Karnataka

Kolar

CC/8/2023

Lavanya.K.C - Complainant(s)

Versus

Star Health And Allied Insurance Company Co Ltd - Opp.Party(s)

28 Jul 2023

ORDER

Date of Filing: 07/03/2023

Date of Order: 28/07/2023

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, OLD D.C. OFFICE PREMISES, KOLAR – 563 101.

 

Dated:28^thDAY OF JULY 2023

SRI. SYED ANSER KALEEM, B.Sc., B.Ed., LL.B., …… PRESIDENT

SMT. SAVITHA AIRANI, B.A.L., LL.M., …..LADY MEMBER

CONSUMER COMPLAINT NO:08/2023

Smt. Lavanya. K.C

W/o. Murali. K

#356, Kanakadasa Road,

Ramaswamy playa,

Maruthi Sewa Nagara (P) Bengaluru-33,

R/at. #1446 Kurubarapete,

Near Gangamma temple,

Kolar.

(Rep. by Sri. Renuka Devi. N, Advocate)                 ….  Complainant.

 

                                                                                                                - V/s –

Star Health and Allied Insurance Co.Ltd.,

2^nd and 3^rd Floor,(above IDBI Bank),

#184/82 Dr. Rajkumar Road,

Joganahalli,

2^nd Block Rajaji Nagar,

Bengaluru-560010.

(Rep. by Sri. G.R. Ramachandra Murthi, Advocate)  ….Opposite Parties.

 

 

 

-: ORDER:-

BY SRI. SYED ANSER KALEEM, PRESIDENT

1)     That the complainant has filed this complaint U/s 35 of the C.P Act 2019 against the Op and pray to direct the OP to pay a sum of Rs.3,00,000/- towards medical expenses incurred as per the insurance coverage and to pay Rs.30,000/- for suffering mental agony also to pay Rs.30,000/- towards the cost of the proceedings along with the interest @12%p.a. 

2)     The brief facts of the complaint is that, the complainant husband K. Murali had obtained Family Health Optima Insurance plan bearing policy No. P/700019/01/0203/000506 from the OP insurance company that is Star Health and Allied Insurance Co. Ltd.  It is stated that, the validity of the said insurance policy is for the period from 28.04.2022 to 27.04.2023 and the sum assured  for Rs.5,00,000/-.  The complainant’s husband had regularly paid premium amount of Rs.13,252/-. Further stated that, the complainant was hale and healthy at the time of obtaining the insurance policy.  It is stated that the  complainant on 26.11.2022 accidently fell down in her home and she had taken to the hospital for treatment at ALTOR hospital Bangalore.  Further stated that, in order to treat the complainant as per the advice of the doctor, complainant took MRI scan, X-ray and also advice to undergo L+Knee operation at Bangalore hospital.  Whereas the complainant for her convenience opted to undergo surgery at Gaurav Orthopedic and Surgical Hospital at Kolar and accordingly on 12.12.2022 she had undergone surgery for her L+Knee operation and taken the suitable treatment and thereby she had incurred medical expenditure.   

3)     Further stated that, subsequent to surgery complainant was approached to the insurance company and to claim the insurance amount as she was incurred towards medical expenditure, but the OP informed the complainant through e-mail and ask her to visit the OP office directly after discharging from the hospital.  It is stated that as per the information from the Op insurance company and  after discharging from the hospital she was approached to the OP and submitted all the necessary documents in order to claim the insurance amount.  Ultimately OP insurance company repudiated the claim, on the ground that, she had a pre-existing disease.  Hence this complaint.

4)     On issuance of notice, OP appeared through its counsel and filed its version.  In the version it is contended that, OP denied the cashless treatment to the complainant and she failure to submit the required documents. Further contended that, the despite the request to produce the required documents, but complainant did not submit the documents asked by the Op, then Op without any other alternative option denied the cashless treatment and also for reimbursement.

5)     Further contended that, that the complainant though having an option extended to approach grievance department and also insurance ombudsman and without exhausting the above remedies the complainant has directly approached this commission.  Op also contended that, they were mailed to the complainant about her pre-existing disease, even if it is found that, the claim made by the complainant is for non disclosure of material facts/pre-existing disease and hence OP Insurance Company repudiate the claim.  Further, OP denies all the allegation of the complainant and ultimately on the above said grounds OP prays to dismiss the complaint.           

6)   In order to prove the case of the parties and both the parties filed their affidavit evidence along with documents.

7)     On the basis of the pleadings of the parties, the following points will do arise for our consideration.

 

1. ) Whether the complainant proves deficiency in service on the part of the OP Insurance Company?

2)  Whether the complainant is entitled for the relief as sought in the complaint?

3)  What Order?

8)    Heard the arguments of the both the parties, perused the evidence placed on record.  Our answers to the above points are as follows.

POINT NO. (1):-  In the Affirmative.

POINT NO. (2):-  In the Affirmative.

