BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Dated this the 21^st day of December 2013

Filed on :23/01/2012

PRESENT:

Shri. A. Rajesh, President.

Shri. Sheen Jose, Member.

Smt. Beena Kumari V.K. Member.

CC.47/2012

Between

Bejoy Francis : Complainant

Pattalath Valiyaveetil house, (By Adv. Alex Antony Sebastian,

Kattipurambu, Kannamaly P.O., 4^th Floor, Thuruthummel Buildings

Kochi. Market road, Kochi-682 018)

Vs

1. Star Health and Allied Insurance : Opposite parties

Co. Ltd., rep. by its Manager, (By Adv. T.J. Lakshmanan

1^st floor, Vijaya Plaza, Penta Queen,Panampilly Nagar,

SS Kovil road, Thampanoor, Cochin-24)

Thiruvananthapuram-695 001.

2. Star Health and Allied Insurance

Co. Ltd., Rep. by its Branch Manager,

219, 2^nd floor, Penta Tower Kaloor,

Kochi-682 017.

O R D E R

A Rajesh, President.

The case of the complainant is as follows:

The complainant availed himself of a family health optima Insurance policy from the opposite parties for the period from 13-08-2010 to 12-08-2011 and thereafter renewed from 13-08-2011 to 12-08-2012. The complainant had medical policy from United India Insurance company from

29-04-2009 to 28-04-2010 and extended from 29-04-2010 to 28-04-2011. On 20-05-2011 the complainant had to spend Rs. 25,147/- towards treatment expenses. The complainant duly submitted insurance claim application before the 1^st opposite party. The 1^st opposite party rejected the claim of the complainant by letter dated 15-07-2011 stating that the complainant’s insurance policy is not completed 1^st year. At the instance of the 2^nd opposite party he submitted another insurance claim application before them that too was rejected stating that the policy is not a renewal policy and it is considered as a fresh policy vide letter dated 08-11-2011. The complainant is entitled to get insurance claim with interest since he was holding valid insurance policy from 29-04-2009 onwards together with costs of the proceedings. This complaint hence.

2.The version of the opposite parties.

The opposite party had granted a fresh Family health optima Insurance Plan policy for the period from 13-08-2010 to 12-08-2011. The complainant had submitted a claim form in connection with his treatment at Lourde’s Hospital. As per Exclusion clause No. 4 in the policy during the 1^st year of operation of the insurance coverage the expenses on treatment of diseases such as hernia is not payable. So the claim of the complainant was repudiated by the opposite parties. The policy taken from the opposite parties are not the continued policy of United India Insurance Company Ltd. When the complainant holding 2 policies simultaneously the policy issued by the opposite parties can not be treated as a continuous one and the same has to be treated as a fresh policy. The united India Insurance company is a necessary party to the proceedings. The complainant is not entitled to get the reliefs as prayed for.

3. The complainant was examined as PW1 and Exts. A1 to A10 were marked. The witness for the opposite parties was examined as DW1 and Exts. X1 was marked on their side. Heard both sides.

4. The points that arose for consideration are as follows:

i. Whether the complainant is entitled to get the insurance claim from

the opposite parties?

ii. Whether the opposite parties are liable to pay the costs of the

proceedings to the complainant?

5. Point No. i. Admittedly the complainant was holding the following insurance policies.

6. The complainant had undergone treatment at Lourdes Hospital, Ernakulam from 19-05-2011 to 21-05-2011 for bilateral direct inguinal hernia evident from Ext. A4 discharge summary. The complainant had to incur treatment expenses as per Ext. A5 medical bills 14 in numbers. The opposite parties repudiated the insurance claim of the complainant vide Ext. A6 letter dated 15-07-2011 which reads as follows:

“First year exclusion:- During the first year of operation of the insurance cover the expenses on treatment of Benign Prostate Hypertrophy, Hernia, Hydrocele, Congenital Internal disease/defect, Fistula in anus, Piles, Sinusuitis and related disorders, gallstones and renal stone removal are not payable.”

7. At the instance of the complainant the opposite parties reconsidered the claim and again repudiated the claim of the complainant vide Ext. A7 letter dated 08-11-2011 which reads as under.

“We received your letter. Based on your letter, our claim review committee reopened and reviewed the claim. The committee made the following observations:-

* The insured had previous Universal Health Insurance policy with

United India Insurance for the period 29/04/2009 to 28/04/2010.

