State Consumer Disputes Redressal Commission
The Manager, The Star Health And Allied ... vs M. Narayana on 25 May, 2026
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL
COM M ISSION : HYDERABAD.
F.A.No. 452 OF 2022
AGAINST ORDERS IN C.C.24/2017
DISTRICT CONSUM ER COM M ISSION-III, HYDERABAD
Between:
1. Mr. Manaboti Narayana,
S/o Late Ramana, Aged about 59 years,
R/o Plot No.173, Near Saibaba Temple,
Srinivas Nagar, Chintal, Hyderabad,
Qutubullapur Mandal, Ranga Reddy District,
Telangana- 500 054.
2. Manaboti Indira, W/o Narayana,
Aged about 57 years,
R/o Plot No.173, near Saibaba Temple,
Srinivas Nagar, Chintal , Hyderabad,
Qutubullapur Mandal, Ranga Reddy District,
Telangana- 500 054
...........Appellants/Complainants
And:
1. The Manager,
The Star Health & Allied Insurance Co., Ltd.,
303/4, 3rd Floor, 12-13-97, Mundra Tara Tycoon,
Tarnaka, Hyderabad - 500 017.
2. The Star Health & Allied Insurance Co., Ltd.,
Rep. by its Managing Director, Regd. & Corporate Office,
1, New Tank Street, Valluvar Kottam High Road,
Nungambakkam, Chennai -600 034.
........Respondents/Opposite Parties
Counsel for the Appellants/Complainants : M/s.Y. Mallikarjuna
Reddy
Counsel for the Respondents/Opposite Parties : M/s. G.S.G.Radha
Krishna
&
2
F.A.No. 535 OF 2022
AGAINST ORDERS IN C.C.24/2017
DISTRICT CONSUM ER COM M ISSION-III, HYDERABAD
Between:
1. The Manager,
Star Health & Allied Insurance Company Ltd.,
303/4, 3rd Floor, 12-13-97, Mundra Tara Tycoon,
Tarnaka Br., Hyderabad - 500 017.
2. Star Health & Allied Insurance Company Ltd.,
Rep. by its Managing Director, Regd. & Corporate Office,
1, New Tank Street, Valluvar Kottam High Road,
Nungambakkam, Chennai -600 034.
...........Appellants/Opposite Parties
And:
1. Sri M. Narayana,
S/o Late M.Ramana, Aged about 53 years,
2. Smt. M. Indira, W/o Narayana,
Aged about 50 years,
Plot No.173, Near Saibaba Temple,
Srinivas Nagar, Chintal , Hyderabad,
Qutubullapur Mandal, R.R. District,
Telangana- 500 054
........Respondents/Complainants
Counsel for the Appellants/ Opposite Parties : M/s.G.S.G.Radha
Krishna
Counsel for the Respondents/ Complainants : M/s.Y. Mallikarjuna
Reddy
QUORUM :
HON'BLE SM T. JUSTICE DR.G.RADHA RANI, PRESIDENT
HON'BLE SM T. M EENA RAMANATHAN, M EMBER - (NON JUDICIAL)
HON'BLE SM T R.S. RAJESHREE- M EMBER (NON-JUDICIAL)
3
M ONDAY, THE 25th DAY OF M AY
TW O THOUSAND TW ENTY SIX
*******
Common Order :
PER HON'BLE SMT. MEENA RAMANATHAN, MEMBER (NON-JUDICIAL)
1. These are the appeals filed U/s 41 of Consumer Protection Act, 2019 by the Complainants in FA 452/2022 and the opposite parties in FA 535/2022, aggrieved by the order of District Consumer Commission-III, Hyderabad, dated 02.05.2022 in CC 24/2017. The District Commission made the following order:-
"In the result, the complaint is allowed in part directing the opposite parties jointly and severally : (i) to pay a sum of Rs.5,65,976/ - and Rs.9,445.30 p.a. towards medical expenses along with interest @ 9% from the date of claim till the date of realization.; (ii) to pay Rs.25,000/- towards compensation; (iii) to pay Rs.10,000/- towards costs of the complaint; time for compliance is 45 days from the date of receipt of this order".
