DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 7th day of July, 2023
Present : Sri. Vinay Menon V., President
: Sri. Krishnankutty N.K., Member Date of Filing: 28/06/2021
CC/93/2021
Radakrishnan,
S/o.Velayudhan,
Yasodhalayam, Maniyampara,
Paruthippulli (PO), Alathur, Palakkad - Complainant
(By Adv. Sri. Shibu Shamsudeen)
Vs
M/s.Star Health & Allied Insurance Co. Ltd.,
No.63C3, 2nd Floor, NSR Road,
Saibaba Colony, Coimbatore - Opposite party
(O.P. by Adv. M/s P. Ratnavally & A. Kiran G. Raj)
O R D E R
By Sri. Vinay Menon V., President
- Complaint pleadings, abridged, are that the complainant and his wife were insured under a Health Insurance Policy issued by the opposite party Insurance Company. Both the complainant and his wife were healthy at the time of filing the proposal form. Complainant’s wife had to undergo treatment for Left L5-S1 neurogenic claudiation with recurrent lumbar canal stenosis. She had underwent treatment during 2011. O.P. repudiated the claim of the complainant on the ground of pre-existing disease. There is deficiency in service on the part of the opposite party and sought for claim amount along with compensation and incidental reliefs.
- O.P. filed version admitting the existence of policy, but defended repudiation on the ground that the complainant had not disclosed the fact that the complainant’s wife had underwent surgery 10 years back and the complainant would become entitled to benefits under the policy only after 48 months of continuous coverage has elapsed. Further the complainant has wilfully failed to answer correctly in the proposal form. Complainant’s wife had not underwent any medical checkup at the time of issuance of the policy as she was yet to complete 50 years when the proposal was submitted. Complainant is devoid of merits.
3. Hence to adjudicate the dispute, the following Issues are to be decided:
1. Whether the complainant is entitled to receive cashless treatment as per policy
terms and conditions.
2. Whether there is any deficiency in service on the part of opposite party ?
3. Whether the complainant is entitled to receive any of the reliefs sought for ?
4. Any other reliefs?
4. (i) Complainant filed proof affidavit and marked Exts. A1 to A11. Marking of Ext. A11 was objected to on the ground that it is a photocopy. Since this Commission is not bound by Indian Evidence Act and that the opposite party is not having a case that Ext.A11 is a forged or concocted document, this objection is overruled.
(ii) Opposite party filed proof affidavit and marked Exts. B1 to B7. Marking of documents were not objected.
Issue No. 1
5. Ext.B7 is a copy of the repudiation of claim. Reason for repudiation is that the condition suffered by the complainant’s wife was a pre-existing disease and therefore the OP was liable to effect payment for treatment of any pre-existing disease only after the expiry of 48 months. To adjudicate whether the repudiation was lawful, this Commission need only consider whether at the time of repudiation, whether the beneficiaries were covered for over 48 months.
6. (1) Ext. B2 is a copy of the Policy document. Part IV of Ext.B2 policy document deals with “Waiting Periods”. This section deals with diseases that would become covered under the policy after a stipulated period rather than out right coverage.
Clause III of Part IV (Waiting Periods) reads as follows:
“The Company shall not be liable to make any payment under this policy if the hospitalization is directly or indirectly for:-
III. Pre-existing diseases as defined in the policy until 48 consequent months of continuous coverage have elapsed since first inception of this policy”.
(2) Pre-existing disease is defined (under Definition Clause) to mean “any Condition ailment or injury or related condition(s) for which the insured person has signs or symptoms and / or was diagnosed, and or / received medical advice / treatment within 48 months prior to the insured person’s first policy with any Indian insurer”.
7. Ext.B5 is the medical records of the treatment underwent by the complainant for which this claim is raised.
The first page of Ext.B5 is the discharge summary issued from the Department of Neurosurgery.
Facing sheet of Discharge Summary shows that the compainant’s wife had underwent “Reexploration lower L3 limited laminectory and left L4, upper L5 laminectomy and dural sac decompression and foraminotomy”.
‘Findings’ in Ext. B5 (facing sheet) show that there was evidence of old laminectomy with interlaminar bony fusion of L3-L5 level.
