By Sri. Jose. V. Thannikode, President:
Brief of the complaint: The Complainant took Medi classic insurance from Opposite Party after remitting Rs.3,858/- on 11.02.2012. Thereafter the said policy renewed on payment of Rs.3,858/- for that Opposite Party issued a policy No. P-181314/01/2013/004956 then Opposite Party assured the treatment of expiry from 11.02.2012.
2. While so on 19.04.2013 when the Complainant stepping down from a bike on side of the road dropped his leg on gutter and subsequent to that, injury happened to his leg and rip. So he went to Shrisha Hospital at Pulpally and on knowing the injury is serious he
admitted in Ayush Aurveda Hospital Kalpetta on 23.04.2013 and discharged on 06.05.2013. For that treatment Complainant spend Rs.42,852/-.
3. On intimation from the Complainant for claim, one officials from Opposite Party come to the hospital and met the Complainant and examined the documents also. Thereafter the Complainant submitted all the documents to the Opposite party. Then Opposite party asked the Complainant to produce the FIR, DL etc but the incident was not occurred on an RTA, the FIR is not registered. Hence the Complainant informed the matter to the Opposite party with a letter dated 06.06.2013 but on 30.07.2013 the claim is rejected by the Opposite Party without understanding the actual fact. The Complainant further says that there is no reason to reject the claim and he is entitled for the same and the Opposite Party is responsible and liable to pay cost and compensation and he further says that the act of the Opposite party is nothing but deficiency of service and unfair trade practice and prayed before the Forum to award cost and Compensation due to the deficiency of service by the Opposite Parties
4. Notice was served to Opposite Parties and Opposite Parties entered appearance and filed version stated that the above complaint is not maintainable either on facts or on low and is liable to be dismissed and further stated there was no any deficiency in the service on the part of the opposite parties as the complainant had suppressed the material facts and has narrated different stories as the reason of his illness. The Opposite parties admit that the complainant had taken the policy named Mediclassic health insurance Policy (Individual) from this Opposite Parties for the period from 11-02-2012 to 10-02-2013 vide policy No.P/181314/01/2012/006273 which was further renewed till 10-02-2014 vide policy No. P/181314/01/2013/004956. There is no history of fall recorded in any of the authentic medical records Neither the first treatment certificate issued by Mr. K.S. Vighneshwara Bhatta, Shrisha hospital, Pulpally, Wayanad produced by the complainant nor the medical certificate issued by the treating doctor of Ayush Ayurvedic Hospital records any history of fall. The story of fall is made up by the treating doctor in the discharge summary for this case only by colluding with the claimant for getting unlawful gains. The insured was admitted at Ayush Ayurvedic Hospital & Research Centre, Kalpetta on 23/04/2013 and was diagnosed IVDP (low back ache) for which he had taken treatment. He thereafter submitted the completed claim form with the medical bills and lab reports. It is submitted that the insured in the claim form had stated that on 22-4-13 at 11 a.m he had fallen from a bike and had sustained the injury for which he had taken treatment for. As per the discharge summary dated 06/05/2013 of Ayush ayurvedic Hospital & Research Centre, Kalpetta, the past medical history history of fall from Motor Bike, Two weeks back, Pain radiating to left leg. Even if there is history of fall two weeks back as per discharge summary as on date of admission 23/04/2013, the date of incident would have been 9thApril 2013. The insured on 6-6-2013 had made another submission before the Opposite Parties that the alleged accident was on 19-4-2013, he had fallen on the side of the road while he was alighting the bike. He had also submitted a certificate from Shrisha Hospital, Pulpally, Wayanad dated 6-6-13 duly signed by Dr.K.S. Vighneshwara Bhatta, in which it was stated that the insured had consulted the Doctor on 21-4-13 with complaints of sprains with back ache. These discrepancies in the dates of alleged fall itself would prove that the history of fall is fabricated by the complainant to get unlawful gains through fraudulent means.
