MRS. P. INIYA W/o. mr.r.kaaviyan v. STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

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frustration suffered by the complainants and to pay the cost of this complaint.

I. The averments of Complaint in brief are as follows:-

1) The Complainants state that based on the representation of 4th Opposite party, the Complainants paid a total premium of Rs.21,782/- for the health insurance policy. The policy was issued in the name of 1^st Complainant (Mrs. Iniya) bearing no. 11250954209800 and product unit number assigned is SHAHLIP23132V02223 and the 2^ndComplainant (Mr. Kaaviyan) was named as the Nominee for the said Policy. The period of insurance was from 14.05.2024 to 14.05.2025, with a sum assured of Rs.15,00,000/-.

2) The Complainants state that after the policy was issued, the 1^st Complainant became pregnant. Based on the assurances given by the opposite parties and the coverage details provided by them, the complainants were confident that the insurance policy would cover all medical expenses and also Delivery related expenses as mentioned in the Policy Summary.

3) The Complainants state that in the last week of January 2025, the 1^stComplainant was affected with severe loose stools and vomiting. As the 1^stComplainant had been regularly consulting Dr. R. Priya Kannappan for Pregnancy related medical care at Dr.Mehta's Hospital in Chennai, she approached the said Hospital on 29.01.2025. On diagnosis it was found that

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the 1^stComplainant was affected with Acute Gastroenteritis, which is an infection caused in stomach by bacterial and parasitic infections. Hence, the 1^stComplainant was referred to Dr. R. Dilip kumar, a specialist in internal medicine, in the said Dr. Mehta's Hospital. Under his care and advise the 1st Complainant was admitted to the hospital and was treated for Acute Gastroenteritis. It is pertinent to mention that her Acute Gastroenteritis condition was no way connected/caused due to pregnancy of the 1^st Complainant.

4) The Complainants state that after admission to the hospital, the Complainants immediately informed the Opposite parties about the hospitalization and requested cashless treatment under the health insurance policy. However, the request for cashless hospitalization was denied. As a result, the Complainants were required to pay the full hospital charges of Rs.34,312/- and the 1^st Complainant was discharged from the hospital on

31.01.2025.

5) The Complainants state that after the discharge, the Complainants continued to follow up with the Opposite Parties for reimbursement of the hospital expenses incurred. However, the Complainants were shocked to receive a letter dated 15.02.2025, in which the 2^ndOpposite party refused to reimburse the expenses and also informed them that as per exclusion- maternity code XL18, the Company is not liable to make any payment in respect of medical treatment expenses, traceable to child birth and the said

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letter was sent by 2^ndOpposite party without even the name of the signee but simply mentioning "Team Star Health".

6) The Complainants state that they were shocked by the refusal of the Opposite Parties on baseless and false ground stated in their letter dated 15.02.2025. The hospitalization of 1^stComplainant on 29.01.2025 had no connection to childbirth or pregnancy. The 1^stComplainant was admitted solely for the treatment of Acute Gastroenteritis, with symptoms of loose stools and vomiting. No treatment related to pregnancy was administered during her hospitalization. Hence alleging deficiency in service the present complaint is filed.

II. Written Version of Opposite Parties in brief is as follows:

7) The Opposite Parties submit that the complainants had purchased Star Women Care Insurance Policy from the Opposite Parties for floater sum insured of Rs.15,00,000/- vide policy no. 11250954209800 valid for the period from 15.05.2024 to 14.05.2025.

8) The Opposite Parties submit that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The terms and conditions of the Policy were explained to the Complainants at the time of proposing policy and the same was served to the Complainants along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS

POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES,

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EXCLUSIONS ETC., ATTACHED". The Complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form.

9) The Opposite Parties submit that the insured patient aged 32 years/female was admitted at Mehta Multispeciality Hospitals India Pvt. Ltd. Chennai on 29.01.2025 for the diagnosis of PREGNANCY and was discharged on 31.01.2025. The insured raised a pre authorization request from the above said hospital on 29.01.2025 to avail cashless treatment. On scrutiny of the pre authorisation request and available documents, it was observed that further evaluation was required to decide the admissibility of the claim. Therefore the pre authorisation request was denied and the insured was requested to approach for reimbursement with complete documents vide letter dated 30.01.2025.

