By. Smt. Bindu. R, President:

            This complaint is filed under section 35 of the Consumer Protection Act 2019 by M. D. Sunil, Mulackal House, Payyampally Post, Mananthavady Taluk, Wayanad against Star Health Allied General Insurance Company Limited, Branch Office, V. M. Tower, Opp. Union Bank, Near T. P. Tiles, Gudalai, Kalpetta, Represented by Its Manager and others as Opposite Parties alleging deficiency of service and unfair trade practice.

            2.  The Complainant states that the Complainant is working in Kerala Police and availed Health Insurance Policy from the Opposite Parties in February 2017 for himself and his family members including his father Devassia.  From February 2017 onwards the Complainant is regularly renewing Health Insurance Policy.  According to the Complainant, since his father is a senior citizen and having more than 65 years of age, it was informed by the Opposite Party No.1 that, he can be included in the Senior Citizen Red Carpet Health Insurance Policy Scheme in which 70% of the amount spent for treatment will be reimbursed and the Complainant availed medi-claim insurance for a sum of Rs.2,00,000/- for his father from 09.02.2017 itself and lastly it was renewed in the 5^th Year from 09.02.2022 to 08.02.2023 with Policy No.P/181314/01/2021/006934 with renewal endorsement No.P/181314/01/ 2022/007957 and the Complainant had paid an amount of Rs.9,978/- towards the premium.  While so on 12.07.2022 the father of the Complainant Sri. Devassia was admitted at Star Care Hospital, Kozhikode for ulcer over left ankle and was discharged on 13.07.2022.  At the time of treatment the Complainant requested for cashless treatment but it was denied and it was also informed by the Opposite Parties that they denied the benefit preliminary only and they will reconsider the matter and sanction the amount after receiving the claim form with discharge summary, final bill, lab reports, medicine bills and a cancelled cheque from the Complainant.  In pursuance to the above direction the Complainant had submitted the entire documents on 21.07.2022 as demanded by the Opposite Party to the Kalpetta office of Opposite Party No.1 and the Complainant had received information that they have received the documents and application on 01.08.2022. Subsequently on 19.08.2022 the Complainant had received the information through mail that the claim is repudiated by the Opposite Party No.3. The main reason stated is that as per the exclusion clause the company is liable to make payment for any pre-existing disease only after expiry of 12 months from 12.07.2022.  It is submitted by the Complainant that for the past 7 years the father of Complainant is having no ailments or disease in connection with varicose vein but in the month of May 2022 his leg struck with a metal sheet and sustained injury to his leg. It is noticed that even after the elapse of 2 months the wound is not cured, as a result, the father of the Complainant was taken to the hospital and it was diagnosed that the non-curing of wound is due to the problem of varicose vein. Under the above circumstance the beneficiary was admitted at the hospital at Kozhikode and undergone treatment. The Complainant is entitled for the cashless treatment as promised by the Opposite Parties. The Complainant had already spent more than Rs.2.5 lakhs within a period of 5 years but till 12.07.2022 he has not claimed any insurance benefits from the Opposite Parties as none of the beneficiaries in the family of the Complainant suffered by any ailment or undergone any treatment.  The Opposite Parties have denied the policy without any valid grounds. On account of the unfair activities of the Opposite Parties, the Complainant had suffered great mental agony and difficulty. The Complainant had availed a service from the Opposite Parties but the service of the Opposite Parties are defective and the actions of the Opposite Parties had caused great loss and damages to the Complainant. There is clear deficiency of service on the part of Opposite Parties and hence the complaint.

