Sri B.NARAYANAPPA,

     President

1. The complainant Smt. G. Savithri, Mysore has filed this complaint against the opposite party The Manager, Star Health and Allied Insurance Company Ltd., Mysore praying to direct the opposite party to reimburse the medical expenses of Rs.1,04,481/- in her favour and to award compensation of Rs.10,000/- and cost of Rs.5,000/-.
2. The brief facts are that:-

The opposite party is a body corporate incorporated under the Indian Companies Act, 1965 with its registered office at #1, New Tank Street,, Valluvar Kottam High road, Nungambakkam, Chennai-600034, having its branches all over India.The opposite party is one such branch at Mysore.

3.       The complainant is the  purchaser of Senior Citizen Red Carpet mediclaim insurance policy  bearing  No.P/141116/012018/006677 issued by the opposite party for a sum of Rs.5,00,000/- valid from 23.01.2018 to 22.01.2019.  The complainant has paid annual premium of Rs.21,240/- for the first time in the year 2017 and renewed for one more year totally she paid premium of Rs.42,480/-.  The complainant under gone a medical procedure for her fractured left hip at the Brindavan Hospital, Mysore due to a mishap and she submitted application to opposite party for pre-authorization of cashless treatment amounting to Rs.85,000/-  which came to be rejected by opposite party.  Therefore the complainant paid Rs.85,000/- to Brindavan Hospital, Mysore by cash for the hospitalization expenses for the period from 20.07.2018 to 24.07.2018.  Thereafter the complainant submitted a claim to opposite party on 02.08.2018 for reimbursement  of medical expenses of Rs.91,652/- as she was  eligible and entitled to be reimbursed of her medical expenses which includes pre-hospitalization and post hospitalization charges totally Rs.91,652/-, but the opposite party repudiated the claim of the complainant vide its letter dated 09.08.2018 alleging that the complainant has not disclosed her pre-existing ailment of Chronic Obstructive Pulmonary Disease (COPD) of 18 years.  It is further case of the complainant that she had undergone for her medical treatment to her fractured left hip, it is nothing to do with any alleged COPD existing with the complainant or any ailment even remotely connected with COPD, the repudiation of the claim of the complainant by opposite party is extremely unlawful.  The complainant has denied the allegation of the opposite party that she has COPD and that she had failed to disclose the same to opposite party.  As a matter of fact the complainant was free, fair and honest when she disclosed to the nurse on duty at the Bridavan Hospital,, Mysore, as she noted down in the case sheet on that day of  admission that she took certain inhaler prescribed by her family doctor on rare and odd occasions due to cold and fever affecting her occasionally.  The erroneous mention of this fact by the nurse and the doctor in the case sheet of Brindavan Hospital, Mysore has been deliberately cherry-picked by the opposite party to suit their convenient and to repudiate the claim of the complainant.  As per terms of the contract of medical insurance policy the complainant is entitle to reimbursement of the medical expenses incurred by her due to her hospitalization with pre- hospitalization and post hospitalization medical expenses, but the opposite party has denied her medical claim.  Hence, this complaint. 

4.  After   institution  of this complaint, notice was ordered to be issued to opposite party.  In response to notice the opposite party appeared through its counsel and has filed version.  Admitting the averments made in para 2 and 3 of the complaint i.e., regarding issuance of Senior Citizen Red Carpet mediclaim insurance policy No.P/141116/012018/006677  issued by opposite party to complainant for a sum of Rs.5,00,000/- valid from 23.01.2018 to 22.01.2019 and also partly admitted the para 5 and 6 of the complaint averments with regard to complainant undergone medical procedure of her  fractured left hip at the Bridavan Hospital, Mysore due to a mishap and the complainant incurred certain medical expenditure and denies the averments made in  para 7 of the complaint that opposite party deliberately raised false allegation stating that the complainant had pre-existing COPD and thereby repudiated the claim of the complainant and contended that the complainant is not entitle to any reimbursement and further admitted that the opposite party had issued Senior Citizen Red Carpet mediclaim insurance policy  to the complainant for the sum insured of Rs.5,00,000/- valid from 23.01.2017 to 22.01.2018 and renewed the same   from 23.01.2018 to 22.01.2019 for the 2^nd year and the patient was hospitalized on 20.07.2018 in Brindavan Hospital, Mysore and discharged on 24.07.2018 and she was diagnosed Cervicotrochanteric Fracture Let Hip  surgery procedure were performed and the insured raised a pre-authorization request to avail cashless facility  which was rejected on 23.07.2018.  Again the complainant submitted claim for reimbursement of medical expenses which was also repudiated on 09.08.2018, because the complainant was suffering from pre-existing disease (COPD) since 18 years and it is further contended by opposite party that the insured patient is a known case of COPD prior to the date of commencement of  the 1^st year policy   which was not disclosed by complainant to opposite party at the time of issuance of Senior Citizen Red Carpet mediclaim insurance policy from 23.01.2017 to 22.01.2018 as per the contract of insurance it is the duty of the proposer to disclose all the material facts to the insurer, so that the insurer evaluate the material fact and decide whether  to accept the proposal or not.  As per the condition No.9 of the policy, if there is any misrepresentation/non-disclosure of material fact by insured the company is not liable to make any payment in respect of any claim and as per condition No.13 of the policy the company may cancel policy on grounds of misrepresentation of non-disclosure of material fact, hence the policy was cancelled with effect from 06.09.2018 due to non-disclosure of COPD  by sending a 30 days notice to the complainant and premium amount of Rs.21,240/- was refunded vide DD No.857624 dated 11.09.2018.  It is further contended that the complainant has not come to this Forum with clean hands and her case is doubtful.  Therefore she is not entitle to any relief.  Hence, prays to dismiss the complaint.

