BEFORE THE DISTRICT FORUM: KURNOOL

Present: Sri.T. Sundara Ramaiah , B.Com B.L., President

And

Sri. M. Krishna  Reddy , M.Sc., M.Phil., Male Member

Monday the 09^th day of August, 2010

C.C. No.125/09                                                                                                                                                                                                                           

Between:

S.Fathima, W/o. S.Akharavali,

R/o. H.No.36/3-127,  Banjara Colony, Balaji Nagar, Kurnool-518 003.                                      …..Complainant

-Vs-

The Divisional Manager, M/o. Oriental Insurance Company Limited, Divisional Office, Bhupal Complex,

Post Box No.33, Park Road, Kurnool-518 002.                                        …Opposite Party

     This complaint is coming on this day for orders in the presence of Sri.S.Siva Rama Krishna Prasad, Advocate, for complainant, and Sri.V.V.Krishnama Raju, Advocate for opposite party and upon perusing the material papers on record the Forum made the following.

    ORDER

(As per Sri. T.Sundara Ramaiah, President)

C.C. No.125/09

1.     This complaint is filed under section 12 of C. P. Act, 1986 praying to direct the Ops    (a)  to pay the sum assured Rs.15,000/- with accrued interest in order to satisfy  the claim of the  complainant  under the policy bearing No. 47/2007/1693. 

(b)    to grant a sum of Rs.25,000/- towards mental agony .

( c)   costs of the complaint and

(d)    such other relief or relief’s as the Hon’ble Forum may deems fit and proper under the circumstances of the case.

1. The case of the complainant in brief is as follows:- The complainant obtained a Universal Health Insurance Policy from OP . The policy was inforce from 17-01-2007 to 16-01-2008. As per the terms and conditions of the policy the OP has to provide medical aid and to pay the hospital bills through 3^rd party administrator to the insured. On     03-06-2007 the complainant joined in Santhiniketan Hospital, Kurnool for the complaint vesico viginal fistula. The complainant undergone operation and she was discharged from the hospital on 13-06-2007. The complainant lodged a claim with OP for the expenditure incurred during her hospitalization. The OP repudiated the claim on 12-07-2007 stating that the deceased suffered by the complainant is excluded during the 1^st year of the policy as per the exclusions clause 4.3. Hence the complaint.     

3.     OP filed written version stating that the complaint is not maintainable. It is true that the complainant obtained the policy from OP on 17-01-2007 by paying a premium of Rs.548/- . The policy covers  period from 17-01-2007 to 16-01-2008. As per the terms and conditions of the policy fistula will not be covered during the 1^st year of the policy. The fistula either in the anus or in the vigena will be treated as one and same.  Hence the claim was repudiated on 12-07-2007. As per the Clause 4.3 of the policy, the complaint is not maintainable. The complainant failed to give the date from which she was suffering from fistula. As per the terms and conditions of the policy, the ailments which are pre-existing at the time of the proposal will not be covered during subsequent period of renewal. The complaint is not entitled to any amount.    

4.     On behalf of the complainant Ex. A1 to A4 are marked and the sworn affidavit of the complainant is filed. On behalf of the opposite party no document is marked and sworn affidavit of OP is filed.  

5.     Heard arguments.

6.     The points that arise for consideration are    

(i)     whether there is deficiency of service  on the part of OP ?

(ii)    whether the complainant is entitled  to any relief ?

1.  To what relief?

7.     Points No.1 & 2 :-  Admittedly the complainant  took Universal Health Insurance Policy from OP . The said  policy  was  in  force  from

17-01-2007 to 16-01-2008. It is the case of the complainant that she  joined in Santhiniketan Hospital, Kurnool on 03-06-2007 and undergone operation for vesico vigina fistula. The complainant in her sworn affidavit stated that she took the policy Ex.A1 from the OP and that she joined in the hospital on 03-06-2007 to undergone operation. Ex.A2 is the discharge summary of the complainant issued by Santhiniketan Hospital, Kurnool. As seen from Ex.A2 it is very clear  that the complainant  joined in the hospital on 03-06-2007 , undergone operation on 05-06-2007 and that she was discharged from  the hospital on 13-06-2007. It is also mentioned in Ex.A2 that the complainant incurred an amount of Rs.17,700/- for undergoing operation , room rent and medicines. Admittedly the complainant after she was discharged from the hospital submitted the claim to the OP and the OP repudiated the said claim as per Ex.A3 on 12-07-2007 stating that as per the terms and conditions of the policy the fistula in anus is excluded during the 1^st year of the policy . Ex.A1 is the policy containing the terms and conditions Clause 4 contains the exclusions. In Clause 4.3 it is mentioned that during the 1^st year of the operation of the policy the expenses incurred on treatment of deceased such as …. Fistula in anus … and related disorders are not payable.  It is also mentioned in Clause 4.3 of Ex.A1 that deceases which are pre existing at the time of proposal will not be covered during subsequent period of renewal. It is not the case of the complainant that she took treatment for Fistula in anus. According to the complainant she was suffering from Fistula in vigina and that she had undergone operation in Santhiniketan Hospital. The repudiation of the claim by the OP on the ground that the policy does not cover the Fistula cannot be accepted. It is also the contention of the OP that the policy does not cover the decease which the insured was suffering by the date of the policy. No material is placed by OP to show that the complainant was suffering from Fistula by the date of the policy. In discharge summary Ex.A2 also there is no mention from which date the complainant was suffering from Fistula. As already stated the Fistula in vigina is not excluded from the preview of the policy Ex.A1. The contention of the OP that it is not liable to pay the medical expenses incurred by the complainant is not sustainable. The complainant claims assured amount of Rs.15,000/- . As seen from Ex.A2 it is very clear that the complainant incurred an amount of Rs.17,700/- for hospitalization medicines etc.,  The OP refused to pay the amount to the complainant on flimsy grounds. There is deficiency of service on the part of the OP.

8. Point No.:3    In the result the complaint is partly allowed directing the OP to pay Rs.15,000/-  with interest at 9% from the date of the repudiation of the claim i.e, on  12-07-2007 till the date of payment along with costs of Rs.500/-.

Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 09^th day of August,  2010.

        Sd/-                                                                        Sd/-            

  MALE MEMBER                                                                    PRESIDENT

      APPENDIX OF EVIDENCE

Witnesses Examined

For the complainant : Nil            For the opposite parties :Nil

List of exhibits marked for the complainant:-

Ex.A1        Copy of insurance policy No.47/2007/1693 along with terms and conditions.

Ex.A2.       Copy of hospital bills and discharge summary card

dt: 13-06-2007 .

Ex.A3.       Repudiation letter dt:12-07-2007..

Ex.A4.       Oriental Insurance Company broacher. .

List of exhibits marked for the opposite parties:  Nil

          Sd/-                                                                                     Sd/-

MALE MEMBER                                                            PRESIDENT

// Certified free copy communicated under Rule 4 (10) of the

A.P.S.C.D.R.C. Rules, 1987//

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Complainant and Opposite parties

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