DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD

Dated this the 20^th day of June 2019 

Present  : Smt.Shiny.P.R,  President

                 : Sri. V.P.Anantha Narayanan, Member                                                Date of Filing : 27/02/2018

      CC/31/2018

Madhu V.K

SREYAS,100 Ft Malapuzha Road,                                                                             -  Complainant

Puthur, Palakkad - 678 001

(By party in person)

                                                                                                 Vs

1. Sreeraj.  K

Relationship Manager,

M/s. Universal Sompo General Insurance

Co. Ltd., II^nd Floor, Grace Corner,

CR, 54/3106, K.K. Road,

Subhash Chandra Bose Road,

Kadavanthara, Cochin - 682 020

2. The Branch Manager                                                                                                     -  Opposite parties

M/s. Allahadabad Bank, II/724,

KAV Central Chandra Nagar,

Palakkad - 678 007

(By Adv.G.Anantha Krishnan & K.B.Priya)

3. M/s. Universal Sompo General Insurance Co. Ltd.,

Assotech 1, 5^th Floor,

C-20, Noida - 201 309   

(1^st and 3^rd opposite parties by Adv.Saji Isaac K J)

                                                                  O R D E R

By Sri. V.P.Anantha Narayanan, Member  

Brief facts of the case are narrated below.

The complainant has taken a health insurance policy for his family from Universal Sompo General Insurance Company Limited (Alahabad Bank Health Care Plus).  At the time of joining, the insurance company, representative Mr.Sreeraj.K, its Relationship Manager informed the complainant for the 1^st year contract senusitis and existing cancer disease will not be covered for the first year, apart from that the complainant is under the coverage.  In November complainant’s wife had a sudden stomach pain for which they depended on nearest Ayurveda Hospital and medicines were given by the doctor, but even after that the pain prolonged.  Hence, they depended on nearest hospital, who gave a pain killer injection and recommended for scanning and other examinations.  Then, they decided to go to Gem Hospital and Research Centre, Pvt, Ltd, Coimbatore for better consultation, from which they came to know that there is a tumour in the stomach and the same has to be removed at the earliest and as per their direction they went for surgery.  When the doctors recommended for surgery, they thought of using the insurance card and contacted hospital insurance department who informed them that they are not accepting the universal sompo health card due to their poor payment.  The complainant contacted universal sompo office who asked the complainant to collect all the documents related to the hospitalization and surgery for which they have registered their claims and claim numbers were 126562 and 127957.  As per their instructions, complainant has collected all the documents and handed over them to their representative Mr.Rohit at Alahabad Bank, Palakkad Branch (all original documents).  After some days they asked the complainant for some more documents (as per their letter dated.23/12/2017) which have been collected from the hospital and sent directly to their Noida office.  After collecting all the documents, they informed the complainant that his claim was rejected vide their letter dated.04/01/2018, explaining that this is not covered in the one year period.  According to the complainant, if it is not covered in the first year period, then why they collected their hospital documents and for that purpose why they gave the complainant the claim numbers.  Complainant pleads that they have given the complainant expectations, when they take a policy they believe that they are safe, but when they are going for claims, companies are raising a lot of terms and conditions (which are not at all explained during the time of taking the policy) and rejecting their claim which results in a very huge financial problem.  Complainant also pleads that he is a common middle class person who is cheated by these companies by offering them security for their life and family; believing that they are spending their hard earned money for the sake of their family and life, but when they depend on them for their needs, they have been thrown out by putting lots of company terms and conditions and as a common man the complainant believes that when he takes a health care policy they are under safe zone.  After surgery, doctor has advised for further three months treatment, every month there is an expense of Rs.8,000/- for injections and medicines and for the 3^rd month they prescribed for scanning and lab test.  For this surgery and hospital expenses the complainant has taken loans from his friends and relatives.  He pleads that only if he gets his claim amount he is able to repay his debts.  As on date complainant states that he has to spend Rs.1,14,651/-.

