By. Sri. Chandran Alachery, Member:-
The complaint is filed under section 12 of Consumer Protection Act for an Order directing the opposite party to pay the claim amount of Rs.11,098/- with 12% interest to the complainant towards medical expenses and also to pay Rs.5,000/- as compensation and cost of the proceedings.
2. Brief of the complaint:- The complainant joined in the mediclaim plan introduced by the opposite party through agent on 14.03.2013 by paying a premium amount of Rs.5,090/- vide policy No.P/181314/1/2013/005969 valid from 14.03.2013 to 13.03.2014. The complainant got illness and was treated at Fathima Mission Hospital, Kalpetta from 26.10.2013 to 29.10.2013. There was giddiness and swelling and diagnosed as vertigo/OA. The complainant had to spent Rs.11,098/- for treatment. Soon after discharge from the hospital, the complainant prepared the claim form with the help of doctor and forwarded to the opposite party. On getting the claim form, the opposite party repudiated the claim and intimated to the complainant on 26.12.2013. The reason cited is that the disease of the complainant was pre-existing and she had taken the policy by suppressing material facts. The reasons stated by the opposite party is absolutely false. Aggrieved by this, the complaint is filed.
3. On receipt of complaint, notice issued to opposite party and opposite party appeared before the Forum and filed version. In the version of opposite party, the opposite party admitted the policy. The proposal form is integral part of insurance contract and correct facts should be furnished. The policy is issued strictly according to the terms and conditions of the policy. In the discharge summary, the diagnosis of the illness was recorded as vertigo/OA (Osteo Arthritis). The opposite party had collected copies of hospital records of the complainant which confirmed that she was suffering from Osteo Arthritis since 2005 and was suffering from diseases like HTM, Bronchial Asthema since 2002 and DLP since 2007, which was not disclosed by the insured at the time of availing the insurance policy from the opposite party company. So complainant suppressed the material facts. Since pre-existing disease, the claim falls under exclusion clause No.1 of the policy. Hence the claim is repudiated.
4. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite party?
2. Relief and Cost.
5. Point No.1:- The complainant filed proof affidavit and is examined as PW1 and Ext.A1 to A2 are marked. Ext.A1 is the Discharge card issued by Fathima Matha Mission Hospital, Kalpetta and Ext.A2 is the Repudiation letter. Opposite party also filed proof affidavit and the opposite party is examined as OPW1 and Ext.B1 to B6 is marked. Opposite party's witness is examined as OPW2. Ext.B1 is the policy and Ext.B2 is the claim form, Ext.B3 is the Discharge card and Ext.B4 is the case sheet of complainant. In Ext.B4, it is recorded by the treating doctor that O.A (Osteo Arthritis) is there. On perusal, it is seen that the doctor written it in the History column. It is not written as per diagnosis. The Forum analyzed that the doctor had written it without verifying any previous records. There is no mention in the case sheet that the complainant had taken any previous treatment for O.A. The complainant is an aged lady. There is no evidence that the doctor had perused any previous records. Therefore, the Forum is of the opinion that there is no cogent and convincing record to prove that the disease of complainant is a pre-existing one. After all, the claim amount of the complainant is a small amount and the complainant is an old lady. So by considering all these facts, the Forum is of the opinion that the complainant is entitled to get the claim amount. Repudiating the claim amounts to deficiency of service from the part of opposite party. The Point No.1 is found accordingly.
7. Point No.2:- Since the Point No.1 is found in favour of complainant, the complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the opposite party is directed to pay Rs.11,098/- (Rupees Eleven Thousand and Ninety Eight) only to the complainant with 12% interest from the date of claim till realization. The opposite party is also directed to pay Rs.2,000/- (Rupees Two Thousand) only as compensation and Rs.1,000/- (Rupees One Thousand) only as cost of the proceedings. The opposite party shall comply the Order within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 10th day of June 2015.
Date of Filing:21.02.2014. PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Moideenkutty. Driver.
Witness for the Opposite Party:-
OPW1. Manu Mohan. Executive Officer(claims), Star Health
Insurance, Trivandrum.
OPW2. Dr. V. J. Sebastian. Doctor, Fathima Matha Hospital,
Kalpetta.
OPW3. Asokan. Insurance Agent.
Exhibits for the complainant:
A1. Copy of Discharge Card.
A2. Copy of Repudiation Letter. Dt:26.12.2013.
Exhibits for the opposite party:-
B1. Medi-classic Insurance Policy.
B2. Proposal Form.
B3. Copy of Discharge Card.
B4. Copy of Consultation Report.
B5. Copy of Repudiation Letter. Dt:26.12.2013.
B6. Authorization Letter. Dt:24.02.2015.
Sd/-
PRESIDENT, CDRF, WAYANAD.
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