Complaint filed on: 20.08.2015

Complaint Disposed on:23.11.2016

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.

COMPLAINT NO.113/2015

DATED THIS THE 23^rd DAY OF NOVEMBER 2016

:PRESENT:

HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT

HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER

HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER

COMPLAINANT:

Jaijagadeesh

S/o K.M.Sundar,

A/a 38 years,

M/s Golden Bar & Restaurant,

Mallandur Road,

Chikmagalur.

(By Sri/Smt. S.S. Venkatesh, Advocate)

V/s

OPPONENT:

The Manager,

Oriental Insruance Company Limited,

Basavanahalli Main Road,

Chikmagalur – 577 101

(OP By Sri/Smt. N.Devendra Kumar, Advocate)

By Hon’ble President Sri. Ravishankar,

:O R D E R:

The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP alleging deficiency in service in not settling the claim towards the treatment.  Hence, prays for direction against OP to reimburse the medical expenses along with compensation of Rs.10,000/- for deficiency in service.

2.     The brief facts of the complaint is that:

The complainant along with his family had obtained medi claim policy form OP under policy No.472602/48/2016/16.  The said policy was continuously renewed from 2012 and still the policy is in force.  Such being the case, the son of the complainant one S.J.Nishanth had underwent surgery for the problem of Harniyotomy and Hydroul and hospitalized at Ashraya Hospital Chikmagalur and taken a treatment as an inpatient from 28/05/2015 to 31/05/2015 and complainant spent Rs.50,000/- towards treatment of his son.  After discharge, the complainant being the beneficiary of the policy had claimed for reimbursement of the said medical expenses spent towards treatment of his son, but so far the OP has not settled the claim made by the complainant without any valid reasons.  Hence, OP rendered a deficiency in service in not settling the medi claim made by the complainant towards treatment of his son.  Subsequently the complainant issued a legal notice and called upon the OP to settle the claim.  Even in spite of receipt of the legal notice, the OP also not settled the claim.  Hence, the complainant filed this complaint alleging deficiency in service and prays for settlement of the claim amount to the tune of Rs.50,000/- along with compensation for deficiency in service as prayed above.  

3.     After service of notice, OP appeared through his counsel and filed version and contended that they have issued medi claim policy to the complainant and his family vide policy No.472602/48/2016/16 which is valid from 26/05/2015 to 25/05/2016.  The liability of this OP is only subject to terms, conditions, liabilities and limitations of the policy.  At the time of issuance of the policy this OP also issued terms and conditions of the policy to the complainant.    

OP further contended that on 09/05/2014 the complainant had issued a self declaration and stated that his son S.J.Nishanth underwent a congenital disease (since birth) and declared himself that the said disease exists since from his birth and as per the terms and conditions of the policy, the disease comes from birth itself will not cover.  Hence, this OP is not liable to pay any claim made by the complainant towards the treatment of his son.

OP further contended that after the claim made by the complainant, they have verified all the medical documents and came to know that the said Nishanth is having said disease since his birth.  Hence, they have repudiated the claim made by the complainant through their letter dated: 29/09/2015 and thereby they have acted as per the terms and conditions of the policy and submit no deficiency in service and pray for dismissal of the complaint.  

4.     The complainant filed affidavit and marked medi claim policy issued by OP since from 2012 to 2015 marked as Ex.P1, claim form for reimbursement of the medical expenses, marked as Ex.P2, request for cashless benefit, marked as Ex.P4, office copy of the legal notice marked as Ex.P5 and postal acknowledgment due marked as Ex.P6.  The OP also filed affidavit evidence and marked authorization letter as Ex.R1 and individual medical policy with terms and conditions as R2.

5.     Heard the arguments:

6.     In the proceedings, the following points do arise for our consideration and decision:

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

2.  Whether complainant entitled for any relief & what Order?

7.     Our findings on the above points are as follows:-

1. Point No.1: Affirmative
2. Point No.2: As per Order below. 

: R E A S O N S :

POINT NOs. 1 & 2:

8.     There is no dispute that OP had issued medi claim policy to the complainant and his family in the year 1012 which was renewed subsequently up-to 2016.  There is also no dispute that the policy without any interruption was renewed from time to time.  During the policy in force, one Nishanth a son of complainant underwent surgery at Ashraya hospital, Chikmagalur with the history of congenital disease and he underwent surgery called Harniyotomy and Hydroul.  Thereafter he was discharged on 31/05/2015.  At the time of hospitalization the complainant claimed for cashless benefit as per Ex.P4.  The said claim was repudiated by OP agency.  Subsequently after discharge, the complainant being beneficiary of the policy had claimed for reimbursement of the medical expenses.  Even the said claim was repudiated by the OP for the reasons that the son of the complainant had congenital disease since his birth and as per the terms and conditions of the policy, the congenital disease are not covered for the risk.  Hence, submits repudiation made by this OP is not amounts to deficiency in service.

