D.O.F. 26.03.2011
D.O.O.05.01.2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM KANNUR
Present: Sri. K.Gopalan : President
Smt. K.P.Preethakumari : Member
Smt. M.D.Jessy : Member
Dated this the 5th day of January 2012
C.C.No.103/2011
A.P.Ajith,
Sree Padam,
Doctor Mukku,
P.O.Kadachira 670 621. Complainant
1.The Branch Manger,
LIC of India Main branch,
Talap, Kannur.
(Rep. by Adv.O.K.Saseendran)
2. The Manager,
(Health Insurance LIC of India)
Divisional Office, Kozhikode. Opposite Parties
(Rep. by Adv.O.K.Saseendran)
O R D E R
Sri.K.Gopalan, President
This is a complaint filed under Section 12 of Consumer Protection Act for an order directing the opposite parties to pay an amount of `8,000 as hospitalization benefit and a sum of `2000 as compensation.
The case of the complainant is as follows: The complainant is a Health Insurance Policy holder. He was admitted in the specialty hospital Thana, Kannur on 4.1.2011 for treatment of stricture Urethra. Surgery was also conducted on 4.1.2011 and he was discharged on 7.1.11.Claim was submitted with all the documents before 1st opposite party. As per the policy the complainant is entitled to get `2000 per day as hospitalization benefit for 4 days. The claim was rejected on the ground of pre-existing illness. The complainant has preferred an appeal but 2nd opposite party did not consider the same. The repudiation is a deficiency in service.
Pursuant to the notice opposite parties entered appearance and filed version. Complainant is a policy holder. Hospital cash benefit is `2000 per day to the principal insured and `1000 to other member. Opposite party has received a claim from the complainant. The opposite party forwarded the same to Med.Asst.(TPA)Kochi for processing the claim. Complainant was admitted in the specialty hospital on 4.1.2011 and discharged on 7.1.2011. He was diagnosed Stricture Urethra and had undergone RD (Rapid dilation) on 4.1.2011. In the claim form dated 8.1.2011 against the question date of injury sustained/disease detected is shown as 4.1.2011. This is the date of RD he has undergone in the hospital for stricture urethra. The TPA rejected the claim for reason pre-existing illness irrespective of prior medical treatment or advice and the same was intimated to the complainant vide letter dated 2.2.2011.Complainant appealed to reconsider the claim has also been rejected while considering the claim TPA observed that “ the diagnosis is supposed to have been made now but the insured already have the ailment prior to the policy”. As per exclusion clause no benefits are available here under and no payment will be made by the corporation for any claim for Hospital cash Benefit under this policy on account of the hospitalization directly or indirectly caused by ailment arising out of pre-existing ailment. The certificate issued by the doctor reveals that complainant was treated for urinary infection which he was suffering from the last 15 years. The claim is rejected due to the suppression of material facts. There is no deficiency. Hence to dismiss the complaint.
On the above pleadings the following issues have been taken for consideration.
1. Whether there is any deficiency on the part of opposite
Parties?
2. Whether the complainant is entitled for the remedy as
prayed in the complaint?
3. Relief and cost.
The evidence consists of the oral testimony of PW1, DW1, DW2 and documentary evidence Exts.A1 to A4 on the side of complainant and Exts.B1to B10 on the side of opposite party.
Issue Nos.1 to 3
Admittedly complainant is a Health Plus insurance policy holder. Complainant was hospitalized on 4.1.2011 for the treatment and discharged on 7.1.2011. He was diagnosed stricture urethra and undergone rapid DIALATION. Claim form was submitted but it was rejected by 1st opposite party. Appeal before 2nd opposite party has also not been considered. Opposite party contended that after perusal of the claim forms and related certificate rejected the claim for reasons of pre-existing illness irrespective of prior medical treatment or advice. The insured have the Ailment prior to the policy.
