IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM

Dated this the 12^th day of July, 2018.

Present: Sri. P.SatheeshChandran Nair, President

Sri. K.N. Radhakrishnan Member

                                                                                     Smt. Renu.P.Gopalan, Member     

CC No.359/2016 (Filed on 28/12/2016)

Between:

          Kuruvilla Philip,

          Vazhakalayil House,

          Chengalam South P.O.

          Kottayam Dist. – 686 022.                                  ..........Complainant

          (Adv. Dimple Raj M.)

And :

12

1. M/s. Star Health and Allied

Insurance Company Ltd.

Zonal Office, 4^th floor,

Carmel Towers, Cotten Hill P.O.

Vazhuthacaud,

Thiruvananthapuram – 695014.

Rep. by its Zonal Manager.

2. Manager,

Kottayam branch office,

Star Health Allied

Insurance Company Ltd.

II Floor, Puthenpurackal Complex,

M.C. Road, Kodimatha, Kottayam                           ........Opposite parties

(Adv. T.J. Lakshmanan)

O R D E R

 Sri. K.N. Radhakrishnan, Member

            The case of the complainant is as follows.

          The complainant had taken a medi-claim policy from the opposite parties.  The complainant while on a visit to his sister’s house at Palakkad, accidently slipped and fell down on 07/05/2015 and due to the impact of this fall he developed walking difficulties and severe low back pain inviting medical treatment.  Hence complainant sought medical treatment “Thitheemu Umma Memorial Ayurveda Hospital and Research Centre” at Kudalloor in Palakkad.  After one week of treatment as outpatient there from 07/05/2015, the complainant was admitted there from 14/05/2015 to 07/06/2015 for a period of 24 days and spend Rs.37,656/- towards medicine and treatment.  Thereafter the complainant submitted all the medical bills with relevant documents for the re-imbursement of the medical expenses by the opposite parties.  But the opposite parties refused to re-imburse the amount citing the reason that the treatment underwent by the xomemployment is covered only after second year of the policy.  The complaint was a healthy person before slipping and falling at her sister’s house at Palakkad.  The treatment was necessitated only due to the accidental fall by the complainant.  Hence the opposite party is liable to                          re-imburse the medical expenses, the complainant spent for his treatment subject to a maximum of Rs.25,000/- for non-allopathic medicine.  The refusal of the medical expenses of the complainant is a gross violation of the policy condition and thereby attracks deficiency of service by the opposite parties.  Hence this complaint.

          The notices were served with the opposite parties.  They appeared and filed their version contending as follows.  The opposite parties issue the policy subject to the terms and conditions and it is a settled law that the parties to the insurance contract are bound by the terms and conditions of the policy.  The complainant had submitted a claim in connection with his treatment undergone for low back pain at Thitheemu Umma Memorial Ayurveda Hospital and Research Centre”  Kudalloor in Palakkad.  The insured was admitted in the hospital on 14/05/2015 and was discharged on 07/06/2015.  The insured submitted a claim in connection with his above mentioned treatment, but the insured not produced the discharge summary alongwith the claim from which is mandatory for the admissibility of the claim as per the terms and conditions of the policy issued and clause 4 of  the policy specify the condition and 4 (4) (C) of the policy condition clearly specify that submission of discharge summary.  After considering all the relevant facts and documents in detail, the opposite party repudiated the claim for the reason that the present illness falls within the two year exclusion clause of the policy, and hence the claim cannot be considered.  The exclusion clause no.3 of the policy clearly specify that “During the First Two years of continuous operation of Insurance cover the expenses on treatment of diseases such as prolapsed of intervertebral disc (Other than caused by accident), conservative and operative treatment of joint diseases (other than caused by accident).  All types of joint replacement (other than caused by accident) degenerative disc and vertebral diseases and degenerative disease of the musculo-skeletal system are not covered”.  As per the discharge summary of the complainant he had no history of trauma / accident.  As per the discharge summary he had the complaint of back ache.  It has been found that the complainant had taken treatment for joint diseases.  In this case, the complainant is not entitled for any reliefs from the opposite party. Since his claim is not payable as per the policy conditions.  After the rejection of the claim by the opposite parties, the complainant sent a letter dtd.24/07/2015 to the opposite party in which for the 1^st time he mentioned that his admission in the hospital was as a result of an accident.  The pleading in the letter dtd.24/07/2015 was narrated only to bring the claim within the purview of the policy conditions.   The after thought of the complainant by creating documents to bring the claim within the purview of the policy condition is not sustainable in the eye of law.  There was no deficiency in service from the side of the opposite parties.  Hence this complaint may be dismissed with costs.

