PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 30th day of December 2011.
Filed on :07-08-2009
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 425/2009
Between
P.K. Vijayan, : Complainant
Parakattukudy house, (By Adv. Tom Joseph,
Pothanicadu P.O., Court road, Muvattupuzha)
Ernakulam.
And
1. M/s. New India Assurance : Opposite parties
Co. Ltd., Madaparambil Chambers, (By Adv. Lakshmanan T.J.)
M.C. Road, Muvattupuzha. Penta Queen, Padivattom,
2. M/s. Medi Assist India Pvt. Ltd., Kochi-24)
Annapoorna, No. 797, 10Main,
4th Block, Jayanagar,
Bangalore-560 011.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is a family medi claim policy holder of the 1st opposite party for the period from 16-06-2008 to 15-06-2009. He was having medi claim policies of M/s. Oriental insurance company Ltd. for several years. While so, the complainant was admitted at Indo American Hospital for the period from 01-05-2009 to 05-05-2009 with complaints of cervical spondlylotic myleopathy C4, C5. He spent Rs. 79,115/- towards treatment expenses. Subsequently a claim was lodged before the opposite parties. But it was repudiated by the 2nd opposite party by their letter dated 22-07.2009 stating that the ailment intervetebral disc prolapse is excluded for 2 years from the inception of the policy. The disease of the complainant was diagonised as cervical spondylotic myleopathy –C4,C5 and not intervartebral disc prolapse. Moreover, the complainant was having policy with M/s. Oriental Insurance Company Ltd., Kothamangalam branch for the last several years. The first opposite party and M/s. Oriental Insurance Company are the subsidiaries of the general Insurance Corporation controlled by the Government of India and so policies have to be considered as continuing policies. The repudiation of the claim on flimsy grounds amounts to deficiency of service. The complainant is entitled for Rs. 70,115/- which he spent towards treatment expenses along with interest at the rate of 12% p.a. He is also entitled for Rs. 10,000/- towards compensation for mental agony and hardships suffered by him due to the repudiation of the claim. This complaint hence.
2. The version of the opposite party.
The 1st opposite party had issued a hospitalization Benefit policy 2007 to the complainant and his family members for the period from 16-06-2008 to 15-06-2009. The same was issued based on the proposal form submitted by the complainant. The complainant has not mentioned any thing about the past insurance coverage in the proposal form. The complainant was admitted in the hospital from 01-05-2009 to 05-05-2009 which is excluded for 2 years from the commencement of the policy as per the exclusion clause of the policy condition. The opposite parties repudiated the claim of the complainant only in accordance with law, there is no deficiency in service on the part of the opposite parties.
3. No oral evidence was adduced by the complainant. Exts. A1 to A4 were marked on his side. The witness for the opposite party was examined as DW1 and Exts. B1 to B7 were marked on the side of the opposite parties. Heard the counsel for the parties.
4. The points that arose for consideration are
i. Whether the complainant is entitled to get insurance claim from
the opposite parties?
ii. Compensation and costs of the proceedings.
5. Point No. i. Admittedly the complainant was holding Ext. A1 policy for the period from 16-06-2008 to 15-06-2009 with sum insured of Rs. 1,00,000/-. During the currency of the policy he underwent treatment at Brain and spine centre Vaikom from 01-05-2009 to 05-05-2009 evident from Ext. B3 discharge summary. Ext. A3 series go to show that the complainant was holding valid insurance policy with oriental insurance company prior to the inception of Ext. B1 policy i.e. for the period from 14-06-2007 to 13-06-2008. Admittedly the complainant’s treatment was for the period from 01-05-2009 to 05-05-2009 which is beyond the period of 2 years from the coverage of the policy. DW1 the doctor who treated the complainant deposed that the present ailment and the previous ailment of the complainant are distinct and different. Nothing is on record to controvert the same. In view of the above we are only to hold that the repudiation of the claim of the complainant as per Ext. A1 letter is unsustainable. Held accordingly.
6. Since the complainant has not opted to produce any document before this forum to substantiate his claim he is free to submit the same before the opposite parties in accordance with law.
7. Point No. ii. The primary grievance of the complainant having been met squarely and adequately we need not order compensation and costs of the proceedings.
8. In the result, we partly allow the complaint and direct that the 1st opposite party shall pay the insurance claim of the complainant as observed above. The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order failing which the amount shall carry interest at the rate of 12% p.a. till payment.
Pronounced in the open Forum on this the 30th day of December 2011.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
