Kerala

StateCommission

A/16/289

THE MANAGER STAR HEALTH AND ALLIED INSURANCE COMPANY - Complainant(s)

Versus

T S BALAKRISHNAN - Opp.Party(s)

G.S KALKURA

27 Sep 2018

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION,  SISUVIHAR LANE VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL NO. 289/16

 

JUDGMENT DATED: 27.09.2018

 

(Appeal filed against the order in CC No.482/2015 on the file of

CDRF, Thrissur order dated 29.01.2016)

 

PRESENT:

 

HON’BLE JUSTICE SRI S.S. SATHEESACHANDRAN	:	PRESIDENT
SRI. T.S.P MOOSATH	:	JUDICIAL MEMBER
SRI. RANJIT. R	:	MEMBER

 

APPELLANT:

 

1.	The Manager, Star Health & Allied Insurance Co. Ltd., Ambika Arcade, M.G. Road, Thrissur.

 

(By Adv. Sri. G.S. Kalkura)

 

VS

 

RESPONDENTS:

 

1.	T.S. Balakrishnan, Thaivalappil House, Kanjani P.O., Thrissur.
2.	Seena Balakrishnan, W/o T.S. T.S. Balakrishnan, Thaivalappil House, Kanjani P.O., Thrissur.

 

(By Adv. Sri. Unnikrishnan V.)

 

 

 

 

JUDGEMENT

 

 

SRI. RANJIT R. :        MEMBER

 

 

            The appeal is filed by the opposite party against the Order dated 29.01.2016 in CC 482/15 the file of CDRF, Thrissur by which the forum allowed the complaint and directed the opposite party to pay Rs.1,58,105 with 10% interest to complainant from the date of the complaint.

          Brief facts of the complaint are that the complainants had taken a policy by name Family Health Optima Insurance Policy for the period from 20.11.14 to 19.11.15.  The 2^nd complainant had undergone treatment at Coimbatore Ganga Medical Centre and incurred a total expense of Rs.3,58,105/-.  As per the terms and conditions of the policy, the complainant is entitled to get full amount, but the opposite party allowed only Rupees Two Lakhs.  The denial of eligible amount was deficiency of service.  Hence she filed complaint for getting the balance amount. 

          The opposite parties were set exparte before the forum.

          Evidence consists of affidavit filed by the complainant and Exts. P1 to P5 marked on her side.   The lower forum on the basis of materials produced has found that the opposite party insurance company is liable to pay the expenses incurred by the complainant for the treatment which she had undergone, as per the terms of the Family interim order as indicated above. 

          Aggrieved by the order the opposite party insurance company has filed this appeal.

          Heard both parties.  Perused records.

          Admittedly the complainant took the policy during November 2008 and the sum insured was Rs.2,00,000/- (Rupees two lakhs).  Policy was renewed every year upto 2012 for the above sum from November 2013 the insurance policy was renewed with the sum insured was enhanced to Rupees three lakhs, as mentioned in Ext. P1. 

          The learned counsel for the appellant handed over to us specimen of the policy.  The appellant contented that as per Clause 9 of the terms and conditions of the policy, if the policy is renewed for enhanced sum, then for illness/disease contracted, the sum insured will be restricted to the previous sum insured where signs or symptoms of disease was originally diagnosed.  The complainant had contracted disease 3 years back and this fact is mentioned in Ext. P2 discharge summary.  The claim was made during March 2014 for Rs.3,58,105/- (Rupees Three lakhs fifty eight thousand one hundred and five).  As per the terms and conditions of the policy, since the insured had contacted the disease during the year 2012 and the sum insured in 2012 was only at Rs.2,00,000/- (Rupees two lakhs) claim of the complainant for treatment expense was limited to Rs.2,00,000/- (Rupees two lakhs and that amount was paid to the complainant.

          Clause 9 of the terms and conditions of the policy states that “if the policy is to be renewed or ported from other Indian insurance company for enhanced sum insured such enhanced sum insured will not be available for illness, disease, injury already contracted under the preceding policy periods.  Further, for illness/disease/sickness already contracted, the sum insured will be restricted to that policy sum insured when the signs or symptoms was diagnosed or received medical advice/treatment”.  To invoke Clause 9 of the policy the period at which the insured first contacted the signs or symptoms of the disease have to be proved.  In the discharge summary (Ext. P2), it is stated, the complainant was having pain in both knees since 3 years, difficulty in walking since 6 months.  She was suffering from bilateral Osteoarthritis and total knee replacement of both legs was done during April 2015.  From this it is clear that the insured was having signs or symptoms of Osteoarthritis only 6 months prior to the date of operation.

          It has to be examined whether the insured was having illness/disease of Osteoarthritis during 2012 i.e. before she enhanced the sum insured to Rs.3 lakhs, as contented by the opposite party.  From Ext. P2 discharge summary what is stated is that the complainant was having difficulty in walking since 6 months.  There is no evidence on record to show that the insured had taken medical treatment for Osteoarthritis or was admitted in any hospital during the period 2012, i.e., before the policy sum was enhanced to Rs.3 lakhs from Rs.2 lakhs.  Pain in both knees for 3 years stated in the discharge summary is not indicating that the patient was having Osteoarthritis at that time.  It cannot be stated that the insurer had contacted disease during the year 2012.  From Ext. P2 discharge summary it can be seen that the patient was suffering from symptoms of Osteoarthritis 6 months prior to the operation and not 3 years prior to operation.  During 2012, the insurer was having only pain in both knees.  Pain in knee cannot be attributed to that of Osteoarthritis.  Since the insured was not having signs or symptoms of illness during 2012.  We find that, the act of the opposite party in restricting the amount of treatment expense to Rupees two lakhs is per-se wrong and the reasons stated for the same are not acceptable.  The had signs or symptoms of Osteoarthritis only 6 months prior to the operation and at that time the sum insured sum was Rs.3,00,000/- (Rupees three lakhs), and, so the insurance company is liable to pay treatment expenses  up to Rs.3,00,000/- (Rupees three lakhs).

          In the light of the above discussion we hold that the insurance company is liable to pay an amount of Rs.3,00,000/- (Rupees three lakhs) towards treatment expenses of the complainant in the hospital.  The appellant has already paid Rupees two lakhs to the complainant and it is liable to pay the balance amount of Rs.1,00,000/- (Rupees one lakh) more to the complainant.

          The lower forum allowed the complaint on the basis of limit of coverage of policy fixed at Rs.3,75,000/-.  But since the sum insured is only Rs.3,00,000/- (Rupees three lakhs).   We modify the order limiting the sum payable as Three lakhs directing payment of the balance amount of Rs.1,00,000/- (Rupees One lakh) to the complainant.

          In the result the appeal is allowed in part as indicated above.

          Both parties to suffer their respective costs.

          Sum deposited to entertain the appeal is to be released to appellant on its application.

 

JUSTICE  S.S. SATHEESACHANDRAN	:	PRESIDENT
T.S.P MOOSATH	:	JUDICIAL MEMBER
RANJIT. R	:	MEMBER

 

 

 

SL