DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD

Dated this the 15^th day of October 2019

Present: Smt.Shiny.P.R. President

              : Sri.V.P.Anantha Narayanan, Member        Date of filing: 23/05/2018

                                                            CC/69/2018

M.G.Rajesh Kumar,

S/o.M.Govindankutty Nair,

“River View”, Thekkummuri(P.O),

Karalmanna(PO), Ottapalam Taluk,                           -           Complainant

Palakkad District. PIN – 678 506.      

(By Advs. K.Arun & V.C.Janardhanan)

Vs 

The Branch Manager,

The United India Insurance Company Limited,

P.B.No.12, D Block, 1^st Floor,                                     -           Opposite Party

Pazhery Plaza, Mannarkkad,

Palakkad District, PIN – 678 582.                  

(By Adv.P.Prasad)       

                                                                        O R D E R

By Sri.V.P.Anantha Narayanan, Member

Brief fact of complaint are stated below:

            The complainant who is a resident at the above address had availed an insurance cover under the “Family Medicare Policy 2014” for self, his wife, his daughter and his son on 03/11/2017 vide Policy No.1012052817P111079422. The annual premium for this policy was Rs.23,542/- which was received by the opposite party under receipt No.10110120517111221818 dated 03/11/2017.  This said policy came into effect from 00 hours on 03/11/2017 after due medical examination and other personal details as required for the policy coverage and the same was held valid until midnight on 02/11/2018.  According to the complainant notwithstanding the terms and conditions, exclusions and definitions contained in the said Medicare Policy, the opposite party has undertaken to reimburse all the insured persons in the event of their contracting any disease or suffering from any illness or sustaining any bodily injury through accident and if such a disease, illness or injury as certified by a duly appointed medical practitioner/ qualified surgeon to incur hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital/Day Care Centre in India as an inpatient, the opposite party will pay through Third Party Administrator to the Nursing Home or Hospital or the insured persons the amount of such expenses as are medically necessary and reasonable and customary in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule of this policy.  The complainant entered into the contract of Family Medicare Policy 2014 which was conforming to the necessary requirements after due consultations.  Exactly after 95 days of availing the Family Medicare Policy on 03/11/2017 the complainant was suddenly taken ill and Cardiology Evaluation was taken from the EMS Hospital, Perinthalmanna and as per their advice Echo test was also conducted on 15/01/2018.  This revealed that the complainant was a victim of “Myxomatous Mitral Valve Prolapse” and was referred to AIMS(Amritha Institute of Medical Sciences, Kochi) on 20/01/2018.  After attending to the inpatient with intensive medical care and further diagnosis, the complainant had undergone “Cardio Vascular and Thoracic Surgery” on 23/01/2018 with instructions to follow up treatment at fixed intervals.  As per the terms and conditions, exclusions and definitions contained in the said Medicare Policy, the complainant understood that the medical expenses incurred were amounting to Rs.3,45,714/- for the said operation performed at Kochi AIMS and was forwarded to the opposite party under the Third Party Administrator Plan enabling cashless treatment of the AIMS, Kochi medical expenses.  Thereafter on the advice at the time of discharge, the complainant had undergone regular checkups on 06/02/2018.  On the very same date complainant was subjected to “Sub Xyphoid Pericardial Effusion drainage” and was discharged on 12/02/2018 with the advice to continue regular checkups.  A further sum of Rs.57,043/- was incurred for the said surgery.  The aggregate amount of medical expenses incurred for availing effective treatment for the illness was Rs.4,02,757/- inclusive of follow up treatment available at AIMS, Kochi.  According to the complainant, this amount of medical expenses are to be reimbursed to the complainant by the opposite party.  Complainant pleads that the expenses incurred for the operation at the AIMS, Kochi were medically and reasonably necessary for the said operation as envisaged in the terms and conditions, exclusions and definitions as contained in the said Family Medicare Plan 2014 availed by the complainant about 3 months back.  The complainant believes that as per the contents of the said policy he is entitled to the claim made on the opposite party.  However on forwarding the claim No.16136172 to the opposite party under the cover of registered A/D article, the same was refused to be entertained by the opposite party expressing its inability to extend cashless facility sending the complainant a curt SMS reply on 16/01/2018.  According to the complainant, he is not at all savvy with the technological development that have become the matter of the time. Given that position, the opposite party has sought the complainant to track or search for the reason for denial or refusal of his claim by it.  This cannot be accepted and complainant has sought from the opposite party to furnish him with the details, in writing vide registered lawyer notice dated 24/02/2018 which has also been acknowledged by the opposite party but as yet no reply has been received by the complainant. The complainant further pleads that the claim lodged with the opposite party is within the terms and conditions, norms, standards, definitions and also the limitations with regard to physical, medical, surgical treatment availed by the complainant at AIMS, Kochi.  The treatment availed is well beyond the exclusions as implied or expressed in the customer information sheet attached to the Family Medicare Policy 2014 No.1012052817P111079422 dated 03/11/2017.  There are no exclusion clauses in the enlisted items of treatment which specifically debarred the complainant’s claim especially when the customer information sheet clearly proclaim that the enlisted items are only illustrative.  Further it does not mention any waiting period for availing the benefits right from the start of the operation of the policy.  For the omissions/commissions on the part of the opposite party the complainant has suffered on account of the defects and deficiencies committed for which the opposite party is solely responsible and accountable to this complainant.  The opposite party’s conduct is of not adhering to the norms, conditions, definitions and exclusions specific to the Family Medicare Policy 2014 held by the complainant for self and three members of his family for a sum of Rs.10,00,000/- insured by him.  Therefore the opposite party has committed deficiency and caused to incur defects in service by refusing to honour the claim through TAP which is a clear violation of the service as defined under the Consumer Protection Act 1986 Under Sections 2(1)(o), 2(1)(d)(ii), 2(1)(e) and 2(1)(g).