2. The parties are herein after referred to as they were arrayed before the District Commission, as complainants and opposite parties.
3. a) The brief averments of the complaint are that the complainant No.1 is a private employee and complainant No.2 is his wife and they have taken family health Optima Insurance Policy vide No.P/131116/01/2016/015086 from opposite party No.1 on 18.03.2016. At the time of taking the policy complainant No.1 underwent a medical examination as per the norms of the opposite parties. On 27.09.2016 4 complainant No.1 suffered profuse sweating and tightness of chest and was shifted to Aster Prime Hospital, Ameerpet. On examination he was advised to undergo Angioplasty and thereafter was admitted as an in- patient in the same hospital and underwent stenting. He submitted pre - authorization request with necessary documents to the opposite party No.1. He claims that he incurred an expense of Rs.5,45,000/- towards the surgery. He also incurred expenses of Rs.11,115.75 ps. towards medical and other expenses. On 29.09.2016 opposite party No.1 rejected his claim stating that, "the patient is admitted for evolve anterior septal wall MI for this patient IHD is an endorsed PED".
b) It is also submitted that the complainant No.1 was ne ver suffering from any pre-existing disease and the rejection of the claim has only caused him great mental agony and harassment. On account of the rejection by the opposite parties his wife complainant No.2 suffered an acute paralytic stroke and was admitted in the same hospital on 01.10.2016 and discharged on 02.10.2016. For her treatment the hospital charged an amount of Rs.20,976/-. Claims were raised for the treatment undergone by complainant No.2 also. Despite issuance of legal notice, the opposite parties have not responded and this constitutes not only deficiency in service but also unfair trade practice, hence, the present complaint is raised for redressal.
4. (a) The brief averments of the written version of Opposite Parties No.1 & 2 : It is admitted that the complainants have availed a Family Health Optima Insurance Policy P/131116/01/2016/015086 with the opposite parties for the period 18.03.2016 to 17.03.2017 for cashless reimbursement of medical expenses. It is submitted that the policy issued was endorsed with "PED of calculous disease of hepato pancreatic-biliary 5 system all complications of renal cysts, treatment of diseases related to cardio vascular system, diabetes mellitus and its complications for Mr.Narayana". Moreover, the insured gave consent for the same vide letter dated 26.03.2016. The policy is contractual in nature and the claims arising therein are subject to terms and conditions of the policy. The terms and conditions specifically states that the insurance company is not liable to pay in respect of any claim, if there is any mis-representation or non-disclosure of material fact by the insured to the Insurer. The complainant had accepted the terms and conditions of the policy and thereafter executed the proposal.
b) The complainant made a pre-authorization request to avail cashless facility for his hospitalization on 27.09.2016. On scrutiny of the pre - medical examination records, the complainant No.1 had endorsed to the following PED diseases:-
Diabetes Mellitus and its complications.
Treatment of diseases related to Cardio Vascular System. All complications of renal cysts.
Calculous diseases of Hepato pancreatico- biliary system.
c) These above exclusions would be covered only after 04 years from the date of inception of the first policy subject to continuous renewal. This was communicated to the complainants and they gave their consent vide letter dated 16.03.2016. Based on the above submissions, the opposite parties contend that there is no cause of action for the present complaint and it is highly vexatious and is an abuse of the benevolent provisions of the Consumer Protection Act.
5. Before the Commission below, complainant filed evidence affidavit as PW1 and marked Ex. A1 to A16. Sri Ch.Veeraraghavaiah, Vice President of opposite parties Company filed evidence affidavit and got marked Ex.B1 to B6.
66. The District Commission on considering the material on record allowed the complaint.
7. Aggrieved by the orders of the District Commission, the present FA 452/2022 is filed by the complainants with the following grounds:-
The order of the District Commission is contrary to law, weight of evidence and probabilities of the case.
The District Commission ought to have granted interest at 18% per annum on the medical expenses awarded to the complainants as claimed by them.
