KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL No. 519/2017
JUDGMENT DATED: 15.12.2022
(Against the Order in C.C. 154/2015 of CDRF, Ernakulam)
PRESENT:
HON’BLE JUSTICE SRI. K. SURENDRA MOHAN : PRESIDENT
SMT. BEENA KUMARY. A : MEMBER
APPELLANT:
Raju Bhaskaran, Veepattu House, Pindimana P.O., Kothamangalam-686 668.
(By Adv. Tom Joseph)
Vs.
RESPONDENT:
M/s Tata AIG General Insurance Co. Ltd., Triton, 3rd Floor, 38/580, S.A. Road, Panampilly Nagar, Kochi-36.
JUDGMENT
SMT. BEENAKUMARY A. : MEMBER
The appellant is the complainant in C.C. No. 154/2015 on the file of the Consumer Disputes Redressal Forum, Ernakulam. The complaint is regarding the repudiation of a medi-claim for the reason that the claim falls under the 30 days waiting period mentioned in the policy.
2. Brief facts of the case are as follows:
The complainant was the holder of a Family Medical Insurance Policy of the opposite party with effect from 20-08-2014, assuring a sum of Rs. 3 lakhs. The complainant fell down due to a slip at 7 a.m. on 25-08-2014. He sustained severe injury over his back and he was immediately taken to St. Joseph Hospital, Kothamangalam. The doctor concerned in that hospital diagnosed the injuries of the complainant as IVDP C5 C6 and he was treated there as inpatient for 2 days. Thereafter he was referred to Medical college Hospital, Kolenchery on 27-08-2014 for better management. He was treated there for 10 days. The complainant had spent Rs. 6,000/- at Kothamangalam Hospital and Rs. 94,000/- at Medical College Hospital, Kolenchery. Immediately thereafter he lodged a claim under the medical ground before the opposite party. As per letter dated 22-01-2015 the mediclaim was repudiated on the ground that the claim falls under the 30 days waiting period of the policy and the illness of the complainant occurred within the two years waiting period. According to the complainant, he suffered the injury as an after math of the accident and the waiting period clause was not applicable to the injuries sustained in any accident. The complainant claims Rs. 1,00,000/- towards reimbursement with interest @ 12% p.a., compensation and costs.
3. Opposite party filed version contending as follows. The complainant had taken the policy from the opposite party covering the period 20-08-2014 to 19-08-2015. The policy was a fresh policy and the liability of the opposite party under the policy is only subject to the exclusion clause contained therein. The complainant had suppressed material facts in the complaint. The complainant had raised a request with the opposite party for availing cashless treatment facility at Medical college Hospital, Kolenchery from 27-08-2014, just a week after the inception of the insurance coverage. In the pre-authorization request for availing the cashless facility, the complainant had stated that he had complaints of sudden onset of neck pain and shoulder pain while doing exercise on 21-08-2014. There was no mentioning of any incident of fall on accident in the said request. C5-C6 Intervertibral Disc Prolapse (IVDP) has been stated to be the ailment and the surgery of cervical distectomy has been the treatment proposed. The said treatment was excluded from the indemnification for a period of 30 years and two years by the exclusion clause in the policy and therefore the cashless facility was declined. The complainant did not raise any protest against this. He paid the hospital bills without any demur. Neither in the discharge summary nor in the pre-authorization request there was any indication of having a fall by the complainant. Similar treatment in St. Joseph's Hospital also did not disclose any case of a fall. The allegation that the complainant had an accidental fall is incorrect. The complainant is not entitled for any compensation, as prayed for. The complainant is not entitled to get the cost of the claim as alleged.
4. The evidence in this case consists of Exbt. A1 to A4 on the side of the complainant and Exbts. B1 to B6 on the side of the opposite party. Exbt. X1 Medical records were also marked in evidence.
5. On the basis of the evidence and arguments of both sides the District Forum found that the complainant had failed to prove his case. If the complainant had genuine case of fall he should have made such a statement while he had made a request for cashless treatment facility. Therefore the District Forum found that the case of fall brought forward by the complainant to claim the insurance was an afterthought. The District Forum found that the complainant was not entitled to get the claim as per the policy conditions. Hence the complaint was dismissed. Against the impugned order the complainant has filed this appeal.
6. We have verified all the documents and heard the arguments of both sides.
7. The appellant/complainant had taken policy covering the period 20.08.2014 to 19.08.2015. The complainant had raised a request with the opposite party for availing cashless treatment facility at Medical College Hospital, Kolenchery from 27.08.2014, just a week after the inception of the insurance policy. In the pre-authorization request for availing the cashless facility the complainant had stated that he had complaints of sudden onset of neck pain while doing exercise on 21.08.2014. Ext. B2 produced by the opposite party proved this contention. The complainant had not objected to that statement. The complainant did not mention any incident of fall or accident in the said request. Neither in the discharge summary nor in the pre-authorization request there was any indication of having a fall. As per the request of the complainant the District Forum called for the treatment records of the complainant from St. Joseph’s Hospital. Nowhere in that record it is seen that the ailment of the complainant was due to fall. The discharge summary of Medical Mission Hospital, Kolenchery stated as follows: “46 years old male was admitted in the Neurosurgery Department with complaints of neck pain and numbness of both hands on 27.08.2014. No other significant medical history in the past”. There is nothing to show that the complainant had a fall as alleged.
8. There is nothing in evidence to show that the complainant had IVDP C5-C6 due to fall other than the Certificate issued by Dr. Joseph Manoj marked as Ext. A1. If the complainant had genuine case of fall, he should have made such a statement when he made a request for cashless treatment facility. The complainant had made such a case only on the basis of Ext. A1 document. This document was issued only on 17.02.2015, i.e; after the repudiation of the claim. The complainant has not proved the veracity of the document. The appellant/complainant claims the insurance benefit under clause 3 Exclusion waiting period (a) “We are not liable for any treatment which begins during waiting periods except if any insured person suffers an accident”. We find that the case of fall put forward by the complainant to claim the insurance was an afterthought. As per policy conditions the complainant/appellant has no right to get the insurance benefit in that stage, i.e; before expiry of the waiting period.
9. In this case the findings of the District Forum are clear and correct. There is no need to interfere with the order passed by the District Forum.
In the result, the appeal is dismissed. We confirm the order passed by the District Forum. No order of costs.
JUSTICE K. SURENDRA MOHAN : PRESIDENT
jb BEENA KUMARY. A : MEMBER
