DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 5th day of July, 2023
Present : Sri.Vinay Menon V., President
: Smt.Vidya A., Member
: Sri.Krishnankutty N.K., Member Date of filing: 14/09/2021
CC/142/2021
Fathima Devi, W/o Thadean Leo Peter.A,
C/o Mangapallam Milk producers Co-operative Society,
Mangapallam, R.V.Pudur, Eruthiyampathy,
Vadakarapathy, Palakkad – 678 555 - Complainant
(Party in person)
V/s
1. The Branch Manager,
M/s Star Health and Allied Inssurance Co.Ltd.,
Branch office, 1st Floor, R.K.Buildings.
Opp Chittur Kavu, Chittur,
Palakkad – 678 101. - Opposite parties
(By Adv. P.Rathnavally)
O R D E R
By Smt. Vidya.A, Member
1.Pleadings of the complainant in brief
The complainant has availed a Family Health Optima Insurance plan vide policy no. P/18126/1/2020/002623 issued by the opposite party covering from 19/12/2019 to18/12/2020. As per the terms of the policy, the opposite party has assured to give health coverage to the complainant and his wife and the complaint had paid Rs. 12,067/- as premium and premium certificate was issued by the opposite party. The mediclaim sum assured was Rs.5,00,000/- .
During March 2020, the complainant had a sudden breathlessness and was taken to Lakshmi Hospital, Palakkad and investigations were conducted and nothing abnormal was found by the doctor. Again During September 2020, same difficulty was experienced and she was taken to Udayappa Medical College and nothing was detected from there, she was taken to Ahalya Hospital and nothing was detected from there also. On 17/10/2020. The complainant experience same difficulty in breathing and was taken to Rajiv Gandhi Co-operative Hospital, Palakkad and was admitted there from 17/10/2020 to 22/10/2020 HRCT Lungs investigation was done on 17/10/2020 and detected marked bilateral Ground glass opacification with Traction Bronchiectasis; CT features are suggestive of interstitial lung disease with NSIP pattern. It also revealed mild to moderate pericardial Effusion and Cardiomegaly with secondary pulmonary Alterial Hypertension. During investigation, it is having severe LV dysfunction. The complainant was not aware of the diseases till she was admitted and diagnosed by the Doctor at Rajiv Gandhi Co-operative Hospital, Cardiomyopathy and LV dysfunction and interstitial lung disease. The complainant spent a sum of Rs.56,829/- for the treatment and investigation’s and claim was lodged with the opposite party with all necessary documents and bills. Complainant had incurred expenses towards her treatment and the opposite party had undertaken to reimburse the amount.
In spite of receiving all necessary documents required for processing the claim, the opposite party rejected the claim. They sent a communication to the complainant on 7/4/2021 to the effect that the claims are not payable for the reason that the disease is pre-existing under waiting 3(iii) of the policy. Waiting period of 48 months is applicable only for the pre-existing disease. In this case complainants disease is not pre-existing and occurred all of a sudden. The complainant suffered breathlessness first time during March 2020 that is after the inception of the policy on 19/12/2019.
The repudiation of the claim by the opposite party is without any valid reasons and this has caused heavy monetary loss and mental agony to the complainant. This amount to clear deficiency and clarification of service.
This complainant is filed for an order
(1) To direct the opposite party to pay Rs. 56,829/- being the amount
payable for meeting the claims of the complainant under ‘Family health
optima Insurance plan’ together with interest at 12%.
(2) To pay Rs.50,000/- as the compensation for the mental agony and
financial loss caused to the complainant.
(3) To pay the cost of the litigation and other incidental reliefs.
2. Complainant was admitted and notice was issued to the opposite party.
The opposite party entered appearance and filed this version.
3. Opposite party in their version admitted that the husband of the complainant had taken a Family Health optima Insurance plan covering himself and the complainant for a sum insured of Rs. 5,00,000/- commencing from 19/12/2019 to 18/12/2020 vide policy No:- P/181226/01/2020/002623. At the time of availing the policy, the complainants were supplied with the Terms of conditions of the policy and were explained to them.
In the proposal form, the complainant has not disclosed any health related issues. During the policy period, the complainant was admitted in Rajiv Gandhi Co-operative Hospital on 17/10/2020 for the treatment of Cardiomyopathy, Severe LV systolic dysfunction, interstitial lung disease and was discharged on 22/10/2020. After discharge, the complainant submitted claim form with discharge summary bills of Rs. 53,435/- and reports.
The opposite party had obtained an expert opinion that the clinical features and echo are favoring chronic features which means that the complainants prior to policy. Since the ailment is pre-existing, the opposite party had repudiated the claim based on waiting periods No:3(iii) of the policy that is pre-existing disease. As per the policy “Pre-existing disease as defined in the policy until 48 months of continuance coverage have elapsed, since inception of the first policy with any Indian General Insurance”.