The Commission below ought to have granted adequate compensation instead of a nominal compensation of Rs.25,000/- which is disproportionate to the sufferance caused to the complainants.
The Commission below did not grant punitive damages of Rs.6,00,000/- as claimed by the complainants and did not assign any reasons for not granting the punitive damages. It ought to have granted punitive damages as the opposite parties acted with malice and deceit which is patent from filing forged and fabricated affidavit of the complainant No.1, marked at the instance of the opposite parties as Ex.B3.
The Commission below ought to have granted expenses of Rs.10,000/- incurred towards the fee paid to the handwriting expert in IA No.93/2020 in CC 24/2017 dated 07.12.2021.
The Commission below ought to have considered the conduct of the respondents in introducing a forged affidavit for the purpose of defeating the claim of the complainants prejudicing the cause of the judicial proceedings undermining the flow of unsoiled stream of justice.
With these grounds and others that will be urged at the time of arguments, requested to set aside the order of the Commission below and to allow the appeal.7
8. Aggrieved by the orders of the Commission below, the present FA 535/2022 is filed by opposite parties No.1 & 2 with the following grounds:
The District Commission while passing order ought to have discussed in legal perspective the evidence on record especially Ex.B1 i.e. policy schedule with its terms and conditions besides other exhibits B2 to B7.
The District Commission ought to have observed from PEDs endorsed on the policy that the Complainant No.1 had undergone pre-medical tests at their expense on submission of his proposal form and based on results of pre-medical examination, PEDs endorsed promptly communicated to the complainant. Whereas, the District Commission grossly erred in observing in its Order stating that their health is found to be normal and no PEDs disclosed, ignoring our evidence of pre-medical tests.
The District Commission ought to have observed that the PEDs will be covered only after 04 years, from the date of inception of first policy subject to continuous renewal whereas, the subject claim occurred in the very first year of policy.
The District Commission grossly erred in passing the order ignoring the facts from time of proposal till issue of insurance policy, fixing liability wrongly upon these opposite parties, that too for a far higher amount than the sum insured of Rs.3.00 lakhs which is the maximum liability of the opposite parties under subject policy, if at all liability is as per terms and conditions of policy established.
With these grounds and others that will be urged at the time of arguments, requested to set aside the order of the Commission below and to dismiss the complaint.
9. Heard both sides. Both the counsel filed written arguments and the same is taken on record.
10. The point that arises for consideration is whether the impugned order as passed by the District Commission suffers from any error or 8 irregularity or whether it is liable to be set aside, modified or interfered with in any manner ? To what relief ?
11. POINT: The complainants have taken family health Optima Insurance Policy vide No.P/131116/01/2016/015086 from opposite party No.1 on 18.03.2016 by paying a premium of Rs.15,217/-. On 27.09.2016 the complainant No.1 suffered a tightness of the chest and was admitted to Aster prime Hospital, Ameerpet and underwent stents for the heart problem. He incurred a total expense of Rs.5,45,000/- towards the surgery plus other expenses of Rs.11,115.75 ps.. The claim was repudiated stating that "the patient is admitted for evolve anterior septal wall MI for this patient IHD is an endorsed PED". On account of the sudden repudiation of the claim, it is submitted that complainant No.2 suffered acute paralytic stroke on 01.10.2016 and for her treatment incurred an expense of Rs.20,976/-. The opposite parties have contended that the complainants had availed the policy P/131116/01/2016/015086 for sum insured of Rs.3.00 lakh only for the period 18.03.2016 to 17.03.2017. It is their main defense that the policy issued was endorsed with "PED of calculous disease of hepato pancreatic-biliary system all complications of renal cysts, treatment of diseases related to cardio vascular system, diabetes mellitus and its complications for Mr.Narayana ". Moreover Mr.Narayana- the complainant No.1 had given his consent and signed the letter dated 26.03.2016 as evidenced vide Ex.B3. Subject to the terms and conditions of the policy, if there is an misrepresentation and non- disclosure of material fact by the insured to the insurer, the Insurance Company is not liable to pay in respect of any claim. A keen perusal of Ex.B3 dated 28.03.2018 re veals that the opposite parties were in a position to grant cover subject to the following exclusions:-
Diabetes Mellitus and its complications.
