By. Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the opposite parties to pay Rs.96,245.61/- towards medical claim and Rs.50,000/- as compensation for the loss and mental agony sustained to the complainant due to the deficiency of service from the part of opposite party along with cost of the proceedings.
2. Brief of the complaint:- The complainant availed a medi-claim insurance policy named Senior citizens Red Carpet Policy. The sum assured is Rs.1 Lakh and the period of policy is from 30.06.2012 to 29.06.2013 and thereafter renewed. The complainant was admitted at Baby Memorial Hospital in Urology and Transplantation surgery on 26.04.2016 due to complaints of increased frequency urination. He had undergone TVRP on 27.04.2016 and was discharged on 04.05.2016. The complainant paid an amount of Rs.96,245.61/- towards hospital expenses. The opposite parties not allowed cashless benefit to the complainant. Thereafter, the complainant send claim form along with medical bills to the opposite party. But till this date, the opposite party not paid the medi-claim amount to the complainant. The act of opposite parties were deficiency of service from their side. Aggrieved by this, the complaint is filed.
3. On receipt of complaint, notices were issued to the opposite parties and the opposite parties appeared before the Forum and filed version. In the version of opposite parties, the opposite parties admitted the policy and the admission and treatment of complainant. The policy is subjected to the terms and conditions and it is served to the complainant. The insured must be above 60 years of age and medical check up is not necessary before joining to policy. Once these pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form. 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. The complainant was diagnosed with BEP ie Benign Enlargement of Prostate, the complainant submitted claim form with all documents. In the secondary diagnosis column of the discharge summary, it is clearly stated that ''complaints of increased frequency with sense of incomplete evacuation with decreased stream of urination since 4 years''. As the illness of the complainant was pre-existing, the complainant has to bear 50% of the expense of the admissible amount of the claim. The total claim was Rs.1,08,845/-. The admissible amount is Rs.64,135/- from the admissible amount, the opposite parties applied 50% co-payment. After applying 50% co-payment, the balance payable amount was Rs.32,067/- which was duly credited to the account of the complainant on 31.08.2016. So there is no deficiency of service from the part of opposite parties.
4. On perusal of complaint, version and documents, the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and Cost.
5. Point No.1:- The complainant filed proof affidavit and is examined as PW1. The opposite parties also filed proof affidavit and the opposite party is examined as OPW1 and Ext.B1 to B6 documents were marked. Ext.B1 is the Copy of Proposal Form of complainant, Ext.B2 is the copy of Policy Schedule and terms and conditions. Ext.B3 is the copy of Claim form. Ext.B4 is the copy of Discharge summary, Ext.B5 is the copy of Bill assignment Sheet. Ext.B6 is the Authorisation Letter. Ext.B1 is the Proposal Form and in Ext.B1's column for the indication of pre-existing disease was answered as 'No'. Ext.B2 is the Policy and policy conditions. In Ext.B2 Policy Conditions, in sub-clause 5 of Exclusion clause, it is stated that 50% of each and every claim arising out of pre-existing diseases as defined and 30% in case of all other claims are to be borne by the insured. In Ext.B4 discharge summary, secondary diagnosis shows complaints of increased frequency with sense of incomplete evacuation with decreased stream of urination since 4 years. As per Ext.B4, the complainant was diagnosed BEP (Benign Enlargement of Prostate). The patient was undergone TVRP on 27.04.2016. On verifying the Ext.B4 document, the Forum found that the pre-existing complaint reported to the complainant had a direct connection with the procedure of TVRP done on 27.04.2016. The pre-existing complaint was not stated in the proposal form. The Forum found that it is a clear suppression of material fact. Since pre-existing complaint is not stated in the proposal form, the complainant is entitled to get only 50% of the admissible amount of the claim amount. The opposite parties already credited Rs.32,067/- being the 50% of admissible amount in the account of the complainant on 31.08.2016. The total sum assured amount is Rs.1 Lakh. The opposite parties calculated the admissible amount as Rs.64,135/- as per the terms and conditions. The Forum found no irregularity in the calculation done by the opposite parties as per Ext.B5 document. Since the complainant is a Senior citizen who has been issued a Senior citizens Red Carpet Policy, the Forum is of the opinion that awarding Rs.15,000/- towards treatment expenses on a non-standard basis will be just and proper. The Forum found no deficiency of service from the part of opposite parties. Point No.1 found accordingly.
6. Point No.2:- Since the Point No.1 is found against the complainant, complainant is not entitled to get cost and compensation.
In the result, the complaint is partly allowed and the opposite parties are directed to pay Rs.15,000/- (Rupees Fifteen Thousand) towards treatment expenses to the complainant within 30 days from the date of receipt of this Order. Failing which the opposite parties are directed to pay interest at the rate of 12% for above sum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 13th day of September 2017.
Date of Filing:02.03.2017.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. Damodaran. Agriculture.
Witness for the Opposite Parties:
OPW1. Balu. M. Executive, Legal, Star Health.
Exhibits for the complainant:
Nil
Exhibits for the Opposite Parties:
B1. Copy of Proposal form. dt:30.06.2012.
B2. Copy of Policy Schedule.
B3. Copy of Claim form – Part A dt:29.05.2016.
B4. Copy of Discharge Summary.
B5. Copy of Bill Assessment sheet. dt:19.08.2016.
B6. Authorisation Letter. dt:26.06.2016.
