PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of July 2012
Filed on : 24/02/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 106/2011
Between
Varghese K.V., : Complainant
Kadickattu house, (By Adv. Tom Joseph,
Perumballoor P.O., Court road, Muvattupuzha)
Muvattupuzha.
And
Manager, : Opposite party
M/s. National Insurance Co. Ltd., (By Adv. Rajan P. Kaliyath,
Branch Office, P.B. No. 6, 42/1824, Near Masjid, Kombara,
1st Floor, Santhi Park, Market road, Kochi-682 019.
Kolencherry-682 311.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant availed a medi-claim insurance policy from the opposite party for the period from 26-11-2009 to 25-11-2010. The sum insured was Rs. 50,000/- each for an insured person. The facts being so the complainant was treated for Coronary Artery Disease from 11-05-2010 to 19-05-2010 at Lissie Hospital, Ernakulam. He had to spend Rs. 1,50,000/- towards treatment expenses. The claim application submitted by the complainant was repudiated by the opposite party vide letter dated 18-10-2010 stating that the claim is inadmissible as per clause 4.1 of the policy. The reason for repudiation of the claim is unsustainable, since the complainant had no history of any disease prior to 16-04-2010. The complainant is entitled to get the sum insured of 50,000/- together with Rs. 5,000/- towards compensation and cost of the proceedings. Hence this complaint.
2. The version of the opposite party is as follows:
The ailment which the complainant had undergone is not admissible as per clause 4.1 of the policy and the claim was repudiated. The policy specifically excluded the liability of the opposite party to pay the sum assured if the illness is pre existing. The complainant was suffering from pre-existing ailments and the repudiation of the claim is proper and legal. There is no deficiency in service on the part of the opposite party in repudiating the claim of the complainant.
3. Proof affidavit has been filed by the complainant and Exts. A1 to A5 were marked. No oral evidence was adduced by the opposite party. Exts. B1 to B5 were marked on the side of the opposite party. Heard the counsel for the parties.
4. The points that arose for consideration are as follows:
i. Whether the complainant is entitled to get Rs. 50,000/- from
the opposite party towards insurance claim?
ii. Whether the opposite party is liable to pay a
compensation of Rs. 5,000/- and costs of the proceedings to
the complainant?
5. Point No. i. It is not in dispute that the complainant was holding an insurance policy of the opposite party for the period from 26-11-2009 to 25-11-2010 with sum insured of Rs. 50,000/-. evident from Ext. B1. It is also not in dispute that the complainant had undergone treatment at Lissie Hospital Ernakulam from 11-05-2010 to 19-05-2010. The disease of the complainant was diagnosed as “Triple Vessel Disease”. Accordingly the complainant submitted a claim application before the opposite party. The opposite party repudiated the claim of the complainant vide Ext. A5 letter dated 18-10-2010 which reads as follows:
“ Date of 1st inception of the policy is 26-11-2009- Ttripple vessel disease –detected on 16-04-2010 – CABG – AWMT thrombolysed -elsewhere – CAG revealed TVD. As the nature of TVD, it takes long duration to develop & dyslipidemia is a risk factor. Hence we are repudiated this claim under the clause 4.1 of the policy (pre-existing disease).
6. According to the opposite party the disease of the complainant was pre-existing at the very inception of the policy and as per clause 4.1 of Ext. B1 policy, the complainant is not entitled to get any medi claim from the opposite party. The opposite party vehemently relied on the clinical summary stated in Ext. B3 discharge summary which reads as follows:
Clinical Summary:
Mr. Varghese K.V., a case of acute Anterior Wall Myocardial Infarction, Thrombolysed (elsewhere) was referred for Coronary Angiogram. On admission his BP was 140/100 mm Hg and pulse rate was 118/mt.
7. It is pertinent to note that no independent medical evidence is record to prove the contentions of the opposite party. The above statement in Ext. B1 alone is not sufficient to establish the contentions of the opposite party, especially when the doctor who treated the complainant issued Ext. A4 certificate which is as follows:
“According to our medical records he was not a known case of coronary artery disease and onset of CAD is from 16-04-2010 and Dyslipidemia detected very recently. Dyslipidemia is a risk factor of CAD, however whether it is a direct cause for development of cardiac ailment is not proven”.
Ext. A4 the certificate issued by the treating doctor goes to show that the disease of the complainant was developed recently that is after the inception of the policy. Therefore the repudiation of the claim relying on clause 4.1 of the policy is unsustainable and the complainant is entitled to get insurance claim for the above treatment at Lissie Hospital from 11-05-2010 to 19-05-2010.
8. Point No. ii. The relief to the maximum extend is being granted in this case which forecloses compensation and costs of the proceedings.
9. In the result, we partly allow the complaint and direct that the opposite party shall pay insurance claim of Rs. 50,000/- to the complainant with interest at the rate of 12% p.a. from the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of July 2012
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Copy of order despatched on :
By Post : By Hand:
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of Hospitalization Benefit
Policy
A2 : Discharge summary
A3 : Copy of medical certificate to be
filled in by the doctor treating the
patient.
A4 : Copy of certificate
dt. 03/11/2010
A5 : Copy of repudiation letter
dt. 18-10-2010
Opposite party’s Exhibits : :
Ext. B1 : Copy of Hospitalization
Benefit Policy
B2 : Copy of repudiation letter
dt. 18/10/2010
B3 : Discharge summary
dt. 26-04-2010
B4 : Copy of discharge summary
