By Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of Consumer Protection Act of 1986 for an order directing the Opposite parties to pay Rs.10,000/- towards treatment charges for the treatment of Complainant's daughter and to pay Rs. 1,00,000/- towards compensation and Rs.50,000/- towards cost of the proceedings.
2. The complainant's case in brief as follows:- The Complainant took a Family Mediclaim Insurance Policy from the Opposite party in the year 30.09.2010 in the first time by paying Rs.2,234/- as one year premium. Then the policy was renewed in the year 30.09.2011 by paying Rs.2010/-. The validity period of the policy is up to 29.09.2012. The total sum assured was Rs.1,00,000/- for the entire family members including complainant, his wife and two children. On 07.01.2012 Complainant's daughter Sinu @ Muhsina was admitted in MIMS Hospital Calicut due to illness. On 09.01.2012, the child was discharged and the Complainant claimed the treatment charges from the Opposite party before paying the hospital bills through the Hospital authorities. But the Opposite party orally repudiated the claim and the Complainant is forced to remit the bill. Therefore, the Complainant 18.01.2012 approached the Opposite party's Kalpetta Branch and as per their direction submitted to claim form with all treatment records at Sulthan Bathery Branch on 18.01.2012. The Manager promised the Complainant to grant the claim amount within 45 days. But when there is no response, the Complainant approached the Sulthan Bathery Manager and enquired. The Manager at that time informed the Complainant that they will never sanction the claim and behaved very bad and the complainant is humiliated. The act of the Opposite Parties are unfair trade practice and deficiency of service. Hence this complaint.
3. On receipt of complaint, notices were issued to the Opposite Parties and Opposite Parties appeared before the Forum and filed version. In the version the Opposite parties contended that the sickness for which the Complainant's daughter was admitted was for a pre-existing disease which is clear from the medical certificate of treating doctor. The Opposite parties admitted the existence of policy . In the proposal form, the insured has specifically declared that his daughter was not suffering from any disease or ailment at the time of submitting proposal form. The Complainant had violated the conditions of agreement. In the certificate issued by the doctor who treated the patient, it is clear from column No.6(a) and 5 (b) that the patient was in treatment with complaint of low back pain and hip pain since
22.05.2010 ie prior to the inception of policy. The Complainant suppressed the material facts of existing illness. Pre-existing disease is excluded as per exclusion clause No.1 of the policy which states that pre-existing disease as defined in the policy until 48 months of continuance coverage have elapsed since inception of the first policy with the company. Hence the Opposite Parties prayed for a dismissed of complaint.
4. On perusal of complaint, version and documents of both parties, the Forum raised the following points for consideration.
1. Whether there is deficiency of service from the part of Opposite parties?
2. What order as to cost and compensation?
5. Point No.1:- In addition to complaint, the Complainant produced proof affidavit and documents. The Complainant is examined as PW1 and documents are marked as Ext.A1 to A9 and Ext.X1 and X2 is also marked. Ext.A1 is the photocopy of policy and Ext.A2 is the premium receipt, Ext.A3 is the policy issued on 30.09.2010. Premium receipt dated 30.09.2010 is marked as Ext.A4. Ext.A5 is the identity card issued by the Opposite Party to the Complainant's daughter. Ext.A6 series are the medical bills, Ext.A7 is the discharge certificate issued by the MIMS Hospital, Ext.A8 is the MRI scan report, Ext.A9 is the letter issued by the Opposite party to the Complainant. The Opposite Party's witness is examined as OPW1 and Ext.B1 to B8 is marked. Ext.B1 is the copy of policy schedule, Ext.B2 is the copy of pre-authorisation, Ext.B4 is the copy of MRI report, Ext.B5 is the copy of expert opinion, Ext.B6 is the copy of claim repudiation letter, Ext.B7 is the copy of the request of documents return. Ext.B8 is the authorisation letter. Ext.X1 is the claim form and Ext.X2 is the proposal Form. On going through the documents produced by the Complainant and Opposite Parties, the Forum found that as per Ext.X1 document ie the claim form filled by the treating doctor, as per column No.5(b) the previous consultation date shown is 22.05.2010. The Complainant took the family insurance on 30.09.2010. So previous consultation is done before the inception of policy. As per Ext.X1 document, the complaint of the patient is low back pain and hip pain. The Forum analysed that there is no records or connected evidence is produced by Opposite Party to prove the previous consultation. The treating doctor is not examined by Opposite party. Details of previous consultation is not described by the doctor. As per Ext.B6, in pre-existing disease, benefits will not be given until 48 months of continuous coverage have elapsed since the inception of the first policy with the company. As per the discharge summary which is not a marked document shows that complaint of low back ache since one week similar episode one year back radiating to right leg. As per Ext.X1, the complaint for the treatment noted by the treating doctor is low back pain and hip pain. But as per case records, the word used “similar episode one year back radiating to right leg”. The word used is similar but not exact. The treating doctor is not examined to prove it beyond doubt. So the Forum analysed that similar episode one year back radiating to right leg is not the disease for which the patient is treated on 07.01.2012. So the disease cannot be treated as a pre-existing one. The Complainant took family mediclaim policy in the year 2010 and it is renewed later. The present claim is on the basis of the treatment done in the year 2012 relating to the disease of complainant's daughter Sinu. The total claim as per claim form is Rs.8,658/- only. So the Forum found that disallowing a meager amount for the treatment of the daughter of Complainant will be an injustice to the Complainant. So the Forum found that there is deficiency of service from the part of Opposite party in dealing with the claim of Complainant. Point No.1 is found accordingly.
6. Point No.2:- Since the point No.1 is found in favour of Complainant, the Complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the Opposite Parties are directed to pay Rs.8,658/- (Rupees Eight thousand Six hundred and Fifty Eight) only as treating expense to the Complainant along with Rs.2,000/- (Rupees Two thousand) only as compensation and Rs.2,000/- (Rupees Two thousand) only as cost of the proceedings. The Opposite Parties shall comply the order within 30 days from the date of receipt of this order failing which the Complainant is entitled to get 12% interest for the whole sum.
Dictated to the C.A transcribed by him and corrected by me and pronounced in the Open Forum on this the 31st day of July 2014.
Date of filing:16.04.2012.
PRESIDENT: Sd/- MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
A P P E N D I X
Witness for the Complainant:
PW1. Hamza. Complainant.
Witness for the Opposite Parties:
OPW1. Padmaprabha. Senior Officer Legal, Star Health Insurance,
Thiruvananthapuram.
Exhibits for the Complainant:
A1. Copy of Family Health Optima Insurance Policy – Schedule.
A2. Copy of Premium Receipt. dt:30.09.2011
A3. Copy of Family Health Optima Insurance - Policy Schedule.
A4. Copy of Premium Receipt. dt:30.09.2010
A5. Identity Cared.
A6 series. Bills.
A7. Discharge Summary.
A8. MRI Scan Report.
A9. Letter. dt:19.03.2012.
Exhibits for the Opposite Parties:
B1. Copy of Family Health Optima Insurance Policy – Schedule.
B2. Copy of Pre-Authorisation Request Form.
B3. Family Health Optima Insurance Plan.
B4. Copy of MRI Report. dt:07.01.2012.
B5. Certificate. dt:17.03.2012.
B6. Copy of Letter. dt:19.03.2012.
B7. Copy of Letter. dt:09.04.2012.
X1. Claim form for Medical Insurance. dt:25.01.2012.
X2. Proposal Form.
