IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 30th day of March, 2021
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
C C No. 90/2020 (filed on 15-07-2020)
Petitioner : P.M. Shaji,
S/o. P.S. Meerannan,
Residing at Palayamparambil House,
Erattupetta P.O. Kottayam.
Vs.
Opposite party : The Manager,
National Insurance Co. Ltd.
St. George Arcade,
Erattupetta Road, Pala P.O.
Pin – 686 575.
O R D E R
Smt. Bindhu R. Member
The complainant’s case is as follows: The complainant took a health insurancepolicy from the opposite party with policy no 570601501910000594for theperiod from 7.11.2019 to 6.11.2020. The petitioner is a subscriber of thepolicy for 10 continuous years without any claim. At the time of inception ofthe policy the complainant was made to believe that the policy would cover allkinds of ailments. While so on 21.11.2019 the petitioner underwent a surgeryfor removing his so many growing fake problems in Carithas Hospital,Thellakom. Anaesthesia was given to the petitioner before surgery and thesurgery took hours of time. As the petitioner was the only son of his parents,he was discharged on the same day upon his request. An amount of Rs.11,271/- was spent by the petitioner for the treatment.Subsequently the complainant submitted the claim to the opposite party butthey rejected the same on the reason that the treatment was done under OPDbasis which was excluded in the policy itself.Due to this rejection the complainant had to undergo severe mental agonyand hardships and the rejection is a clear deficiency in service from the part ofthe opposite party. Hence this complaint is filed.
Upon notice from this commission, the opposite party appeared and filed
version in which the contentions raised are that the allegation that thecomplainant was made to believe that the policy would cover all the ailments
is not true and if some agent had done so, he would have been there in the
party array. As the agent was not made a party to the complaint, thecomplaint is bad for non joinder of necessary parties.
Further that the treatment alleged to have undergone by the complainant wasin an OPD basis. As per the policy conditions, the treatments under OPD basisare excluded from payment. Moreover, the complainant has not produced anyhospital records before the commission. So the complainant has approached
the commission without any bonafides.
The complainant has filed proof affidavit along with Exhibits A1 to A4 and theopposite party filed Exhibit B1 along with the affidavit.
On an evaluation of the pleadings and evidence, we would like to frame thefollowing issue that whether the complainant has succeeded in establishing
the deficiency in service on the part of the opposite party which should becompensated?
The complaint is filed for the payment of insured amount against a claim putforward by the complainant to the opposite party which was rejected on the
ground of exclusion on ground of OPD basis.Answering the issue we would like to analyse the documents on record. Wefind that the complainant has not produced any of the hospital records toprove his case that he was admitted for some deceases which requiredinpatient treatment. All the documents produced by the complainant are onlyrelated to the policy and claim rejection.
On the other side the opposite party’s contention was that as the treatment
was done under the OPD basis, they were unable to award the claim as thecontract itself stipulated this as exclusion. The opposite party cannot actbeyond the provisions of the contract of policy. They have produced Exhibit B1
which is the policy conditions in which under Clause 4 exclusions cl.4.18is “out
patient Department Treatment (OPDTreatment)” and 4.19 “Diagnostic andevaluation purpose where such diagnosis and evaluation can be carried out as
outpatient procedure and the condition of the patient does not requirehospitalisation.”
Thus the opposite party has rejected the claim of the complainant on the
above ground which seems not unlawful though the opposite party has not
explained how they could reach to such a conclusion in the absence ofhospital records.
On a detailed examination of the evidence, we are unable to find a single
document in support of the claim of the complainant like hospital discharge
summary, op ticket etc. The complainant has failed to prove his claim by producing anycogent evidence to substantiate his claim. So we are of the opinion that thecomplainant has not approached this commission with clean hands.Hence we dismiss the complaint.
Pronounced in the Open Commission on this the 30th day of March, 2021.
Smt. Bindhu R. Member Sd/-
Sri. Manulal V.S. President Sd/-
Appendix
Exhibits marked from the side of complainant.
A1 : Policy copy issued by the respondent
A2 : Copy of prospectus issued by opposite party
A3 :Copy of reimbursement claim form
A4 : Letter dtd.12-02-2020 issued by opposite party
Exhibits marked from the side of opposite party.
B1 : Policy certificate no.570601501910000594 issued by opposite party
By Order
Senior Superintenden
