SMT. RAVI SUSHA  : PRESIDENT

          Complainant filed this complaint  under Sec.12 of the Consumer Protection Act 1986   seeking for a direction to the opposite parties to pay  an amount of Rs.49756/- being  the balance claim amount with interest @12% from the date of entitlement of claim with Rs.1,00,000/- as compensation for the mental agonies and  hardship  alleging deficiency in service on the part of OPs.

   Briefly stated, complainant has taken insurance policy namely Senior citizens Red Carpet health insurance policy from opposite parties vide policy No.P/181313/01/2018/002988 dtd.19/9/2017.  She sustained  serious fracture on her left hip due to a fall on 1/12/2017.  She was admitted in Dhanalakshmi Hospital Kannur on that date  itself and was treated as inpatient  there upto 8/12/2017 and surgery was conducted on 4/12/2017.  She has spent an amount of Rs.97063/- for treatment.  The claim filed  by the complainant was considered by the Ops and credited only an amount of Rs.47308/- to her account.  On enquiry no valid reason has been given by the  Ops.  So complainant issued legal notice to the Ops, but Ops did not even send any reply notice or given the balance claim amount.  According to the complainant she is entitled to get the  balance claim amount and hence allowing  of the claim in partial was not justified.  She therefore, lodged this consumer complaint before this commission.

  On being noticed, the opposite party  resisted the allegation of the complainant and contended that as per the terms of the policy clause 5 explains that the policy is subject to copayment of 50% of each and every claim arise out of all pre-existing diseases”.  It is further stated that the complainant had disclosed in the proposal form about Diabetic Mellitus as pre-existing disease.  Hence based on the condition stipulated in the policy, the claim amount has been arrived as 53,493/-.  So complainant is  entitled to get Rs.6185/- as balance payable amount and they are ready to give that amount.  According to Ops complainant is not entitled to any amount as a balance claim amount except Rs.6185/-.

   Evidence in this case consists of chief affidavit filed by the son of the complainant Mr.Sajith Kumar.A.K and Exts.A1 to A9 series  were marked.  Mr.BaluM, Sr.Executive Legal of the opposite party has filed his chief affidavit and marked Exts.B1 to B3 on their side.  Both witness were cross examined for the rival parties.

   The learned counsel appearing for the complainant Adv.K.Gopakumar filed written argument note and also placed oral argument before us.  The learned   senior counsel of the opposite party Adv.V.V.Gopinathan made oral argument.  We have carefully perused the documents brought before us by both parties and considered the submissions of both learned counsels.

   The learned counsel for the Ops submitted that as per  terms and conditions of the complainant’s policy, on those pre-existing diseases which are specifically declared by the  proposer in the proposal form are covered under the policy and here the complainant had disclosed  diabetic  Mellitus as pre-existing disease in the proposal form.  Hence as per clause 5 of the policy  insured is only entitled to get  co-payment of 50% of each and every claim arising out of all pre-existing diseases.  The learned counsel further submitted  that as per the condition  in the policy the complainant is only eligible to get  Rs.53493/- out of which they had already paid Rs.47308/-.  So further eligible to get Rs.6185/- as balance  amount to the complainant.  On the other hand  the learned counsel for the complainant  submitted that complainant claimed only eligible treatment expense to the opposite parties through Ext.A4 claim form, so  she is entitled to get the full amount as claimed in Ext.A4.

   It is not disputed that Clause  5 of the  Senior citizens Red carpet health insurance policy explained  about  co-payment  ie  this policy is subject to copayment of 50% of each and every claim arising out of  pre-existing diseases  and 30% of each and every claim for all other claims.  Perusal of medical record further reveals that the  complainant was admitted at Dhanalaksmi Hospital Kannur on 1/12/2017 for the treatment of  Trochantric Fracture Left Hip and after  treatment she was discharged on 8/12/2017 within the Ext.A1 policy period and her diagnosis revealed as per Ext.A3 discharge summary as “Trochantric# Left Hip” and history as “ Fall at Home”.  So the patient was admitted with complaint of pain left hip and procedure performed was “under SAB CRIF with PEN was done on 4/12/2017”.

    Apparently, as per clause 5 of Ext.A1 policy co-payment of 50% of each and every claim arising out of all pre-existing diseases but the complainant herein is claiming medical expenses incurred for treatment of   Trochantric Fracture Left Hip which is covered under the senior citizens Red carpet policy and  she is entitled to get  reimbursement of expenses incurred on this treatment.

   From the perusal of   discharge summary it is obviously reveal that present treatment was not a complication of pre-existing disease and surgery was conducted on 4/12/2017 on her left hip for the fracture.

  It is also clear that the  complainant was not a defaulter of policy premium and submitted claim application (Ext.B1) to the Ops within time with all medical records.  From the record(Ext.A9 series) it becomes clear that the total treatment expense incurred to the complainant was Rs.96015 which was not related to complication of pre-existing disease  diabetic mellitus as contended by the opposite parties.

   In the light of the  above discussion, we are of the view that complainant’s treatment pertaining to Trochantric Fracture Left Hip was not under clause 5  in the insurance policy and the opposite parties committed deficiency in service  in not allowing the entire treatment expenses incurred to the complainant as per the claim form(Ext.B1).  So the complainant is entitled to get Rs.49756/- as balance claim amount with interest.

        In the result complaint is allowed in part.  Opposite parties are directed to pay Rs.49756/- being the balance claim amount with interest@4% per annum from the date of this complaint till the date of realization of amount.  Opposite parties are further directed to pay Rs.15000/- as  compensation for the mental agonies and hardships.  The opposite parties shall  comply this order within one month from the date of receipt of this order, failing which the amount of Rs.49756/- carries interest@12% per annum till realization.  Complainant can realize the award amount by filing execution petition as per the provisions  envisaged in Consumer Protection Act 2019.

Exts:

A1- Senior Citizens insurance policy

A2-Claim receipt dt.20/12/17

A3-copy of discharge summary

A4-claim form dt.20/12/17

A5-lawyer notice  to Ops 2&3

A6-postal receipts(2 in Nos.)

A7-Acknowledgment card

A8-lab report

A9series- medical bills

B1-Policy schedule

B2&B3- discharge summary bills

B3- assessment sheet

PW1-Sajithkumar.A.K- witness of complainant

DW1-Balu.M- witness of OP

      Sd/                                                Sd/                                                                               Sd/

PRESIDENT                                 MEMBER                                                      MEMBER

Ravi Susha                      Molykutty Mathew.                     Sajeesh K.P

eva                    

/Forwarded by Order/

                                                                              SENIOR SUPERINTENDENT