CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 20th day of January, 2012.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 31/01/2011
CC / 17 / 2011
Safiya,
W/o. Moidhukutty,
Kallurkkal House,
Pazhambalakode,
Palakkad - Complainant
(BY ADV. VINOD KAYANAT)
Vs
The Manager,
The United India Insurance Co. Ltd.,
Divisional Office,
Park House Building,
Round North,
Thrissur – 680 001.
The Manager,
The United India Insurance Co. Ltd.,
Ottapalam, Ottapalam (P O),
Pin – 679 101. - Opposite parties
(BY ADV. C. MOHANRAM)
O R D E R
BY SMT. BHANUMATHI. A. K, MEMBER
Complaint in brief is as follows:
The complainant and her family members have taken Individual Health Insurance Policy in 2004 from the opposite parties and the same was renewed in 2010 vide policy No. 101203/48/10/97/00000754. About two years back the complainant experienced pain on the upper part of the right hand. At the initial stage the pain will disappear on application of pain balm. When the pain increased she had consulted a doctor at Pazhambalakode, who advised the complainant to consult an Orthopaedic Surgeon . Accordingly she consulted Dr. Premkumar and has undergone surgery at Aswini Hospital, Thrissur.
Altogether the complainant spent an amount of Rs. 32,160/- for treatment. Details of the treatment were informed to the opposite parties in time to time. On 26/07/2010, the complainant submitted claim form with all necessary documents before the opposite parties to reimburse the amount according to the insurance policy. But the opposite parties refused the complainant's claim on the ground that decease suffered by the complainant is congenital in nature.
The above act of the opposite parties amounts to deceit and at the time of taking policy the opposite parties made the complainant believe that the policy will cover all types of ailments. Every year the complainant paying insurance premium correctly. But when the reimbursement was claimed it was repudiated without any valid reason. It is deficiency of service on the part of opposite parties.
When the policy was taken the complainant was not suffering from any ailment for which surgery was done and she was not aware about the same. Even if it is existing the amount is payable as the complainant had taken her first policy in the year of 2004.
So the complainant seeking an order directing the opposite parties to pay an amount of Rs. 32,160/-, which is spent by the complainant for treatment and Rs. 10,000/- as compensation for mental agony and Rs. 5,000/- as cost of the proceedings.
Opposite parties entered appearance and filed version with the following contentions:
Opposite parties admit that the complainant has taken an Individual Health Insurance Policy 2009 as per policy No. 101203/48/10/97/0000075. But the period of insurance is from 09/07/2010 to 08/07/2011. The insurance policy issued by opposite parties will not show that it is a continuation of the policy from 2004.
Opposite parties also admit that the complainant had submitted a claim form it is not correct to say that the opposite parties repudiated the said claim without any valid reason. After getting the claim form submitted by the complainant opposite parties have submitted it before the panel doctors for the purpose of obtaining their opinion. The doctors have already opined that the ailment suffered by the complainant is congenital.
The doctors have diagnosed the ailment as subcutaneous Hemangioma. The MRI Scan also confirm the same and it further shows that the oedema/swelling was there since 10 years. It is clear indication of manifestation of the ailment prior to the inception of the insurance coverage. But the complainant had suppressed this material fact and has taken the insurance policy. It has not been stated in the proposal form. The opposite parties have repudiated the claim on valid grounds and the same was communicated to the complainant in time. Even if the ailment is existing, it is payable as per clause 1,2and 3 of the policy is not correct because 48 months continuation coverage of the insured person has elapsed ever since her first policy is done. There is no deficiency of service on the part of opposite parties and the complainant is not entitled to get for any compensation for mental agony and the complaint may be dismissed with cost.
The evidence adduced consisted of testimony of DW1, DW2, Ext. A1 to A11 and Ext. B1 to B8.
Issues to be considered are:
1. Whether there is any deficiency of service on the part of opposite parties ? If so,
2. What is the relief and cost?
Issues I & II
Complaint is claiming compensation against opposite parties for deficiency in service on their part. The case of the complainant is that she had taken an Individual Health Insurance Policy in the year 2004 and has been renewing the same annually. The complainant experienced pain over her right hand about two years back and consulted a doctor at Pazhampalakode, who directed her to an Orthopaedic Surgeon, Dr, Premkumar of Aswini Hospital, Thrissur and conducted surgery. For this purpose she had to spent a sum of Rs. 32,160/-. The claim form submitted by the complainant was repudiated by the opposite parties on the ground that the ailment of the complainant is congenital in nature.
