DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 30th day of April 2011
Present : Smt.Seena H, President
: Smt. Preetha.G. Nair, Member
: Smt. Bhanumathi.A.K, Member Date of filing: 25/09/2010
(C.C.No.118/2010)
Janaki,
W/o.Late Narayanan,
Cherupushpanilayam,
Kannimari Post,
Pattanchery,
Chittur Taluk, Palakkad - Complainant
(By Adv.K.V.Sujith)
V/s
The Manager
National Insurance Co.Ltd.
Branch Office,
Kanoos East Fort Resort,
18/77, 3rd Floor,
Kunnathurmedu Post,
Palakkad – 678 013. - Opposite party
(By Adv.A.R.V.Sankar)
O R D E R
By Smt.SEENA.H. PRESIDENT
Case of the complainant in brief:
Complainant has availed a Mediclaim Policy issued by opposite party on 29/9/2009 for the period 29/9/2009 to 28/09/2010. The sum assured was Rs.1,50,000/- for which Rs.2590/- was paid as premium. As per the terms and conditions of the policy, opposite party has assured health coverage to the complainant. During February 2010, complainant experienced a sudden swelling on her neck and the doctor consulted found her suffering from solitary Noudulat Goitore and suggested for a surgery. Complainant was admitted on Palana Hospital on 4/5/2010 for surgery and was discharged on 8/5/2010. Complainant submitted claim form claiming treatment expense of an amount of Rs.23,371/- Further documents pertaining to the treatment of the complainant was also submitted as per their request. Inspite of receiving all necessary documents, opposite party failed to disburse the claim amount. The policy was repudiated by the opposite party on 6/8/2010 stating that under exclusion clause 4.2 of the policy excludes “any hospitalisation expense incurred in the first 30 days from the commencement of the insurance cover except in case of injury arising out of accident. According to the complainant, the claim preferred by the complainant is not contracted within 30 days of the inception of the policy as alleged by the opposite party. The complainant never had the history of solitary Noudulat Goitore before. The certificate of the treated doctor dated 13/5/2010 goes on to show that the patient was suffering from the disease since 3 months. The inception of the policy is on 29/9/2009. Opposite party has repudiated the claim without any genuine reason. Hence the complaint. Complainant prays for an order directing the opposite party to pay Rs.23,371/- being the claim amount alongwith Rs.10,000/- as compensation for the mental agony and hardship caused to the complainant due to the deficiency in service on the part of opposite party.
Opposite party contented that the claim preferred by the complainant is not payable as per clause 4.2 of the policy. As per the said clause hospitalization expenses incurred in the first 30 days from the commencement date of insurance cover is excluded. Here the complainant was admitted on 4/5/2010 for the disease 'Nodule right Thyroid' and after surgery was discharged on 8/5/2010. The certificate issued by the treated doctor reveals the fact that she was suffering from the same illness for the last 3 to 6 months. That is within 30 days from the inception of the policy. According to the opposite party since the repudiation was as per the terms of the policy, there is no deficiency in service on the part of opposite party.
The evidence led by the complainant consists of the chief affidavit, Ext.A1 to A4 and testimony of Smt.Janaki. Opposite party also filed chief affidavit and Ext.B1 to Ext.B5 were marked. Witness was examined as DW1
Now the issues that arise for our consideration are
Whether there is any deficiency in service on the part of opposite party ?
If so, what is the relief and cost complainant is entitled to ?
Issue 1 & 2
The specific case of the complainant is that she availed a mediclaim policy from the opposite party for the period 29/9/2009 to 28/09/2010. Thereafter on 4/5/2010 she was hospitalised and surgery was also done. Complainant claimed the insurance amount from the opposite party, but opposite party repudiated the claim without any genuine reason.
Opposite party on the other hand contented that the claim is not payable since clause 4(2) of the policy excludes hospitalization expenses incurred in the first 30 days from the commencement date of insurance cover. Further, the insured was having the same illness even before effecting the policy.
Heard both parties and has gone through the entire evidence on record.
As per Ext.A1, the period of the policy commences from 29/9/2009 to 28/9/2010. It is admitted by both parties that the complainant was admitted for treatment and further surgery on 4/5/2010. Opposite party has relied on Ext.B2 & Ext.B5, the scan report and an attachment which the treated doctor has given as per the request of the insurance company stating the approximate duration of the disease. Ext.B2 report is seen dated 23/4/2010. DW1, the treated doctor has deposed that the duration of the disease stated as 3 to 6 months in the report is based on the size of the nodule and is only approximate. It is relevant to note the answers provided by the treated doctor in Ext.A3 which is the medical certificate filled by the doctor treating the patient which is as follows :
Q.No.6 (a) With what complaints was the patient admitted for ?
Answer : Swelling neck
(b) Since when was the patient suffering from the said
complaints ?
Answer : 3 months
Q.No.7. Past History of the patient (if any) with the duration of illness?
Answer : Nil
Ext.A3 clearly reveals the fact that the complainant has no pre-existing disease as alleged by the opposite party at the time of availing policy.
Another major contention is claim is not payable since it is excluded under clause 4.2 of the policy clause. Clause 4.2 of the policy read as follows:
The company shall not be liable to make any payment under this
policy in respect of any expenses whatsoever incurred by an insured person in connection with or in respect of:
Any hospitalization expenses incurred in the first 30 days from the
commencement date of insurance cover except in case of injury
arising out of accident.
The evidence on records clearly shows that the hospitalization expenses incurred by the complainant is not within 30 days from the commencement of the policy. Policy commenced on 29/9/2009 and the expenses claimed is for the hospitalization on 4/5/2010 to 8/5/2010.
The facts and circumstances of the case and the evidence on record clearly establishes the deficiency in service on the part of opposite party. Opposite party has without any valid reasons repudiated the genuine claim of the complainant.
In the result complaint is allowed. Opposite party is directed to pay complainant an amount of Rs.23,371/ (Rupees Twenty three thousand three hundred and seventy one only) being the claim amount along with Rs.2,000/- (Rupees Two thousand only) as compensation and Rs.1,000/- (Rupees One thousand only) as cost of the proceedings. Order shall be complied within one month from the date of receipt of order, failing which the whole amount shall carry 9% interest per annum from the date of order till realization.
Pronounced in the open court on this the 30th day of April 2011
Sd/-
Seena H
President
Sd/-
Preetha G Nair
Member
Sd/-
Bhanumathi.A.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Policy of complainant (original) with conditions
Ext.A2 – Copy of claim Form
Ext.A3 – Copy of Medical Certificate issued by Dr.A.R.Kannan
Ext.A4 – Repudiation letter issued by the opposite party to the complainant
dated 6/8/2010
Complainant cross examined
PW1 - Janaki
Exhibits marked on the side of the opposite parties
Ext.B1 – Copy of Policy with conditions
Ext.B2 – Scan report of complainant issued by Palana Hospital dated 23/4/10
Ext.B3 - Claim Form of complainant dated 19/5/2010
Ext.B4 – Discharge Summary of complainant issued by Palana Hospital
dt.8/5/10
Ext.B5 – Doctor's Report
Witness examined on the side of the Opposite party
DW1 – Dr.Kannan
Cost Allowed
Rs.1,000/- allowed as cost of the proceedings
