KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No. 600/2015

JUDGMENT DATED: 25.10.2024

(Against the Order in C.C. 211/2013 of DCDRC, Wayanad)

PRESENT:

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR            : PRESIDENT

SRI. AJITH KUMAR D.                                                                 : JUDICIAL MEMBER

SRI. RADHAKRISHNAN K.R.                                                     : MEMBER

APPELLANT:

The Branch Manager, Star Health Insurance Co. Ltd., SulthanBathery Branch, Afthab Building, NH 212, Manikuni, SulthanBathery, Near Karuna Hospital.

(By Adv. G.S. Kalkura)

                                                Vs.

RESPONDENT:

Varghese Panachikkal, ChullothKuzhiyil Veedu, Chettappalam P.O., Pulpally, Wayanad-673 579.

                               (By Adv. P. Rajmohan)

JUDGMENT

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR  : PRESIDENT

The appellant is the opposite party and the respondent is the complainant in C.C. No. 211 of 2013 on the files of the District Consumer Disputes Redressal Commission, Wayanad (for short “the District Commission”).

2.  The respondent had taken a health insurance policy on 26.03.2011 and the said policy covered the treatment of the respondent, his wife and children.  In order to get the benefit of the policy, there should be treatment as inpatient at least for twenty four hours in a hospital.  The respondent renewed the policy on 26.03.2012 and 26.03.2013. Therefore, the policy was valid till 25.03.2014. The respondent was admitted in Meppadi WIMS DM hospital for the treatment of severe stomach ache.  It was diagnosed that the respondent was suffering from hernia.  Therefore, operation was conducted and the respondent was discharged from the hospital on 01.05.2013.  The respondent was under treatment as inpatient in the hospital from 26.04.2013 to 01.05.2013.  The respondent submitted a claim application before the appellant after the discharge from the hospital.  The appellant repudiated the claim stating that the disease was a pre-existing disease. 

3.  The appellant filed version admitting the policy.  The appellant also admitted that the respondent was treated as inpatient in Meppadi WIMS DM hospital from 26.04.2013 to 01.05.2013.  However, the appellant contended that the respondent was suffering from the disease for more than three years prior to the admission in Meppadi WIMS DM hospital on 26.03.2013.

4.  PW1 was examined and Exhibits A1 and A2 were marked for the respondent.  OPW1 was examined and Exhibits B1 to B7 were marked for the appellant.  Exhibit X1 series were also marked.  The District Commission, after evaluating the evidence, found that there was deficiency in service on the part of the appellant as the appellant had repudiated the claim of the respondent.  Accordingly, the District Commission directed the appellant to pay Rs. 35,000/- (Rupees Thirty Five Thousand only) towards the treatment expense with interest.  The appellant was further directed to pay Rs. 10,000/- (Rupees Ten Thousand only) as compensation and Rs. 2,000/- (Rupees Two Thousand only) as costs.  Aggrieved by the said order, this appeal has been filed. 

5.  Heard both sides and perused the records.

 6.  It is not disputed that the respondent was treated for hernia as an inpatient in Meppadi WIMS DM hospital from 26.04.2013 to 01.05.2013.  It is also not disputed that the respondent had undergone surgery for hernia in the hospital.  It is also not disputed that during the period of treatment of the respondent in the hospital, the health insurance policy issued by the appellant was having validity. 

7.  The learned counsel for the appellant has argued since it was recorded in the relevant past history column in Exhibit B3 as ‘L+IH->3 yrs’ by the doctor who treated the respondent, it is clear that the respondent had concealed the fact that he was having hernia even at the time of taking the policy in 2011 and consequently, the respondent is not entitled to get any relief under the policy and hence the District Commission was not justified in granting the relief to the respondent.

8.  The learned counsel for the respondent, on the other hand, has argued that the doctor who treated the respondent had correctly stated in Exhibit A2 medical certificate that the respondent was suffering from the disease only for 1½ years prior to the admission in the hospital and in the said circumstances, the District Commission was perfectly justified in granting the relief to the respondent.

