This C.C. is coming on before us for final hearing in the presence of Sri.Ch.D.Nageswar Rao & V. Venkateswarlu, Advocates for complainant and of Sri.B.Gangadhar, Advocate for opposite party; upon perusing the material papers on record and upon hearing the arguments, this Forum passed the following order;
ORDER
(Per Sri Vijay Kumar, President)
This Complaint is filed u/s.12-A of Consumer Protection Act, 1986. The averments made in the complaint are that the complainant had taken Mediclaim Policy in the year 2002 by paying Premium Rs.2,404-00 for the period from 11-06-2002 to 10-06-2003 vide Policy No.610902/34/08/11/00000070 for the sum assured Rs.50,000/- the policy was renewed from 2002 to 2009-2010. The complainant submitted that the policy amount was enhanced from Rs.50,000/- to Rs.1,00,000/- w.e.f 13-06-2008 and the complainant paid the premium amount of Rs.7,756/- on the enhanced policy amount of Rs.1,00,000/- vide policy No.61090/08/34/11/00000071. The complainant further submitted that he felt ill health and he admitted in the Apollo Hospital, Jubli Hills, Hyderabad on 25-05-2009 and after completion of treatment he was discharged on 30-05-2009. The complainant claimed Rs.1,00,000/- from opposite party for payment of medical charges. But the opposite party paid Rs.50,000/- and directed the complainant to send certain information. The opposite party send claim payment statement stating that in the remarks column “As DM since five years enhanced SI Rs.50,000/- not applicable. Hence deduction done”. And the complainant further submitted that as per renewed Policy No.610902/08/34/11/00000071 issued by opposite party, the complainant entitled for the claim of Rs.1,00,000/- and the opposite party paid only 50,000/-. And also submitted that as the opposite party postponing payment, the complainant issued legal notice on 22-10-2009 and the opposite party neither paid the remaining balance amount of Rs.50,000/- nor gave any reply. As such the complainant approached the Forum.
2. On behalf of the complainant, the following documents were filed and marked as Exs.A.1 to A.12.
Ex.A.1 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2002-03
Ex.A.2 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2003-04
Ex.A.3 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2004-05
Ex.A.4 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2005-06
Ex.A.5 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2006-07
Ex.A.6 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2007-08
Ex.A.7 - Mediclaim Policy & Receipt for Rs.1,00,000/- for the year 2008-09
Ex.A.8 - Mediclaim Policy & Receipt for Rs.1,00,000/- for the year 2009-2010.
Ex.A.9 - Additional Document Request by the opposite party dt.8-2-2009.
Ex.A.10 - Additional Document Request by the opposite party dt.7-3-2009.
Ex.A.11 - Claims Payment Statement
Ex.A.12 - Office copy of notice issued to opposite party with acknowledgement.
3. On receipt of notice, opposite party appeared through their counsel and filed counter. In their counter opposite party submitted that there is no dispute about taking mediclaim policy by the complainant from the opposite party company for sum assured Rs.50,000/- for the period from 2002-2003. Since the said policy was renewed up to 2007 to 2008. There after in the year 2008-2009 the policy assured amount was enhanced from 50,000/- to 1,00,000/- and taken policy bearing No.610902/34/08/11/00000071 valid from 13-06-2008 to 12-06-2009. The opposite party further submitted that they are not disputed that the complainant admitted in Apollo Hospitals, Hyderabad for taking treatment to his chronic diabetic decease on 20-05-2009 and due to diabetic, his right leg below knee amputation was done by conducting operation and discharged on 30-05-2009. The complainant has claimed Rs.1,00,000/- in view of enhanced assured amount of Rs.50,000/- to 1,00,000/- in this regard, the opposite party submitted that the complainant is chronic diabetic patient and due to gravity of diabetic, his right leg below knee was amputated. As per terms of mediclaim policy under head of pre-existing diseases: all the diseases, which are pre existing when the cover incepts for the first time (except as show hear under). Any complication arising from pre existing disease will be considered as a part of pre-existing condition. The exclusion will be deleted after 4 consecutive claim free policy hear provided there was no hospitalization for the pre-existing disease during the said four years of with out company.
Compulsory coverage for specific pre-existing conditions: On payment of additional premium, which is compulsory for persons suffering the pre-existing conditions of diabetes mellitus and hypertension there specific pre-existing conditions only are covered int eh following manner.
1st year - No- Claim
2nd year - No-claim
3rd year - 50% of admissible claim or 50% of the sum insured set or the
individual whichever is less
4th year - 75% of admissible claim or 75% of the sum insured set for the
Individual Whichever is less.
5th year on-wards - 100% of admissible claim or sum insured set for the individual ,
whichever is less.
And also submitted that in view of the above circumstances, of mediclaim, first year policy should not entertain the pre-existing disease. The policy bearing No.610902/34/08/1100000071 valid from 13-06-2008 to 12-06-2009 is first year policy for the assured amount of Rs.1,00,000/- . The policy for Rs.50,000/- is old policy, which was taken in the year 2002 and renewed from time to time and which was in-force by the time of the taken treatment by the complainant. In the light of the above material facts and terms and conditions of the policy, the opposite party company accepted mediclaim and assured Rs.50,000/- and settled claim Rs.57,500/- and the complainant received the cheque from the opposite party. As such there was no deficiency of service on their parrot of opposite party and prayed to dismiss the complaint.