There is no deficiency in service on their past and the claim was repudiated strictly on the basis of the Terms of conditions of the policy. The complainant is not entitled to the reliefs claimed. The complainant had only submitted bills of Rs. 53,435/- and after processing the claim and as per the terms of conditions of the policy, the payable amount comes to Rs. 49,148/-. Even though the claim is not payable as per the Terms and Conditions of the policy, if any liability is found upon the opposite party then the liability is limited to Rs. 49,148/-. The complaint has to be dismissed with cost of the opposite party.
4. From the pleadings of both parties, the following points arise for consideration
(1) Whether the repudiation of the claim by the opposite party was as per the
terms and conditions of the policy ?
(2) Whether there is any deficiency in service/unfair trade practice on the
part of opposite party ?
(3) Whether the complainant is entitled to the reliefs claimed ?
(4) Reliefs if any, as cost of compensation.
5. Complainant filed proof affidavit and Exts. A1 to A4 marked from her
side. For the opposite party, the council for the opposite party filed proof
affidavit and it was rejected and their evidence was closed. Later the
opposite party filed IA..to re-open evidence along with fresh proof
affidavit filed by the opposite party and documents. Even after granting ample time, the OP failed to file proof affidavit. Hence their evidence was closed.
6. Point No:1
The opposite party admits that the husband of the complainant had availed a family health optima insurance plan covering himself and the complainant for a sum insured of Rs. 5 lakhs commencing from 19/12/2019 to 18/12/2020 vide policy No.P/181226/01/2020/002623. They also admit that during the policy period, complainant was admitted in Rajiv Gandhi Co-operative Hospital, Palakkad on 17/10/2020 for the treatment of Cardiomyopathy, serve L V systolic dysfunction, Interstitial lung disease and was discharged on 22/10/2020. After discharge from hospital, complainant submitted claim form with discharge summary, bills of Rs.53,435/- and reports. They repudiated the claim on the ground that illness existed prior to the commencement of the policy and it falls under preexisting disease.
6. Complainant’s contention in this regard is that during March 2020, she had sudden breathlessness and was taken to Lakshmi Hospital, Palakkad and on investigation, nothing abnormal was found. Again during September 2020, she experienced the same difficulty and was taken to Udayappa Medical College, Walayar and there also nothing was detected. Then the complainant was taken to Ahalya Hospital for further investigation and there also nothing abnormal was found. On 17/10/2020, she experienced same difficulty in breathing and was taken to Rajiv Gandhi Co-operative Hospital and admitted as inpatient from 17/10/2020 to 22/10/2020. HRCT lungs investigation was done on 17/10/2020 and detected marked bilateral Ground glass application with Traction Bronchiectasis. CT featurers are suggestive of interstitial lung disease with NSIP pattern. It also revealed mild to moderate pericardial effusion and cardiomegaly with secondary pulmonary Arterial Hypertension.
7. The complainant produced ‘ Discharge Summary’ dated 17/10/2020,
issued by Rajiv Gandhi Co-operative Hospital, which is marked as Ext.A2. Ext.A3 is HRCT LUNGS Report which shows the impression ‘Marked Bilateral Ground Glass opacification with traction Bronchiectasis. CT features are suggestive of interstitial lung disease with NSIP pattern.
Mild to Moderate periodical effusion Cardiomegaly with secondary pulmonary arterial Hypertension. Documents pertaining to the condition suffered by the complainant does not show the history of any disease. From this it is not possible to findout that the complainant had a pre-existing disease.
8. Even after granting ample time, for opposite party failed to file proof affidavit. Hence their evidence was closed. The opposite party did not take any steps to examine any expert or the Doctor who treated the complainant to prove their contention of pre-existing disease. So we find no merit in repudiation of the claim by the opposite party. Point No. 1 is decided accordingly.
Point No. 2 to 4
In view of the findings in point No.1, we hold that there is deficiency in service on the part of the opposite party in repudiating the complainant’s claim and the opposite party is bound to compensate the complainant for the mental agony and financial loss suffered by the complainant.
In result, the complainant is allowed,
We direct the opposite parties.
- To pay the admissible claim amount to the complainant as per the Terms and conditions of the policy.
- To pay Rs. 25,000/- compensation for the mental agony of financial loss suffered by the complainant due to the deficiency in service on the part of the opposite party.
- To pay Rs. 15,000/- as cost of the litigation.
Pronounced in open court on this the 5th day of July, 2023.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Documents marked from the side of the complainant:
Ext. A1: Original Family Health Optima Insurance Plan.
Ext. A2: Copy of Discharge Summary, Rajiv Gandhi Co-operative Hospital.
Ext. A3: HRCT Lungs investigation report copy.
Ext. A4: Repudiation letter issued by the opposite party
Documents marked from the side of opposite parties:
Witness examined from the complainant’s side: Nil
Witness examined from the opposite parties side:
Cost: 15,000/-
NB: Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
Forwarded/By Order,
Assistant Registrar
Fair copy on : 25/07/2023
Despatched on:
