SRI.K. VIJAYAKUMARAN, PRESIDENT.

            This is a complaint filed seeking the insurance amount under a Medi claim policy, compensation and costs.

          The averments in the complainant can be briefly summarized  as follows:

          The complainant is a subscriber of Medi claim Insurance policy from the opp.party.   The complainant , complainant’s wife, son and mother  of the complainant are covered by the said Insurance policy.   The complainant has taken in the policy  No.2001/8500609 from the opp.party for the period from 26.3.2002 to 25.3.2003 in continuation of the said policy the complainant subscribed the medi claim policy bearing No.570500/48/02/8501031 in respect  of the period 26.3.2003 to 25.3.2004.  During the  subsistence of the policy the complainant’s mother  fell ill and she was admitted in the KIMS  Hospital, Thiruvananthapuram as in patient and under gone treatment from 18.3.2003 to 28.3.2003 and from 9.4.2003 to 16.4.2003.  A sum  of Rs.52,005/- was spent for the treatment of the mother.  On 11.6.2003 the complaint submitted  a claim before the opp.party in respect of the treatment charges of his mother.   Though the  complainant contacted  the opp.party on several occasions the opp.party failed to  expedite  the said claim.  The conduct of the opp.party amounts to deficiency of service and unfair trade practice.  The complainant is a consumer of the opp.party and the opp.party  is legally bound to disburse the claim within 3 months  of submission of the Medi claim form.   Hence the complaint.

          The opp.party filed a version contending, interalia, that the complaint  is not maintainable either in law or on facts.  The complaint  is lnot preferred by the insured Smt. Saraswathy Sukumaran for the claim of her treatment under the medi claim policy .    The complaint is bad for non-joinder of necessary party.   The complainant has approached  this Forum  with unclean hands by suppressing  material facts regarding the case.    The definition complaint, complainant, consumer dispute service as defined in section 2 [1] of the Consumer Protection Act  do not cover the claim made out in the  complaint.  This opp.party had issued  a medi claim insurance policy covering the complainant and his family members mentioned in the policy with a sum insured of Rs.50,000/- per person.   The policy was issued on the basis of the declaration given by the insured in the proposal form .  One of the insured Smt.  Sarasawthy Sukumaran was suffering from the disease of Hypothyrodism  at the time of joining the policy as per the declaration given in the proposal form and the said disease is specifically excluded from the insurance cover  of the policy issued by the opp.party.   The complainant’s mother  has  under gone treatment for  her illness associated  with Hypothyroidism  Hypokalemea of unknown Etiology  systemic hypertension, type 2 diabetes mellitus and depressive illness etc. at Kerala Institute of Medical Science  Thiruvananthapuram during  the period 18.3.2003 to  28.3.2003  and subsequently 9.4.2003 to 16.4.2003.  The discharge summary of the patient  issued from  the KIMS Hospital  shows that the patient was having known history of Hypothyroidism, Systemic Hypertension, Type 2 diabetes mellitus at the time of admission  and she was on regular treatment  for the same.  The patient was again admitted at KIMS Hospital on  9.4.2003  with the complaint of Hypothyroidism, systemic hypertension Type 2 diabetes mellitus etc. and had undergone treatment upto  16.4.2003.  In the discharge summary   the treated doctor has specifically stated that the patient was on regular treatment  for the complaints diagnosed even prior to the admission  in the said hospital.  The complainant’s mother was suffering from the disease Hypothyroidism  at the time of proposing  the medii claim policy on 15.3.2001  itself and on the basis of the declaration given in the proposal form   regarding  the above existing illness the said disease was clearly excluded from the coverage given under the policy.   The opp.party  after getting the claim intimation  and after verifying the treatment records produced  by the complainant  had deputed  an investigator   Mr. Santergeens for conducting an investigation  as to the claim preferred by  the complainant   The Investigator met the complainants mother  and obtained  a signed statement  from her  in which she had stated  that she was a patient of Dr. Rawther at Upasana Hospital prior to her admission at KIMS hospital  and she has under gone treatment of Dr. Roy Mathew of Medical College, Thgiruvananthapuram  about  4 to 5  years before  for the complaints of Hypothyroidism.   The investigator further reported that the complainant’s mother was under the treatment  of Dr.  S. Ramanathan at Surya Clinic, Kilikolloor  for depression which is a complaint characterized  to Hypothyroidism from 2002 onwards.  Therefore  it is clear that the complainant’s mother was   suffering from the disease of Hypothyroidism, systemic hypertension, depressive illness, hypokalemea and diabetes mellitus etc. for the last many years and was on regular treatment for the same.  Since the disease Hypothyroidism and it’s related disease are clearly excluded from coverage of the policy, the opp.party  shall not liable to  make any payment for the expenses incurred for the treatment of the complainant’s mother  under exclusion clause 4 [1]  of the policy.    Therefore the opp.party repudiated  the claim  dated 19.1.2004.  The claim of Rs.52,005/- preferred by the complainant is also baseless and false.   The complainant has paid only Rs.37,676.81 towards  the  hospital expenses during the above inpatient treatment  and out of which Rs. 2,628/-is paid for Cafeteria, Miscellaneous charges, Telephone charges  ambulance charges etc.  which are clearly excluded from the coverage of the policy.  There is no deficiency in service on the part of the opp.party.  The complainant is not entitled to get the amount as claimed in the complaint .  Hence the opp.party prays to dismiss the complaint with their costs.