On the 2nd face of discharge summary is the part dealing with ‘comment’. The treating doctor’s comment is as follows:
“Comment: This 51 year old female, old operated case of L4-L5 listhesis, underwent re-exploration lower L3 limited laminectomy and left L4, upper L5 laminectomy …………………… and merits regular follow up”.
The 3rd page of Ext.B5 is the cross consultation record. Reason for referral shows that the wife of complainant was operated in 2011 for L4 laminectomy and posterior fusion.
Thus it can be seen that the wife of complainant underwent treatment and surgery for laminectomy, same condition for which she was treated during 10/09/2020 till 18/09/2020.
8. Crux of the dispute that is to be adjudicated is the period that was completed after availing the policy.
Ext.B1 is the common proposal form dated 12/7/2018. Period of coverage at the first inception of policy is from 13/7/2018 to 12/7/2019. This policy was subsequently renewed. Policy that covers the relevant period is Ext.A1. The said policy covers a period from 13/7/2020 to 12/7/2021. Period of hospitalization was from 10/9/2020 to 18/9/2020. Starting from 13/7/2018, surgery occurred within 36 months from the date of 1st inception of the policy.
Thus wife of the complainant was hospitalized before the completion of 48 months period, and therefore within the Waiting Period as contemplated under Clause III of Part IV of Ext. B2 Policy conditions.
9. Thus we do not find any illegality or irregularity on the part of opposite party in repudiating the claim of the complainant. The complainant is not entitled to receive the expenses incurred.
Issue No. 2
10. Complainant filed argument notes along with a decision rendered by the Hon’ble High Court of Kerala in Mereeta Jesudas Vs. Religare Health Insurance Company Ltd. (W.P.(C) 7208/2021) reported as 2023(2) KLJ 394. Precedent they intend to high light is that the Insured was liable to disclose only an existing disease at the time of the issuance of the policy as held in paragraph 23 of the said decision. A point of law or a question of law need to be understood by reading of the entire decision and not some portion of a decision that befits ones requirement in exclusion of all other parts. On a complete reading of the said Judgment, it could be seen that what the Hon’ble High Court highlighted was that the life insured need to have knowledge of the existing disease at the time of submitting the proposal.
It is important to note that in the facts herein, policy was not repudiated on the basis of non-disclosure of material facts (eventhough the complainant had willfully not disclosed material facts as is evidenced by Ext. B1 proposal form), but on the ground that the surgery was within the Waiting Period of 48 months. Thus the aforesaid decision is not applicable to the facts and circumstances of the case.
11. Based on the discussions above, we hold that there is no deficiency in service on the part of the O.P. Accordingly this complaint is dismissed.
Issue Nos. 3 & 4
12. Resultantly, the complainant is not entitled to any of the reliefs sought for.
13. In the facts and circumstances of the case, parties are directed to suffer their respective costs.
Pronounced in open court on this the 7th day of July, 2023.
Sd/-
Vinay Menon V
President
Sd/- Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant :
Ext.A1 – Copy of Policy Schedule bearing policy No.P/121111/01/2020/002599
Ext.A2 – Copy of Email communication dated 15/6/2021
Ext.A3 – Copy of rejection of authorisation for cashless treatment dt.15/9/2020
Ext.A4 – Copy of discharge summary dated 18/9/2020
Ext.A5 – Copy of communication dated 15/9/2020
Ext.A6 – Original bill bearing No.14114 dated 21/8/2020
Ext.A7 – Original receipt dated 18/9/2020
Ext.A8 – Original imaging bill receipt dated 4/9/2020
Ext.A9 – Original IP bill (detail) dated 18/9/2020
Ext.A10 – Original dispense bill dated 18/9/2020
Ext.A11 – Copy of Policy Schedule bearing policy No.P/181214/01/2022/004477
Exhibits marked on the side of the opposite party:
Ext.B1 – Copy of common proposal form dated 12/9/2018
Ext.B2 – Copy of policy schedule alongwith terms and conditions.
Ext.B3 – Copy of request for cashless treatment
Ext.B4 – Copy of query on authorisation for cashless treatment.
Ext.B5 – Copy of treatment records of the wife o f complainant
Ext.B6 – Copy of rejection of authorisation
Ext.B7 – Copy of repudiation of claim
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.