5. The complainant in order to prove her case has filed her affidavit by way of examination in chief and the same was taken as P.W.1 and produced certain documents.  On the other hand the opposite party has also filed its affidavit by way of examination in chief and the same was taken as R.W.1 and produced certain documents.

6. We have heard the arguments of both the counsels appearing on behalf of both the parties and also they have filed their respective written arguments.

7. The points that would arise for our consideration are as under:-  

1. Whether the complainant proves that the act of opposite party in repudiating her medical claim under her Senior Citizen Red Carpet mediclaim insurance policy  amounts to deficiency in service?
2.  What order?

8.       Our findings on the aforesaid points are as follows:

       Point No.1 :- Partly in the affirmative;

      Point No.2 :- As per final order for the following

:: R E A S O N S ::

9.        Point No.1:- The learned counsel for the complainant has vehemently argued   as per the contention taken in the complaint, affidavit of complainant and documents produced by the complainant and as per the notes of arguments.

10.      On the other hand learned counsel for opposite party has also vehemently argued and submitted as per version of opposite party and notes of arguments and documents produced in support of the case of the opposite party.

11.      We have carefully gone through the complainant6 documents, affidavit of complainant, documents produced by the complainant and notes of arguments and version of opposite party and notes of arguments and documents of opposite party.

12.      It is not in dispute that the opposite party had issued Senior Citizen Red Carpet mediclaim insurance policy  bearing No. No.P/141116/012018/006677 to complainant for a sum of Rs.5,00,000/-  valid for a period from 23.01.2018 to 22.01.2019 by receiving annual premium of Rs.21,240/- from the complainant.  The complainant for the first time has purchased the said policy in the year 2017 and renewed the same for 2^nd year by totally paying premium amount of Rs.42,480/-.

13.      It is also not in dispute that the complainant being senior citizen  was hospitalized on 20.07.2018 in Brindavan Hospital, Mysore for fracture of left hip and surgery procedure were performed for  fractured left hip was done and she was discharged on 24.07.2018 and according to the complainant she incurred hospitalization charges of Rs.85,000/- and post-surgery charges of Rs.6,652/- totally Rs.91,652/- the claim of complainant for reimbursement of said amount has been repudiated by the opposite party on the ground that the complainant was suffering from pre-existing disease called COPD since 18 years it was not disclosed by her at the time of inception of policy.  It is also not in dispute and that the opposite party has also admitted the repudiation of claim of complainant for reimbursement of medical expenditure of Rs.91,652/- on the ground that the complainant was suffering from pre-existing disease called COPD stating that at the time of inception of policy the complainant not disclosed the pre-existing disease called COPD.  Therefore contends that the non-disclosure of COPD the pre-existing disease of complainant to opposite party is misrepresentation, fraud on the part of complainant, therefore the complainant was not entitle for reimbursement of medical expenditure.  Hence, opposite party contends that it has repudiated the claim of the complainant on 23.07.2018, 09.08.2018 and ultimately the policy was cancelled with effect from 06.09.2018 due to non-disclosure of COPD and refunded premium amount of Rs.21,240/- to the complainant on 11.09.2018.

