DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  10^th day of May, 2024

Present      :   Sri. Vinay Menon V., President

                    :   Smt. Vidya A., Member                        

                   :   Sri. Krishnankutty N.K., Member                               Date of Filing: 13/12/2022    

              CC/247/2022

P.K.Parameswaran,
            Pothampadam House,

Muthalamada (PO), Palakkad.                                               -           Complainant

(By Adv. J.Kamesh)

                                                                                      Vs

Star Health & Allied Insurance Company Ltd.,

1^st Floor, R.K. Building,

Opp. Chitturkavu, Palakkad Road,

Chittur, Palakkad                                                       -           Opposite parties

(O.P. by Adv. M/s. Ratnavally P. & Kiran G Raj A.)

O R D E R

By Sri. Vinay Menon V., President

1. Devoid elaboration complaint pleading are that the complainant had availed an Arogya Sanjeevani  Policy. During the subsistence of the said policy the complainant developed coronary artery disease and incurred huge expenses. Opposite party repudiated the claim of the complainant on the ground that the said condition was a direct complication of diabetes mellitus. Complainant had disclosed the existence of diabetes mellitus while preparing the proposal form. The repudiation is therefore illegal and the complainant sought for the expended amount together with compensation and other ancillary expenses.
2. Opposite party filed version admitting the complaint pleadings. They submitted that the complainant had disclosed the factum of diabetes mellitus. They further stated that the policy was issued under the condition that pre-existing diseases and its complications will be covered only after 48 months from the date of inception of first policy.
3. The following issues were framed.

1. Whether the conduct of OPs repudiating the claim of the complainant for acute coronary artery disease is justifiable?
2. Whether there is deficiency in service on the part of OP ?
3. Whether the complainant is entitled to the reliefs sought for?
4. Any other reliefs?

4.         (i)   Complainant filed proof affidavit and marked Exts.A1 to A3.        

            (ii)    Exts.B1 to B4 were marked on the part of OP.                     

(iii)   Doctor who treated the complainant was examined as CW1.

 Issue No.1

5. In order to answer this Issue, two question will have to be answered:

1. Whether the hospitalization was within the exclusion period?
2. Whether the condition suffered by the complainant was a direct complication of DM?

1.         Whether the hospitalization was within the exclusion period?

6. Complainant’s case is that he had availed the policy at the first instance during the year 2020. Thereafter it was renewed on 2021. It was during the subsistence of renewed policy that the complainant suffered cardiac issues and was hospitalized. OP stated that claim was rejected as there was an exclusion period of 48 months for DM and its direct complications since DM was a PED.
7. Ext.A2 is the policy covering the relevant period. On the facing sheet it is shown that diabetes mellitus and its complications are taken as Pre-existing disease.

Ext.B2 is the policy terms and conditions for Arogya Sanjeevani Policy.  Clause 5 in page 5 of Ext.B2 relates to Exclusion. Clause 5 (1) (a) reads as follows:

“Expenses related to the treatment of a PED and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the 1^st policy with the insurer”.

8.         Admittedly inception of the 1^st policy was on 30/11/2020. Complainant was hospitalized on 6/3/2022 ie.  after 16 months of the inception of policy.

9.         Thus, we find that hospitalisation was within exclusion period.

2.         Whether the condition suffered by the complainant was a direct complication of DM?

10.       The next question that needs to be ascertained is whether the cardiac condition suffered by the complainant was a direct complication of diabetes mellitus.

OP examined Dr. Muhammed Mazharudeen, who is an Associate Cardiologist in Sahakarana Hridayala Rajiv Gandhi Co-op. Hospital. He was one of the doctors who treated the complainant.  In his chief examination, he had stated that the patients with diabetic mellitus are more prone to develop cardio-vascular co-morbidities. Cardio-vascular disease, as per CW1, was one of the complications associated with diabetes mellitus.  Even though the deposition by CW1 illustrates a general scenario during chief examination, he nailed the case of the complainant while being cross examined by the complainant. In page 3, lines 4 to 8  CW1 deposed as herein below:

            “I have treated the complainant. As far as this patient is concerned whether DM is the only cause for coronary artery disease(Q). Yes.”

11.       Thus, deposition of the treating doctor shows that the condition suffered by the complainant is a direct consequence of diabetes mellitus.

12.       Having satisfied that both the elements required in answering the issue are in favour of the O.P., we hold that there is no illegality on the part of opposite party in repudiating the claim of the complainant.  

            Issue Nos. 2 to 4

13.       We hold that there is no deficiency in service on the part of the opposite party.

14.       Complainant is not entitled to any of the reliefs sought for.

15.       With the above findings, this complaint is dismissed.

16.       In the facts and circumstance of the case, parties are directed bear their respective costs.

                         Pronounced in open court on this the 10^th  day of May, 2024.        

                             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   - Original  policy certificate covering 30/11/2020 to 29/11/2021.

Ext.A2  –  Original policy certificate covering 30/11/2021 to 29/11/2022

Ext.A3 – Copy of repudiation of claim

Exhibits marked on the side of the opposite party:

Ext.B1   -  Copy  of proposal form

Ext.B2 – Copy of policy certificate alongwith terms and conditions.

Ext.B3 – Copy of discharge summary

Ext.B4 – 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:

CW1 – Dr. Muhammed Mazharudeen

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.