Date of Filing:15.05.2009<br /> Date of Order:10.11.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 10TH DAY OF NOVEMBER 2009<br /> <br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> COMPLAINT NO: 1122 OF 2009<br /> <br /> Vasant Prabhu,<br /> Flat No.3A, Rustumbagh View Apartments,<br /> 29-30, Rustumbagh Layout, <br /> Behind Manipal Hospital,<br /> Old HAL Airport Road, <br /> Bangalore-17. Complainant<br /> <br /> V/S<br /> <br /> Mr. Krishan,<br /> Operations Incharge, <br /> Royal Sundaram Alliance Co Ltd.,<br /> Corporate Claims department,<br /> Sundaram 45 & 46 whites road,<br /> Chennai-600014. Opposite Party<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed by the complainant under Section 12 of the Consumer Protection Act, 1986.<br /> The facts of the case as stated by the complainant are as under:-<br /> “The complainant has a family health insurance cover with Royal Sundaram Alliance Co Ltd., that he had availed through my Citibank Credit Card facility. The insurance covers undersigned (sum insured 2-lacks), wife (sum insured 2-lacks) and son (sum insured 1-lack) and was iss0ued to them effective 16/12/2008 as per their records. His son suffered difficulty in breathing and was taken to the emergency ward of Manipal Hospital on 18/01/2009. He was administered emergency pediatric treatment and was discharged the same day. However since the problem persisted the next day (19/01/2009) he was admitted to the hospital where he was kept under observation and suitable medical treatment. Their claim pertaining to this treatment was submitted to the Royal Sundaram office on 28/01/2009 with necessary supporting and the Hospital discharge summary report. In their response dated 24/02/2009 the Insurance company rejected his claim stating that the patient started suffering from symptoms since last week which falls within 30 days of policy inception. Treatment for diseases contracted during the first 30 days from commencement of policy is outside the scope of policy.”<br /> “He applied for reconsideration on 06/03/2009 with a clarification letter from the Hospital which repudiated the insurance claim that the disease was contracted within the 30 day policy period. The letter from the Hospital doctor, Dr. Arvind Shenoi, who is Bangalore’s leading pediatrician restated the Hospital diagnosis that the symptoms was a recent diagnosis of 1 day duration and that the child has no previous history of wheeze. In his letter to the insurance company he appealed to look at the facts of the case and reiterated that the child developed the symptoms of exacerbation of wheeze only on 181/01/2009 when he underwent emergency treatment and not one week earlier as per the insurance company assessment. He also stated that the child has been registered in Manipal Hospital since 2.5 years and there has been no prior history of related kind in his records.”<br /> “The Insurance Company in its letter dated 04/04/2009 once again rejected his reconsideration claim restating that the patient started suffering from symptoms from 12/01/2009 which falls within 30 day period.”<br /> “His grievance is that the insurance company has made false medical assumptions to conveniently suit its rules and regulations in denying his consumer rights. The insurance company contrary to medical reports from the hospital that the symptoms were of 1 day duration only has made false assumptions that the symptoms to the disease were contracted 1 week prior to the actual symptom date of 18/01/2009. By doing this the insurance company places the contracting of the symptoms to the disease on 12/01/2009 which just short of the 30 day notice period of the company. In the process the insurance company has ignored the Hospital record for the past 2.5 years that there has been no prior history of such symptoms to the patient given by a leading pediatrician of Bangalore from a repudiated private hospital. Therefore such an assumption by the insurance company has been done with malaises intentions to deny his consumer rights to avail the insurance claim which is just and honourable.” <br /> “The insurance company has caused mental agony and stress by rejecting his claims on flimsy technical grounds. They have been made to do undergo a lot of physical hardships in repeatedly going to their office and the hospital for submitting clarifications and follow-ups. Despite the clarifications and submission by a reputed hospital, they have rejected his claim on false presumptions which does not hold true as per facts and medical records. Therefore, seek settlement of his insurance amount in addition to a compensation of Rs. 50,000/- for the mental agony and the physical hardships faced by him.” <br /> <br /> 2. After admitting the complaint, notice was issued to the opposite party. Opposite party appeared through Advocate and filed defence version stating that, the complainant had availed health shield insurance policy from the opposite party for the period from 16/12/2008 to 15/12/2009. The complainant had made claim under the above policy in respect of Nikhil Prabhu for ailment cough and cold in Manipal Hospital. It is submitted that the insured was suffering from the said ailment from past one week prior to date of admission on 19/01/2006 i.e., within 30 days from the inception of the policy as the policy was issued