DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE

PRESENT : Sri. P.C. PAULACHEN, M.Com, LLB    : PRESIDENT

                Smt. PRIYA.S, BAL, LLB, MBA (HRM) :  MEMBER

Sri. V. BALAKRISHNAN,  M Tech,  MBA,  LL.B,FIE:  MEMBER

Friday  the 17th  day of December  2021

C.C.313 /2016

Complainant

1.  Praksh K M  61 Years

        S/o Sankaran Gurukkal

       Sreyas, Kuruvattoor P O

        Kakkodi,Kozhikode  - 673 611

2.     Smt.Sreelatha  N 

         W/o Prakash K M

       Sreyas, Kuruvattoor P O

      Kakkodi,Kozhikode  - 673 611

(By Adv.Sri. K. Pavithran  )

Opposite Parties

1.     The Oriental Insurance Company Ltd.

        Regd Office:  Oriental House,  P B No.  7037, A-25/27

       Asaf Ali Road, New Delhi – 110 002

2   .The Oriental Insurance Company Ltd.

      Branch Office : Kings Way Buildings

     1st Floor, Mavoor Road Junction,

      Kozhikode – 673 001

(By Adv.Sri. K. Abdurahiman)

3.     Medi Assist India TPA Pvt Ltd

         Chicago Plaza, 4th Floor, Rajaji Road

        Ernakulam – 682 035

       (Ex-parte)

 ORDER

By Sri. P.C. PAULACHEN  – PRESIDENT.

        This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.

        2. The case of the complainants, in brief, is as follows:

            The  second complainant is the wife of the  first complainant. The first complainant had taken a family mediclaim policy  from the opposite parties  and timely renewed  the same. During the policy period, the second complainant  was hospitalised due to  heavy back pain due to falling down with a bucket of water on 10/02/2016. She was admitted  in the MIMS hospital, Kozhikode. She underwent a surgery for spinal canal stenosis  with impending cauda syndrome and L5, S1 roots  compression on  13/02/2016. She was an inpatient for 9 days  and the first complainant  paid hospital bill for Rs.1,50,372/-. Later he submitted the bill with relevant records for reimbursement before the 3^rd opposite party on 07/03/2016. But the claim was rejected on 26/03/2016 without any valid or sufficient reason. The complainants are legally entitled for the mediclaim . The claim was rejected stating the reason that this had not happened due to accident. On 27.04.2016 the complainants issued a lawyer notice to the opposite parties, for which, no reply was sent. Because of the non payment of the claim, they had suffered  loss and had to raise funds from financiers  for settling the bill amount in the hospital, for which, they had to pay Rs.16,000/- towards interest. They are entitled to get compensation of Rs.25,000/- for  pain and suffering. They are also entitled to claim Rs.2,500/- being the notice charges and Rs.7,500/- as expenses for  filing the complaint.  However, the claim is limited to Rs.2,00,000/-.  

3. The first and second opposite parties jointly  filed version. The third opposite party was set ex-parte.

4. In the version, the first and  second opposite parties  have admitted the policy. The lodging of claim for Rs.1,50,372/- towards the treatment of the second opposite party for back ache and other ailments from MIMS hospital, Kozhikode is admitted. On a perusal of the documents relating to the treatment, it was found that the ailment for which she was treated was for age related osteoarthritis and osteoporosis and as per the exclusion clause 4.2 of the policy, the insured is not entitled to get compensation for 3 years from the date of  inception of the policy. Since the complainant submitted the claim during the 2^nd year of the policy, the insured is not entitled to get the claim towards the treatment for the above ailment. Hence the claim was repudiated and intimated to the party.  There is no deficiency of service, unfair trade practice or any imperfection on the part of the opposite parties. Without prejudice to the complainant the contention that the opposite parties are not liable to pay compensation, it is submitted that  the amount of treatment claimed by the complainant is excessive and without any basis.  According to the first and second opposite parties, the complaint is devoid of merits and liable to be dismissed. 

                5.  The points that arise for determination  in this case are:

                (1)  Whether there was any deficiency of service on the

                      part of the opposite parties, as alleged ?

(2)  Reliefs and costs.

6.  PW1 was examined and Exts. A1 to A7 were marked on the side of the complainant. PW1 is none other than the first complainant who  filed proof affidavit and deposed in terms of the averments in the complaint. The Assistant Manager of the Oriental Insurance Company filed proof affidavit on behalf of the company. But he was not cross examined.  Ext. B1 was marked.

