ADV. RAVI SUSHA, MEMBER.

            The complaint filed by the complainant for getting the medical reimbursement claim of Rs.47,278/-, compensation and  costs etc.

          The averments in the complaint can be briefly summarized as follows

 The complainants have  been a subscriber of mediclaim Insurance Policies issued by the opp.parties.   The opp.parties one of the authorized agent came to the complainant’s house and explained the importance and benefits of the health plus medical expenses policy  The complainant has joined the policy with the intention of getting medical Insurance coverage to the complainants. On 26.4.04 the 1^st complainant had paid Rs.2819/- to the agent for renewing the existing policy and for the amount he issued receipt  On 27.5.04 the agent had given the Health Plus Medical Expenses Policy/Individual Health to the complainant vide Policy No.760905/48/04/00230 dt. 26.5.2004 and the validity of the policy period is 27.5.2004 to 26.5.2005  After the expirty of the existing policy the complainants had renewed the policy for the next one year [Policy No.760905/48/05/75036  As per the said policy the insured, the 1^st complainant and his two other family members have also covered by the said policy and entitled to get the benefits and their names also recorded in the policy.  On 2o.6.2005 the 2^nd complainant sustained stomach paid and for the severe pain she consulted the Doctor at A.M. Hospital, Karunagappally.   The doctor conducted elaborate check up and found that she has Incisional Hernia.    She was admitted and treated in the said hospital from 20.6.05  to 30.6.05.    On 21.6.05 repair of hernia was done after render spinal Anaesthasia,  On 30.6.05 she was discharged with an advice of complete bed rest and continuing treatment.    On 2.7.2005 she was readmitted in the said hospital following palpitation, high fever and other discomfortness and hence she was admitted in the ICU  and treated in the  AM hospital till 6.7.05.  On 6.7.05 she was discharged on request for a better treatment and hence she was admitted and treated in the SP Fort Hospital, Thiruvananthapuram till 15.7.05.  After her discharge from SP Fort Hospital she was again admitted in the A.M. Hospital, Karunagappally from 16.7.05 to 20.7.05.    On 11.8.2005 after her discharge the complainants submitted the claim form before the 1^st opp.party with all the relevant documents  ie.  original bills for Rs.47,278/- and the treatment records   :The 1^st opp.party verified the documents and advised the complainants will get the amount as per the policy at the earliest.  But unfortunately the 1^st complainant got a cheque bearing No.6498 dt. 10.9.2005 for Rs.2582/- along with a letter dt. 10.9.05 from the opp.parties  stating that Acceptance of the above mentioned cheque by the insured is in full and final settlement of the claim  and the insurer stands fully discharged of its liability under the mediclaim policy.  After  receiving the letter the complainant approached to the opp.parties and explained the previous policy and the continuation of its renewal and the liability of the opp.parties for the allotment of the genuine claim of the complainants.  On 29.9.2005 the complainants got another letter from the opp.parties stating that this claim pertains to repair of Incisaional Hernia, Previous history of hypothyroidism on treatment and COPI in the claim stands Repudiated under clause 4.1, [pre-existing Ailments, 4.2[ claim within 12 days of policy cover]. and 4.3.[[Hernia repair surgeries are excluded in the 1^st year of policy cover]  After received the letter the complainant  again contact with the opp.parties and convinced to them that the mentioned diseases are not the pre-existing  diseases or it is not the follow up disease as stated by the opp.paries and also the 2^nd complainant had not claimed any amount from the opp.parties in the previous year and hence the opp.parties are liable to pay the claim amount as per the policy There is deficiency in service on the part of the opp.parties.  Hence the complainant approached this Forum for relief.

