Karnataka

Kolar

CC/21/2023

Murali.K.Ramanujam - Complainant(s)

Versus

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

Sri.B.Kumar

28 Jul 2023

ORDER

Date of Filing: 16/03/2023

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:21/2023

 

Sri. Murali K. Ramanujam.

S/o. Ramanujam K.N.,

Aged about 58 years,

Door. No.196/2,

Varadaraja Swamy Temple Street,

Ammavaripet,

Kolar-563101.

(Rep. by Sri. B. Kumar, Advocate)                  ….  Complainant.

 

 

                                                                                                                - V/s –

 

M/s. Star Health and Allied Ins Co.Ltd,

Branch Office, 1^st Floor,

Kolar Nursing Home Building,

Antaragange Road,

Kolar-563101

(Rep. by Sri. G.R. Ramachandra Murthy, Advocate) ….Opposite Party.

 

 

 

-: ORDER:-

BY SRI. SYED ANSER KALEEM, PRESIDENT

1)     That the complaint has filed this complaint U/s 35 of the C.P Act 2019 against the OP alleging deficiency in service and praying for direction to the OP to pay a sum of Rs.69,404/- towards the medical expenses incurred along with compensation of Rs.25,000/- for suffering mental agony and to pay Rs.25,000/- towards cost of the proceedings along with interest @ 12% p.a. and other relief. 

2)     The brief fact of the complaint is that, the complainant had obtained the Health Insurance Policy bearing No.P/161130/01/2022/106448 from the OP Insurance Company and the validity of the policy for the period from 29.11.2021 to 28.11.2024.  It is stated that, complainant subsequently taken the top up policy to an extent of Rs.10,00,000/-.  

3)    Further complainant states that, during the month of February 2023 he was suffering from cough and chest discomfort and leads to shortness of breathe and thereby he was admitted to Vydehi Institute of Medical Science and Research Centre and took the treatment.  That the complainant stated that, for the above treatment he incurred medical expenditure of Rs.69,404/- and also incurred expenditure for the transportation.  It is stated that, the complainant was discharged from the Hospital on 27.02.2023 and thereafter, complainant in order to claim Insurance benefit and filed all the necessary papers to the OP Insurance Company, but the OP Insurance Company repudiated the claim of the complainant on the ground that complainant has made misrepresentation in securing the Insurance policy by not disclosing the pre-existing disease Lymphosarcoma since prior to inception of policy.  It is stated that, the complainant had under gone surgery about 40 to 45 years ago but the OP’s repudiated the claim.  Hence this complaint. 

 

 

4)   On issuance of notice, OP appeared through its counsel and filed their version.  In the version it is contended that, the policy was issued based on the details furnished by the complainant at the time of inception of policy and a pre look period of 15 days time was also extended to review the terms and conditions of the policy.  It is contended that, the complainant did not mentioned any pre medical history and pre-existing disease in the proposal form which amounts to misrepresentation and non disclosure of material facts.  It is contended that, the OP Company will issue policy to the persons having utmost good faith and beliefs.  Further contended that, the OP insurance company having team of Doctor’s and through their investigation and thereon repudiated the claim.  Further OP denies all the allegation of the complainant and ultimately on the above said grounds prays to dismiss the complaint.           

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

6)    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?

7)    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

8) POINT No. (1):-  On perusing the pleadings of the parties and the evidence placed on record it is not in dispute, that the complainant had obtained the Health Insurance Policy bearing No. P/161130/01/2022/106448 from the OP Insurance Company.  Further it is not in dispute that during the month of February 2023 that the complainant was admitted to Vydehi Institute of Medical Science and Research Centre for the treatment of cough and Chest discomfort which leads to shortness of breath.  Further it is not in dispute that the complainant for his treatment incurred medical expenditure to an extent of Rs.69,404/-.  It is also not in disputes subsequent to discharged from the Hospital that, the complainant was moved the claim papers to the OP Insurance Company and the OP Insurance Company repudiated the claim of the complainant on the ground that, the complainant by suppressing the pre existing disease and he had obtained the present policy in question. 

9)    On perusal of the affidavit evidence of the complainant and the complainant deposed all the facts in his evidence as replica of his pleadings.  On perusal of the patient discharge summary issued by the Vydehi Institute of Medical Science and Research Centre Bangalore, it reveals that, the complainant was admitted to the above Hospital on 23.02.2023 and discharged on 27.02.2023.  As per the history of illness, it discloses that, complainant/patient was apparently normal 5 months ago, then he developed exertional breathlessness which was insidious in onset and gradually progressed from breathlessness.  Further the report discloses that, no seasonal variation, No history of chest pain.  Further on perusing in-patient bill dated 28.02.2023, that the complainant was incurred medical expenditure of Rs.69,404/-.

