State Consumer Disputes Redressal Commission
Star Health And Allied Insurance Co Ltd vs Dr Ajit Haribhau Kittur on 5 September, 2018
1 (A/12/33)
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
MAHARASHTRA, MUMBAI
FIRST APPEAL NO.A/12/33
(Arisen out of Judgment and order dated 21/10/2011 passed by Ld.
Kolhapur District Forum in complaint No.522 of 2010)
Star Health And Allied
Insurance Co.Ltd.
Jemstone, New Shahupuri,
Kolhapur. Appellant(s)
versus
Dr.Ajit Haribhau Kittur
Plot No.53/294/A,
E Ward, Near LIC Office,
Nagala Park,
Kolhapur. Respondent(s)
BEFORE:
Hon'ble Mr.Justice A.P.Bhangale, President
Hon'ble Mr.A.K.Zade, Member
PRESENT:
For the Advocate Shri.A.S.Vidyarthi
Appellant(s):
For the
Respondent(s): Advocate Shri.Uday Wavikar
ORDER
Per: Hon'ble Mr.Justice A.P.Bhangale, President
[1] By this appeal appellant has questioned validity and legality of the impugned Judgment and Award dated 21/10/2011 in consumer complaint No.522 of 2010 decided by the learned District Consumer Disputes Redressal Forum, Kolhapur whereby complainant was granted sum of Rs.2,00,000/- pursuant to the mediclaim policy together with interest @9% p.a. w.e.f. the date of repudiation dated 08/07/2010, litigation costs in the 2 (A/12/33) sum of Rs.1,000/- and compensation for mental harassment in the sum of Rs.1,000/- was also granted.
[2] Heard submissions at the bar.
[3] Ld.Advocate Shri.Vidyarthi on behalf of appellant submitted that the policy bearing No.P/151117/01/2010/000184 undertaken by the appellant for Dr.Ajit Haribhau Kittur resident of Plot No.53/294/A, E Ward, near L.I.C. office, Nagala Park, Kolhapur was for insured sum of Rs.2,00,000/-. It is submitted that the learned Forum below erred to grant entire sum of Rs.2,00,000/- although the appellant has considered the claim for approval of expenses to the tune of Rs.76,600/- only. Our attention is invited to the claim in respect of medical treatment for ICU room, professional charges, investigation charges and other ancillary expenses for which appellant has made total deduction in the sum of Rs.1,89,124/- from total bill of Rs.2,65,724/-. Thus appellant/opponent approved sum of Rs.76,600/- only as payable to the complainant. Further according to the Ld.Advocate for the appellant no any claim ought to have been paid to the complainant since he had suppressed material fact of his earlier ailment and since contract of insurance is of 'utmost good-faith' complainant is not entitled to claim any amount. Our attention is invited to the Discharge Summary dated 17/03/2010 whereby in the history of patient-Dr.Ajit Kittur, aged about 64 yrs, male, it was disclosed 'known case of type II Diabetes Mellitus and non-hypertensive Evaluated one of IHD-old IWMI and (CAD Proximal LAD-30-40%, distal RCA-subtotal occlusion (coronary Angiography done on 04/03/1995 and he has undergone PTCA to Distal RCA in 1995). Patient presented with complaints of exertional chest discomfort since 1-2 months for which he had consulted at a local doctor diagnosed as IHD-Unstable Angina and referred here for further management'. According to the Ld.Advocate Shri.Vidyarthi since patient had already undergone the ailment in the year 1995 he should have disclosed it to the appellant before he entered into the insurance contract. However, in the 'Star Senior Citizens Red Carpet Insurance Proposal' of the appellant he answered in the negative 3 (A/12/33) the question as to whether he had suffered from any disease or illness irrespective of whether he was hospitalized or not or sustained any accident, he had answered in negative. Therefore, it is contended that the learned District Forum on the ground of suppression of material fact ought to have dismissed the complaint.
[4] On the other hand Ld.Advocate Shri.Wavikar argued that it is a Senior Citizen's Red Carpet Insurance policy and senior citizen is bound to suffer from ailment or other in the past. It cannot be expected that he should be fully healthy person and principles of section 45 of the Insurance Act must be borne in mind while considering the claim pertaining to the senior citizen. It was mediclaim policy for the insured sum of Rs.2,00,000/- and the patient had submitted bill in the sum of Rs.2,65,724/- for the medical treatment undergone by him. In fact, insurer ought not to have deducted any amount from the claim on account of ICU room, professional charges as also investigation, medicine and other expenses payable. The amount of Rs.1,89,124/- was wrongly deducted so as to partially approve the claim to the extent of Rs.76,600/- only. That being so, it is contended that in such cases where medical insurance policy in respect of senior citizen is undertaken without any evidence as to which terms of the printed contract of insurance were explained to the insured, there can be no justification for the deductions. Our attention is invited to the ruling of Union Territory Consumer Disputes Redressal Commission, UT Chandigarh in Appeal No.191 of 2010 between National Insurance Company Limited versus Dharam Singh and others, decided on 12/10/2010 whereby complainant was entitled to total expenses incurred on the treatment since in case of treatment/operation of the heart problems the beneficiary of this scheme is entitled upto a sum of Rs.1,50,000/- and if the expenses incurred for the said treatment is more than Rs.1,50,000/- then the member would be entitled to 50% of the amount in excess of Rs.1,50,000/- to Rs.2,00,000/-, apart from claim as to compensation for mental agony and harassment in the sum of Rs.20,000/- and litigation expenses of Rs.5,000/-. We have 4 (A/12/33) considered the ruling sited before us. We have considered the Financial Approval form. In our opinion when total bill amount was in the sum of Rs.2,65,724/- as expenses incurred by the senior citizen the deduction to the extent of Rs.1,89,124/- was unreasonable and uncalled for as senior citizen who had taken the mediclaim policy is entitled to receive best of the available treatment subject to maximum coverage of the insurance policy. In this case, coverage was in the sum of Rs.2,00,000/-. The alleged medical ailment in respect of past history was long back in the year 1995 and that cannot be considered so as to deduct the expenses particularly considering the nature of insurance policy and when the beneficiary is senior citizen under the policy. We are therefore of the opinion that no interference is warranted in the facts and circumstances of the case with the impugned Judgment and Award. That being so, appeal is dismissed. No order as to costs.
Certified copy of this order be supplied to both the parties. Pronounced on 5th September, 2018.
[JUSTICE A.P.BHANGALE] PRESIDENT [A.K.ZADE] MEMBER rsc