Treatment of diseases related to Cardio Vascular System.9
All complications of renal cysts.
Calculous diseases of Hepato pancreatico- biliary system.
12. This letter was supposedly signed by the proposer- complainant No.1. This exhibit was sent to the Central Forensic Science Laboratory for expert examination and opinion. The signature on Ex.B3/Q1 examined with the signatures on enclosures marked Ex.A1 to A10 and the opinion was forwarded to the President, District Consumer Commission-III, Hyderabad vide letter dated 26.12.2019. The opinion reads as follows:-
"My opinion is based upon the cumulative consideration of various dissimilarities occurring both between the questioned on one hand and the standards on the other. The questioned signature marked Q1 is drawn and formal in nature exhibiting inherent signs of forgery.
The cumulative consideration of above mentioned observations are convincing and sufficient and are all beyond the range of natural variations and intended disguise and do not coincide in the writing habits of a common person and when considered collectively leads me to opinion of their different authorship".
13. The opposite parties have repudiated the claim on a document that is apparently forged and concocted by the Insurance Company to repudiate the claim. The complainants have preferred this appeal urging that the District Commission failed to assign any reason for the conduct of the opposite parties who have unethically introduced a forged affidavit and that they have not been adequately compensated for this fabrication and unfair repudiation. A perusal of the policy filed vide Ex.A1 discloses that the period of insurance is from 18.03.2016 to 17.03.2017 and basic floater sum insured is Rs.3,00,000/-.
14. The District Commission in their impugned order did not advert to the forged document or the expert opinion received from Central Forensic 10 Science Laboratory, Govt. Examiner of Questioned Documents, DFSS, MHA Govt. of India, Ramanthapur Hyderabad. This absolute disregard for such a fabrication by the District Commission is a grave error and cannot be thus ignored. Although the complainants submitted bills for Rs.5,45,000/- (Ex.A5) and Rs.9,370 ps. vide Ex.A14 . The District Commission gravely erred in granting the entire amount when the policy coverage is restricted to only Rs.3.00 lakh. The District Commission cannot grant an amount over and above the policy coverage limits. The District Commission failed in their primary duty of perusing the policy document and went beyond the coverage limit. The claim of Complainant No.2 is only for a sum of Rs.20,976/- as e videnced vide Ex.A8. She was admitted in Aster Prime Hospital on 01.10.2016 and discharged on 02.10.2016. She is also entitled to the reimbursement as the policy is taken in the name of her husband and the family members. Although, the principal claim amount cannot exceed the sum insured, the complainants deserve additional compensation for the harassment and deficiency in service for the wrongful denial based on a fabricated document. The impugned order did not provide adequate reasoning and thus the order is set aside and the appeal is partly allowed by modifying the impugned order.
15. In the result, the FA 452/2022 and FA 535/2022 filed by both the parties is partly allowed by modifying the impugned order dated 02.05.2022 in CC 24/2017 passed by the District Consumer Commission- III, Hyderabad, with the following directions:-
(i) The opposite parties are directed jointly and severally to pay the Complainant No.1 a sum of Rs.3,00,000/- along with interest at 9% per annum from date of claim (i.e. 29.09.2016) till realization.11
(ii) The opposite parties are directed jointly and severally to pay the Complainant No.2 a sum of Rs.20,976/- along with interest at 9% per annum from date of claim (i.e. 29.09.2016) till realization.
(iii) The opposite parties are directed jointly and severally to pay a sum of Rs.50,000/- towards compensation for the unfair and unethical practices adopted by them along with costs of Rs.10,000/-.
Time for compliance is 30 days from the date of receipt of this order.
Typed to my dictation by Stenographer on the System; corrected by me and pronounced by us in the Open Court on this the 25th day of May' 2026.
Sd/- Sd/- Sd/-
PRESIDENT M EM BER-NJ M EM BER-NJ
Dt: 25.05.2026
AD*