DATE OF FILING : 27.7.2016
IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 27th day of April, 2017
Present :
SRI. S. GOPAKUMAR PRESIDENT
SRI. BENNY. K. MEMBER
CC NO.214/2016
Between
Complainant : Sasidharan Nair,
Ayyanickal House,
Perumpillichira P.O.,
Thodupuzha, Idukki.
(By Adv: K.M. Sanu)
And
Opposite Parties : 1. The Manager,
United India Insurance Co. Ltd.,
Prakash Building,
Muvattupuzha Road, Thodupuzha,
Thodupuzha P.O., Idukki.
2. The Manager,
United India Insurance Co. Ltd.,
GM Arcade, Post Office Junction,
Piravam – 686 664.
(Both by Adv: Sony George)
O R D E R
SRI. BENNY. K. (MEMBER)
The complainant availed a mediclaim policy from the opposite party through the Rubber Growers and Processors Association, Kochi and it was renewed promptly for a period from 20.12.2015 to 19.12.2016 by paying the premium of Rs.8240/-. The opposite party issued the policy number is 1011012815 P111814350. As per the policy, the complainant and his wife are entitled to get Rs.1.5 lakhs health care benefit, Rs.1.5 lakhs critical illness care and personal accident benefit for Rs.2 lakhs. While the policy was existing, the complainant was admitted in St.Mary’s Hospital for chest pain and diagnosed as coronery artery disease and conducted angioplasty for removing the block in the artery. The complainant was admitted in the hospital for 6 days as inpatient. The total cost for hospitalization was Rs.1,40,430/-. For getting the treatment expenses, complainant filed the claim form along with all medical
(cont......2)
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bills and all other documents relating the treatment. But the opposite party issued only Rs.10000/-. The opposite parties are deliberately denied the balance amount. It is a gross deficiency from the part of opposite parties, hence this petition is filed for getting the balance amount with interest and also for compensation.
In the written version, opposite parties admitted that the complainant is entitled only for Rs.10000/-. The terms and conditions are agreed by the petitioner and clause (2) of special terms and conditions provided that the pre-existing illness is excluded from the total coverage and it is limited to Rs.10000/- only. The petitioner is well aware of the clause 4 under the head "Exclusion". The company shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of clause 4.1, any pre-existing condition as defined in the policy, until 48 month of continuous coverage of such insured person have elapsed, since inception of his / her 1st policy with the company. So there is no liability for the opposite parties to pay the balance amount.
The point for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?
The evidence consists of oral testimony of PW1 and Exts.P1 to P3 marked on the side of complainant. No oral evidence adduced by the opposite parties and Ext.R1 marked on their side.
The POINT :- The complainant examined as PW1 and he availed a policy from the opposite parties, through the Rubber Growers and Processors Association, Kochi. . Ext.P1 is copy of policy. The policy was renewed for a period from 20.12.2015 to 19.12.2016, by paying the premium of Rs.8240/-. While the policy was existing, the complainant was admitted in St. Mary’s Hospital for artery disease. Ext.P2 is discharge summary. Complainant undergone angioplasty and he was discharged after 6 days’ treatment. Total bill was for Rs.1,40,430/-. Ext.P3 is copy of medical report. For getting this expense, complainant approached the opposite party with all relevant documents relating to the treatment. But the opposite parties disbursed only
(cont......3)
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Rs.10000/-. Ext.P5 is the print out of e-mail letter of claim settlement. Hence this petition is filed to the balance treatment expenses and compensation.
In the written version, opposite parties admitted that the complainant is entitled only for Rs.10000/-. The terms and conditions are agreed by the complainant while availing the policy. While availing the policy, the complainant purposefully suppressed the pre-existing disease. While filing the proposal form, the petitioner has suppressed the material fact that he has coronary artery disease. At the time of joining the policy, the opposite party should convince all matters to the complainant. There is no evidence adduced by the opposite party to show the pre-existing disease of the complainant.
We think that the complainant was regularly paying the premium of Rs.8240/- and he is entitled for balance amount. There is no contention for the opposite party that the complainant had produced a fabricated bill or forged bill to the opposite party. There is no document produced by the opposite party to show the pre-existing disease. Simply, denying the balance amount cannot be advisable. So the opposite parties should compensate the complainant adequately.
Hence the petition allowed. The opposite parties are directed to pay an amount of Rs.1,30,430/- as the balance amount, to the complainant for the treatment expenses and also directed to pay Rs.5000/- as compensation and Rs.2000/- as cost of this petition, to the complainant within 30 days of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default, till its realization.
Pronounced in the Open Forum on this the 27th day of April, 2017
Sd/-
SRI. BENNY. K., MEMBER
Sd/-
SRI. S. GOPAKUMAR, PRESIDENT
(cont......4)
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APPENDIX
Depositions :
On the side of the Complainant :
PW1 - N. Sasidharan Nair.
On the side of the Opposite Party :
Nil.
Exhibits :
On the side of the Complainant :
Ext.P1 - copy of policy.
Ext.P2 - discharge summary.
Ext.P3 - medical report.
Ext.P4 - break up of bills.
Ext.P5 - print out of e-mail letter.
On the side of the Opposite Party :
Ext.R1 - break up of bills.
/ Forwarded by Order /
SENIOR SUPERINTENDENT
