CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 28th day of September, 2012.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 23/01/2012
CC /21/2012
K.V.Deepu,
S/o.K.K.Viswanathan,
248A, Railway Colony, - Complainant
Kallekulangara P.O,
Olavakkode, Palakkad-678 009
(BY K.Dhananjayan)
Vs
1. Branch Manager,
United India Insurance Co.Ltd,
Ottapalam Branch, Palakkad.
(BY ADV.K.Lakshminarayanan)
2. Rajesh Kannan, agent of 1st opposite party,
Agent Code 8531, C/o.M/s.United India
Insurance Co.Ltd, II nd Floor, - Opposite parties
Parappurath Towers, Main Road,
Ottapalam, Palakkad-679 101
(BY ADV.K.Lakshminarayanan)
3. Smt.Vidya/Authorised Signatory,
M/s.E.Meditek-TPA services Ltd,
Branch Office(Cochin), 35/392
Challirikkal House, Pottakkuzhi Road,
Opp.Popular Automobiles, Paraparambu Lane,
Mamangalam, Palarivattom Post,
Cochin-682 025
(BY ADV.K.Lakshminarayanan)
O R D E R
BY SMT. BHANUMATHI. A.K, MEMBER
Case of the complaint is as follows:
The complainant had joined in a medical insurance policy with the opposite party insurance company in the year 2003. Thereafter he had join in 'Super Top-up' Medical insurance policy in the year 2009 and continued the policy without any break. On 15/09/2011 he had under gone for Kidney transplantation in Medical Trust Hospital, Ernakulam. For that surgery and allied expenses he had incurred an amount of Rs.4,45,701/-. Thereafter as per the provisions of the 'Super Top-up policy he had filed a claim petition for reimbursement of the above amount. But the opposite party company has repudiated the claim of the complainant for the reason that he is not entitled to get the reimbursement and his claim satisfied on account of a specific contention stated in exclusion contained and stated in 4.1 in the policy conditions.
When he has filed a claim application they have sent an amount of Rs.70,000/- through a cheque dtd.11/01/2012drawn on SBI Olavakkode Branch. Complainant is entitled to get the balance amount also. Even before the surgery itself the 2nd opposite party assured that the expenses of the surgery will be reimbursed by the insurance company.
So the complainant seeking an order directing the opposite parties to pay the balance amount of Rs.4,35,701/- deducting the received amount of Rs.70,000/- from the total expense of Rs.5,05,701/- and Rs.2,00,000/- as the compensation for mental agony and financial loss.
Opposite parties entered appearance and filed version with the following contentions.
The opposite parties admit that the complainant had taken a Super Top-up Medicare Policy from the opposite party for the period 30/07/2011 to 29/07/2012. It is also admitted fact that he was having a mediclaim policy from 2002 onwards. He has shifted to Super Top-up Policy in 2011. While issuing the policy it was well informed that if any disease is existing, the coverage will be after 48 months from the date of issue of the policy. This is very clear from the terms and conditions mentioned in the policy. As per Exclusion Clause 4.1 “The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases, injuries which are pre-existing when the cover inceps for the first time. For the purpose of the Super Top-up policy taken from United India Insurance Company Limited shall be taken provided the renewals have been continuous and without any break”. The present treatment for a diagnosis of renal allograft recipient 3 years back. As per the records maintained by the company the first date of policy inception (Super top policy) is 30/07/2009. Existing diseases are covered only after 4 consecutive policy renewals without break as per terms and conditions of super top policy. Since the applicant's disease was a pre-existing one, the company repudiated the claim. The company was having a health insurance policy prior to the Super top policy and the company was indemnifying his claim subject to the terms and conditions in the policy. The complainant has suppressed the material fact that he is under going treatment for the disease. The claim made by the complainant was considered by the company and has paid Rs.70,000/- on his general policy and not under the disputed Super Top up policy.
Except canvassing the insurance policy 2nd opposite party has no control over the scrutiny of the policy. While canvasing the policy it is well informed the complainant about the terms and conditions in the policy. 3rd opposite party is the authorized agency to scrutinize the documents and to verify the genuineness of the mediclaims raised by the policy holder under the Super Top up policy. On verification of the documents forwarded by the complainant it is seen that the complainant was already undergoing treatment for the disease and as per the terms and conditions in the policy any existing disease will not cover for 48 months from the date of the insurance of the policy. So as per clause 4.1 in the policy the claim was repudiated by the agency. There is no deficiency of service on the part of opposite parties and complaint is liable to be dismissed with cost.
