IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM

            DATED THIS THE 31ST  DAY OF MAY 2016

Present: -        Smt. G.Vasanthakumari, President            .

Adv. Ravisusha, Member

Adv.M.Praveen Kumar, Member

         CC.No.139/2014

Vipin.K                                                                      :           Complainant

Puthenpurayil

Pada North

Karunagappally

Kollam – 690518

[By Adv.Ram Manoj.A.S, Kollam]

V/S
            1.         M/s Bajaj Allianz Life Insurance :              Opposite parties

                        Company Ltd.

                        GE Plaza, Airport Road, Yerwada

                        Pune – 411006

            2.         Health Administration Team

                        2nd Floor, Bajaj Finserv Building

                        Survey Number 208/B-1, Behind

                        Weikfield IT Park, Viman Nagar

                        Pune – 411014

            3.         The Manager

                        M/s Bajaj Allianz Life Insurance Company Ltd.

                        Kollam Branch

                        [By Adv. Venu.J.Pillai, Kollam]

ORDER

ADV. RAVISUSHA, MEMBER

            Complainant’s case is that the complainant is a consumer of Bajaj Alliance Life Insurance Company Ltd by claimant ID card No.BAL 0183133726-75888 A , Policy No.OG-0183133726 , valid from 16/08/2010 to 16/08/2016 for an assured amount of Rs.2,00,000/-.  The said policy is a family policy (Bajaj Alliance - Family Care First), so the sum assured would float across all the covered family members. All the family members together can utilize upto a maximum of chosen sum assured in the policy for hospitalization benefit. As per the policy, the

(2)

policy holder has the option to avail cash less service facility in network hospitals as specified by the company. For the said purpose the complainant is provided with a photo identity card with membership number. As per the policy the complainant is the Primary Member and his wife and daughter are the dependent members covered.

            On 15/01/2014, wife of the complainant named P.R.Divya Mole was admitted as inpatient at Kerala Institute of Medical Science Hospital, Anayara P.O, Thiruvananthapuram, due to abdominal pain and vomiting. On diagnosis it is revealed that she was having Umbilical hernia and there she underwent surgical correction ie, open umbilical hernia repair with mesh on 16/01/2014. The patient was discharged from the hospital on 21/01/2014. Since he is entitled to avail cashless facility as per the policy, on 15/01/2014 the complainant applied for the same by submitting a duly filled health insurance claim form of Bajaj Alliance with supporting documents. But on 21/01/2014 the 2nd opposite party denied the claim of cashless facility stating that “ The pre authorization request states that the patient is diagnosed having Large Incisional Hernia, any medical/surgical expenses incurred on treatment of the said ailment is a standard exclusion under the policy, hence the cashless stands denied under clause 6 hh”. Thus the complainant was compelled to pay an amount of Rs.85,334/- as medical/ hospital expenses. When he enquired about it to the 3rd opposite party it was informed that he will be reimbursed. Subsequently the complainant received a claim repudiation letter dated 14/02/2014 from the 2nd opposite party stating that “verification of the claim documents reveals that the patient is diagnosed of having Large Incisional hernia and treated for the same . As per the policy clause expenses related towards the Incisional hernia are payable only if the claim for previous surgery has been paid by the company. Hence the claim is not payable” The very act of the opposite party is violation of policy condition since hernia is not an excluded ailment as per the policy. The complainant is the consumer of Bajaj Alliance Life Insurance Company Ltd. from 2009 onwards. As per the conditions of policy any member is entitled to get the policy benefits if he/she is diagnosed or hospitalization taking place due to hernia within one year of the policy commencement date. More over that in this case the patient is diagnosed of having Umbilical hernia and not Incisional hernia as claimed by the opposite party in their claim repudiation letter. Umbilical hernia is quite different from Incisional hernia.

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The act of the opposite parties in rejecting the deserving claim of the complainant by baseless arguments and frivolous reasons caused much hardships and sufferings to the policy holder. By rejecting the claim of the policy holder the company itself shows the deficiency in service to its consumers. Therefore the opposite parties are jointly and severally liable to pay compensation to the complainant for the deficiency of service from their part. Hence this complaint.

            Opposite parties filed version contending that the complainant had availed Medi claim policy under the name and style of Bajaj Alliance Family care first under the policy bearing No.018133726 for a sum assured amount of Rs.2,00,000/- only. That the patient was admitted in Kerala Institute of Medical Science on 15/1/2014 with c/o abdominal pain and vomiting since 3 days. She noticed a swelling at umbilical region since last 6 months, gradually increasing in size. USG abdomen done on 16/1/2014 reveled large incisional hernia at the level . She underwent open umbilical hernia repair with mesh under spinal + epidural anesthesia on 16/1/2014. As per indoor case papers, the PH has history of lower segment cesarian (LSCS) in 2009 & 2013. Verification of the claim documents revealed that the patient is diagnosed for Large Incisional Hernia and treated for the same and as per the policy clause expenses related towards Incisional hernia are payable only if the claim for previous surgery has been   paid by the company and hence claim is not payable.

            The company shall not be liable to make any payment if hospitalization or medical expenses or claims are attributable to. Medical expenses incurred due to Ventral/ Incisional Hernia unless the company has paid the first operation. The claim was repudiated as per exclusion clause 5hh. All contracts of insurance are contracts and once entered into the contract is binding on all parties to the contract and no one can claim or go beyond the terms and conditions of that contract and as such the complaint needs to be dismissed as not maintainable. There is no deficiency of service on the part of these opposite parties. These opposite parties are bound to act as per the stipulations in the policy conditions and insurance laws. These stipulations are also binding on the complainant.

