BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 3rd day of May 2017
Filed on : 02-03-2015
PRESENT:
Shri. Cherian K. Kuriakose, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
CC.No.154/2015
Between
Raju Bhaskaran, : Complainant
Veepattu house, (By Adv. Tom Joseph, Court road,
Pimdimana P.O., Muvattupuzha)
Kothamangalam-686 698.
And
M/s. TATA AIG General Insurance : Opposite party
Company Ltd., Triton, (By Adv. R. Ajit Kumar Varma,
3rd Floor, 38/580, 39/1747, Chittoor road,
S.A. Road, Panampilly Nagar, Ernakulam South, Kochi-682 016)
Kochi-36.
Cherian K. Kuriakose, President.
1. Complainant's case
2. Mr. Raju Bhaskaran, aged 46 years, the complainant in this case, holds a Family Medical Insurance Policy of M/s. Tata AIG General Insurance Company Ltd with effect from 20-08-2014, assuring a sum of Rs. 3 lakhs. The complainant fell down due to a slip at 7 a.m. on 25-08-2014. He sustained severe injury over his back and he was immediately taken to St. Joseph Hospital, Kothamangalam. The doctor concerned in that hospital diagnosed the injuries of the complainant as IVDP C5 C6 and he was treated there as inpatient for 2 days. There after he has referred to Medical college Hospital, Kolenchery on 27-08-2014 for better management. He was treated there for 10 days. The complainant had spent Rs. 6,000/- at Kothamangalam Hospital and Rs. 94,000/- Medical College Hospital, Kolenchery. Immediately there after he lodged a claim under the medical ground before the opposite party. As per letter dated 22-01-2015 the mediclaim was repudiated on the ground that the claim falls under the 30 days waiting period of the policy and the illness of the complainant occurred within the two years waiting period. According to the complainant, he suffered the injury as an after math of the accident and the waiting period clause was not applicable to the injuries sustained in any accident. The complainant claims Rs. 1,00,000/- towards reimbursement with interest @ 12% p.a., compensation and costs.
3. Notice was issued to the opposite party, who appeared and contested the claim by filing a version contending inter-alia as follows.
4. The complainant had taken the policy from the opposite party covering the period 20-08-2014 to 19-08-2015. The policy was a fresh policy and the liability of the opposite party under the policy is only subject to the exclusion clause contained therein. The complainant had suppressed material facts in the complaint. The complainant had raised a request with the opposite party for availing cashless treatment facility at Medical college Hospital, Kolenchery from 27-08-2014, just a week after the inception of the insurance coverage. In the pre-authorization request for availing the cashless facility, the complainant had stated that he had "complaints of sudden onset of neck pain and shoulder pain while doing exercise on 21-08-2014. There was no mentioning of any incident of fall on accident in the said request. C5-C6 Intervertibral Disc Prolapse (IVDP) has been stated to be the ailment and the surgery of cervical distectomy has been the treatment proposed . The said treatment was excluded from the indemnification for a period of 30 years and two years by the exclusion clause in the policy and therefore the cashless facility was declined. The complainant did not raise any protest against this. He paid the hospital bills without any demur. Neither in the discharge summary nor in the pre-authorization request there was any indication of having a fall by the compensation. Similar treatment in St. Joseph's Hospital also did not disclose any case of a fall. The allegation that the complainant had an accidental fall is incorrect. The complainant is not entitled for any compensation, as prayed for. The complainant is not entitled to get the cost of the claim as alleged.
5. The evidence in this case consists of the documentary evidence Exbt. A1 to A4 on the side of the complainant and Exbts. B1 to B6 on the side of the opposite party. Exbt. X1 Medical records were also marked in evidence.
6. The Issues
i. Whether the complainant has proved that there was any deficiency on the part of the opposite party in the matter of service?
ii Reliefs and costs
7. Issue No. i. The learned counsel for the complainant argued that the complainant had a fall and was treated at St. Joseph Hospital, Kothamangalam. Dr. K. Joseph Manoj of st. Joseph hospital gave a certificate on 17-02-2015 to the effect that the complainant was admitted in Ortho ward on 25-08-2014 following IVDP C5-C6 following a fall. He was treated with soft cervical collar, NSAIDS and the supportive measures. On taking the MRI IVDP C5-C6 level was found and he was referred to Medical Mission Hospital, Kolenchery. The discharge summary issued from Medical College Hospital, Kolenchery on 07-09-2004 did no disclose the fact that the complainant had a fall and as a consequence he developed C5-C6 IVDP with cord compression. The medical History shown in Exbt. A2 discharge summary of the Medical Mission Hospital, Kolenchery was as follows:
" 46 year old mail was admitted in the Neurosurgery Department with the complaints of neck pain and numbness of both hands on 27-08-2014. No other significant medical history in the past"
During the general investigation conducted in the Medical Mission Hospital there is nothing to show that the complainant had a fall as alleged. The complainant was discharged with an advice to review after one week in the O.P department of Dr. Boby Jose.
