Date of filing : 29-09-2010
Date of order : 19-08-2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.203/2010
Dated this, the 19th day of August 2011
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT.K.G.BEENA : MEMBER
Varghese Joseph, } Complainant
S/o.Joseph,
Uruppakattu House,
Po.Balal, Via. Parappa,
Kasaragod Dist.
(Adv. K.Shrikanta Shetty, Kasaragod)
1. Star Health And Allied Insurance Company Ltd. } Opposite parties
Branch Office, 1st floor, Grand Plaza,
Fort Road, Kannur. 670 001.
(Adv. P.Venugopalan, Hosdurg)
2. Manoj.P.K, S/o.Shashi,
Velayil House, Vellarikundu.Po,
Via. Parappa, Kasaragod.
O R D E R
SMT.K.G.BEENA, MEMBER
Bereft of unnecessaries the case of the complainant Sri.Varghese Joseph is that he and his family members are insured with the opposite party No.1 as per the family Health Optima Insurance Plan ref. policy No.P/181313/01/2011/000893 covering the period from 30-06-2010 to 29-06-2011. The policy was canvassed by opposite party No.2. The complainant is an agriculturist and on 5-8-2010 he fell down at home and sustained injury to his right shoulder joint and to his head. Due to severe pain the complainant was admitted in A.J. Hospital & Research Centre Mangalore on 6-8-2010. The doctors gave initial attention to head injury and treated him. But the shoulder pain increased and on 11-8-2010 MRI of the shoulder joint was taken and observed that full thickness tear of supraspinatous tendon with subdeltoid Bursal fluid. Dr. Sudharshan Bandary started to treat the complainant. Rotater cuff repair done under G/A on 12-8-2010, medicine for 5 days given and advised to review the same. On 8-9-2010 the complainant was admitted in the hospital for physiotherapy since the hand is not moving properly as before the fall and discharged on 16-8-2010. The claim for reimbursement of amount spent by the complainant was placed before the opposite party No.1 which was repudiated for the reason that hospitalization was for the Management of an ailment which is related to a pre-existing injury. That reasoning is unjustifiable and against the policy norms without any basis. Complainant had spent more than `1 lakh for treatment and available bills of hospital are `64,100/-. Hence this complaint for necessary redressal.
2. According to opposite party No.1 this complaint is filed against opposite parties for an unlawful monetary gain and there is no deficiency on the part of the opposite party No.1.
3. Complainant filed proof affidavit in support of his case. Exts A1 to A8 series marked on the side of opposite parties. Sri. Sharath Mohan.K. Branch Manager filed affidavit. Both sides heard, documents perused.
4. The complainant and his family are insured by opposite party No.1 as per the family Health Optima Insurance plan covering the period from 30-06-2010 to 29-06-2011. On 5-8-2010 the complainant fell down at home and sustained injury to right shoulder and head. Due to severe pain when he was admitted to A.J Hospital, Mangalore on the very next day doctors given initial attention to head injury, shoulder pain increased day by day and at last Dr. Sudharshan Bandary started to treat him. After the regular treatment and physiotherapy when the claim for cash to hospital spent by the complainant was placed before opposite party No.1. They rejected for the reason that the Hospitalisation is for the Management of an ailment which is related to a pre-existing injury. Ext. A6 is a certificate issued by Dr. Sudharashan Bhandary, who treated the complainant. Ext.A6 removes all ambiguities. As per Ext.A6 the complainant had pain in the shoulder for 2 months. However, his tear of the Rotator cuff is an acute injury of two weeks duration. This was due to a fall on his out stretched hand….. “ The tear was acute and not an ordinary tear. Hence the suggestion that the tear is a pre-existing disease is wrong”. This is the certificate of the doctor who treated the complainant and he is the best person to certify it. There is no evidence produced adduced to prove that there is collusion between the Doctor who treated the complainant.
5. As per the norms of policy the complainant made a claim for the amount spent for treatment. In the evidence opposite party No.1 revealed that they used to direct policy holder for Medical check-up if the policy holder is above the age of 50. This complainant also undergone medical checkup. Had there been pain or injury at that time why did they issue policy to him? Subsequent treatments after his fall are mentioned in Ext.A6 document. Usually the opposite partyNo.1 insurance company want to sell their products largely in the market. For that they will adopt any strategy. But whenever customer makes a Medi-claim, the company will try level best to dishonour the claim even if it is genuine. That insurer is aiming only on ‘profit’ and not in service. Here the complainant had Health policy and after Medical check-up the policy has been issued to him. During the existence of policy he fell down and had undergone treatment. The policy holder made a claim before the insurance company. The claim is a genuine one. The doctor who treated the complainant certifies that the disease is a pre-existing disease is wrong. The acute injury is of 2 weeks duration. The repudiation of the claim by opposite party No.1 is unjustified and against the policy norms and without any basis. Pre-existing disease as per the policy condition is any condition ailment or injury or related conditions for which the insured person had signs or symptoms and/or was diagnosed and/or received any medical advice treatment within 48 months prior to the first policy with the company. Hence the complainant was examined by a doctor before granting his policy. The complainant had produced Ext.A6 document which clearly says “This cause for rejecting the claim of Mr.Vargheese is unreasonable. The patient had pain in the shoulder for 2 months. However his tear of Rotator cuff is an acute injury of two weeks duration. This was due to a fall on his out stretched hand. He was admitted in A.J. Hospital and Research Centre after the fall on 06-08-2010 at that time the diagnosis of rotator cuff tear was made however the concerned doctor did not advice surgery. When I examined the patient I advised MRI which showed a complete tear. The tear was acute and not an ordinary tear. Hence the suggestion that the tear is a pre-existing disease is wrong”. No document was produced by opposite party No.1 to contradict Ext.A6. Hence we are of the view that the claim of the complainant has to be allowed. But the claim of complainant `1 lakh. The bills produced amount of `64,100.50.
In the result, complaint is allowed and opposite party No.1 is directed to give the bill amount of `64,000/- (rounded figure) to the complainant with a cost of `3,000/- towards the settlement of claim. Time for compliance is limited to 30 days from the date of receipt of copy of this order. Failing which opposite party No.1 shall further liable to pay 9% interest for `64,000/- from the date of complaint till payment.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exts.
A1. Photocopy of policy schedule of OP No.1.
A2.8-6-2010 CT Scan of Brain report of complainant.
A3. 10-8-2010 Discharge Summary.
A4. 11/8/2010 MRI report of Shoulder Joint of complainant.
A5. 8-9-2010 Discharge Summary
A6. Certificate issued by Dr. Sudharshan Bhandary
A7. Rejection letter fax copy of OP NO.1.
A8 series (26 Nos) Medical Bills.
PW1.Varghees Joseph
DW1.Sharath Mohan.K.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Pj/ Forwarded by Order
SENIOR SUPERINTENDENT
