Kerala

Kollam

CC/04/449

Shyla.V,Vinayaka,Punnathala - Complainant(s)

Versus

General Manager,Oriental Insurance Co. Ltd. and Other - Opp.Party(s)

Mineendra.S.R.

31 Oct 2009

ORDER


C.D.R.F. KOLLAM : CIVIL STATION - 691013
CONSUMER DISPUTES REDRESSAL FORUM ::: KOLLAM
consumer case(CC) No. CC/04/449

Shyla.V,Vinayaka,Punnathala
...........Appellant(s)

Vs.

General Manager,Oriental Insurance Co. Ltd. and Other
M/s. TTK Health Care Services Pvt. Ltd.
...........Respondent(s)


BEFORE:


Complainant(s)/Appellant(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):




ORDER

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SRI.K. VIJAYAKUMARAN, PRESIDENT.

 

            Complainant filed this complaint for realization of insurance claim.

 

          The averments in the complaint can be briefly summarized as follows:

 

          The complainant is running a Beauty Parlour in the name and style  Charmes Beauty Parlour at Kollam.    The complainant is a policy holder of Mediclaim with Oriental Insurance Co. Ltd., Kollam.  She had a  valid policy bearing No.4441400/2003/1086 and it is valid for the period from 28.2.2003 to 27.2.2004.  During 2003 the complainant had pain  and bulging in her stomach .   So she consulted doctors in Amritha  Institute of Medical Science, Ernakulam on 7.8.03 and under gone   many medical examinations and  she finally undergone surgery  for  incisional Hernia .  She was admitted   as in patient on  8.9.03 undergone treatment upto  19.9.2003 and she had incurred an expenditure of Rs.60,000/-  in connection with the hospitalization and treatment.  Though she made a claim for the amount the opp.party has repudiated the claim and hence the complaint.

 

          The opp.party filed version contending interalia that the complaint is not maintainable either in law or on facts.   The complainant is not a consumer within the meaning of Section 2[1] [d]  of the Consumer Protection  Act. The complaint  is bad for non-joinder  of necessary party. The complainant had not impleaded M/s. T.T.K. Health Care Service, Bangalore who is authorized  to decide the genuiness and admissibility of the claim  is not made a party.   The complainant approached the Forum  with unclean hands .   It is  submitted that the opp.party  has issued a medi claim policy  for Rs.35,000/-  to the complainant for a period from 28.2.2003 to 27.2.2004.  The complainant is liable to comply with the policy conditions  in order to  got indemnity  the claim.    It is mandatory that the complainant shall give  immediate notice of claim  with particulars relating to the policy the medical practitioner, hospital etc.  It is also obligatory  on the part of the complainant insured  to submit the final claim along with the receipts and  bills to the opp.party within 7 days from the discharge from the hospital.   The above mandatory conditions have been violated by the complainant. The opp.party in fact got knowledge about the  claim of amount  only on  receipt of the advocate notice.   The opp.party had no opportunity to examine the genuiness or admissibility of the claim preferred by the complainant before the Advocate notice.   Therefore the complainant  had willfully violated the policy condition.   The complainant has not submitted any of the documents before this opp.party and thereby violated the policy conditions.  The opp.party has not liable to consider an admissibility of the claim as it is belated..  There is no deficiency in service on the part of this opp.party . 

 

          This opp.party filed an addition version.   The 3rd opp.party who was impleaded subsequently has repudiated the claim of the complainant as early as on 23.11.2003 stating specific  reason for  the same.   The complainant  was suffering from  complaints of incisional hernia  before the inception of her first policy which was commencing from 28.2.2000  The complainant had produced the discharge summary issued from the  hospital which shows that the complainant was suffering from the disease of incisional Hernia  since  4years prior to her admission in the hospital on 7.8.2003.  It is further stated in the  discharge summary  that the complainant had undergone surgery  for hysterectomy in 1997.  The claim  preferred by the complainant being one for a disease which was pre-existing prior to  inception of the policy, the  claim preferred by the complainant  is not covered by the exclusion clause 4.1.  Under exclusion clause 4.3  also the disease  of the complainant is not covered  The complainant has willfully suppressed existence of the above disease at the time of submitting the proposal form  for the insurance.. Hence the opp.party prays to dismiss the complaint with compensatory costs.

