IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 18th day of October, 2012.
Present : Sri. Jacob Stephen (President)
Sri. N. Premkumar (Member)
Smt. K.P. Padmasree (Member)
C.C.No.221/2011 (Filed on 17.11.2011)
Between:
Shaji Varghese,
Zest House,
Keezhcherimel,
Chengannur.P.O.,
Alleppey, Rep. by Renjithu Varghese,
Sobhas Madolil House, Poovathoor.P.O.,
Koipuram Village, Thiruvalla taluk,
Pathanamthitta. …. Complainant
And:
The Oriental Insurance Co. Ltd.,
Divisional Office, Marthoma Buildings,
T.K. Road, Thiruvalla – 689 101,
Rep. by its Manager.
(By Adv. P.D. Varghese) …. Opposite party
O R D E R
Sri. N. Premkumar (Member):
The complainant has filed this complaint against the opposite party for getting a relief from the Forum.
2. Fact of the case in brief is as follows: Complainant took Happy Family Floater Policy for his family with opposite party. He paid ` 3,938 towards premium for said policy to cover whole hospitalization and domiciliary benefits from 28.12.2009 to 27.12.2010. On 09.02.2010 the complainant’s wife was admitted at Medical Mission Hospital, Thiruvalla for unrelenting pain in her body. On 12.02.2010 she was referred to Lakeshore Hospital, Kochi for diagnosis. On 27.02.2010 she was diagnosed to have metastatic breast cancer. She was discharged on 28.02.2010. She incurred an expense of ` 1,15,389.76. After that he has been treated in various hospital. She has undergone a surgery at Lourdes Hospital, Kochi. The total expenses incurred to her is ` 2,59,454.59.
3. Complainant submitted the reimbursement claim form along with details of discharge bills, of above hospitals twice before opposite party. They rejected the claim twice stating that ailment seems to be complication of pre-existing disease. Hence this complaint for getting the claim amount with interest, compensation and cost.
4. Opposite party entered appearance and filed version stating that complaint is not maintainable either in law or on facts. They admitted the issuance of Happy Family Floater Policy to the complainant and family members which was valid from 28.12.2009 to 27.12.2010. Complainant claimed the reimbursement of medical expenses incurred for the treatment of Prabha Shaji, the wife of the complainant. As per investigation the ailment of which Prabha Shaji undergone treatment was pre-existing. She consulted the doctor Umesh Kumar, at Thiruvalla Medical Mission on 08.02.2010 and the doctor issued the Medi claim Medical Report stating that Prabha Shaji was suffering from the said ailment for one month before approaching the doctor. Dr. P.S. Sreedharan, Lakeshore Hospital and Research Centre, Kochi has also issued certificate to the effect that she was suffering from the said ailment for one month. So it can be seen that the patient was suffering from the ailment from 10.01.2010 onwards. As per Clause 4.2 states that “Expenses incurred on any disease, except as specified under 4.3 contracted by the insured person during the first 30 days from the commencement date of the policy except treatment for accidental external injuries are excluded. As per the medical records, it can be concluded that the ailment for which Prabha Shaji undergone was a pre-existing disease and it existed at the date of commencement of the policy. Therefore, complainant is not entitled to claim the medical expenses reimbursement. Hence they canvassed for the dismissal of the complaint with their cost.
5. From the above pleadings, following points are raised for consideration:
(1) Whether the complaint is maintainable before the Forum?
(2) Whether the reliefs sought for in the complaint are allowable?
(3) Reliefs & Costs?
6. Evidence of the complaint consists of the oral deposition of PW1, DW1, DW2 and marked Exts.A1 to A13 and B1 to B3. After closure of evidence, both parties were heard.
7. Point Nos. 1 to 3:- In order to prove the complainant’s case, complainant’s authorized representative filed proof affidavit along with certain documents. He was examined as PW1 and the documents produced were marked as Exts.A1 to A13. Ext.A1 is the authorization letter issued by the complainant. Ext.A2 is the policy certificate issued by opposite party. Ext.A3 is the copy of discharge summary issued from Thiruvalla Medical Mission Hospital. Ext.A4 is the discharge bill for ` 1,15,389.76 issued by Lakeshore Hospital & Research Centre Ltd., Kochi. Ext.A5 is the discharge summary issued by Dept. of Medical Oncology, Lakeshore Hospital & Research Centre. Ext.A6 is the certificate issued by Lakeshore Hospital & Research Centre Ltd dated 19.04.2010 stating that the patient is not aware of her disease before 28.02.2010. Ext.A7 is the bills of ` 21,165 issued from Thiruvalla Medical Mission Hospital. Ext.A8 is bills of 4 in number issued from Thiruvalla Medical Mission Hospital. Ext.A9 is the bill of ` 82,848 issued from Lourdes Hospital, Ernakulam dated 19.04.2010. Ext.A10 is the pharmacy bill of ` 34051.83 issued from Lourdes Hospital. Ext.A11 is the discharge summary issued from Lourdes Heart Institute & Neuro Centre. Ext.A12 is the claim rejection statement issued by TPA dated 23.03.2010. Ext.A13 is the repudiation letter dated 20.09.2010 issued by the opposite party.