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?

(4)

The evidence in this case consists of the oral testimony of PWs 1 and 2  and documentary evidence of  Exts P1 to P9.

Opposite parties did not adduce any evidence on their part.

Points:-It is not disputed that the policy of the complainant was valid from 16/8/2010 to 16/8/2016 during the treatment time (15.1.2014 ) of the wife of the complainant. But when the complainant applied for getting the claim amount, to the opposite party the application was denied by them, stating that the patient is diagnosed having large incisional hernia and this ailment is a standard exclusion under the policy.

            Complainant’s pleading is that the complainant is the consumer of Bajaj Alliance Life Insurance Company Ltd. from 2009 onwards. As per the conditions of policy any member is not entitled to get the policy benefits if she is diagnosed or hospitalization taking place due to hernia within one year of the policy commencement date. According to the complainant the patient is diagnosed of having Umbilical hernia and not Incisional hernia as claimed by the opposite party and umbilical hernia is quite different from Incisional Hernia.  “ For proving this point, the complainant produced Ext.P7 discharge summary of the patient of KIMS Hospital dated 15/01/2014 issued by Dr.Firoz Khan MH( Associate Consultant) who conducted the surgery on the wife of the complainant. In Ext.P7 it is obviously seen that the discharge diagnosis is “Large Umbilical Hernia” . More over from the complainant’s side the said doctor Dr.Foroz Khan was examined as PW2. The testimony   of PW2 reveals that “Diagnosis  sNbvX-t¸mÄ F´v tcmK-amWv F¶mWv t_m²-y-s¸-«Xv? Umbilical Hernia. Umbilical Hernia ¡pÅ Surgical correction  BWv sNbvXXv.  Umbilical Hernia F¶ AhØ ap³]v GsX-¦nepw surgery \S-¯n-b-Xnsâ outcome Bbn  D­m-Im-dpt­m? D­m-Im-dp­v.  B `mK¯v Operation sNbvXn-«p-s­-¦n Cu Particular case  ap³]v \S-¯nb surgery bpsS outcome Bbn D­m-b-XmtWm ? AÔ. On cross examination PW2 deposed that “ Umbilical Hernia. bpw Incisional Hernia bpw X½n-epÅ hy-X-ymkw? Operation sâ AS-bmfw Incisional Hernia F¶Xv t\ct¯ Hcp surgery \S-¶-Xn \n¶pw D­m-Ip¶ Hernia. BWv.ap³]v Cu patient  \v c­v Operations ( LSCS) \S-¯n-bn-«p­v. A§-s\-bp-Å-t¸mÄ imkv{Xob ]cn-tim-[\ \S-¯msX F§s\ Umbilical Hernia BWv F¶v t_m²-y-s¸-«p? Clinically

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t_m²-y-s¸-«p. Clinically means doctor F¶ \ne-bnepÅ ]cn-tim-[\bn a\-kn-embn. t\ct¯ c­p surgery \S-¯nbXmbn t_m²-y-s¸-«m AXv Incisional Hernia ¡v BWtÃm km²-yX IqSp-XÂ?. Rm³ hntbm-Pn-¡p¶p.  Umbilical Hernia, birth  D­m-Ip-¶Xpw D­v, ]n¶o-Sv develop sN¿p-¶Xpw D­v. Incisional Hernia bv¡mWv Cu patient s\ ]cn-tim-[n-¨-sX¶pw patient sâ _-Ôp-¡-fpsS kzm-[o\w ImcWw  Umbilical Hernia F¶v If-hmbn ]d-bp-I-bmWv F¶p ]d-bp¶p ?  icn-bÔ

Hence the medical evidence shows that the patient was undergone surgery for large umbilical hernia. This point found accordingly.

            As per the policy conditions, hernia is not an excluded ailment and any member is entitled to get the policy benefits if he/she is diagnosed or hospitalization taking place due to hernia within one year of the policy commencement date. Considering this condition the complainant is legally entitled to get the insurance claim. From Ext. P5 the total treatment expenses is Rs. 85334.02.

            In the result, the complaint is allowed in part. The opposite parties are directed to pay Rs.85,334/- to the complainant with 4% interest from the date of complaint till realization of the amount. The opposite parties are further directed to pay Rs.25,000/- as compensation and Rs.2500/- as cost to the proceedings to the complainant. The order is to be complied with within one month from the date of receipt of this order. Failing which the complainant is entitled to get 9% interest for the claim amount (Rs.85334).

Dated this the 31st   day of May  2016.                                                                                                                                                                     

G.VASANTHAKUMARI:Sd/-

ADV.RAVISUSHA:Sd/-

ADV.M.PRAVEENKUMAR: Sd/-

Forwarded/by Order

Senior superintendent

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I N D E X

PW.1:-Vipin .K

PW.2:-Dr.Firos khan

Ext.P.1:-Policy certificate No. 0183133726

Ext.P.2:-Health card

Ext.P.3:-Policy certificate No.0130000705

Ext.P.4:-Details of cashless facility

Ext.P.5:-Copy of bills

Ext.P.6:-Denial of cashless facility (Repudiation letter) dated 14/02/2014

Ext.P.7:-Discharge summary

Ext.P.8:-Product circular

Ext.P.9:-Renewal premium receipt dated 31/08/2013