            As a direct result of the deficiency in services and incurring/causing defects in settling the claim of the complainant, the opposite party has occasioned avoidable financial losses, mental strain and stress in a state when this complainant is recuperating from a cardiac operation.  The valuation of this complaint is Rs.4,02,757/-(Rupees Four lakhs Two thousand Seven hundred and Fifty seven only) for the deficiencies/defects caused by the opposite party plus four numbers of Indian Postal Orders of Rs.50/- denomination aggregating Rs.200/- tendered towards the court fee under Rule 9A of Consumer Protection Rules 1987.  The complainant also submits that the opposite party is legally liable and bound to honour the cashless settlement as declared in the Family Medicare Policy 2014 dated 03/11/2017.  The complainant prays for passing appropriate orders by this Hon’ble Forum against the opposite party as shown below:

1)To direct the opposite party to make cashless settlement of the claim lodged with them for Rs.4,02,757/-(Rupees Four lakhs Two thousand Seven hundred and Fifty seven only) as available to the complainant as per the provisions of the Family Medicare Policy 2014 and as per the bills issued for the treatment availed by him at the AIMS, Kochi. 

2) To direct the opposite party to pay penal bank interest at prevailing PLR until the settlement

3) To grant exemplary damages amounting to Rs.10,000/-(Rupees Ten thousand only) towards avoidable inconveniences, physical and mental strains undergone by the complainant owing to deficiency/defects in service and consequent ignominy suffered by the complainant at the hands of the opposite party. 

4) To order adequate cost envisaged under Section 14(i) ibid to this complaint and such other reliefs.

The complaint was admitted and notice was issued to the opposite party to file their version by appearance. The opposite party filed their version in which they contend that all the allegations, averments and claims in the complaint are denied except those specifically admitted.  They also contend that the complaint has no basis and it is false, frivolous and vexatious and therefore it is liable to dismissed.  The cashless treatment is denied by the third party team of doctors(TPA) on the grounds of pre existing deceases.  According to the opposite party for this there is no basis. The insured(complainant) had not submitted claim for refund nor submitted any discharge summary or treatment details with this opposite party.  The pre existing diseases are not covered as per the policy terms and conditions.  Also since the disease falls under the exclusion clause of the policy, the opposite party is not liable. This opposite party understands that the complainant had not spent Rs.4,02,757/-(Rupees Four lakhs Two thousand Seven hundred and Fifty seven only) for treatment.  The bills are for Rs.57,043/-.(Rupees Fifty seven thousand and Forty three only).  According to this opposite party, the complainant should produce a copy of the discharge summary, treatment records and medical bills before this opposite party to substantiate his claim.  There is no deficiency of service and unfair trade practice on the part of this opposite party.  This opposite party has also not caused any mental agony to the complainant.  The complaint is devoid of merits and bonafides and this opposite party is not liable for any of the claims made in the complaint and the same is to be dismissed.  Hence this opposite party humbly prays to this Hon’ble Forum to dismiss this complaint with cost. 

            The following issues arise in this case for consideration by this Forum.  

