SMT. RAVI SUSHA: PRESIDENT
Complainant filed this complaint U/s 12 of Consumer Protection Act 1986 seeking to get an order directing OP to settle the claim of the complainant by reimbursing the amount of Rs.1,03,228/- to the complainant the amount spent for the treatment together with Rs.50,000/- towards compensation for mental pain and agony happened to the complainant due to the deficiency in service on the part of OP.
In brief the facts of the case are that the complainant purchased a Mediclaim Happy Family Floater policy for himself and daughter from the OP. The policy covering period was from 07/11/2017 to 06/11/2018 sum insured was Rs.4 lakhs. On 2nd May2018, daughter of complainant, Akshaya Saseendran admitted in Indiana hospital for an operation. She discharged from the hospital on 04/05/2018. His daughter was hospitalized with sinusitis with left sided deviated nasal septum. The doctors in hospital advised for an operation and she had undergone through an operation for which he spent an amount of Rs.38,832/- towards the hospital expenses. The complainant has duly submitted the claim form after the treatment. He has also submitted document to substantiate his case. After two months, the complainant had admitted in the same hospital on 20/7/2018 with adenomatous goiter thyroid. He had also underwent through an operation and discharged from the hospital on 24/07/2018. An amount of Rs.64,396 was spent for the treatment. He has submitted claim application but he has neither received the amount incurred for the medical treatment nor received any reply from the OPs. The complainant also sent a lawyer notice on 17/02/2019 to the OP calling upon to pay to reimburse the medical expenses of Rs. 1,03,228/- for which the OP had sent a reply stating that the claim is forwarded to the 3rd party administrator, who has the authority to take a decision upon the claim and the decision of the 3rd party administrator is awaited and the same will be intimated to the complainant. He has put to much mental pain and agony due to the long delay on the side of OP in settling the claim. He assesses the compensation in this regard is Rs.50,000/-. Hence complaint.
Insurance company filed version and pleaded that the policy is subjected to various conditions and exclusions. As per Exclusion No.4.1 of the policy, any ailment /diseases, which are pre-existing, when the insurance coverage incepts for the first time are excluded. The complainant admitted in the Hospital on 20/07/2018 for the ailment of Adenomatous Goiter Thyroid. Policy is taken on 07/11/2017. Discharge summary shows that complaint of swelling in connection with Adenomatourus Goiter Thyroid in the neck of the complainant is six months back from 20/07/2018. Complainant was admitted in the hospital and examuined on 20/07/2018. That means, the complainant suffered Adenomatours Goiter Thyroid before the commencement of the policy and so he is not entitled to get any benefit from the insurer as per Exclusion NO.4.1 of the policy. Further submits that in case of complainant’s daughter Akshaya as per Exclusion No.4.3(XII), Sinusitis is covered after 2 years of the commencement of the policy. The policy is taken on 07/11/2017. Complainant’s daughter, Akshaya Saseendran, had undergone operation for the ailment of Sinusitis on 03/05/2018. Evidently this date is after 6 months from the commencement of the policy. Sinusitis will be covered only from 07/11/2019 onwards. So the present claim is hit by Exclusions No.4.1 as well as Exclusions No.4.3 of the policy. In view of the policy exclusion, the complaint itself is vexatious. There is no basis in the complaint. There is no deficiency in service on the part of the opposite party. Hence prayed for dismissal of complaint.
The question for consideration is whether the non-payment of policy benefit to complainant by the insurance company on the aforesaid grounds was justified?
At the evidence stage, complainant’s daughter Akshaya Saseendran had filed her chief affidavit and Ext.A1 to A6 had been marked as documents on the side of complainant. On the side of OP Divisional Manager, M/s oriental Insurance company Ltd., Kannur District Sri. Rathnavally P C has filed her chief-affidavit on behalf of OP and Ext.B1 to B6 were marked. After that the learned counsel of complainant and the learned counsel of OP vehemently argued the matter. The learned counsel of complainant filed written argument note also with Judgment of Hon’ble High Court of Kerala.
Ext.A1 Record Policy (Ext.B1) reveals that complainant had taken the Happy Family Floater - 2015 policy scheme for himself, his wife and his daughter for a sum of Rs.4,00,000/- from The Oriental Insurance Company Ltd. The policy was taken on 07/11/2017. Thereafter complainant had admitted in the Hospital Indiana on 20/07/2018 for the treatment of Adenomatous Goiter thyroid and he had underwent surgery on 21/07/2018 Hemithyroidectomy under GA. In Ext.A3 Discharge summary, it is seen that the C/o swelling in the neck before 6 months and after surgery complainant was discharged on 24/07/2018. Ext. B3 series Impatient bills of complainant for his treatment in the said hospital amounts Rs.63147.27/- which was paid by complainant. Ext.B5 series shows that the complainant has claimed on 06/08/2018 for an amount of Rs.63147/- before the Insurance company, with medical bills, for getting his treatment expense.