8. In order to prove the opposite parties contention, opposite party filed proof affidavit along with certain documents. He was examined as DW1 and the documents produced were marked as Ext.B1 to B3. Ext.B1 is the Mediclaim Medical Report (MMR) of Prabha Shaji. Ext.B2 is the claim form in which the certificate of Dr. P.S. Sreedharan is also included. Ext.B3 is the true copy of the “Happy Family Policy Schedule” with condition. Ext.B3(a) is Clause 4 and Ext.B3(b) is the Clause 4.2 of exclusion.
9. On the basis of the contention and argument of the parties, we have perused the entire material on record. Complainant’s case is that he had taken a Happy Family Floater Policy and during the tenure of the policy her wife Prabha Shaji was hospitalized. His reimbursement claim of treatment expenses was repudiated by the opposite party without valid reason. Hence this complaint.
10. Opposite party’s contention is that complainant’s wife undergone pre-existing disease during the commencement period of the policy. As per policy clause 4.2 and 4.3 complainant is not entitled to get the claim and therefore they repudiated it. It is seen that there is no dispute regarding the policy and treatment. The policy start date is 28.12.2009. As per Ext.A2, the policy coverage has given to complainant, his wife and two children. Ext.A3 shows that complainant’s wife had admitted on n09.02.2010 and referred to Lakeshore Hospital for further expert management. Ext.A6 reveals that after frequent tests and observation Lakeshore Hospital diagnosed the disease as metastasis breast cancer on 27.02.2010. Therefore, the detection of disease has done only after the expiration of more than two months from the policy start date i.e. 28.12.2009.
11. According to opposite party the insured Prabha Shaji undergone treatment was pre-existing. She consulted the Dr. Umeshkumar at Thiruvalla Medical Mission on 08.02.2010. The said doctor issued mediclaim Medical Report and in which it is recorded that Prabbha Shaji was suffering from ailment for one month before approaching the doctor. Therefore, she was suffering from the ailment from 10.01.2010 onwards. The policy start date is 28.12.2009. Prabha Shaji was admitted on 08.02.2010 and doctor find the ailment start prior to month i.e. within the lock period. As per policy condition disease incurred with 30 days from the policy start date is not payable.
12. It is pertinent to note that as per Ext.A3, Prabha Shaji was treated from 09.02.2010 to 12.02.2010 and referred to Lakeshore Hospital by Dr. Umeshkumar. Evidence on record shows that the said patient was treated and diagnosed the disease at Lakeshore Hospital and discharged on 28.02.2010. After that the patient was again treated at Thiruvalla Medical Mission on 30.03.2010, 09.04.2010 and 04.04.2010. It is revealed that Dr. Umesh kumar had been treated the patient again on that said period. In that circumstances, the said doctor has got the opportunity to go through the treatment details of Lakeshore Hospital and development and stages of the patient. This fact is admitted by DW2 in his deposition which is as follows:- “LakeshoreþÂ NnInÕ \S-¯n-bn-cp¶p F¶v Sn patient ]n¶oSv Fs¶ consult sN¿m³ h¶-t¸mÄ ]d-ªn-cp-¶p”.
13. As per Ext.A3, the final diagnosis as subsubclavian vein thrombosis and as per Ext.B1 the present disease suffered as chronic cough was due to Lymphoma. This is evident in DW2’s deposition, which is as follows:- “]cn-tim-[-\-bn Sn Npa-bpsS ImcWw Lymphoma Bbn-cp-¶p. Lymphoma F¶Xv Hcp Xcw Im³kÀ tcmK-amWv”.
14. On a perusal of Ext.B1, it is noted that the date of issuing is not recorded. Dr. Umeshkumar has treated the patient from 09.02.2010 to 12.02.2010 and issued Ext.A3. The patient was further treated on 30.03.2010, 09.04.2010 and 04.04.2010 after her treatment at Lakeshore Hospital. If he issued Ext.B1 on 12.02.2010 he cannot go further from Ext.A3. Therefore every chance of issuing the Ext.B1 after the date of 09.04.2010. This is evident in the nonmatching of Ext.A3 and Ext.B1. He has not done a single whisper with regard to the Lymphoma in Ext.A3. If he found Lymphoma during 09.02.2010 to 12.02.2012 and its ailment prior to one month what prevented him to record in Ext.A3. Moreover, his further deviation is that he diagnosed the disease based on the narration of the patient. This is evident in DW2’s deposition, which is as follows: “Hcp amk-ambn Npa-bp-s¶v patient ]-d-ª-Xnsâ ASn-Øm-\-¯n-emWv SnbmÄ¡v Hcp amk-ambn Lymphoma Ds¶v Rm³ ]d-ªXnsâ ASn-Øm\w”.
