BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH,                                                                                                         MANGALORE

Dated this the 30^th November 2016

PRESENT

SRI. VISHWESHWARA BHAT D          :  HON’BLE PRESIDENT

 SRI. T.C. RAJASHEKAR                       :  HON’BLE MEMBER

ORDER IN

C.C.No.261/2013

(Admitted on 23.09.2013)

Mrs. Lalitha,

W/o Koragappa,

Aged about 44 years,

R/at Kallare House,

Puttur Kasba Village,

Puttur, D.K.

                                             ….. COMPLAINANT

(Advocate for the Complainant: SD)

VERSUS

1. Senior Divisional Manager,

The Oriental Insurance Co. Ltd,

Divisional Officer,

Beauty Plaza, 2^nd Floor,

Balmatta Road, Mangalore  01.

2. Manager,

TTK Health Care TPA, Pvt. Ltd.,

#2, H.B, Complex, 100 Ft, BTM Ring Road,

BTM 1^st Stage, BTM Layout,

Bangalore  68.

                                                  …......OPPOSITE PARTIES

(Advocate for the Opposite Parties No.1: AKK)

 (Opposite Parties NO.2: Ex-parte)

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI. VISHWESHWARA BHAT D:

I.       1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against claiming certain reliefs. 

The brief facts of the case are as under:

     The complainant is the holder of Mediclaim Policy issued by opposite party No.1 for the period from 2.9.2011 by paying the required premium. On 21.9.2011 she was admitted and undervent operation at Mahaveer Medical Centre Puttur for complaint of pain Abdomen, Bleeding per Vagine   since 6 month, Fibroid Uterus for Surgical MGMT (Abdominal Hysterectomy) and was discharged on 26.9.2011.  When opposite party lead claim for under the policy with opposite party No.1 for the bill amount of Rs.17,940/ it was repudiated by pointing to exclusion in 1^st  and 2^nd  years on untenable grounds.  Hence seeks direction to opposite party to make payment with 12% interest, to pay compensation and cost.

      II.   Opposite party No.1 in the written version admitted Happy Family Floater Mediclaim Insurance Policy issued to complainant as claimed but the liability was denied in view of exclusion clause 4.3(ix) of the policy on evaluation of the claim by 3^rd party administer that opposite party No.2 this was admitted to claim.   Hence she is not entitled for any of the reliefs claimed.  2.  In support of the above complainant Mrs. Lalitha filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked as Ex.C1 to C7 detailed in the annexure here below.  On behalf of the opposite party Mr. Gopikrishna Rao.M (Rw1) Administrative officer also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked as Ex.R1 detailed in the annexure here below.

III.     In view of the above said facts, the points for consideration in the case are:

1. Whether the Complainant is a consumer and the dispute between the parties?
2. If so, whether the Complainantis entitled for any of the other reliefs claimed?
3. What order?

      We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:

             Point No. (i): Affirmative

            Point No. (ii): Negative

           Point No. (iii): As per the final order.

                                                                                      REASONS

IV.      POINTS No. (i):  The insurance policy purchased by complainant from opposite party No.1 as mentioned in the complaint is admitted by defense.    However the liability to pay the expences of hospitalization is repudiated by opposite party No.1 the service provider to complainant the consumer.  Hence we answer point No.1 in the affirmative.

POINT NO.(ii):   Ex.C1 is the  Health card issued by opposite parties under the Insurance Policy purchased by complainant.  Ex.C2 is the discharge summary of the treatment of the complainant for the ailment as mentioned in the complaint.  Ex.C3 are the series of the bill receipts towards the medical expences.  Ex.C6 is the intimation given to complainant by opposite party No.2 repudiating the claim by point out the 2 column 4.3 (ix) of the policy. Has seen from the policy 4.2and 4.3(ix).

    2.       Ex.R1 the policy under 4.3(ix) which reads thus:

   The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy.

   If the diseases are pre-existing at the time of proposal the exclusion no.4.1 for pre-existing condition SHALL be applicable in such cases:

(ix)  Hystercectomy for menorrhagia or fibromyoma or     

       myomectomy or prolapse of uterus.       2 years.

3.     Infact 4.1 of the policy mentioned another type of exclusion 4.1 of Ex.R1 read thus:

     Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 4 years of this policy being in force continuously.

4. As seen from the allegation from complaint the complainant herself mentions which is also reflected in Ex.C2 the discharge summary that she was suffering this ailment 6 months prior to date of admission.  The health policy admittedly purchased on 2.9.2011 just about 3 weeks prior to the admission of the complainant to the hospital.  Hence we are of the opinion viewed from any angle repudiation of the claim by opposite party No.1 is justified.   Hence answer point No. 2 in the negative.

POINTS No. (iii): Wherefore the following order

ORDER

                                                                                         The complaint is dismissed.

Copy of this order as per statutory requirements, be forward to the parties free of costs and file shall be consigned to record room.

(Page No.1 to 6 Dictated directly to the computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 30^th  November 2016)

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  Mrs. Lalitha

Documents marked on behalf of the Complainant:

Ex.C1: 02.09.2011     : Copy of the Insurance Card

Ex.C2: 26.09.2011     : Original discharge summary

Ex.C3: 26.09.2011     : Original bills (17)

Ex.C4: 15.10.2012     : O/c of the regd lawyer s notice

Ex.C5: 17.10.2012     : Postal Acknowledgement of 1^st O.P

Ex.C6: 09.11.2012     : Reply of the 2^nd O.P

Ex.C7: 26.09.2011     : Repudiation letter of 2^nd O.P

Witnesses examined on behalf of the Opposite Parties:

RW1:  Mr. Gopikrishna Rao.M

Documents marked on behalf of the Opposite Parties:

Ex.R1: Mediclaim Policy bearing No.422207/2012/232 issued to the Complainant valid from 02.09.2011 to 01.09.2012

Dated:  30.11.2016                                  PRESIDENT