Date of Filing : 09.03.2011
Date of Order : 19.11.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 19th day of November 2011
PRESENT
Sri.H.V.Ramachandra Rao B.Sc., BL …. President
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 482/2011
T.Sridhar,
S/o.Thimmappa,
R/at No.232/19, 4th Main,
13th Cross, Vyalikaval,
(Between Rajesh Hotel & vyalikaval Police station),
Bangalore 560 003.
(By Advocate Sri.C.Gowrishankar) ……. Complainant
V/s.
1. The Manager,
ICICI Lombard Health Insurance
Also known as
ICICI Lombard Health Care,
Having office at
“Zenith House”, Keshavrao Khade Marg,
Mahalakshi, Mumbai.
2. The Manager,
ICICI Lombard Health Insurance,
II Floor, SVR Complex, 89,
Hosur Main Road,
Madivala, Koramangala,
Bangalore 68.
(By Advocate Sri.B.C.Shivannegowda) …… Opposite Parties
ORDER
(By the President Sri. H.V.RAMACHANDRA RAO)
The brief antecedents that yet to be filing of the complaint under section 12 of the Consumer Protection Act seeking direction to the OP to pay a sum of Rs.60,000/- and to pay Rs.20,000/- every month are necessary:
1. The complainant had obtained Mediclaim policy from the OP in the year 2006 and it was renewed and as on day the three policies bearing Nos. 1) 4034/FNP/01592432/00/000, 2) 4034/CHI/05646163/00/000 and 3) 4034/HIR/04133672/00/000 are in vogue. The complainant went for as an outpatient for dialyses and incurred expenditure which the OPs are liable to reimburse. The claim was rejected by the OPs which is unfair trade practice. The reason given is untenable.
3. In brief the version of the OPs are:
The OPs has issued health care policy in respect of the complainant and his family for the period 14.12.2006 to 13.12.2008. The complainant had declared at the time of obtaining the policy that he is not suffering from any pre existing disease and further under the policy all the pre existing disease have been exceeded. The treatment were taken for pre existing disease, the discharge summary produced by the complainant clearly establishes that he was suffering from said pre-existing disease prior to inception of the policy and clause 3.1 of the policy condition clearly is applicable. According to the discharge summary the complainant has undergone treatment for renal failure and acute onset of Dysonea greade IV associated with orthoponea and PND due to earlier disease that is type 2 DM and hypertension and the same is not covered as per policy condition. The complainant had undergone laser treatment for b/e for diabetic retinopathy on two occasion. The allegation to the contrary are denied.
4. To substantiate their respective cases the complainant had filed the affidavit of his wife and the OP has filed affidavit of its employee, the documents were filed. The complainant had filed the written arguments. The arguments were heard.
5. The point for consideration are
A) Whether there is deficiency in service ?
B) What order?
6. Our answers
A) Negative
B) As per the detailed order for the following reasons
REASONS
7. Reading the pleadings in conjunction with the affidavits and documents on record it is an undisputed fact that the complainant had obtained the medi claim policy in the year 2006. It is also an admitted fact that the complainant was admitted to Appllo Hospital on 09.08.2007 and discharged on 14.08.2007. The complainant had admitted to the hospital on the complaint of K/C/O type-2DM/HTN regarding this she has given the past history that has been recorded in the discharge summary thus:
K/C/O Type -2 DM/HTN 3 years on regular treatment H/o Laser treatment for b/e for diabetic retinopathy-2 sittings.
That means he was having this diabetics and hypertension since from 2004 and he was also taken laser treatment. This was the history given by the doctor of Apollo hospital since from 03years earlier. He has been treated for this pre existing disease and discharged. He has claimed payment of Rs.60,000/- which has been incurred by him and also he wants every month Rs.20,000/- has to be paid regarding this.
8. Clause 3.1 of the policy reads thus “all pre-existing disease are not covered by the policy” that means regarding the pre existing disease that is incurring pre existing disease mediclaim is not available.” As this disease is pre existing disease the OP rightly repudiated the claim.
9. The main contention of the complainant is that as per clause 3.3 which is an exclusion clause this pre existing disease is not mentioned hence he is entitled. The clause 3.1 is also an exclusion clause hence the complainant is not entitled to this. The complainant would have taken policy to incur reimbursement regarding the pre existing disease that has not been done. We are governed by the contract between the parties. The policy does not cover pre existing disease hence complainant is not entitled to any relief. Hence we hold the above points accordingly and pass the following order.
ORDER
1. The complaint is dismissed.
2. Return the extra sets to the concerned parties as under regulation 20(3) of the consumer protection Regulation 2005.
3. Send copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 19th day of November 2011
MEMBER PRESIDENT
