THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.321/2010
Dated this the 2nd day of July, 2015
( Present: Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
By Rose Jose, President:
The petition is filed under Section 12 of the Consumer Protection Act, 1986 on 04/09/2010 seeking an order for directing the opposite parties to repay the total expenses of her appendicitis operation. The case of the complainant is that her husband one Mr. Ajithkumar has subscribed for the Family Health Insurance of the Opposite Party together with the complainant and children under the Family Health Optima Policy with effect from 31/10/2009 which will expire on 30/10/2010. The complainant was admitted as inpatient at Nirmala Hospital, Calicut on 07/12/2009, after that she has undergone the above said operation and was discharged on 14/12/2009. The expenses occurred by her for the surgery and medicines was Rs.20,310/-. The complainant claimed to get the policy amount with all documents, it was repudiated by the Opposite Party on the ground that illness was pre-existing. Hence she filed this petition claiming the reimbursement of the amount of Rs.50,000/- and Rs.10,000/- as compensation for her mental agony and losses.
In the above matter notice was issued to both parties and they appeared and filed their version and they stated that the petitioner was suffering from acute appendicitis with complaints of severe abdominal pain and vomiting with effect from 09/11/2009 and her first consultation date was 10/11/2009 as per the Medical Certificate issued by the Doctor treated her. The date of inception of policy is 31/10/2009. As per the Policy, Exclusion Clause 2, it is clearly stated “Any disease contracted by the insured person during the first 30 days from the commencement of the date of the Policy” and that the petitioner is not entitled to get the reimbursement as such, that is why the claim of the complainant was rejected by the company. As per Clause 2, Company can prevent fake claims.
The Complainant, Opposite Party and Doctor were examined as PW1, RW1 and RW2 and documents from the complainant’s side were marked as Ext. A1 to A 25 and from the Opposite Party were marked as B1 to B8.
Based on the above averments and evidences, the Points for consideration are:
1)Whether there is any deficiency of service or unfair trade on the part of Opposite Party?
2)If so what is the relief?
For the sake of convenience both issues are considered together. The complaint is filed for reimbursement for her medical expenses.
Point No. 1: After filing the complaint, the Opposite party entered appearance and filed their version and posted for evidence. The Points to be decided is that whether there is any policy coverage to the wife of Ajithkumar who has taken Family Health Optima Policy. The Policy started on 31/10/2009 which ends on 30/10/2010 and all the family members were covered by the policy. Among the marked documents, Ext. A1 is the receipt issued by Star Health the Opposite party, for the received premium amount. A2 is the Policy schedule of the complainant. A3 to A25 are various bills with regard to the treatment. Both parties were admitted that Complainant’s husband has taken one Mediclaim Policy and she has admitted in the hospital for appendicitis operation. As per the conditions of the policy, Exclusion Clause 2 which is marked as Ext. B1, it is seen that Any disease contracted by the insured person during the first 30 days from the commencement of the date of the Policy is not entitled for reimbursement. Ext. B4 to B8 produced and marked at the time Chief Examination of RW2. These exts shows that illness were pre-existing appendicitis. The RW1 Doctor has disposed on his oath that the petitioner was treated by him on 10/11/2009 and diagnosed of appendicitis. From this, it is clear that the disease was existing within the waiting period as per the Exclusion Clause 2. Hon’ble State Commission in its Order dated 30/11/2011 in Appeal No. 481/2009 highlighted the Exclusion Clause 2 regarding the waiting period of 30 days.
The point to be decided is that whether the patient’s disease was a pre-existing one within in the exclusion period. The claim of the petitioner was repudiated by the insurance Company due to the reason that it was excluded as per the policy conditions. Based on the above contentions and evidence we came to a conclusion that as per Clause 2 ‘for the first 30 days from the commencement of the policy, any disease contracted by the insured person is not eligible for the insured amount’. The disease was diagnosed by RW 2 as appendicitis on 10/11/2009 which was in the exclusion period of 30 days and was proved by Ext. B4 to B8. Complainant has not produced any other evidence on the contrary of Opposite Party’s evidence. Here the respondent established that the disease was within the exclusion period as per the policy Clause 2. The Complainant has undergone appendicitis operation after joining in the Family Health Optima Policy with effect from 31/10/2009 to 30/10/2010. But unfortunately, the disease was diagnosed as appendicitis on 10/11/2009 which was within 30 days from 31/10/2009, ie the date of commencement of the policy. As per the conditions of the Policy, premium is collected for 12 months. But there was an exclusion period of 30 days, Policy Companies are keeping this condition to prevent fake claims. Policy is a contract between the Company and Policy holder ie. Insurer and Insuree. As per the agreement both parties are bound to accept the terms and conditions mentioned in the Policy.
In view of the findings in Point No.1, we are not considering other points.
In the result, petitioner is not entitled to get any relief or compensation from the Opposite Party. Hence the petition is dismissed.
Dated this the 2nd day of July 2015.
Date of filing: 04.09.2010
SD/- PRESIDENT SD/-MEMBER SD/-MEMBER
APPENDIX
Documents exhibited for the complainant
A1. Cash premium receipt received from the opposite party
A2. Policy schedule issued by the opposite party
A3. X-ray received from Nirmala Hospital
A4. Bill received from Nirmala Hospital
A5. Bill received from Nirmala Hospital
A6. Bill received from Nirmala Hospital
A7. Bill received from Nirmala Hospital
A8. Bill received from Nirmala Hospital
A9. Bill received from Nirmala Hospital
A10. Bill received from Nirmala Hospital
A11. Bill received from Nirmala Hospital
A12. Bill received from Nirmala Hospital
A13. Bill received from Nirmala Hospital
A14. Bill received from Nirmala Hospital
A15. Bill received from Nirmala Hospital
A16. Bill received from Nirmala Hospital
A17. Bill received from Nirmala Hospital
A18. Bill received from Nirmala Hospital
A19. Bill received from Nirmala Hospital
A20. Bill received from Nirmala Hospital
A21. Bill received from Nirmala Hospital
A22. IP Bill received from Nirmala Hospital
A23. . Bill received from Nirmala Hospital
A24 Discharge summary received from Nirmala Hospital
A25. Claim Rejection letter received from the opposite party
Documents exhibited for the opposite party:
B1.Plan condition for Family Health Optima Insurance Plan issued by the opposite party
B2. Investigation report conducted by the opposite party
B3. Request received from the complainant’s husband
B4. OP records received from Nirmala Hospital
B5. Clinical Notes received from Nirmala Hospital
B6. OP Registration form received from Nirmala Hospital
B7. OP continuation sheet received from Nirmala Hospital
B8. Operation record sheet received from Nirmala Hospital
Witness examined for the complainant:
PW1. Ajithkumar, Pulari” House, Yerimala, Nayarkuzhi P.O., N.I.T. (Via) Pin – 673 0601
Witness examined for the opposite party:
RW1. Dileep kumar P.C .,Star Health & Allied Insurance Co. Ltd., S.S. Kovil, Thampanoor,
Thiruvananthapuram
RW2.Dr. K.G. George, Kalimundakka, 2266, Marikunnu P.O., Calicut
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