 

          Points that would arise for consideration are:

1.     Whether  there is  deficiency in service on the part of the opp.party

2.     Whether the claim preferred by the complainant is hit by policy condition NO.4

3.     Reliefs and costs.

For the complainant PW.1 is examined.   Ext. P1 to P8 are marked.

For the opp.party DW.1is examined..  Ext. D1 to D4 are marked.

 

As a matter of fact the policy is not disputed.  The contention of the complainant is that despite the  fact that she was having a valid insurance policy her claim for re-imbursement of the medical expenses incurred by her in connection with her treatment at the Amritha Hospital, Ernakulam was repudiated which is illegal.

 

          It is the contention of the opp.party  that  the claim preferred by the complainant is in respect of a pre-existing disease and therefore the claim is not covered  under the policy.  Policy Condition No.4.1 and 4.3  of Ext.P1`.  It is further contended that even  at the inception of the policy the complainant was suffering from incisional hernia and the policy was taken  suppressing this aspect..

 

Ext.P7 is the discharge summary issued from the Amritha Hospital  to the complainant.   Ext.D2  is also the copy of the discharge summary in respect of the complainant produced by the opp.party .   Ext. P7 and D2 shows that the illness for which the complainant had under gone treatment and surgery is for incisional hernia.  In the discharge summary  against history and physical findings  the treated doctor has stated that the patient has  given history of swelling in the infraumbilical region since four years prior to her admission in hospital and that  it  slowly increased in size  and attained  the present size. It is argued by the learned counsel for the opp.party that the insurance policy in this case was taken by the complainant on 28.2.2000  and the same was being renewed periodically.  The complainant was admitted in hospital  on  8.9.03 ,  From  the statement of the complainant to the treated doctor that she was having incision or hernia for the  last four years it is obvious that  she was suffering from the disease from 1999 onwards which means that the disease was a pre-existing one at the inception of the policy on 28.2.2000.  Under the exclusion clause 4[1] a pre -existing disease is not cover by the  policy.

          It is to be noted that  PW.1  herself  has stated  to  the doctor who treated her that she was having incisional hernia 4 years prior to her admission in the Amritha Hospital on 8.9.03 .  The complainant has no case that the period of 4 years  was stated to the doctor due to any inadvertence or slip of tongue.   There is not even suggestion to that effect of PW.1, when  she was in the box.   When the complainant herself states that she was having incisional hernia even prior to the inception of the policy the repudiation of the claim cannot be said to be not  proper and we feel that we shall not be justified in interfering with the repudiation  of the claim of the complainant.   There no  deficiency in service as alleged.   Point found accordingly.

 

          In the result the complaint fails and the  same is hereby dismissed.  No costs.

 

            Dated this the     day of October, 2009.

 

                                                                                    I N D E X

 

List of witnesses for the complainant

PW.1.- Shyla

List of documents for the complainant

P1. – Policy certificate

P2. –Registration card of Amritha Hospital

P3. – Registration Certificate of Amritha Hospital

P4. – Advocate notice to the 2nd opp.party

P5. – Acknowledgement card

P6. – Farmacy bill of Amritha Hospital

P7. – Discharge summary

P8. – Repudiation letter of 2nd opp.party

List of witnesses for the opp.party

DW.1. – Raju.N.

DW.2. -  R. Ashok Kumar

List of documents  for the opp.party

D1. – Policy conditions

D2. – Discharge summary of complainant

D3. -  Treated Doctors Certificate

D4. – Intimation Letter from TTK