10) The Opposite Parties further submit that, subsequently the insured submitted claim documents for reimbursement of medical expenses. On perusal of the medical records, it was observed that the insured patient has undergone primary treatment for pregnancy and its related complications. As per Exclusion No. 18 (i)of the policy issued to the insured,

"Maternity - Code Excl 18: The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of, Medical treatment expenses traceable to childbirth including complicated deliveries

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and caesarean sections incurred during hospitalization except ectopic pregnancy and towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period."

Hence the claim was repudiated and the same was communicated to the insured vide letter dated15.02.2025

11) The Opposite Parties submit that there is no deficiency in-service rendered by the insurance company and hence, Complainants are not entitled for the any amount as prayed in the complaint.

III. The Complainants have filed proof affidavit, in support of their claim in the complaint and has filed 10 documents which are marked as Ex.A-1 to Ex.A-10. The 1^st, 2^nd, 3^rd & 4^th Opposite Parties had submitted their proof affidavit. On the side of Opposite Parties Ex.B-1 to Ex.B-9 were marked. Written arguments of Complainants and Opposite Parties filed.

Points for Consideration:-

1. Whether there is any deficiency in service on the part of the Opposite Parties?

2. Whether the Complainants are entitled for the reliefs sought for?

3. To what other relief, the Complainants are entitled to?

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POINT NO. 1 :-

12) The facts that the Complainants availed Star Women Care Insurance from the Opposite Parties based on the representation of the 4^th Opposite party on payment of total premium of Rs.21,782/- and the policy was issued in the name of the 1^stComplainant and the 2^ndComplainant was a nominee for the said policy covering the period from 15.05.2024 to 14.05.2025 for the sum assured of Rs.15,00,000/- are not disputed. According to the Complainants based on the guidance of the 4^thOpposite party working with the 3^rdOpposite party that the policy would cover maternity expenses in addition to general additional expenses they had availed the Health Insurance Policy. After the policy was issued the 1^st Complainant became pregnant. While so, in the last week of January 2025, the 1^stComplainant was affected with severe loose stools and vomiting. She approached Dr.Mehta's Hospital in Chennai, on diagnosis it was found that she was affected with Acute Gastroenteritis which is an infection cause in stomach by bacterial and parasitic infections, and was treated for the same at the hospital. After admission to the hospital the Complainants informed the Opposite parties about the hospitalization and requested cashless treatment under Health insurance policy. However the request for cashless hospitalization was denied and the Complainants were required to pay the full hospital charges of Rs.34,312/- and the 1^stComplainant was discharged on 31.01.2025. Even after the discharge the Complainants continued to follow up with the Opposite parties for reimbursement of hospital expenses.

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However they received a letter dated 15.02.2025, in which the 2^nd Opposite party refused to reimburse the expenses as per the exclusion-maternity code

XL18.

13) The Opposite parties admitted that the Complainant purchased Star Women Care Insurance policy from the Opposite parties for the floater sum insured of Rs.15,00,000/- vide policy No.11250954209800 valid for the period from 15.05.2024 to 14.05.2025. Further submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The Complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Further submitted that the insured patient aged 32 years/female was admitted at Mehta Multispeciality Hospitals India Pvt. Ltd Chennai on 29.01.2025 for the diagnosis of PREGNANCY and was discharged on 31.01.2025. The insured raised a pre authorization request from the above said hospital on 29.01.2025 to avail cashless treatment. On scrutiny of the pre authorisation request and available documents, it was observed that further evaluation was required to decide the admissibility of the claim. Therefore the pre authorisation request was denied and the insured was requested to approach for reimbursement with complete documents vide letter dated 30.01.2025.

14) The Opposite Parties further submitted that, subsequently the insured submitted claim documents for reimbursement of medical expenses.

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On perusal of the medical records, it was observed that the insured patient has undergone primary treatment for pregnancy and its related complications. As per Exclusion No. 18 (i)of the policy issued to the insured, the Company shall not be liable to make any payments under the policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of Medical treatment expenses traceable to childbirth. Hence the claim was repudiated and the same was communicated to the insured vide letter dated 15.02.2025.