Points that would arise for consideration are:

1. Whether  the complainant is entitled to get the  amount claimed in the complaint?

 2. Whether there is deficiency in service on the part of the opp.party?

  3. Reliefs and costs

For the complainant PW.1  and 2 are examined.  Ext.P1 to P6 are marked.

For the opp.party DW.1 is examined.   Ext.D1 to D4 are marked.

POINTS:

          There is no dispute that the complainant’s mother  undergone treatment in KIMS  Hospital, Thiruvananthapuram and  that she had insurance coverage under Ext.P1 /D1 policy during that period.   According to the complainant though he preferred a claim the opp.parties did not allow the claim or repudiate the same.

          The opp.parties will content that the claim was already repudiated as per Ext.D4 and intimated the complainant as the treatment of the complainant’s mother was in relation to a pre-existing disease.

It is an admitted fact that the complainant’s mother  was admitted in the Kims Hospital for hypokalemia on unknown etiology and she had undergone treatment there as impatient from 18.3.2003 to 20.3.2003.  She was again admitted on 9.4.2003 and  undergone treatment as inpatient till 16.4.2003 .  At the time of taking policy she was suffering from hypothyroidism and Diabetes which was disclosed in the proposal form.  DW.1  has admitted  in chief examination itself in page No.1  this aspect.  He has stated that while taking policy for mother  it was clearly stated therein that mother is having  hypothyroidism, Diabetes and that the  policy was issued excluding these diseases.  If that  be so,  it cannot be said that there is any suppression.  It is pertinent to point out in this context that the proposal form  was not produced or  for reasons best known to the opp.party.  If only the same is produced it can be ascertained as to whether there are any wrong answers to questions or not or whether there is suppression of any disease.

          In Ext.P4 under the head history and clinical  findings it is stated that she has known history of Type II diabetes mellitus, hypothyroidism, systemic hypertension and normal pressure hydrocephalus at the time of admission..  There is no mention of hypokalemia .  It is further stated in the 1^st discharge summary that she was admitted one day after the symptoms first manifested PW.2  is the doctor who had seen the patient before admission to KIMS Hospital.  He has stated that hypokalemia is not a character or symptom of hypothyroidism.  In cross examination PW.3 asserted that there is no possibility of hypothyroidism developing into other diseases due to metabolic disorder.  According to PW.2 hypokalemia is a sudden  onset and not a pre-existing one. There is also  no material before us to show that hypokalemia is a consequence of other diseases present in her.  No medical evidence  was also adduced by the opp.parties to contradict  the evidence of PW.2 and  establish that hypokalemia  is a related disease of hypothyroidism, Diabetes Mellitus or any other disease mentioned in the discharge summary.   The burden to establish hypokalemia  is a related disease of the diseases mentioned in the discharge summary is on the opp.parties which they failed to discharge .  The opp.parties in our view failed to establish that hypokalemia is a pre existing disease or related disease of the disease mentioned in Ext.P4  in the case of  complainant’s mother and therefore repudiation of the claim by the opp.parties as per Ext. D4  is not proper and the complainant is entitled to get the amount incurred by him for the treatment of his  mother  less expenses incurred for cafeteria Miscellaneous charges, Telephone charges..  Point found accordingly.

          In the result the complaint is allowed directing the opp.parties to pay the complainant Rs.36,548/- for the treatment from 18^th to 28^th March 2003 and Rs.18203/- for the treatment from 9^th to 16^th April 2003  with interest @ 12% per annum from 19..1..2004 till payment.   The complain antis allowed Rs.2000/- towards compensation and Rs.1000/- towards costs.  The order is to be complied with within one month from date of this order.

            Dated this the 30^th day of  March, 2009.

I N D E X

List of witnesses for the complainant

PW.1. –Ajith.S.

PW.2. – Muhammad Ibrahim Rawther

List of documents for the complainant

P1. – Policy

P2. – 2^nd polict

P3. – Claim Forim

P4. – Dischargement summary, Doctors report, Bills

P5. – Diet sheet

P6. – Claim settlement  Covering letter

List of witnesses for the opp.party

DW.1. – Michel Antony

List of documents for the opp.party

D1. – Policy with condition

D2. – Discharge summary dated 18,3.2003 to 28.3.2003

D3. – Discharge summary dated 9.4.2003 to 16.4.2003

D4.- Repudiation letter.