9.  Exhibit A2 medical certificate was issued by the doctor who treated the respondent, which would show that the patient had approached the doctor with the complaint of swelling in left inguinal region.  It is seen recorded in Exhibit A2 that the above mentioned complaint of swelling aggravated during the last six months.  The duration of illness was clearly stated in Exhibit A2 as one and a half year.  It is true that the past history was stated in Exhibit B3 as ‘L+IH->3 yrs’.  However, Exhibit B3 is only a record of anesthesia.  Exhibit X1 series also contain Exhibit B3.  It is seen that Exhibit B3 was signed by the anesthesiologist and not by the doctor who treated the respondent.  Admittedly, the doctor who signed Exhibit A2 medical certificate was the doctor who treated the patient. The above facts are clear even from the evidence of OPW1. There is absolutely no material before the Commission to indicate that the respondent was treated in any other hospital in connection with hernia.  It appears from Exhibit A2 that the diagnosis was made by the doctor who treated the patient in Meppadi WIMS DM hospital.  It is true that it was recorded in page No. 7 of Exhibit X1 series that there was complaint of swelling in left inguinal region since three years.  There also, it was not recorded that any diagnosis with regard to hernia was made prior to the diagnosis made in Meppadi WIMS DM hospital.  It may be true that the respondent was having swelling on the left inguinal region for the last three years.  However, that was not diagnosed till he was admitted in the hospital for treatment on 26.04.2013. Since there is no evidence to indicate that the hernia was diagnosed at any time prior to the present treatment, merely because there was an entry in page No. 7 of Exhibit X1 series that there was complaint of swelling in left inguinal region since three years, it cannot be said that the respondent was aware that the swelling in the left inguinal region was due to hernia. Even though the past history was stated in Exhibit B3 as ‘L+IH->3 yrs’, it is to be noted that Exhibit B3 was signed by the anesthesiologist and not by the doctor who treated the respondent.  The duration of illness was clearly stated in Exhibit A2 medical certificate, by the doctor who treated the respondent as one and a half years. The evidence of PW1 coupled with Exhibit A2 medical certificate would show that the respondent was suffering from hernia only for the last one and a half years. There is no medical record other than Exhibit B3 to indicate that the respondent was suffering from hernia since three years.  Exhibit B3 does not state the basis upon which the anesthesiologist recorded that the respondent was having hernia since three years. 

10.  The evidence on record, as discussed above, would clearly show that the contention of the appellant that the respondent concealed the fact that he was having hernia even at the time of taking the policy in 2011, could not be established by the appellant.  Having gone through the relevant inputs, we are satisfied that the District Commission was perfectly justified in finding that there was deficiency in service on the part of the appellant.  In the said circumstances, we find no reason to interfere with the finding by the District Commission in this regard.

11.  The District Commission directed the appellant to pay the treatment expense with interest.  The District Commission further directed the appellant to pay Rs. 10,000/- (Rupees Ten Thousand only) as compensation and Rs. 2,000/- (Rupees Two Thousand only) as costs. We do not find any reason to hold that the treatment expense with interest, the compensation and the costs ordered by the District Commission are disproportionate, calling for interference by this commission.

12.  Even though the respondent had a valid policy during the time of his hospitalization and treatment, the appellant did not grant benefit of the policy to the respondent.  The respondent had to pay the entire treatment expense.  Considering the facts and circumstances of the case, including the loss and mental agony sustained by the respondent, we are of the view that it is only just and proper to direct the appellant to pay costs to the respondent.

In the result, this appeal stands dismissed with costs of Rs. 5,000/- (Rupees Five Thousand only) and the order dated 25.05.2015 passed by the District Commission in C.C. No. 211/2013 stands confirmed. 

The statutory deposit made by the appellant shall be given to the respondent, to be adjusted/credited towards the amount ordered by the District Commission, on proper acknowledgement.

JUSTICE B. SUDHEENDRA KUMAR: PRESIDENT

                                                                  AJITH KUMAR D. : JUDICIAL MEMBER

                                                                        RADHAKRISHNAN K.R.  : MEMBER

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