15. All the said irregularities in Ext.B1, incompatibility between Ext.A3 and Ext.B1 and contradiction with regard to the diagnosis shows that Dr. Umeshkumar’s opinion of ailment start one month before his treatment is not supported by medical test and clinical observation. Therefore it is not believable.
16. As per Ext.B2 Mediclaim Medical Report, the details of previous history of disease is recorded as Nil. In Ext.B1 and B2 MMR “She may be suffering from present disease before approaching the doctor is one month. It is only a presumption not based on any clinical test. As far as medical science is concerned, the mere opinion or presumption has no value. It has to be confirmed with help of medical science and investigation. Therefore claim cannot be denied by mere assertion or forecast.
17. Moreover in Ext.B2 Mediclaim Medical Report Column No.15 the period of illness and date when the illness is recorded as 27.02.2010. Ext.A6 also reveals that Lakeshore Hospital diagnosed the disease as metastasis breast cancer on 27.02.2010. Therefore it is proved that detection of disease only after the expiration of more than two months from the policy start date i.e. 28.12.2009. Hence as per policy condition, the patient Prabha Shaji is entitled to get the policy benefit.
18. From the overall facts and circumstances based on the observation and finding and the available evidence on record, we are of the view that denying complainant’s claim is unjust, unfair, malafide, illegal and against all cannons of consumer justice. It is a clear deficiency of service and therefore complaint is allowable and maintainable before the Forum.
19. Though the claim amount as per medical bill amount is `2,59,459.59, as per policy conditions he is entitled to get only ` 1,50,000. The said amount is allowable with interest from the date of filing of this complaint onwards. Since interest is allowed, no separate compensation or cost is allowable.
20. In the result, complaint is allowed, thereby the opposite party is directed to pay ` 1,50,000 (Rupees One lakh fifty thousand only) with 8% interest per annum from the date of filing of this complaint, till this date within 20 days from the date of receipt of this order, failing which the whole amount will follow 10% interest from this date till the realization of the whole amount.
Declared in the Open Forum on this the 18th day of October, 2012.
(Sd/-)
N. Premkumar,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Renjith Varghese.
Exhibits marked on the side of the complainant:
A1 : Authorization letter dated 16.08.2011 executed by the
complainant in favour of Renjith Varghese.
A2 : Policy certificate issued by opposite party.
A3 : Discharge summary issued by Thiruvalla Medical
Mission Hospital.
A4 : Discharge bill for ` 1,15,389-76 issued by Lakeshore
Hospital & Research Centre Ltd., Kochi.
A5 : Discharge summary dated 28.02.2010 issued by Dept.
of Medical Oncology, Lakeshore Hospital & Research
Centre.
A6 : Certificate issued by Lakeshore Hospital & Research
Centre Ltd dated 19.04.2010.
A7 : Inpatient bills of ` 21,165 issued from Thiruvalla
Medical Mission Hospital.
A8 : I.P.bill receipts issued from Thiruvalla Medical Mission
Hospital.
A9 : Discharge bill for ` 82,848 issued from Lourdes
Hospital, Ernakulam dated 19.04.2010.
A10 : Pharmacy bill for ` 34,051.83 issued from Lourdes
Hospital, Ernakulam.
A11 : Discharge summary issued from Lourdes Heart
Institute & Neuro Centre.
A12 : Claim rejection statement issued by TPA dated
23.03.2010.
A13 : Clam repudiation letter dated 20.09.2010 issued by the
opposite party.
Witness examined on the side of the opposite party:
DW1 : S. Krishnamoorthy.
DW2 : Dr. Umesh.
Exhibits marked on the side of the opposite party:
B1 : Mediclaim Medical Report (MMR) of Prabha Shaji.
B2 : Claim form.
B3 : Copy of the “Happy Family Floater Policy Schedule”
with condition.
B3(a): Clause 4 of Ext.B3.
B3(b): Clause 4.2 of Ext. B3.
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) Renjithu Varghese, Sobhas Madolil House,
Poovathoor.P.O., Koipuram Village,
Thiruvalla taluk, Pathanamthitta. (2) The Manager, Oriental Insurance Co. Ltd.,
Divisional Office, Marthoma Buildings,
T.K. Road, Thiruvalla – 689 101,
(3) The Stock File.
