DOF.26 /11 /05 DOO.14/7/ 10 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 14th day of July 2010 C.C.No.302/2005 O.K.Devendran, Ozhikandathil House, P.O.Edat, Cherat, Payyannur. Complainant (Rep. by Adv.K.Gopakumar) 1. Branch Manager, National Insurance Company Ltd, Branch Office, P.B:No.32, Perumal Building, Main Road, Perumba, Payyannur. Opposite Party (Rep. by Adv.V.K.Rajeev) O R D E R Smt.K.P.Preethakumari, Member This is a complaint filed under section 12 of consumer protection act for an order directing the opposite party to pay Rs.20, 000/- the insured amount along with Rs.25, 000/- as compensation. The complainant’s case is that he is the holder of mediclaim policy having number 571103/48/2002/8500933 for Rs.20, 000/-. As per conditions the opposite party is liable to pay the policy during the period 16.7.02 to 15.7.03 in the event of any such disease. On 26.9.02 the complainant was admitted in the hospital for ‘multiple sclerosis’ at BKM Hospital, Payyannur and later he was referred to KMC hospital, Mangalore for the treatment and admitted there for 4 days and discharged on 4.10.02 and spent Rs.25,000/- for treatment and medicine. After discharge, during October 2002 he submitted all the medical bills to the respondent. But they had neither repudiated the claim nor paid the disbursed amount. So the complainant was constrained to issue a lawyer notice. But opposite party replied that as per the medical certificate he is suffering the disease multiple sclerosis and the probable duration of the disease is 6 years. According to the complaint, if there is such observation in the medical certificate it is not a conclusive finding. The symptoms of the disease were traced out only during 2002 when his limbs were paralised. At present he is not in a position to move from his bed. He raised the funds by pledging the properties in a scheduled bank and his family is struggling hard to meet the two ends of life. The complainant requires the help of his bystander to attend his basic needs. The complainant already submitted the medical bills before the opposite party and he is entitled to get Rs.25, 000/- covered by the policy. Hence this complaint. Upon receiving notice from the Forum opposite party appeared and filed their version. The opposite party admitted that the complainant was insured as per mediclaim policy, but denies their liability to pay insured amount for the hospitalization expenses, he had to incur for the treatment of the disease mentioned in the claim form as per the exclusion clause 4 -1 of policy conditions. Since the disease was pre-existing prior to the risk inception of policy. As per the above said exclusion clause pre-existing condition of the disease also means any sickness or its symptoms which existed prior to the effective date of policy. Whether or not the insured person had knowledge of the symptoms were relating to the sickness arising from the pre-existing disease. The case history according to Dr.R. C.Udaya Shanaker, Asst. Professor, Neurology, KMC, who treated the patient, had certified that the nature of the disease of the complainant is demyelinating disease caused due to scerosis. Demyelination is a disease process selectively damaging the myelin sheath in the central or peripheral nervous systems and in turn affects the function of the nerve fiber which the myelin normally supports. Multiple sclerosis is a chronic disease of the nerves system affecting young and middle aged adults. According to the doctor he had observed in the certificate that though a relapsing and remitting disease, the complainant has currently reported improvement but sequel persist. So it is evident from the medical certificate that the disease of the complainant was pre-existing and that he had full knowledge of the existence of the disease prior to the inception of the policy. The complainant is also not entitled to the mediclaim policy as per conditions of 5.3, 5.4 and 5.7. As per 5.3 upon happening of any event which give rise to a claim, notice with all particulars shall be sent to the company within 7 days from the date of hospitalization. As per 5.4, the claim must be field within30 days from the date of discharge from the hospital. As per 5.7, the insurer shall not be liable to make any payment under the policy in respect of any claim, if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf. The complainant had not incurred Rs.25, 000/-. The complainant had only submitted bills worth Rs.8209/- to the opposite party. Even if the claim is allowable the complainant is not entitled to get Rs.8209/-. The complainant is not entitled to any claim as claimed and hence the complaint is liable to be dismissed. On the above pleadings the following issues were raised for consideration. 1. Whether there is any deficiency in service on the part of opposite parties? 2. Whether the complainant is entitled for the relief as prayed in the complaint? 3. Relief and cost. The evidence in this case consists of the oral testimony of PW1 and DW1 and Exts.A1 to A9 and B1 to B4. Issue Nos. 1 to 3 The complainant’s case is that the mediclaim of his was wrongly repudiated by the opposite party on the ground that the disease has been pre-existing to the effective date of insurance. In order to prove his case, he has produced Ext.A1 Mediclaim policy schedule from 16.7.02 to15.7.03, A2 medical certificate dt.29.3.03, A3 lawyer notice, A4 Acknowledgement card, A5 reply, A6 toA8 Mediclaim Insurance policy with condition, A9series i.e. bills 110 in number. Opposite party also produced documents such as Exts.B1 policy with conditions, B2, claim intimation, B3 claim application, and B4 b ills 28 in numbers. The opposite party admits that the complainant was insured as per the medi claim policy issued to him for the period 16.7.02 to15.7.03. But according to opposite party s per clause 4(1) of the policy the insurer is not liable to make any payment under the policy in respect of any expenses whatever incurred by the insured in connection with or in respect of any disease, which have been pre-existing . In order to prove this the opposite party mainly depend upon B 3 – Medi claim certificate issued by the attending doctor, which was issued by Dr. Sankar. In it he stated that “the probable duration 6 years”. He has stated only probable duration, but has not definitely stated the duration of the disease. The opposite party has not proved the disease is pre-existing and the doctor who has issued Ext.B3 certificate was not examined. There is no other evidence before the Forum to prove that the disease, demyelinating disease due to multiple sclerosis is pre-existing before the date of commencement of risk. So the opposite party failed to prove their contention that the disease was pre-existing. So we are of the opinion that the opposite party was wrongly repudiated the claim. Since the policy is a mediclaim policy another issue to be decided is what is the amount the complainant entitled to receive. The complainant has produced bills for an amount of Rs.43, 422.99and opposite party also produced 28 bills. The complainant is continuing treatment and he had produced the bills. The bills produced by the complainant, amounts to more than Rs.30, 000/- during the relevant period. So we restricted the amount as Rs.20,000/- since the sum insured is Rs.20,000/- to the complainant as his medi claim benefit with 5 % interest from 7.5.03 i.e. one month after lawyer notice, since A5 has no date with Rs.1000/- as the cost of proceedings and the complainant is entitled to receive the same and hence order passed accordingly. In the result, the complaint is allowed directing the opposite party to pay Rs.20, 000/- (Rupees Twenty thousand only) with 5% interest from 7.5.03 till payment along with a cost of Rs.1000/- (Rupees One thousand only) to the complainant within one month from the date of receipt of this order, failing which the entire amount will attract 5% interest from the date of order till realization and the complainant is entitled to execute the order as per the provisions of consumer protection Act. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1. Ext.A1 Mediclaim policy schedule from 16.7.02 to15.7.03 A2 Medical certificate dt.29.3.03 A3 lawyer notice A4 Acknowledgement card A5 reply A6 toA8 Medi claim Insurance policy with condition A9. Bills 110 in number Exhibits for the opposite party Exts.B1 policy with conditions B2, claim intimation B3 claim application B4 bills 28 in numbers Witness examined for the complainant PW1.Complainant Witness examined for the opposite party DW1.T.A.Sankarankutty /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur
| | [HONORABLE PREETHAKUMARI.K.P] Member[HONORABLE MR. GOPALAN.K] PRESIDENT[HONORABLE JESSY.M.D] Member | | 
