Date of filing : 26-11-2011
Date of order : 28 -06-2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.325/2011
Dated this, the 28th day of June 2012
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT. K.G.BEENA : MEMBER
Koppal Abdula, S/o. Late.Koppal Abdulla, } Complainant
Garden House, Bangera Kunnu,
Nellikunnu, Kasaragod. 671 121.
(Adv. K.Shrikanthashetty, Kasaragod)
1. National Insurnace Co.Ltd, High Lane Plaza, } Opposite parties
M.G.Road, Kasaragod, 671121 rep. by
It’s Manager.
(Adv.Balagopalan, Kasaragod)
2. Good Health Plan Ltd,
Plot No.49, Nagarjuna Hills, Panjagutta,
Hyderabad. 82, Rep. by it’s Manager.
O R D E R
SMT.K.G.BEENA, MEMBER
This complaint is filed against the repudiation of Hospitalization benefits as per the policy after the admission for investigation and evaluation of the complainant in the hospital from 29-07-2011 to 01-08-2011. The cash less payment claim forwarded by the complainant through hospital before opposite party No.2 was denied for the reason. ‘As admission for investigation and evaluation is not covered under the insurance norms’. Hence the complaint for necessary relief.
2. According to opposite parties, they were unaware of the diseases of the complainant. Complainant never disclosed before issuing the policy that he had hypertension, Diabetes, heart problem and renel problem. Complainant was undergone hospitalization only for evaluation and diagnostic purposes. Even after the evaluation and diagnostic procedure complainant had not undergone any active treatment. As per terms and conditions of policy expenses incurred primarily for evaluation and diagnostic purposes not followed by active treatment during hospitalization comes under exclusion clause. Hence opposite party repudiated the claim.
3. Complainant filed proof affidavit. Exts A1 to A6 marked. On the side of opposite parties Exts B1 & B2 marked. Both sides heard and documents perused.
4. Now the points arises for consideration are:
1. Whether the repudiation of claim of the complainant amount to any deficiency in service on the part of opposite parties?
2. If so, what is the relief?
5. Here the complainant and his family are insured with opposite party No.1 as per hospitalization benefit policy. In Medi claim policy i.e Ext.B2. The complainant had hypertension, Diabetes, heart problem renel problem and was under medication and regular checkup. He was admitted in KMC hospital Mangalore for evaluation and treatment. The inpatient admission was from 29-07-2011 to 1-8-2011 as per Ext.A4. But the claim Ext.B1 forwarded by the complainant through hospital before opposite partyNo.2 was denied for reason “Admission for investigation and evaluation is not covered under insurance norms”. So the claim is rejected through Ext.A3 relying on clause 4.10 of Ext.B2 which states that expenses incurred primarily for evaluation and diagnostic purposes not followed by active treatment during hospitalization are not payable. Ext. A1 is the payment receipt of KMC Hospital, Managalore. Ext.A5 is the prescription shows that he was already under regular checkup and treatment. Moreover opposite parties had a contention that there is suppression of material facts on the part of the complainant regarding earlier diseases at the time of taking policy. In National Insurance Company Ltd V. Ashok Kumar Gupta NCDRC CPJ P 547 it is held that complainant was guilty of non disclosure of material fact relating to his health under the heading “Insured Personal Details”.
6. In Usha Sharma V. New India Assurance Co.Ltd NCDRC CPJ P 488 held that the policy cannot cover diseases which are not stated or are specifically excluded. Insurance policy is a contract between 2 parties and its terms and conditions once accepted are binding on both parties.
In the result, the complaint is dismissed with no order as to costs.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exts.
A1.1-8-11 photocopy of Payment receipt KMC Hospital, Mangalore.
A2. 30-7-11 photocopy of Denial of cashless access.
A3. Photocopy of letter.
A4. Medical Report of Attending Doctor.
A5.2-8-11 Prescription
A6.UGI Endoscopy.
B1. Claim Form.
B2. Medi claim Insurance Policy.
PW1.Koppal Abdulla
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Pj/ Forwarded by Order
SENIOR SUPERINTENDENT
