DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 22nd day of May, 2023
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member Date of Filing: 30/01/2021
CC/18/2021
Nisanath P.P.,
W/o. Jouhir Ubaid,
“Ecstasy”, Nhangattiri P.O.,
Pattambi, Palakkad. - Complainant
(By Adv. T.V. Pradeesh)
Vs
- M/s.Star Health & Allied Insurance Co.Ltd.,
No. 15, Sri. Balaji Complex, 1st Floor,
White Lane, Royapettah, Chennai.
2. M/s.Star Health & Allied Insurance Co.Ltd.,
Fourth Floor, Fine Centre, Shakunthala Jn.
T.B.Road, Palakkad – 678 014 - Opposite parties
(O.P.s by Adv. M/s. Ratnavally P. & Kiran G. Raj A.)
O R D E R
By Sri. Vinay Menon V., President
- Complaint allegations in a nut-shell are that the complainant is a beneficiary of a policy issued by the opposite parties. But the O.P. failed to provide cash-less benefit or honour a claim for indemnification of the treatment underwent by the complainant, which she was legally entitled to. Aggrieved thereby, this complaint is filed.
- The opposite party admitted complaint pleadings but claimed that the condition suffered by the complainant arose within 30 days of inception of the policy, which is contractually excluded. Thus they canvassed for dismissal of the complaint.
- The following issues arise for consideration:
- Whether the disease suffered by the complainant arose within the period of exclusion (Waiting Period) under the Policy schedule?
- Whether there is any deficiency in service or unfair trade practice on the part of the O.P.s?
4. Whether the complainant is entitled to any reliefs sought for?
5. Any other Reliefs?
4. (i) Evidence on the part of complainant comprised of proof affidavit and Exts. A1 to A4. Ext. A4 is a series of medical records.
Exts. A1 and A2 were objected to on the ground they were e-mail communications unaccompanied by S. 65B certification. Since this Commission is not bound by Indian Evidence Act and in the absence of a case on the part of the O.P. that the said document is forged or fabricated, the objection is overruled.
(ii) OPs also filed proof affidavit. Documents filed by opposite parties were marked as Ext.B1 to B5.
Issue No.1
5. As already stated supra, the ground for rejection of the complainant’s claim was that the complainant developed the disease during the first 30 days from the inception of the policy.
Ext. B1 is the Policy schedule. Part 3 of Ext. B1 relates to Waiting Periods. The 1st clause is as follows:
“1. Any disease contracted by the insured person during the first 30 days from the commencement of the policy.”
As per the aforesaid clause of Ext. B1, any disease that the complainant catches/contracts within a span of 30 days from the date of inception of the policy is excluded. Validity of this clause is not disputed by the complainant.
6. Inorder to adjudicate this issue, it is only necessary that this commission go through the dates that are relevant.
Srl. No. | Date | Particular | Remarks |
1. | 30.11.2019 | Inception of Policy | Not disputed |
2. | 30.12.2019 | First 30th day from policy inception | Cl. 1, Part 3 of Ext. B1 |
3. | 15.02.2020 | Radiology Report created(Ext. B7) | Clinical Information: complainant suffered from dizziness since 2 months. |
4. | 15.12.2019 | Date two months prior to 15.02.2020. | This date is within the 30 days period in row 2 |
7. Ext. B7 is a Radiology report of the MRI underwent by the complainant. This forms part of Ext. A4 series of documents also. Clinical Information in Ext. B7 shows that that the complainant had dizziness “since 2 months”. In the pleadings the complainant states that she answered 2 months to mean January.
Complainant herself is a doctor. She is not a layman when it comes to understanding the necessity of stating precise and accurate answers to queries put by treating doctors. We cannot accept that she was naïve enough to give a casual answer to a physical illness suffered by her. Further she also has no case that the said statement in Ext. B7 is a mistake on the part of the treating doctors or the technicians.
8. Thus we conclude that the disease started within the waiting period of 30 days from the inception of the policy.
Issue No.2
9. We hold that there is no deficiency in service or unfair trade practice on the part of the O.P.s.
Issue No.3 & 4
10. Resultantly, the complainant is not entitled to any of the reliefs sought for. In the facts and circumstances of the case, the parties are directed to suffer their respective costs.
11. With the above observations, this complaint is dismissed.
Pronounced in open court on this the 22nd day of May, 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 email communication dated 27/8/2020
Ext.A2 – Copy of email communication dated 12/9/2020
Ext.A3 – Copy of email communication dated 1/10/2020
Ext.A4series - A set of medical records of the treatment underwent by the complainant
Exhibits marked on the side of the opposite party:
Ext.B1 – Original Policy Schedule
Ext.B2 – Copy of request for cashless hospitalisation
Ext.B3 – Copy of query on authorisation for cashless treatment
Ext.B4 – Copy of communication dated 11/7/2020
Ext.B5 – Copy of denial of pre-authorisation request for cashless treatment
Ext.B6 – Copy of communication requiring additional documents and information
Ext.B7 – Copies of radiology reports
Ext.B8 – Copy of repudiation letter
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.
