BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 18/2011 Filed on 22.01.2011

Dated : 15.12.2012

Complainant :

R. Vijayakumar, Vijaya Nivas, T.C No. 27/1148(3), Vanchiyoor P.O, Thiruvananthapuram.

(By adv. Kumarapuram J. Mohanan Nair)

Opposite parties :

1. The Branch Manager, United India Insurance Co. Ltd., Hospital Junction, Neyyattinkara, Thiruvananthapuram-695 121.

    

   (By adv. R. Jagadish Kumar)

    

2. The Manager, M.D. India Health Care Services (P) Ltd., EL 63/521, Opposite Karuna Printers, Kazim Lane, Near St. Augustin School, Kalloor P.O, Ernakulam.

This O.P having been taken as heard on 21.11.2012, the Forum on 15.12.2012 delivered the following :

ORDER

SMT. S.K. SREELA, MEMBER

The complainant is a tailor by profession. The complainant was issued with a health insurance policy by the opposite party for a period commencing from 13.03.2010 to 12.03.2011. Whileso the complainant was admitted to S.P. Fort Hospital, Thiruvananthapuram due to Osteoporosis on 30.07.2010 vide I.P. No. 10/003367 and thereafter on 30.08.2010 and undergone intensive treatment for the said disease at the hospital. That in connection with the aforesaid treatment the complainant had spent Rs. 88,573/- for which bills were issued from the hospital. After discharging him from the hospital he sent claim form along with all supportive documents. Thereafter the opposite parties repudiated and disclaimed the genuine claim of the complainant on one reason or another which is unsustainable as per the conditions stipulated in the policy issued by the 1^st opposite party. The complainant had to suffer a lot of pain and sufferings because of the negligence and gross dereliction of duty and deficiency in service on the part of the opposite parties. Hence this complaint.

2^nd opposite party remains ex-parte. 1^st opposite party filed version contending that the consumer case is not maintainable either on facts or law. It is true that a medi claim policy No. 100403/48/09/97/00003303 was issued to the complainant and others by the 1^st opposite party. The disease alleged by the complainant is osteoporosis, the same is a degenerating disease and the same is not possible to commence within a short span. There is suppression of material facts and the same is a pre-existing one. During hospitalization the patient/complainant received no active line of treatment and the hospitalization. As per policy condition the claim is not payable under clause 4.10 and hence the claim had to be repudiated. No deficiency as alleged in the consumer case is there and hence the consumer case will not lie. The complainant is not entitled to any of the reliefs sought for. There is no negligence and delay at all from the side of this opposite party.

Complainant has been examined as PW1 and Exts. P1 to P7 marked. Ext. D1 & D2 were marked on the part of the 1^st opposite party. No oral evidence on the part of opposite parties.

The issues for consideration are:-

1. Whether the complainant was suffering from any pre-existing disease as alleged by the opposite parties?

2. Whether there is any deficiency in service on the part of the opposite parties?

3. Reliefs and costs.

Points (i) to (iii):- There is no dispute with regard to the policy. As per Ext. P1 the period of insurance is from 13.03.2010 to 12.03.2011. It is the case of the complainant that due to osteoporosis he was admitted to S.P Fort Hospital on 30.07.2010 and thereafter on 30.08.2010 and he had incurred an amount of Rs. 88,573/-. But his claim has been repudiated on the ground that osteoporosis – 6 months as per discharge summary and during hospitalization no active line of treatment received by patient, hospitalization is not justifiable. We have gone through the records produced by both parties. As per Ext. P2 discharge summary, it has been noted that complaint of back pain for 6 months. Further in Ext. P3 the diagnosis is osteoporosis, back pain for 7 months and the X-ray shows osteoporosis. But as per Ext. P2, history has been noted as complaints of back pain for 6 months. As per the deposition of PW1 this is the third policy. During cross examination complainant has deposed that the first policy is from 02.03.2007. Ext. P1 is the policy relating to the period from 13.03.2010 to 12.03.2011. From Ext. P1 it could be seen that the 1^st policy is from 02.03.2007. From Exts. P2 & P3 documents it is evident that the complainant availed medical treatment during the existence of the third policy which has been taken on 13.03.2010. There is no dispute that the Ext. P1 policy is a genuine policy and even if we assume that there is a break in the policy then the opposite parties have no case that the complainant suffered disease during the existence of the previous policy. This is not being disputed by the opposite parties. Hence Ext. P1 could be treated as a continuous policy of the first two policies. In such a situation as the complainant has not made any claim with regard to osteoporosis, the contention of the opposite parties that the disease claimed by the complainant is a pre-existing one will not stand. The complainant has approached the S.P Fort Hospital with the complaint of back pain which later was diagnosed as osteoporosis. Further though the opposite parties have taken out a contention that there was no line of active treatment the complainant has produced the discharge summary wherein the treatment given has been mentioned as Inj. Forteo started and he has been advised certain medicines. Again during review on 30.08.2010 he has been given certain treatment and on the date of discharge i.e; on 31.08.2010 he has been advised certain medicines. From the above facts and circumstance of the case we find that the contention of the opposite parties that the disease was a pre-existing one is not sustainable. Hence the contention of the complainant that his claim has been unjustifiably repudiated though the same was covered under the terms and conditions has merit. The insurance company has repudiated the claim without any justifiable reason. Hence the complainant is found entitled for refund of Rs. 88,380/- incurred as per Ext. P4 series.

In the result, the complaint is allowed. Opposite party shall refund Rs. 88,380/- to the complainant. Opposite parties shall also pay an amount of Rs. 5,000/- towards compensation and Rs. 3,000/- towards costs. Time for compliance one month from the date of receipt of the order failing which the entire amount shall carry interest @ 9% from the date of receipt of this order till realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 15^th day of December 2012.

Sd/-

S.K. SREELA : MEMBER

Sd/-

G. SIVAPRASAD : PRESIDENT

Sd/-

BEENAKUMARI. A : MEMBER

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C.C. No. 18/2011

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - Vijayakumar. R

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of details of individual health insurance policy issued by

United India Insurance Co. Ltd.

P2 - Copy of discharge summary issued by SP Fort Hospital.

P3 - Copy of discharge summary issued by SP Fort Hospital.

P4 - Copies of bills

P5 - Copy of claim rejection/repudiation statement issued by 2^nd

opposite party.

P6 - Copy of advocate notice dated 22.12.2010.

P7 - Copy of acknowledgement card

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Copy of Individual Health Insurance Policy

D2 - Copy of claim rejection/repudiation statement issued by 2^nd opposite party.

Sd/-

PRESIDENT

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