BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.218-2019

DATED ON THIS THE 26^th September, 2019

      Present:   1) Sri. C.V.Maragoor

B.Com., L.L.M., - PRESIDENT   

                     2) Sri. Devakumar.M.C.           

                                        B.E., LLB., PGDCLP   - MEMBER

Sri C.V.MARAGOOR,

President

1.       This complaint has filed by Durga Prasad S/o Durgappa resident of Mysuru to direct the opposite party M/s Star Health and Allied Insurance Company Limited, Chennai through its Branch Manager, Mysuru for reimbursement of medical expenses of Rs.1,47,000/- with interest at the rate of 18% p.a., damages of Rs.50,000/- and cost of litigation of Rs.10,000/-.
2.       The complainant has taken Family Health Optima Insurance Policy from the opposite party for the period from 13.02.2018 to 12.02.2020.  The sum assured is Rs.5,00,000/-.  The complainant has insured himself and his wife Smt.Manjula.  The wife of complainant did not conceive after marriage so she has visited Dr.Bhageerathi of Manoj Poly Clinic for treatment and thereafter Smt.Manjula was referred to Chitra’s IVF Hospital, Mysuru for taking further treatment i.e. for conceiving a baby. The wife of complainant took treatment at Chitra’s IVF Hospital, Mysuru from 26.02.2019 to 12.03.2019 and she was treated successfully and conceived.  The complainant has paid medical expenses a sum of Rs.1,47,000/- for his wife treatment.  Thereafter, the complainant has submitted claim application to the opposite party, but later has unilaterally and arbitrarily repudiated the claim on 16.07.2019.  Hence, this complaint.
3.       The opposite party after the service of notice appeared through its learned counsel and filed written version admitting that the complainant has taken Family Health Optima Insurance Policy from their company.  The opposite party contention is that it is not aware with regard to treatment taken by the wife of complainant at various hospitals.  It is the case of opposite party that it has issued Family Health Optima Insurance Claim covering the complainant and his wife for sum of Rs.5,00,000/- in the year 2015. The insured wife was admitted on 12.03.2019 in Chitra’s IVF Hospital, Mysuru and discharged on the same day.  The discharge summary of the treating hospital indicates that the complainant’s wife has undergone treatment for primary infertility.  The opposite party has repudiated the claim as per exclusion clause No.4/14 of the policy.  On the amongst other grounds, the opposite party asked to dismiss the complaint.
4.       The complainant filed his affidavit and got marked Exhibits P.1 to P.4 documents.  On behalf of opposite party one Upendrakumar Nayak, Branch Manager of Mysuru branch office filed his affidavit and got marked Exhibits R.1 to R.8.
5.        We have heard the arguments advanced by the learned counsel for the complainant and opposite party in addition to written brief submitted by the learned counsel for the opposite party and the points that would arise for determination are as under:-  

1. Whether the complainant proves that the repudiation of medical claim by opposite party is not justifiable?
2.  Is complainant entitled to the reliefs sought for?

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

Point No.1 :- In the affirmative;

Point No.2 :- In the partly affirmative for the below;

:: R E A S O N S ::

