cccccPBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of October 2012
Filed on : 30-12-2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 728/11
Between
P.P. Varghese, : Complainant
S/o. Poulose, (By Adv. Jeemon John,
Pallippattu house, E-Colony, MDV. Complex, Opp.
Angamally-688 572. L.F. Hospital, Angamally
Pin-683 572.)
And
1. Oriental Insurance Com. Ltd. : Opposite parties
1st. Floor, (By Adv. MGK Menon,
KV Varkey Memorial Complex, CC/39/1521, Ernakulam,
Near Bus Station, Angamally, South railway station road,
Ernakulam-688572 Cochin-682 016)
2. M.D., India Health Service
(P) Ltd., EL-68/521,
Kasini lane, Opp. Karuna Printers,
Near St. Augustine School,
Kaloor, Kochi-682 017.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant availed himself of an insurance policy of the 1st opposite party for the period from 27-03-2010 to 26-03-2011. Since 27-03-2011 being a Sunday he could renew the policy only on 28-03-2011 which is valid from 28-03-2011 to 27-08-2012. The complainant had undergone treatment at Little Flower Hospital, Angamally from 11-07-2011 to 18-07-2011 for disc prolapse and he had to undergo a surgery. He incurred a sum of Rs. 55,158.50 towards treatment expenses. His claim application for insurance was repudiated by the 2nd opposite party vide letter dated 19-08-2011. The repudiation of the claim is not sustainable. The complainant is entitled to get the insurance claim together with compensation and costs of the proceedings. This complaint hence.
2. The version of the opposite parties is as follows:
The complainant had been taking medi claim insurance policies from the 1st opposite party till 26-03-2011. Thereafter the complainant took a new medicalm policy valid from 28-03-2011 to 27-03-2012. The complainant submitted a medi claim application for Rs. 55,153.50 the expenses he incurred for treatment of Lumbar Spine degenerative disc disease at LF Hospital, Angamally between 11-07-2011 and 16-07-2011. The 2nd opposite party repudiated the claim of the complainant stating that treatment of diseases such as surgery for prolapsed intervertebral disc unless arising from accident is not payable from the first 2 years of operation of the policy. Moreover the complainant failed to intimate the opposite party within 48 hours of admission on or before discharging from hospital regarding hospitalization. There is not deficiency in service on he part of the opposite parties and the complaint is liable to be dismissed.
3. The complainant was examined as PW1 and Exts. A1 to A7 were marked. No oral evidence was adduced by the opposite parties. Exts. B1 to B4 were marked on their side. Heard the learned counsel for the parties.
4. The points that arose for consideration are as follows?
i. Whether the complainant is entitled to get insurance claim
from the opposite parties?
ii. Whether the opposite parties are liable to pay compensation
and costs of the proceedings to the complainant ?
5. Point No. i. The complainant availed the following policies from the 1st opposite party.
Sl.No. | Exhibits | Period of the policy |
1 | A4/B2 | From 27-03-2010 to 26-03-2011 |
2 | A3/B3 | From 28-03-2011 to 27-03-2012 (Break of 2 days in renewing the policy) |
6. During the currency of Ext. A3/B3 policy the complainant underwent treatment at LF Hospital Angamaly from 11-07-2011 to 16-07-2011 evidenced by Ext. A1 case summary and discharge card. The disease was diagnosed as degenerative disease of lumbar spine with degenerative disc disease (L4-5 IVDP).
7. The claim for insurance was repudiated by the 1st opposite party vide Ext. A7 letter which reads as under.
“We therefore regret to inform you that liability under
the claim is rejected on account of following
reason/s.
1. Treatment of diseases such as Surgery for prolapsed intervertebral disc unless arising from accident, are not payable for first two years of operation of the policy.
As per claim documents received, it has been observed
that the claim intimation was not given to us within 48
hours after admission in hospital. Hence, the claim
is Repudiated as the claim is intimated after
unreasonable delay.
2. As per policy terms and conditions, claim is not payable, Under Clause No. 4.3+5.4
The final repudiation will be given by the insurance Company.”
8. Clause 4.3 and 5.4 in Ext. B1 terms and conditions of the policy is as follows:
“4.3. During the period of insurance cover, the expenses on treatment of following ailment/diseases/surgeries for specified periods are not payable if contracted and /or manifested during the currency of the policy.
X X X X X X
XX Surgery for prolapsed inter vertebral disk unless arising from accident - 2 yeas”
“5.4 NOTICE OF CLAIM: Immediate notice of claim with particulars relating Policy Number, ID Card No., Name of Insured Person in respect of whom claim is made. nature of disease/illness/injury and Name and Address of the attending medical practitioner/Hospital/Nursing Home etc. should be given to the Company/TPA while taking treatment in the Hospital/Nursing Home by Fax, Email, Such notice should be given within 48 hours of admission or before discharge from Hospital/Nursing Home, unless waived in writing”
9. It is pertinent to note that the disease mentioned in Exclusion clause No. 4.3XX is “prolapsed inter vertebral disk”. Whereas the disease of the complainant diagnosed at the hospital is “degenerative disease of lumbar spine with degerative disc disease” which are distinct and different. So clause No. 4.3XX in Exbt. B1 policy is not applicable in this case.
10. The other contention raised by the opposite parties is that there is a break of 2 days in renewing Ext. A4 policy . We are not to accept the said contention especially even the insurance company can condone the delay of 14 days in renewing the policy. If at all the insurance claim is not payable in view of clause 4.3 in the policy, admittedly the complainant was holding valid policy since according to the Hon’ble National Consumer Disputes Redressal Commission break of 15 days in renewing the policy is not a ground to deny insurance claim. Oriental Insurance Company Vs. Parkash Devi II (2008) CPJ 267 (NC), Oriental Insurance Company Vs. Madan Kumr Dutta II (2008) CPJ 366
11. Exbt. A1 the medical records goes to show that the complainant had undergone treatment at Little Flower Hospital, Angamally. The opposite parties do not have a case that Ext. A1 is a forged or concocted one. Therefore there is no merit in the contentions of the opposite parties that the complainant failed to intimate the hospitalization as per clause 5.4 of the policy. Further the said clause is not mandatory but only
directory in nature.
12. In the above circumstances we are of the firm view that the complainant is entitled to get the insurance claim from the opposite parties together with interest @ 9% p.a.
13. Point No. ii. In due consideration of the proper claim of the complainant we are of the view that no compensation and costs of the proceedings are called for though the claim has to be paid fully.
14. In the result, we partly allow the complaint and direct that the 1st opposite party shall pay the insurance claim of the complainant together with interest @ 9% p.a. from the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of October 2012
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Case summary and
discharge record
A2 : Copy of letter
A3 : Copy of individual Medical policy
schedule
A4 : individual medical policy schedule
A5 : “ “
A6 : copies of bills
A7 : copy of pre repudiation statement.
Opposite party’s Exhibits : :
Ext. B1 : Mediclaim insurance policy
(Individuals)
B2 : Individual Medicalim
policy schedule
B3 : Individual medical policy
Schedule
B4 : copy of non cash less claim.
Depositions:
PW1 : Vargheses P.P.
