THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.170/2011
Dated this the 17th day of March, 2017
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, M.A., L.L.B. : Member
ORDER
Present: Rose Jose, President:
This petition is filed under Section 12 of Consumer Protection Act, 1986 for getting an order directing opposite party to provide the legitimate claim of Rs.16,318/- and cost of the proceedings to the complainant.
The petitioners are husband and wife. The crux of the petition is that the 1st petitioner is having a Family Health Insurance Policy of the opposite party with Policy No. P/181311/01/2010/003807 for the period from 08/02/2010 to 07/02/2011. This policy covers the hospitalization charges of the petitioner and his family as per its conditions. While so the 2nd petitioner was admitted at the District Co-operative Hospital, Kozhikode on 16/04/2010 due to acute pain in abdomen and treated there under Dr. Shylaja Rao. On diagnosis it was found that the reason for the acute pain was due to a sudden growth of cyst outside the uterus. After surgery she was discharged on 22/04/2010. The petitioner made a claim before the opposite party for re-imbursement of the expenses – Rs.16,318/- which he had incurred at the hospital with all the relevant documents. But opposite party had rejected the claim on lame excuses through a letter dated 06/09/2010.
The petitioner alleged that, the reason stated by the opposite party was not sufficient for rejecting a claim. It is stated that the cyst outside the uterus was not in any way related with her pregnancy and it was a sudden growth and was not a pre-existing disease. There was no such cyst while taking the policy and so there was no question of any suppression of material facts in this case as alleged by the opposite party. As per the policy conditions the opposite party is bound to honour his legitimate claim and the denial of the same on flimsy reasons is deficiency in service on their part and that caused much mental pain, financial loss and other difficulties to him. Hence this petition seeking reliefs.
The opposite party filed version with the following contentions. Admittedly the petitioner is their policy holder for the period from 08/02/2010 to 07/02/2011. It is submitted that Smt. Nisha, the 2nd petitioner had admitted at District Co-operative Hospital, Kozhikode on 16/04/2010 and diagnosed as pregnancy with twisted left para ovarian cyst. It is true that she had submitted completed claim form with all required documents. In that medical certificate submitted, in Column No. 4, the diagnosis is shown as “twisted left para ovarian cyst”. In the discharge summary the diagnosis would go to show that “pregnancy with twisted left para ovarian cyst.” In the trans abdominal US scan dated 16/04/2010 the details of pelvis is shown as “large cyst measuring 9X7.3X5.9 cm with thin walls and anechoic fluid noted in the midline abutting the left ovary.” In the impression column it is recorded that pelvis cyst is increasing in size compared to previous study, torsion cannot be excluded, Cyst seen to abut the left ovary.
It is submitted that, since previous study was referred in the report they collected the previous scan report of the 2nd petitioner dated 10/03/2009 from the said hospital. In that report it is recorded that “left adenexa –large cyst measuring 6X7.5X5.5cm with thin walls and an anechoic fluid. Tiny echogenic nodule measuring 8mm noted in its posterior wall.”
The scan report dated 10/03/2009 and 16/04/2010 clearly shows that the cyst noted in both the scans are the same one, and are in the same location. It is also clear that the cyst has gradually grown in size. Hence it is found that the 2nd petitioner was suffering from left ovarian cyst and associated diseases even prior to 10/03/2009 ie. before the date of inception of policy.
It is further contended that as per policy exclusion clause No. 1, all pre-existing diseases/conditions are excluded from the scope of the policy until 48 months of continuous coverage is elapsed since inception of the 1st policy with the company. So also under exclusion No. 15 of the said Family Health Optima Policy “Treatments arising from pregnancy, child birth, miscarriage, abortion or complications of any of these including caesarian section ie. pregnancy and related illness are excluded from the scope of the policy. From the available data it was clear that the petitioner was aware of her previous illness at the time of taking the policy and she had suppressed this material fact and fraudulently acted to deceive the company to make a wrongful gain. As the said two grounds are against the policy conditions, it is found that the claim could not be allowed and so the claim was rejected on 28/07/2010 and this was informed to the petitioner also. They have acted as per the policy conditions only and hence there is no deficiency in service on their part as alleged and the petitioner is not entitled for the reliefs sought for in the petition and so prayed to dismiss the petition with cost to them.
Evidence consists of the affidavit filed by the 1st petitioner Ext.s B1, B2 and X1 and deposition of PW1 and RW1.
The petitioner has not produced any documents as evidence on his side. He submitted that he had given all the documents related with the policy and treatment of the 2nd petitioner to the opposite party along with the claim form. So the opposite party filed IA71/2013 to call for all the records pertaining to the treatment of the 2nd petitioner Smt. Nisha dated 10/03/2009 and 16/04/2010 and also to direct Dr. Shylaja who had treated Smt. Nisha at District Co-operative Hospital, Kozhikode to give evidence in this regard. The IA was allowed and the said documents are produced and marked as Ext.s B1, B2 andX1 and Dr. Shylaja was examined as RW1 before this Forum.
It is argued by the opposite party that, the 2nd petitioner had suppressed her pre-existing disease by putting signature in the proposal form stating that she has no pre-existing disease. The petitioner has not produced the copy of the proposal form to prove otherwise if so. In Ext. B2 report of Smt. Nisha from District Co-operative Hospitl, Kozhikode dated 10/03/2009, it is recorded that “Left adenexa –large cyst measuring 6X7.5X5.5 cm with thin walls and anechoic fluid. Tiny echogenic nodule measuring 8 mm noted in its posterior wall.” In Ext. B1 report of Smt. Nisha from the said hospital dated 16/04/2010 it is reported “Pelvis:-large cyst measuring 9X7.3X5.9 cm with thin walls and fluid noted in the midline abutting the left ovary which otherwise appear normal. A comparison of these two reports shows that pelvic cyst is increasing in size. This was admitted by Dr. Shylaja who had treated Smt. Nisha, the 2nd petitioner while she was cross-examined. In her scan report it is diagnosed as pregnancy with twisted left para ovarian cyst. The opposite party further argued that diseases related with pregnancy are excluded from the scope of the policy as per exclusion clause No. 15 of the Family Health Optima Policy and pre-existing diseases are excluded as per Clause No. 1 of the policy conditions. The opposite party further submitted that they are having different premiums if the existing illness was disclosed by the petitioner. But the petitioner has not disclosed her diseases and that is why they have issued the said Family Health Optima Policy to the petitioners. In cross examination the doctor also had admitted that the petitioner had previous illness. Ext. B2 report is dated 10/03/2009 and the commencement of the policy was from 08/02/2010 onwards. This ratified the contention of the opposite party that the 2nd petitioner had pre-existing disease at the time of taking the policy and she had suppressed the same at that time.
Thus evidence shows that the petitioner had pre-existing disease related with her pregnancy and she had suppressed the same. As these two conditions are excluded from the policy coverage and the claim of the petitioner was rejected on these basis, we cannot attribute any deficiency in service on the part of the opposite party in rejecting the claim of the petitioner. Hence we are of the opinion that this petition is liable to be dismissed and the petitioner is not entitled for the reliefs sought for in the petition.
In the result, the petition is dismissed. Parties will bear their costs.
Dated this the 17th day of March, 2017
Date of filing: 03/05/2011
SD/-MEMBER SD/-PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
Nil
Documents exhibited for the opposite party:
B1. Scanning report
B2. Scanning report
Witness examined for the complainant:
PW1. Sajeesh Madhavan (Complainant)
Witness examined for the opposite party:
RW1. Dr. Shylaja Rao, ‘Sneha’, Thiruvannur
X1. In patient’s record
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
