CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present Sri.Santhosh Kesavanath.P. President Smt.Bindhu M.Thomas Member Sri.K.N.Radhakrishnan Member
CC.No.166/2008 Monday, the day of 22nd, February, 2010.
Petitioner. Satyadevan.T.R. Saras House Kurichy.P.O. Kottayam. (Adv.Jobin Mathew) Vs. Opposite parties. 1. National Insurance Co., C.S.I. Square Baker Hill, Kottayam Kerala 686 001. (Adv.C.J.Jomi) 2. T.T.K. Health Care Services Pvt. Limited 1460 B, Mareena Buildings M.G.Road, Ravipuram Cochin-682 016. O R D E R Smt.Bindhu M.Thomas, Member.
The complainant's case is as follows.
The complainant had insured himself his wife and son through a mediclaim policy vide policy No.570600/48/06/85000000833 with the first opposite party. The period of the policy is from 23-8-2006 to 22-8-2007. The said policy is being renewed for the past several years. As per the conditions of the policy the complainant and his wife will get medical expenses upto Rs.50,000/- each and the son will get Rs.25,000/-. Colloid cyst, foremen of monroe was diagonised and the complainant had undergone operation for transcallosal excisim of the said cyst on 26-3-2007 at Indo American Hospital Brain and spine centre, Vaikom. For the said treatment the complainant was admitted in the hospital on 24—2007 and was discharged on 4-4-2007. The matter was informed to the opposite parties and they sanctioned cash loss facility for the treatment to the complainant upto 50,000/-. The treatment expenses of the amounted only Rs.48,784/-. Since the opposite parties offered cash less acility, the petitioner was discharged without the bills at the hospital. Contrary to the assurances and undertaking the opposite parties were reluctant to pay the entire hospital expenses and had sanctioned only Rs.25,000/- as treatment expenses. The hospital authorities has called the complianant to pay the balance amount and abused him that he had tried to cheat the hospital authorities. The petitioner duly informed the matter to the first opposite party and the second opposite party sent reply stating untenable conditions for evading the payment. In order to avoid further shame to his honour the complainant paid the balance amount and settled the bill. Alleging deficiency in service on the part of opposite parties the complainant filed this complaint claiming the balance amount of Rs.23,784/- with 18% interest, compensation Rs.10,000/- and cost Rs.5,000/-. Notice was served to first and second opposite parties. Second opposite party was called absent hence set exparte. First opposite party entered appearance and filed version with the following main contentions. As per the terms of the policy it was obligating on the part of the insured to declare his existing disease wilst taking the policy and clause 3.5 of the conditions of policy says ''pre existing diseases means any ailment/disease/injury that the person is suffering from known/not known, heated/untreated, declared/not declared in the proposal whilst taking the policy. Continuing or recurrent nature of disease/complaints which the insured has ever suffered will be excluded from the scope of cover so far as enhancement of sum insured is considered. As the sum insured of the complainant was below one lakh his sum insured amount was raised to Rs.50,000/- as per clause 5.12 of the policy condition in accordance with his written request. But in this request he has not shown any pre-existing disease. The opposite party denied the claim of the complainant exceeding Rs.25,000/- because the disease for which the complainant had undergone treatment was pre-existing. The treatment was for collect cyst, foramen of Monroe and in case summary and discharge record it was clearly stated by the doctor ''past history of sudden onset of headache andnomiting 2 year back and was diagonised to be having cyst in the brain. Patient did not take any treatment. Since the disease was pre-existing at the time of enhancement, the insurance company is not liable to pay the enhanced claim amount and rightly repudiated the claim exceeding Rs.25,000/- as per clause 5.12 of the policy conditions. The complainant has purposefully not disclosed the fact of existing disease at the time of enhancement of sum insured or an entire occasion. There is no deficiency in service of the opposite party and acted only as per the terms and conditions of the policy.
Hence the opposite party prayed to dismiss the complaint with cost to them.
| | HONORABLE Bindhu M Thomas, Member | HONORABLE Santhosh Kesava Nath P, PRESIDENT | HONORABLE K.N Radhakrishnan, Member | |
