DATE OF FILING : 20.2.2015

IN THE CONSUMER DISPUTES  REDRESSAL FORUM, IDUKKI

Dated this the   28th  day of  July,  2017

Present :

SRI. S. GOPAKUMAR PRESIDENT

SRI. BENNY. K. MEMBER

CC NO.66/2015

Between

Complainant       :    Shijo N. Kuriakose., S/o. Kuriakose,

Naduvathu House,

  Kalayanthani P.O.,

Thenmary, Thodupuzha, Idukki.

(By Advs: T.J. Augustine & V.V. Sunny)

And

Opposite Parties                                        :   1. The Branch Manager,               

     National Insurance Company Ltd.,

     Thodupuzha, Idukki.

     (By Adv:  Thomas Sebastian)

2.  The Regional Manager,

     Medi Assist India Pvt. Ltd.,

     406, Chandralaya, Kurisupally Road,

     Temple Lance, Ravipuram, 

     Kochi – 682 015. 

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

Case of the complainant is that,

        Complainant had joined in a health insurance plan of the 1st opposite party on 6.7.2012 and it is valid from 6.7.2012 to 5.7.2013, covering the complainant, his wife and minor daughter to a limit of one lakh rupees each.  While so, the daughter of the complainant was admitted at Mount Sinai hospital on 15.10.2012due to fever. Since the fever was persisted she was referred to MOSC Medical College Hospital, Kolenchery, for better treatment and he was admitted and treated there till 3.11.2012.  The diagnosis of the doctor at Mount Sinai Hospital was Broncho pneumonia.  The doctor who attended Georgia, daughter of the complainant at MOSC MCH, has treated her for Multi locuted Fibrino Purulent Empyema left side.  A total amount of Rs.51,542/- had spend for the treatment in both the hospitals.

               (cont....2)

-  2  -

Immediately after the discharge of the daughter, complainant filed his claim before the opposite parties, along with all relevant documents as directed by the 1st opposite party.  Since the 1st opposite party not turned up to honour the claim of the complainant, he approached 1st opposite party directly and enquired about the matter.  At that time, 1st opposite party stated that, the claim of the complainant was rejected by the 2nd opposite party due to some technical grounds and on further enquiry complainant came to know that, the 2nd opposite party denied his claim due to the reason that the child was having ‘inguinal hernia” as it is stated in the discharge summary.  The complainant further averred that, the minor child was not treated for hernia and the entire treatment was done for Broncho pneumonia and Multilocuted Fibrino Parulent Empyema and the decease was affected after taking the policy.  Another reason stated by the 2nd opposite party is that the Empyema was affected three months back and hence that is within one month of taking the policy.  But the doctors opinion was given after discharge that is, after 4 months and these reasons for denying the claim are baseless and it amounts gross deficiency in service from the part of opposite parties.  Moreover, there was no proper communication in this matter from the side of the opposite parties.  This act of the opposite parties caused much mental agony and other hardships to the complainant and he approached the Forum against the opposite parties for directing the 1st opposite party to honour the claim of the complainant and also to pay Rs.1 lakh as compensation and Rs.15000/- as litigation cost.

        On notice, opposite parties entered appearance and filed detailed version denying the allegation against them.  The opposite parties further contended that, eventhough they admitted the validity of the policy and the submission of 2 claim forms claiming Rs.4080/- towards treatment of the complainant’s daughter at Mount Sinai Hospital and Rs.47,462/- for treatment at MOX MCH, Kolenchery, for Empyema left side and left inguinal hernia.  The  discharge summary issued from MOSC Medical College Hospital, Kolenchery, shows that she was treated in referred hospital for Broncho pneumonia and she had Broncho pneumonia three months back.  The date of commencement of the said policy was on 6.7.2012, the discharge summary reveals that the ailment 

   (cont....3)

-  3  -

contracted during the first 30 days of inception of the policy.  Opposite party further contended that as per exclusion clause 4.2, the insurance company shall not liable to make any payment under the policy in respect of any disease other than those stated in clause 4.3 contracted by the insured person during the next first 30 days from the commencement of the policy.  Since the present ailment in the complication of Broncho pneumonia, which contracted within the first month of policy inception, the claim is not payable as per the exclusion clause No.4.2.  As per exclusion clause 4.3, expenses for treatment of Hernia are not payable for the first two years of policy inception.  Therefore both claims were repudiated by the 1st opposite party on valid grounds.  So there is no deficiency in service on the part of the opposite parties in repudiating the claim.

