BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of July 2012
Filed on : 28/11/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 662/2011
Between
Paul N.P., : Complainant
Mankoottathil house, (Adv. Tom Joseph, Court road,
Mathirapilly, Muvattupuzha)
Kothamangalam-686 691.
And
The Branch Manager, : Opposite party
United India Insurane Co. Ltd., (By Adv. Jayasree S,
Mattamana Building, C.No.8/316, Siva Temple Lane
Kothamangalam. Near TDHS South Cherlai,
Mattancherry, Cochin-2)
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is a family medi claim policy holder of the opposite party. The minor son of the complainant master Vivek Paul consulted Dr. Nirmalan Raja, Professor of surgery MOSC Medical College Hospital, Kolenchery with complaints of recurring urinary infection. The disease was diagnosed as phimosis. He suggested circumcision in order to cure the disease. Accordingly circumcision was done on 03-09-2011. The complainant had to expend Rs. 8,627/- towards treatment expenses. Thereafter a claim was lodged with the opposite party. But the claim was repudiated by the TPA of the opposite party by their letter dated 02-11-2011. The reason given was that circumcision is not payable under clause 4.3 of the policy. The reason given for repudiation is not at all sustainable. On a perusal of the ;discharge summary, it is clear that the duration of the disease was for 2 weeks. The circumcision was done as part of the treatment procedure as to cure the disease. Hence the repudiation of the claim by invoking clause 4.3 of the policy amounts to deficiency in service. The complainant is entitled for claim amount of Rs. 8,627/- along with interest at the rate of 15% per annum from the date of complaint till realization. He is also entitled for Rs. 3,000/- as compensation for the mental agony and hardships suffered due to the repudiation of the claim alleging flimsy reasons. This complaint hence.
2. The version of the opposite party is as follows:
The complainant availed a family health insurance policy for the period from 24-02-2011 to 23-02-2012. The present claim for treatment of disease of the complainant’s son is phimosis comes under clause 4.3 of the exclusion of the insurance policy. Phimosis is a pre-existing and congenital disease and the claim for treatment or correction of this condition is not payable under the policy. Since phimosis is a congenital disease claim for treatment of that disease by way of circumcision is not payable under clause 4.5 of the policy. The repudiation of the claim was strictly on the basis of the terms and conditions of the policy.
3. No oral evidence was adduced by the parties. Exts. A1 to A5 and B1 were marked on the side of the complainant and the opposite party respectively. Heard the learned counsel for the parties.
4. The only point that emanates for consideration is whether the complainant is entitled to get insurance claim together with a compensation of Rs. 3,000/- from the opposite party or not ?.
5. Admittedly the complainant availed Ext. B1 Individual Health Insurance Policy for himself and his family for the period from 24-02-2011 to 23-02-2012. During the currency of the policy complainant’s son Vivek Paul underwent treatment at MOSC Medical College, Kolenchery from 02-09-2011 to 05-09-2011. His disease was diagnosed as ‘Phimosis’ (Circumcision done under SAB) evidenced by Ext. A4 Discharge summary. The opposite party repudiated the insurance claim of the complainant stating that circumcision is not payable under clause 4.3 of the policy evident from Ext. A5.
6. Clause 4.3 of Ext. B1 policy reads as follows:
“During the first two years of the operation of the policy, the expenses on treatment of diseases such as cataract, benign prostatic Hyperthrophy , Hysterectomy for menorrhagia or fibromyoma, hernia, hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases, Joint Replacement due to Degenerative condition and age-related Osteoarthritis & Osteoporosis are not payable. If these diseases (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing”
7. We are not to rely on the above clause in the instant case especially since the patient came to know about the illness only 2 weeks prior to the 1st consultation with the doctor evident from Ext. A4 discharge summary and that too well within the currency of the policy. So it is evident that the disease of the complainant’s son was not pre-existing as stated in clause 4.3 of Ext. B1 policy. The last potion of the said clause is also a saving clause in favour of the minor.
8. In the result, we allow the complaint and direct that the opposite party shall pay the insurance claim of the complainant of Rs. 8,627/- with interest @ 12% p.a. from the date of repudiation of the claim till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of July 2012
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of claim form
A2 : Copy of receipt dt. 17/09/2011
A3 : Copy of medical certificate
dt. 05-09-2011
A4 : Copy of general surgery 1
A5 : Copy of repudiation letter
Opposite party’s Exhibits : :
Ext. B1 : Brochure