to the complainant on 16/12/2008. Therefore, opposite party is not liable to pay claim amount. Same attracts the 30 day’s exclusion clause. On this ground the opposite party has repudiated the claim of the complainant. <br /> 3. Both the parties have filed affidavit evidence and documents. Arguments are heard. <br /> <br /> REASONS<br /> 4. It is an admitted case of the parties that the complainant had taken family health insurance policy with the opposite party. The policy covers complainant, his wife and son Nikhil Prabhu. The sum insured for the Nikhil Prabhu is Rs.1,00,000/-. Period of insurance was from 16/12/2008 to 15/12/2009. The son of complainant Nikhil Prabhu suffered some ailment and breathing problem and he was taken to Manipal Hospital on 18/01/2009. He was administered some emergency pediatric treatment and was discharged on the same day. Since the problems persisted on next day on 19/01/2009 he was again taken to Hospital and admitted where he was kept under observation and suitable medical treatment. The complainant submitted the claim with the opposite party for a total amount of Rs.13,380/-. The complainant has produced health shield claim form and also bill cum receipt of Manipal Hospital, Bangalore for the amount of Rs.12,762/-. The complainant has produced discharge summary. The complainant has produced medical certificate of Dr. Aravind Shenoi, the consulting pediatrician of Manipal Hospital dated 03/03/2009. In this certificate Doctor has opined Master Nikhil aged 4 years, presented to the pediatric ER with history of difficulty in breathing and noisy breathing of 1 day duration. Even though the child had minimal cold and cough past 1 week only on admission on 19th Jan-2009 after relevant investigation it was found that he had acute exacerbation of wheeze. It was a resent diagnosis only on admission and the child has no previous history of wheeze. When this is a clear certificate of Doctor where as the exclusion clause applicable to the present case. Admittedly, the policy commenced from 16/12/2008 and the child was admitted to Hospital on 19/01/2009 after 30 days from the date of taking policy. The exclusion clause relied on by the opposite party is not at all applicable. For the first time, the child was taken to hospital on 18/01/2009 and after some treatment he was taken to home. Again on 19/01/2009 he was admitted to hospital and he was treated under medication. There is absolutely no evidence or proof to show that the child was taken to Hospital and under medication within 30 days from the date of taking policy. Admittedly for the first time, the child was admitted to Hospital on 19/01/2009 after expiry of 30 days from the date of commencement of policy. Therefore, the repudiation of the claim put up by the complainant by the opposite party is wholly unjustified. It is very unfortunate that the opposite party repudiated the claim of the complainant which is for a small amount. This type of attitude on the part of the opposite party company is not proper, it will not in any way enhance the reputation of the company. The complainant was made to file complaint and approach this Forum for getting justice and for getting the amount spent for the hospitalisation of his son. The opposite party could have fairly and rightly accepted the claim and paid the amount soon after receipt of the claim from the complainant. A very legal and genuine claim of the complainant has been unnecessarily repudiated by the opposite party. The opposite party company should change its attitude towards the customers. Consumer Protection Act is a social and benevolent legislation intended to protect better interest of consumers. The complainant has not claimed any amount spent towards treatment of the child within 30 days of the policy. Admittedly, the child was admitted to hospital on 19/01/2009 after expiry of the 30 days of taking policy and the amount spent towards treatment in the Manipal Hospital has been claimed. This is very legal claim. This valid and legal claim has been unnecessarily repudiated by the opposite party. Therefore, the opposite party should be asked to pay compensation of Rs.5,000/- to the complainant for mental agony, harassment and inconvenience caused to him. In the result, I proceed to pass the following:- <br /> ORDER<br /> 5. The complaint is allowed. The opposite party is directed to pay claim amount as per the Manipal Hospital bill of Rs.12,761/- to the complainant. The opposite party is further directed to pay Rs.5,000/- as compensation to the complainant for mental agony, inconvenience and harassment caused to him.<br /> <br /> 6. The opposite party is directed to comply the order within four weeks from the date of this order. <br /> <br /> 7. The opposite party company is directed to pay the amount directly to the complainant by way of cheque or D.D with intimation to this Forum.<br /> <br /> 8. In the event of non compliance of the order within four weeks, the above amount carries interest at 9% p.a from the date of this order till payment/realisation.<br /> <br /> 9. Send the copy of this Order to both the parties free of costs immediately as a statutory requirement. <br /> <br /> 10. Pronounced in the Open Forum on this 10TH DAY OF NOVEMBER 2009. <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> MEMBER MEMBER<br /> <br />