BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No: 226/2006 Filed on 17/8/2006 Dated: 15..12..2009 Complainant:
M.P. Jayakumar, Padmasree, T.C.27/922 (2), Latha Timbers Lane, Vanchiyoor, Thiruvananthapuram – 35.
Opposite parties:
Chairman and Managing Director, New India Assurance Co. Ltd., New India Assurance Building, Mumbai – 400 001. Chief Regional Manager, New India Assurance Regional Office, Kandamkulathy Tower, M.G. Road, Ernakulam. Divisional Manager, New India Assurance Co. Ltd., Divisional Office, II, Rema Plaza, NSS Coil Road, Thampanoor, Thiruvananthapuram 01.
(By Adv. M. Nizamudeen)
This O.P having been heard on 13..11..2009, the Forum on 15..12..2009 delivered the following:
ORDER
SMT. S.K.SREELA, MEMBER:
The case of the complainant is as follows: The complainant and his family had taken a medi claim policy of the opposite parties' insurance company and the same was being renewed without any default. On 13/6/2006, complainant's wife was admitted in the SUT hospital for an operation in connection with stomach ache and bleeding. The complainant had given the card, issued by the opposite parties, to the hospital and conducted operation. On 22/6/2006, complainant was asked to remit the bill amount immediately as his card has returned. Since the complainant was under the impression that no amount need be paid at the hospital as he was possessing the card, the complainant was not having Rs.27,000/- to be paid at the hospital. Then complainant somehow borrowed money from others and made the payment at the hospital and his wife was discharged from there. As per the direction of the hospital authorities, the complainant had submitted all the papers regarding insurance to the opposite parties. But the complainant's claim was repudiated on the ground that his wife was suffering from the same disease from 2001 onwards and since it being pre-existing his claim is not allowable. The complainant challenges the same and has further pleaded that she has been suffering from the same for the last 10 months only and not a pre-existing one as stated by the opposite parties. Hence this complaint for redressal of his grievances.
2. The 3rd opposite party has filed their version for and on behalf of other opposite parties also contending as follows: The complaint is not maintainable, the complainant is not a consumer, there is no hiring of service between the complainant and opposite parties. The opposite parties admit that the complainant was insured with this opposite party. The medi claim policy issued to the complainant bearing No. 761400/48/84/75217 was taken as a fresh policy with effect from 13/9/2004 to 12/9/2005. The complainant's wife had submitted request for cashless hospitalisation/claim form on 13/6/2006. The said request/claim form clearly shows that she was suffering from severe dysmenorrhagia and menorrhagia for the last 5 years. The illness was in existence for a very long time, even before proposing the insurance. Exclusion No.4.1 of the conditions of the Medi claim insurance policy issued to the complainant states that all diseases and injuries which are pre-existing when the cover incepts for the first time are excluded from the scope of the policy. The opposite parties were constrained to repudiate the claim submitted by the complainant for the reasons that the disease was pre-existing to the commencement of the policy since as per policy conditions all pre-existing disease are excluded. The opposite parties had repudiated the claim of the complainant only on the basis of the policy conditions and as per records produced by the complainant's wife herself. There is no deficiency in service on the part of the opposite parties in repudiating the claim. Hence prays for dismissal of the complaint with compensatory costs.
3. The complainant has been examined as PW1 and marked Exts. P1 to P14. 3rd opposite party has been examined as DW1 and marked Exts. D1 to D4.
4. From the contentions raised the following issues arise for consideration:
Whether the act of the opposite parties in repudiating the claim of the complainant is justifiable? Whether there is any deficiency in service on the part of the opposite parties? Reliefs & costs?
5. Points (i) to (iii) : The hospitalisation and domiciliary hospitalization benefit policy in the name of the insured/complainant has been marked as Ext.P9. Accordingly, the policy period is from 13/9/2005 to midnight of 12/9/2006. As per the complaint, it has been pleaded that as the wife of the complainant had bleeding following stomach ache and since Dr. Girija Balachandran advised to conduct operation for permanent cure of the said illness, the complainant was admitted in SUT on 13/6/2006 and operation was conducted on 22/6/2006. The complainant pleads that the said illness was not pre-existing as contended by the opposite parties and the discharge summary also reveals that the complainant is suffering from the illness for the last 8 – 10 months only. Opposite parties contend that as per the claim form it is clear that the complainant is suffering from dysmenorrhagia menorrhagia for the last 5 years. At this juncture, what we have to consider is whether the illness is pre-existing as contended by the opposite parties.
