By: Smt. R.K.Madanavally, Member
Brief facts
The complainant had joined in a family health insurance policy called ' Family health optima' under opposite parties on 31.12.10. It was offered by the opposite party that, if any illness was happened after 2 years of the availing of the policy, the complainant will get an insurance coverage of Rs.100000/-. The said policy was renewed in December 2011.
Thereafter the complainant consulted Dr. Dharmaraj at Craft hospital, Kodungalloor from where he got advice that he should undergone a surgery. For the said surgery, he was admitted on 28/2/13 and discharged on 2/3/13. Before the surgery, when the complainant discussed with the opposite parties, they promised him that he will get the insurance amount.
After the surgery the complainant submitted all the bills and documents before the opposite parties, but they rejected the claim. Hence this complaint.
The availing of the policy, and rejection of the claim etc were admitted by the opposite party No.1 to 3 in their written version. All other averements were denied by them. Opposite party No.4 set exaprte. The complainant was admitted for OATS Bilateral vericocele (oligoastheno terratozoospermia bilateral vericocele) for which he had undergone bilateral subinguinal microscopic varicocelectomy and discharged on 2/3/13. Thereafter entire records were produced by the complainant before opposite party No.1 to 3.
The medical certificate and discharge summary shows the treatment was for bilataral varicocelectomy for OATS ( Oligoasthenoterratozoospermia). OATS is a condition that includes Oligozoospermia ( low number of sperm), asthernozoospermic (poor sperm movement) and terato zoospemia (abnormal sperm shape). It is the common cause of male infertility. Varicocelectomy is the most commonly performed surgical procedure for the treatment for male infertility. So according to opposite party, the complainant had under gone the treatment of infertility and so it falls under exclusion clause No.10 of the policy. Hence they repudiated the claim.
The policy is issued strictly according to the terms and conditions only. The complainant had agreed all the terms and conditions in the policy. Hence no deficiency is committed by them and so the complaint has to be dismissed with cost.
Now the questions arises for our consideration here in are;
(1) Whether the repudiation of claim is justifiable?
(2) Whether the opposite parties are deficient in service ?
(3) Relief and cost.
Point No.1 and 2
The complainant is examined as PW1. His documents are marked as Ext. A1 to A19. Ext. A1 is the claim form, Ext. A2 to A4 are the prescriptions issued by Craft hospital, Ext. A5 is the receipt dated 1/3/13, Ext. A6 is the bill, Ext. A7 is the discharge summary issued by Craft hospital, Ext. A8 to A13 are bills, Ext. A14 (s) are the lab test results, Ext. A15 is the claim form, Ext. A16 is the Brochure issued by opposite parties, Ext. A17 is the features of health policy of LIC, Ext. A18 is the policy issued by opposite parties and Ext. A19 is the claim repudiation letter. Opposite party filed affidavit and their documents are marked as Ext. B1 to B4, Ext. B1 is the policy conditions, Ext. B2 is the claim form Ext. B3 is the claim repudiation letter and Ext.B4 is the letter issued by the opposite parties infavour of the complainant.
The relying document of the complainant is Ext. A16 which is the Brochure issued by the opposite parties. According to the complainant, on the basis of Ext. A16, he had joinded in the health insurance. The Ext. A16 contains some exclusions. The infertility is not mentioned in Ext. A16. But at the same time, opposite parties are depending upon the Ext. B1 which contains the terms and conditions. As per clause 10 of the Ext. B1, infertility is excluded. So the real terms and conditions were not supplied to the complainant and only Brochure was issued to him.
It is admittedly true that, in Ext. A16, there was a 'note' directing the parties to refer policy documents for detailed list of exclusions. The documents supplied to the complainant will not contain the entire exclusion clauses. The important document ie, Ext. B1 was kept in the custody of opposite party. By believing Ext. A16, the complainant had applied for the claim. More over, the opposite party has no such case that, they had supplied Ext. B1 to the complainant at the time of availing the policy.
Hence suppression of an important document and there by misleading the consumers are unfair trade practice. All formalities were complied by the complainant for getting the insurance. His policy was in existence at the time of the treatment. He had to spent nearly 50,000/- towards his treatment. The policy was already renewed up to 30/12/13. So the denial of the policy by the op postie parties cannot be justifiable. By denying the policy, opposite parties had committed clear deficiency in service. Though opposite parties submitted the facts according to Ext. B1, they ought to have informed the complainant or they ought to have supplies the material document to the complainant at the time of availing the policy. Hence we are holding the view that the opposite parties are deficient in their service. So, the 1st two points are answered accordingly.
Point No.3
In view of the above discussions and findings we are allowing the complaint and the opposite party No.1 to 3 shall jointly and severally pay an amount of Rs.50,000/-/- being the treatment expense along with a compensation of Rs.20000/- for the mental agony suffered by the complainant and cost of Rs.10,000/-.
This order shall be complied within one month from the date receipt of the copy of this order, failing which, the complainant is entitled get 12% interest upon the said amount from the date of pronouncement of this judgment.
Dated this 26th day of August, 2016.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
APPENDIX
Witness examined on the side of the complainant : PW1
PW1 : Complainant, Manoj.C
Documents marked on the side of the complainant : Ext.A1to A19
Ext.A1 : Claim form.
Ext.A2 : Prescription issued by Craft hospital, dated 1/3/2013
Ext A3 : Prescription issued by Craft hospital, dated 2/3/2013
Ext A4 : Prescription issued by Craft hospital, dated 02/03/2013
Ext A5 : Receipt, dated 1/3/2013
Ext.A6 : Bill dated 2/3/2013
Ext.A7 : Discharge summary issued by Craft hospital, dated 2/3/2013
Ext A8 : Bill dated 1/3/2013
Ext A9 : Bill dated 2/3/2013
Ext A10 : Bill dated 2/3/2013
Ext.A11 : Bill dated 2/3/2013
Ext.A12(s) : Bill dated 2/3/2013
Ext A13 : Bill dated 28/2/2013
Ext A14(s) : Lab test result dated 14/02/2013
Ext.A15 : Medical certificate
Ext.A16 : Brochure
Ext A17 : Features of the health policy.
Ext A18 : Policy schedule
Ext.A19 : Claim repudiation letter.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B4
Ext.B1 : policy conditions
Ext.B2 : Claim Form for Medical Insurance
Ext.B3 : Claim repudiation letter.
Ext.B4 : letter issued by the opposite parties infavour of the complainant.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
