IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 28th day of March, 2012.
Present : Sri. Jacob Stephen (President)
Sri. N. Premkumar (Member)
Smt. K.P. Padmasree (Member)
C.C.No.120/2011 (Filed on 13.05.2011)
Between:
1. Mathai Thomas,
Chelleth Sampreethy Bhavan,
Kadapra.P.O., Koipuram Village,
Thiruvalla Taluk,
Pathanamthitta.
2. Anu Thomas,
-do. –do.
(By Adv. P.K. Jayamohan) ….. Complainants
And:
National Insurance Co.,
Rep. by the Branch Manager,
Thiruvalla, Ennakkattil Estate,
M.C. Road, Thiruvalla,
Pathanamthitta.
(By Adv. P.P. Mohammed Musthapha) ….. Opposite party.
O R D E R
Smt. K.P. Padmasree (Member):
The complainant Mathai Thomas and his wife Smt. Anu Thomas, Chelleth Sampreethy Bhavan, Kadapra, Thiruvalla Taluk has filed this complaint against the opposite party for getting a relief from the Forum.
2. The facts of the complaint are as follows: The complainant had taken a medi claim policy from opposite party and the policy had valid coverage from 07.10.2009 to 06.10.2010. As per the conditions of the policy, complainant, his wife and children are entitled for the benefits under the policy. During February 2010, complainant’s wife became ill due to the complaint of stress urinary incontinence. On 16.02.2010 she was admitted at Poyyanil Hospital, Kozhencherry and on 17.02.2010 Tension Free Vaginal Tape (TVT) under spinal anesthesia was done. She was discharged on 19.02.2010. For the said treatment ` 38,000 was paid as hospital bill and medical bill. After discharge, complainant claimed the amount from the opposite party. But they repudiated the claim by letter dated 03.06.2010. They repudiated the claim stating that her disease is pre-existing. The repudiation of claim is a deficiency of service of the opposite party and therefore the complainant has filed this complaint for getting the medical expenses of ` 38,000 along with compensation and cost. Complainant prays for granting the reliefs.
3. Opposite party entered appearance and filed version with the following contentions. The complaint is not maintainable either in law or on facts. Opposite party admitted the policy and the complainant’s claim for medical expenses. Opposite party forwarded the above claim to TPA for investigation and found the claim as not payable, as per Clause 4(1) of the medi claim policy. As per the said clause, pre-existing diseases are excluded from the purview of the policy. The discharge summary shows that she is suffering from ‘Urinary Incontinence’ for 4 years. Non-disclosure of pre-existing disease is a suppression of material facts. Her ailment is pre-existing and it is suppressed at the time of taking the policy which is clear violation of the terms and conditions. Thus, the repudiation of the claim is with reasonable ground and there is no deficiency in service from the part of the opposite party and hence they canvassed for the dismissal of the complaint.
4. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint is allowable or not?
5. The evidence in this case consists of the oral testimony of PW1, DW1 and DW2 and Exts.A1 to A3 series and Exts.B1 to B3. After closure of evidence, both sides were heard.
6. The Point:- Complainant’s case is that she had undergone treatment for stress urinary incontinence at Poyyanil Hospital, Kozhencherry while she had a valid medi-claim policy. For the said treatment, ` 38,000 is paid towards medical and hospital bills and the complainant claim the above said amount from the opposite party. But they repudiated the claim by stating that her disease is a pre-existing. But according to the complainant, her disease is not a pre-existing disease and the repudiation is illegal and the said repudiation is a deficiency of service from the part of the opposite party.
7. In order to prove the complainant’s case, complainant adduced oral evidence as PW1 based on her proof affidavit and the documents produced were marked as Exts.A1 to A3 series. Ext.A1 is the copy of the letter sent by the opposite party. Ext.A2 is the carbon copy of reply letter sent by the complainant. Ext.A3 series are the medical bills paid by the complainant in connection with her treatment.