Both parties filed their respective affidavits and and Ext.A1 to A5 marked on the side of complainant and Ext.B1 to B7 marked on the part of opposite parties.
Heard both parties and gone through the documents on record.
Issues to be considered are
Whether there is any deficiency of service on the part of opposite party?
If so, what is the relief and cost?
Issues No.I & II
It is the admitted fact that the complainant was having a mediclaim policy from 2002 onwards and he has shifted to Super Top Up Policy in 2011. The period of Super Top Up Policy is 30/07/2011 to 29/07/2012. On 15/09/2011 the complainant had undergone for kidney transplantation and incurred an amount of Rs.4,45,701/-. These facts are evident from Ext.A3 and A4 document. Thereafter complainant had filed a claim petition for reimbursement of the above said amount. But the opposite party company has repudiated the claim of the complainant on account of specific contentions stated in exclusion clause contained in 4.1 in the policy condition.
Exclusion clause 4.1 is as follows: Company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of 4.1. Any pre-existing conditions as defined in the policy until 48 months of continuous coverage of such insured person have elapsed since inception of his/her Super Top Up Medicare Policy with the company.
Pre-Existing Condition/Disease definition- Any condition ailment or injury or related condition for which insured person had sign or symptoms, and/or were diagnosed and/or received medical advice/treatment, within 48 months prior to his/her Super Top Up Policy with the company.
N.B: In case of persons having any other health insurance policy from any company with a sum insured above threshold level at the time of taking this policy, the exclusion period of 48 months for pre-existing disease/conditions will be reckoned from the date of inception of the policy.
Hence the inception of Super Top Up Policy is on 30/07/2011. The complainant had undergone Kidney transplantation treatment was on 15/09/2011. But the 1st opposite party itself admits that the complainant was having a mediclaim policy from 2002 onwards. According to the Suffix to the 4.1 exclusion clause of Ext.A2 document it can be seen that “In case of persons having any other Health Insurance Policy from any company with a sum insured above Threshold level at the time of taking this policy, the exclusion period of 48 months for pre-existing disease will be reckoned from the date of inception of the policy”
In Ext.A2 document the threshold is for an amount of Rs.2,00,000/-. But the sum insured under Individual Health Insurance Policy is 1,00,000/- only. It is below the threshold level of Super Top Up Policy. The wife and children of the complainant are having the coverage of 2,00,000/- each. So that the complainant is not entitled to get the claimed amount from the opposite parties as per Super Top Up Insurance Policy.
When the complainant has filed a claim application the opposite parties have sent an amount of Rs.70,000/- through a cheque dated.11/01/2012 to the SBI, Olavakkode Branch. At the time of argument counsel for the opposite parties submitted that this payment is not related to the Super Top Up Policy. It is related to the mediclaim policy. Under mediclaim policy the complainant is having the coverage of Rs.1 lakh. So the opposite parties are liable to pay an amount of Rs.1 lakh to the complainant.
As only an agent 2nd opposite party is exonerated from the liabilities.
In the result complaint partly allowed. 1st and 3rd opposite parties jointly and severally directed to pay an amount of Rs.30,000/- (Rupees Thirty thousand only) to the complainant along with Rs.1,000/- (Rupees One thousand only) as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order failing which the whole amount shall carry 9% interest per annum from the date of order till realization.
Pronounced in the open court on this the 28th day of September, 2012.
Smt. Seena. H
President
Smt. Preetha.G.Nair
Member
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext.A1– Photocopy of Individual Health Insurance Policy-2010
Ext.A2- Photocopy of Super Top Up Medicare Policy
Ext.A3- Inpatient Bill of Medical Trust Hospital
Ext.A4- Photocopy of Discharge summary
Ext.A5- Photocopy of SBI Passbook page
Exhibits marked on the side of opposite party
Ext.B1- Treatment records 2007-2008
Ext.B2- Treatment records 2009-2010
Ext.B3- Treatment records 2010-2011
Ext.B4- Treatment records 2011-2012
Ext.B5- Repudiation letter issued by the 3rd opposite party
Ext.B6-True copy of the Insurance Policy (Super Top Up issued in favour of the complainant with the terms and conditions.
Ext.B7-Xerox copy of the proposer details
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite party
Nil
Cost allowed
Rs.1000/- (Rupees One thousand only) allowed as cost of the proceedings.