10)    The crux of the matter is to consider, whether the OP Insurance Company is justified for repudiating the claim of the complainant?

11)     In order to falsify the case of the complainant and the OP filed evidence of the Manager of the OP Insurance Company, in the evidence deposed that, complainant was obtained the policy by non disclosure in the fact and failed to mentioned the previous medical history while obtaining the policy in question.  Hence OP contending justification for the repudiation on the ground of non disclosure of previous medical history.  It is worth to note that, on perusal of the Insurance Policy, it is evident that, the date of inception of the policy is on 29.11.2021 and it is a comprehensive policy and the period of policy is commencing from 29.11.2021 to 28.11.2024 and on perusal of the discharge summary that, the complainant was admitted on hospital on 23.02.2023 and he was discharged from the hospital 27.02.2023 and hence it is evident that, when the policy is in force that the complainant was admitted to the hospital for the treatment.  Further it is note worthy to mention that, though the OP’s contended that complainant by suppressing the earlier medical history got obtained the policy in question, whereas the OP failed to produce any piece of cogent evidence to establish that earlier treatment taken by the complainant is direct nexus with the present illness of the complainant for taking treatment at Vydehi Institute of Medical Science and Research Centre.  Hence in absence of the cogent evidence for disproving the case of the complainant we cannot accept the contentions of the OP raised in their evidence.  Further on perusing the decision of the Hon’ble Supreme Court through the extract of the Live Law produced by the OP with due respect to the decision rendered by the Hon’ble Supreme Court and the facts discussed in that case is quietly different from the evidence placed on record and hence the said decision will not comes to the aid of the OP.

12)     The object of the Insurance is to cover the risk of the insured; however it is true that, Insurance is a contract based on utmost faith.  Having faith on the Insurance Company and to meet the unforeseen incidents, injury or diseases and to overcome financial difficulties insured always resort to the Insurance policies.  Whereas the Insurance Company repudiated the claim on technical grounds.  On perusal of the Insurance policy it discloses that, the complainant paid Rs.92,487/- towards premium of the policy and since the year 2021 till obtaining treatment during the year 2023 that, the complainant duly renewed the policy and fairly claiming the medical expenditure incurred.  The non honoring of the claim without cogent evidence relating to suppression of material fact leads to deficiency in service on the part of the OP.  Accordingly we answered this Point No. (1) In the Affirmative.

13) POINT No.(2):-  On perusal of the medical records it discloses that,  the complainant was admitted to the Hospital on 23.02.2023 and was discharged from the Hospital on 27.02.2023 and incurred medical expenditure of Rs.69,404/-.  On perusal of the certificate Issued by Vydehi Institute of Medical Science and Research Centre dated: 28.02.2023 it is evident that, the complainant was undergone surgery about 40 to 45 years ago to which there is no documents or evidence and the present complaint has nothing to do with the past surgical history, this certificate of the treating Doctor is evident, that there is no nexus between the previous treatment taken by the complainant and to the subsequent treatment taken at the Vydehi Institute of Medical Science and Research Centre.  Moreover the OP failed to give any rebuttable evidence to disbelieve the complainant case.  Hence the complainant entitled for the medical expenditure incurred for the treatment.  In addition to the medical expenditure complainant also entitled for the interest @ 7.5% p.a from the date of repudiation till its realization of the amount to the complainant.  Further, due to act of the OP and it made the complainant to wander from pillar to post and hence complainant is entitled for the cost of the proceedings to an extent of Rs.5,000/-  Accordingly we answered this point No.(2) In the Affirmative.

14)  POINT NO. (3):-   On the basis of answering the Point No. (1) & (2) and the reasons assigned thereon, we proceed to pass the following.

ORDER

1. Complaint is hereby allowed with cost.
2. That the OP “M/s Star Health and Allied Insurance   Company Ltd”., Represented by its Manager is directed to pay a sum of Rs.69,404/- along with interest @ 7.5% p.a to the complainant from the date of repudiation till realization of the amount within 30 days from the date of Order.
3. That the OP Insurance Company is directed to pay Rs.5,000/- towards the cost of the proceedings.
4. That the OP Insurance Company is directed to submit the compliance report within 45 days from the date of Order.
5. Send a copy of this order to all the parties to 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