BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 03/08/2010
Date of Order : 30/06/2011
Present :-
Shri. A. Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 451/2010
Between
M.C. Joseph, | :: | Complainant |
Mundackal (H), Ramalloor, Kothamangalam. P.O. |
| (By Adv. Tom Joseph, Court Road, Muvattupuzha – 686 661) |
And
1. M/s. Oriental Insurance Co.Ltd., | :: | Opposite parties |
Branch Office, Elenjical Plaza, Church View Jn., Kothamangalam. 2. M/s. MD India Healthcare Services (TPA) Ltd., E1-63/521, Opp. Karuna Printers, Kasim Lane, Near St. Augustine School, Kaloor, Kochi – 682 017. |
| (Op.pty 1 by Adv. A.R. George, Anthikkatt House, P.O. Vennala, Cochin – 28) (Op.pty 2 absent) |
O R D E R
C.K. Lekhamma, Member.
1. The complainant's case is as follows :
The complainant has been a family mediclaim policy holder of the 1st opposite party for the last 5 years. The daughter of the complainant underwent treatment for breast abscess from 16-02-2010 to 20-02-2010 at Mar Baselious Hospital, Kothamangalam. She incurred Rs. 7,000/- towards treatment expenses. The claim submitted by the complainant was repudiated by the 2nd opposite party stating that the illness is a pregnancy related one. According to the complainant, the reason given for repudiation is not correct and hence unsustainable. The complainant contented that the breast abscess is not a pregnancy related one. The daughter of the complainant delivered a child on 28-01-2010. She was treated for breast abscess after 2 weeks from the date of delivery. Hence the repudiation of the claim amounts to deficiency of service. This complaint filed for seeking reliefs sought against the opposite parties under the following heads:
The claim amount Rs. 7,000/- along with interest.
Rs. 3,000/- towards compensation for the mental agony and hardships and costs of the proceedings.
2. Version of the 1st opposite party is as follows :
The entire averments and allegations contained in the complaint are not correct and denied. It is true that the complainant had initially proposed and contracted a Good Health Insurance Policy with the opposite party in the year of 2005 and it had been periodically renewed upto 08-03-2007. Thereafter, the complainant contracted for a fresh Individual Mediclaim Policy upon a fresh proposal for the period from 09-03-2007 to 08-03-2008. The said policy has been renewed periodically. The 2nd opposite party processed the claim application of the complainant and found that the treatment and procedures underwent by the complainant's daughter was towards breast abscess while being a lactating mother after her delivery. In terms of Clause 4.12 of the Individual Mediclaim Policy, the illness which are directly or indirectly due to pregnancy/related to pregnancy are not reimbursable. Further, as per the terms and conditions in the policy, if the child is aged above 18 years is employed or if the girl child is aged above 18 years is employed or if the girl child is married, he or she shall cease to be covered under the policy. Hence the claim was repudiated strictly in terms of the contract of insurance policy. Under such circumstances, the contentions to the contrary contained in this complaint has no merit, consideration and the same is liable to dismissed summarily.
3. The complainant and the 1st opposite party represented through the counsel. The 2nd opposite party remained absent. Both sides did not adduce oral evidence. Ext. A1 was marked on the side of the complainant and Exts. B1 and B2 were marked on the side of the 1st opposite party. Thereafter, we have heard the respective counsel.
4. The only point that arose for our consideration is whether there is any deficiency in service on the part of the opposite parties or not? There is no dispute with regard to the issuance of the policy and its continuation. The reason stated in Ext. A1 repudiation letter reads “In terms of Clause 4.12 of the Individual Mediclaim Policy the illness which are directly or indirectly due to pregnancy/related to pregnancy are not reimbursable. If the child above 18 years is employed or if the girl child is married, he or she shall cease to be covered under the policy.”
5. Ext. B1 is the prospectus of the mediclaim insurance policy. In which under the head “Definition of family” towards the sub devision 'C' it is specifically stated as follows :
“Dependent Children (i.e. legitimate or legally adopted children) upto the age of 21 years. If the child above 18 years is employed or if the girl child is married he or she shall cease to be covered under the policy and no claim shall be admissible. However male child cannot covered upto the age of 26 years if he is a bonafide regular student and fully dependent on primary insured. Female child can be covered until she is unmarried.”
6. In the instant case, the complainant does not have a case that his daughter is unmarried. Moreover, the disease of the complainant's daughter is related to pregnancy and the delivery. In view of the above clause, the opposite parties are not liable to pay insurance claim to the complainant and there is no deficiency in service on the part of the opposite parties. Hence the complaint is hereby dismissed without any order as to costs.
Pronounced in open Forum on this the 30th day of June 2011.