POINT NO. (3):- As per the final order for the following.

 

                                    REASONS

9) POINT No. (1):-  On perusal of the pleadings of the parties, it is an undisputed fact that, the complainant husband Mr.K. Murali had obtained family Health Optima insurance policy from the OP insurance company i.e., Star Health and Allied Insurance Co.Ltd., on 28/04/2022 bearing Policy No: P/700019/01/2023/000506 and the validity of the said insurance policy is for the period from 28.04.2022 to 27.04.2023 and the sum assured for Rs.5,00,000/- and complainant paid premium of Rs 13,252/-.  

10)   The complainant is the wife of Mr.K. Murali  herselg and other family members were are also covered under the above said health insurance policy. It is the allegation of the complainant that, when the accident occurred and when she had taken the treatment and the said insurance policy is in force. 

11)   The crux of the matter is consider that, whether Ops placed any cogent evidence on record to demonstrate that, the complainant covered under policy in question had pre-existing decease and the same is related to the alleged L+knee surgery ?

12)   In order to substantiate the case of the complainant produced the medical records as part of her evidence. On Perusal of document No. C-9, it discloses that, on 12/12/2022 complainant was admitted to the Sri Gaurav orthopedic and Surgical  Hospital and undergone knee surgery and discharge from the hospital on 16-12-2022 and the said document also discloses that complainant had incurred expenditure of Rs.106,175. The annexed documents to C-9 document are the X-report, consultation record from the Bangalore hospital and these documents sufficiently proves that, complainant had a bone injury and also it clearly mentioned at page 25 of the document it reveals that self fall injury at home 2 weeks ago and initially treated at ALTOR HOSPITAL BANGALORE. Hence there is clear corroboration of the pleadings of the complainant and the records as well shown in the discharge summary. Under the circumstances we cannot disbelieve the case of the complainant in absence of any rebuttable evidence.

13)   Further on perusal of the insurance policy at ink page No. 4, it is evident that the complainant is also insured as detailed in the details of insured persons. Accordingly the conditions and privileges of the Health policy it covers the risks of the health of family members who had obtained the above said health insurance policy.

14)   The main allegation of the complainant is that, when she had approached the Op for claim of the above said insurance policy along with all the original documents which are asked by the Op, but the Op has failed to honor the claim of the complainant and finally repudiated claim on the ground of preexisting disease. It is worth note that, the Op failed to produce any authentic document to show that, the complainant had a pre existing disease and also failed to establish the nexus of the pre existing disease and the knee surgery; hence in absence of cogent evidence the contention raised by the Ops is not acceptable one. Under the circumstances, when the policy in force and when the complainant suffered fall injury and undergone surgery, incurred medical expenditure and as per the coverage of the policy, it is bouden duty of the insurer to settle the legitimate claim of the insured and not doing so, it is clear deficiency in service on the part of the Op. Accordingly we answered this Point No. (1) In the affirmative.

15)   POINT NO.(2):- On perusal of the document C-9 the expenditure bill generated by the concerned hospital and medical charges incurred by the complainant to extent of Rs.1,06,175.00. Further in addition to that above said amount of expenditure complainant also incurred other expenditures as per the additional bills filed that is exhibit C-1 to C-18, it is worth to note that, expenditure shown in the C-15 document is already generated in the bill that is C-9 document.  Further on carefully taking into consideration of above stated additional bills and it comes to Rs.11,773/- and in toto it comes to Rs.1,17,948/-.  Under the circumstances we deem it just and proper that, the complainant is only entitled to Rs.1,17,948/- towards medical expenditure incurred and the OP Insurance Company liable to pay the same.  Further due to non- honoring the legitimate claim of the complainant and the OP Insurance Company made the complainant to wander from pillar to post and it leads to filing of this complaint.  Further not settling the claim of the complainant well in time and thereon, complainant is entitled for interest @ 7.5% from the date of repudiation till the realization along with Rs.5,000/-towards the cost of the proceedings and the compensation.  Accordingly we answered the Point No. (2) In the affirmative.

16)   POINT NO. (3):-   on the basis of the discussion made above while assigning the reasons for Point No. (1)&(2) and answering thereon, we proceed to pass the following order.

ORDER

1. The complaint is hereby allowed in part with cost.
2. The Op Insurance Company is hereby directed to pay a sum of Rs. 1,17,948/-  to the complainant along with interest @ 7.5 % from the date of repudiation till its realization.   
3.  The OP Insurance Company is also directed to pay Rs. 2,000/- towards the cost of the proceedings.
4.  The OP Insurance Company is directed to submit compliance report within 45 days from the date of receipt of the order.
5. Send a copy of this order to both parties the proceedings at free of cost.

       (Dictated to the Stenographer, transcribed by him, corrected   and then pronounced by us on this 28^th DAY OF JULY 2023)

 

 

 

 

             LADY MEMBER                      PRESIDENT