The opposite parties are of the opinion that the insurance policy issued by the opposite parties will not show that it is a continuation of the policy from 2004. The panel doctors of the opposite parties opined that the ailment suffered by the complainant is congenital. The MRI scan also confirm the same and it further shows that the swelling was there since 10 years. But the complainant suppressed this fact and taken the insurance policy. As per the exclusion clause 4,8 of policy the claim is not payable and was reputed. Opposite parties produced B1 document which is of the year of 2004.
The opposite parties have produced Ext. B2, the Proposal form which is dated as 09/07/2004.
In the Ext. B3, MRI Scan, it is written as “swelling / oedema right forearm-10 years history”. But Ext. B4 document issued by Dr. Premkumar. V (Consultant Ortho Surgeon) by whom the surgery was conducted, shows that “pain right FA one year”.
We seem that Ext. B4 document is more reliable in this case as it is issued by the doctor, who has treated the complainant and conducted the surgery. In this document it is stated “Pain Right FA One year”. In MRI Scan B3 document , it is written as “swelling/oedema right forearm 10 years history”. It may be happened by a mistake. More over B3 document is issued by Dr. Prasanna Nagenahalli who has not examined before the Forum.
From the above discussions we are of the view that there is deficiency of service on the part of opposite parties in repudiating the claim made by the complainant.
In the result complaint allowed. Opposite parties are jointly and severally directed to pay Rs. 32,160/- which is the amount spent by the complainant for treatment and Rs. 5,000/- as compensation and 1,000/- as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.
Pronounced in the open court on this the 20th day of January, 2012
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of the complainant
Ext. A1 – Individual Health Insurance Policy Schedule (copy) issued by the opposite parties to the complainant.
Ext. A2 – Claim Form (copy) submitted by the complainant.
Ext. A3 Series – Copy of Bill (No. 304) issued by the Vita Diagnostics to the complainant dated 17/07/2010.
Ext. A4 – MRI Scan Report (copy) of the complainant issued by the Vita Diagnostics dated 17/07/2010.
Ext. A5 Series – Lab Report (copy) of the complainant issued by the Aswini Hospital, Thrissur dated 19/07/2010.
Ext. A6–Electro Cardiographic Report (copy) by Aswini Hospital to the complainant dated 19/07/2010.
Ext. A7 – IP Medicine Prescription Sheet (copy) with OP No. 479547 issued by the Aswini Hospital to the complainant.
Ext. A8 – Discharge Summary (copy) by the Aswini Hospital to the complainant.
Ext. A9 – Letter (copy) from TTK Health Care TPA Private Limited to the complainant dated 25/08/2010.
Ext. A10- Letter (copy) sent by the complainant to the 2nd opposite party dated 01/10/2010.
Ext. A11- Letter (copy) sent by the 2nd opposite party to the complainant dated 02/12/2010.
Exhibits marked on the side of the opposite parties.
Ext. B1 -Individual Health Insurance Policy – 2009 (copy) issued by the 2nd opposite party to the complainant.
Ext. B2 – Medi-Guard (original) Insurance Proposal Form issued by the opposite parties to the complainant.
Ext. B3 - MRI Scan Report (original) of the complainant.
Ext. B4 –Discharge Summary (original) of the complainant issued by Aswini Hospital, Thrissur.
Ext. B5 – Claim Form (original) submitted by the complainant.
Ext. B6 – Claim repudiation letter (original) sent to the complainant from TTK Health Care TPA Pvt. Ltd.
Ext. B7 – Letter (copy) sent by the opposite parties to the complainant dated 08/11/2010.
Ext. B8 – Letter (copy) sent by the 2nd opposite party to the complainant dated 02/12/2010.
Witness examined on the side of complainant
Nil.
Witness examined on the side of opposite parties
DW1 – Balagopalan. N
DW2 – Dr. Mahesh. A.B
Cost allowed
Rs. 1,000/- (Rupees One thousand only) allowed as cost of the proceedings.