Ext.A2 shows that Miss Akshaya Saseendran (D/o complainant) was admitted on 02/05/2018 at Indiana Hospital. Diagnosis found on 02/05/2018 was DNS+Turbinate Hypertrophy and she underwent septoplasty + turbinoplasty on 03/05/2018 and discharged on 02/05/2018.
The Insurance company has repudiated the claim of the complainant only on the ground that complainant had concealed his ailment of adenomatous Goiter Thyroid and in fact, he was suffering from the ailment of thyroid prior to 6 months from 20/07/2018 the date of admitting in the hospital. OP contended that the above said fact reveals that the complainant suffered thyroid complaint before the commencement of the policy and so he is not entitled to get any benefit from the insurer as per Exclusion clause No.4.1 of the policy. Here Ext.B1(A1) policy shows that the complainant has taken policy on 07/11/2017. From Ext.A3 the thyroid diagnosed on 20/07/2018 and treating doctor stated that c/o swelling in the neck 6 months prior to 20/07/2018 ie from Ext.A3 discharge summary swelling in the neck started from February 2018, after the date complainant took the policy moreover the Insurance company failed to produce any document (treatment record) to show that complainant was suffering from thyroid complaint before taking the policy as well as the proposal form. Further there is no evidence on record which may suggest that the complainant, at the time of filing the proposal form or obtaining the policy, had any knowledge of his disease or had swelling in the neck related to thyroid.
Here the learned counsel of complainant has submitted before us a decision of Hon’ble High court of Kerala in the matter of star health and Allied Insurance company Ltd Vs. V P Satheesh Menon 2020(1) KLJ71. In which Hon’ble High Court held that A disease can be said to be contracted for the purpose of insurance claim, only when after diagnosis it is clinically found that the patient is suffering from the disease. The symptoms related to the disease may be in existence for long periods prior to the diagnosis and the symptoms may be within the knowledge of the patient. For the purpose of an Insurance claim, a disease can be said to be contracted only when it is diagnosed by a competent physicians and confirmed.
In the present case OP Insurance Company failed to prove that a competent physician diagnosed the thyroid complaint on the complainant prior to 07/11/2017 ie the date when he took the policy.
For the reason stated above, we are of the view that the non-payment of the claim of complainant Mr. Saseendran K M, by the Insurance company cannot be held to be justified. Complainant is entitled to get Rs. 63,147/- as his treatment expense from the OP.
Next point to be considered about Miss Akshaya Saseendrn’s (D/o complainant) claim.
OP contended that as per exclusion clause No.4.3(XII), Sinusitis is covered after 2 years of the commencement of the policy. Further stated that since she had undergone operation for the ailment of sinusitis on 03/05/2018, she will get claim only from 07/11/2019 onwards.
On perusal of Ext.B1, clause 4.3(XII) it is stated that the expenses on treatment of Sinusitis and related disorders for a period of 2 years are not payable if contracted and / or manifested during the currency of the policy. Here, as per Ext. A2 discharge summary of Akshaya issued from Indiana Hospital, reveals that the disputed ailment diagnosed on 02/05/2018, ie within 2 years from the date of taking the policy. In the present case complainant does not have a case that the particular disease was existed back from 4 years from the date complainant took the policy. In such cases as per clause 4 (1) she is entitled to get policy benefit. Hence as per clause 4 (3) XII, complainant is not entitled to get reimbursement of treatment expense from Insurance company for the treatment of his dauthter Miss.Akshaya.
For the reasons stated above, we find that there is deficiency in service on the part of OP in repudiating Ext.B5 claim of complainant without any reasonable ground. Hence complainant is entitled to get reimbursement of Rs.63,147/- the amount claimed in Ext.B5 with interest and compensation.
In the result, complaint is allowed in part. Opposite party is directed to pay Rs.63,147/- with interest @ 4% per annum to the complainant from the date of complaint till the date of realization. Opposite party is further directed to pay Rs.10,000/- towards compensation for the mental agony and monetary loss happened to complainant due to the deficiency in service of Opposite party, Opposite party shall comply the order within one month from the date of receipt of orders. Failing which Rs.63,147/- carries interest @ 9% per annum from the date of complaint till realization. Complainant can realize the awarded amount by filing execution application against the Opposite party as per the provisions mentioned in Consumer Protection Act 2019.
Exts.
A1-Policy
A2-Discharge summary(Indiana Hospital)
A3-Discharge Certificate
A4-Lawyer notice
A5-Postal receipt
A6-Reply notice
B1-Insurance Policy
B2- Discharge summary
B3(series)-Medical bills 22 in numbers
B4(series)-Medical reports 10 Nos
B5(series)-Claim form 2 in numbers
B6-Proposal form
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
