SRI.K. VIJAYAKUMARAN, PRESIDENT.

            This is a complaint seeking realization of Insurance amount, compensation and costs.

The averments in the complaint can be briefly summarized as follows:

The complainant and her minor daughter aged 17 years had joined the Family Health Plan of United India Insurance Company.  The period of policy was from 31.1.2007 to 30.1.2008 and the policy  coverage was Rs.50,000/-  as per the terms of the policy for inpatient treatment in hospitals which are  in the network of the  Insurance Company, the payment will be made directly by the company and in respect of the  other hospital, the claim is to be submitted separately.  The policy was  taken through one Ravi Pillai who was the Insurance agent.  On 24.9.07 during the subsistence of the policy   the complainant’s daughter was laid up with Pilonidal and  was admitted  by the AM hospital, Karunagally which is a hospital coming under the net work of the Insurance  company.  On the date of admission itself the necessary documents such as policy card etc. were entrusted to the hospital. On the previous day of discharge the  Manager of the hospital informed that for the disease of her daughter  insurance claim is not admissible..  When contacted it was informed that it was not the illness but the fact that the treatment was undergone during the first year of the policy that is material  and therefore the insured is not entitled to the  benefits.   Therefore,  the complainant had to remit Rs.6,673/- which,  the complaint is entitled  to get as per the terms of the insurance policy..  Since the opp.party has not paid  above sum to the hospital  in accordance with the terms of policy it amounts to deficiency in service and unfair trade practice.  Hence the complaint.

          The opp.parties filed a joint  version contending, interalia,  that the complaint is not maintainable either in law or on facts.  The complaint is bad for the  non-joinder of necessary parties as the daughter of the complainant and the Family Health Plan Limited were not impleaded in the party array.  At the time of joining the policy conditions were narrated to the complainant.  The disease alleged will not come within the ambit of this Health Insurance policy.  No surgery for the alleged disease in question will become necessary unless the said disease was a pre-existing one for  a very long period.   The complainant has suppressed  this material fact which amounts to violation of policy conditions and therefore the policy will become automatically void.   The insured was admitted in the AM Hospital for the period from 24.9.07 to 29.9.07  with complaint of  pain and bleeding from perianal region .   The hospital authorities requested for cashless treatment and  the said Family Health Insurance plan  Ltd. denied cashless facility  since the 1^st year exclusion is not ruled out.  So far the complainant has not submitted the claim paper as per the condition of the scheme.  The opp.parties have no intention to make any deficiency in service or unfair trade practice.  There is no deficiency in service on the part of the opp.parties.  Hence the opp.parties prays to dismiss the complaint.

Points that would arise for consideration are:

1.     Whether the complainant is entitled to get the insurance amount?

2.     Whether there is deficiency in service on the part of the opp.parties?

3.     Reliefs and costs.

For the complainant PW.1 and 2 are examined.  Ext.P1 to P9 are marked

For the opp.parties DW.1 is examined.  Ext D1 to D3 are marked.

POINTS;

Policy is admitted.  Hospitalization and surgery of complaint’s daughter is also not disputed.   The grievances of the complainant is that despite the fact that there was a valid insurance policy  the claim was repudiated by the opp.party which is deficiency in service.

          A perusal of the evidence and records in this case would show that the claim was objected mainly on two grounds .   The 1^st ground is that the illness was pre-existing  one which was not disclosed and so  there is material suppression and the 2^nd ground is that the illness comes within the exclusion clause 4[3] of the policy.

          Though the contention that the illness of the insured is a pre-existing one is raised no attempt is made by opp.parties 1 to establish that contention.  No medical evidence was adduced to establish that the illness was a pre-existing one.   Regarding material suppression also there is no material worth believable.   The proposal form furnished by the insured is not produced for reasons best known to the opp.parties.   So the 1^st contention that the illness of the insured is a pre-existing one and that there is material suppression are unfounded.

          The opp.parties failed to substantiate the 2^nd contention also.  According to the opp.parties the illness of the insured comes  under exclusion clause 4[3] and in respect of such diseases no coverage under Ext.P1 is available for the 1^st 2^nd  years.   According to the opp.parties the illness of the insured comes under sinusitis and allied diseases which comes under exclusion clause 4[3] .  The contention of the complainant is that the illness for which the insured had undergone surgery is pilonidial sinus which has no connection with sinusitis and allied diseases.   Ext.P5 discharge summary also shows  that the illness  diagnosed was pilomidial sinus and the surgery undergone was excision abices.  Even DW.1  in cross examination admitted that this  disease is not  mentioned in exclusion clause 4 [3].  The burden to establish  by adducing cogent medical evidence that the above disease would come under exclusion clause 4[3] is on the opp.parties  which they failed to discharge.

          Another contention is that the insured has not submitted claim form.  It is argued by the complainant that they have joined the cashless settlement scheme in which the network hospital bills are settled by the Insurance company directly Ext. D3 shows that  the hospital wherein the treatment was under gone is a net work hospital and that the cashless settlement was denied.   So as argued by the complainant no separate claim need be forwarded to opp.party 1.

          Another contention is that the complainant failed to implead the Family Health Plan Limited who is the claim settling agent  and so the complaint is bad for non joinder or necessary parties.   Even though they are the claim settling agents and a formal party non impleadment of them  in our view is not fatal to the complainant.  On a careful consideration  of the entire evidence is this case  we are of the view that the insured is entitled to get the expenses incurred by her for hospitalization and surgery.  Points found accordingly.

          In the result the complaint is allowed, directing the opp.parties to pay the complainant Rs.6673/- being the expenses incurred by her for the treatment of her minor daughter with interest @ 12% per annum from 29.9.2007 till payment.  The opp.parties are also directed to pay Rs.2500/- towards compensation and costs.   The order is to be complied with within one month from the date of receipt of this order.

          Dated this the 10^th day of December, 2009.

I N D E X

List of witnesses for the complainant

PW.1. – Jayasree

PW.2. – Jayraj

List of documents for the complainant

P1. – Insurance policy

P2. – Receipt

P3. – Insurance Schedule

P4. –Lab result

P5. – Discharge summary

P6. – Bills

P7. - Fax

P8. – True copy of CBSE Certificate

P9. – Age certificate

List of witnesses for the opp.parties

DW.1. - . – C. Leela

List of documents for the opp.parties

D1. – Certificate

D2. –Conditions of policy

D3. – Repudiation letter