BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 22nd day of September 2011
Filed on : 18/03/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member
Smt. C.K. Lekhamma, Member
C.C. No. 158/11
Between
M.K. Sadanandan, : Complainant
S/o. Kumaran, (By Adv. Roy Varghese,
Madathiyani Padath house, Kadaikal Apartments, Near Over
Church road, Thykoodam, Bridge, K.K. Road, Kathrikadavu,
Vyttila P.O., Kochi-19. Kochi-17)
And
1. M/s. United India Insurance : Opposite parties
Company Ltd., (1st O.P. by Adv. Jayasree S.,
Rep. by its Divisional Manager, Pranavam, 1st floo0r, Kollasseri
Bancassurance Division, Madom, Poimblassaeri lane,
7th Floor, United India Towers, Ravipuram, Kochi-16.)
Basheerbagh, Hyderabad-29.
2. Family Health Plan
(TPA) Ltd., Rep. by its Managing (Absent)
Director/Manager, No. 39/4967
G. Uznaz Towers, 5th Floor,
Medical Trust Junction,
Pallimukku, M.G. Road, Kochi-16.
3. Andhra Bank, (O.P 3 By Adv. Abraham
Rep. by its HR. Manager, Mathew, (Vettoor) A-92
Vyttila Branch, Thykoodam, Vettoor & Associates,
Vyttila P.O., Kochi-19. St.Benedict’s road,
Ernakulam-682 018)
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
Complainant availed himself of a mediclaim policy from the 1st opposite party through the 3rd opposite party. The policy was renewed up to date for the last three consecutive years. The complainant had undergone treatment at the Lissie Hospital in Ernakulam for the period from 19-08-2010 to 20-08-2010. The insurance claim was repudiated by the 2nd opposite party alleging pre-existing disease. Thereafter the complainant again underwent treatment in the Hospital for cancer for the period from 30-09-2010 to 18-10-2010. The claim for insurance also was repudiated by the 2nd opposite party alleging that “in spite of repeated reminders sent on 06-12-2010, 15-12-2010 and 23-12-2010 the previous consultation prescriptions before April 2010 were not submitted”. The complainant underwent further treatment in Lakeshore Hospital and Welcare Hospital as he was referred from Lissie Hospital. Complainant is entitled to get insurance claim from the opposite parties together with Rs.10,000/- towards compensation.
2. Version of the 1st opposite party.
The complainant had taken AB Arogyadaan Policy from the Hydrabad office of the 1st opposite party only for the year 2009 and the sum insured is Rs. 1,00,000/-. The claim submitted by the complainant for treatment undergone at Lissie Hospital was repudiated by the 2nd opposite party due to the reason that it came under the exclusionary clause 4.1 under the policy. The 2nd claim application was repudiated by the opposite party since the complainant has not complied with the formalities in processing the claim application. In spite of repeated requests, previous consultation records were not submitted by the complainant. There is no deficiency in service on the part of the 2nd opposite party.
3. Version of the 3rd opposite party
The complainant is fully aware that the claim, if any, on account of hospitalization or treatment are to be made to the opposite parties 1 and 2 and this opposite party has absolutely no role to play in the matter of entertaining or scrutiny of such claims. If at all any claim as made by the complainant is to be settled, the same has to be done by the opposite parties 1 and 2 alone.
4. In spite of service of notice from this Forum the 2nd opposite party did not respond to the same for their own reasons. No oral evidence was adduced by the parties. Exts. A1 to A3 and B1 and B2 were marked on the side of the complainant and the 1st opposite party respectively. Heard the counsel for the complainant and the 1st opposite party.
5. The points that arose for consideration are
i. Whether the complainant is entitled to get the insurance claims form the 1st opposite party?
ii. Whether the complainant is entitled to get a compensation of Rs. 10,000/- from the opposite parties.
6. Point No. i. Admittedly Ext. A1, AB Arogyadaan policy is valid for the period from 05-03-2010 to 04-03-2011. The 1st claim of the complainant was for the treatment which he had undergone in Lissie Hospital from 10-08-2010 to 20-08-2010 which is within the currency of Ext. A1 insurance policy. The same was repudiated by the 2nd opposite party by Ext. A2 letter dated 08-03-2011 stating that the disease was pre-existing prior to the inception of the policy. The repudiation of the 1st claim is justifiable since the complainant had undergone treatment for Coronary Artery Disease previous Lateral wall myocardial infarction (2009 March) evident by Ext. B1 discharge summary. Though the complainant claims that he had been holding insurance policy for 3 years nothing is on record to substantiate the same where the 1st opposite party, disclaims the same for no evidence on record.
8. According to the 1st opposite party they could not process the 2nd claim application since the complainant failed to subject the relevant documents for the same as requested by them in their letters The complainant contented that he has not received any intimation to submit the documents.
9. Be that things as it may, we think that a direction to the 1st opposite party to process the claim application of the complainant is enough to meet the ends of justice provided the complainant submits the relevant documents for the same as called for purportedly in their letters dated 09-12-2010, 15-12-2000 and
23-12-2010.
10. Point No. ii. No deficiency in service on the part of the 1st and 3rd opposite parties have been proved squarely so no compensation is called for.
11. In the result, we partly allow the complaint and direct that :
the 1st opposite party shall process the 2nd insurance claim application of the complainant (claim DN No. Hyd 107956) within 30 days from the date of receipt of the documents from the complainant which the complainant is bound to submit before them failing which the 2nd prayer of insurance claim stands disallowed.
ii. The complainant shall submit the documents mentioned in Ext. B2 series within 30 days from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 22nd day of September 2011
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of policy
A2 : Copy of repudiation letter dt. 08-03-2011
A3 : copy of repudiation letter dt. 08-03-2011
Opposite party’s exhibits :
B1 : Copy of discharge summary
dt. 20-08-2010
B2 series : copies of hospitalization claims