1. Whether there is any deficiency in service and / or unfair trade practice committed by the opposite party?
2.  If so, the relief and cost available to the complainant?

Issues 1 & 2 in detail

             Exts.A1 to A8 are documentary evidences filed by the complainant to support his arguments, whereas Ext.B1 is produced by the opposite party to defend his contentions. Ext.A1 is original Family Medicare Policy 2014 bearing policy No.1012052817P111079422 in the names of complainant, his wife and two others.  It clearly states the terms and conditions, norms, standards, definitions, limitation and exclusions of this policy.  Ext.A2 evidences payment of premium of Rs.23,542/-(Rupees Twenty three thousand Five hundred and Forty two only) by the complainant on the above Family Package Policy 2014 taken by him from the opposite party.  Ext.A4 is a xerox copy of discharge summary issued by Amritha Institute of Medical Sciences and Research Centre, Kochi in the name of the complainant which shows speciality of the complainant patient as Cardio Vascular and Thoracic Surgery and discharging status as follow up.  This Ext. also shows diagnosis of the complainant as “Mitral Valve Prolapse-Severe Mitral Regurgitation A2- A3 Mild Prolapse, Ruptured chordac to P2”.  This Ext. also states operative findings as surgery findings.  Ext.A5 is a xerox copy of legal notice sent by complainant’s counsel to the opposite party which states that complainant incurred an expenditure of Rs.3,45,714/- (Rupees Three Lakhs Forty five thousand Seven hundred and fourteen only) towards the cost of operation at the Amritha Institute of Medical Sciences, Kochi which was medically and reasonably necessary for this operation and there is no reason for disentitling the complainant for the medical benefit as per the terms, norms and conditions of the policy availed by the complainant.  This Ext. also asks the opposite party to furnish detailed reasons in writing to the complainant for disallowing complainant’s claim.  Ext.B1 is a copy of Family Medicare Policy 2014 issued by the opposite party to the complainant which clearly states the terms and conditions, exclusions, norms, standards and limitations of the policy. 

            We have perused the affidavits and documentary evidences submitted by both the parties before this Forum and understood that the complainant has taken “Family Medicare Policy 2014” for self, his wife and for his two minor children paying an annual policy premium of Rs.23,542/-(Rupees Twenty three thousand Five hundred and Forty two only) and this policy came into effect from 00 hours on 03/11/2017 and valid upto the midnight of 02/11/2018.  We observe that the complainant suddenly became ill on 15/01/2018 and consulted with the doctors of EMS Hospital, Perinthalmanna and then was admitted at Amritha Institute of Medical Sciences, Kochi on 20/01/2018 which is clear from Ext.A4 discharge summary, where “Cardio Vascular and Thoracic Surgery” was performed on the complainant on 23/01/2018 and was discharged on 29/01/2018 with instruction to report for follow up treatment at fixed intervals which is also clear from Ext.A4.  It is also understood that complainant had undergone further surgery on 06/02/2018.  We find that complainant has been carrying “Myxomatous Mitral Valve” and the “Severe Mitral Regurgitation, MVP-AML-A2-Prolapse Flail PML Severe MR Valve” which is clear from Ext.A4 discharge summary issued by Amritha Institute of Medical Sciences, Kochi, which will not occur within two or three months and will occur at least six months prior to 22/12/2017.  Further as per this policy terms and conditions, exclusion clause 4.1 mentioned in Ext.A1 the pre existing diseases will be covered only after a waiting period of 48 months.  We also observe that there are no prior policies taken by the complainant covering 48 months.  The DW1 deposition before this Forum also support that the complainant has got pre existing disease which will be covered as per this policy only after a waiting period of 48 months. 

