BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 28/08/2009

Date of Order : 26/11/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 473/2009

Between

And

O R D E R

Paul Gomez, Member.

1. The complaint stems out of the following facts :

The complainant has been holding mediclaim policy with the 1^st opposite party, since 2005 and the disputed claim arose during the currency of the policy. The 2^nd opposite party is the TPA of the 1^st opposite party. The complainant was treated at St. George Hospital, Muvattupuzha from 12-06-2009 to 14-06-2009 for which she had shelled out Rs. 33,158/- (Rupees thirty three thousand one hundred and fifty eight only). When a claim was preferred before the 2^nd opposite party, it was repudiated on the ground of pre-existing disease, invoking clause 4.1 of the policy conditions. The dismissal of the claim is unjustified, since she was not suffering from the disease indicated for repudiation previously. Moreover, the doctor had stated the duration of the illness as 3 months prior to the date of commencement of the impugned hospitalization. Hence this complaint demanding the hospital expenses along with interest as also compensation and costs of the proceedings.

2. The opposite parties filed version denying the allegations :-

The complainant was covered by the mediclaim policy, since 21-10-2008 only and not from 2005 as claimed in the complaint. It is submitted that the impugned condition of the insured could develop only after a prolonged period of ailments. The present ailment for which the complainant was treated falls within the purview of the pre-existing disease, hence the repudiation is justified in law. There is no deficiency of service on the part of the opposite parties, and therefore, it is urged to dismiss the complaint with costs.

3. No oral evidence for the complainant. Ext. A1 to A6 were marked on her side. The opposite party was examined as DW1. Hospital records was marked as Ext. X1. Exts. B1 and B2 were marked on the side of the opposite parties. Heard the counsel on both sides.

4. The following points arise for consideration :-

1. Whether the opposite parties are justified in the repudiation of the mediclaim?

2. What are the reliefs, if the answer to the first point is in the negative?

5. Point Nos. i. and ii. :- The complainant is the holder of Ext. A2 Janatha Medical Policy. During the currency of the policy, the complainant had undergone treatment in St. George Hospital, Muvattupuzha from 12-06-1009 to 14-06-2009 for the ailment called 'stress urinary incontinence'. Later, she submitted Ext. A6 claim application by which she claimed Rs. 33,158/- being the expenses incurred towards hospital charges. The hospital treatment is borne out by Ext. A4 discharge card and Ext. A5 medical certificate issued from the hospital. Unfortunately, the said claim was rejected by Ext. A1 letter issued by the 2^nd opposite party on the ground of pre-existing disease under clause 4.1 of the terms and conditions of the policy. It is pertinent to reproduce the relevant reason stated for dismissal of the claim. It states as follows : “Since the condition, pre-existing cannot be ruled out, the claim stands declined under clause 4.1.” The language is obviously not in uncertain terms showing the want of confidence on the part of the third party administrator in rejecting the claim. In this context, it will be beneficial for us to turn to Ext. A5 certificate wherein answer to the question 'how long has the patient been suffering from this disease as on the date of first consultation', it is stated by the doctor who issued the certificate as 3 months. Of course, it is not known whether the doctor who had issued the certificate had treated the lady. According to the doctor, it was only from 12-06-2009, the patient was aware of the existence of this disease. Even if the statement that the patient had been suffering from the disease, since 3 months is taken on its face value, that period falls well within the date on which the policy was taken for the first time, ie. 21-10-2008. It is worthwhile to note that DW1 has deposed that it was not possible to indicate the reasons for the disease. It is also important to note his opinion that it is not easy to find out the duration of the illness.

6. On an overall assessment of the materials on record and deposition of DW1 who had actually treated the lady, it cannot be identified with certainty how long the patient had been suffering from the disease. The 2^nd opposite party also was not quite sure as to whether the disease under dispute was pre-existing to the proposal, which is borne out by the equivocal language used in Ext. A1 rejection letter. In that view of the matter, the conclusion is inescapable that the claim form was rejected without proper application of mind by the TPA and hence it comes to fore that the 1^st opposite party has ultimately illegally dismissed the complainant's claim. Therefore, we hold that the complainant is entitled for the payment of the claim amount.

7. In the facts and circumstances of the case, we do not think that the complainant deserves any other reliefs except interest and costs.

8. Accordingly, the complaint is partly allowed as follows :-

1. The 1^st opposite party is directed to pay to the complainant Rs. 33,158/- (Rupees Thirty three thousand one hundred and fifty eight only) along with interest @ 9% p.a. from 20-06-2009 till realisation.

2. The 1^st opposite party is also directed to pay Rs. 1,000/- towards costs of the proceedings in the Forum.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 26^th day of November 2011.

Sd/- Paul Gomez, Member. Sd/- A. Rajesh, President.

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 :-

=========