Smt. RENUKAMBA.C

      MEMBER

1.      The brief facts leading to this complaint may be summarized as under:

2.      The complainants had taken “Shravak Arogyam Star Health Policy, A group health along with his dependants 1) Bhavani M Shah, , (wife) (2) Dhruvi M Shah, (daughter) 3) Deepen M Shah, (son) 4) Fathechand G.Shand(Father) and 5) Mradula F Shah(Mother) in the year 2017. Complainant renewed the policy for another period from 31.03.2018 to 30.03.2019 for the sum of Rs. 5,00,000/- by paying a renewal premium 23,010/- under policy No.P/900000/01/20018/000012 through opposite party  No.1 to from opposite party no.2

3.    The complainant submits that when he claimed medical expenses incurred to an extent of Rs. 30,487/- on admitting his mother for the treatment of “Obesity OSA Hypertension Acos” from 09.08.2018 and discharged on 13.08.2018 from JSS hospital Mysore, the opposite party no.2 denied the same stating that as per exclusion No.13 of the policy. The company is not liable to pay any expenses of sleep apnea.

4.     The complainant submits that under policy clause no.6  pre-existing diseases are covered from day one and when such being the case availing of treatment repudiating the same under exclusion clause 13 is not proper and valid the eye of law.

5.     The complainant states that the act of the opposite party in repudiating the valid claim on baseless grounds amounts to deficiency in service. Therefore the complainant prays to direct opposite parties to  settle the entire  claim of Rs. 30,487/- along with interest at 18% pa the date of claim till the date of payment Rs. 25,000/- towards mental agony complainant indicates deficiency in service on the part of opposite parties. Hence complainant prays to allow the complaint.

6.      Version in brief the opposite party admits the facts that the complainant has availed group health insurance policy through Jain International Organization covering the complainant self, his wife Smt Bhavani M. Shah and daughter Ms Dhruvi M Sha, son Master Deepen M. Sha and parents by name Mr.Fatehchand G.Shah and Mrudula F.Shan for the floater sum insured of Rs, 5 Lakhs for the period covering from 31.03.2018 to 30.03.2019 the opposite party  also admits that the insured admit  on 09.08.2018 in JSS Hospital, Mysore and discharged on 13.08.2018. As per the discharged summary the insured patient was diagnosed for OBESITY OSA HYPERTENSION ACOS . The insured has submitted the claim documents for re-imbursement of medical expenses. On scrutiny of the claim documents it is observed that as per the discharge summary of the treating hospital, the present admission of the insured patient is primarily for obesity sleep apnea.

7.      Opposite parties denies that obesity osa hypertension Acos is covered under insurance. Opposite party submits that from the above finding it is noted that the present admission of the admission of the insured patient is primarily for obesity obstructive sleep apnea which is not payable as per exclusion no.13 of the policy which says that the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of expenses incurred on weight control services including surgical procedure of or treatment of obesity medical treatment for weight control treatment for genetic and endocrine disorders, treatment for sleep apnea. Hence the claim was repudiated and communicated to the insured through the letter dated 15.09.2018.

8. The opposite party submits that in sony cherian versus oriental insurance com. LTDLK 1999(6) SCC 451, the Hon’ble supreme court has held as follows the insurance policy between the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim any thing more that what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein.

9.      Opposite party submits that the complainant is aware of the terms and condition of the policy and upon issuance of an insurance policy the insurer under takes to indemnity the loss suffered by the insured on account of risks covered by the policy its terms have to be strictly construed to determine the extent of liability of insurer, Hence opposite prays to dismiss the complaint.

10.    The complainant filed his affidavit evidence with several documents marked as exhibits P1 to P5 and not filed the written arguments.

11.    Opposite party has filed his affidavit evidence with several documents marked as exhibits R1 to R4 .

12.   We have heard the arguments of both sides. Opposite party counsel has filed written arguments. Perused the records.

13.    Now, the points that arises for our consideration are as under:

1. Whether the complainant has proved that there is deficiency in service on the part of opposite party and complainant is entitled for reliefs sought?

2.What order?

14.   Our findings on the aforesaid points are as follows:

Point no.1:In the negative

Point no.2: As per final order

                                                                                ​REASONS

15.   Point No 1: The complainant is a member of Jain international Organization and admits that complainant had taken Shravak Arogyam Star Health policy, a group health insurance covering complainants family and himself. Opposite party admits the fact that complainant got renewed the policy by  paying a renewal premium Rs.23,010/- for a period from 31.03.2018 to 30.03.2019 for Rs. 5,00,000/- under policy no P/900000/01/2018/000012, complainant had taken this policy in 2017 and the same is valid for a period from 31.03.2018 to 30.03.2019. Opposite party also admit the fact that complainants mother was admitted to JSS hospital, Mysuru on 09.08.2018 and was diagnosed with obesity OSA hypertension  ACOS and got discharged on 13.08.2018, the total cost of the hospitalization was Rs.30,487/-which the complainant had claimed. The above facts are admitted has true by the opposite party and also by the complainant, therefore there is no necessity to prove the same.

16.      The opposite parties repudiated the claim stating that as per-exclusion no 13 of the policy the company is not liable to make any payment in respect of any expenses for the treatment of sleep apnea. But as per the documents submitted by the complainant, it is noticed that, in clause no.6 of the policy issued by opposite parties its clearly mentioned the coverage for pre-existing disease from day one, opposite party have not denied about clause no.6 of the policy in their version, but speaks only about exclusion no.13. Therefore, it is clear that, clause no.6 of the policy covers pre-existing disease from day one.

17.   The opposite party have not denied the fact that the complainant mother was admitted for  obesity OSA hypertension ACOS  and also admits JSS hospital diagnose as true. But opposite party only speaks only about obesity and its treatment not covered in their policy as per clause no.13, opposite party no where in their version speaks about sleep apnea   being covered or not in their policy. It is brought to the notice of the commission that, as per the doctor discharge summary issued by JSS hospital, the complainants mother was diagnosed with obesity OSA sleep apnea a deceased which caused by obesity complainants mother was admitted for complainant sleep apnea and not for obesity. Sleep apnea pre-existing decease which is covered under clause no.6 of the policy, which is not denied by the opposite party anywhere in its version. But as per the version of opposite party under exclusion clause 13 for obesity obstructive sleep apnea which is not payable under the terms and conditions of the policy. Therefore opposite party contends that it is not liable to make any payment under this policy in respect of any expenses incurred by the insured person and further contains that the insured taken treatment for obesity which  leads to sleep apnea which is not covered under the policy. Therefore it repudiate the claim of the complainant. The contention taken by opposite party is appears to be correct, accordingly the repudiation of the claim of the complainant made by opposite party is justified. Under such circumstances there is no deficiency in service on the part of opposite party. Therefore we are of the opinion that the complaint is liable to be dismissed. Hence we answer point no.1 in the negative.

18.    Point no 2:- From the discussion made above and conclusion arrived at, we pass the following order.

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                                            ​ORDER

                            The complaint is dismissed.

                             No order as to cost.

                             Furnish the copy of order to the complainant at   free of cost

(Dictated to the stenographer transcribed, typed by her ,corrected by us and then pronounced in open Commission on this the 21^th October 2020).