DOF.14/2/2006 DOO2/8/2010 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Prethakumari: Member Smt.M.D.Jessy: Member Dated this, the 2nd day of August 2010 CC.No.30/2006 Mrs.Lissy Benny, Chudaliyankal House, Vattiyanthode P.O.Mattara Complainant (Rep.by Adv.E.P.Hamza kutty) 1. The Divisional Manger, Oriental Insurance Co.Ltd. Divisional Office, RAS Building, South Bazar, Kannur 2. (Rep. by Adv.K.C.Santhoshkumar) 2. Authorised Signatory, T.T.K Health Care Service Pvt.Ltd., opposite parties 1400 Mareena Building, MG Road. Cochin 16. O R D E R Smt.M.D.Jessy, Member This is a complaint filed under section12 of consumer protection act for getting an order directing the opposite parties to pay Rs.25, 000/- towards medical expenses together with compensation. The case of the complainant is as follows: the complainant insured under the mediclaim policy of the opposite parties from 8.12.2000 onwards.The opposite party issued a Health card to the complainant and as per that policy scheme the complainant is entitled to get the amount spent for her medical treatment. On 16.11.04 and 17.11.04 complainant treated from Pariyaram Medical College Hospital for her vascular headache. For her treatment from Pariyaram Medical College she spent Rs.5, 303.60. As per the rules and regulations of mediclaim policy complainant applied for the amount spent for the treatment before the opposite parties. But opposite parties rejected the application through their letter dt. 28.4.05 and 18.3.05. The complainant hospitalized on 16.11.04 to 17.11.04 during the period of the policy No.1953 from26.12.03 to 25.12.04. Prior to that another policy was alive from 28.12.02 to 27.12.03 Complainant issued a lawyer notice to opposite parties. The 2nd opposite party had not sent reply to the complainant. 1st opposite party sent a reply denying the claim. The deficiency of service on the part of the opposite parties caused mental agony to the complainant. Hence this complaint. After receiving complaint forum sent notices to opposite parties. 2nd opposite party remained absent and subsequently set exparte. 1st opposite party appeared and filed version contending that the complaint is filed on the wrong assumption that the renewal policy were issued in the name of the complainant in spite of the fact that the Janarogya Policies are being issued for the period of 12 months from the date of commencement. The policy bearing NO.1888 taken by the complainant was expired on 7.12.02. But there was no renewal making her eligible to get the protection of insurance coverage from 8.12.02. Subsequently on 28.12.02 complainant was issued afresh policy without mentioning any existing disease. But the medical document submitted by the complainant reveals that she was suffering from vascular headache since 2001 onwards. As such there was a suppression of material facts which makes the policy void abinitio. The investigation undertaken with the help of medical experts proved unequivocally that vascular headache can be caused due to sinusitis. As per clause 4(3) all the illness originated from Sinusitis are excluded from the purview of the policy. The complaint is not entitled to get any compensation on the basis of the said policies. Hence opposite party prays for dismissal of the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency on the part of opposite parties? 2. Whether the complainant is entitled for the remedy as prayed in the complaint? 3. Relief and cost. The evidence consists of oral testimony of PWs1 and 2 and documentary evidence Ext.A1 to A7 on the side of complainant and DW1 and Exts.B1 to B10 on the side of opposite parties. Issue No.1 It is the admitted case that the complainant has taken mediclaim policy from opposite parties on 7.12.01 onwards. The first policy was having coverage from 8.12.01 to 7.12.02 even though the said policy was not renewed before the date of lapse of the policy. A some set of family policy was issued by the opposite party on 27.12.02 which is valid from 28.12.02 to 27.12.03. Before the lapse of the said policy another policy was also issued which is having coverage from 26.12.03 to 25.12.04. The case of complainant is that the complainant admitted in Pariyaram Medical college as an inpatient on16.11.04 for treatment of vascular head ache and discharged on 17.11.04. Ext.A1 is the photocopy of the discharge card issued from Pariyaram Medical college hospital to the complaint and Ext.B9 is its original which shows that complainant treated for vascular headache form the hospital and discharged on 17.1.04 with direction to continue the treatment of OP. In Ext.A1 there is