BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 1st day of February 2018
Filed on : 17-04-2015
PRESENT:
Shri. Cherian K. Kuriakose, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
CC.No.244/15
Between
Divya Satheesh, : Complainant
W/o. Satheesh, (By Adv. Tom Joseph, Court road,
Edakattukudiyil house, Muvattupuzha)
Varapetty P.O.,
Kothamangalam-686 691.
And
M/s. HDFC ERGO General : Opposite party
Insurance Company Ltd., (By Adv. Ramu P.S.
Branch Office, Chicago Plaza, Ernakulam)
Rajaji Road, Ernakulam,
Kochi-35, rep. by its
Branch Manager.
O R D E R
Cherian K. Kuriakose, President.
Complainant’s case.
The complainant is one of the insured persons in the family mediclaim policy taken by her husband from the opposite party from 17-02-2012 on wards. As per the terms and conditions of the policy the insured was eligible to get the medical expenses reimbursed up to an amount of Rs. 2,00,000/- and Rs. 1,000/- per day towards hospital daily cash benefit. During the 2nd year of the policy during 19-02-2013 to 28-02-2013 the complainant was treated in Amrita Hospital, Ernakulam for the disease “ left polar renal Angiomyolipoma and bilateral lung cysts”. She had spend Rs. 1,12,769/- towards the treatment expenses. The claim lodged by the complainant was not settled by the opposite party. Who had asked the complainant to produce certificate from treating doctor regarding the duration of the illness. The date of inception of the policy was from 17-02-2012 and the claim made by the complainant was for the treatment received by her during the 2nd year of policy. The complainant is therefore entitled for the benefit of the policy. However, the opposite party had denied the benefits. Hence the complaint.
2. Notice given to the opposite party was served and they appeared to contest the matter by filing a version and resisting the claim contenting inter-alia as follows:
3. The complaint is not maintainable. The policy and its renewal has stated in the complaint is admitted. In the policy, M/s. Applo Munich General Insurance Company Ltd was a co-insurer and they were not made a party in the proceedings and hence the complaint is bad for non-jointer of necessary parties. On verification of the discharge summary issued from Amrita Medical College Hospital, the complainant was found to have i. left upper polar renal Angeomyolipoma and ii. Multiple bilateral lung cysts. The Angeomiyolipoma is a Tumor composed of Vascular and Muscular Tissue elements. It is a most common benign tumor of Kidney. Bilateral lung Cysts are usually found on the outside surface of the lung . Therefore the ailment of the complainant was tumor on Kidney and cysts on lungs. These ailments and treatment underwent by the complainant was not covered under the Health Suraksha Policy issued by the opposite party. Under Section 9 A (a) of the policy the illness of the complainant was excluded during the waiting period as per the terms and conditions. The complainant did not complete the mandatory waiting period of 24 months for availing the benefits under the policy. Therefore the repudiation of the claim is justifiable and the complaint is sought to be dismissed.
4. On the above pleadings the following issues were settled for consideration.
Whether the complainant has proved that the opposite parties had committed deficiency in service as alleged.
Reliefs and costs.
5. The evidence in this case consists of the Exbts. A1 to A5 documents on the side of the complainant and Exbts. B1 to B4, in addition to the oral evidence of DW1 on the side of the opposite party.
6. Issue No. i. The complainant is the beneficiary of the policy issued as Exbt. A1, and there is no dispute to the fact that the policy was continued during the 2nd year without any gap. The complainant was diagnosed with left upper polar renal Angeomyolipoma and Multiple Bilateral lung cysts as per Exbt. A2 discharge summary . She was presented to the hospital with history of recurrent fever with cough without expertoration for one month . Her abdomen has shown a large exophytic lesion with fat density 10x9.6x15 cmts. in size with aneurysm and bleed inside . She had also Bilateral multiple lung cysts in the chest. She was admitted and she underwent selective Angeoembolization of left renal upper polar antery Exbt. A4 document would go to show that the complainant had spent a huge amount of Rs. 1,12,769/- towards treatment expenses. On the filing the claim for reimbursement the complainant was issued with Exbt. A5 letter directing her to produce a certificate from treating doctor showing the duration of suffering from the disease with consultation papers. Exbt. A5 was issued on 18-12-2013. The complainant did not produce any such documents as per Exbt. A5 on the ground that she had already produced discharge certificate which shows the details of her illness. The complainant thereafter chose to file this complaint before this forum on 17-04-2015.
7. The contention taken by the opposite party was that as per exclusion clause of the policy renal surgery was not covered if the treatment was taken within 2 years from the inception of the policy. The complainant was therefore not entitled to get the benefits of the policy within that period.
8. As per clause 9 which is about exclusion all claims payable will be subject to the waiting periods specified below:
i. . General waiting period of 30 days for all claims payable under the policy except claims arising due to an accident.
ii. A waiting period of 24 months shall apply for the treatment, whether medical or surgical, of the disease/conditions mentioned below. Additionally the said 24 months waiting period shall be applicable to all surgical procedures mentioned under surgeries in the following table, irrespective of the disease/condition for which the surgery is done, except claims payable due to the occurrence of cancer.
Illnesses : Internal congenited disease, non-infective arthritis, calculous diseases of gall bladder including cholecystitis and Urogenital system e.g. Kidney stone, Urinary Bladder Stone, pancreatitis xxxxxxxxxxxxxxx internal tumors ,cysts , Nodules etc.
It is not in dispute that the complainant did not complete the mandatory waiting period of 24 months for avail the benefit under the policy. Therefore, the claim of the complainant will come under the exclusion clause of the policy. Therefore, we find that the complainant has not proved any deficiency in service on the part of the opposite party. As per Exbt. A5/B4 the complainant was directed to produce the details of her clinical history as certified by the physician who treated her. Admittedly the complainant did not respond to that letter on the ground that the discharge summary is self speaking. The complainant having not produced the required documents before the opposite party, cannot be said to have come before this Forum with a clean hand. Contract of insurance is a contract in uberrimae fides. Utmost good faith is expected from both parties. We find the issue therefore against the complainant.
Issue No. ii. Having found the issue number i against the complainant, we find that the complaint is liable to be dismissed and is accordingly dismissed.
Pronounced in the open Forum on this the 1st day of February 2018
Sd/-
Cherian K. Kuriakose, President.
Sd/-
Sheen Jose, Member.
Sd/-
Beena Kumari V.K., Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant's Exhibits
Exbt. A1 : Copy of letter dt. 08-02-2013
A2 : Copy of discharge summary
dt. 21-02-2013
A3 : Copy of hospitalization claim form
A4 : Copy of In Patient collection
& Appropriation.
A5 : Copy of 1st reminder letter
dt. 18-12-2013
Opposite party's exhibits:
Exbt. B1 : Certified true copy of Health
suraksha – policy schedule
B2 : Certified true copy of Health
Suraksha Policy.
B3 : Copy of Health suraksha policy
B4 : Copy of 1st reminder letter
dt. 18-12-2013
Depositions
DW1 : Sanjai Kumar S.
Copy of order despatched on :
By Post: By Hand:
