D.O.F:12/05/2022
D.O.O:20/01/2023
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.No.88/2022
Dated this, the 20th day of January 2023
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Divyaraj .M.K
S/o Gopalan Nair,
R/at Maliyakkal House, Kattippara, : Complainant
Vattamthatta P.O,
Kasaragod
(Adv. Benny Jose)
And
The Branch Manager
Star Health and allied Insurance Co.Ltd : Opposite party
2nd floor, Aramana Arcade
Bank Road
Kasaragod- 671121
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed under section 35 of the Consumer Protection Act, 2019, for compensation on the ground of service deficiency on the part of the Opposite Parties.
The fact of the case in brief is that the complainant took a comprehensive Insurance policy of the Opposite Parties with policy No.P181325/01/2022/00107. The validity period was from 04.05.2021 to 03.05.2022 and while the policy was in force, the complainant had some disc problem and he consulted with Dr. Venkitesh of Christian Medical College, Vellure on 19.07.2021 and a date was fixed for operation. But due to the sudden rise in blood pressure and severe head ache, the operation scheduled was cancelled and the complainant had to return to his house. Thereafter the complainant consulted with Dr.Sooraj of Janardhana Hospital Kasaragod, who advised him to do some advanced tests. Accordingly CT Scan was done at Christian Medical College, Vellure and a tumor was found at the head of the complainant. So a surgery was done by Dr.George Chacko and team of Christian Medical College, Vellure on 03.11.2021 to remove the tumour .The complainant was discharged on 10.11.2021 on payment of Rs.3,64,290/- towards the hospital bill. Even though the intimation was given from the hospital regarding the admission of the complainant to the hospital, cashless facility was not allowed by the opposite party. Therefore after the discharge, the complainant submitted a claim before the opposite party for reimbursement, with all the original documents but the claim was rejected as per the letter dated 10.01.2022 on the ground “non disclosure of pre-existing disease”.
The complainant was not having any idea or knowledge about the existence of cancer in his brain. It was identified all on a sudden and cannot be considered as non-disclosure. The reason stated by the opposite party for repudiating the claim is highly artificial and imaginary and the same cannot be accepted in a civilized society. The denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony. Hence the complaint is filed for a direction to the opposite parties to pay the complainant Rs.3,62,290/-, with interest along with Rs.1,00,000/- as compensation and costs.
The notice sent to opposite parties are duly served but they remained absent. Their names called absent and was set exparte.
The complainant filed proof affidavit in lieu of chief examination and documents Ext.A1 to A5 are marked. The document Ext.A1 is the Discharge Summary dated 16.03.2021, Ext.A2 is the Discharge Summary dated 10.11.2021, Ext.A3 is the Discharge Bill dated 10.11.2021, Ext.A4 is the Insurance Policy, Ext A5 is the repudiation letter dated 10.01.2022
Based on the pleadings and evidence of the rival parties in this case the following issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of the opposite parties?
3. If so, what is the relief ?
For convenience, all these issues are considered together. Here the specific case of the complainant that even though his treatment was done during the validity
period of insurance policy and the intimation was given from the hospital regarding the admission of the complainant to the hospital, cashless facility was not allowed by the opposite party. Also, the claim submitted for reimbursement was rejected by the opposite party as per the letter dated 10.01.2022 on the ground “non-disclosure of pre-existing disease”, which is not at all a valid reason. It is submitted that the complainant was not having any idea or knowledge about the existence of cancer in his brain. It was identified all on a sudden and cannot be considered as non-disclosure. The reason stated by the opposite party for repudiating the claim is highly artificial and imaginary and the same cannot be accepted in a civilized society. The complainant adduced reliable evidence to prove his case. It is clear that the presence of tumour has been diagnosed and treated first time and there is no history of previous treatment for tumour or cancer by the complainant. So no question of any nondisclosure would arise in complainant’s case.
Therefore considering the facts and circumstances of the case and in the absence of rebuttal evidence this commission is of the view that the denial of the insurance benefit to the complainant on the basis of invented ground is not justified and there is service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony.
Therefore the Opposite Party is liable to pay the entire hospital bill amount of Rs.3,62,290/-and also compensation for mental agony and hardships. This commission hold that Rs.20,000/- will be a reasonable amount of compensation in this case. Since the insurance benefit is denied by the opposite party for no valid reason, he is entitled for interest over the amount.
ln the result, the complaint is allowed and the Opposite Party is directed to pay a total amount of Rs.3,62,290/- (Rupees Three Lakhs Sixty Two Thousand Two Hundred and Ninety only) with 8% interest per annum from 12.05.2022, the date of complaint till payment to the complainant. The Opposite Party is also directed to pay a compensation of Rs.20,000/- (Rupees Twenty Thousand only) along with Rs.5,000/- (Rupees Five Thousand only) towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibit
A1: Discharge summary
A2: Discharge summary
A3: Discharge bill
A4: Copy of insurance policy
A5: Repudiation letter
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
