IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 16th day of November, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 268/2021 (Filed on 09/11/2021)
Petitioner : Saju Mathew,
Vellanchiyil Houe,
Kaipuzha P.O.
Kottayam – 686602
Vs.
Opposite parties : Mr. Sukesh P. Bhave,
Head, Accident and Health
Claiming, SBI General Insurance
Co. Ltd. Corporate & Registered
Office, Nutraj 301, Junction of Western Express, Highway Andheri, Kurla Road, Andheri East
Mumbai - 400069
(Adv. Agi Joseph)
O R D E R
Sri. K.M. Anto, Member
The complaint is filed under section 35 of the consumer protection Act 2019
The brief of the complainant’s case is as follows. The complainant is member of Arogya plus policy of SBI General Insurance Company. Due to Heart attack the complainant was admitted in caritas Hospital on 7.05.2021.The block was removed and a stent was placed. The Hospital issued a bill for Rs.161461/-When the bill amount was claimed the opposite party informed that there is a lock period of one year for this specified ailment.
The opposite party was approached to know the details of locking period for heart attack in the terms and conditions of the policy. No repay was received. The act of the opposite party is unfair trade practice and deficiency in service. Hence this complaint is filed for getting the Hospital Expenses and compensation for the sufferings.
On admission of the complaint copy of the complaint was duly served to the opposite party. The opposite party appeared and filed their version.
The version of the opposite party is that the complainant had taken the Arogya plus Policy from the opposite party with policy no.18962857 for the period 18/09/2020 to17/09/2021 subject to policy terms and conditions. A claim was lodged by the complainant for Hospitalization at Caritas Hospital, Kottayam from 7/05/2021 to 11/05.2021.
On the basis of Discharge summary issued by the Hospital the complainant was treated for coronary artery disease (CAD) a heart ailment and the procedure
underwent is Angioplasty. Under the policy conditions the heart ailment is named exclusion for the first year of coverage. The claim denial was in line with the policy. There is no deficiency in service or unfair trade practice on the part of the opposite party.
The complainant filed proof affidavit and marked Exhibits A1 to A3. The opposite party filed proof affidavit and marked Exhibits B1 to B4.
On the basis of the complaint, version of the opposite party and evidence adduced we would like to consider the following points
1) Whether there is unfair trade practice or deficiency in service on the part of the
opposite party?
2) If so what are the reliefs and costs?
Points 1 and 2
Ongoing through the complaint, proof affidavit of the complainant and evidence on record it is evident that the complainant had availed an Arogya plus Health Insurance Policy from the opposite party. The policy was for the period from 18/09/2020 to 17/09/2021 with policy no.0000000018962857.The complainant was admitted for treatment in Caritas Hospital, Kottayam on 07/05/2021 and was discharged on 11/05/2021.
From Ext A2 Discharge bill it is clear that the complainant was admitted in caritas Hospital on 07.05.2021 and was undergone Angiography and Angioplasty and was discharged on 11.05.2021.
As per Ext B1 policy schedule the date of inception of the policy is 18.09.2020 with period of insurance from 18.09.2020 to 17.09.2021.
Ext A3 is the terms and conditions of Arogya Plus policy issued by the opposite party. Clause V of Ext A3 is the Exclusions under the policy. As per this exclusion “Hypertension, Heart disease and related complications” were not covered during the first year of operation of the Insurance cover. But this exclusion would not be applicable in case of continuous renewal with grace period up to sum insured and/or limit under previous policy.
From the above findings it is clear that the complainant had undergone treatment for heart disease and related complications in the first year of operation of the policy cover. There is no claim on the part of the complainant that the policy is on continuous renewal during the claim period. The Repudiation letter as Ext A1 is as per the terms and conditions under the policy. There is no evidence to prove deficiency in service or unfair trade practice on the part of the opposite party. The complaint is liable to be dismissed. The complaint is dismissed.
Pronounced in the Open Commission on this the 16th day of November, 2022
Sri. K.M. Anto, Member Sd/-
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of letter dtd.08-10-2021 by SBI General Insurance to complainant
A2 – Copy of discharge bill dtd.11-05-21 by Caritas Hospital
A3-Copy of SBI Genral insurance (Arogya plus policy- terms and conditions)
A3(a) – Copy of details of policy coverage
Exhibits marked from the side of opposite party
B1 – Copy of letter dtd.18-09-20 with policy terms and condition
B2 – Copy of Re-imbursement claim form
B3- Copy of discharge summary from Caritas Hospital dtd.11-05-21
B4 – Copy of letter dtd.08-10-2021 from SBI Gen. Insurance to complainant
By Order
Assistant Registrar
