By Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019
2. Facts of the case in brief:- The Complainant availed Family Health Optima Insurance Policy from Opposite Parties for himself, his wife and children, on 28.02.2019 and renewed in the year 2020. It is averred that due to left Maxillary Fungal Sinusitis, the Wife of the Complainant, Shyla Shaju, got admitted at Aster Wayanad Speciality Hospital Meppadi on 22.12.2020. She was undergone a surgery and she underwent left fess under GA. Fungal ball removed left Maxillary sinus on 23.12.2020 and discharged on 24.12 2020. The bill amount was Rs.37,500/- and the same was sent for medi-claim, but the claim was rejected on the ground that the diagnosed illness would come under the exclusion within 24 months. When the Complainant perused the customer information sheet, there were no exclusion listed thereto the above disease. The repudiation of claim amounts deficiency of service and unfair trade practice. After that the Complainant issued lawyer notice to the Opposite Parties on 22.03.2021 and the Opposite Parties sent reply by denying all the statements and denied the claim. Hence, this complaint.
3. On receipt of notice, the Opposite Parties appeared and filed version contending the following:- The Opposite Party admitted that the Complainant had taken Family Health Optima Insurance Policy from 1st Opposite Party on 28.02.2019, which has been renewed up to 27.02.2021. It is submitted that at the time of availing the policy the Complainant was supplied with the terms and conditions of the policy and also explained to the Complainant at the time of proposing policy and the same was served to the Complainant along with policy schedule. The Opposite Parties received a request for cashless hospitalization from DM Wayanad Institute of Medical Sciences stating that the wife of the Complainant was admitted at the hospital on 22.12.2020 and was provisionally diagnosed with Maxillary Sinusitis. The hospital has forwarded treatment records and lab reports. As per the treatment records, it is clear that the insured patient was treated for Maxillary Sinusitis, a disease of ENT related. As per the terms and conditions of the policy, Treatment of ENT is excluded for a period of first two years as per waiting period No. 3 (ii)(a) of the policy. As per the waiting period no.3 (ii) (a) of the policy, a waiting period of 24 consecutive months of continuous coverage from the inception of the policy will apply to the Disease of ENT. The illness falls under two year waiting period/ exclusion clause and hence the Opposite Party rejected the cashless facility vide letter dated 22.12.2020. Hence, there has been no unfair trade practice/deficiency in service from the side of Opposite Party. It is also submitted that the Complainant has not submitted any documents claiming Rs. 44,044/- being the treatment expense and had not submitted any original bills/documents. So, the Opposite Party prayed for dismissal of the complaint with cost of the Opposite Party.
4. The Complainant was examined as PW1 and the documents produced were marked as Ext. A1 to A7. The Opposite Party was examined as OPW1 and the documents produced were marked as Ext B1 to B7.
5. The points for consideration are:
- Whether there is any deficiency in service on the part of the Opposite Party?
- Whether the Complainant entitled for the relief prayed for?
6. After considering all the facts and circumstances of the case in the light of the arguments by the parties, it emerges that the Complainant filed complaint against Opposite Parties alleging deficiency in service on their part on the ground that his claim was wrongly repudiated by the Opposite Party. Admittedly, the Complainant had purchased the policy in question from the opposite Parties. It is also admitted that the policy in question is continuing from the year 2019. It is also admitted that wife of the Complainant was hospitalized during the subsistence of insurance policy. The claim of the insured has been repudiated by the Opposite Parties, vide letter, Ext. B5 dated 22.12.2020 on the ground which is reproduced as under: We have scrutinized the request for approval for cashless treatment of the above insured for the diagnosed disease of Maxillary Sinusitis. It is observed from the documents submitted that the hospitalization for treatment of Maxillary Sinusitis has arisen within two years from the date of commencement of the first policy. As per the waiting period/exclusion no. 02 of the policy, the claim is not admissible for a period of 2 years from the date of inception of the first policy. We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease. It is observed from the submitted records including the discharge summary of the above hospital that the insured person has undergone treatment for the above disease which is during first year of the policy. As per exclusion specified disease/procedure waiting period-code Excl. 02 of the above policy expenses incurred by the insured person for treatment of said disease shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy. We have perused the documents, Ext.A1 shows that the date of inception of the first policy is given as 28.02.2019 and the date of treatment is 22.12.2020 i.e., within the period of one year from the date of starting of the insurance. Therefore, the condition No.3 (ii)(a) is applicable. A perusal of above extracted section makes clear that in the list of illness it has been mentioned that the diseases of ENT is not covered for a period of first two years. Now it has to be seen as to exactly what disease Shyla Shaju suffered from for which she hospitalized. In this context, it would be pertinent to refer discharge summary, Ext. A6, where in it is clearly shows that in history of the patient is nasal obstruction left side along foul smell in nose since six months. Moreover, the Complainant was treated by ENT Specialist. All these facts reveals that the disease of the Complainant is related to ENT.
7. In the present case, it was the first year of the policy and during the same itself the Complainant had to face the problem. It being so, there was no question of the Opposite Parties to pay to the Complainant for the expenses incurred by him for the treatment. In these circumstances, we find that the whole ground facts and circumstance leans towards the side of the Opposite Parties. The case is lame of strength and therefore, liable to be dismissed. Taking into consideration all the facts and circumstances of the case. We have no hesitation to hold that the Complainant has failed to prove that there has been any deficiency in service on the part of the Opposite Parties or that the Opposite Parties adopted any unfair trade practice.
As such, the complaint is devoid of any merit and the same is hereby dismissed without costs.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 4th day of March 2024.
Date of Filing:-04.08.2021
PRESIDENT : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Shaju. Agriculture.
Witness for the Opposite Parties:-
OPW1. Balu. M. Deputy Manager, Legal.
Exhibits for the Complainant:-
A1. Family Health Optima Insurance Plan for the period of 28.02.2020
to 27.02.2021
A2. Customer Information Sheet Family Health Optima Insurance Plan.
A3. Copy of Lawyer Notice. Dt:22.03.2021.
A4. Postal Receipts (2 Numbers).
A5. Acknowledgment Card.
A6. Copy of Discharge Summary.
A7. Bills (28 Numbers).
Exhibits for the Opposite Parties:-
B1. Copy of Common Proposal Form.
B2. Copy of Letter. Dt:28.02.2020.
B3. Copy of Request for Cashless Hospitalization for Health Insurance.
B4. Copy of Doctor’s Initial Assessment. Dt:22.12.2020.
B5. Copy of Rejection of Authorization for cashless treatment.
Dt:22.12.2020.
B6. Copy of Lawyer Notice. Dt:22.03.2021.
B7. Copy of Reply Notice. Dt:13.04.2020.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