8. The learned counsel for the complainant argued that the certificate issued by Dr. K. Joseph Manoj on 17-02-2015 disclosed that the complainant had a fall and therefore the repudiation of the claim on the ground that it was not an accident is an unfair trade practice and service deficiency on the part of the opposite party in denying the claim. Relying on 2016 (4) CPJ - 438 NC the complainant's counsel argued that the disease of Malaria occurred due to an insect bite would amount to an accident and that the term 'accident' has not been defined in the policy which the complainant had taken and therefore the contextual dictionary meaning of the said term has to be taken for the purpose of deciding whether the injury caused to the original complainant was due to accident or not?. An accident is defined as ( 1) an unpleasant event especially in a vehicle, that happened unexpectedly and causes injury or damage (2) something that happened unexpectedly and is not planned in advance. (Oxford Advance Learners Dictionary 8th edition). The Hon'ble National Commission in that case was having the evidence to come to a conclusion that the complainant therein had a mosquito bite accidentally, which resulted in the onslaught of the disease called Malaria. In the instant case there is nothing to show that the complainant had a fall and that fall was a causative factor for the complainant to get treatment for this collapse. There is nothing in evidence to show that the complainant had IVDP C5 -C6 due to a fall other than the certificate issued by Dr. Joseph Manoj marked as Exbt. A1.
9. We had called for the medical records of the complainant from St. Joseph's Hospital, Kothamangalam. It is seen that the complainant went to St. Joseph Hospital, Kothamangalam on 24-08-2014 with the complaints of neck pain. He was given treatment after examination. On the same day at 10-50 p.m. the complainant is seen to have made a complaint that he had pain over right arm. On 25-08-2014 when he was examined it is seen interliniated in the medical records that he had history of fall with the complaints of pain on right arm. There is nothing to show in Exbt. X1 medical record that he was referred to Medical Mission Hospital, Kolenchery. There is nothing to show in Exbt. X1 to come to a conclusion that the complainant had any external injury consequent to a fall. We therefore find that Exbt. X1 is not proved to have been a document prepared during the regular course of day to day treatment. The complainant had failed to prove the writings in Exbt. X1, especially the one which relates to the alleged fall, through the author thereof. If the complainant had a genuine case of fall he should have made such a statement while he had made a request for cashless treatment facility. Therefore we find that the case of fall brought forwarded by the complainant to claim the insurance was an after thought. We are not impressed with the arguments of the learned counsel for the complainant that the complainant is entitled to get the insurance claim holding that the IVDP of C5-C6 occurred to the complainant only as a consequence of the fall on 25-08-2014, when he was admitted in St. Joseph's Hospital Kothamangalam on 24-08-2014.
10. For the above reasons, we find that the complainant has not proved any deficiency in service on the part of the opposite party in the matter of service. Issue is accordingly found against the complainant.
11. Issue No. ii. In the result, the complaint stands dismissed, in the circumstances of the case, we make no order as to costs.
Pronounced in the open Forum on this the 3rd day of May 2017
Sd/-
Cherian K. Kuriakose, President.
Sd/-
Sheen Jose, Member.
Sd/-
Beena Kumari V.K., Member.
Forwarded/ByOrder,
Senior Superintendent.
APPENDIX
Complainant's Exhibits
Exbt. A1 : Certificate dt. 17-02-2015
A2 : Copy of discharge summary
dt. 07-09-2014
A3 : Denial letter dt. 22-01-2015
A4 : Policy wordings
Opposite party's Exhibit's:
Exbt. B1 : Policy schedule
B2 : Copy of request for cashless
hospitalization for medical Insurance for
medical insurance policy
B3 : Discharge summary dt. 07-09-2014
B4 : Copy of diagnosis report
B5 : Claim Form – Part B
B6 : True copy of letter dt. 20-10-2014
Copy of order despatched on:
By Post: By Hand:
