BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 114/2009 Filed on 21.05.2009

Dated : 30.08.2010

Complainant:

George Koshy, Athiyalil House, T.C 2/2196, A.N 60, Pattom P.O, Thiruvananthapuram.

(By adv. Paraniyam R.T. Devakumar)

Opposite parties :

1. The Divisional Manager, United India Insurance Co. Ltd., Divisional Office No. 1, III Floor, CWC Building, L.M.S Compound, Trivandrum-695 033.

    

   (By adv. R. Jagadish Kumar)

    

2. Family Health Plan Ltd., No. 39/4967 G, Uznaz Towers, 5^th Floor, Medical Trust Junction, Pallimukku, M.G. Road, Ernakulam-682 016.

This O.P having been heard on 17.07.2010, the Forum on 30.08.2010 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

Complainant was insured under an individual medical policy by the 1^st opposite party for Rs. 1,50,000/- vide policy No. 100400/48/06/20/00003162 for any injury sustained and any disease contracted by him during the period of the policy after the first 30 days waiting period of the policy. The aforesaid policy was effective from 10:51 hours of 13.12.2006 to midnight of 12.12.2007 with M/s Family Health Plan Limited as the Third Party Administrators. On 25.01.2007 while the complainant was in the Republic of Maldives, he developed symptoms of suffocation. Though he consulted a local doctor, his illness could not be diagnosed for want of proper medical facilities in that country. Thereafter the complainant returned to India and had his first medical check up and diagnosis of the disease at the hospital St. Gregorios Cardio Vascular Centre at Parumala on 12.02.2007. As the diagnosis revealed that the complainant was suffering from Coronary Artery Disease, Renal Dysfunction, Triple Vessel Disease, NIDDM and Hypertension, he was admitted to the aforesaid hospital on 26.02.2007 for a surgery on 27.02.2007. After a 6-day hospitalization the complainant was discharged on 05.03.2007. On return home from the hospital the complainant preferred a claim with all necessary documents before the 1^st opposite party as per the policy condition for the reimbursement of his medical expenses which amounted to Rs. 1,06,205/-. The 1^st opposite party, thereafter, forwarded the claim to the 2^nd opposite party for settlement. Unfortunately, the claim was repudiated by the 2^nd opposite party for the reason that as per the documents submitted, the claim fell under the “30 days waiting period” of the policy. Complainant immediately took up the matter with the 1^st opposite party who also wrote back to the complainant quoting more of the reason for rejection as indicated by the 2^nd opposite party. The 2^nd opposite party not only failed to take proper notice of the date indicated in the Medical Certificate, but also deliberately reckoned the date as being within the “30 days waiting period”. The 2^nd opposite party also callously wrote vide No. claim ID Chn. 127736 dated 10.05.2007 to inform the complainant, a heart patient, of his unscrupulously baseless repudiation of the claim for such a large amount incurred and defrayed already by the complainant. The 1^st opposite party went a step further and wrote to the complainant vide his letter CNRO.TECH 886:07 dated 26.11.2007 falsely stating that the doctor also certifies that the duration of the complaints could be one month prior to 12.02.2007. Further the 1^st opposite party irresponsibly wanted the complainant to treat the matter as closed. Aggrieved gravely by the utter deficiency in service and unfair trade practice adopted by the 1^st and 2^nd opposite parties, the complainant had no alternative but to approach this Hon'ble Forum for justice. Complainant submits that as a result of the wilful negligence of the opposite parties, he has suffered undue and avoidable agony which could have jeopardized his life. The complainant has purchased an Insurance Package for his whole family for Rs. 3,00,000/- and his claim is within the limit admissible for him. The refusal of the claim by the opposite parties is baseless, unfounded and unjust. The opposite parties have resorted to enriching the profit of their business by unethical and exploitative methods. The repudiation of the claim is malafide, illegal, arbitrary, ultravires the policy. It is intentionally intended to vex, harm and harass the hapless complainant. Hence this complaint.

1^st opposite party, United India Insurance company filed version. In the version 1^st opposite party admitted the medi claim policy of the complainant. They stated that when the question of compensation comes the opposite party is strictly bound by the recitals mentioned in the policy conditions. The recitals of the policy would say after the inception of the policy, there is a waiting period of 30 days and any claim made during this period will not be entertained by the opposite party. The complainant has himself pleaded in the complaint, he has developed the symptoms of the disease on 25.01.2007. According to the treating doctor the patient consulted him on 12.02.2007 and the doctor also certified that the duration of the disease could be one month prior to this, i.e; to say either on 12.01.2007 or 25.12.2006, both the dates coming within the waiting period slot which extends till 13.01.2007. Hence the opposite party cannot compensate since it is a claim arising within the lock-in period. Moreover the treating doctor also says that the complainant had previous history of hypertension and diabetes and the entire claim comes outsides purview of the policy conditions and the opposite party is not legally bound to compensate. The opposite party further states that the claim of the complainant is a claim for CAD, Renal Dysfunction, Triple Vessel disease, NIPPM, HTN and the submitted documents would substantiate that the claim falls within the 30 days waiting period of the mediclaim and hence the claim was repudiated. This being the reason, no deficiency of service can be attributed to the opposite party. The claim was rejected by the opposite party under clause 4.2 of the policy. There was never any deficiency of service nor negligence from the part of the opposite party towards the complainant. As soon as the claim was lodged the same was processed and since the claim falls outside the purview of the policy, the same was repudiated.

The 2^nd opposite party Family Health Plan Limited remains exparte.

Complainant in this case has filed proof affidavit and examined him as PW1. He has produced 7 documents which were marked as Exts. P1 to P7. Opposite party did not adduce any evidence.

The points which arise for consideration are:-

1. Whether there has been deficiency in service or unfair trade practice occurred from the side of opposite parties?

2. Whether the complainant is entitled to get the reliefs sought for and costs?

Points (i) & (ii):- The case of the complainant is that he is entitled to get the medi-claim benefit for his treatment as per the terms and conditions of the policy. The opposite party contended that the claim falls within 30 days waiting period of the mediclaim and hence the claim was not sustainable. Hence we have to ascertain whether the symptoms of the illness occurred during the waiting period.

In this case complainant has produced 7 documents to prove his contentions. Ext. P1 is the policy copy of the complaint. As per this policy, period of insurance is from 13.12.2006 to 12.12.2007. Ext. P2 is the doctor's prescription of the complainant dated 25.01.2007 in Maldives. Ext. P3 is the prescription of medicines. This was the first consultation of the illness after taking the medi-claim policy. The complainant returned from Maldives on 09.02.2007 for further treatment. Ext. P4 is the copy of passport showing the journey. Thereafter he underwent medical examination on 12.02.2007 and found that he was suffering from Coronary Artery Disease, Renal Dysfunction, Triple Vessel Disease, NIDDM and Hypertension. And he was admitted in hospital on 26.02.2007 and operated on 27.02.2007. He was discharged on 05.03.2007. Ext. P5 is the copy of treatment record of the complainant. This document is the evidence for the entire treatment from 26.02.2007 to 05.03.2007 of St. Gregorios Cardio Vascular Centre. As per the medical report prepared by the doctor Madhu Paulose the complainant, insured has been suffering from the illness for one month before the admission date i.e; 26.02.2007. From this report we find that the symptoms of the illness occurred from 25.01.2007 and the complainant reported the hospital as out-patient on 12.02.2007. Ext. P7 is the payment receipt of insurance premium amount Rs. 5,770/-.

In this case the opposite parties did not adduce any evidence. 1^st opposite party United India Insurance Company filed version. The main contention of the opposite party is that the complainant has developed the symptoms of the disease within the waiting period for 30 days and any claim made during this period will not be entertained. The opposite party stated that complainant has developed the symptoms of the disease on 25.01.2007. According to the treating doctor the patient consulted him on 12.02.2007 and the doctor also certifies that the duration of the disease could be one month prior to this i.e to say either on 12.01.2007 or 25.12.2006 both the dates coming within the waiting period slot which extends till 13.01.2007. Hence the opposite party cannot compensate since it is a claim arising within the lock-in period. And the opposite party further contended that the treating doctor says that the complainant had previous history of hypertension and diabetes and the entire claim was outside the purview of the policy conditions and the opposite party is not legally bound to compensate. But the opposite party did not prove their contentions. The argument of the complainant is that he took the insurance policy on 13.12.2006. There is no dispute regarding this date. Ext. P1 is the evidence of that statement. He developed symptoms on 25.01.2007. Ext. P2 is the evidence of the same. The first consultation was after 42 days of taking policy. The operation was conducted on 27.02.2007 i.e after 74 days. Hence the argument raised by the opposite party is baseless. From the documents and other evidences adduced by the complainant we find that the symptoms of the disease occurred after the waiting period of 30 days. Hence the opposite party is liable to pay the medical expenses as per the policy conditions. The refusal of the claim by the opposite parties are baseless and unjust. Repudiating the complainant's claim without properly verifying the documents or wrongfully interpreting the facts to their own advantage constitutes clear violation of the expected service of the opposite parties under the policy conditions and the acts of the opposite party is amounting to deficiency in service and unfair trade practice.

In this case the opposite party stated that the complainant had previous history of hypertension and diabetes. But the opposite party failed to establish that contention. At the time of cross examination the counsel for the opposite party asked the complainant that “നിങ്ങള്‍ diabetic patient ആണല്ലോ? (Q) Heart attack വന്നപ്പോഴാണ്

diabetic ആണെന്ന് മനസ്സിലായത്(A). The opposite party has not adduced any evidence to show that the complainant had a previous history of hypertension and diabetes. Hence that contention of the opposite party is not sustainable. As per Ext. P5 hospital bill, the complainant has paid total amount of Rs. 1,00,900/-, i.e Rs. 85,000/- + Rs. 15,900/-. As per Ext. P5 bill Rs. 6,000/- is in the heading as camp concession. And also Rs. 500/- is paid as the food expenses from the total amount. Hence the opposite party is liable to pay Rs. 1,00,400(Rs. 1,00,900-Rs. 500/-). As per the Individual Medi-claim policy the insured amount is for Rs. 1,50,000/-. The complainant is entitled to get an amount of Rs. 1,00,400/- from the insurer, the United India Insurance Company Ltd. Hence the complaint is allowed.

In the result, 1^st opposite party is directed to pay Rs. 1,00,400/- with 9% annual interest from 05.03.2007(the bill date) till the date of realization. The 1^st opposite party shall pay Rs. 2,000/- as costs to the complainant. There is no separate order as to compensation since interest has been ordered. Time for compliance one month from the date of receipt of the order.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 30^th day of August 2010.

BEENAKUMARI. A : MEMBER

G. SIVAPRASAD : PRESIDENT

S.K. SREELA : MEMBER

jb

C.C. No. 114/2009

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - George Koshy

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of individual medi-claim policy

P2 - Copy of doctor's prescription dated 25.01.2007

P3 - Copy of bill dated 25.01.2007

P4 - Copy of passport showing the journey

P5 - Copy of I.P bill No. IP 06-07/1913 dated 05.03.2007

P6 - Copy of medical certificate dated 09.06.2007

P7 - Copy of receipt dated 13.12.2006.

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

NIL

PRESIDENT

jb