14.      It is the specific contention of the opposite party that due to non-disclosure of pre-existing disease called COPD by the complainant, she was not entitle for reimbursement of medical claim and according to the contention of opposite party the complainant was suffering from pre-existing disease called COPD since 18 years.  On perusal of the terms and conditions of Senior Citizen Red Carpet mediclaim insurance policy  as per clause No.3(III) of the policy the waiting periods for pre-existing disease is 12 months, so from this  terms of the policy it is crystal clear that waiting period for pre-existing disease is 12 months  admittedly  in the year 2017 itself.  The complainant purchased Senior Citizen Red Carpet mediclaim insurance policy   and it was renewed for one more year which was valid from 23.01.2018 to 22.01.2019, so the complainant was the holder of the Senior Citizen Red Carpet mediclaim insurance policy   for a period of 2 years i.e., for a period of 24 months and according to the waiting period for any pre-existing disease is 12 months as per the policy conditions of the opposite party.  Therefore it is crystal clear that in the 2^nd year after the complainant obtained/renewed Senior Citizen Red Carpet mediclaim insurance policy   that too after 12 months of waiting period the opposite party came to know that the complainant was suffering from pre-existing disease called COPD.  Since the waiting period of 12 months for any pre-existing disease is over as per the policy terms and conditions the opposite party cannot deny the medical reimbursement to the policy holder and admittedly the policy was valid from 23.01.2018 to 22.01.2019 and the complainant admitted to hospital on 20.07.2018  for treatment to her ailment and she was discharged on 24.07.2018 as she suffered fracture to her  left hip  due to  mishap as she fell down in the house, so it is clear that during the validity period of insurance policy the complainant took treatment to fracture of her left hip in Brindavan Hospital, Mysore from 20.07.2018 to 24.07.2018 whereas the opposite party after coming to know about the pre-existing disease called COPD according to opposite party which was not disclosed by the complainant at the time of inception of policy, the opposite party has repudiate the claim of the complainant and cancelled the policy of complainant with effect from 06.09.2018 that too after discharge of complainant from hospital on 24.07.2018 and refunded the insurance premium amount of Rs.21,240/- to the complainant which appears that only with an intention to repudiate the claim of the complainant the opposite party did such a misdeed in refusing the claim of the complainant for reimbursement of her medical expenditure.  More over according to the opposite party the complainant was suffering from COPD since 18 years and according to the terms and condition of the policy the waiting period for any pre-existing disease is 12 months i.e., for one year  and admittedly the complainant has obtained her insurance policy in the year 2017 and it was renewed for 2^nd year which was valid from 23.01.2018 to 22.01.2019 and during 2^nd year the complainant due to mishap/fell in the house sustained fracture to her left hip.  Therefore she was hospitalized from 20.07.2018 to 24.07.2018 and necessary surgical procedure were done in the Brindavan Hospital, Mysore and she incurred medical expenditure of Rs.91,652/- which has been denied by the opposite party on the simple ground that the complainant not disclosed the pre-existing disease called COPD which is not fair on the part of the complainant and more over the allegation made by the opposite  party against the complainant that she was suffering from pre-existing disease called COPD since 18 years but the said alleged disease of complainant is no way connected to the injuries sustained by the  i.e., complainant fracture of her left hip which was accidental one due to  sudden mishap in her house under such circumstances the opposite party cannot connect the alleged pre-existing disease of complainant called COPD to her ailment i.e., the fracture of left hip of complainant which was purely accidental one.  Therefore it is crystal clear that the contention taken by the opposite party that the complainant not disclosed the pre-existing disease called COPD at the inception of policy.  Therefore it repudiated the claim of the complainant for reimbursement of medical expenditure is not a  genuine, true and valid ground on the part of opposite party since the alleged disease  called  COPD is not at all totally not related to the disease called COPD.

15.      By taking into the consideration of the terms and conditions and exclusion of the policy issued by opposite party to complainant as per 1.COVERAGE –D  for Anesthesia, Blood, Oxygen, Operation Theatre charges, surgical appliances, medicines and drugs etc., the liability of opposite party is subject to maximum of 50% of the sum insured per hospitalization according to this condition itself atleast the opposite party is liable to pay  50% of the total claim of the complainant towards her medical reimbursement since the complainant was the holder of Senior Citizen Red Carpet mediclaim insurance policy   which was valid at the time when she suffered fracture to her left hip and took treatment in the Brindavan Hospital, Mysore and that she had incurred medical treatment expenses of Rs.1,04,481/- which includes post hospitalization charges also.  But the complainant instead of making payment of atleast 50% of the medical reimbursement of the complainant has totally declined to pay the same on the simple ground that the complainant not disclosed the pre-existing disease called COPD and the opposite party went to the extent that it has cancelled the insurance policy of the complainant on 06.09.2018, after the complainant took treatment in the hospital from 20.07.2018 to 24.07.2018 and refunded premium of Rs.21,240/- to the complainant which is  not only deficiency in service but unfair  trade practice on the part of the opposite party which is against to the policy terms and conditions of the insurance policy.  Therefore, we are of the opinion that the complainant is entitle to be reimbursed 50% of the total claim amount of Rs.1,04,481/- i.e., Rs.52,240/-  (-) Rs.21,240/- = Rs.31,000/- Rs.21,240/- premium amount which was already refunded to complainant by cancelling the insurance policy of the complainant on 06.09.2018 vide DD No.57624 dated 11.09.2018.  The act of repudiation of claim of complainant by opposite party is nothing but deficiency in service.  Therefore the opposite party is liable to pay 50% of the total claim of Rs.1,04,481/- i.e., Rs.52,240/- (-) Rs.21,240/- which comes to Rs.31,000/-.  Therefore we answer point No.1 partly in the affirmative.

16. Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

The complaint of the complainant is allowed in part.

The opposite party is hereby directed to pay a sum of Rs.31,000/- together with interest @ 6% p.a. to the complainant within 2 months from the date of this order till its realization.

No order as to cost.

Furnish the copy of order to both the parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Forum on this the 24^th June, 2020)