DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  20^th  day of November,  2023

Present      :   Sri. Vinay Menon V.,  President

                  :  Smt. Vidya A., Member                        

                  :  Sri. Krishnankutty N.K., Member                                Date of Filing: 26/02/2022    

     CC/41/2022

Noor Muhammed M.,

S/o. Muhammed Ibrahim,

Shamna Manzil, Pudupariyaram,

Valparambu, Palakkad – 678 731.                             -           Complainant

(By Adv. Dhanajyayan K.)

                                                                                                Vs

1. M/s. Star Health & Allied Insurance Co. Ltd.,

No.15, 1^st Floor, Sree Balaji Complex,

Whites Lane, Royal Petta, Chennai – 14.

2. M/s.Star Health & Allied Insurance Co. Ltd.,

No.15, 1^st Floor, Sree Balaji Complex,

Whites Lane, Royal Petta, Chennai – 14,

Rep. by its MD/Manager/Authorised Signatory

3. M/s. Star Health & Allied Insurance Co. Ltd.,

Zonal Office, 4^th Floor, Carmel Towers,

Cotton Hill Post, Vazhuthacaud,

Trivandrum.

4. The Branch Manager,

M/s.  Star Health & Allied Insurance Co. Ltd.,

Fine Centre, 4^th Floor, TB Road,

Palakkad – 678 014.

(By Adv. M/s. Ratnavally & Kiran G Raj A)           -           Opposite parties          

O R D E R

By Sri. Vinay Menon V., President

1. Gist of the pleadings, essential for adjudication, is that the complainant and his wife were beneficiaries of an insurance policy issued by the opposite parties for Rs.3 lakhs. During the subsistence of valid coverage under the policy, wife of the complainant suffered from a heart ailment. Even though the complainant is legally entitled to receive Rs.1,29,098.19/- being the amount expended for the treatment of his wife, his claim was repudiated by  the opposite parties on the grounds of non-disclosed pre-existing disease and the waiting period of 48 months of continuous coverage since inception of the policy for existing diseases as contemplated under Clause 6.1(a) of the policy schedule.  Aggrieved thereby, this complaint is filed seeking for amounts expended and compensation and cost of the proceedings.
2. Opposite parties filed version admitting complaint pleadings. Their statement is that pre-existing disease would come under the coverage only after 48 months of continuous coverage. Said contingency having been contemplated under the policy, there is no illegality whatsoever and sought for dismissal of the complaint.
3.  The following issues arise for consideration: 

1. Whether the complainant’s wife was suffering from any pre-existing disease prior to the commencement of the policy ?
2. Whether there is any  deficiency in service/unfair trade practice on the part of the opposite parties  in repudiating the claim ?

3.         Whether the complainant is entitled to any of the reliefs sought for?

4.         Any other reliefs ?

4.         (i) Evidence comprised of proof affidavit and Exhibits A1 to A8 marked on the part of complainant.  Marking of all documents were objected to on the ground that they were photocopies. Ext.A5 was additionally objected to as it was a doctor’s prescription and could be marked only through the doctor who prepared it.  Since this Commission is not bound by the tenets of Indian Evidence Act and in the absence of a case that the said documents are forged or concocted, these  objections are over-ruled.

            (ii) Opposite parties filed proof affidavit and marked Exts. B1 to B5. 

            Issue No.1

5.         Policy certificate and terms and conditions were marked as Ext.B1.  Ext.B1 shows that the proposal date and date of inception is 16/3/2021.  

6.         Ext.B4 is the repudiation of claim.  The reason for repudiation is stated as herein below:

            “Non Disclosed Pre Existing Disease :- It is observed from the treatment records that the insured patient had history of Cardiac complaints prior to inception of medical insurance policy. Hence it is a pre-existing disease. The present admission and treatment of the insured patient is for the pre-existing disease.

            As per Waiting Period No:- 6.1(a) of the policy issued to you, the Company is not liable to make any payment in respect of expenses for treatment of the pre-existing Disease and its direct complication until 48 months of continuous coverage has elapsed, since inception of policy i.e., from 16/03/2021.

            We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

7.         Ext.B3,copy of discharge summary issued by department of Cardiology, Thankam Hospital, shows that the complainant’s wife had been hospitalized from 26/5/2021 till 31/5/2021.  The presenting complaint is that there was a ‘history of chest pain since 6 days’, ie from 20/5/2021 onwards.

 8.        Ext.B2 is the proposal form prepared by the complainant. The said document does not show any cardiac issue existing at the time of preparation of the proposal form. 

9.         Ext.B1 Arogya Sanjeevani policy schedule defines a pre-existing disease as herein below:

            “(3) Definitions :-

            3(37) Pre-existing disease (PED):- Pre existing disease means any condition, ailments, injury or disease.

            (a) That is / are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or

            (b) For which medical advice or treatment was recommended by, or received from a physician within 48 months prior to the effective date of the policy or its reinstatement.

            (c) A condition for which any symptoms and or signs if presented and have resulted within 3 months of the issuance of the policy in a diagnostic illness or medical condition.”

10.       O.P. relies on Sub clause (c) of the definition. We can check whether the said clause applies to the case of the complainant’s wife.

                                    Proposal form was prepared and policy was issued on 16/3/2021. The complainant was admitted on 26/5/2021. Her pain started on 20/5/2021, ie.  two months and a couple of days post issuance of the policy.

                                    We therefore hold that the complainant was suffering from pre-existing disease as contemplated under the definition of Pre-existing disease in Clause 3.37(c) of the Terms and Conditions of policy. 

Issue No.2

11.       In view of the finding in Issue no. 1, we hold that there is no deficiency in service on the part of OPs.  

            Issue Nos. 3

12.       Resultantly, complainant is not entitled to any of the reliefs sought for.

            Issue Nos. 4

13.       As already stated supra in issue No.1 the opposite parties had made an observation that  the conditions suffered by the complainant is a non disclosed pre-existing disease. A perusal of the documents would show that the said conditions came to the attention of the complainants only after the date of inception of policy.  Therefore, based on the available evidence before us, the OPs are hereby directed to refrain from initiating or resorting to any proceedings that might even distantly indicate that such non-disclosure was a conscious act or conduct on the part of the complainant to avail unfair advantage or illegal benefit from the opposite party. 

14.       With the above direction, the complaint is dismissed.

Pronounced in open court on this the 20^th   day of  November,  2023.        

                                                                              Sd/-                                                                                                   

                                                                                             Vinay Menon V

                                                      President

                                                             Sd/-

   Vidya.A

                       Member        

         Sd/-                                                                   Krishnankutty N.K.

                                                                                                      Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1   -   Copy of Policy certificate bearing No.P./181214/01/2021/014224   

Ext.A2  –  Copy of collection receipt dated 16/3/2021  

Ext.A3   - Copy of discharge summary dated 31/5/2021

Ext.A4  -  Copy of discharge bill dated 31/5/2021   

Ext.A5  –  Copy of   certificate dated 24/9/2021

Ext.A6 – Copy of adhoc PTCA report dated 26/5/2021

Ext.A7 –Copy of coronary angiogram  report dated 26/5/2021

Ext.A8 – Copy  of letter of repudiation of claim dated 30/11/2021

Exhibits marked on the side of the opposite party:

Ext.B1 –   Copy of policy certificate alongwith terms and conditions

Ext.B2 –   Copy of proposal form

Ext.B3 –   Copy of Ext.A3

Ext.B4  –  Copy of Ext.8

Ext.B5  –  Copy of communication dated 22/12/2021

Court Exhibit:  Nil

Third party documents:  Nil

 Witness examined on the side of the complainant: Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.