Kerala

Idukki

CC/79/2020

Sajan v k - Complainant(s)

Versus

National insurance co ltd - Opp.Party(s)

Adv: km Sanu

03 Nov 2022

ORDER

 

DATE OF FILING : 18/06/2020

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  3rd day of November 2022

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.79/2020

Between

Complainant                            :   Sajan V.K.,

                                                     Vazhikkottu House,

                                                     Kudayathoor P.O.,  Thodupuzha

                                                     (By Adv.K.M.Sanu)

                                                           And

Opposite Party :                      :   1 .  The Manager,

                                                           National Insurance Co.Ltd.,

                                                           Thodupuzha Branch, Thodupuzha P.O.

                                                     2 .  The Manager,

                                                           National Insurance Co.Ltd.,

                                                           Perumbavoor Branch, Perumbavoor P.O.,

                                                           A.M.Road, Pin – 683 542.

                                                           (By Adv.Lissy M.M.)

 

O R D E R

SRI.AMPADY K.S., MEMBER

 

Complainant raised the following allegations against opposite parties and sought for the following reliefs:-

 

1 . Complainant was a Mediclaim Policy holder of opposite parties from 2007 and renewing the same without any break.  He paid Rs.9543/- towards premium and period of policy was 11/03/2019 to 10/03/2020.  As per policy, Rs.1 Lakh coverage was provided for him, wife and three children.  During the policy period, he suffered joint pain and difficulties and therefore he was hospitalised and treated at Sree Sudheendra Medical Mission Hospital, Ernakulam from 13/02/2020 to 14/02/2020.    After examination it was found that “Rheumatoid Arthritis” and treated there.  He had to spent Rs.27522/- for the treatment.

(Cont.....2)

-2-

2 .  After discharge from hospital, he filed claim application.  Even after several months, opposite party has not paid the amount.  On enquiry with opposite party through their agent, it was informed that amount would not be paid.

 

3 .  Policy was taken to meet unexpected treatment expenses by paying huge amount.  But even low claim amount was not paid by them.  It is a deficiency in service.   He is entitled to get treatment expenses along with 18% interest and compensation for deficiency in service.

 

So he prayed for the following reliefs.

 

a . Hospital treatment expenses with 18% interest may be recovered from opposite parties and give to him.

b .  Compensation of Rs.25000/-  may be recovered from opposite partys and give to him.

c . Costs of litigation of Rs.5000/- may be allowed.

 

Opposite parties filed written version in the following lines.

 

The complaint is not maintainable either in law or on facts.  There is no cause of action for the complaint.  So this case is not maintainable before the Forum.

 

As  the complaint is not maintainable either on facts or in law and is liable to be dismissed.

 

All the averments in paragraph No.1 and 2 of the complaint is not fully correct hence denied.  It is true that the complainant had availed the policy from the opposite parties.  It is submitted that the complainant approached the opposite party for availing the policy, the opposite parties has explained all terms and conditions of the policy.  After knowing the terms and conditions of the policy the complainant had opted the Mediclaim policy.  According to policy condition 3.12 Hospitalization means admission in hospital as an inpatient for minimum period of 24 consecutive hours except for specified procedure/treatment.

 

Relaxation of 24 hour minimum duration for hospitalization is allowed in  Day care Procedure/Surgeries (as listed in Appendix-1) where such treatment is

 

(Cont.....3)

-3-

taken by an insured person in a hospital/day care centre (but not the outpatient) to advancement of medical science require hospitalization for less than 24 hours and for which prior approval from company/TPA is mandatory.  The treatment given on 13/02/2020 is injection Rituximab.  Injection Rituximab procedure is not coming under day care treatment list.  This could be done as outpatient treatment and usually done on outpatient basis are not payable.

 

Based on the available Medical records, it is proved that at the time of taking the policy, the complainant was well aware about the health condition and he has wilfully suppressed his pre-existing diseases.  He has already suffering Rheumatoid Arthritis.  He purposefully suppressed those facts in the proposal form despite there is specific question in the proposal form.  The object of the proposal forms is to gather information about a potential client, allowing the insurer to get all information which is material to the insurer to know in order to assess the risk and fix the premium.   Proposal forms are a significant part of the disclosure procedure and warranty accuracy of statements.   The complainant was aware of the fact that while making a declaration, that if any statement is not true the opposite parties may cancel the contract and forfeit the premium.

 

All the averments in paragraph 3 and 4 of the complaint is not correct hence denied by the opposite parties.  The opposite party is not responsible for the loss or liable to pay the amount.  There is no deficiency in service on the part of the opposite party.  Hence the opposite parties are not liable to pay any amount as compensation to the complainant.

 

Hence they prayed for dismissal of the complaint with costs of the opposite parties.

 

No oral evidence is adduced by both sides.  Complainant produced 4 documents and marked as Ext.P1 to P4 respectively.

 

Ext.P1-  Original policy document No.571001501810004149 effective from    

               11/03/2019 to 10/03/2020 with premium amount Rs.9543/-  

               including GST.

 

Ext.P2 series(6 in Nos)- Hospital and Pharmacy Bills (Copy).

 

(Cont.....4)

-4-

 

Ext.P3 - Claim form part A dated 25/02/2020 and Part B signed by doctor

               on 29/02/2020 (Copy).

 

Ext.P4 – Discharge summary dated 14/02/2020 (Copy).

 

Opposite parties filed self certified copy of 3 documents which were marked as Exts.R1 to R3 respectively.

