IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 22nd day of August, 2022.
Present: Sri. Manulal V.S. President
Sri. K.M. Anto, Member
C C No. 147/2021 (Filed on 13/08/2021)
Petitioner : Sneha Thomas,
D/o. Thomas,
Lavanya House,
Poovanthuruthu P.O.
Panachickadu village,
Kottayam – 686012.
(Adv. Akash K.R.)
Vs.
Opposite party : (1) Star Health and Allied Insurance
Company Ltd. Branch Office,
II Floor, Puthenpurackal Complex,
M.C. Road, Kodimatha, Kottayam
Pin – 686 013.
Rep. by its Branch Manager (2) Star Health and Allied Insurance
Company Ltd. Registered
and Corporate Office,
New Tank Street, Valluvar
Kottayam High Road,
Nungambakkam, Chennai
Pin – 600034.
Rep. by its Manager.
(For Op1 and 2, Adv. Avaneeh V.N.)
O R D E R
Sri. Manulal V.S. President
The complainant filed the complaint U/s 35 and 36 of the Consumer Protection Act, 2019.
Brief facts as stated in the complaint are that the complainant had purchased Mediclaim Classic Insurance Policy (Individual) from opposite party vide policy No.P/181113/01/2020/010118 by paying an amount of Rs.3869/-. The period of insurance was, from 29-02-2020 to 28-02-2021 and the sum assured was Rupees Two Lakhs. In the month of July 2020 the complainant identified a swelling in the lower inner quadrant of her left breast and was diagnosed with Fibro Adenoma Left breast at Mandiram Hospital, Kottayam. The complainant was admitted in the said hospital from 28-8-2020 to 30-8-2020 for the treatment of the same and as advised underwent Excision Fibro adenoma Left Breast. The complainant had spent Rs.40,844/- for the treatment. It was pleaded by the complainant that in spite of claim papers and bills, the insurance company had repudiated the claim of the complainant for the reason that as per waiting period clause no. IV(II)(B) of the policy the company is not liable to make any payment for treatment of Subcutaneous Bengin Lumps, Sebaceous Cyst, Dermiod Cyst, Mucous Cyst/lip/Cheek, Carpal Tunnel Syndrome, trigger Finger Lipoma, Neurofibroma, Fibroadenoma, Ganglion and similar pathology during the first two years of the policy. The opposite party has not disclosed any conditions, exclusions, waiting periods to the complainant. The repudiation of the genuine claim of the complainant is illegal. This act and conduct of the opposite parties amounts to deficiency in service.
Upon notice, opposite party appeared and filed written version as follows:
At the time of availing the policy the complainant was supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy schedule. In the light of terms and conditions of the medi claim policy in question, it was found that the claim was not payable as that the treatment for fibro adenoma is excluded for a period of first two years. Since the present illness falls within the two years exclusion clause, the opposite parties are not liable to consider the claim. .The Grievance department of the opposite parties had reviewed the claim and it was finalized that there was no need to alter the earlier decision thereby an email has sent to the complainant explaining the decision on 4-1-2020. It is submitted that the opposite parties had repudiated the claim based on two-year waiting period and not for suppression of any material fact. Hence, the complainant was not entitled to the relief claimed for.
Complainant tendered in evidence his affidavit along with documents i.e. Ex.A1 to Ex.A5.
Opposite Parties tendered in evidence affidavit of Padma Prabha, Legal Manager of the opposite party along with documents i.e. Ex.B1 to B5.
Points for consideration
1)Whether there is any deficiency in service on the part of the opposite parties?
2) If so what are the reliefs ?
