THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.569/2013
Dated this the 17th day of December 2014.
( Present: Sri. G. Yadunadhan, B.A., LLB. : President)
Smt.Beena Joseph, M.A : Member
ORDER
By G.Yadunadhan, President:
The case of the complainant is that complainant had joint a Star Health policy of Star health Allied insurance Company Ltd. On 10.11.2012 complainant was traveling in a vehicle which made with an accident at Kallai Road. Due to accident complainant had injury on her left knee. Suddenly the complainant had taken to MIMS Hospital, Calicut for treatment From the treatment from 10.11.2012 to 13.11.2012 at MIMS Hospital, huge amount have been spent for her treatment. After from the discharge of the hospital complainant claim the mediclaim policy against the opposite party and opposite party rejected the claim without having any reason. Therefore complainant seeking relief against opposite party directing them to pay Rs.1,00,000/- along with compensation of Rs.50,000/-
Opposite party after serving notice entered in appearance and filed their version stating that this opposite party has granted a Medi Family Package plan having policy No.P181111/01/2013/006541 during the period from 25/07/12 to 24/07/2013. The said policy was issued based on the proposal form filled, signed and submitted by the complainant, narrating the health conditions of the persons who were proposed to cover under the above mentioned policy. The opposite party granted the said policy subject to the terms and conditions and it is a settled law that the parties to the insurance contract are bound by the terms and conditions of the policy issued. Complainant was admitted in MIMS Hospital, Calicut on 10.11.2012 and diagnosed ACL tear (Anterior Cruciate ligament) Lateral Meniscus tear & MCL & LCL tear left knee. In the present admission, the treating doctor had advised surgery after 6 weeks. The complainant was again admitted for surgery on 08.01.2013 and underwent arthroscipic lateral meniscal balancing & anterior cruciate ligament reconstruction and discharged on 11.01.2013. The allegation contained in the complaint that complainant had sustained injury on her left knee in a road accident at Kallai on 10.11.2012 while she was traveling in a vehicle and she was treated at MIMS Hospital is not admitted by these opposite parties. There is absolutely no documentary evidence to substantiate that a road accident has occurred at 8.15 p.m. on 10.11.2012 at Kallai road while the complainant was traveling in the vehicle and the alleged injuries were sustained by the complainant. Only the entries in the wound certificate prepared by the MIMS Hospital are available. The entries in the wound certificates were made as per the information provided by the complainant. On perusal of the wound certificate in the light of information in other documents, it is obvious that the wound certificate is made in collusion with the hospital to obtain an unlawful claim. The complainant has not filed any complaint before the police in order to investigate the matter and to register a case. There is absolutely no document to show that MIMS authorities have reported the alleged road accident before the police station concerned. As per the information given by the complainant at the time of admission. In case of road accident, it is mandatory on the part of the hospital authorities to repot/inform the accident to the police concerned. No FIR was submitted along with the claim documents. On receiving the insurance claim from the complainant, the insurance company sent the connected medical records submitted by the complainant for an expert opinion to Dr.Sabarishree.M, Orthopedics surgeon, Department Orthopedics. Government Medical College, Thiruvananthapuram. In the opinion given by the said surgeon, it is stated that the left knee injury of the complainant is of a duration of more than one year. Hence the claim of the complainant that she had sustained the left knee injury in an accident alleged to have occurred on 10.11.2012 can not be correct. The claim submitted by the complainant with enclosures is produced along with version. The opposite parties have rightly repudiated the claim of the complainant. The claim was repudiated as the treatment taken by the complainant was for a pre existing disease. Pre-existing disease is excluded as per exclusion clause No.1 of the policy which states that Pre-existing disease condition as defined in the policy, until 48 months of continuous coverage have elapsed, since inception of the first policy with the company. There is no deficiency of service on the part of opposite party. Therefore complaint is liable to be dismissed.
Points for consideration
- Whether any deficiency of service on the part of opposite party?
- Whether complainant is entitled to get any relief from the opposite party? If so what is the relief and cost?
Complaint was filed on 05.12.2013. Version filed on19.03.2014. From there onwards complainant was continuously absent not filed affidavit or adduce any evidence as the case is mediclaim policy. On perusal of complaint itself it is admitted by the complainant that there is an accident while she was traveling in a vehicle . Due to accident complainant was hospitalized in Baby Memorial Hospital and the complainant had spent huge amount for her treatment. This was intimated to the first opposite party but they are not responded against the claim. According to the opposite party there is no document s to show that whether she made with an accident, or any surgery due to pre-existing disease. That can not be proved by the complainant. On the documents produced by the complainant itself nothing to show there is an accident occurred on 10.11.2012 , surgery was admitted in medical records it is stated that the left knee injury of the complainant is of a duration of more than one year. Certificate also issued by Dr.Sabarishree, dtd.19.01.2013 , due to that certificate opposite party repudiated the claim by the complainant to substantiate their repudiation that the complainant has not produced any documents to supporting their claim. According to the opposite party the claim can be released only by the terms and conditions of the policy. Here pre existing disease of the complainant opposite party has not in a position to release the amount. Pre-existing disease complainant itself treated by MIMS Hospital issued certificate an expert opinion by Dr.Sabarishree.M, Orthopedics Surgeon, Department Orthopedics, Government Medical College, Thiruvananthapuram, the information given by the said surgeon that the left knee injury of the complainant is of a duration of more than one year . Due to that opposite party rejected the claim of the complainant. No other supporting documents produced by the complainant, since complainant was continuously absent not produced any documents Fora can not pass an order in favour of the complainant. No merit in this complaint , complaint is liable to be dismissed.
Pronounced in the open court this the 17th day of December 2014.
Date of filing:05.12.2013.
SD/-PRESIDENT SD/-MEMBER
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