 

Ext.R1 – Discharge summary

Ext.R2 – Claim form

Ext.R3 – Hospital and Pharmacy bills.

 

Above documents were already marked on the side of complainant.   We have examined the pleadings and evidence on record.  On a careful examination of the same, following points arise for consideration.

 

  1. . Whether the complainant is entitled to hospital treatment expenses from   

opposite parties and whether there is any deficiency in service on the

part of opposite parties?

  1. . If so, for what reliefs the complainant is entitled to ?
  2. . Costs of litigation?

 

Point No.1

 

On a perusal of Ext.P1, it is seen that complainant and his family members were insured under Mediclaim Policy for a sum of Rs.1 Lakh cumulative bonus of Rs.10,000/- is also  shown in the policy document.  This shows that complainant was having policy during previous period also.  Nothing to the contrary is proved or any contention is raised to that effect by the opposite parties.  The most important contention raised by the opposite parties is that hospitalisation not less than 24 hours is necessary.  The treatment given on 13/02/2020 is Rituximab Injection.  Rituximab   procedure is not coming under day care treatment list. This could be done as outpatient treatment and usually done on outpatient basis are not payable.  They rely on policy condition 3.12.  But no such condition is produced by them before this Commission.  Another contention raised is that complainant

 

(Cont.....5)

-5-

 has wilfully suppressed his pre-existing deceases.  He has already suffering from Rheumatoid Arthritis.  Both the above contentions are not sustainable for the following reasons.   From the policy document itself, it is seen that it was not a fresh policy.  Besides opposite parties has failed to prove that complainant had wilfully suppressed relevant materials.  Hospital records produced from both sides reveal that complainant had treated in the hospital as an inpatient for more than 24 hours and the injection was given under strict supervision.  It is for the doctor who treated the patient to say authoritatively about the treatment given, health condition, medical advice etc. given by him.  Opposite parties have not produced any reliable medical opinion of specialist doctors to prove their contention.  As per the Ext.P4 discharge summary, it is seen that complainant was admitted on 13/02/2020 3.49pm and discharged on 14/02/2020 4 pm.  So, the contention of the opposite parties regarding the time treated in the hospital does not subsist.  In the absence of policy condition, opposite parties cannot challenge that  such pre-existing disease are not covered by the policy for a specific period.  Opposite parties denied the claim without any cogent evidences.  If the policy is a continuing one, the waiting period ends on the expiry of the said period.  In the absence of evidence, contentions of the opposite parties are not acceptable.

 

On an entire analysis of the facts and evidence of the case we are of the considered view that there is deficiency in service on the part of opposite parties in not honouring the claim of the complainant within the reasonable period for which opposite parties are liable to pay reasonable compensation to the complainant. Eventhough complainant claimed hospital expenses of Rs.27522/- he has produced copy of bills for Rs.24782/- only.  So we find that complainant is entitled to recover the treatment expenses Rs. 24782/- ( Twenty-four Thousand Seven Hundred and Eighty-two) and Rs.5,000/- (Five Thousand) towards compensation for their deficiency in service from the opposite parties.  So Point No.1 is answered accordingly.

 

Point No.2

 

          In the light of discussion and finding on Point No.1 we order that opposite parties shall pay treatment expenses Rs.24782/-  (Twenty-four Thousand Seven Hundred and Eighty-two) and Rs.5000/- (Five Thousand) as compensation for their deficiency in service to the complainant.  Point No.2 is answered as above.

 

(Cont.....6)

-6-

 

Point No.3

 

Considering the entire aspect of the case, litigation cost Rs.3000/- to be paid by opposite parties to the complainant.

 

In the result complaint is allowed in part as follows.

 

1 . Opposite parties are directed to pay Rs.24782/-(Twenty-four Thousand Seven Hundred and Eighty-two) towards treatment expenses to the complainant within 30 days of receipt of this order.

2 . They are also directed to pay Rs.5000/- to the complainant towards compensation for deficiency in service on the part of opposite parties within the above period.

3 . Litigation cost of Rs.3000/- is also to be paid by opposite parties to the complainant within the said period.

 

Amounts ordered to be paid as per clauses 1 and 2 above, if not paid within above period, shall carry 12% interest from the date of complaint.  Parties to take back extra copies produced.

 

       Pronounced by this Commission on this the 3rd  day of November, 2022.

 

                                                                           Sd/-

                                                                   SRI.AMPADY K.S., MEMBER

                                                                                               Sd/-

                                                                    SRI.C.SURESHKUMAR, PRESIDENT

                                                                                               Sd/-

                                                                            SMT.ASAMOL P., MEMBER

 

 

 

 

 

 

 

 

 

(Cont.....7)

-7-

 

 

APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1 - Original policy document No.571001501810004149 effective from

              11/03/2019 to 10/03/2020 with premium amount Rs.9543/-

               including GST.

 

Ext.P2 series(6 in Nos)- Hospital and Pharmacy Bill (Copy)

Ext.P3 - Claim form part A dated 25/02/2020 and Part B signed

               by doctor on 29/02/2020 (Copy)

Ext.P4 - Discharge summary dated 14/02/2020 (Copy).

On the side of the Opposite Party :

Ext.R1 -  Discharge summary

Ext.R2 - Claim form

Ext.R3 - Hospital and Pharmacy bills.

 

                                               

                                                                                               Forwarded by Order

 

 

                                                                                         ASSISTANT REGISTRAR

 

 

 

 

 

 

 

 

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