The complaint was admitted and notices were issued to the opposite parties to enter their appearance and file their versions. 

In the version jointly filed by the 1^st and the 3^rd opposite parties, they deny all the allegations in the complaint except those expressly admitted; according to them this complaint is an abuse of the process of law and not maintainable.  The allegations in various paras of the complaint are denied by these opposite parties, being false.  According to these opposite parties, they had sought for medical documents to identify the mode of treatment and diagnosis.  Actually the complainant availed the universal Sompo General Insurance Alahabad Bank Health Care Plus Policy from these opposite parties and this had coverage from 24/07/2017 to 23/07/2018 and had been issued to the complainant at his request after submitting the proposal form.  These opposite parties further contend that complainants wife had sought treatment for adnexal, endometriotic, cyst and umbilical hernia from 22/11/2017 to 25/11/2017 and according to the terms and conditions of the policy issued to the complainant hospitalization expenses incurred in the 1^st year of operation of the insurance policy cover treatment of skin and all internal tumours/Cysts/nodules/nasalpolyps/calculi/sinusitis and related disorder of any kind, hernia and hydrocele are specifically excluded.  These opposite parties also contend that the present ailments for which the insured had undergone treatment fall under the specific 1^st year exclusions and beyond the scope of policy coverage.  In the present case complainant’s wife had undergone treatment within the 1^st year of the insurance policy for diseases which had a specific waiting period of one year from the date of inception of the policy.  Hence these opposite parties are not liable to make payment to the complainant.  According to these opposite parties complainant is not entitled for Rs.1,14,651/- with or without interest; there has been no deficiency in service on the part of these opposite parties.  They have not evaded from payment and have not caused any mental agony to the complainant, he is also not entitled to any amount towards cost.  These opposite parties further contend that they are, under the conditions of the policy, entitled to repudiate the claim of the complainant because the policy holder complainant availed treatment during the 1^st year insurance coverage for diseases that were specifically not covered during the 1^st year of insurance policy coverage.  Insurance contract is a contract based on the terms and conditions of the policy and these opposite parties are liable only as per the conditions, terms, limitations and exclusions of the policy.  Hence these opposite parties pray to this Hon’ble Forum to dismiss the complaint with cost. 

The 2^nd opposite party also denies all the averments mentioned in the complaint by the complainant.  As per their version it is contended that save those expressly admitted all the averments are denied by them.  This opposite party further contends that the complainant had joined this scheme after understanding all the terms and conditions of this insurance policy taken from the 3^rd opposite party; the complainant himself had spoken to the representative of the 3^rd opposite party and was convinced about the policy terms and conditions.  The complainant had only paid the premium amount of the policy through this opposite party bank and this opposite party is not liable for any claims and the liability on the policy falls only on the 3^rd opposite party.  This opposite party also contends that it does not know of the averments about the policy incidents happened to the complainant’s wife and therefore they are denied.  The averment of the complainant that he has handed over all the documents to the representative Rohit at Alahabad Bank, Palakkad branch is also not correct and hence denied.  According to this opposite party, Rohit is the representative of the 3^rd opposite party and all the incidents mentioned in the complaint happened between the complainant and the 3^rd opposite party and this opposite party (2^nd opposite party bank) has no connection in these incidents.  Hence this opposite party contends that this opposite party is an unnecessary party in this complaint and the claim alleged is against the 3^rd opposite party only and the complainant is entitled to reliefs only from the 3^rd opposite party.  Therefore this opposite party prays to the Hon’ble Forum to accept their contentions and dismiss the complaint with cost. 

Complainant filed chief affidavit and the opposite parties also filed their affidavits.  From the side of the complainant Exts.A1 to A4 and from the part of the opposite parties Exts.B1 to B3, including Ext.B2 series were marked.  Documents produced from Gem Hospital, Coimbatore were marked as Ext.X1.  Complainant and opposite parties filed their notes.

The following issues arise in this case for consideration by this Forum.  

1. Whether there is any deficiency in service and unfair trade practice from the part of opposite parties 1, 2 & 3?
2. If so, the relief and cost available to the complainant?