          The complainant filed proof affidavit and documents which are marked as exhibits A1 to A5.  The opposite parties filed proof affidavit and documents which are marked as Exbts.B1 to B4.

          Heard both sides.  We have gone through the complaint, version, documents and evidences of both sides.

Points for consideration

1. Whether there is any deficiency in service from the side of the opposite parties?
2. Reliefs and costs?

Point No.1 and 2

For the fair disposal of the case point numbers one and two is to be considered jointly.  The case of the complainant is that the medi-claim of the complainant was rejected by the opposite parties without any basis.  According to the complainant he is entitled for the treatment expenses as per the policy.  The opposite parties had taken a contention that the as per the policy the complainant is not entitled the claim put forward by the complainant.  According to the opposite parties as per the policy and as per the discharge summary the complainant is not entitled for the insurance claim.  As per the discharge summary there was not mentioned anywhere that the treatment taken by the complainant was due to accident.  The specific case of the complainant is that the treatment for ailment was on the basis of after accident.  From the documents produced by the complainant and the opposite parties it can be seen that the treatment given for the complainant was due to the sudden fall.  From Ext.A4  it can be seen that the details of the treatment elaborately written by the Hospital who treated the patient.  The opposite parties specific case is that the complainant has not produced the discharge summary before the opposite parties.  We are of the opinion that the case of the complainant is to be allowed.  Hence Point Nos. 1 and 2 found in favour of the complainant.

     In the result, the complaint is allowed as follows.

1. We direct the opposite parties to pay the claim amount Rs.25,000/- (Rupees Twenty five thousand only) as per the policy subject to the production of the discharge summary by the complainant.
2. If the opposite party fails to comply the Order within the stipulated period, the complainant is eligible to realise the said amount with interest @ 10% per annum from the date of Order onwards.  No Order for costs and compensation.

     Pronounced in the Open Forum on this the 12^th day of July, 2018.

                                                                        Sd/-

Sri. K.N. Radhakrishnan Member

Sri. P.SatheeshChandran Nair, President                             Sd/-

Smt. Renu.P.Gopalan, Member                                   Sd/-

Appendix

Exhibits marked on the side of the complainant

A1- Original insurance policy certificate.

       no.P/181113/01/2015/006770 for the period from 31/03/15 to 30/03/16.

A2 – Photocopy of notice dtd.21/08/15 issued by the op to compl.

A3  - Copy of lawyers notice dtd.07/10/15

A4 – Photocopy of medical certificate.

A5 – Photocopy of original patient case file.

Exhibits marked on the side of the opposite party

B1 – Copy of proposal form

B2 – Copy of insurance policy with condition

B3 – Copy of discharge summary dtd.24/06/15

B4 – Copy of letter dtd.08/07/15 issued by op to compl.

                                                                                                By Order

                                                                                      Senior Superintendent

Copy to:

1.  Kuruvilla Philip,

               Vazhakalayil House,

              Chengalam South P.O.

               Kottayam Dist. – 686 022.                                      

2. M/s. Star Health and Allied

Insurance Company Ltd.

Zonal Office, 4^th floor,

Carmel Towers, Cotten Hill P.O.

Vazhuthacaud,

Thiruvananthapuram – 695014.

Rep. by its Zonal Manager.

3. Manager,

Kottayam branch office,

Star Health Allied

Insurance Company Ltd.

II Floor, Puthenpurackal Complex,

M.C. Road, Kodimatha, Kottayam       

4) Stock file