D.O.F:03/12/2021      

                                                                                                             D.O.O:18/12/2023

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION, KASARAGOD

CC.224/2021

Dated this, the 18^th day of December 2023

PRESENT:

SRI.KRISHNAN.K                                         : PRESIDENT

SMT. BEENA. K.G                                      :MEMBER

Mr. Surendran.M,

S/o Late B Narayanan Nair,

R/at Ama House,

Bethurpara, Muliyar,

Kuttikkol Village,

Vattamthatta P.O,

Kasaragod Taluk and District,                                     : Complainant

(Adv: A Gopalan Nair).

                                                                                    And

The Manager,

Star Health & Allied Insurance Company Ltd,

4^th Floor, Carmel Towers,

Cotton Hill P.O, Vazhuthacaud,                                              : Opposite Party

Thiruvanathapuram – 695014.

(Adv: K. Vinod Kumar)

ORDER

SRI. KRISHNAN.K : PRESIDENT

     The case of the complainant is that he obtained a health Insurance Policy with coverage of Rs. 5 lakhs from the Opposite party by paying premium of Rs. 8351/- covering himself spouse and two children for a period of one year from 15/09/2021.  On 15/10/2021 at 12.30 hours his both children’s admitted at Chaithra Medical Centre Kasaragod with high fever and cough under Dr.Vineetha.  Diagnosed with febrile sisezures.  Initial approval amount of Rs. 10,000/- submitted but rejected for the reasons admission occurred within the first 30 days from the date of commencement of policy.  Children’s  discharged on 18/10/2021 with a bill for Rs. 18,173/- and Rs.  4660/- for the other child.  The rejection of policy claim is not as per law thus there is serious negligence and deficiency in service.  Complainant claims Rs. 2,00,000/- compensation for mental agony medical expense for Rs. 22,833/- and cost of litigation cost.

     The Opposite party filed written version policy was admitted the policy with terms and condition in the policy.  Company received two claims and also pre- authorization request .  As per exclusion of the policy company is not liable to pay any amount during the 1^st 30 days from the commencement of the policy and therefore.  Claim is rejected in accordance with the terms and conditions.  The complainant is not entitled to any relief in the case.  

     The complainant filed chief affidavit marked documents Ext A1 to A6.  Ext A1 and 2 are the rejection letter for cashless treatment.  Ext A3 and A4 are medical bills and A5 is the cashless authorization letter and Ext A6 is the copy of judgment of the State Redressal Commission Chadigrab.

     Considering the rival contention following points arise for consideration.

1. Whether the rejection of the medi claim submitted by the complainant is covered by the insurance policy issued by the Opposite party? Whether the complainant is entitled to medical insurance claim.
2. Whether there is any deficiency in service and entitled to any compensation thereof and if so what reliefs?

     The insurance company avoids the liability to pay insurance claim during the first 30 days of obtaining policy.  The policy in this case is admittedly covered for the period from 15/09/2021 to 14/09/2022.  The complainant while examining as Pw1 admits having received the policy documents by whatsapp with full details immediately, by post within one month.  They went to Hospital    on 15/10/2021 with fever and cough.  Pw1 denied the suggestion children suffered fever and cough 3-4 days prior to 15/10/2021.  After discharge no claim made for reimbursement.  He admits the policy condition Ext B1.  The Opposite party made a suggestion that the claim is rejected for the reasons illness is prior to condition but denied by the Pw1.  Still Opposite party has no case each and every terms and conditions in Ext B1 policy including the condition that no claim is allowed for the 1^st 30 days of the policy.  No suggestion to the complainant that each and every terms and conditions in the policy was explained to the policy holder and that he was agreed to the terms and condition that the policy holder agreed to the same and affixed his signature in the policy contract and thereby complainant is not entitled to the claim.  On the other hand claim of the Opposite party is that it is prior illness long prior to the hospitalization but rejection letter Ext A1 and A2 shows as per the waiting period exclusion clause No.1 in the policy claim is not admissible.  The    Opposite party has no case that complainant suppressed and concealed any material facts while obtaining policy.  There is no justification to reject the claim on the ground the claim is made within 1^st 30 days period as long as the claim is not made for treatment expences for the sudden and immediate illness of fever and cough only.  Under the circumstances unless Opposite party proves to the satisfaction that each and every terms and conditions are explained to the policy holder and signed by him after admitting the contents therein as long as there is a valued policy covering the period rejecting the claim for model bills is not in accrued with law.

          We referred the citation in 2022 Live law.

          (SC) 303 Hemant Gupta V Ramesh subramaniyam)

          Special leave to appeal (c) No(s) 3978/2022

          : 11-03-2022 the oriental Insurance Company verses Sanjeesh and others

     The principal in the case are similar to this case.  Hence claim is rejected saying that any claim is barred within one month of the policy.  Therefore commission finds that the complainant is entitled insure benefits namely Rs.22833/- being the medical bill already paid to the hospital.  There is deficiency in service on the part of Opposite party in rejecting the claim for which complainant is entitled compensation of Rs. 10,000/- (Rupees Ten thousand only) and cost of litigation.

     In the result complaint is allowed in part Opposite party is directed to pay a sum of Rs. 22,833/- with 8% interest from the date of complaint till its realization and an amount of Rs. 10,000/-(Rupees Ten thousand only) as compensation and Rs. 5000/- (Rupees five thousand only) as cost of the litigation to complainant with 30 days of the receipt of the order.

      Sd/-                                                                                              Sd/-

MEMBER                                                                                      PRESIDENT

Exhibits

A1 & A2 - Rejection of pre – authorization for cashless treatment.

A3 – Inpatient bill.

A4- Inpatient bill.

A5- Cashless authorization letter.

A6- The copy of judgement of the State Redressal Commission Chadigrab.

B1- Certificate of insurance

Witness Examined

Pw1- Surendran.M

      Sd/-                                                                                        Sd/-

MEMBER                                                                            PRESIDENT

Forwarded by Order

                                                                      Assistant Registrar

Ps/