By. Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of Consumer Protection Act for an Order directing the opposite parties to pay Rs.2,18,388/- being the hospital bill amount to the complainant along with compensation of Rs.30,000/-.
2. Brief of complaint:- The complainant's mother took a medi claim policy named Senior Citizens Red Carpet Policy from the 1st opposite party through agent Paulson Chulliyode on 21.04.2012. The sum assured amount is Rs.3,00,000/-. This policy does not require medical checkup. The complainant paid Rs.15,000/- as premium amount. Due to illness the complainant's mother was taken to Dr. Vineeth Gladson on 20.09.2012 for check up and Doctor after taking ECG, the patient was referred to MCH, Kozhikode. On 24.09.2012, Echo test was done at MCH, Calicut and on 29.09.2012 CAG test was also conducted. The complainant's mother was taken to Moulana Hospital Perinthalmanna and admitted there on 04.03.2013 and operation conducted on 05.03.2013. This matter was informed to opposite parties and opposite parties informed the complainant that they cannot give cashless benefit but only reimbursement. The opposite parties assured the complainant that they will pay insurance amount to the complainant but when claim arised, the opposite parties repudiated the claim. The act of opposite parties amounts to deficiency of service and hence this complaint.
3. On receipt of complaint, notice was issued to opposite parties and opposite parties appeared before the Forum and filed version. In the version of opposite parties, the opposite parties stated that there is no deficiency of service on the part of opposite parties since the heart disease suffered by the complainant's mother was within the period of 30 days from the date of inception of policy which is clear from the case records of the insured who underwent treatment at St.Martin Hospital, Ambalavayal. The opposite parties admitted the policy. The insurance contracts are contracts of uberrima-fide. The policy is issued according to the terms and conditions of policy. The complainant's mother was admitted at Moulana Hospital, Perinthalmanna on 04.03.2013 and was diagnosed in severe calcific as and she had undergone surgery of Aortic Valve replacement on 05.03.2013 and was discharged on 15.03.2013. On enquiry, it was found that the insured was on treatment for valve complaints since 18.05.2012. The policy commenced from 21.04.2012 and the illness is within 30 days of policy. The claim falls under Exclusion clause No.2 of the policy ie "Any disease contracted by the insured person during the 1st 30 days from the commencement date of the policy. There is suppression of material facts".
4. On perusing the 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 parties?
2. Relief and Cost.
5. Point No.1:- The complainant filed proof affidavit and is examined as PW1 and documents are marked as Ext.A1 to Ext.A10. Opposite party No.1 also filed proof affidavit and is examined as OPW1 and Ext.B1 to B7 marked. On verifying the policy details the Forum found that the policy commenced on 21.04.2012 and the validity period is 21.04.2012 to 20.04.2013. The opposite parties admitted the policy. On verification of records, the Forum found that in Ext.B4 document ie pre-authorization request, it is recorded that the mother of the complainant was suffering from heart disease since 3 months from the date of admission. So the opposite parties contented that there is pre-existence of illness, the opposite parties has denied the cashless facility. Moreover in Ext.B6 document, the mother of complainant was treated in St. Martin Hospital, Ambalavayal on 18.05.2012 and the Doctor recorded valve complaint. The policy was taken on 21.04.2012. As per Ext.B6 document, the treatment was done on 18.05.2012. So the treatment is within 30 days from the date of inception of the policy and the disease is reported within 30 days of inception of policy. As per clause exclusion clause 2 of the policy, the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of any disease contracted by the insured person during the first 30 days from the commencement date of the policy. The complainant's mother had undergone operation for the same disease on 05.03.2013. In Ext.B6 document, the doctor had recorded valve complaint without verifying any details and details not known to the doctor. In Ext.B4 also, the doctor filled up the column medical history and recorded and Heart Disease "since 3 months" without basing any document. As per clause 2 of the policy the condition is that the treatment is within 30 days of the commencement of the policy, the company is not liable.
6. Here in this case, the treatment done on 18.05.2012 ie after 27 days of commencement of policy. Only 3 days is left in completing the specified time limit. More over, the policy is a senior Citizens Red Carpet Insurance Policy. Considering all these aspects, the Forum is of the opinion that the complainant's mother is entitled to get the treatment expenses. If a senior citizen who took a special policy named senior citizens red carpet insurance policy, repudiation of claim due to minor discrepancies is not fare. The Forum is of the opinion that since the insured being a senior citizen and under humanitarian consideration also, it is just and proper to award medical expenses to the complainant. Repudiation of claim of complainant's mother is a deficiency of service from the part of opposite parties. 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 parties are directed to pay Rs.2,18,388/- (Rupees Two Lakh Eighteen Thousand Three Hundred and Eighty Eight) only towards treatment expenses to the complainant along with Rs.1,000/- (Rupees One Thousand) only as compensation and Rs.1,000/- (Rupees One Thousand) only as cost of the proceedings. The opposite parties shall comply the Order within 30 days from the date of receipt of this Order, failing which the complainant is entitled to get 12% interest for the whole sum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 16th day of April 2015.
Date of Filing:07.11.2013.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Azeez. Complainant.
Witness for the Opposite Parties:-
OPW1. Padma Prabha. Senior Officer, Legal, Star Health.
Exhibits for the complainant:
A1. Copy of Brochure and ID card.
A2(1), (2). Copy of Claim Repudiation Letter. dt:28.06.2013.
A3(1). Copy of Claim Form for Medical Insurance.
A3(2). Copy of Medical Certificate to be filled in by treating Doctor.
A3(3). Copy of Bill Details.
A4. Doctor's Prescription. dt:20.09.2012.
A5. Copy of Echocardiography Report. dt.24.09.2012.
A6. Report of Department of Cariology. dt:29.09.2012.
A7. Copy of OP Ticket.
A8. Copy of Doctor's Prescription. dt:25.02.2013.
A9. Copy of Discharge Summary.
A10. Certificate. dt:24.02.2014.
Exhibits for the opposite parties:-
B1. Policy Schedule and conditions of Star Senior Citizens Red Carpet Insurance Policy.
B2. Copy of Proposal Form.
B3. Copy of Discharge Summary.
B4. Copy of Pre-Authorisation Request Form.
B5. Copy of Cashless Denial Letter. dt:04.03.2013.
B6. Copy of Case sheet.
B7. Copy of Repudiation Letter. dt:28.06.2013.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
