Kerala

Thiruvananthapuram

CC/13/193

J SOPHIA - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE CO LTD - Opp.Party(s)

07 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD : THIRUVANANTHAPURAM

 

PRESENT

 

                                  SRI.P.V.JAYARAJAN         : PRESIDENT

SMT. PREETHA G. NAIR	:	MEMBER
SRI. VIJU  V.R.	:	MEMBER

                                               

C.C.No.193/2013     Filed on 18.05.2013

ORDER DATED: 07.10.2021

Complainant:

 

J. Sofia, W/o M. Ali residing at T.C.05/1687, A.S. Manzil, TRRA 54-A, Kaithavilakam Lane, Ambalamukku, Thiruvananthapuram

 

(by Adv. C. Suresh Kumar)

 

Opposite parties:

 

1.	Star Health & Allied Insurance Company Ltd., 1, New Tank Street, Vallulvar Kottam High Road, Nungambakkam, Chennai – 600 034 (represented by the Branch Manager the 2nd opposite party)
2.	The Branch Manager, The Star Health & Insurance Company Ltd.,T.C.05/99, 2nd Floor, Memana Building, Near Govt. H.S.S., Ambalamukku, Peroorkada, Thiruvananthapuram – 695 005

 

(by Adv. Mann Janarddanan Nair)

 

This C.C having been heard on 21.01.2020, the Forum on 15.07.2020 delivered the following:

ORDER

SRI. VIJU  V.R.,  MEMBER:

          The complainant has presented this complaint before this forum under section 12 of the Consumer Protection Act 1986, alleging that she took a health policy of Star Health & Allied Insurance Company with policy No.P/181118/01/2012/005368 valid from 14.02.2012 to midnight of 14.02.2013.  The insured sum is Rupees Two Lakhs.  The complainant is aged 35 years.  The complainant was admitted to Punarjani Super Speciality Hospital, AKG Nagar Road, Peroorkada, Thiruvananthapuram on 23.08.2012 and an emergency operation was performed on 24.08.2012.  The complainant was discharged on 27.08.2012.  Immediately on admission to the hospital, the Star Health & Allied Insurance Company Ltd. was informed by the complainant and the opposite parties were issued a claim number No.CL1/2013/181118/077282 in the name of the complainant.  The complainant submitted to the opposite parties all the relevant records and hospital bills pertaining to her treatment for an amount of Rs.55,000/-.  To the utter shock and dismay of the complainant all the documents submitted were returned to the complainant without effecting payment by the opposite parties.  The above action on the part of the opposite parties is a breach of contractual obligations and deficiency in service.  The complainant issued a legal notice to the opposite parties but there was no response from the side of opposite parties, hence this complaint.

          The opposite parties entered appearance and filed version.  The contentions raised by them are that there is neither breach of contractual obligations nor there was deficiency in the service on the part of the opposite parties.  There is no cause of action for the complaint as the case is coming under the exclusion clause which is well known to the complainant.  The complainant had taken Mediclassic Insurance Policy from the opposite party vide policy No.P/181118/01/2012/005368 for a sum insured of Rupees One Lakh during the period 14.02.2012 to 13.02.2013.  The complainant was admitted at Punarjani Super Speciality Hospital, Peroorkada on 23.08.2012 for the treatment of Adenomyosis, Fibroid uterus and underwent total Abdominal Hysterectomy (TAH) on 24.08.2012.  The complainant was discharged on 27.08.2012.  The complainant submitted completed claim form with medical bills and lab reports. 

             The treating doctor has clearly recorded in column no.6(a) of the Medical Certificate that the complainant was admitted for the complaints of severe bleeding and severe Dysmenorrhagia for which she underwent the surgery – Total Abdominal Hysterectomy.  In the discharge summary, the diagnosis shows Fibroid Uterus.  Fibroid Uterus is also designated as Fibromyoma of uterus.  The hospitalisation was mainly for Hysterectomy for Menorrhagia, the opposite parties rejected the claim based on Exclusion Clause No.3 of the policy (two year Exclusion).   Exclusion Clause No.3 of the policy states that “the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of during the first two years of continuous operation of insurance cover, the expenses of treatment of Cataract, Hysterectomy for Menorrhagia or Fibromyoma, Knee replacement surgery (other than caused by an accident), Prolapse of intervertibral disc (other than caused by an accident), Varicose veins and varicose ulcers.”  Hence the opposite parties rejected the claim based on Exclusion Clause No.3 of the policy (two year Exclusion) and informed the complainant on 10.11.2012.  The complainant kept silent with regard to her ailment and its treatment in the complaint deliberately.  The opposite party had sent a reply vide a registered letter to the legal notice on 06.04.2013.  The complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the opposite party with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDA functioning under Government of India. 