Issues 1 & 2

            The complainant has produced Exts.A1 to A4 before this Forum to support his arguments.  Ext.A1 is Allahabad Bank Health Care Plus Policy Schedule issued by the 3^rd opposite party which discloses name of the intermediary, policy number, period of insurance, premium amount, details of insured etc.  Ext.A2 which is in series show discharge summary, biochemistry, MDCT Abdomen, Cytology report, Histopathology report, Gynaec, IP case sheet, OT-Check list for surgical patient safety, ward surgery check list, operation notes, doctors medication chart, inpatient case chart, outpatient bill, cash bill, advance receipt, inpatient prescription chart.  Ext.A3 is a without prejudice deficiency letter issued by the 3^rd opposite party to the complainant acknowledging the receipt of claim documents and seeking clarification sent by the complainant and asking for some more documents namely original discharge summary, investigation reports, complete set of attested indoor case papers.  Ext.A4 is a claim repudiation letter dated.04/01/2018 sent by the 3^rd opposite party to the complainant which states that complainants wife was diagnosed as a case of adnexal, endometriotic, cyst and umbilical hernia and as per standard policy terms and conditions the ailments fall under 1^st year exclusion, hence it is out of policy scope and claim stands repudiated.  The opposite parties filed Exts.B1, B2 series and B3 to defend their contentions.  Ext.B1 is Allahabad Bank Health Care Plus Insurance Policy schedule cum tax invoice issued by the 3^rd opposite party to the complainant which shows policy number, invoice number, policy type, policy issued date, branch name, health floater sum assured, membership number, name of the proposer, period of insurance, type of cover, premium for Health Insurance etc.  Ext.B2 series is the discharge summary of Gem Hospital and Research Centre Pvt, Ltd, Coimbatore in respect of complainant’s wife which shows diagnosis, surgery, complaints, examinations, per-abdomen, investigations, operative findings, course in hospital, operation notes, condition at discharge, MDCT abdomen.  Ext.B3 is a claim repudiation letter dated.04/01/2018 issued by the 3^rd opposite party to the complainant informing him that his claim number 126562 is not admissible as per the policy clause.  “As per standard policy terms and conditions of Allahabad Bank; 2 hospitalization expense incurred in the first year of operation of the insurance cover on treatment of the diseases; skin and all internal tumours/cysts/nodules/nasalpolyps/calculi/sinusitis and related disorder of any kind.  Hernia and Hydrocele.”     Ext.X1 is doctors medication chart of Gem Hospital and Research Centre Pvt, Ltd, which shows patient name, hospital days, date of her admission as 22/11/2017, date of her discharge as 25/11/2017, OP number, IP number, diagnosis details, operational and surgical diagnosis, investigations, provisional diagnosis, treatment plan, Pre-OP order, Doctors notes, operation notes, anesthesia report etc. 