7.         Point Nos.1 and 2:- The learned counsel for the complainant submits that after informing the opposite party, the complainant has got treatment to his wife for sub-fertility.  The inception date of policy is from 2015, but not 2018 as contended by the opposite party.  Therefore, exclusion clause is not applicable to the complainant.  As against this, the learned counsel for the opposite party vehemently argued that for the first time the complainant has submitted proposal in the year 2015 for a sum of Rs.3,00,000/-.  Policy of the year 2016-17 was not covering the treatment of infertility.  The complainant has increased the sum assured from Rs.3,00,000/- to Rs.5,00,000/- in the month of July, 2017 to eligible for infertility and the policy must be inforce for a period of 36 months.  The opposite party considering the eligibility of reimbursement of medical expenses has repudiated the claim which is proper in accordance with terms and conditions of the policy. 
8.          The opposite party has not disputed taking Family Health Optima Insurance Policy by the complainant for himself and his wife since 2015 and the policy was in force on the date of treatment to the complainant’s wife on 12.03.2019.  The complainant produced Ex.P.1 discharge summary of Smt.Manjula wife of complainant issued by Chitra’s IVF Hospital, Mysuru and according to this the wife of complainant was admitted on 12.03.2019 and on the same day she was discharged.  The doctor has diagnosed primary infertility.  The opposite party has also produced discharge summary of Chitra’s IVF Hospital, Mysuru which is marked as Ex.R.7.  The opposite party has produced Ex.R.1 proposal form submitted by the complainant for the period of insurance from 13.02.2015 to 12.02.2016.  Ex.R.3 is renewal notice issued by the opposite party to the complainant for the period from 12.02.2017.  Ex.R.4 Family Health Optima Insurance Policy for the period from 13.02.2016 to 12.02.2017.  Under Ex.R.4 the complainant has enhanced sum insured from Rs.3,00,000/- to Rs.5,00,000/- as on 08.02.2017.  The opposite party has not disputed that the policy was in force on the date of treatment i.e. 12.03.2019.  
9.          The opposite party has produced Ex.R.5 customer information sheet (CIS) Family Health Optima Insurance Policy for the year 2017-18 and Ex.R.6 terms and conditions of the policy.  Under heading coverage clause No.1S the company will reimburse medical expenses incurred on  Assisted Reproduction Treatment where indicated for sub-fertility subject to:
   1. Awaiting period of 36 months from the date of first inception of this policy with the company for the insured person.  The maximum liability of the company for such treatment shall be limited to Rs.1,00,000/- for sum insured of Rs.5,00,000/- and Rs.2,00,000/- for sum insured of Rs.10,00,000/- and above for every block of 36 months and payable on renewal.
   2. For the purpose of claiming under this benefit, in-patient treatment is not mandatory.
   3. Automatic Restoration of basic sum insured.  Recharge benefit shall not be applicable for this benefit.’
10. Note under clause 1S says that – “To be eligible for this benefit both husband and spouse should stay insured continuously without break under this policy every block.  This coverage is available only for sum insured option of Rs.5,00,000/- and above”. The learned counsel for the complainant brought to the Forum notice google website meaning of inception of policy – “Inception date is a very important factor in an insurance policy.  From the point of view of insurance company, it is the date when the customer paid the first premium.  After a period of 365 days, the same date serves as the renewal date for continuation of the policy”.  Further, the learned counsel brought to the Forum notice meaning of sub-fertility. Sub-fertility is a delay in conceiving.  Infertility is the inability to conceive naturally after one year of trying.  In subfertility, the possibility of conceiving naturally exists, but takes longer than average.  Primary infertility refers to couples who have not become pregnant after at least one year having sex without using birth control methods.  Secondary infertility refers to couples who have been able to get pregnant at least once, but now are unable.  In Ex.R.6 policy given definition of Assisted Reproduction Treatment means “intrauterine insemination, intra-Cytoplasmic Sperm Injection (CSI), In-Vitro Fertilization and Tesa/Tese (Testicular/Epidymal Sperm Aspiration/extraction).

11.         The opposite party contention is that the complainant has increased sum assured limit from Rs.3,00,000/- to Rs.5,00,000/- on 08.02.2017, as such exclusion clause 4/14 applicable since the complainant policy was not inforce for a period of 36 months on the date of taking treatment by his wife on 12.03.2019. But, clause 1S of Ex.R.6 says that this policy taken by the insured with the company is eligible for reimbursement of medical expenses incurred on assisted reproduction treatment.  As already observed that inception date is the day when the customer paid the first premium.  After a period of 365 days the same date serves as the renewal date for continuation of the policy. The complainant has paid the first insurance premium as on 13.02.2015 and i.e. the inception date according to clause 1S of Ex.R.6. Therefore, the policy was inforce for more than 36 months on the date of taking treatment by the wife of complainant as on 12.03.2019.  It is not mentioned in clause 1S of Ex.R.6 that from the date of inception of policy sum assured amount should be Rs.5,00,000/-.  But, on the date of taking treatment, the policy covered sum assured should be                   Rs.5,00,000/-. The complainant has enhanced the limit from Rs.3,00,000/- to Rs.5,00,000/- w.e.f. 08.02.2017.  It is specifically mentioned in clause 1S of the policy that the waiting period of 36 months from the date of first inception of the policy with the company by the insured person.  It is not dispute by the opposite party that the complainant has insured himself and his wife on 13.02.2015 and the said policy was renewed continuously without any break.  Therefore, the treatment taken by the wife of complainant covers the eligibility for reimbursement of medical expenses.  However, the complainant is entitled to medical expenses to a sum of Rs.1,00,000/- as per clause 1S as sum assured by him is Rs.5,00,000/-.  Therefore, the complainant is entitled for medical reimbursement of Rs.1,00,000/- out of claimed amount of Rs.1,47,000/-.  The complainant is entitled for interest on the said amount at 10% p.a. from 12.03.2019 till payment. 
12.        The complainant has not produced any material for award of damages a sum of Rs.50,000/- for hardship, harassment and physical sufferings.  But, he might have suffered mental agony for not reimbursing medical expenses though eligible under the policy on his claim application.  Therefore, the complainant is entitled a sum of Rs.15,000/- as compensation for his mental sufferings apart from litigation expenses of Rs.10,000/-.  Accordingly, we proceed to pass the following:-

:: ORDER ::

1. The complaint filed by Durga Prasad S/o Durgappa is partly allowed directing the opposite party to pay a sum of Rs.1,00,000/- as medical reimbursement to the complainant with interest at the rate of 10% p.a. from 12.03.2019 till the date of payment.
2. It is further ordered that the opposite party shall pay a sum of Rs.15,000/- as damages and Rs.10,000/- as litigation cost to the complainant within 45 days.  Otherwise, it carries interest at the rate of 10% p.a. from the date of filing this complaint till realization.
3. Furnish the copy of order to the complainant and opposite party at free of cost.

(Dictated to the Stenographer transcribed and typed by her, corrected by us and then pronounced in open court on this the 26^th September, 2019)