8. On the other hand, the contention of the opposite party is that complainant’s disease is a pre-existing disease and the complainants took the policy by suppressing her pre-existing ailment. Non-disclosure of pre-existing disease is a breach of policy condition. Hence the opposite party repudiated the claim as per exclusion clause 4.1 of the terms and conditions of the policy. In order to prove the contention of the opposite party, opposite party Branch Manager was examined as DW1 and the documents produced were marked as Exts.B1 and B2. Ext.B1 is the copy of the medi-claim policy, issued by the opposite party. Ext.B2 is the terms and conditions of the policy and Ext.B2(a) is the clause 4.1 in Ext.B2. The doctor who treated the complainant was examined as DW2 and the discharge summary issued by him is marked as Ext.B3.
9. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record. There is no dispute that the complainant has a valid policy at the time of treatment. The main question to be considered is whether her disease is a pre-existing one? According to the opposite party, complainants ailment is pre-existing one and as per the terms and conditions of the policy, pre-existing diseases are not covered by the policy. In order to substantiate the contention they are relying on Ext.B3 document, which is the discharge summary. As per Ext.B3, the complainants’ ailment was diagnosed as ‘stress urinary incontinence’. This diagnosis is based on the various tests conducted at Poyyanil Hospital on 16.02.2010. The complainant was subjected for the above said test on the basis of the consultation of the complainant with the doctor. There is no medical evidence showing that the complainant is undergoing treatment for stress urinary incontinence at the time of taking the policy. The history and duration of illness recorded by the doctor in Ext.B2 is as ‘Urinary incontinence – 4 years’. This fact is observed by the doctor from the complainant during the consultation/discussion between the doctor and the complainant. On the basis of the observation, doctor advised for various test and test result showed that the complainant is suffering from ‘stress urinary incontinence’. The complainant approached the doctor with certain complaints. She narrated the complaints. At the time of narrating her complaints or before that she is not aware that she is a patient having ‘stress urinary incontinence’. She came to know about her disease only after her consultation with DW2 doctor during February 2010. So opposite party is not justified in saying that complainant’s ailment is a pre-existing disease and she had suppressed the fact while taking the policy. Opposite party has also not produced any evidence to show that she was a patient having stress urinary incontinence and she was undergoing treatment for the said disease at the time of taking the policy. So the entry “Urinary Incontinence – 4 years” seen in Ext.B3 is not sufficient for denying the complainant’s claim. Therefore, the repudiation based on Ext.B2 can’t be justified and hence the repudiation is a clear deficiency in service on the part of the opposite party. Hence this complaint can be allowed partly with cost and compensation.
11. In the result, this complaint is allowed, thereby the opposite party is directed to pay an amount of ` 38,000 (Rupees Thirty Eight Thousand only) the actual medical expense as per Ext.A3 series along with ` 2,500 (Rupees Two Thousand Five hundred only) as compensation and ` 1,000 (Rupees One Thousand only) as cost to the complainant within 30 days from the date of receipt of this order, failing which the whole amount will follow 9% interest from this date till realization of the whole amount.
Declared in the Open Forum on this the 28th day of March, 2012.
(Sd/-)
K.P. Padmasree,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Sri. N. Premkumar (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Anu. C. Thomas.
Exhibits marked on the side of the complainant:
A1 : Copy of letter dated 03.06.2010 sent by the opposite party to the
first complainant.
A2 : Carbon copy of reply letter dated 07.06.2010 sent by the first
complainant to the opposite party.
A3 series : Medical bills.
Witness examined on the side of the opposite party:
DW1 : Jacob Varghese.
DW2 : Dr. Prasad. A. Cheeramattom.
Exhibits marked on the side of the opposite party:
B1 : Copy of the medi-claim policy issued by the opposite party. B2 : Terms and conditions of the medi claim policy.
B2(a) : Clause 4.1 in Ext.B2 terms and conditions.
B3 : Discharge Summary.
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) Mathai Thomas, Chelleth Sampreethy Bhavan,
Kadapra.P.O., Koipuram Village, Thiruvalla Taluk,
Pathanamthitta.
(2) The Branch Manager, National Insurance Co., Thiruvalla,
Ennakkattil Estate, M.C. Road, Thiruvalla, Pathanamthitta.
(3) The Stock File.