*It is further renewed for a period from 29/04/2010 to 28/04/2011.

*The insured had taken a fresh Family Health Optima policy with Star

Health Insurance for the period from 13/08/2010 to 12/08/2011,

parallel to Universal Health Insurance policy.

*Our policy is a not a renewal one. It can be considered as a fresh

One

* Moreover family health optima policy is a family floater cover with

entirely different coverage which is totally different from Universal

Health Insurance Scheme. So Family Health Optima policy can never

be considered for continuity with Universal Health Insurance Scheme.

*The present disease of hernia comes under first year exclusion clause

of the policy. Hence it is excluded.

In view of the above findings, it has been decided to repudiate the claim for the following reasons:-

*Exclusion Clause No. 4:- During the first year operation of insurance cover the expenses on treatment of diseases such as Benign Prostate Hypertrophy, Hernia, Hydrocele Congenital Internal disease/defect, fistula in anus, piles, sinusitis and related disorders gallstones and renal stone removal are not payable. If these diseases are pre-existing at the time of proposal, they will be covered subject to Exclusion No. 1 above”.

8. According to the opposite parties the complainant was holding Exbt. A2 and A3 policies issued by the United India Insurance Company till 28-04-2011. The opposite parties maintain that during the currency of Ext. A3 policy the complainant joined Exbt. A1 policy from 13-08-2010 to13-08-2011 and so Ext. A1 can only be treated as a fresh policy.

9. We are not to agree with the reasons stated in Exts. A6 and A7 letters to repudiate the insurance claim of the complainant especially when the complainant was holding a valid insurance policy of the United India Insurance Company a public undertaking for more than 2 years prior to his treatment at the Lourdes Hospital, Ernakulam. Evidently the policy of the complainant with the United India Insurance Company expired on 28-04-2011. The complainant had undergone treatment from 19-05-2011 to 21-05-2011. At the time of treatment the complainant was not holding Insurance policy of United India Insurance Company. Therefore the apprehension of the opposite parties that the complainant might have been reimbursed the treatment expenses from United India Insurance Company is out of question especially when the complainant has produced Ext. A5 series original bills in this forum. Moreover potability of health insurance policy is permitted as per the guide line and circular issued by Insurance Regulatory and Development Authority (vide Ref. IRDA/HLT/MISC/CRI/209/09/2011 dated 09/08/2011 and Ref. IRDA/HLT/MISC/CIR/030/02/2011 dated 10-02-2011 respectively )

10. In all respects the repudiation of the Insurance claim of the complainants amounts to deficiency in service on the part of the opposite parties. The opposite parties are to pay the Insurance claim as per Ext. A5 series to the complainant with interest @ 12% p.a. from the date of complaint till realization.

11. Point No.i i. Legally the complainant was within limits in raising this claim which has been substantiated. But the very fact that he had to approach this Forum to redress his grievances which could easily have been remedied by the opposite parties in the first place has put him to unnecessary vexatious an award of Rs. 1,000/- as costs of the proceedings would adequately suffice.

12.. In the result, we partly allow the complaint and direct as follows:

i. the opposite parties shall jointly and severally pay the amount to the complainant as per Ext. A5 series medical bills 14 in number to the complainant being the insurance claim with interest @ 12% p.a. from the date of complaint till realization.

ii. The opposite parties shall jointly and severally also pay Rs. 1,000/- to the complainant towards costs of the proceedings.

The above said order shall be complied with within a period of 30 days from the date of receipt of a copy of this order.

Pronounced in the open Forum on this the 21^st day of December 2013.

Sd/-A. Rajesh, President.

Sd/- Sheen Jose, Member.

Sd/-Beena Kumari V.K., Member.

Forwarded/By Order,

Senior Superintendent.

Appendix

Complainant’s exhibits :

Ext. A1 :Star Health and Allied Insurance

Company Ltd.,

A2 : Copy of schedule dt. 28-04-2008

A3 : Copy of schedule dt. 28-04-2011

A4 : Copy of discharge summary

A5 series : Copies of bills (15 nos.)

A6 : Claim repudiation letter dt. 15-07-2011

A7 : Copy of letter dt. 08-11-2011

A8 : Lawyer notice dt. 07-12-2011

A9 : A.D card

A10 : Postal receipt.

Opposite party’s exhibits: : Nil

Deposition s

PW1 : Bejoy Francis

DW1 : Dr. Santhosh John Abraham