   Hence complaint may be dismissed and allow costs and compensation to the opposite parties and tender justice.

Issues to be ascertained:

1. Whether there is deficiency in service from the side of opposite parties    1 &2?
2. Whether the complainant is entitled to get the reliefs?

Issues (i) and (ii)

             The complainant has filed affidavit in lieu of chief examination and has produced 4 documents which were marked as Ext.P1 to P4.  The complainant was not cross examined.  The opposite parties filed affidavit in lieu of chief examination and the Chief Manager of opposite parties was examined as DW1.  The documents produced by the opposite parties were marked as D1 to D4(a).  Both the parties filed argument notes.  The complainant made an allegation that DW1 has no right to give deposition as there is no proper authorisation letter.  On going through Ext.D1, it can be seen that the Senior General Manager has given authorisation to the Assistant Manager, Legal.  So the authorisation can be considered and the deposition of DW1 can be taken into evidence.

              The complainant has not stated in his complaint nor in the affidavit in lieu of chief examination for what purpose she was admitted in the hospital.  From Ext.P4 it can be seen that the complainant was treated for Adenomyosis, Fibroid Uterus, Chocolate Cyst right ovary and the procedure conducted was TAH with BSO.  The allegations raised by the complainant is that the complainant was hospitalised for Adenomyosis and not for Menorrhagia.  Hence it will not come under the Exclusion Clause as stated by opposite parties.  It can be seen from Ext. P4 and Ext. D2 the complainant was diagonised with Adenomyosis, Fibroid Uterus, Chocolate Cyst right ovary and DUB.  The treatment given for the ailments of complainant was Total Abdominal Hysterectomy (TAH).

             The contention raised by opposite parties that Hystectomy for Menorrhagia or Fibromyoma comes under the Exclusion Clause and they are not bound to reimburse the medical expenses incurred by the complainant.  It can be clearly seen from Ext. P4 and Ext. D2 that the complainant was treated for Adenomyosis and not for Menorrhagia.  There is slight difference between Adenomyosis and Menorrhagia.  The Exclusion Clause excludes only for Hysterectomy for Menorrhagia or Fibromyomia and not for Adenomyosis.  The surgery was conducted for treating Adenomyosis and not for Menorrhagia.  So the opposite parties cannot evade from paying the medical reimbursement.

              Hence we find that the complainant has succeeded in proving her case.  The opposite parties 1 & 2 are jointly and severally liable to compensate the complainant.

             In the result the complaint is allowed.  The opposite parties 1 & 2 are jointly and severally directed to pay an amount of Rs.55,000/- (Rupess Fifty Five Thousand), pay Rs.15,000/- (Rupees Fifteen Thousand) as compensation to the complainant for the mental agony suffered by the complainant and Rs.2,500/- (Rupees Two thousand and five hundred) towards the cost of proceedings within one month from the date of receipt of this order failing which the amount except cost carries interest @ 9% per annum from the date of order till realisation.

  A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

   Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Commission, this the 7^th day of October, 2021.

P.V.JAYARAJAN	:	Sd/- PRESIDENT
PREETHA G. NAIR	:	Sd/- MEMBER
VIJU  V.R.	:	Sd/-  MEMBER

                   

SL

C.C.No.193/2013

APPENDIX

 

1. COMPLAINANT’S WITNESS

 

 

2. COMPLAINANT’S DOCUMENTS

 

		Copy of the policy schedule
		Copy of acknowledgment letter dated 07.02.2013
		Copy of bills (37 nos.)
		Copy of discharge summary

 

3. OPPOSITE PARTY’S WITNESS

 

Padmaprabha P.

 

4. OPPOSITE PARTY’S DOCUMENTS

 

		Copy of authorisation letter
		Copy of medical certificate
		Copy of letter of repudiation of claim
		Copy of policy schedule
		Copy of terms and conditions of the policy

 

5. COURT EXHIBITS

 

 

 

 

                                                                                                                Sd/          

PRESIDENT

 

 

SL