BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 15/12/2010

Date of Order : 29/05/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 648/2010

Between

And

O R D E R

A. Rajesh, President.

1. The facts leading to this complaint are as follows :

The complainant has been a mediclaim policy holder of the opposite party. The complainant preferred a claim to the treatment received by him at Lissie Hospital, Ernakulam from 17-02-2010 to 24-02-2010 and from 16-03-2010 to 22-03-2010 at M.O.S.C. Medical College Hospital, Kolenchery respectively. The treatments were done for Kidney related ailment. The complainant spent Rs. 60,000/- for treatment expenses. The policy coverage is only for Rs. 50,000/-. The complainant had received a claim earlier for Rs. 13,000/-. The complainant is entitled to get Rs. 36,400/- towards insurance claim. The opposite party repudiated the claim of the complainant by letter dated 18-10-2010 relying on Clause No. 4.1 in the policy. The repudiation of the claim amounts to deficiency in service on the part of the opposite party. The complainant is legally entitled to get the insurance amount with interest together with compensation and costs of the proceedings. This complaint hence.

2. The version of the opposite party is as follows :

The claim submitted by the complainant was examined by the opposite party and it was noticed that the treatment was for pre-existing disease. The claim was related to an earlier claim under CCN No. 1238315 submitted during the year 2008, which was repudiated on the reason 'pre-existing ailment', and therefore, the repudiation done in this case is legal and valid under Clause 4.1 of the policy. The medical records go to show that the complainant is a known case of various ailments such as Diabetes Mellitus, systemic hypertension, chronic kidney disease initiated on hemodialysis. The rejection of the claim is legal and proper and there is no deficiency in service on the part of the opposite party.

3. No oral evidence was adduced by the parties. Exts. A1 to A3 and B1 to B4 were marked on the side of the complainant and the opposite party respectively. Heard the learned counsel for the parties.

4. The points that came up for consideration are as follows :

1. Whether the complainant is entitled to get the insurance claim from the opposite party?

2. Whether the opposite party is liable to pay compensation and costs of the proceedings to the complainant?

5. Point No. i. :- Admittedly, the complainant availed himself of Ext. B1 policy from the opposite party. During the currency of the policy, the complainant had undergone treatment at Lissie Hospital, Ernakulam from 17-02-2010 to 24-02-2010 and at M.O.S.C. Medical College Hospital, Kolenchery from 16-03-2010 to 22-03-2010 evidenced by Exts. A2 and A3 medical certificates. The claim of the complainant was repudiated by the opposite party by Ext. A1 letter dated 18-10-2010. The reason for rejection of the claim as per Ext. A1 reads as per Exts. A2 and A3 is as follows :

“Date of first inception is 17/10/2005. Admitted with Arteriovenous fistula. Please refer CCN # 1238315 which was repudiated under Clause 4.1. Hence we are repudiated this claim under the Clause 4.1 of this policy (pre-existing disease)”

5. The learned counsel for the complainant contended that the previous ailment has no nexus with the present ailment of the complainant. Admittedly the previous ailment of the complainant was diagnosed as Arteriovenous Fistula. The present disease of the complainant was diagnosed as follows :

“Final Diagnosis : (as per Ext. A2)

Type 2 Diabetes mellitus

diabetic Retinopathy

Systemic hypertension

Chronic Kidney disease-initiated on hemodialysis.

Early 2 degree Piles.”

Diagnosis : (as per Ext. A3)

“END STAGE RENAL DISEASE ON HEMODIALYSIS

GRADE 3 HAEMORRHOIDS – haemorrhoidectomy done under SA”

6. It is to be noted that the complainant has not challenged the repudiation of the substantiation of the opposite party in 2005 which clearly goes to show that a deficiency on his part is visuable. The same has been repeated in 2010 again for which there is no reasonable explanation is forthcoming. For the lack of forthcoming explanations to thes e, we are at a loss to uphold or entertain the case of the complainant. There is no iota of evidence to disprove the same. Had it been so, this Forum would not have dissented from accepting the contentions of the complainant. This Forum is only to dismiss the complaint hence.

Pronounced in open Forum on this the 29^th day of May 2012.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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