DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 7th day of May 2016
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 7/10/2015
: Sri.V.P.Ananatha Narayanan, Member
(C.C.No.137/2015)
Kunnath Venugopalan
C-15, Venkitesapuram Colony,
Puthur Post, Palakkad – 678 001 - Complainant
(By Adv.M.P.Ravi)
V/s
The Manager,
M/s.United India Insurance Co.Ltd.
Branch Office Soorya Complex,
Mission School Junction, Palakkad - Opposite party
(By Adv.T.P.George)
O R D E R
By Smt.Shiny.P.R. President.
Brief facts of complaint.
Complainant had taken a Mediclaim policy under the name Individual Health Insurance Policy as per Policy No.101201/28/14/P102136299 for the period from 26/8/2014 to 25/8/2015 and the policy is a continuing policy and he has regularly paying the premium. Complainant had undergone cardiac surgery in the year 2003 and the said fact is revealed to the respondent immediately when the policy was renewed. After that the complainant is under continuous treatment for cardiac diseases.
On 9/3/2015 complainant had pain on the left arm and he has consulted a doctor at AIMS Ernakulam and was advised to undergo treatments for which he had incurred expenses to the tune of Rs.12,850/-. Then the complainant had preferred a claim for the said amount on 2/4/2015 alongwith necessary bills and records. But the opposite party have repudiated the said claim as per letter dated 26/5/2015 on the ground that there is no hospitalization for 24 hours and the treatment was primarily for diagnostic study and not followed with active treatment. Complainant submitted that reasons for repudiating the claim of the complainant is unjust and without any basis. The act of repudiation of the claim by the opposite party is purely arbitrary and unsustainable and it amounts to deficiency of service on the part of the opposite party.
The complainant sent a lawyer notice to the opposite party on 17/6/2015 and the opposite party has received the same on 19/6/2015. Though they have received the notice, till date, the opposite party has not settled the claim and they have not even cared to issue a reply. On earlier occasions also the complainant had such a bitter experience of repudiation of the claim without any valid grounds and aggrieved by that the complainant had filed a complaint before the C.D.R.F. Palakkad as CC/87/2012 and the same was allowed by the Forum. The complainant apprehends that in order to wreck the vengeance for filing the case, the opposite party have deliberately repudiated the claim.
Due to the deficiency of service on the part of the opposite party the complainant had suffered a lot of mental agony apart from the financial loss and the opposite party is liable to pay the same apart from the claim amount. Hence complainant prays for an order directing the opposite party to settle the claim of Rs.12,850/- and to pay a sum of Rs.50,000/- as compensation to the complainant and to pay the entire cost of the proceedings and to pay compensatory cost.
Complaint was admitted and notice was issued to opposite party. After receiving the notice, opposite party appeared before the Forum and filed their version contending the following:
Opposite party admitted the policy. As per the policy and subject to the terms, conditions, exclusions and definitions contained in the policy, company undertakes that during the policy period the insured person contracts any disease or suffers from any illness or sustains any bodily injury through accident and if such diseases or injury requires such insured person, upon the advice of a doctor to incur hospitalization expenses for medical / surgical treatment at any nursing home/hospital as an inpatient the company will pay through TPA to the hospital or the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person.
There are certain exclusion clauses also as per the terms of the policy. Sub clauses of clause 4 exclude certain treatment expenses like diagnosis, x-ray, or laboratory examinations or other diagnostic studies not consistent with incidental to the diagnosis and treatment of positive existence of any ailment, sickness or injury, for which confinement it required at a hospital. Expenses on vitamins, tonic etc. are also excluded. Only those diseases, ailments and injuries or related conditions, for which insured person had signs or symptoms were diagnosed and received medical treatment.
The complainant had undergone cardiac surgery in 2003. So every year he has to undergo routine heart check up for evaluation of the functioning of the heart. Only for that purpose he has consulted the cardiologist and as per his advice a myocardial scan was taken and it was found he was perfectly all right. Doctors have not found existence of any ailment. So the consultation was only for the evaluation / diagnostic purpose and not consistent with treatment of positive existence of any ailment or disease as per the discharge summary. So all expense claimed are excluded vide exclusion clause No.4.10 of the policy. The medical bills for Rs.12,850/- submitted by the complainant are spent only for diagnosis and laboratory examinations and not consistent with treatment of a positive existence of any ailment or disease as per the discharge summary and no hospitalization was required for any of the ailments or sickness. Hence there is no deficiency of service on the part of these opposite party. Complaint is liable to be dismissed with cost.
Both parties filed their respective chief affidavits. Ext.A1 to A4 were marked from the side of the complainant. Exts.B1 to B4 were marked from the side of the opposite party.
The following issues are considered
1.Whether there is any deficiency in service on the part of opposite party?
2.If so, what is the relief?
Issue 1& 2.
Heard. We have perused the documents filed before the forum. Opposite party admitted the policy. Complainant submitted that he had pain on the left arm and he has consulted a doctor at AIMS Ernakulam and as advised by the doctor has undergone treatments. But nothing was produced to show that he has pain on left arm and has consulted doctor for the same. Both parties admitted that the complainant has undergone cardiac surgery in 2003. Ext B3 documents shows that only diagnostic tests are carried out from 9-3-2015 to 31-3-2015. Sub clause 4.10 of Ext B1 exclude certain treatment expenses like diagnosis, x-ray, or laboratory examinations or other diagnosis studies not consistent with incidental to the diagnosis and treatment of positive existence of any ailment, sickness or injury, for which confinement is required at a hospital. As per Ext B2 document it is seen that the complainant has consulted doctor for evaluation of the functioning of heart and after that the doctors came to a conclusion that there was no evidence of reversible ischaemia in any segment of LV myocardium. As per medical report of Ext B3 which was issued by the doctor at AIMS the diagnostic test were carried out to stress MIBI and the present condition of the patient stable. In the above circumstances we are of the view that the complainant consulted the doctor for evaluation of functioning his heart and not consistent with treatment of positive existence of any ailment or disease. Opposite party rightly repudiated the claim as per the terms and conditions of the policy. Hon’ble National Commission held in National Insurance Co.Ltd Vs Aparna Kahar that Insurance claim can only be allowed within terms and conditions of policy (2014 NCJ 850(NC). In Ind Swift Ltd. Vs New India Assurance Co.Ltd Hon’ble National Commission held that it is to be construed strictly as per policy terms and conditions which are binding contract between parties and nothing can be added or subtracted by giving different meaning to words mentioned therein (2012 CPJ IV NC148). Hence we cannot attribute deficiency in service on the part of opposite party.
In the result complaint dismissed.
Pronounced in the open court on this the 7th day of May 2016.
Sd/-
Shiny.P.R.
President
Sd/-
Suma.K.P.
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 – Photocopy of claim form
Ext.A2 - Photocopy of repudiation letter by opposite parties
Ext.A3 series – Photocopy notice sent by the complainant with acknowledgement card and receipts.
Ext.A4 – Photocopy of Order in CC/87/2012 of CDRF, Palakkad
Exhibits marked on the side of complainant
Ext.B1 – Photocopy of policy in the name of Kunnath Venugopalan
Ext.B2 - Photocopy of Test report issued by Amrita Institute of Medical
Sciences dtd.31/3/2015
Ext.B3 – Photocopy of Policy Claim form dated 2/4/2015
Ext.B4 – Photocopy of claim repudiation letter by opposite party dtd.26/5/15
Cost
Nil
