By Sri. Chandran Alachery, Member:

The complaint filed under section 12 of Consumer Protection Act for an order directing Opposite parties to pay a sum of Rs.1,30,000/- to the Complainant being the treatment expenses incured and to pay Rs.1,00,000/- as compensation for repudiation and Rs.1,00,000/- as compensation for denial of subsequent benefit and to pay the cost of the proceedings.
 

2. Complaint in brief :- The Complainant has taken the Medi Clasic Individual Policy from 2^nd Opposite party on 30.07.2009 and the same was continually renewed without any break for 3 years. On the expiry of the latest policy the Complainant has approached the 2^nd Opposite party on 29.07.2012 with the premium but the 2^nd Opposite Party has not accepted the amount without any valid reason and the Opposite Parties have not renewed the same. Hence the complainant was forced to take the medi claim policy for M/S New India Assurance Company Ltd., Kalpetta.

3. During the validity period of the policy, by the end of the first policy period, the Complainant had pain right side of hip, and the Complainant thought that it might have muscular pain and had taken some conventional treatment like balm, oil massage surgery was the only remedy. The matter of disease was already intimated to the Opposite parties office, and on the consent of them, the Complainant had undergone treatment at the Medical College Hospital, Thiruvananthapuram. Surgery was also done on the Complainant. The treatment certificate and other documents including bills for about Rs.1,30,000/- was also produced to the Opposite parties for refund as per the terms of the policy. But to the surprise of the Complainant, the claim of the Complainant was repudiated by the 1^st Opposite Party vide letter dated 16.01.2012. The act of the Opposite Parties is nothing but unfair trade practice and deficiency of service. The repudiation was made by the Opposite Parties without any valid reasons, nor the reasons stated was correct and sound.

4. The Opposite Parties repudiated the claim with a reason that the disease is pre-existing one. The Complainant is entitled for the benefit and the act of Opposite parties are deficiency of service. Aggrieved by this the complaint is filed.

5. On receipt of complaint, notice were issued to Opposite Parties and Opposite parties appeared before the Forum and filed version. In the version of 1^st and 2^nd Opposite Parties, Opposite parties No.1 and 2 contended that the sickness for which the Complainant was admitted was for a pre-existing disease which is clear from the medical certificate of the treating doctor. As per the records submitted by the treating doctor, it is clear that the patient was suffering from AVN and the complication of AVN led to the present ailment ie secondary osteoarthritis. IRDA circular dated 31.03.2009, states that the health insurance policy shall not be renewable if there is suppression of material facts. Hence Opposite Parties cannot renew the policy and denied the subsequent benefit of the policy to the Complainant. There is no deficiency of service from the part of Opposite parties.

6. On going through the complaint, version and documents, 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?

7. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents are marked as Ext.A1 to A5. The Opposite party filed affidavit and Opposite party is examined as OPW1 and Exts.B1 to B9 is marked. Hospital records are marked as Exts.X1 and X2. On going through the evidence, it is found that the Opposite Parties had rejected the claim of Complainant with a reason that the disease is pre-existing one as per records. The Forum perused Ext.X1 records produced by the Hospital. In Ext.X1(3) document, the doctor stated in the column that “since when the patient suffering from the said complaint. The answer is “two and half years”. And in the column “whether the present ailment is a complication of pre-existing disease the answer is “Two and half years”. On perusal by the Forum the above statement by the doctor is not based as any material before him. Absolutely there is no evidence before the Forum that whether the disease is diagnosed before the inception of policy or whether any treatment is taken by the patient or not is not proved. The statement of doctor must be supported by documents. No other produced documents shows that the disease is pre-existing one except Ext.X1(3). The section 3 of the policy ie the exclusion portion there is a clear provision that “all disease injuries which are pre-existing when the cover incepts for the first time”. In such cases, the company is not liable to pay any amounts to the insured person. But in this case there is no evidence that the Complainant was suffering from the ailments before the inception of policy which leads to the present treatment. Mere statement of doctor in Ext.X1(3) is not sufficient to decide whether the disease is pre-existing or not. It should be supported by documents. In Ext.B9 document, the doctor narrated the history of ailment. But in Ext.B9 also no averments that the disease was diagnosed 2 ½ years back or any treatment was taken from that period onwards are not stated. So the Forum is of the opinion that the Opposite Party failed to prove their case beyond doubt. In such circumstances, non payment of claim amount to the Complainant is a deficiency of service from the part of Opposite parties. Point No.1 is found accordingly.

8. Point No.2:- Since point No.1 is found in favour of Complainant, the Opposite Party No.1 is found in favour of Complainant, the Opposite Party is liable to pay cost and compensation.

In the result, the complaint is partly allowed and the Opposite party is directed to pay the total claim amounts of Rs.1,30,000/- (Rupees One Lakh and Thirty thousand) only to the Complainant along with 12% interest from the date of filing of this complaint till payment. The Opposite Parties are also directed to pay Rs.2,000/- (Rupees Two thousand) only as compensation and Rs.1,000/- (Rupees One 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.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 16^th day of January 2015.

Date of filing:10.08.2012

PRESIDENT : Sd/-

MEMBER : Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Ronivas Complainant.

Witness for the Opposite Parties:

OPW1. Padmaprabha. P Senior Legal Officer, Star Health and Allied

Insurance Co. Ltd., Thiruvananthapuram.

Exhibits for the complainant:

A1. Copy of Medi Classic Health Insurance Policy (Individual) Schedule.

A2. Letter. dt:16.01.2012

A3 series (17 sheets) Copy Bill.

A4 series Medi Classic Health Insurance Policy (Individual) Schedule.

A5. Renewal Notice. Dt:18.06.2012.

X1 series (60 Pages) Hospital Records.

X2. Copy of Case Records.

Exhibits for the opposite Parties.

B1. Copy of Medi Classic Individual Policy Schedule.

B2. Copy of Discharge Card.

B3. Copy of Medical Certificate. dt:13.10.2011.

B4. Copy of Letter. dt:14.05.2014.

B5. Copy of Letter. dt:16.01.2012.

B6. Copy of Letter.

B7. Copy of Letter. dt:19.07.2012.

B8. Copy of Letter. dt:31.03.2009.

B9 Copy of Proposal Form.