IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM

            DATED THIS THE 8TH  DAY OF MARCH 2016

Present: -        Smt. G.Vasanthakumari, President

Adv. Ravisusha, Member

Adv.M.Praveen Kumar, Member

         CC.No.253/2012

1. C.P.Suresh Kumar                                               :                       Complainant

S/o K.Pachupillai

C.P.S.Vihar

Kannimelcherry

Kavanad P.O

Kollam - 691003

2. S.Sreelatha

W/o. C.P.Suresh Kumar

Residing at – do-

[By Adv.Uliyakovil.S.Navas, Kollam]

V/S

            1.         The Manager                                     :                       Opposite parties

                        Oriental Insurance Co.Ltd.

                        L.I.C.Building, 3rd Floor

                        Residency Road, Chinnakkada

                        Kollam- 691001

                        [By Adv.N.Sarat Chandramenon, Kollam]

            2.         M.D. India Health Care Service (T.P.A) Pvt.Ltd

                        Regional Office EL-63/521

                        Opposite Karuna Printers

                        Kasim Lane, Near St. Antony School

                        Kaloor, Cochin – 682017

            3.         Irshad (Additional opposite party)

                        Edayadithara

                        Chinnakada, Kollam

                        LIC Building, 3rd Floor, Residency Road

                        Chinakkada, Kollam

                        [Impleaded as per order on IA 100/14 dated 09/10/2014) 

ORDER

ADV. RAVISUSHA, MEMBER

Complainant’s case is that the complainants are husband and wife. The 1st complainant availed a mediclaim policy from the 1st opposite party. The 2nd opposite party is the third party administrator (TPA) and the 3rd opposite party is the agent of 1st opposite party.

(2)

The mediclaim covers the medical expenses incurred for the complainants and their 2 children. The policy coverage is for 2 lakhs rupees. The policy was taken in the year 2007 and it was renewed every year. The 1st policy period was from 20/12/2007 to 19/12/2008 (No.441400/48/2008/2657). The 2nd policy period was from 20/12/2008 to 19/12/2009( No.441400/48/2009/1820). The 3rd policy period was from 02/03/2010 to 01/03/2011(No.441400/48/2010/1577) and 4th policy period was from 11/04/2011 to 10/11/2012 (No.441400/48/2012/20)

While the policy was inforce, the 2nd petitioner suffered severe head pain and nerve pain and she consulted Dr. Sager Cheriyan, Neuro Surgeon of Holy Cross Hospital, Kottiyam. As advised, she was admitted as inpatient on 21/07/2011 and discharged on 23/07/2011. The hospital authorities issued bill for Rs.13,074/-. The petitioners approached the 1st opposite party on 01/08/2011 for getting the amount refunded as per the policy conditions. But the 1st opposite party declined to refund the bill, instead directed them to approach the 2nd opposite party. Hence the application was sent to the 2nd opposite party. On 13/08/2011 the petitioners received letter from the 2nd opposite party and in answer to the said letters the petitioners replied on 05/09/11 explaining the details of medical bills and hospital records. Even though the 2nd opposite party received the letter , no intimation was received from them. Since there was inordinate delay from the part of the 2nd opposite party in processing the claim, the petitioners contacted the 2nd opposite party and they informed that they are processing the claim.

As per their direction, the 1st petitioner arranged to sent the treatment details through the hospital authorities to the 2nd opposite party on 27/12/2011.  After a lapse of 2  months the petitioner again contacted the 1st opposite party. They had handed over a copy of email on 02/03/2012 repudiating the mediclaim filed by the petitioners. On 29/03/2012 the petitioner filed review petition, but on 21/05/12 the Kochi office of the 1st opposite party intimated that the claim is repudiated. Hence filed this complaint.

Opposite party 1 filed version contending that the statement in para 1 of the complaint that the complainant used to continuously renew the policy is incorrect and hence denied. The previous policy was not renewed in time. There was a gap of more than one month since the expiry of the previous policy. Therefore the policy in question shall be considered as a first year policy only.

(3)

The opposite party has been intimating its clients systematically through letters, SMS, e-mail etc. Even if there was no intimation (not admitted), the complainant was bound to renew the policy in time. If there was no renewal in time, then it shall be treated as a first year policy only. In the letter dated 25/08/2011 of the 2nd opposite party to the 2nd complainant it required the complainant to furnish the following informations:-

Details of treatment given during hospitalization from the treating physician
To provide indoor case papers
Certificate from the treating physician for need for hospitalization

However the complainant has not furnished the details called for but sent a reply dated 05/09/2011.

It is admitted that the complainant sent a letter dated 29/03/2012 to the 1st opposite party and that a reply was sent vide letter dated 30/04/2012. It is also admitted that the medi-claim of the complainant could not be considered favourably by the 1st opposite party as advised by the 2nd opposite party. This matter was promptly intimated to the complainant vide letter dated 21/05/2012 showing valid reasons.

The proximate cause for hospitalization was head ache purportedly caused by hypertension which is excluded for 2 years under the policy. The investigations could have been done as OP. No active line of treatment was given to the second complainant. Hypertension is excluded under clause 4.3 for the first two years of the policy. There has been no deficiency of service on the part of the opposite parties. It is therefore prayed to dismiss the complaint with costs.

Opposite party 2 and additional opposite party 3 are exparte.

