BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 17/08/2011

Date of Order : 29/03/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 449/2011

Between

And

O R D E R

Paul Gomez, Member.

1. The factual matrix of the complaint :-

Mrs. Kurian Mathew, wife of the complainant is the holder of senior citizen mediclaim policy for 1 lakh rupees. Mrs. Kurian Mathew underwent angiogram and angioplasty at Medical Trust Hospital incurring Rs. 2,00,000/- towards treatment expenses. When a claim application was lodged with the opposite party through their TPA, M/s. Medi Assist, it was repudiated on the ground that diabetes and hypertension are excluded for 1.5 years from the date of inception of the policy. The doctor certified that the complainant had been diagnosed to have diabetes and hypertension since August 2010. The policy was issued after conducting thorough medical checkup by the panel doctor of the opposite party. Moreover, the doctor who treated the complainant had certified that wife of the complainant was diagnosed to have the diabetes mellitus and hypertension since August 2010. It is pointed out that the treatment was for heart ailment and not for hyper tension and diabetes. Hence the repudiation of the claim amounts to deficiency in service. Thus, the complainant is seeking direction against the opposite party to allow the relief and cost of this proceedings.

2. The following averments are made in the version :-

It is true that wife of the complainant is holding a senior citizens mediclaim policy for the period from 16-03-2010 to 15-03-2011. According to the said policy, as per condition No. 4.2, the opposite party is not liable to pay for the conditions of Diabetes and Hypertension for a waiting period of 18 months from the date of commencement of the policy. The treatment under dispute has been received for effort angina which is a complication of diabetes and hypertension and hence the opposite party is justified in repudiating the claim.

3. No oral evidence was adduced by the complainant. Exts. A1 to A6 were marked on the side of the complainant. No oral evidence for opposite party either. Exts. B1 to B3 were marked for them. The learned counsel Advocate Tom Jose and Advocate Ganappan appearing for the complainant and opposite party respectively were heard.

4. The points that emerge for settlement :

1. Whether the repudiation is justified?

2. What are the reliefs, if any?

5. The mediclaim policy for senior citizens lies at the focal point of discussion. Eventhough the real claimant before the insurance company is the wife, the complaint has been filed before the Forum by her husband, may be because both of them were holding the same policy. In the currency of the policy, the wife underwent angioplasty at Medical Trust Hospital, Ernakulam for which they incurred huge expenses.

6. The real issue starts with lodging Ext. B2 claim application to the tune of Rs. 1,14,990/- which was repudiated by the opposite party. It is pertinent to note that against the column of ailment/diseases, the claimant stated her disease as “Effort Angina Class II”. She might have copied it down from the statement made by the treating doctor in Ext. B3 discharge summary where against the column history, the learned doctor has recorded as follows :

“Known case of diabetes, hypertension. Effort Angina Class II since 15 days on treatment.”

It is based on this diagnostic finding recorded by the doctor, the opposite party has rejected the claim. They rely on Clause 4.2 of Ext. B1 terms and conditions of the policy, which enlist the diseases and conditions for which some waiting period is respectively prescribed. According to the said Clause waiting period for Diabetes Mellitus and hypertension are 18 months. It is in this back ground, we have to examine the relevant part of the contention of the opposite party as stated by the argument note filed by the learned counsel Advocate Ganappan. According to him, “Effort Angina” is a complication of Diabetes and hypertension and as per Ext. B1 policy condition 4.2 diabetes and hypertension are excluded for a period of 18 months from 16-03-2010. Of course, Ext. A5 letter would show that the complainant's wife was “diagnosed to have Diabetes Mellitus and hypertension since August 2010.”

7. Shortly put, the argument of the learned counsel is that angina, the heart ailment is the fall out of Diabetes and hypertension, the diseases which are temporarily excluded from coverage as per the policy conditions. Therefore, the complainant cannot have any claim to cover the treatment expenses incurred in this case. We cannot uphold the above contention since in our view Effort Angina, the heart disease and hypertension and diabetes are distinct physical ailments eventhough the latter two bodily, conditions may augment the heart disease. The aforesaid heart disease can also develop independent of hypertension and diabetes. Hence, we are inclined to allow the complaint to the extent permissible. Eventhough the claim amount of Rs. 1 lakh has not been established by medical bills, in view of the fact that aspect has not been made a point of dispute. We allow the amount claimed in the complaint, because that is the maximum allowable sum. The opposite party shall also pay costs of these proceedings.

8. To conclude, the complaint is allowed and the opposite party is directed to pay Rs. 1,00,000/- (Rupees one lakh only) along with interest @ 9% p.a. from the date of this complaint till realisation and to pay Rs. 1,000/- towards costs of this proceedings to the complainant.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 29^th day of March 2012.

Sd/- Paul Gomez, Member.

Sd/- A. Rajesh, President.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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