a clinical note that this headache was started about 2years back. The opposite party is sick on their contention that since the ailment was started two years back the complaint has a duty to inform about the same to the insurer before taking the policy. But here it is pertinent to note that if the ailment is started before 2 years it is well covered within Ext.B5 policy. But here is no evidence to show that the complainant had admitted in any hospital and treated for the same. In such a case if at all a mild attack of headache may caused to the complaint but the same is not cared so the contention of the opposite party that while taking the Ext.B6 policy this ailment caused to the complainant was not revealed to the opposite party is not sustainable. From this argument the opposite party is trying to escape from their liability by raising baseless allegations. The further contention of the opposite party that since the vascular headache was caused due to sinusitis as per clause 4(3) of the policy all the illness originated from Sinusitis are excluded from the purview of policy. Hence the opposite party is not have a specific contention that the vascular head ache caused to the complainant was duet to the attack of sinusitis. The evidence of PW1 admits that vascular head ache is covered by the policy. There is no medical evidence to show that complainant is suffering from sinusitis and the vascular headache was emanated from sinusitis. Even though claim was repudiated on the ground sinusitis and related disorders re not payable it cannot be ignored that exclusion clauses are not binding at all time. The material evidence available on record would not show that the insurance company had explained all exclusion clauses to complainant. Hon’ble National Commission held the view in United India Insurance co. Ltd., Anr. Vs. S.M.S.Tele Communications & Anr. Reported in 2009(3)CPC 364, that the unexplained or unnoticed exclusion clauses would not be binding to the insured. Hence the contention of opposite party that it was not revealed before the insurance company cannot be taken as justifiable ground to repudiate the claim. The complainant is entitled to get reimbursement of the medical expenses from the opposite parties under Ext.B7 policy. The opposite party rejected the same upon baseless contentions and to get undue advantage. The act of the opposite party definitely caused deficiency of service towards the complainant and the issue No.1 is answered in faovur of the complainant. Issue Nos. 2 & 3 The complainant alleged that she has sustained a medical expense of Rs.5303/- for treatment. It is also stated that she submitted all the relevant document to the opposite parties along with the claim form. The opposite parties had not made any objection regarding the expenses met by the complainant for her treatment. Since it is found that the complainant is entitled to get the medical expenses from the opposite parties under the Ext.B7 policy cover, the opposite parties are jointly and severally liable to pay the Rs.5303/-to the complainant. No other documents are seen produced by the complainant. Since the opposite parties purposefully repudiated the claim of the complainant she is entitled to get Rs.2500/- towards compensation for mental agony. Issue Nos. 2 & 3 are also answered in faovur of complainant.. In the result, the complaint is allowed directing the opposite parties to pay an amount of Rs.5303/-( Rupees Five thousand Three hundred and three only) towards medical expenses together with a sum of Rs.2500/- (Rupees Two thousand Five hundred only) as compensation together with Rs.1000/- (Rupees One thousand only) as cost of this proceedings to the complainant within one month from the date of receipt of this order, failing which the complainant is entitled to execute the order against opposite parties as per the provisions of consumer protection Act. Sd/- President Sd/-Member Sd/-Member APPENDIX Exhibits for the complainant A1.Copy of the discharge summary issued from Prdiyaram Medical college A2.Copy of the letter dt.28.4.05 sent by OP1. A3.Letter dt.18.3.05 sent by OP2 A4.Copy of the lawyer notice sent to OP A5 & 6..Postal receipt and AD A7.Reply notice Exhibits for the opposite parties B1.Copyof the letter sent by 2nd OP to complainant and 1st OP B2.Copy of the letter dt.28.4.05 sent to complainant B3.Copyf the reply notice sent to complainant B4.Postal AD B5 to B10..Copy f the policy schedule Witness examine for the complainant PW1.Complainant Witness examined for the opposite party DW1.K.Sreedharan /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 | | 