        Opposite party further contended that the 1st opposite party is liable to make payments in respect of expenses subject to terms and conditions of the policy.  In claim for Rs.4080/-, Rs.30/- is paid as admission charge and Rs.110/- is for injection charges, these are not covered under policy exclusion clause 4.17.  In claim for Rs.47,462/-, Rs.12.283/- is paid towards room rent and nursing charges.  As per the clause No.I of the policy, room rent and nursing charges per day payable is 10% of the sum insured, that is, Rs.1000/- per day.  The patient underwent inpatient treatment for 12 days.  The amount payable is Rs.12000/- only.  Moreover, Rs.124/- is claim for Nebuliser Mask and Rs.1939/- is collected  for dietary.  As per clause 4.16 of the policy condition, diet charges and non-medical items are excluded.  Therefore Rs.140/- in claim for Rs.4080/- and Rs.2348/- in claim for Rs.47,462/- is not payable.  So the maximum amount payable in both claims according to clause No.1.0 and exclusion clause Nos.4.16 and 4.17 of this policy is Rs.49,054/-.  Without prejudice to the contention raised above, evenif the Forum finds that the claim of the complainant is allowable as per condition of policy, the maximum amount payable is only Rs.49,058/-.

 

Complainant was examined as PW1 and Exts.P1 to P4 were marked.  Ext.P1 is the copy of insurance policy.  Ext.P2 is the receipt showing the premium paid to the insurance company.  Ext.P3(series) are the the claim form, discharge card and medical bills.  Ext.P4 is the request for document.  From the defence side, manager of 1st opposite party was examined as DW1.  Exts.R1 to      (cont....4)

-  4  - 

 R5 were marked.  Ext.R1 is copy of medical certificate form filled by the treating doctor.  Ext.R2 is copy of policy.  Ext.R3 is the copy of medical certificate.  Ext.R4 is copy of discharge summary.  Ext.R5 is letter issued by 2nd opposite party to 1st opposite party. 

 

We have heard the learned counsel of both the sides.

The points that arose for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?

The POINT :-  We have carefully perused the evidence on record and depositions of witnesses.  The only point remain on consideration is that whether the ailment of the minor child of the complainant was pre-existing and whether it is excluded in the insurance policy.  Here eventhough the learned counsel for the opposite parties vehemently argued that the ailment that stated in Ext.R2 treatment history of the minor Georgia is excluded in clause 4.1 and clause 4.3 of the insurance policy, no clear and cogent evidence produced.  It is seen from the records that the patient was admitted and treated for Broncho pneumonia in Mount Sinai hospital, Thodupuzha from 15.10.2012 to 20.10.2012.  Thereafter she was referred to MOSC Medical College Hospital, Kolenchery and treated there as inpatient from 22.10.2012 to 3.11.2012 for Multilocuted Fibrino Purulated Empyema left side.  It is an admitted fact that Empyema is a complication of Broncho pneumonia, but no evidence is produced by the opposite party whether it is pre-existing.  The 1st opposite party denied the claim on the basis of an entry in the medical certificate that “H/o Broncho pneumonia 3 months back”.  Except this opinion of the doctor, no clear and cogent evidence is produced to convince the Forum that whether the child was treated for the same disease previously.  Also no evidence is produced by the opposite parties to show that the minor child was treated for “inguinal hernia”.  Ext.R4 is the detailed treatment summary of minor Georgia Shijo.  By perusing the document also we cannot find that the child was undergone any treatment for ‘inguinal hernia’.  If the treatment and surgical procedure adopted by the hospital authorities as narrated in the Ext.R1 is for inguinal hernia, it is to be clarified by the opposite party through medical experts.  Here opposite party failed to do so.  Hence version of the opposite party cannot be justified in denying the insurance claim of the complainant.                    (cont....5)

-  5  -

It is manifest that the daughter of the complainant suffered serious disease and underwent medical treatment and spent an amount of Rs.51,542/- for treatment alone.  It is not open to the insurance company to place conditions which are unlikely to be fulfilled with a view to create a device to escape from the payment of compensation.

On the basis of the above discussion, the complaint allowed.  The Forum directs the opposite party to pay a total amount of Rs.49,054/- as narrated in paragraph No.7 of the written version, as per 4.16 and 4.17 of the exclusion clauses of the policy, along with Rs.3000/- being the cost of the petition within 30 days of receipt of a copy of this order, failing which the amount stated above in two heads shall carry 12% interest per annum from the date of default, till its realization.   No order to compensation.

Pronounced in the Open Forum on this 28th day of July, 2017

 

Sd/-

  SRI. S. GOPAKUMAR, PRESIDENT

 

Sd/-

SRI. BENNY. K., MEMBER

 

 

 

 

 

 

 

 

 

 

(cont....6)

-  6  -

 

APPENDIX

Depositions :

On the side of the Complainant :

PW1              -  Shijo No. Kuriakose.

On the side of the Opposite Party :

DW1             -  S. Manoj.

Exhibits :

On the side of the Complainant :

Ext.P1                 -  copy of insurance policy.  

Ext.P2               - receipt showing the premium paid to the insurance company. 

Ext.P3(series)   - the claim form, discharge card and medical bills.  

Ext.P4               -  the request for document.

On the side of the Opposite Party :

Ext.R1               -   copy of medical certificate form filled by the treating doctor. 

Ext.R2             -  copy of policy.  

Ext.R3             -  copy of medical certificate.  

Ext.R4             -  copy of discharge summary.  

Ext.R5             -  letter issued by 2nd opposite party to 1st opposite party. 

 

 

Forwarded by Order,

 

 

SENIOR SUPERINTENDENT