15) Ex.A-1 and B-2 are one and the same which is the Health Insurance Policy issued by the 3^rdOpposite party on 16.05.2024 in the name of the 1^stComplainant for the period from 15.05.2024 to 14.05.2025 for the basic floater sum insured of Rs.15,00,000/-. During the policy period the 1^st Complainant was admitted in Dr.Mehta's hospitals on 29.01.2025 on complaints of vomiting, loose stools as evident from Ex.A-3. It is found from Ex.A-4, the discharge summary that Dr.R.Dhilipkumar, had diagnosed the 1^stComplainant with Acute Gastroenteritis, after conducting various tests was treated for loose stools and was discharged on 31.01.2025. The Complainant has incurred a sum of Rs.34,312/- as medical expenses in the said hospital as per Ex.A-5, the consolidated bill issued by Dr.Mehta's Hospital. As per Ex.A-6 the Opposite parties had rejected the claim of the Complainants stating that as per policy exclusion-Maternity- Code XL18 of the policy the company is not liable to make any payment in respect of medical treatment

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expenses traceable to Child birth. Hence the Complainant had issued a legal notice dated 05.03.2025 under Ex.A-7 seeking reimbursement of the claim amount from the Opposite parties which was duly received by them.

16) The Opposite party contended that the Complainant had accepted the policy after being fully aware of the terms and conditions and executed the proposal form dated 15.05.2024 under Ex.B-1. The pre-authorization request form of the Complainant on 29.01.2025 under Ex.B-4 was denied by the Opposite parties on 30.01.2025 as seen in Ex.B-5. Subsequently on the discharge of the 1^stComplainant as per the discharge summary dated 31.05.2025, Ex.B-7, the Complainant had claimed for reimbursement of the medical expenses under Ex.B-6 and same was rejected on 15.02.2025 under Ex.B-8 quoting the exclusion clause-maternity-code XL18 of the insurance policy.

17) On the facts and circumstances of the case it is clear that during the subsistence of the policy the 1^stComplainant was admitted in Dr.Mehta's Hospital on 29.01.2025 and got discharged on 31.01.2025 by incurring an expenses of Rs.34,312/-. The contention of the Opposite party is that the Complainant has undergone primary treatment for pregnancy and its related complications and therefore excluded under clause 18 of the policy. It is true that the insurance company is not liable for the medical treatment expenses traceable to child birth which is extracted hereunder:

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"Maternity - Code Excl 18: The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of; Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy and towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period."

18) However a perusal of the discharge summary would reveal that the 1^stComplainant was admitted on complaints of loose stools which was diagnosed as Acute Gastroenteritis which is no way connected to the pregnancy/child birth. Hence the repudiation of the Opposite parties on the ground that the treatment was related to pregnancy/child birth is untenable and is liable to repay the medical expenses. The Complainant has proved that the Opposite parties committed deficiency in service in repudiating the lawful claim of the Complainants. Accordingly point no.1 answered.

Point 2 & 3

The Complainants has proved the expenses incurred for the medical treatment of the 1^stComplainant at Dr.Mehta's Hospital vide consolidated bill issued under Ex.A-5 for the sum of Rs.34,312/-, which the Opposite parties are liable to reimburse the Complainants. The Opposite parties are also liable to pay a sum of Rs.10,000/- as compensation for deficiency in service along with to pay a sum of Rs.10,000/- towards cost of the litigation. The

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Complainant is not entitled for any other relief/s. Accordingly Point Nos.2 and 3 are answered.

In the result the complaint is partly allowed. The 1^st, 2^nd 3^rd & 4^th Opposite Parties are jointly and severally directed to reimburse the sum of Rs.34,312/- (Rupees Thirty Four Thousand Three Hundred Twelve only) towards medical expenses and to pay a sum of Rs.10,000/- (Rupees Ten Thousand Only) as compensation for deficiency in service along with a sum of Rs.10,000/- (Rupees Ten Thousand Only) towards cost of the litigation, within 8 weeks from the date of receipt of this order, failing which the above amounts shall carry interest at 9% per annum from the date of filing of the complaint till the date of realization.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 29^th day of October 2025.

T.R. SIVAKUMHAR B.JIJAA

MEMBER I PRESIDENT

List of documents filed on the side of the Complainant:-

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List of documents filed on the side of the Opposite Parties:-

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T.R. SIVAKUMHAR B.JIJAA

MEMBER I PRESIDENT