            3.  Upon notices Opposite Parties entered into appearance and filed joint version.  The taking of policy in the name of Devassia on 09.02.2017 and the subsequent renewal up to 08.02.2023 by the Complainant is admitted by the Opposite Parties.  According to the Opposite Parties the terms and conditions of the policy were explained to the Complainant at the time of proposing the policy and are served to the Complainant.  It is contented by the Opposite Parties that in case of Senior Citizen Red Carpet Insurance Policy medical examination is not required as the insured must be above 60 years of age.  As per terms and conditions of the Senior citizen Red Carpet policy issued to the insured, only those Pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form, for the insurer to provide coverage with suitable co-payment, ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured.  During the aforesaid policy period, the Opposite Parties received a request for cashless hospitalization from Star Care Hospital, Calicut stating that the Complainant’s father, Mr.M.M.Devassia was admitted at the hospital on 12.07.2022 and was provisionally diagnosed with varicose vein left lower limb.  Based on the pre-authorization and documents forwarded by the hospital, the Opposite Parties had initially authorized an amount of Rs.30,800/- as provisional amount and informed the hospital vide letter dated 12.07.2022. According to the Opposite Parties, in the condition No.12 of the terms and conditions of authorization, it was clearly stated that “If the claim is found to be not admissible due to discrepancies in the details provided by the hospital in the Pre-Authorization request form and discharge summary and other documents, the company is not liable to make any payment and the amount approved will be withdrawn and the bill will not be settled”.  It is submitted that thereafter the hospital has forwarded the treatment records and reports. As per the treatment record from the hospital dated 12.07.2022, the patient has a history of Sclerotherapy to left lower limb 7 years back.  Based on the available medical records, it is clearly evident that the patient, Mr.Devassia, has been suffering from this disease/condition for the past 7 years which is prior to the inception of the policy and hence it is a pre-existing disease. As per the policy, Pre-existing disease is excluded under Exclusion No:3 (1)(A) of the policy which states that the Company shall not be liable to make any payments under the policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 12 months of continuous coverage after the date of inception of the first policy with insurer. Moreover it is elaborately explained in the Definition clause of the policy that Pre- Existing Disease means any condition, ailment or injury or disease a) That is/are diagnosed by a physician, within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or b) For which medical advice or treatment was recommended by or received from a Physician within 48 months Prior to the effective date of the policy issued by the insurer or its reinstatement. It is contented that since there is history of pre-existing disease, the claim was rejected and was informed to the Complainant vide letter dated 19.08.2022 in accordance with the terms and conditions of the policy and hence prayed for dismissal of the complaint with cost of the Opposite Parties.

            4.  Evidence in this case consists of the oral testimony of PW1 and Ext.A1 to A6 from the side of the Complainant and oral testimony of OPW1 and Ext.B1 to B8 from the side of the Opposite Parties.

            5.  Heard both sides and perused the records in detail.  Ext.A1 series are the copies of Policy Certificates from 09.02.2017 to 08.02.2023.  Ext.A2 is the copy of Discharge Summary dated 13.07.2022 issued from Star Care Hospital, Kozhikode. Ext.A3 is the Copy of Claim Form.  Ext.A4 is the Printout of Acknowledgment for receipt of documents from Opposite Parties.  Ext.A5 is the Copy of Certificate from Doctor and the Rejection Letter.  Ext.A6 is the Copy of Certificate from Doctor and the Repudiation Letter.

            6.  Ext.B1 produced from the side of Opposite Parties is the Proposal Form signed by the Complainant dated 09.02.2017.  Ext.B2 is the Copy of renewed Policy dated 25.01.2022.  Ext.B3 is the Request for cashless hospitalization.  Ext.B4 is Cashless Authorization Letter.  Ext.B5 is the Assessment Sheet dated 12.07.2022.  Ext.B6 is the Rejection and withdrawal of approval given earlier dated 13.07.2022. Ext.B7 is the Copy of Discharge Summary and Ext.B8 is the Repudiation Letter.

            7.  The Commission had made a very thorough examination into the complaint, version, documents filed from either side and the depositions of both sides.

            8.  The following are the main points to be analyzed in this complaint to derive in to an inference of the fact.

1. Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Parties?
2. If so, the quantum of compensation and other reliefs for which the Complainant is eligible to get..?

9.  The case of the Complainant is that the Complainant had availed an Insurance Policy with the Opposite Parties in February 2017 for himself and his family members including his father Devassia and is renewing the policy regularly.  The case of the Complainant is that, since his father is a senior citizen having more than 65 years of age, Opposite Party No.1 informed that he can be included in the Senior Citizen Red Carpet Health Insurance Policy Scheme in which 70% of the amount spent for treatment will be reimbursed and the Complainant availed medi-claim insurance for a sum of Rs.2,00,000/- for his father from 09.02.2017 itself.  When a claim was submitted to the Opposite Parties in 2022, the same was repudiated on the ground that there is history of pre-existing disease.  On the other hand the version of Opposite Party is that as per terms and conditions of the policy, only those pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy.