We have heard the learned counsel for the parties and have carefully gone through the record on the file. Admittedly, the complainant has obtained the exhibit B1 policy bearing No. 233300/48/2016/4289 for himself, from the opposite parties for a period from 29-02-2020 to 28-02-2021 and the sum assured was Rupees Two Lakhs. The complainant identified a swelling in the lower inner quadrant of her left breast and was diagnosed with Fibro adenoma Left breast at Mandiram Hospital, Kottayam. It is proved by Exhibit A1 that the complainant was admitted in the said hospital from 28-8-2020 to 30-8-2020 for the treatment of the same and underwent Excision Fibro adenoma Left Breast. She remained admitted in the hospital from 12.05.2016 to 18.05.2016. The complainant spent Rs.40,844/- towards the treatment vide exhibit A2 receipt. The opposite parties repudiated the claim of the complainant vide Exhibit A3 dated 26-9-20 on the ground that the policy was in first year running and waiting for two years was required for Fibro adenoma Left breast and reimbursement cannot be provided as per waiting period clause IV(II)B of the terms and conditions of the policy. A perusal of Exhibit A3 which is a repudiation letter dated 26-9-20 written by the opposite parties to the complainant clearly states the denial clause and reason for repudiation of the claim which is done as per clause IV(II)B ) of the terms and conditions which envisage that during the period of insurance cover, the company is not liable to make any payment for treatment of Subcutaneous Bengin Lumps, Sebaceous Cyst, Dermiod Cyst, Mucous Cyst, lip/Cheek, Carpal Tunnel Syndrome, trigger Finger Lipoma, Neurofibroma, Fibroadenoma, Ganglion and similar pathology during the first two years of the policy.
The learned counsel for the complainant relied on the decision of Hon’ble supreme court which is reported in 2019 ICO 1334 (Bharath Watch company vs National Insurance Company). In that decision the Hon’ble apex court has held that the policy was not handed over to insured by insurer, then it is not open to
the insurer to rely upon the exclusionary clause. Now addressing the contentions of the complainant that the terms and conditions have not been supplied along with the policy by the said Insurance Company to the complainant. On perusal of exhibit B1 policy schedule we can see that it was clearly stated therein that “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached”. Thus if he terms and conditions are not provided to the complainant then she can approach the opposite party to provide the same after receiving the policy schedule either to supply the terms and conditions of the policy or to cancel the policy. Here in the case on hand, the complainant has no case that in spite of her request the opposite party did not serve the terms and conditions to her. In this regard, the Hon’ble Supreme Court has already decided that once the policy of insurance has been issued by the insurance company then the terms and conditions of the policy deemed to be sent to the complainant. It is a matter of fact that whenever any insurance policy is taken, it is an agreement between the insurer and the insured, which is signed by both the parties.
Therefore, the complainant cannot take the plea that he was not aware of the terms and conditions of the insurance policy and accordingly, this plea of the complainant does not find merit with us.
In the light of the terms and conditions of the mediclaim policy in question as stated above, we are also of the view that the claim was not payable as per waiting period clause IV(II)B). Even on perusal of claim documents it was found that the complainant was admitted with a case of fibrodenomea and that the inception of insurance policy from the opposite parties was from 29-02-2020 and accordingly the two years of waiting period is applicable as per the said clause of the insurance policy related to fibrodenomea. Subsequently, the claim was also denied as per Ex.A3, which is in accordance with the terms and conditions of the said mediclaim policy. It is a common knowledge that the contract of insurance is based on the principle of utmost good faith between the parties. If the insured has violated any of the exclusion clauses or any other terms and conditions of the policy, the insurance company has the right to repudiate the claim and cannot be held liable for the same. Accordingly, we are of the view that the complainant is
estopped by his own act and the repudiation of the claim by the opposite parties is justified in view of the observations and denial/exclusion clause stated above.
In view of the above discussions, the present complaint filed by the complainant before us stands dismissed.
Pronounced in the Open Commission on this the 22nd day of August, 2022
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of discharge summary issued by Mandiram Hospital
A2 – Copy of impatient receipt dtd.30-08-20 issued by Mandiram Hospital
A3 – Copy of repudiation claim letter issued by opposite party to complainant
A4 – Copy of letter dtd.17-10-2020 from petitioner to Grievance Redressal
Officer
A4(a) – Postal AD card
A4 (b) – Copy of postal receipt
A5 – Copy of Medical Certificate
Exhibits marked from the side of opposite party
B1 – Copy of insurance policy issued by opposite party
B2 – Duplicate copy of policy conditions
B3 – Copy of discharge summary dtd,30-08-2020 issued by Mandiram Hospital
B4 – Copy of repudiation claim letter dtd.26-09-2020
B5 – Copy of review replay mail
By Order
Assistant Registrar
