DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD
Dated this the 17th day of September 2012
Present: Smt.Seena.H, President
: Smt.Preetha.G.Nair, Member
CC No.87/2012
Kunnath Venugopal,
S/o.Late Gopalan Nair,
C-15, Veena,
Venkitesapuram Colony,
Puthur,
Palakkad – 678 001 - Complainant
(By Adv.M.P.Ravi)
Vs
The Branch Manager,
United India Insurance Co.Ltd.,
Branch Office,
Surya Complex,
Mission School Junction,
Palakkad - Opposite party
(By Adv.P.Prasad)
O R D E R
By Smt.PREETHA G NAIR, MEMBER
The complainant has taken a Medi Claim Policy under the name individual Health Insurance Policy-2010 as per Policy No.101201/48/11/97/00001141 for the period from 26/8/11 to 25/8/12. He has also taken another policy named Medi Guard Policy as per Policy No.101201/48/11/97/00001142 for the period from 26/8/11 to 25/8/12 and paid total sum of Rs.6,303/- towards premium charges. Two policies are continuing policies.
The complainant is having coronary artery disease and he had undergone byepass surgery in 2003. On 5/1/2012 when he felt uneasiness, he went for a medical check-up and ECG, Echo and TMT were taken. It was positive and hence they have advised for angiogram. So angiogram was also taken from Kuppu Swami Naidu Hospital and the doctor recommended for angioplasty and angiogram was also taken. The complainant had spent a total sum of Rs.10,080/- in total including hospital charges and medical expenses. The complainant had preferred a claim with the opposite party on 25/1/2012 and furnished all the details required along with the copy of the bills. The opposite party repudiated the claim by their letter dated 29/3/2012 stating that as per exclusion clause No.4.10 of the policy “the charges incurred at hospital or nursing home primarily for diagnosis, X-ray or laboratory examinations or diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness injury for which confinement is required at a hospital / nursing home”. The complainant is a heart patient from 2003 onwards and hence the present treatment will not amount to diagnosis as alleged by the opposite party. The act of opposite party amounts to deficiency in service and unfair trade practice. Hence the complainant prays an order directing the opposite party to pay 1) the claim amount of Rs.10,080/- with 12% interest per annum from the date of claim and 2) pay Rs.5,000/- as compensation for mental agony.
Opposite party filed version stating the following contentions.
The complaint is not maintainable in law. As per the policy condition Exclusion clause 4.10 the claim made for expenses incurred for diagnosis test is not allowable and the company is not liable to make any payment. After angiogram, no further treatment was done and document produced is only for investigation purpose and hence the claim is rejected. The opposite party already settled the clam for enlargement of prostate glands since there is diagnosis and treatment and paid Rs.7,474/- on 4/1/10. The company paid an amount of Rs.21,400/- in the year 2008 for the same treatment. In the present case there is only diagnosis test and no further treatment. There is no deficiency in service or unfair trade practice on the part of the opposite party. Hence the opposite party prayed that dismiss the complaint with cost.
Both parties filed their affidavits and documents. Ext.A1 to A4 marked on the side of the complainant. Ext.B1 marked on the side of the opposite party. Complainant and opposite party examined as PW1 and DW1.
Issues to be considered are;
1. Whether there is any deficiency in service on the part of opposite party?
2. If so, what is the relief and cost?
Issue No.1 & 2
We perused relevant documents on record. The opposite party stated that after angiogram no further treatment was done and hence the claim is rejected. As per exclusion clause 4 – 10 the company shall not be liable to make any payment and the claim made for expenses incurred for diagnosis test is not allowable. In Ext.A3 the copy of medical report shows that Doctor required angioplasty. Also at the time of cross examination the complainant deposed that as per the advice of Dr.Jayakumar angiogram taken in Kuuppu Swamy hospital and report produced. No contradictory evidence produced by the opposite party.
The opposite party admitted that they have already settled the claim for enlargement of prostate glands since there is diagnosis and treatment and paid Rs.7,474/- on 4/1/2010 and for the same treatment the company paid an amount of Rs.21,400/-in the year 2008. In Ext.A3 attached the copy of claim form and bills shows that the complainant paid Rs.8380/- for angiogram and C.T.Scan in Kuppu Swamy hospital and Rs.1700/- for ECG, ECHO, and TMT in Palakkad diabetic Centre. Ext.A4 dated 29/3/12 shows that the opposite party repudiated the claim as per the policy exclusion clause 4.10. The opposite party has not produced evidence to show that the complainant claim is only for diagnosis test. Moreover the opposite party had paid the claim amount earlier since there is diagnosis and treatment. The complainant had spent Rs.10,080/- for hospital charges and medical expense. The complainant stated that he is a heart patient from 2003 onwards and hence the present treatment will not amount to diagnosis as alleged by the opposite party. No contradictory evidence produced by the opposite party.
In the above discussions we are of the view that there is deficiency in service on the part of opposite party. In the result complaint allowed. We direct the opposite party to pay the complainant an amount of Rs.10,080/- (Rupees Ten thousand and eighty only) as the claim amount with 12% interest from the date of repudiation of claim i.e. on 29/3/12 to date of order and pay Rs.1,000/- (Rupees One thousand only) as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order, till realization.
Pronounced in the open court on this the 17th day of September 2012.
Sd/-
Seena.H,
President
Sd/-
Preetha.G.Nair,
Member
Appendix
Witnesses examined on the side of complainant
PW1- Kuunathu Venugopalan
Witnesses examined on the side of opposite parties
DW1 – John Jimmy
Exhibits marked on the side of complainant
Ext.A1 – Photocopy of Individual Health Insurance Policy issued by the opposite party to the complainant dated 23/8/11
Ext.A2 - Photocopy of the Medi Guard Policy issued by the opposite party to the complainant dated 23/8/11
Ext.A3 - Photocopy of the Claim form submitted by the complainant to the opposite party dated 25/1/12
Ext.A4 - Letter issued by the opposite party to the complainant repudiating the claim
Exhibits marked on the side of opposite parties
Ext.B1 – Medi Guard Policy No.101201/48/11/12/00001142
Cost Allowed
Rs.1,000/- allowed as cost of proceedings.
