By Smt. C. S. Sulekha Beevi, President,
1. The complainant is aggrieved by the repudiation of the mediclaim policy by opposite party. Complainant availed a mediclaim policy from opposite party on 18-7-2008 for a period of three years. During the currency of the policy on 27-01-2009 complainant was admitted in MIMS Hospital with complaints of 'ache all over the body for a past few days'. After examinations and investigations, the complainant was diagnosed to have multinodular goiter left lobe. She was advised for immediate surgery. Complainant underwent left hemithyroidectomy. She spent Rs.45,859/- towards claim to opposite party along with necessary documents. But opposite party repudiated the claim stating that the ailment suffered by the complainant is a pre-existing disease and is excluded under clause 10 of the policy. Complainant alleges that opposite party has repudiated the policy on unsustainable grounds. Hence this complaint alleging deficiency in service.
2. Opposite party filed version admitting the issuance of the medi-claim policy to complainant. It is submitted that as per condition No.10 in page VII of the policy conditions, the injury, illness, disease that has been in existence prior to the effective date of the policy is clearly excluded from the scope of the policy coverage. That the claim of the complainant comes under this condition/exclusion clause and that therefore opposite party is not liable to pay any claim. That there is no deficiency.
3. Evidence consists of the proof affidavit filed by complainant and Exts.A1 to A7 marked for her. Opposite party filed counter affidavit and Exts.B1 marked for opposite party.
4. The only question that arises for analysation is whether the surgery (hemithyroidectomy) undergone by the complainant comes under the exclusion clause as contended by opposite party.
5. Ext.B1(b) is the policy details produced by opposite party. It was submitted by the counsel for complainant that the complainant was issued only Ext.A1 premium receipt and that policy details have not been received by the complainant so far. On perusal of Ext.B1(b) the condition No.10 states as under:
“The Company shall be liable to make payment for any Hospitalisation or Medical expenses incurred due to Pre-Existing Condition only after one year from the first Renewal Date or date of Revival, whichever is later, provided Hospitalisation or Medical expenses due to Pre-Existing Condition incurred one year after the first Renewal date or date of Revival, whichever is later. The first Renewal will be due after three years from the Policy Commencement Date.”
In Ext.B1(b) the policy commence date is shown as 18-7-2008. the policy is issued for three years and the first renewal date is shown as 19-7-2011. Complainant was admitted on 21-7-2009. No evidence is placed before us by opposite party to show that the ailment suffered by complainant was a pre-existing one. Ext.A2 which is the discharge summary issued from MIMS hospital reveals the history of the disease as under:
“HISTORY AND PHYSICAL EXAMINATION FINDINGS
This 43-year-old lady presented with complaints of vague ache all over body since last few days. She was initially evaluated by Dr. Abdulla Chorayakkat. She noticed thyroid swelling 1 month ago. C/o pain + numbness (R) hand of 4 months duration.
Ext.A2 establishes that the disease was not existing prior to the inception of the policy.
6. Counsel for opposite party then drew our attention to clause 7 of the policy and contended that opposite party is not liable to make payment for thyroidectomy as it is specifically excluded in the policy. Clause 7 provides as under:
“7. The Company shall not be liable to make any payment during the currency of the policy if claims are made due to;
(a) Any treatment of illness diagnosed or Hospitalisation or Medical Expenses incurred during the first thirty days of the policy Commencement Date or date of Revival, whichever is later;
(b) Any of the following illnesses if diagnosed or Hospitalisation or Medical Expenses incurred due to the following within one year of the Policy Commencement Date or date of Revival whichever is later;
i) Tonsillectomy
Cancer of any kind
It is submitted by the learned counsel for opposite party that Tonsillectomy and thyroidectomy are diseases on the neck and hence they are one and the same. This submission is blantantly erroneous and therefore needs no further discussion. Opposite party has failed to prove that the disease for which complainant availed treatment is a pre-existing one. We therefore safely conclude that opposite party has illegally repudiated the claim of the complainant. Disallowing claim of the consumer without justifiable grounds is deficiency. We find opposite party deficient in service.
7. Complainant prays for Rs.45,859/- towards treatment expenses and Rs.25,000/- as compensation for mental agony. Ext.A3 discharge bill supports the claim of the complainant regarding treatment expenses. The sum assured as per the policy is Rs.1,00,000/-. We consider that complainant is entitled to Rs.45,859/- along with interest @ 12% from date of complaint till payment together with cost of Rs.1,000/-.
8. In the result we allow the complaint and order that opposite party shall pay tot he complainant Rs.45,859/-(Rupees Forty five thousand, eight hundred and fifty nine only) along with interest @ 12% from date of complaint til payment together with costs of Rs.1,000/-(Rupees one thousand only) within one month from the date of receipt of copy of this order.
Dated this 14th day of January, 2011.
Sd/-
C.S. SULEKHA BEEVI, PRESIDENT
Sd/-
MOHAMMED MUSTAFA KOOTHRADAN, Sd/-
MEMBER E. AYISHAKUTTY, MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1 to A7
Ext.A1 : Receipt dated, 18-7-2008 from opposite party to complainant.
Ext.A2 : Discharge Summary dated, 04-02-2009 from MIMS hospital to complainant.
Ext.A3 : Discharge bill dated, 04-02-2009 from MIMS hospital to complainant.
Ext.A4 : Care First Claim Form dated, 12-02-2009 by complainant to opposite party.
Ext.A5 : Claim repudiation letter dated, 29-4-2009 from opposite party to complainant.
Ext.A6 : Care First Claim Form (pharmacy bills) by complainant to opposite party.
Ext.A7 : Certificate dated, 06-2-2009 given by Dr. Rojan Kuruvilla MS, DNB, FRCS (Edin), Consultant Surgeon to complainant.
Witness examined on the side of the opposite parties : Nil
Documents marked on the side of the opposite parties : Ext.B1
Ext.B1 : Photo copy of the Policy Schedule.
Sd/-
C.S. SULEKHA BEEVI, PRESIDENT
Sd/-
MOHAMMED MUSTAFA KOOTHRADAN, Sd/-
MEMBER E. AYISHAKUTTY, MEMBER