            We have closely examined the affidavits filed by both the complainant and the opposite parties in this case before this Forum and understood that the complainant took a Health Insurance Policy Universal for him and his family from the 3^rd opposite party, namely Allahabad Bank Health Care Plus.  We also observe that the period of this insurance policy is from 24/07/2017 to 23/07/2018 which is clear from Ext.B1.  We also understand that complainant’s wife was treated in Gem hospital and Research Centre Pvt, Ltd, from 22/11/2017 to 25/11/2017 which comes within one year of the date of commencement of the above policy i.e 24/07/2017.  We observe that on page number 10 of the policy it is mentioned that the 3^rd opposite party will exclude hospitalization expenses incurred in the first year of operation of the insurance cover on treatment of certain diseases for treatment of which complainant’s wife is hospitalized in Gem Hospital and Research Centre, Pvt, Ltd, Coimbatore; she was investigated and diagnosed as a case of adnexal, endometriotic, cyst and umbilical hernia and discharged with follow up advice.  As per standard policy terms and conditions the ailment of the complainant falls under first year exclusion clause and hence it is out of scope of the policy.  We also observe that it is specifically mentioned in the policy that hospitalization expenses incurred in the first year of operation of the insurance cover in the case of diseases, namely, hernia, hydrocele, sinusitis and related disorders, skin and all internal tumours/cysts/nodules/polyps of any kind are excluded.  We also view that in the present case the wife of the complainant underwent treatment within the first year of the inception of the insurance policy for diseases which had a specific waiting period of one year from the date of commencement of the policy i.e 24/07/2017.  Also these opposite parties (Opposite parties 1 & 3) are not seen to have caused any mental agony to the complainant as there is seen no deficiency in service on the part of the 1^st and 3^rd opposite parties.  Hence we view that complainant is not entitled to get Rs,1,14,651/-(Rupees one lakh forteen thousand six hundred and fifty one only) from these opposite parties.  We also view that these opposite parties (Opposite parties 1 & 3) are seen to have acted as per the terms and conditions, limitations and exclusions of the subject policy.  Regarding the case of the 2^nd opposite party it is observed that the complainant has only paid premium amount of the policy through the 2^nd opposite party bank and therefore the 2^nd opposite party has no liability to make payment of any claim under the subject policy and the liability on the policy lies only with the 3^rd opposite party.  Hence it is observed that there is no deficiency in service against the 2^nd opposite party also.  Under these circumstances we view that complainant is not entitled to get Rs.1,14,651/- /-(Rupees one lakh forteen thousand six hundred and fifty one only) with interest from the 1^st, 2^nd & 3^rd opposite parties. 

                Taking into consideration all the above facts we decide to dismiss this complaint. 

Pronounced in the open court on this the 20^th day of  June 2019.  

                                                                                                 Sd/-                                                                                                                               Shiny.P.R                                                                                 

                                       President

                                                Sd/-

                 V.P.Anantha Narayanan

                                Member

Appendix

Exhibits marked on the side of complainant

Ext.A1        -  Photocopy of policy details of Allahabad Bank Health Care Plus Policy Schedule

                         issued by the 3^rd  opposite party to the complainant

Ext.A2 series     -  Photocopy of treatment record issued by Gem Hospital and Research

                                      Centre  Pvt, Ltd. Coimbatore to the complainant

Ext.A3        -  Copy of  without prejudice deficiency letter issued by the 3^rd opposite party to the

                         complainant acknowledging the receipt of claim documents and seeking

                         clarification

Ext.A4        -  Copy of claim repudiation letter dated. 04/01/2018sent by the 3^rd opposite party

                         to the complainant

Ext.X1        -  copy of doctors medication chart of Gem Hospital and Research Centre Pvt, Ltd,

                         which shows patient name, hospital days, date of admission as 22/11/2017, date

                        of discharge as 25/11/2017, OP number, IP number, diagnosis details, operational

                        and surgical diagnosis, investigations, provisional diagnosis, treatment plan, Pre-

                        OP order, Doctors notes, operation notes, anesthesia report etc

Exhibits marked  on the side of Opposite parties

Ext.B1        -  copy of policy details Allahabad Bank Health Care Plus Insurance Policy schedule

                         cum tax invoice issued by the 3^rd opposite party to the complainant which shows

                          policy number, invoice number, policy type, policy issued date, branch name,

                         health floater sum assured, membership number, name of the proposer, period of

                         insurance, type of cover, premium for Health Insurance etc.

Ext.B2  series -  discharge summary of Gem Hospital and Research Centre Pvt, Ltd,

                 Coimbatore in respect of complainant’s wife which shows diagnosis, surgery, complaints,  examinations, per-abdomen, investigations, operative findings, course in hospital,  operation notes, condition at discharge, MDCT abdomen           

Ext.B3  -  claim repudiation letter dated.04/01/2018 issued by the 3^rd opposite party to the

                      complainant which shows the reasons for not admitting the claim of the  complainant

Witness examined on the side of complainant

Nil
 

Witness examined on the side of opposite parties

Nil

Cost

                      Nil