D.O.F:13/10/2022

                                                                                                         D.O.O:30/10/2024

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION, KASARAGOD

CC.311/2023

    Dated this, the 30^th day of October 2024

PRESENT:

SRI.KRISHNAN.K                          : PRESIDENT

SMT.BEENA.K.G                              : MEMBER

Mohammed Junaif C.H.

S/o Eramullan (L)

Junaif Villa, Chathappady

P O Nekraje, Pin – 671543.

Kasaragod, Kerala                                                                             : Complainant

                                                                        And

1. Dr. Guru Mageswaran

Grievance Redressal Officer

Corporate Grievance Department

Whites Lane

White Road, Royapettah,

Chennai – 600014.

2. The Manager

Star Health Insurance

Regd 8 Corporate Office

New Tank Street, Valluvar Kottam

Highs Road,

Chennai – 600034.

(Adv: K Vinod Kumar) : Opposite Parties

ORDER

SRI.KRISHNAN.K  : PRESIDENT

            The case of the complainant is that he obtained a family Health Insurance Policy from Star Health Insurance Company in 2021, with a premium of Rs. 7,000/- per head per year.  His wife Beefathima hospitalized from 03/07/2023 to 04/07/2023 due to fever, tiredness, throat pain and headache.  He spent nearly Rs. 7,000/- as hospital bill.  The complainant filed claim before opposite party but for one reason or other processing delayed.  The opposite party denied cash less payment and instructed to apply for re-imbursement.  Thereafter the complainant filed claim application with all the documents.  But till claim not allowed.  The complainant is an accountant he lost job for 20 days.  The rejection of insurance claim without justifiable reason is deficiency in service.  He claims Rs. 1, 50,000/- (Rupees One lakh Fifty thousand only).  The insurance company rejected the claim on the ground that hospitalisation is not medically necessary.

            The opposite party appeared and filed written version.  The opposite party denied the allegations.  The opposite party admitted that the complainant obtained Arogya Senjeevani Policy for the period from 21/09/2022 to 20/09/2023 for himself and his family subject to the terms explained to him.  His wife is admitted for acute febrile, illness and discharged on the next day.  Thereafter submitted the claim.  There is no positive existence of illness regarding admission thereafter claim is rejected. 

The complainant filed chief affidavit and Ext. A1 to A5 marked.  Ext. A1 is the copy of the insurance policy, Ext. A2 is the copy of the medical certificate, Ext. A3 is the copy of the Aadhaar card, Ext. A4 is the copy of the hospital case sheets and Ext. A5 is the copy of the death certificate. The opposite party not adduced any evidence. 

            The following points arised for consideration in the case for decision.

1. Whether repudiation of insurance claim on the ground that hospitalization is not required for the illness is valid or sustainable in the eye of law?
2. Whether there is any negligence or deficiency in service in the part of opposite party?
3. Whether the complainant is entitled for compensation?  If so for what reliefs?

In this case, there is no serious cross examination of the complainant.  No serious suggestions even that hospitalization is not required.  Suggestion is that no illness required hospitalization treatment.

Whether hospital treatment is advised or necessary, nature of illness, its seriousness treatment required are all well within the decision of doctor and not to be decided by opposite party company.  No suggestion that Insurance is to claimed falsely or complainant was not suffering from illness for which doctor advised hospital treatment.

Thus denial of Insurance benefits by obtaining Insurance policy, paying premium and insurance company reject insurance policy benefits for reason that it has no justification.  Insurance company is liable to pay and satisfy the claim.  The repudiation is not as per mandate of law.

Thus rejection of the policy benefits is unjustified.  There is deficiency in service, negligence and unfair trade practice.  Thus opposite party is liable to pay insurance benefits and compensation for deficiency in services.

In the result complaint is allowed in part, opposite party No. 2 is directed to pay an amount of Rs. 7,000/- (Rupees Seven thousand only) as medical bills with 8% interest from date of complaint till realization and Rs. 10,000/- (Rupees Ten thousand only) as compensation for deficiency in service and Rs. 3,000/- (Rupees Three thousand only) as cost of litigation within 30 days of the receipt of the order.

     Sd/-                                                                                                                   Sd/-

MEMBER                                                                                                      PRESIDENT

Exhibits

A1 – Copy of the insurance policy

A2 – Copy of the Medical certificate

A3 – Copy of the Aadhaar card

A4 – Copy of the hospital case sheets

A5 – Copy of the death certificate

Witness cross-examined

PW1 – Muhammed Junaif C.H.

     Sd/-                                                                                                                   Sd/-

MEMBER                                                                                                      PRESIDENT

Forwarded by Order

                                                                                    Assistant Registrar

JJ/