BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 19th day of August 2014
Filed on : 08/06/2012
PRESENT:
Shri. A. Rajesh, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
CC. 342/2012
Between
Anil Kumar T.S., : Complainant
S/o. Sukumaran, (By Adv. Varghese Prem,
Thekumthala House, 5th Floor, Metro Plaza, North
Manapally, Ayyampilly, Market road, Kochi-18)
Ernakulam-682 501.
And
HDFC ERGO General Insurance : Opposite party
Company Ltd., (By Adv. R. Ajit Kumar Varma,
Rep. by its Principal Officer, 39/1747, Chittoor road,
6th Floor, Leela Business Park, Ernakulam South, Kochi,
Andheri-Kurla Road, Pin-682 016)
Mumbai-400 059.
O R D E R
A. Rajesh, President.
The case of the complainant is as follows:
The complainant availed a health Suraksha policy from the opposite party for the period from 26-08-2009 to 25-08-2010. On 08-06-2010 he was admitted to Lourdes Hospital for the treatment of “DNS, Ethmoidal Poly posis” and was discharged on 12-06-2010. He incurred a total sum of Rs. 15,908/- towards treatment expenses. The complainant duly submitted an insurance claim to the opposite party. Till date the opposite party has not paid the amount to the complainant which amounts to deficiency in
service on their part. Thus the complainant is before us seeking direction against the opposite party to pay the insurance claim with interest @ 18% p.a. together with compensation and costs of the proceedings. This complaint hence.
2. The version of the opposite party is as follows:
The complainant had taken the insurance policy from the opposite party. The complainant preferred a claim with the opposite party for the expenses of Rs. 15,905/- incurred by him for hospitalization at the Lourdes
Hospital from 08-06-2010 to 12-06-2010. The disease of the complainant has been diagnosed as Ethmoidal polyposis and consequent deviation of the nasal Septum (DNS). As per Section 6 of the policy exclusion, the illness of the insured is not covered for the first 2 years of the policy, this has been intimated to the complainant as per letter dated 28-06-2010. The complainant is not entitled to get the Insurance Claim and the complaint is liable to be dismissed.
3. The complainant was examined as PW1 and Exbts. A1 to A4 were marked. No oral evidence was adduced by the opposite party. Exbts. B1 and B2 were marked. Heard the counsel for the parties.
4. The points that arose for consideration are as follows:
i. Whether the complainant is entitled to get the Insurance
claim from the opposite party?
ii. Whether the opposite party is liable to pay compensation and costs
of the proceedings to the complainant ?
5. Point No. i. Admittedly the complainant availed Exbt. B2 Health Suraksha Insurance policy from the opposite party for the period from
26-08-2009 to 25-08-2010. During the currency of Exbt. B2 policy the complainant underwent treatment at Lourdes Hospital, Ernakulam for the period from 08-06-2010 to 12-06-2010. His ailment was diagnosed as “DNS, Ethomodal, Polyposis” as evidenced by Exbt. A1 discharge summary.
The insurance claim application of the complainant was rejected by the opposite party vide Exbt. B1 letter dated 28-06-2010 which reads as follows:
“As per the submitted documents the claims falls under the First 2 years exclusion clause of your policy. Hence we regret to inform you that your claim is repudiated”.
6. Section 6 (a) in Exbt. B2 reads as follows:
a. The illnesses and treatments listed below will be covered
subject to a waiting period of 2 years in the third Policy Year
as long as the Insured Person has been insured under an
Health Suraksha Policy continuously and without any break.
i. Illnesses: Internal congenital diseases, arthritis if non
infective, calculus diseases of gall bladder and urogenital
system; cataract; fissure/fistuala in anus, hemorrhoids,
pilonidal sinus, gastric and duodenal ulcers, gout and
rheumatism; internal tumors, cysts, nodules, polyps
including breast lumps (each of any kind unless malignant);
osteoarthritis and osteoporosis if age related; polycystic
ovarian diseases, sinusitis and related disorders and skin
tumors unless malignant.
ii. Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); hysterectomy for menorrhagia or fibromyoma or prolapse of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder
and bile duct unless necessiated by malignancy; surgery of genito urinary system unless necessitated by malignancy; surgery of begnin prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter vertebral; disk; surgery of varicose veins and varicose ulcers; Nasal septum deviation, surgery on tonsils and sinuses”.
7. Exbt. A1 the discharge summary issued by the doctor attached to Lourdes Hospital, Ernakulam would make it clear that the complainant was suffering from “DNS Ethmodidal Polyposis”. The said ailment is specifically excluded from cover of insurance claim as per Exbt. B2 for 2 years from the date of inception of the policy. Admittedly the complainant availed the Exbt. B2 policy with effect from 26-08-2009 and he had undergone treatment at the hospital from 08-06-2010 to 12-06-2010. According to the Hon’ble Supreme Court, while construing the terms of the contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly
construed in order to determine the extent of the liability of the insurer. (Export Credit Guarantee Corpn. Of India Ltd., Vs. M/s. Gang Sons International 2013 (1) KHC SN 16 SC).
8. In that view, of the matter, we do not find any deficiency in service on the part of the opposite party in repudiating the insurance claim of the complainant. We are only to dismiss the complaint. Ordered accordingly.
Pronounced in the open Forum on this the 19th day of August 2014
Sd/-
A. Rajesh, President.
Sd/-
Sheen Jose, Member.
Sd/-
Beena Kumari V.K., Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of discharge summary dt. 12-06-2010
A2 : Copy of discharge bill dated 12/06/2010
A3 : Copy of statement dt. 09/06/2010
A4 : Copy of letter
Opposite party’s exhibits :
Ext. B1 : Copy of e-mail dated 28-06-2010
B2 : Copy of policy
Depositions:
PW1 : Anil Kumar