Complainant adduced evidence by way of chief affidavit in tune with the pleadings. He has adduced evidence that he took the policy on the promise that `2000 will be allowed for the treatment of each day hospitlaisation.Ext.A1 is the repudiation letter. Ext.A2 is the copy of appeal memorandum. Ext.A2 he has revealed that he met Dr. Sathyendran Nambiar on 13.8.2008. On enquiry he told him that he was undergoing Ayurvedic treatment for urinary infection for more than 10 years. So while issuing medical certificate the doctor noted 15 years in the case sheet. Then it was also stated he had never treated for ailment stricture urethra before 31.8.2009 and previously treated only for urinary infection. It was only on 4.1.2011 diagnosed that he was suffering stricture urethra. The certificate issued by Dr. Aravindakshan, DAM shows that the complainant was suffering from Mutrakrichram(urinary infection) and was under his treatment from 22.8.2003 to 20.2.2006. Ext.B4 is the certificate issued by Dr.Sthyendran Nambiar who treated the complainant/insured. He has certified that he had treated complainant with features of urinary tract from 8th month 2008 as an out patient basis. He was seen by him in OP with similar complaints in 2008 as well. It is also certified that he was admitted under his care on 4.1.2011 for further evaluation and on examination he was found to stricture urethra and had undergone Rapid dilation on 4.1.2011. The certificate undoubtedly makes it clear that the ailment stricture urethra was diagnosed by the doctor under his treatment during the hospitalization on 4.1.2011. Ext.B10 the medical certificate to be filed in by the doctor treating the patient filled the column Diagnosis stricture urethra and in Colum No.6 filled he was suffering these 15 years. Dr.Sathyendran Nambiar/DW1 in his cross examination deposed that he has seen the patient/complainant on August 2008. He has also deposed as follows: He came with features of urinary tract. He had diagnosed stricture urethra on 4.1.11. In cross examianti9on he was asked a question whether the recording in Ext.B10 that the complainant was suffering stricture urethra for the last 15 years is correct? DW1 answered No and continued to say that “in order to clarify this I have issued Ext.B4 certificate. I have detected stricture urethra only on 4.1.2011”. He has also answered to another questioned that “U.T.I and stricture urethra are not one and the same. Treatment of both these disease are different. DW2, the Ayurveda doctor Aravindakshan deposed that Ext.A5 is issued by him and he has stated that patient was undergone treatment under him from 22.8.03 to 20.12.06 frequently. He was suffering from UTI.
It can be seen that the evidence adduced by DW1 & 2 undoubtedly make it clear that the ailment stricture urethra was diagnosed by DW1 on 14.1.2011 and before that he was suffering from urinary tract infection only. Opposite party has no pleading that urinary tract infection would come under exclusion cause. The evidence of DW1 makes it ascertain that it was under his treatment during the hospitalization from 4.1.2011 to 7.1.2011 stricture urethra was diagnosed and undergone rapid dilation. Hence it is absolutely wrong to say that the patient/complainant, the insured had been suffering from stricture urethra prior to the policy. Opposite party failed to substantiate their contention that the disease was a pre-existing one. Hence the repudiation of claim amounts deficiency in service on the part of opposite parties.
The opposite parties have pleaded that no benefit would be paid for the first 48 hours (two days) of hospitalization. Even if the claim is admissible the amount payable is `4000 only i.e. `2000 per day for 2 days. The opposite party did not adduce any evidence to prove this aspect. The first page of the proposal form Ext.B1 under the caption in bold capital letters “C.Details of all Members to be insured (including the principal insured) 7th column for initial Daily Cash Benefit the first member Ajith A.P the principle insured cover `2000. That means the principle insured is entitled for `2000 daily. There is no indication of exemption of 48 hours. If any terms unnoticeably added anywhere else that can only be treated as an unfair trade practice since `2000 offer clearly written in the first page itself to attract the policy holder. Such clause is not seen written in Ext.B1 stating that no benefit would be paid for the first 48 hours.Ext.B2 column NO.3 initial daily Hospital cash Benefit (HCB) under principal insured it is clearly written `2000.So there is no substance in the contention of opposite parties. The insured is entitled for `2000 each as initial daily Hospital Cash Benefit for 4 days.
In the light of the above discussions we are of the opinion that the repudiation of claim is a deficiency in service on the part of opposite party and the complainant/insured is entitled to get `8000 towards Hospital Cash Benefit together with `1000 as cost of these proceedings.
In the result, the complaint is allowed directing the opposite parties to pay `8,000 (Rupees Eight thousand only) towards Hospital Cash Benefit to the complainant together with a sum of `1000(Rupees One thousand only) as cost of this litigation to the complainant within one month from the date of receipt of this order, failing which the complainant is allowed to execute the order against opposite parties as per the provisions of consumer protection Act.
Sd/- Sd/- Sd/-
President Member Member
APPENDIX
Exhibits for the Complainant
A1.Copy of the letter sent by OP
A2.Copy of the letter dt.15.2.11 sent to OP
A3. Copy of the certificate dt.12.2.11 issued from Specialty Hospital,
Kannur.
A4.Copy of the Medical certificate dt.14.2.11 issued from Amrutham
Aryavaidya Pharmacy.
Exhibits for the opposite parties:
B1.Copy of the proposal form issued to complainant
B2.copy of the policy
B3.Copy of the discharge card issued from Specialty Hospital
B4.Certificate dt.12.2.11 issued from Specialty Hospital,
Kannur.
B5. Medical certificate dt.14.2.11 issued from Amrutham
Aryavaidya Pharmacy
B6. Claim form dt.8.1.11 submitted by complainant
B7. Copy of the letter dt.2.2.11 sent to complainant
B8. Letter dt.15.2.11 sent by complainant
B9. Copy of the letter dt.21.3.11 sent to complainant
B10. Copy of the medical certificate filled by the Doctor treating the
complainant
Witness examined for the complainant
PW1.Complainant
Witness examined for the opposite parties
DW1.Dr.Sathyndran Nambiar
DW2.Dr.A.V.Aravindakshan
/ forwarded by order/
Senior Superintendent
Consumer Disputes Redressal Forum, Kannur