DW1 deposition before this Forum is also to be noted that Rm³ ChnsS sXfnhv sImSp¡p¶Xv Hcp expert  F¶ \nebnemWv.  C³jpd³kv I¼\nbpsS DtZymKس AÃ.  Rm³  TPAbpsS claims Manager BWv. Rm³ TPA(Third Party Administration)bpw FXrI£nbpw (insurance  company bpw) X½nepÅ relations ImWn¡p¶ tcJIÄ H¶pw lmPcm¡nbn«nÃ.  Policy issue sN¿p¶Xn\v ap³]pÅ lÀPn¡mcsâ imcocnI AhØ F´mWv F¶v F\n¡dnbnÃ.  bmsXmcphn[ medical examination\pw medical check upDw Cu policy issue sN¿p¶Xn\p ap³]v \S¯nbn«nà witness adds TPA sNbvXn«nÃ. Insurance Company examination \S¯nbn«pt­m F¶v AdnbnÃ.  lÀPn¡mcsâ Mitral valve collapse F¶ deformity                3 amk¯n\pÅn severe Bbn hcnà F¶pÅ Imcyw GXv booksâ ASnØm\¯nemWv ]dbp¶Xv.(Q) A§s\ ]dbm³ ]änÃ.  CXv severe BbXpsIm­mWv aq¶v  amk¯n\pÅn hcnà F¶v ]dbp¶Xv. aäpÅ c­v hmÄhpIÄ¡v sNdnb XIcmdpw. Mitral valve\v severe Bb XIcmdpamWv DÅXv.  lmPcm¡nb tcJIfn Cu tcmKw aq¶v amk¯n\v ap³]v h¶XmsW¶v ImWp¶nÃ.  hyàambn Cu Imebfhn C§s\sbmcp  deformity hcmw F¶v F\n¡v ]dbm³ ]änÃ.  TPA claim reject sNbvXXv lÀPn¡mcs\ tcJmaqew Adnbn¨n«nÃ(Adds) Hospitals\ Adnbn¨n«p­v.  BbXp ImWn¡p¶ tcJIÄ lmPcm¡nbn«nÃ.  Mitral valve collapse F¶ disease\v cash less facility In«nà F¶ kwKXn Ext.A1 policy conditions sIm­v ImWnà F¶v ]dªm icnbmWv.(Adds) t]cv FgpXnbn«nÃ. GXv tcmK§Ä Cu policy {]Imcw cover sN¿psat¶m FsXÃmw cover sN¿nà Ft¶m Cu policy conditions ImWnà F¶p ]dªm icnbÃ.  Adds pre existing  FÃmw s]Spw.  lÀPn¡mc\v D­mbn«pÅ tcmKw Hcp pre existing disease Aà F¶v ]dªm icnbÃ.   TPA¡v th­n sXfnhv sImSp¡m³ F\n¡v                 locus standi Cà F¶p ]dªm icnbÃ.  lÀPn¡mcsâ AkpJw P·\m AÃmsXbpw hcmhp¶ AkpJamWv.  s]s«¶v hcmhp¶ AkpJw BWv.

            Similarly we also observe that as per the policy clause exclusions 4.1 which are mentioned in the policy which states that pre existing diseases are not covered within 48 months, but after 48 months they will be covered, if it is a continuous policy.  Thus we observe that as per the terms and conditions of the policy the complainant is not entitled to get the mediclaim amount since the waiting period of 48 months is not over for the preexisting diseases which the complainant in this case is actually suffering from.  Also it is seen that complainant has no prior policies.  Hence we order that the complaint is dismissed and the opposite party is not liable to honor the prayer of the complainant and pay the prayed amount.

Pronounced in the open court on this the 15^th day of October 2019.

                                                                                                          Sd/-                                                                                                                                     Shiny.P.R

                   President    

                                                                                                                         Sd/-

    V.P.Anantha Narayanan

                   Member

Appendix

Exhibits marked on the side of complainant

Ext.A1 – Family Package Policy 2014 issued by opposite party dated 03.11.2017.(Original)

Ext.A2 – Receipt issued by the opposite party to the complainant dated 03.11.2017.(Original)

Ext.A3 – Xerox copy of In-Patient Collection & Appropriation issued in the name of

   complainant by AIMS&RC, Kochi dated 12.02.2017.

Ext.A4 – Xerox copy of discharge summary issued by AIMS&RC, Kochi dated 29.01.2018.

Ext.A5 – Xerox copy of lawyer notice issued to the opposite party by complainant counsel

   dated 24.02.2018.

Ext.A6 – In-Patient Collection & Appropriation – summary of transactions issued in the

                name of complainant by AIMS&RC, Kochi dated 29.01.2018.(Original)

Ext.A7 – Pharmacy issue report issued by AIMS&RC, Kochi dated 29.01.2018.

Ext.A8Series – Copy of material issue report and material bills issued by AIMS&RC, Kochi

   dated 29.01.2018.

Exhibits marked on the side of Opposite Parties

Ext.B1 - Copy of Family Package Policy 2014 issued by opposite party dated 03.11.2017.

Witness examined on the side of complainant

PW1    - Rajeshkumar

Witness examined on the side of opposite parties

DW1 – Ashok Kumar