The opp.parties filed version contending, interalia, that the complaint is not maintainable either in law or on facts.  The opp.parties issued a Health plus medical expense policy bearing Policy No.760905/48/04/00230 in favour of the complainant for a period of one years starts from 27.5.2004 to 26.5.05.    The expiry of the existing policy the complainants had renewed in continuation of the said policy for the next one year is not true.  The policy bearing No.760905/48/05/5035 mentioned in the petition is not the continuation of the earlier policy.   There is a break of 12 days happened therein.    So the 2^nd policy can be treated as a new policy begins to run for a period of one year starts from 8.6.05to 7.6.06. and there is admission of policy from 8.6.05 to 7.6.06 the opp.parties have no liability to make any payment in respect of treatment expenses incurred to insured complainants under the exclusion clauses 4.1, 4.2 and 4.3 of the policy conditions because there is grave violation of policy conditions.    The complainant had pre-existing decease and surgery done for the same on earlier occasion.  But the complainants suppressed these facts in the proposal form for issuing the policy.  On 20.62005 the complainant sustained stomach pain and thereafter on detailed medical checkup, found that she has the complaint of incisional Hernia and as a result on 21.6.05 repair of hernia was done in A.M. Hospital, Karunagappally.     As per clause 4.2 of the policy conditions, any disease other than those stated in  has no liability to pay compensation.  clause 4.3. contracted by the insured person during the 1^st 30 days from the commencement date of the policy, the insurer  has no liability to pay compensation.   The claim pertains to the treatment of wound infection of a pre-existing Hernia Incisional scar done for a period between 20.6.05 and 30.6.05.   The discharge card issued from the AM Hospital show the medical history as previous history of COPD[+] known hypothyroidism and so the opp.parties rejected the complainant’s claim of expense for the treatment done from 20.6.05 to 15.7.05 as per clause 4.1.   The 2nddischarge card  issued from the A.M Hospital, Karunagappally also show the period of treatment between 2.7.05 to 6.7.2005.   The discharge summary of SP Fort Hospital for the treatment period from 6.7.05 to 15.7.05 also shows that medical history of Hypothyroidism on treatment and stopped treatment for last 3 weeks with a diagnosis that would infaction, lower respiratory infection and newly developed diabetes etc. which are all the continuation of treatment from 20.6.05 to 15.7.05 for the pre existing disease of the 2^nd complainant and hence the expense incurred for the treatment in such period fall under clause 4.1, 4.2 and 4.3 of the policy conditions and hence the opp.party rejected the claim.    When the claim application received the opp.parties made all effort to settle the claim and verified the treatment records submitted by the complainants.     The discharge card issued from the A.M., Hospital Karunagappally for the period of 17.7.2005 to 20.7.2005 show that the 2^nd complainant has been treated there with in the policy period and there is no exclusion under any clause of the policy and hen ce the bill amount submitted by the complainant were settled by the opp.parties.  There is no deficiency in service on the part of the opp.party.  Hence the opp.parties prays to dismiss the complaint.

Points that would arise for consideration are:

1.     Whether there is deficiency in service on the part of the opp.parties

2.     Reliefs and costs.

For the complainant PW.1 is examined.   Ext.P1 to P12 are marked.

For the opp.parties DW.1 is examined.   Ext. D1. to D19 are marked

Points:

          The complainant’s case is that they were a subscriber of the medi claim Insurance Policy issued by the opp.parties.   The validity of the policy period is 27.5.2004 to 26.5.2005.  After the expiry of the existing policy the complainant renewed the said policy for the next one year.   As per the policy the 1^st complainant and his two other family members have also covered in the policy.   The 2^nd complainant was admitted and treated in the hospital due to stomach pain and for the sever pain from 20.6.05 to 20.7.05.  After the discharge from the hospital she submitted the claim form before the 1^st opp.party.  But the claim was repudiated.  Hence the complainant filed this complaint for getting g the treatment expenses.  Opp.parties main contention is that as there is grave violation of policy conditions the opp.party has no liability to make any payment in respect of treatment expenses incurred to the 2^nd complainant.  Here the point to be decided is that whether the claim repudiation made by the opp.party in this case is justifiable.   According to the complainant the policy bearing No.760905/48/05/75036 is a continuation of the 1^st policy.  But opp.parties version is that the policy bearing No.760905/48/05/7506 is not the continuation of the  earlier mentioned policy.   There is a break of 12 days.  So the policy No.760905/48/05/75036 can be treated as a new policy starts from 8.6.05 to 7.6.06.  On verification of policy period of two policies there is a break of 12 days.   There is no dispute that the 1^st policy period is 27.5.2004 to 26.5.2005 and the renewed policy period is 8.6.2005 to 7.6.2006.  Then there is a break of 12 days for taking the 2^nd policy and it cannot be treated as the continuous policy after 1^st policy.  It can be treated only as a new policy begins from 8.6.2005 to 7.6.2006.   The opp.party repudiated the claim preferred by the complainant under the exclusion clauses4.1, 4.2. and 4.4 Ext. P10 the discharge summary from SP Fort Hospital shows that the history and clinical findings is Hypothyroidism on treatment and stopped treatment for the last 3 weeks.  That means the complainant had pre-existing disease and surgery done for the same on earlier occasion.  But the complainant suppressed these facts in the proposal form for issuing new policy.   As per clause 4.2 of Ext. D3 policy conditions any disease other than those stated in clause 4.3 contracted by the insured person during 1^st 30 days from the commencement date of the policy, the insurer has no liability to pay compensation.   The claim preferred to a treatment for a period between 20.6.2005 to 15.7.2005 ie. The  treatment  started within the first 30 days of policy cover.   As per clause 4.3 of Ext. D3 during the 1^st year of the operation of Insurance cover, the expenses on treatment of diseases such as cataract, Hernia, Vydrocolo etc. are not payable.   The claim pertains to the treatment of incisional Hernia.   There is no difference between  Hernia and Incisional Hernia.  Hence the disease comes under clause 4.3.   From the entire evidence we are of the view that though the policy period of the new policy bearing No.760905/48/05/75036 is from 8.6.05 to 7.6.2006 , the opp.party has no liability to make any payment in respect of treatment expenses incurred to the 2^nd complainant under the exclusion clause 4.1., 4.2 and 4.3 mentioned in Ext. D3 policy condition with regard to discharge card from A.M. Hospital, Karunagappally for a period from 17.7.2005 to 20.7.2005, there is no exclusion clause as per policy conditions.  In these circumstances we are of the view that the repudiation of the claim under exclusion clause 4.1., 4.2 and 4.3 in proper.   There is no deficiency in service on the part of the opp.party.  Point found accordingly.

In the result the complaint fails and the same is hereby dismissed. No costs.

          Dated this the 4^th day of February, 2010

I N D E X

List of witnesses for the complainant

PW.1. – Niza

List of documents for the complainant

P1. – Policy Certificate

P2. – Letter dt. 10.9.05

P3. – Copy of cheque dt. 10.9.2005

P4. – Letter dated 21.9.05

P5. Letter dated 22.9.05

P6. – Letter dated 29.9.05

P7. – Letter dated 26.10.05

P8. – Treatment certificate dt. 31.10.05

P9. – Discharge certificate

P10. – Discharge summary from S.B. Fort Hospital

P11. – Discharge card dt. 6.7.06

P12. – Discharge card

List of  witnesses for the opp.party

DW.1. – V. Jayaraman

List of documents for the opp.party

D1. – Policy certificate

D2. – 2^nd policy certificate from 8.6.05 to 7.6.06

D3. – Policy conditions

D4. –mClaim form

D5. – Medical certificate

D6. – Repudiation letter dt. 31.8.05

D7. – Repudiation letter dt, 9.9.2005

P8. – Claim form No.2

P9. – Connected Medical certificate from A.M. Hospital

D10. – Repudiation letter dt. 25.10.2005

D11. – Repudiation letter dt. 26.10.2005

D12. – Claim form No.3

D13. – Connected medical certificate

D14. – Repudiation letter dt. 13.9.05

D15. – Repudiation letter dt. 21.9.2005

D16. – Claim form No.4 treated from 17.7.05 to 20.7.05

D17. – Connected medical certificate

D18. – Settlement letter for a period from 17.7.05 to 20.7.05

D19. – Proposal form connected to Ext. P2