SMT. RAVI SUSHA: PRESIDENT

Complainant filed this complaint U/s 12 of Consumer Protection Act 1986 seeking to get an order directing opposite parties to pay Rs.1,50,000/- towards hospital expenses together with Rs.1,50,000/- as compensation for the deficiency in service by the insurance company.

            Brief facts of the complaint are that the complainant is a senior citizen, he had taken a health insurance policy namely Arogya Plus Policy from the SBI general Insurance company for himself and spouse for a floater sum Insured of Rs.3,00,000/-.  Further the policy was issued for the period of 08/02/2018 to 07/02/2019, under policy No.0000000008296070.  OP No.1 promised that if the complainant took this policy from him, he will be arranged reimbursement of all medical expenses spent by the complainant, admitted in hospital as inpatient.  He will get all benefits within 30 days from the date of join the policy.  He paid Rs.10,502/- to OP as policy premium.  The complainant admitted on 29/10/2018 at KMC Hospital, Manipal with disc problem and remitted Rs.1,28,882/- as treatment expenses. After this the complainant applies for the claim directly and through hospital. But OP rejected without any reasons.  The complainant sent a lawyer notice on 25/03/2019 to OP and received it. But OP did not give any reply.  The action of the OP in rejecting the claim of the complainant is unlawful and illegal. In fact the complainant was covered under this policy which was valid and in force during the hospitalization period.  The service procedure and treatment availed by him is a covered plan benefit. Denial of reimbursement by the OP has caused acute mental agony and distress to the complainant.  Therefore the OPs are liable to compensate for that aspect also.  Hence filed this complaint. 

            It was alleged by the OP Insurance company that as the claim of the complainant under the policy was for the ailment of vertebra-spinal disorders and surgery for intervetebral disc prolapsed which is per as an exclusion in the 1^st years of the policy.  Since the claim is squarely applicable against the named exclusion in the policy, it was rightly denied.  Further submitted that the complainant had taken a health insurance policy namely Arogya  Plus Policy from the OP for himself and spouse for a floater sum insured of Rs.3,00,000/-.  Further, the policy was issued for the period of 08/02/2018 to 07/02/2019, under policy No.0000000008296070, subject to policy terms and conditions.  That a claim was lodged in the above policy alleging hospitalization of complainant at KMC Hospital.  Further on receipt of the claim documents it was noted that ailment for which hospitalization claimed was ‘vertebro-spinal disorders and surgery for intervertebral disc prolapsed’.  However, the said ailment is specifically excluded in the policy for the 1^st year of coverage.  It is not in dispute that the policy is in the 1^st year of coverage and the policy is also well within the knowledge of the complainant.  Therefore the claim for the said ailment is not payable in this policy.  Hence, the OP is justified in repudiating the claim.  In this case the exclusions are clearly and expressly worded, and ailment is squarely hit by the said exclusion thereof.  Hence the policy does not underwrite the risk for the said ailment in the 1^st year of coverage.  Thus the clam was rightly repudiated.  It is submitted that the claim was repudiated as per the policy terms and condition, further the exclusion in the policy are clear and unambiguous.   Hence, the claim is not payable in the policy, thus repudiated.  Hence there is no deficiency in service or unfair trade practice as defined under the Consumer Protection Act of 1986 and prayed for the dismissal of complaint.

            Both parties led evidence.  From the complainant’s side, policy produced marked as Ext.A1, Lawyer notice Ext.A2, Acknowledgment card (Ext.A3), medical bills issued by Manipal hospital (Ext.A4 series).  From the side of OP policy wording marked as Ext.B1, Claim form Ext.B2.  After that the learned counsel of OP placed oral argument before us.  We have perused the available documents and considered the submissions of both parties.

            It is an admitted fact that complainant had taken SBI General’s Arogya plus Policy of OP.  It is also not in dispute that complainant had availed treatment from KMC hospital on 29/10/2018 and also the complainant has submitted claim form before OP for getting medical reimbursement of Rs.1,50,000/-.

            OPs contention is that the ailment for which hospitalization claimed was          vertebro-spinal disorders and surgery for intervertebral disc prolapsed, the said ailment is specifically excluded in the policy for the 1^st year of coverage.  For proving the contention, OP produced the policy conditions marked as Ext.B1 in which Annexure B exclusions (2) mentioned that during the 1^st  year of operation of the insurance coverage any medical expense incurred on surgery for prolapsed intervertebral disc unless arising from accident vertebro-spinal disorders (including disc) and knee conditions, exclusion will apply on the claim arising under hospitalization.  In Ext.A1 policy with conditions given to insured also mentioned in Exclusion clause V(2) Vetebro-spinal disorder is excluded for 1^st year of policy.  Here complainant produced discharge summary from KMC Hospital marked as Ext.A5.  On perusal ofExt.A5, the insured was admitted as IP on the above said hospital on 29/10/2018 and discharged on 05/11/2018.  Diagnosis was L5-siIVDP (intra Vertebral Disc prolapse) with Right LL Radiculopathy.

            It is seen that the said disease is rightly come under the exclusion clause.  Hence as per policy condition, policy does not under write the risk for the said ailment in the 1^st year of coverage.

            In this case it is pertinent to be noted that through Ext.B2, complainant has submitted claim form to OP.  But OP has neither repudiated the claim nor settled the claim.  During cross-examination of Pw1 the learned counsel for OP asked a question page നിങ്ങൾക്ക്‌ Repudiation letter തന്നിരുന്നൊ? അയച്ചുതന്നില്ല. വാക്കാൽ പറഞ്ഞതാണ്.  Here OP also not submitted repudiation letter before the commission.  Hence though the complainant availed treatment within one year of policy and the disease included in exclusion clause of policy, the non-intimation about the claim of insured by Insurance company amounts to deficiency in service on their part.  It cannot be said that the insurance company refused the claim of complainant.  Hence OP is entitled to pay compensation to the complainant for their deficiency in service.

            In the result complaint is allowed in part.  Opposite party is directed to pay Rs.25,000/- as compensation to the complainant for the deficiency of service on the part of OP in non-repudiating the claim form of the complainant .  Opposite parties are also directed to pay Rs.5000/- as cost to the proceedings of this complaint.  Opposite parties  shall comply the order within one month from the date of receipt of this order.  Failing which Rs.25,000/- carries interest @ 9% per annum from the date of order till realization.  Complainant is at liberty to file execution application against Opposite parties under the provisions of Consumer Protection Act 2019.

Exts.

A1- Policy

A2- Lawyer notice

A3- Acknowledgement card

A4(series)- Medical receipts issued by Manipal hospital

B1- Policy with terms and conditions

B2- Claim form

Pw1-Complainant

Dw1- Leo John-witness of OP

      Sd/                                                                          Sd/                                                     Sd/

PRESIDENT                                                                   MEMBER                                                   MEMBER

Ravi Susha                                                               Molykutty Mathew                                     Sajeesh K.P

(mnp)

/Forward by order/

                                                        Assistant Registrar