3. On behalf of the opposite party, the following documents filed and marked as Exs.B1 to B5.
Ex.B1- Copy of claims payment statement.
Ex.B2- Discharge summary of Apollo Hospital, pertaining to the complainant.
Ex.B3- Medical certificate issued by Dr.Kannekanti Sivaramakrishna.
Ex.B4- Copy of Mediclaim Policy
Ex.B5- Policy Schedule of the mediclaim policy.
4. Heard the arguments from both parties. Upon perusing the material papers on record, now the point that arose for consideration is,
Is there any deficiency on the part of opposite party company? Whether the complainant is entitled for the claim?
Point:
In this case the complainant had taken Mediclaim Policy from the opposite party in the year 2002 by paying Premium and the policy was renewed from time to time, from 2002 to 2009-2010. In the year 2008, the complainant enhanced the policy amount from Rs.50,000/- to Rs.1,00,000/- w.e.f 13-06-2008 and paid the premium amount of Rs.7,756/-. The complainant felt ill and he admitted in the Apollo Hospital, Jubli Hills, Hyderabad on 25-05-2009 and after completion of treatment he was discharged on 30-05-2009. The complainant claimed medical expenses of Rs.1,00,000/- but the opposite party company paid Rs.50,000/- and postponing the payment of remaining balance amount. For that the complainant approached the Forum for redressal.
It is an undisputed fact that the complainant has taken mediclaim policy and renewed the same up to 2009-2010. There is no dispute about the enhanced amount from 50,000/- to 1,00,000/- w.e.f. 13-06-2008. And also there is no dispute about taking treatment in Apollo Hospital, Jubli Hills, Hyderabad by the complainant on 25-05-2009 and discharged on 30-05-2009.
From the documents and material available on record, we observed that the opposite party company accepted the mediclaim for Rs.50,000/- and settled claim Rs.57,500/- and the complainant received the amount through cheque. There is an objection raised by the opposite party company for the remaining amount of Rs.50,000/-for that the opposite party company submitted that “As per terms of mediclaim policy under head of pre-existing diseases: all the diseases, which are pre existing when the cover incepts for the first time (except as show hear under). Any complication arising from pre existing disease will be considered as a part of pre-existing condition. The exclusion will be deleted after 4 consecutive claim free policy hear provided there was no hospitalization for the pre-existing disease during the said four years of with out company. As per the terms and conditions, first year policy should not entertain pre-existing disease. Admittedly the policy bearing No.610902/34/08/1100000071 valid from 13-06-2008 to 12-06-2009 is first year policy for the assured amount of Rs.1,00,000/- . And also to support their case opposite party company filed Ex.B3, medical certificate issued by doctor, Sri Kannekanti Siva Rama Krishna, M.D., General Medicine in which he certified that the complainant is suffering with Diabetic Mellitus and hypertension since last 5 years and the complainant is under his treatment since 5years. In view of the terms and conditions of the policy the document Ex.B1 submitted by the opposite party the complainant is suffering with diabetic mellitus and hypertension since last 5 years, which is said to be pre-existing disease. For that the opposite party company had paid the mediclaim amount for the previous policy amount along with bonus to the complainant. For the above we agree with the objection taken by the opposite party company as per the terms and conditions of mediclaim, the complainant is not entitled for the remaining amount. And also observed there is no deficiency of service on the part of opposite party company. Accordingly this point is answered in favour of the opposite party.
In the result, the complaint is dismissed. No costs.
Dictated to steno, transcribed by her, corrected and pronounced by us in the open forum, on this 26th day of June, 2012.
PRESIDENT MEMBER
DISTRICT CONSUMER FORUM,
KHAMMAM
APPENDIX OF EVIDENCE
Witnesses examined for complainant:- None
Witnesses examined for opposite parties:- None
Exhibits marked for Complain ant:
Ex.A.1 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2002-03
Ex.A.2 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2003-04
Ex.A.3 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2004-05
Ex.A.4 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2005-06
Ex.A.5 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2006-07
Ex.A.6 - Mediclaim Policy & Receipt for Rs.50,000/- for the year 2007-08
Ex.A.7 - Mediclaim Policy & Receipt for Rs.1,00,000/- for the year 2008-09
Ex.A.8 - Mediclaim Policy & Receipt for Rs.1,00,000/- for the year 2009-2010.
Ex.A.9 - Additional Document Request by the opposite party dt.8-2-2009.
Ex.A.10 - Additional Document Request by the opposite party dt.7-3-2009.
Ex.A.11 - Claims Payment Statement
Ex.A.12 - Office copy of notice issued to opposite party with acknowledgement.
Exhibits marked for opposite parties:-
Ex.B1- Copy of claims payment statement.
Ex.B2- Discharge summary of Apollo Hospital, pertaining to the complainant.
Ex.B3- Medical certificate issued by Dr.Kannekanti Sivaramakrishna.
Ex.B4- Copy of Mediclaim Policy
Ex.B5- Policy Schedule of the mediclaim policy
PRESIDENT MEMBER
DISTRICT CONSUMER FORUM, KHAMMAM
