D.O.F. 01.01.2009
D.O.O. 02.12.2010
IN THE CONSUMER DISPUTES REDRESSAL FORUM KANNUR
Present: Sri. K.Gopalan : President
Smt. K.P.Preethakumari : Member
Smt. M.D.Jessy : Member
Dated this the 2nd day of December, 2010.
C.C.No.01/2009
1. Dinesh Kumar T.
“Santhosh Nivas”,
P.O. Kappad,
Kannur district.
2. Mrs. Anushka T., : Complainants
W/o. Dinesh Kumar T.,
Thayattil House,
Nr. RKUP School, Valapattanam
Kannur District.
( Both Rep. by Adv. Sajith Kumar Chalil)
M/s. United India Insurance Company Limited,
Chovva Branch, Caltex junction, : Opposite party
Kannur District.
(Rep. by Adv. V.V. Gopinathan)
O R D E R
Sr. K. Gopalan, President.
This is a complaint filed under Section 12 of Consumer Protection
Act for an order directing the opposite party to pay a sum of ` 25,000 as compensation and cost.
The brief facts of the case of complainant are as follows. The complainant is a Medi Guard policy holder for a period from 05.07.2007 to 04.07.2008. His wife complainant No.2 also come under the cover of the Insurance protection. The complainant No.2 was under treatment in the month of September 2007. During the course of treatment a pain was developed on her right hype area and on 26.09.2007 she was referred to Dr.P. Mahesh, Consultant Sonologist, for better treatement. She was brought before Dr. Mahesh. On 28.09.2007 she was evaluated and Ultra Sound Scan of her abdomen was done. This showed multiple gall bladder calculi. Mrs. Anushka was referred to Lakeshore Hospital & Research Centre Ltd., Kochin for emergent surgery and the very next day of admission on 18.10.2007 a laparoscopic cholecystectomy was performed. On 18.10.2007 she was discharge with advise to visit for reviewing her postoperative physical condition. She was taken for review on 09.11.2007. Complainant could not submit the claim before opposite party since he was accompanying his wife during the surgery period and post surgery period, But he informed Insurance agent of the opposite party about the treatment and surgery, and as per his advice the complainant contacted to the opposite party through telephone and he was informed that the claim form can be submitted after the completion of the treatment. In the month of November, 2007, the complainant sent a written letter to the opposite party requesting to send him a claim form. But there was no response. But after an unexplained delay complainant received the claim form from the opposite party on the last week of December, 2007. Claim intimation to the opposite party had been given within the stipulated period of seven days from the date of hospitalization through the agent and he presented duly filled claim form before the opposite party immediately after the discharge of his wife from the hospital which is within the time. Wherever complainant approached opposite party they dragged the matter by saying same excuses. The attitude of the opposite party made clear that they have no intention to allow the claim. Lawyer notice was sent. They sent reply with denial of claim stating the reasons that the claim intimation not given within the stipulated period of 7 days from the date of hospitalization and claim documents not submitted within 30 days from discharge etc. It is not correct. Complainant submitted claim intimation within the stipulated period of seven days from the date of hospitalization of his wife through the Insurance Agent and filed claim form immediately after discharge within time. If any delay caused to submit claim form it was only due to the deliberate and wilful delay of opposite party in sending claim form to the complainant. Complainant is entitled to get the mediclaim benefit. Hence this complaint.
Pursuant to the notice opposite party entered appearance and filed version denying the allegations of complainant, content of which in brief are as follows : The complainant did not comply the requirements as per the terms and conditions of the policy. Claim intimation should be submitted to the opposite party within 7 days from the date of admission and documents relating to the claim should be submitted within 30 days from the date of discharge. Complainant did not complied both these requirements. So opposite party is not liable to compensate the loss to the complainant. Since the disease contracted the insured person during the first 30 days of inception of the policy, the opposite party is not liable for any relief sought in the complainant as per the terms and conditions of the policy. This complaint is a test case preferred by the complainant. So opposite party is not liable for any relief in the complaint. Hence to dismiss the complaint.
On the above pleadings the following issues have been taken for consideration.
1. Whether there is any deficiency in service on the part of opposite party.
2. Whether the complainant is entitled for the relief as prayed in the complaint?
3. Relief and cost.
The evidence consists of the oral testimony of PW1, PW2, DW1, Ext.A1 to A12, Ext. B1 to B3.
