THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C. 437/2011
Dated this the 3rd day of May, 2016
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
Present: Beena Joseph, Member:
This petition was filed on 04.11.2011. The complainant alleging that her husbands medical insurance claim was illegally repudiated by the Opposite party. Hence this petition.
The complainant states that her husband Sathyanadhan joined in a mediclaim insurance policy as per policy number P/181311/01/2011/007089. During the insurance period insured Sathanadhan was undergone an operation from M.N. Orthopedic hospital Chennai and he paid Rs. 4 lakh as hospital expense and they submitted mediclaim application along with documents to the opposite party. But opposite party repudiated the claim on 05.09.2011 as pre-existing disease. Hence she claims hospital expense Rs.50,000/- and compensation of Rs. 50,000/- from the opposite party. Hence this complaint.
In this matter notice were served on both parties, both of them appeared. Opposite party filed version stating the following facts. Opposite parties disputes the negligence or deficiency in service on their part. Opposite party admits the mediclaim policy, which was valid for a period from 26.03.2011 to 25.03.2012. Opposite party admits that, the petitioner’s husband was admitted on 24.06.2011 at M.N.Othopaedic hospital Chennai and diagnosed that petitioners husband suffering from chondrosarcoma pubic bone right side. The insured submitted claim with all medical bills and Lab report. The medical record of the complaint shows that patient was admitted for pain and swelling past eight months. The records shows that the patient was suffering from said complaint since 8 months. The policy owned by the petitioners husband is commencing from 26.03.2011 based on a fresh proposal, wherein the insured has not revealed the pre existing illness. Thus he suppressed material facts and contract is void. The above claim of the petitioner was rejected on the ground of pre-existing disease as per exclusion clause number one of the policy. Company has no liability to compensate the disease which pre-existing within 48 months prior to the insured persons first policy. That is why the opposite party repudiated the claim of the petitioner. Hence there is no service deficiency or illegal trade practice on the part of this respondent. Hence the petition is liable to be dismissed.
In this matter complainant was examined as PW1 and Exts.A1 to A5 were marked on their side. Opposite party examined as RW1 and Exts.B1 to B6 were marked.
Considering the rival claims evidence and documents, the following issues were framed.
- Whether there is any consumer relationship between the parties?
- Is there any service deficiency on the part of opposite party?
- If yes. What are the awards to be passed?
Above stated points 1 & 2 are interlinked and it can be discussed together for the brevity of the case. Complainant produced the mediclaim certificate which marked as Ext.A1, is the policy for an amount of 2 lakhs for the period from 26.03.2011 to 25.03.2012, issued to the petitioner’s family. The existence of said policy was not disputed by the opposite parties. Hence it can be safely held that petitioner is having consumer relationship with the opposite party. This point is found in favour of the petitioner. Ext.A2 is the discharge summary of M.N. Hospital at Chennai. Ext.A3 is the claim document receipt. Ext.A4 is the repudiation letter issued by the opposite party. Ext.A5 is the policy certificate of the petitioner for the period from 27.02.10 to 26.02.11.
The opposite party submitted Ext.B1 to B6 documents. Ext.B1 is the photocopy of policy. B2 is the bills submitted by the petitioner before the Opposite party. Ext.B3 is the original claim form submitted by the complainant. Ext.B4 is the discharge summary issued by M.N. Orthopaedic hospital, Chennai. Ext.B5 is the proposal form given by the petitioner to the opposite party on 25.03.2011. Ext.B6 is the discharge summary issued by Iqraa hospital dtd.03.08.2010.
On going through both parties documents, it is seen that coverage in the year 2011 to 2012 as per Ext.A1 & Ext.B1 which was not timely renewed by the complainant. Ext.B5 is the proposal Form filled and submitted by the complainant in order to avail mediclaim insurance as per Ext.A1, wherein complainant stated that he had not suffering from any pre existing diseases. In Ext. B3 the claim form submitted by the petitioner wherein, the certified doctor says that the petitioner’s husband was suffering from the above disease for the last 8 months. The petitioner was admitted in M.N.Hospital on 24.06.2011 and discharged on 09.07.2011. which clearly shows that the patient was suffering from chondrosarcoma pubic bone right side from 2010 onwards. Opposite party produced Ext.B6 document issued by Iqraa hospital Kozhikode dtd.03.08.2010 the discharge summary of the complainant wherein also it stated that, petitioners husband was suffering from chondrosarcoma pubic bone which was suppressed by the complainant while obtaining the mediclaim policy, this was evident from the Ext.B5document.
As per the policy conditions pre-existing diseases prior to 48 months were excluded from coverage. The petitioner was having valid policy for the period from 26.03.2011 to 25.03.2012. Petitioner’s husband here had a prior policy in the year 2010-2011, which was lapsed due to non renewal. So the second policy can be considered only as a fresh policy. As per the policy conditions, the claim which lodged by the complainant’s husband is preexisting disease which excluded as per the policy conditions. More over in this case petitioner purposefully suppress the material facts that he was suffering from the above disease from 2010 onwards which evident from Ext.B6. In this circumstances it can be seen that the petitioner approached this forum without clean hands and good faith. Hence it is held that there is no merit in the above petition.
In the result the petition is hereby dismissed without cost.
Dated this the 3rd day of May 2016
Date of filing: 04.11.2011.
SD/-MEMBER SD/- PRESIDENT SD/- MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. Mediclaim certificate issued by the opposite party
A2. Discharge summary issued by M.N. Orthopedic Hospital
A3. Claim document receipt
A4. Claim Repudiation letter
A5. Policy Certificate
Documents exhibited for the opposite party:
B1. Copy of policy certificate
B2. Medicine bill submitted by the complainant
B3. Claim form submitted by the complainant
B4. Discharge summary
B5. Proposal form submitted by the complainant
B6. Discharge summary
Witness examined for the complainant:
PW1. Sajinakumari (Complainant)
Witness examined for the opposite party:
RW1. Dilip Kumar, T.C. 16/21(1), Eswari Vihar, Krishna Vilasam Road, Jagathy, Trivandrum
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
