DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  16^th  day of  August, 2023 

Present      :   Sri. Vinay Menon V., President

                   :   Smt. Vidya A., Member

                  :   Sri. Krishnankutty N.K., Member                               Date of Filing:  03/08/2021     

                                                                                  CC/118/2021

Nirmesh C.R.,

S/o. Late Radhakrishnan,

Chorakode Kalam,

Appalam, Peruvambu

Palakkad – 678 531                                          -                     Complainant

(Party in person)

                                                                                                Vs

1. Star Health & Allied Insurance Co. Ltd.

Sree Balaji Complex,

15, Whites Road, Chennai – 600 014

2. Radha Vijayaraghavan,

Grievance Redressal Officer,
Corporate Grievance Department,

Star Health & Allied Insurance Co. Ltd.,

5^th floor,  MKM Chambers, No.42,

Kodambakkam High Road,

Nungambakkam, Chennai – 600 034

3. The Branch Manager,

Branch Office,

Star Health & Allied Insurance Co. Ltd.

4^th Floor, Palakkad Fine Centre, 

TB Road, Palakkad – 678 014                   -                       Opposite parties  

       (OPs by Adv. M/s. P.Ratnavally  &  Kiran R. Raj A.)

O R D E R

By  Sri. Vinay Menon V., President  

1. In a nutshell, complaint pleadings are that complainant is a beneficiary of a Family Health Optima Insurance Plan floated by the opposite party Insurance Company. During the subsistence of coverage of the policy he was identified to be suffering with ‘Cervical Disc Prolapse’.  The opposite party failed to indemnify the complainant for the amount expended by him and also rejected his claim for cashless treatment.  This is the cause of this complaint.
2. Opposite party filed version admitting the subsistence of policy as well as subsequent hospitalization. But the claim of the complainant  was rejected as the condition suffered by the complainant came under exclusion clause 3(2)(A) and 3(2) (F)(a)(d) of the policy terms and conditions wherein treatment arising out of any disease pertaining to tendon, ligament, fascia, bones and joints etc,. were excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with the company. They sought for dismissal of the complaint as the complainant suffered his condition within the two years waiting period.
3.  The following issues were framed for consideration:

1. Whether the condition suffered by the complainant falls under the exclusion clauses of policy document?
2. Whether there is any deficiency in service / unfair trade practice on the part of OP in repudiating the claim?
3. Whether the complainant is entitled to any reliefs sought for?
4. Any other reliefs?

4.         (i)         Complainant filed proof affidavit and marked Ext.A1 to A7. Marking of all             documents were objected to on the ground they are photocopies. Since this Commission is not bound by Indian Evidence Act and in the absence of any claim         that the said documents are fabricated, this objection is overruled.

(ii)        OP filed proof affidavit and marked  Exts. B1 to B6. 

Issue No. 1

5.         Admitted case of the parties is that the complainant was suffering from cervical disc prolapse. He was hospitalized from 7/4/2021 to 12/4/2021. Opposite  parties submitted that claim of the complainant was rejected as the conditions underwent by the complainant  was excluded for a period of 24 months until the expiry of 24 months of continuous coverage after date of inception of the first policy with the company.

6.         In order to ascertain whether the condition of the complainant was within 24 months from the date of inception of the first policy relevant dates are to be considered:

            A perusal of the dates in the schedule above, as availed from the pleadings and documents of the complainant, reveal that the complainant was hospitalized for his treatment within 13 months after the inception of 1^st policy.

7.         Ext.B1 is the entire policy document with regard to the policy issued to the complainant. Page 7 of the said document contains the Exclusion Clause. The relevant exclusion clause is reproduced herein below:

            “3. EXCLUSIONS:

            (2) Specified disease / procedure waiting period :

                 (A) Expenses related to the treatment of the following listed Conditions, surgeries /    treatments shall be excluded until the expiry of 24 months of continuous      coverage after the date of inception of the first policy with us. This exclusion shall not be applicable to claim arising due to accident.

                (F) : List of specific diseases / procedures : 

                        (a) Treatment of cataract and diseases ………………… Prolapse of Intervertebral             Disc (Other than caused by accident), ………………………..

                        (d) All treatments (Conservative, Operative treatment) and all types of                        intervention of Diseases related to Tendon, Ligament, Fascia, Bones and Joint             including Arthroscopy and Arthroplasty /  Joint replacement (other than                caused by accident)”

            Thus we can see that the treatments arising out of disc prolapse is excluded for a period of 24 months from the date of inception of the 1^st policy.        

8.         Thus we can see that the condition suffered by the complainant falls under the Exclusion Clause of policy document.     

Issue No. 2  

9.         Resultantly, we hold that there is no deficiency in service or unfair trade practice on the part of the opposite parties.

            Issue Nos. 3 & 4 

10.       Pursuant to the findings above we hold that the complainant is not entitled to any of the reliefs sought for.

11.       Considering the facts and circumstances of the case, parties are directed to suffer their respective costs.

12.       With the aforesaid findings and orders, we dismiss the complaint.

                  Pronounced in open court on this the 16^th  day of August,  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 schedule

Ext.A2 –  Copy of rejection of authorisation for cashless treatment

Ext.A3 –  Copy of report of MRI (Whole Spine)

Ext.A4 –   Copy of discharge prescription

Ext.A5(a) – Copy of receipt bearing No.W21005036 dtd.12/4/2021

Ext.A5(b) – Copy of bill No.X21002198 dtd.12/4/2021

Ext.A5 (c) - Copy of bill No.CS2101803  dtd.12/4/2021

 Ext.A5 (d) - Copy of bill No.CS21CD00004206  dtd.12/4/2021

 Ext.A6 – Copy of Hospital bill bearing No.EIP-21-61 dtd.27/4/21

Ext.A7 – Coy of discharge summary

 Exhibits marked on the side of the opposite party:

Ext.B1 – Copy of policy documents

Ext.B2 – Copy of request for cashless hospitalisation   

Ext.B3 –  Copy of query on authorisation for cashless treatment 

Ext.B4 –  Copy of treatment records issued from PSG Hospital

Ext.B5 -  Copy  of screen shot of MRI Report 

Ext.B6 –  Copy of rejection of authorisation for cashless treatment

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.