Issues 1 to 3 :
Admittedly complainant is a policy holder of Medi Guard insurance policy for a period from 05.07.2007 to 04.07.2008. In the month of September the 2nd complainant undergone treatment. She was admitted in the hospital on 15.10.2007. On 16.10.2007 she was taken up for surgery and a laparoscopic, cholecystectomy was performed. She was discharged on 18.10.2007. She was again taken to hospital on 09.11.2007 reviewing her post operative physical condition. Complainant submits that he has given claim intimation to the opposite party within the stipulated period of seven days of hospitalization of his wife through the insurance agent immediately after discharge from the hospital. But the claim was rejected on the ground that the claim intimation not given within the stipulated period of seven days from the date of hospitalization and claim documents has not been submitted within 30 days.
The main contention of opposite party is that the complainant did not submit the claim intimation within 7 days from the date of hospitalization and documents within 30 days from the date of discharge. Ext.A1 is the certificate of Medi Guard Insurance policy for the period from 05.07.2007 to 04.07.2008. Clause 5-3 of Terms and Conditions contained in Ext.AA1 reads this : “upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to the company within 7 days from the date of Hospitalization/domiciliary hospitalization. So also in Clause 5-4 provides “All supporting documents relating to the claim must be filed within 30 days from the date of discharge from the hospital…..”
Whether or not complainant has satisfied the above mentioned two conditions are very material points to decide the question of deficiency in service. What is pleaded by the complainant is that he has given the claim intimation to the opposite party within the stipulated period of seven days from the date hospitalization of his wife, through insurance agent of opposite party and he presented duly filled claim form immediately after the discharge of his wife from the hospital within time. Complaint did not mention the date of intimation. He has stated only claim intimation given within time but not given the date. The intimation said to be given to opposite party by agent and not by the complainant. It is not clear whether complainant is aware of the date of intimation. So also he has stated that claim form presented before opposite party within time but the date not given. It has to be taken into account that this is a case wherein the complainant’s claim became inadmissible mainly on the following reasons viz.
1. Claim intimation not given within the stipulated period of 7 days from the date of hospitalization.
2. Claim documents relating to the claim not submitted within 30 days from the date of discharge.
3. Disease contracted by the insured person during first 30 days from commencement date of the policy.
The importance of date arose on the first and second reasons. Complainant has not mentioned the date of intimation and date of submission of document. It is the insurance agent who has given the intimation. There is no evidence before the Forum to ascertain the date of intimation and to ascertain whether the claim was submitted within time, though the date of admission and discharge is given correctly. The concerned agent was able to state the truth but complainant has not taken any steps to summon him for examination. He is the fit person to say where did the intimation was given. Non-examination of the agent badly affected the complainant’s case especially in proving the above said aspects. There is substance in the contention of opposite party. Ultimately the case of complainant is that immediately after the course of treatment the complainant informed the insurance agent of the opposite party about the treatment and surgery, and as per his advise the complainant contacted the opposite party through telephone. If that be so examination of the said agent is a must without which the case of the complainant cannot be proved. Complainant miserably failed to prove that the complainant has submitted claim intimation and documents within the stipulated time as per the terms and conditions of the policy. Hence there is no point in alleging deficiency in service against the opposite party. It can also be seen that the disease has been contracted by the person, second complainant during the first 30 days which attracts exclusion clause 4.2. Complainant did not give any answer to this point, which can only be considered as an open admission.
In the light of the above discussion we are of opinion that the complainant failed to prove his case that he has given claim intimation to the opposite party and submitted documents within the stipulated period as per the terms and conditions of the policy. Hence it is not possible to fasten liability on the shoulders of opposite party. The issues 1 to 3 are found against complainant.
In the result the complaint is dismissed.
Sd/- Sd/- Sd/-
President Member Member
APPENDIX
Exhibits for the Complainant
A1. Medi-Guard policy issued by United India Insurance Company.
A2. Receipt issued by United India Insurance Company dated
04.07.2007.
A3. Copy of lawyer notice issued by the complainant to the opposite
party dated 28.07.2008.
A4. Copy of claimform.
A5. Acknowledgement card.
A6. Reply notice send by opposite party to complainant dated
31.07.2008.
A7. Postal receipt.
A8. Abdominal Sonography Report dated 28.09.2007.
A9. Ultrasound scan report dated 15.10.2007.
A10. Discharge summary.
A11. Blood test report dated 15.10.2007.
A12. Cash bills.
Exhibits for the opposite party
B1. Claim form – Mediclaim Insurance Policy.
B2. Medical report.
B3. Annexure B dated 10.12.2007.
Witness examined for the complainant
PW1. Complainant No.1
PW2. Complainant No.2
Witness examined for opposite party
DW1. Dr. P. Mahesh
/forwarded by order/
SENIOR SUPERINTENDENT
