Karnataka

Bangalore 4th Additional

CC/1883/2018

Mrs. Sujatha.S, - Complainant(s)

Versus

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

18 Jan 2019

ORDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORDER

 

Under section 12 (3) of Consumer Protection Act. 1986.

 

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

 

            1.        The Complainant prays for direction against the Ops 1 & 2 Star Health and Allied Insurance Company Ltd., to pay the claimed amount of Rs.3,84,337/- with total damages of Rs.1,10,000/- and interest.

 

            2.        The Complainant aged 60 years got mediclassic insurance policy through S.S.Prasad, her brother-in-law/Proposer for the period of 2 years ending on 28.2.2018 as per Annexure-A policy copy.

 

            3.        The Complainant was admitted to Apollo Hospital on 3.9.2017 and got the replacement of the right knee through surgery at the cost of Rs.3,78,864/- and took further treatment till 13.9.2017as supported by Annexures B & C copies of discharge summary and medical bills.

            4.        When she submitted the claim form, the Ops repudiated her claim through additional letter Annexure-E, with observation that their senior medical panel by revisiting and reviewing the claim records observed that cashless benefit requisition did not mention any history of trauma and X-ray also shows no evidence of fracture and thereby as per Exclusion 3 of the policy, the said claim filed within 2 years of the continuous operation of the insurance cover, cannot be considered.

            5.        The Complainant approached the Ombudsman against this repudiation letter and got the order dt.26.9.2018 wherein also the repudiation letter dt.27.10.2018 on the ground of claim falling within waiting period was upheld with the following observation:

18 (b): The Discharge Summary confirmed that the insured patient was diagnosed as Osteoarthritis Right Knee. X-ray and report did not show any evidence of fracture. It showed that medical joint space reduction present, subchondral sclerosis and osteophytes present which showed that it was a clear case of osteoarthritis knee and fell under exclusion clause No.3 (e) of the policy which reads as “ A waiting period of 24 consecutive months of continuous coverage from the inception of the policy will apply to the following specified ailments/illness/diseases: All types of treatment for Degenerative disc and Vertibral diseases including Replacement of bones and joints and degenerative diseases of the musculoskeletal system”

           

21.3.2:  It is noted from the findings of X-ray Right Knee AP & Lat view report dt.10.7.2017 that (1) Evidence of asymmetrical joint space reduction is seen. (2) Marginal osteophytes are seen around the knee. (3) Similar changes also seen in patella femoral joint and (4) No definite radiodense loose bodies identified. The impression provided was ‘Features suggestive of Right Knee Osteoarthritis’. No effect of fall is mentioned in the said report.

21.3.3:  It is noted from the X-ray report of both lower limb standing-AP view dt.3.9.2017, as an inpatient in the hospital that (1) Osteoarthritis seen in both knee. (2) Both hip and ankle joints are normal. (3) Varus deformity noted in both knee. In this x-ray report also, there is no mention of effects of fall.

21.3.4:  It is noted that the details of fall of the insured patient are not recorded in any of the discharge summary.

21.4:      On verifying Dr.Sanjay Pai’s (treating doctor) indoor case papers dt.10.7.2017, no details of fall are recorded. On verification of said doctor’s certificate dt.28.8.2017 with the indoor case papers dt.10.7.2017, 25.7.2017 and 21.8.2017 of the same doctor, it is found that the handwriting and signature of the doctor differs.

21.4.1:   Under the circumstances, the Forum is constrained not to take cognizance of the said doctor’s certificate. Therefore, there is no record which confirms the said alleged fall (accident)

21.5          It is noted from the doctor’s certificate dt.28.8.2017 that ‘She had an injury on 16.7.2017 following which knee pain worsened. Thus, the said alleged did not cause breaking/injury to bone/knee necessitating the knee replacement. Infact the reports indicate that the patient was suffering ‘Osteoarthritis Right Knee’, which led to her surgery of knee replacement which has a waiting period of 2 years under the policy.

21.5.1.      The treatment provided is for ‘Degenerative disease’ which falls under exclusion 3 (f) of the policy. Further, joint replacements are not allowed as per exclusion 3 (e) of the policy. Hence, the claim is not admissible.

 

6.    Annexures B,C,D,E relied on by the Complainant as observed by the Ombudsman also do not show the alleged fall of the Complainant from the staircase which caused the alleged grievous injuries to right knee. Whether the alleged injury and treatment was on account of accidental fall on that day is not the subject matter of this Consumer Forum to determine. The contents of all the produced documents go against the complainant’s case. Such being the case, there is no need to summon the Ops to seek their explanation. The Complainant utmost can agitate their right before the proper competent Civil Court, but becomes not maintainable before Consumer Forum. Thereby, the complaint is rejected u/s 12 (3) of the CP Act.

 

 

(ROOPA.N.R)          MEMBER

(VASANTHKUMAR.H.Y)  PRESIDENT