9.     On going through Ex.R2 which was produced by OP, where in the terms and conditions of the policy in exclusion clause, we noticed that the OP/agency is not covering the congenital external disease to the policy holder, whereas in clause 4.3 we noticed that the policy covers congenital internal disease after lapse of two years of the policy.  Admittedly the policy obtained by the complainant in the year 2012 which was renewed without any break and the son of the complainant underwent surgery in the year 2014 i.e. after lapse of two years of taking the policy.  Hence, congenital internal diseases are covered under the policy.  The OP has failed to notice the exclusion clause 4.3 properly.  The exclusion clearly indicates as follows:-

4 EXCLUSIONS:

The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:

4.1 Pre-existing health condition or disease or ailment / injuries: Any ailment / disease / injuries / health condition which are pre-existing (treated / untreated, declared in the proposal form), when the cover incepts for the first time are excluded upto 4 years of this policy being in force continuously.

For the purpose of applying this condition, the date of inception of this Medi claim policy taken from Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any break in period.

This exclusion will also apply to any complications arising from pre existing ailments / diseases / injuries. Such complications will be considered as a part of the pre existing health condition or diseases. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions.

4.2 Any disease other than those stated in clause 4.3 contracted by the insured person during the first 30 days from the commencement date of the policy except treatment for accidental external injuries.

4.3 During the period of insurance over, the expenses on treatment of following ailment/diseases/surgeries for specified periods are not payable if contracted and / or manifested during the currency of the policy.

If the continuity of the renewal is not maintained with oriental insurance company then subsequent cover will be treated as fresh policy and clauses 4.1, 4.2, 4.3 will apply unless agreed by the company and suitable endorsement passed on the policy.

4.4 Injury or disease directly or indirectly casued by or arising from or attributable to War, invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons/materials.

4.5 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.

4.6     Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.

4.7 Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure filing of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalization for treatment.

4.8 Convalescence, general debility, “run down” condition or rest cure, congenital external disease or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to and or use misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc.

10.   The OP company has only repudiated the claim basing on the exclusion clause 4.8 which says that the congenital external diseases are not covered form the risk and repudiated the claim without observing the clause of 4.3.  Hence, the OP rendered deficiency in service in repudiating the claim of the complainant. 

11.   The learned advocate for complainant vehemently argued that the son of the complainant has underwent surgery for congenital internal disease and not congenital external disease.  Hence, prays for payment of medical expenses.  But OP without proper observation has repudiated the claim.  Hence, the OP is liable to pay the eligible medical expenses spent by the complainant.  Further, the OP is also liable to pay compensation of Rs.10,000/- for deficiency in service in not settling the claim by observing the clause along with litigation cost of Rs.1,000/-.  As such for the above said reasons, we answer the above points accordingly and proceed to pass the following:-

: O R D E R :

1. The complaint filed by the complainant is allowed in part.
2. The OP is directed to pay the eligible medical expenses to the complainant. 
3. The OP is further directed to pay Rs.10,000/- towards compensation and Rs.1,000/- towards litigation cost to the complainant.
4. The OP is further directed to comply the above order within one month from the date of knowledge/order, failing which the payable amount shall carry 9% interest from the date of complaint to till realization.

5. Send free copies of this order to both the parties.

(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 23^rd day of November 2016).

                                 (RAVISHANKAR)

                                      President

(B.U.GEETHA)                                         (H. MANJULA) 

     Member                                                    Member   

ANNEXURES

Documents produced on behalf of the complainant:

Ex. P1               -           Medi-claim policy issued by OP since from 2012 till 2015

                                    As per the renewal        

Ex.P2                -           Mandate form for reimbursement of the medical expenses

Ex.P3                -           Claim form for reimbursement of the medical expenses

Ex.P4                -           Request for cash less benefit, marked as Ex.P4

Ex.P5                -           Office copy of the legal notice

Ex.P6                -           Postal acknowledgment

Documents produced on behalf of the OPs:

Ex.R1               -           Authorization letter

Ex.R2               -           Individual medical policy with a terms and conditions.

Dated:23.11.2016                                          President 

District Consumer Forum,

                                                                   Chikmagalur.            

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