The points that would arise for consideration are:-

(1). Whether there is any deficiency in service on the part of the opposite parties?

(2). Reliefs and costs?

Points:- The complainant filed this case  for getting back the medical expenses Rs.13074/- and other expenses incurred by the complainants for the 2nd complainants medical treatment.

            Evidence in this case consists of the oral testimony of PW1 and DW1 and documentary evidence of Exts.P1 to P8 and Exts D1 to D6. Opposite party 2 and opposite party 3 are exparte.

(4)

In this case there is no dispute that the 1st complainants has mediclaim policy with 1st opposite party during the treatment period of 2nd complainant ie 21/07/2011 – 23/07/2011. After the treatment, the 1st complainant submitted claim form to the 1st opposite party, which was repudiated by the 1st opposite party as per the advice of 2nd opposite party through Ext.D2. 1st opposite party repudiated the claim on the ground that the policy in question is a first year policy and the proximate cause for hospitalization was head ache purportedly caused by hypertension which is excluded for 2 years under the policy.

            From the evidence it can be seen that the 1st policy period was from 20/12/2007 to 19/12/2008(No.441400/48/2008/2657). The 2nd policy period was from 20/12/2008 to 19/02/2009 (No.441400/48/2009/1820). The 3rd policy period was from 02/03/2010 to 01/03/2011(No.441400/48/2010/1577) and 4th  policy period was from 11/04/2011 to 10/11/2012 (441400/48/2012/20).

            Even though the 1st opposite party admitted the mediclaim policy of the 1st complainant for a period from 11/04/2011 to 10/04/2012, they contended that the previous policy was not renewed in time. There was a gap of more than one month since the expiry of the previous policy. Therefore the policy in question shall be considered as a first year policy only.

            The complainants pleaded that there is a legal duty cast upon the opposite parties to intimate its customers for renewing the policy, but the opposite parties did not produce any evidence to show that there was intimation regarding renewal of policy. The 1st opposite party contended that even if there was no intimation, the complainant was bound to renew the policy in  time and if there was no renewal in time, then it shall be treated as a first year policy only. Here both parties admitted that there was a gap of more than one month (more than the grace period) for renewing the policy. Even if there is a failure on the part of opposite parties to intimate the complainant about the renewal of policy, that itself cannot be treated as a negligence on the part of opposite parties. The insured must be vigilant about the renewal of his policy.

            Ext.D2 is the repudiation letter. Ext.D2 shows that the 1st opposite party repudiated the claim of the complainant on the ground that as per policy terms and conditions, the claim is not payable under clause 4.3 and 2.3. A perusal of Ext.D1 policy conditions, it can be seen that hospitalization period: Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. During the period of insurance cover, the expenses on treatment of following ailment /diseases/ surgeries for specified periods are not

(5)

payable if contracted and/or manifested during the currency of the policy, ie Condition No.XVII. Hypertension. Further the claim repudiated on the ground that “CRS explanation as per claim documents received it is observed that current hospitalization is only for investigation and is  only for investigation and is not succeeded by an active line of treatment hence claim is repudiated as per policy terms and conditions , As per claim documents it has been observed that insured was admitted for hypertensions and the treatment for hypertension is excluded from the scope of policy for two years from date  of inception, hence claim is not payable”.

The documentary evidence before us to check the repudiation grounds prescribed by opposite party 1 is Ext.D3, D4 and D5. Ext.D3 is certificate issued by Dr.Sagar Cheriyan (Doctor in Holly Cross Hospital), D4 is discharge summary, Ext.D5 is MRI scan report. A perusal of Ext.D4 discharge summary one of the diagnosis is Hypertension and  Ext.D3 the certificate issued by Dr.Sagar cheriyan shows that the doctor advised for emergency diagnosis and treatment. Ext.D5 MRI scan report shows that ‘No abnormality seen in the brain parenchyma/CVJ. Here the complainant failed to produce evidence to show that the complainant has been undergone treatment in any hospital .Hence the grounds prescribed by the opposite party in Ext.D2 are correct.

The details of treatment given during hospitalization from the treating doctor is necessary. Hence the 2nd complainant is not entitled to get the claim amount ie treatment expense. From the available  evidence  (oral and documentary)  we are of the  view that the repudiation of the claim submitted by the complainant is justifiable. There is no deficiency in service on the part of the opposite parties.

Here the complainant failed to prove his case. Hence the complaint is dismissed but without cost.

Dated this the 8th day of  March 2016.                                                                                                                                                                      

G.VASANTHAKUMARI:Sd/-

ADV.RAVISUSHA: Sd/-

ADV.M.PRAVEENKUMAR: Sd/-

Forwarded/by Order

                                                                                                Senior Superintendent

(6)

I N D E X

PW.1:-C.P.Suresh Kumar

DW.1.Sugunambal

Ext.P.1:-Letters

Ext.P.2:-Reply letter

Ext.P.3:-Email

Ext.P.4:-Copy of complaint

Ext.P.5:-Reply

Ext.P.6:-Policy certificate

Ext.P.7:-Claim certificate

Ext.P.8:-Courier, postal receipts, letter

Ext.D.1:-Terms and conditions of policy

Ext.D.2:-Repudiation letter

Ext.D.3:-Certificate of Dr.SagarCheriyan

Ext.D.4:-Discharge summary of Holy Cross hospital

Ext.D.5:-MRI scan report

Ext.D.6:-Medical bill