The complaint is in respect of mediclaim. The averements in the complaint are as follows.
The first opposite party is the insurance company and the second opposite party is its agent. On the advice of second opposite party complainant availed an insurance policy from opposite party No.1. At the time of availing the policy he made believe that during hospitalization the hospital charges would be paid by the first opposite party. On 20-6-2015 the complainant was admitted in Moulana hospital Perinthalmanna for under going left ovarian endometrioma aspiration. She was discharged from the hospital on 23-6-2015 Rs.19000/- (Ninety thousand only) spent for this treatment. For paying the bill amount in the hospital no amount was paid by first opposite party. Though an employee of the first opposite party came to the hospital and collected the information's from complainant and disclosed her claim number also. But the first opposite party failed to disburse the hospital expenses of the complainant and that shows their deficiency of service.
first opposite party filed version alleging as follows.
It is true that complainant had availed a star gain health plan insurance policy from this opposite party for the period from 18-1-2014 to 17-1-2015 and that was renewed up to 17-1-2016 for a sum assured of Rs.3 lakhs. This opposite party received as per authorization request for cash less hospitalization from Moulanan hospital Perinthalmanna in which it was stated that the complainant was admitted on 20-6-2015 with a complaint of left Ovarian endometrioma. The treating doctor has recorded in the column provided for past history of patient that the complainant had under gone Laproscopy in 2005. When this opposite party requested for the details of the treatment under gone by the complainant in 2005, the hospital submitted a report of modern diagnostic centre in which it was clearly stated that treatment for the complainant in 2005 was for ovarin cyst. At the time of submitting the proposal form complainant suppressed the above fact hence the cash less facility was denied to her . The complainant was admitted in the hospital on 20-6-2015 for the treatment of ovarin cyst. So the repudiation of claim is justified. As per condition No.3 of the policy a claim must be filed with in 15 days from the date of the discharge from the hospital and as per condition No.4 the insured person shall furnish the company with all original bill receipts and other documents up on which the claim is made . In this case complainant has not submitted any document for processing a claim. The opposite parties also lost opportunities for processing the claim on merits. The allegations of the complainant regarding the circumstances under which the policy was taken are denied by the first opposite party. All other allegations against opposite party No.1 also were denied in the version. There is no deficiency on the part of this opposite party. The complainant filed this complaint for un due gain and that is liable to be dismissed.
Second opposite party also filed a separate version repeating the same allegations of opposite party No.1.
The complainant and opposite parties filed affidavits and Ext. A1 to A3 and B1 to B6 are marked.
Points arise for consideration
(1) Whether there is any deficiency of service on the part of opposite parties?
(2) Whether complainant is entitled to the amount spent for her treatment?
(3) Reliefs and cost.
Point No.1 and 2
Admittedly the complainant had under gone left ovarin endometrioma aspiration on 22-6-2015. She was impatient in the hospital for this purpose from 20-6-2015 till 23-6-2015 . The first allegation of the opposite parties is that the complainant did not prefer a claim with in the period as provided in the condition noted in the policy. But it is admitted by opposite party No.1 in the version it self that a pre authorization request for cash less hospitalization from Moulanan hospital perinthalmanna had been received by the first opposite party and there in it was stated that the complainant was admitted on 20-6-2015 diagonized with left ovarian endometrioma and that document marked as Ext. B4 . It is true that the complainant failed to prefer a claim form with in 15 days with all original bills. But as per condition No.3 and 4 shown in Ext. B3 conditions it is clear that the claim must be filed with in 15days from the date of discharge with all original bills receipts etc. But in condition No.3 itself it is made clear that if necessary, the time limit can be relaxed. So there is no justification in denying the claim on the ground that the complainant failed to prefer the claim with in 15 days after the discharge with all bills receipts documents etc. The opposite party No.1 is service provider and that they came to know that the complainant was admitted in the hospital so they could have intimated the complainant to produce all original bills receipts etc, if she intended to prefer any claim for the amount. But that is also not done either by first opposite party or by their agent second opposite party . Thus denial of claim of the complainant on that ground is unethical, improper and violation of all norms . After filing the present complaint the complainant produced all the documents before this Forum and after perusing those documents the opposite party could have taken a decision . There for there is no justification for denial of the claim of complainant on the ground of violation of condition No,.3 and 4 in Ext. A3.
Another ground taken by the opposite party for escaping from the liability is the non disclosure of Laproscopy conducted in 2005 for ovarian cyst. This ground is taken by the opposite party on the presumption that the complainant was subjected to left ovarian endometrioma aspiration because of the right ovarian endormetroioma in 2005. As per Ext. A1, the discharge summary the complainant had under gone Laproscopy for right overain endometroima in 2005. But there is nothing on record to show that the complainant had been stricken with left ovarian cyst at the time of filling the proposal form and complainant was aware of the presence of the same.. So it can not be concluded that complainant suppressed any material facts at the time of filing proposal form. The opposite party can not wash his hands only on the ground that she has ovarian cyst even at the time of proposal form even though she was not aware of that. The first opposite party can not reject the claim of complainant on the basis that her disease was pre existing. There is no records before us to prove that at the time of the proposal for the insurance the complainant had been stricken with the said disease . There for the opposite party can not reject the claim of complainant on the ground mentioned in the version filed by them . If that be so the complainant is perfectly entitled to the amount spent by her for her treatment in the hospital and compensation for mental agony suffered by her and for deficiency of service of the opposite parties . Complainant produced A3 series bills to prove the hospital expenses and that comes to Rs.19420/- (Ninety thousand four hundred and twenty only) and opposite party shall pay that amount to complainant . The denial of the hospital expenses caused mental agony to complainant and that shows the deficiency of service of first opposite party . Hence the opposite party shall pay Rs.50000/- (Fifty thousand only) as compensation to complainant. Points are decided accordingly.
Point No.3
On the basis of finding on the above points we allow this complaint and opposite parties are directed to pay Rs.19420/-(Ninety thousand four hundred and twenty only) as the hospital expenses of complainant and Rs.50000/- (Fifty thousand only) as compensation for the mental agony suffered by the complainant and deficiency of service on the part of the opposite parties . Complainant is also entitled to Rs.1000/- (One thousand only) as cost of the proceedings. The above amount shall be paid to the complainant with in 30 days from the date of receipt of the copy of this order failing which they shall pay the same with interest at the rate of 9% per annum from the above date till realization.
Dated this 31st day of January, 2017.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A3
Ext.A1 : Discharge summary.
Ext.A2 : Discharge summary
Ext A3(s) : Pharmacy Bills.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B6
Ext.B1 : Photo copy of the proposal form.
Ext.B2 : Policy Schedule and conditions.
Ext.B3 : Policy conditions.
Ext.B4 : Copy of request for cashless hospitalization for medical insurance policy.
Ext.B5 : Query on pre authorization.
Ext.B6 : Query on pre authorization.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
