koliyadi, Nenmeni Village and Post, :
Sulthan Bathery Taluk, 673592. :
(Agent of 2nd Opposite Party). : Opposite Parties.
2. Star Health and allied Insurance Co Ltd, :
Rep by Its Branch Manager, :
Sulthan Bathery Post, Village and Taluk, :
Wayanad – 673592. :
Complainant by:- Adv. T. P. Ealias.
Opposite Parties by:- Adv. P. C. Chithra.
ORDER.
By. Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the complaint:- The Complainant is the beneficiary of Opposite Parties as per policy No.P/181315/01/2022/001490. The 1st Opposite Party approached the Complainant and explained the features of the Family Health Insurance Plan of 2nd Opposite Party and also he caused to convince the Complainant that the policy is more beneficial and hurdles free etc. and told that the coverage is for entire diseases, low premium, treatment is available in any hospitals, intimation to the agents is the only duty of policy holders and claim would be settled within 30 days etc. Believing the words of the 1st Opposite Party, who is the agent of the 2nd Opposite Party, the Complainant joined in the policy of the Opposite Party in 2017 and renewed till date. The wife of the Complainant suffered from Obesity Hypoventilation Syndrome OSA which leads to Respiratory failure and treated as out-patient in Aster Mims, Calicut on 29.10.2021 and treated there till 11.11.2021. The Complainant submitted the claim form to the 1st Opposite Party. When the Opposite Party enquired about the matter, they understood that the Complainant was not admitted in the hospital due to spreading of COVID-19 pandemic. The Opposite Party processed the claim and provided claim number and offered benefits. Thereafter the Opposite Party vide letter dated 17.12.2022, repudiated the claim of the Complainant on the ground that the treatment taken by the Complainant is not covered under the policy and the treatment taken as out-patient and treated disease is not covered under the policy. Hence, this Complaint.
3. Notice was issued to the Opposite Parties from this Commission, both Opposite Parties appeared and filed version.
4. The Opposite Parties filed version denying the allegations made in the Complaint. The Opposite Parties admitted that the Complainant had taken a Family Health Optima Insurance Policy from the 2nd Opposite Party on 22.06.2018, covering himself and his wife for a sum assured of Rs.10,00,000/-which has been renewed up to 21.06.2022. The Opposite Party submitted that at the time of issuance of policy, the Complainant was supplied with terms and conditions of the policy and explained the content and the policy schedule also handed over to him. As per the Recital clause of the policy, company undertakes that during the policy period the insured person suffers from any disease and if such disease requires such insured person upon the advice of a doctor to incur hospitalization expenses for medical treatment at any hospital as an inpatient, the company will pay to the insured person, the amount of such expenses are reasonably and necessarily incurred up to the limit indicated in the schedule. As per the bills submitted by the Complainant along with claim application, shows that the wife had underwent treatment for Obstructive Sleep Apnea as an out-patient only. As per the terms and conditions of the policy, coverage is available for inpatient treatment only. The wife of the Complainant had only taken treatment as an out-patient in the hospital. So the Opposite Parties are not liable to consider the claim. Moreover, as per the exclusion clause No. 3(33) of the policy Sleep Apnea is not covered under the policy. The Opposite Parties Further submitted that they had returned all the documents submitted with claim form on the request of Complainant. The Complainant has not submitted any documents to show that the wife of the Complainant was not admitted due to Corona Virus Pandemic. There has been no unfair practice or the Complainant has not suffered heavy loss and damages due to the act of the Opposite Party. Hence the Opposite Party prayed to dismiss the complaint with compensatory cost.
5. To substantiate the above case, both parties have filed their respective affidavit along with documents. Ext.A1 to A3 marked on the side of the Complainant. Ext.B1 and B2 marked on the side of the Opposite Parties. Complainant was examined as PW1 and Assistant Manager-Legal of 2nd Opposite Party was examined as OPW1.
6. On the basis of pleadings of the parties, the following points were raised for consideration:-
- Whether there is deficiency in service on the part of the Opposite Parties?
- Whether the Complainant is entitled to any relief?
7. On perusing the pleadings of the parties, it is an undisputed fact that the Complainant had taken Family Health Optima Insurance Policy from the 2nd Opposite Party on 22.06.2018 for a sum assured for Rs.10,00,000/- covering his wife also, which was renewed up to 21.06.2022. The wife of the Complainant was treated for Obesity Hypoventilation Syndrome OSA, Type 2 of Respiratory failure as out-patient in Aster Mims, Calicut on 29.10.2021. Thereafter, the Complainant submitted the claim application, but the Opposite Party repudiated his claim with a reason that the treatment undertaken by the insured was as out-patient and treatment for Sleep Apnea is not covered under the policy.
8. We have carefully gone through the record and also heard the counsels for both the parties.
9. It is not disputed that Complainant has obtained medi-claim policy from the 2nd Opposite Party, insurance company. Ext.A2 is the OP Summary, in which Provisional Diagnosis has been mentioned as Obstructive Sleep Apnea Obesity Hypoventilation. The perusal of Ext.B1, the terms and conditions of the policy the treatment of Sleep Apnea falls under the Exclusion Clause of 3 (33), which reveals that treatment for the said disease are not payable under the policy. Hence, repudiation of claim of the Complainant by the Opposite Party is justified.
10. For the forgoing reasons, we are of the Opinion that the Opposite Party had rightly repudiated the claim of the Complainant.
In the result, the Complaint is dismissed without cost.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 4th day of December 2023.
Date of Filing:-21.05.2022.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. George Varghese. Business.
Witness for the Opposite Parties:-
OPW1. Balu. M. Assistant Manager Legal.
Exhibits for the Complainant:-
A1. Referral Letter issued from Aster Wayanad. Dt:29.10.2021
A2. Copy of OP Summary from Aster Mims.
A3. Bill of Supply (7 Numbers).
Exhibits for the Opposite Parties:-
B1. Terms and Conditions of the Policy.
B2. Copy of Repudiation Letter. Dt:17.12.2021.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-