        7. Heard both sides.  Brief argument note was filed by the complainants.  

        8. Point No.1 :  The policy is admitted. The policy was originally taken for the period from  25/03/2014 to 24/03/2015  (Ext.A1) . The policy was renewed from 25/03/2015 to 24/03/2016 and again renewed from 29/03/2016 to 28/03/2017 (Ext.A5 series).   So there was valid policy at the relevant time. As per the policy, the second complainant, being the spouse of the first complainant, is also covered. The total sum insured is Rs.2,00,000/-. The treatment of the second complainant in the MIMS hospital, Kozhikode was from 10/02/2016 to 18/02/2016 as can be seen from Ext.A4 discharge summary. She had undergone surgery on 13/02/2016. The total expenses for treatment was Rs.1,50,372/-. The claim preferred by the complainant was repudiated by the opposite parties. There is no serious dispute on the above aspects.

        9. None of the parties has produced the repudiation letter before this Commission. However, it is not disputed that the claim was rejected by the Insurance company in view of the exclusion clause 4.2 of the policy. Ext B1 is the copy of the policy produced by the opposite parties. The treatment undergone by the second complainant was for prolapsed inter vertebral disc. Ext. B1 shows that the treatment undergone is not covered under the exclusion clause 4.2 (XX), unless it has arisen from an accident within 2 years of the commencement of the policy. The policy was commenced  on 25/03/2014. The claim was lodged on 07/03/2016 and it is within two years. There is absolutely nothing in evidence to show that  it has arisen from an accident. The contention of the complainants is that  due to lifting of  heavy bucket of water she fell down and her disc got dislocated. In this context, it is worthwhile to have a glance at Ext A4 discharge summary issued from the MIMS hospital, Kozhikode. In Ext.A4, it is specifically stated that  the patient gave a history of lifting heavy bucket of water. The patient did not give a history of falling. Further she had history of back pain one and half years duration. The impression given in Ext.A4 is “Degenerative disc disease with spinal canal stenosis and crowding of nerve roots at L4 – L5 level – vertebral hemangiomas in bodies of L4 and S1 vertabrae”. The final diagnosis was spinal canal stenosis with impending cauda aquina syndrome and L5, S1 roots compression. The procedure/surgery done was spine decompression, stabilisation and fusion from L4 to S1. Thus from medical records, it is very clear that it was a degenerative disc disease and not an accident as claimed by the complainants. The  degenerative disc disease will not happen all of a sudden in an accident. Moreover, in Ext.A6 lawyer notice issued by the complainants to the opposite parties, there is no case of any such accident. Since the ailment was not because of any accident, the complainants are not entitled to get the claim amount in view of the  exclusion clause 4.2 (XX) of the policy.  So the claim was rightly repudiated by the opposite parties. That being so, no deficiency of service can be attributed against the opposite parties and the relief sought for is not allowable.  

 10. Point No. 2  :

     In view of the finding on the above point, the complaint is only to be dismissed.

In the result, the complaint is dismissed. However, no order as to costs.

Dictated to the Confidential Assistant, transcribed by her and corrected by me and pronounced in the open commission  on this the  17^th  day December   2021.

Date of Filing: 18/07/2016.                         Sd/-

                                                        PRESIDENT

                                                         Sd/-

                                                        MEMBER

                                                           Sd/-

                                                        MEMBER

APPENDIX

Exhibits for the Complainant :

Ext. A1 – Copy of policy policy  taken for the period from 

             25/03/2014 to 24/03/2015 

Ext. A2 – Copy of  certificate issued from MIMS Hospital

Ext. A3 – Copy of  claim details

Ext. A4 – Copy of discharge summary issued from the MIMS hospital.

Ext.A5  series – Copy of policy renewed from 29/03/2016

                        to 28/03/2017

Ext.A6 – Copy of lawyer notice issued by the complainants

             to the opposite parties

Ext –A7 – Copy of Bank Statement

Exhibits for the Opposite Parties

Ext.B1 – Copy of the Medi claim policy schedule produced by the

                opposite parties.

Commission Exhibits

Nil

Witnesses for the Complainant

PW1 –  Prakash.K.M  - Complainant

Witnesses for the opposite parties

 Nil                                                                   Sd/-                                                                                  PRESIDENT

                                                                   Sd/-

                                                                   MEMBER

                                                                     Sd/-

                  MEMBER

                        Forwarded / By Order

                          Senior Superintendent