6. We have perused all the records produced by both parties. It is true that as per Ext.D4 it could be seen that the illness of the complainant as dysmenorrhagia menorrhagia - 5 years. Ext. D4 is a photocopy of the fax page 1 of request for cashless hospitalization/claim form for medical insurance policy which is seen dated 13/6/2006. This is only page 1 of the said document, and moreover not seen signed by Dr. Girija Balachandran the treating doctor who is supposed to have filled the same. The complainant, who appeared in person to contest his case argued that the said document is incomplete, some columns are left unfilled etc. The opposite parties have not examined the said Dr. Girija Balachandran to corroborate Ext.D4. On the other hand, the complainant has produced Ext.P1, issued by the very same Dr. Girija Balachandran on 12/8/2006 wherein the doctor has certified that Mrs. Sreekala was suffering from severe dysmenorrhagia menorrhagia since past few months. The doctor has furthermore stated in Ext.P1 that “considering the fact that she had completed her family and that medical treatment was not effective, a decision to do surgical treatment (hysterectomy) was done. Menorrhagia Dysmenorrhagia and even fibroid uterus as such are not serious diseases and it affects 70 – 80% of ladies at some time or other. Only when the symptoms are very severe and affect health, definitive treatment is indicated. In her case, only the past few months, her symptoms were serious enough to warrant hysterectomy. This does not mean that she was suffering from some major illness since long”.
7. Besides the above, in the discharge summary marked as Ext. P2, under the head 'History' it has been recorded that C/o dysmenorrhagia menorrhagia since 8 – 10 months. Hence from Ext.P2 also it could be seen that the complainant had the complaint of the said disease since 8 to 10 months from the date of admission which is 13/6/2006. In Ext. P3, the Medical Certificate (Attending doctor's report) dated 23/6/2006 also towards the column “How long has the patient been suffering from her disease as on the date of first consultation' it has been stated that symptoms were more since 2 months. Hence came for consultation. Had symptoms off and on since past 8 – 10 months but was controlled by medicines”.
8. From the above documents we are of the view that the illness of the complainant was not pre-existing as contended by the opposite parties. The complainant has succeeded in establishing his complaint and we find that the opposite parties have repudiated the claim of the complainant without any justifiable reasons. Hence the complainant is found entitled for refund of the hospital expenses along with compensation and costs.
In the result, complaint is allowed. Opposite parties shall refund Rs.27,012/- and a compensation of Rs.2,000/- along with a cost of Rs.1,000/- within a period of one month from the date of receipt of the order, failing which the entire amount shall carry interest @ 9% from the date of the order till realization.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, on this the 15th day of December, 2009.
S.K. SREELA, MEMBER.
G. SIVAPRAKASH, PRESIDENT.
BEENA KUMARI. A, MEMBER. ad.
O.P.No.226/2006 APPENDIX I. Complainant's witness: PW1 : M.P. Jayakumar II. Complainant's documents: P1 : Photocopy of medical certificate issued by Dr. Girija Balachandran
P2 : " discharge summary
P3 : " medical certificate issued by SUT Hospital
P4 : " Policy Claim Form
P5 : " pay bill No.629 dated 22/6/2006 issued by SUT Hospital
P6 : " Tx Report dated 15/5/2006 issued by SUT Hospital P7 : " letter issued by opposite parties. P8 : " ..do.. P9 : " ..do.. P10 : " ..do.. P11 : " ..do.. dated 15/9/2004
P12 : " premium certificate issued by opposite parties
P13 : " Hospitalisation and Domiciliary Hospitalisation Benefit Policy
P14 : " receipt issued by opposite party dated 11/8/06.
III. Opposite parties' witness:
DW1 : Joy Joseph, Senior Divisional Manager, New India Assurance Company.
IV. Opposite parties' documents:
D1 : Details of policy submitted by opp. Parties.
D2 : Photocopy of letter dated 18/7/06 submitted by opposite parties. D3 : " Hospitalisation and Domiciliary Hospitalisation Benefit Policy submitted by opp. Parties.
D4 : : request for cashless Hospitalisation/Claim Form for Medical Insurance Policy dated 13/6/2006 submitted by opp. Parties.
PRESIDENT
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