Karnataka

Mysore

CC/180/2015

Late Sri. Chotelal Jaluka (Insured) - Complainant(s)

Versus

M/s Star Health and Allied Insurance Co. Ltd., - Opp.Party(s)

Sri. Raghavendra

06 Aug 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

 

CONSUMER COMPLAINT NO.180/2015

DATED ON THIS THE 6^th August 2015

 

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                                          B.E., LLB.,    - MEMBER

 

 

COMPLAINANT/S	:	Late Sri Chotelal Jaluka (insured) since deady by L.Rs Sri Arun Jaluka, S/o Late Sri Chotelal Jaluka, 49 years, No.10, 2nd Floor, 16th Block, 2nd Stage, Srirampura, Mysuru.            (Sri Raghavendra.E., Adv.)
V/S
OPPOSITE PARTY/S	:	M/s Star Health and Allied Insurance Co.Ltd., KRM Centre, VI Floor, No.2, Harrington Road, Chetpet, Chennai-600037, Through its Branch Manager, No.51, 8th Main, 5th Cross, Saraswathipuram, Mysuru-09.   (Sri B.N.Shashidhara., Adv.)

 

 

Nature of complaint		:	Deficiency in service
Date of filing of complaint		:	03.03.2015
Date of Issue notice		:	13.03.2015
Date of order		:	06.08.2015
Duration of Proceeding		:	5 MONTHS 3 DAYS

Sri Devakumar.M.C.

Member

 

1.     The complainant has filed the complaint under section 12 of the C.P.Act, against the opposite party, seeking realization of the hospitalisation expenses.
2.     The complainant’s father was subscribing to health insurance policy with opposite party company, since August 2012.  In the month of November 2013, he suffered severe stomach pain and got admitted to hospital at Vellore, Tamilnadu.  On diagnose, the complainant’s father was suffering from carcinoma prostate disease and took treatment, as inpatient from 15.11.2013 to 22.11.2013.  Later discharged on 22.11.2013.  The hospitalization expenses amounting to `75,000/- has been claimed.  On repudiation of the claim amount, alleged the deficiency in service and prayed for compensation.
3.     The opposite party has filed its version denying the allegations as baseless.  The opposite party has admitted that the complainant’s father was subscribing to the health insurance policy with effect from August 2012 and the premium was paid regularly.  Further admitted that, the complainant’s father had taken treatment at Christian Medical College at Vellore.  After discharging from the hospital claimed `75,000/- towards hospitalization expenses. The opposite party has repudiated the claim of the complainant, on the ground of mis-representation and suppression of material facts.  Hence, there is no deficiency in service on his part.  As such prays for dismissal of the complaint.
4.     Both parties filed their affidavits, written arguments along with documents and submitted decisions on similar cases.  After hearing both sides, matter posted for orders.
5.     The points that arise for consideration of this Forum are as follows:-

1. Whether the complainant has proved the deficiency in service by the opposite party and he is entitled for reliefs as sought?
2. What order?

 

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- Partly in the Affirmative

Point No.2 :- As per final order for the following

 

:: R E A S O N S ::

 

7.    Point No.1:- The complainant’s father subscribed to health insurance policy from August 2012.  Suffering from stomach pain, got admitted to hospital and took treatment as inpatient from 15.11.2013 to 22.11.2013.  On discharge the hospitalization expenses of `75,000/- was claimed.  The opposite party denied the claims.
8.    The opposite party has denied the allegations and admitted that the complainant’s father was subscribing to health insurance policy since August 2012.  Further admitted that the complainant’s father had taken treatment as inpatient, for the disease diagnosed as carcinoma prostate.  Later died on 25.11.2013.  On investigation by the medical team of the opposite party company, ascertained that the complainant’s father was suffering with the said disease prior to subscription to the policy.  Hence, as per, the exclusion condition No.7 of the policy, the claim has been repudiated by the opposite party for concealment of the material facts.  But, the opposite party has failed to produce the medical documents to prove the same. However, the opposite party has clearly stated in its repudiation letter (Annexure-3), that, in case of claims arising out of all pre-existing diseases, the insured is liable to pay 50% of the claim amount.  The advocate representing the opposite party submits the following citations:-
   1. I (2005) CPJ 121 (NC)
   2. I (2015) CPJ 62 (NC)
   3. I (2015) CPJ 5c (CN) chka
9.    The complainant was not aware of the existence of the disease prior to subscription to the policy.  As such, the complainant had not concealed the material facts.    Thereby the citation relied by opposite party not applicable to case an hand.
10. In view of the condition No.5 of the exclusion clause, the opposite party ought to have paid atleast 50% of the claim amount. Without looking into such clause of their own document, the opposite party has repudiated the claim.  The defence is frivolous and it amounts to unfair trade practice.  Thereby, there is deficiency in service and hence, the complainant is entitled for the reliefs.
11. Accordingly, we answer the point No.1 partly in affirmative.
12.  Point No.2:- In view of the above finding, we pass the following

:: O R D E R ::

1. The complaint is partly allowed.
2. The opposite party is directed to pay `75,000/- to the complainant, with interest at 18% p.a. from 22.11.2013 within 30 days of this order.
3. Further, the opposite party shall pay a sum of `5,000/- towards mental agony and `2,000/- towards litigation expenses within 30 days from the date of this order.  In default, the opposite party shall pay interest at the rate of 10% p.a. on the said sum of `7,000/-.
4. In case of default to comply this order, the O.P. shall undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
5. Give the copies of this order to the parties, as per Rules.

 

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 6^th day of August 2015)

 

 

                          (H.M.SHIVAKUMARA SWAMY)  

                                      PRESIDENT     

 

 

(M.V.BHARATHI)                           (DEVAKUMARA.M.C.)

      MEMBER                                         MEMBER

 

*SRL*