Denial Of Insurance Claim Due To Suppression Of Bleeding Issue During Menstrual Period Prior To Policy , Malappuram District Commission Holds Star Health Insurance Company Liable
The District Consumer Disputes Redressal Commission, Malappuram presided by Sri. Mohandasan K( President) , Smt.Preethi Sivaraman C ( Member ) Sri. Mohamed Ismayil C.V( Member) held Star Health & Allied Insurance Company Limited, liable for deficiency in service and unfair trade practice for denying the insurance claim. It was held that the bleeding issue during menstrual period is...
The District Consumer Disputes Redressal Commission, Malappuram presided by Sri. Mohandasan K( President) , Smt.Preethi Sivaraman C ( Member ) Sri. Mohamed Ismayil C.V( Member) held Star Health & Allied Insurance Company Limited, liable for deficiency in service and unfair trade practice for denying the insurance claim. It was held that the bleeding issue during menstrual period is a natural biological process of a woman.
Facts of the case
The complainant, Mr. Sathynathan , purchased an insurance policy for his family from Star Health & Allied Insurance Company Limited ( opposite party No. 1 ) on 09.10.2020 for a sum of Rs.4, 00,000/- vide policy No. P/181312/01/2023/006993. He had remitted Rs.14, 989/- towards the premium and renewed the same every year after remitting premium.
The complainant stated that he subscribed the insurance policy at the instigation of second opposite party (agent) and assurance that he could avail insurance benefit of up to 4, 00,000/- per year. It was contended that while availing the insurance policy the opposite party had not conducted any medical check-up of the complainant or the family members
Claim was made by the complainant as his wife had undergone a treatment while the policy was in force . The claim for Rs. 1, 07,027/- was initially approved by the opposite party but later withdrew the approval. The reason for withdrawal was that the wife of the complainant had consulted a doctor as outpatient during the year 2018 much prior to the commencement of policy. It was submitted that the wife of the complainant was not having any ailment to deny the insurance claim as it was natural biological process of a woman.
The complainant approached the consumer commission due to the denial of claim
Contention of the Opposite Party
The first opposite party, Star Health & Allied Insurance Company Limited, and third opposite party, insurance agent jointly filed their written version. The second opposite party, agent, filed version contenting that the complaint is not maintainable and the same is liable to be dismissed. He added that he is not aware of the facts mentioned in the complaint.
The opposite parties 1 & 3 stated that the policy was issued according to the terms and conditions only and it is a settled principle that the parties to the insurance contract are bound by the terms and conditions of the policy issued. They submitted that during the policy period the opposite party had received a request for cashless hospitalization from NIMS hospital, Malappuram stating that wife of the complainant was admitted in the hospital on 25/06/2023 and was provisionally diagnosed with urinary tract infection / cystitis.
Based on the discharge summary, the wife of the complainant was diagnosed with left tubo ovarian mass with abscess, urinary tract infection, type II diabetes mellitus, lap left salpingo oophorectomy under GA on 02/07/2023. Based on the available documents and bills, the first opposite party initially approved an amount of Rs. 1, 07,027/-.
The opposite party submitted that hospital record showed that the patient has a history of abnormal uterine bleeding and found that the wife of the complainant was consulted at NIMS hospital, Malappuram on 02/07/2018 with complaints of bleeding.
The opposite party stated that as per records the patient has been suffering from abnormal uterine bleeding since 2018 which is prior to the commencement of the policy. It was further submitted that the complainant failed to disclose the above history in his proposal form which amounts to non-disclosure of material facts. The opposite party contended that they repudiated the claim after the approval due to nondisclosure of pre-existing disease prior to inception of insurance policy
Observations By the Commission
The Commission observed that the policy was taken in the year 2020 and the outpatient consultation was in the year 2018, the policy was renewed up to 2023. No document is on record to show that the patient had undergone treatment during the policy period. It was observed that the patient is a lady, aged 42 years who consulted a doctor with a complaint of bleeding. The bleeding issue of a female that too of 42 years cannot be treated as an ailment as contended by the opposite party. The Bleeding Issue During Menstrual Period is a natural biological process of a woman. The Commission added that the opposite party initially approved the insurance claim for cashless treatment and with that expectation the patient has undergone the treatment. Therefore, the opposite party is liable for deficiency in service as well as unfair trade practice.
The Commission found that the first opposite party, Star Health & Allied Insurance Company Limited, is responsible for the deficiency in service and directed to pay Rs. 1, 07,027/- as the insurance claim amount to the complainant , Rs.50, 000/- as compensation on account of deficiency in service and Rs. 10,000/- as cost of the proceedings.