10.  In the instant case during the pendency of policy period, the father of the Complainant, the insured was admitted in the Star Care Hospital, Calicut on 12.07.2022 and was provisionally diagnosed with varicose vein left lower limb, and the Opposite Parties received a request for cashless hospitalization. According to Opposite Parties as per the treatment records from the Hospital dated 12.07.2022 the patient has a history of sclerotherapy to left lower limb 7 years back and hence it is pre-existing disease and therefore the claim is repudiated.  Ext.B7 is the Discharge Summary of the insured in which the history of present illness states “This 69 years male presented with complaints of non-healing ulcer over left ankle since 2 months following trauma.  There is no significant past medical history.  He was admitted electively for Endovenous Laser Therapy to left GSV + Hook Phlebectomy + Forum Sclerotherapy”.  There is no mention regarding pre-existing illness of the insured as contented by the  Opposite Parties.  During cross-examination of PW1 it is deposed that “Rm\mWv proposal form fill sNbvXv sImSp¯Xv AXp{]Imcw AÑ\p­mbncp¶ AkpJ§sfms¡ ImWn¨n«p­v.  Ct¸mÄ ImWn¨v tcJbnteXv Fsâ H¸mWv.  B1 Rm\mWv \ÂInbnXv  AXp{]Imcw AÑ\v AkpJapffXmbn ImWnÃ.  AkpJw At¸mÄ CÃmbncp¶Xn\memWv ]dbmXncp¶Xv”.  During cross-examination of OPW1 it is came out in evidence that “Ext.A5 {]Imcw injury aqeapff apdnhv  heal BImXncp¶Xn\memWv NnInÕn¨sX¶mWv ImWp¶Xv. Varicose vein aqeamWv tcmKw t`ZamImXncp¶sX¶v tcJbn CÃ.  BZyambn policy FSp¯Xv 09.02.2017 \mWv.  12.07.2022 \mWv NnInÕ¡v t]mbXv AXmbXv 5 hÀjhpw A©v amkhpw IgnªmWv NnInÕ¡v t]mbXv”.  OPW1 further deposed that “sclera therapy \S¯nbncp¶p F¶XmWv  claim \ntj[n¡m³ ImcWw.  AXv F¶v FhnsS \S¯n F¶v  details AdnbnÃ.  AXn\v tijw 12.07.2022 hsc CXv kw_Ôn¨v aäv NnInÕ \S¯nbXmbn AdnbnÔ.  It is also deposed by OPW1 that “Cu policy ¡v medical examination BhniyanÃm¯XmWv.  policy FSp¡p¶ kab¯v \nehnepffXpw XpScp¶Xpamb AkpJamWv pre-existing disease Cu case  policy FSp¯v 5 hÀjhpw 5 amkhpw asämcp tcmKNnInÕbpw \S¯nbXmbn AdnbnÔ.  Further OPW1 deposed that “Cu tIkn varicose vein AkpJ¯nsâ direct cause sIm­Ã and¨v trauma (injury) sIm­mWv NnInÕn¨n«pffXv”.

11.  The overall consideration of the evidence on record shows that the insured was hospitalized only in July 2022 during the existence of policy ie from 09.02.2022 to 08.02.2023 which was a continuously renewing properly from 08.02.2018 onwards.  In the present case the contention and argument of Opposite Party is that the disease of the insurer is a pre-existing one and at the same time OPW1 deposed that the treatment was taken for the injury caused to the patient and not for varicose vein.  Moreover there is absolutely no evidence to substantiate the contentions of the Opposite Party and hence this Commission found that Point No.1 is proved by the Complainant in his favour and therefore passed the following Order.

1. The Opposite Parties are directed to pay an amount of Rs.65,394/- towards the treatment expenses with 12% interest from 12.07.2022 till the date of payment.
2. The Opposite Parties are also directed to pay an amount of Rs.25,000/- (Rupees Twenty Five Thousand Only) towards compensation and Rs.5,000/- (Rupees Five Thousand Only) towards cost of the proceedings.

Needless to say that the Opposite Parties are jointly and severally liable to pay the amounts stated above and the Order is to be complied with within one month from the date of receipt of the copy of this Order.  Otherwise the Opposite Parties will be liable for 6% interest for the entire amount except that is awarded as costs from the date of Order till date of realization.

Consumer Case is allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 12^th day of March 2024.

Date of Filing:-05.09.2022.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Sunil. M. D.                                                  Government Service.

Witness for the Opposite Parties:-

OPW1.          Balu. M.                                                        Deputy Manager.

Exhibits for the Complainant:-

A1(Series).   Copy of Insurance Policies (6 Numbers).

A2.                  Copy of Discharge Summary.

A3.                  Copy of Claim Form .                                            dt:21.07.2022.

A4.                  Copy of Acknowledgment of Documents.      Dt:01.08.2022.

A5.                  Copy of Repudiation of Claim letter.                Dt:19.08.2022.

A6.                  Copy of Rejection and Withdrawal of Approval Given Earlier.

                        Dt:13.07.2022.

Exhibits for the Opposite Parties:-

B1.                  Copy of Proposal Form.

B2.                  Copy of Policy for the period from 09.02.2022 to 08.02.2023.

B3.                  Copy of Request for cashless Hospitalization for Medical Insurance

Policy.

B4.                  Copy of Cashless Authorization Letter.                        Dt:12.07.2022.

B5.                  Copy of Assessment Sheet.

B6.                  Copy of Rejection and Withdrawal of Approval Given Earlier.

                        Dt:13.07.2022.

B7.                  Copy of Discharge Summary.

B8.                  Copy of Repudiation of Claim letter.                Dt:19.08.2022.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-