5. The Opposite Party obtained an expert Orthopedic opinion which has confirmed that IVDP is not due to traumatic fall. The complainant had claimed suppressing the material facts of his illness by cooking up an imaginary story of a fall which could not be brought out by any of the documents produced by him. It is submitted that on going through the records of the treating Doctor it is clear that the complainant had undergone treatment for IVDP(intervertibral disc prolapse).Since the treatment was for IVDP, the claim falls under exclusion clause No.3 of the policy. As per the Exclusion clause No3 of the policy, the company is not liable to make any payment in respect of any expense incurred by the insured person in connection with or in respect of "During the First two Years of continuous operation of Insurance cover, the expenses on treatment of Cataract, Hysterectomy for Menorrhagia or Fibromyoma, Knee Replacement Surgery (other than caused by an accident), Joint Replacement surgery (other than caused by an accident), Prolapse of intervertibral disc (other than caused by an accident), Varicose veins and varicose ulcers. If these diseases are pre-existing at the time of proposal they will be covered subject to exclusion No.1 above". More over the opposite party company is not be liable to make any payment under the policy in respect of any claim if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. As per the Condition No.6 of the policy issued to the complainant it is clearly stated that, “The Company shall not be liable to make any payment under the policy in respect of any claim if such claim is in any manner fraudulent or supported by any fraudulent means of device, misrepresentation whether by the Insured person or by any other person acting on his behalf". Hence the Opposite Party rejected the claim of the complainant which was
intimated to him on 5-8-13. The complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the opposite parties with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. In this case the complainant has made up an imaginary story and has tried to defraud the company by and is trying to get compensation. Hence the policy was vitiated by the element of fraud. It is humbly submitted from the above facts and submission that there is no deficiency of service on the part of the opposite party. The opposite party is entitled to get compensatory cost from the complainant for the reason that (1) the complainant had made fraudulent stories to get claim from the company, (2) moreover the complainant dragged the opposite parties in to an unnecessary litigation knowing fully well that his treatment falls under exclusions as per policy. Therefore compensatory cost may be allowed. In view of the above facts and submissions this Honorable Forum may be pleased to dismiss the complaint and allow cost and compensation to the opposite party and tender justice.
6. The Complainant filed proof affidavit and he is examined as PW1 and Exts.A1 to A7 is marked. Exts.A2 to A7 marked with objection since it is photo copy. Exts.X1 and X2 is also marked. (Opposite party produced the original of document Ext.A2 to A7). Opposite Party also filed proof affidavit and he is examined as OPW1 and Opposite Parties document is marked as Ext.B1 to B7. Ext.A1 is the Medi classic Health Insurance Policy (Individual) Schedule when the policy covered between 11.02.2013 to 10.02.2014. Ext.A2 is marked with objection but the Opposite party produce the original of Ext.A2 document and it is marked as Ext.B3, which shows the claim is repudiated on the ground that there was a misrepresentation by the Complainant. Ext.A3 is marked with objection since it is photocopy but the Opposite party produce the same document as Ext.B6. Ext.B1 is the letter given by the Complainant to the Opposite Party stating that the incident is occurred not in any RTA and hence the FIR is not registered. Hence he is not able to produce the FIR DL. Ext.A4 is the certificate issued by the Shrisha Hospital which shows that on 21.04.2013 the Complainant taken treatment from Shrisha Hospital. Ext.A5 is the document which is marked as subject to proof hence it was a photocopy. Ext.A6 is the discharge summary which is marked as subject to proof and Opposite Party marked the original of Ext.A6 as Ext.B4. In which it can be seen that Date of Admission is 23.04.2013 and Date of Discharge is 06.05.2013. Diagnosis is shown as (Law back ache) past medical history is written as History of full from motor bike, two weeks back and pain relating to left leg. Ext.A7 is the particulars of treatment and expected amount of treatment. Ext.B2 is the letter given by the Shrisha Hospital which shows that the Complainant is treated in the Hospital on 21.04.2013. Ext.B5 is the claim form in which the History of disease is noted as law back ache and in the brief particulars of the accident column, it is noted as fall from motor bike, pain to left leg. In the medical report by the treating doctor it is written as for the question. “Since when the patient suffering from the said complaints. Answer- 2 weeks. There in our opinion is that the certificate is prepared on 06.05.2013. The 2 weeks ago means the incident occurred approximately on 21.04.2013. Ext.X1 is the medical treatment record from the Shrisha Hospital where the Complainant treated first. It shows that on 21.04.2013 the Complainant was taken treatment for the injury. Ext.X2 is the treatment record from the Ayush Hospital where the Complainant admitted and taken treatment. In which also it is stated that symptom started from five days back after fall from a motor bike.
7. On perusal of complaint, version, affidavits, deposition and documents produced by both parties the Forum taken the following points for consideration.
1. Is there any deficiency in service from the part of Opposite parties?
2. Relief and cost.
8. Point No.1:- The main contention of the Opposite Parties are that misrepresentation of the facts and suppressing the material facts of his illness by the Complainant and also contended that the date of incident is different in same document and from the statement of doctor. In the opinion of the forum it is not true. The incident is happened on 19.04.2013 it is evidenced from Exts B2, B6, Complainant Ext.X1 and X2 ie why he has taken treatment from 21.04.2013 onwards. Another contention of the Opposite Parties are that, no document is there to show that the injury happened due to a fall from the motor bike. The Exts.A3, A6 (B4), B6, B5 clearly shows that the incident is occurred on a fall from a Motor bike.
9. The other contention of the Opposite Parties is that according to the statement of the doctor in Ext.B4 and Ext.A6, the injury caused two weeks back, it means the incident would have been 9th April 2013 is not admissible because the discharge summary is written on 06.05.2013. Hence the incident would have been about 19th April 2013 and OPW1 also deposed that “if we calculate two weeks from the date of discharge, it would come to 19.04.2013.
10. The other contention of the Opposite Party is that the illness IVDP is comes under the exclusion clause No.3 is also not true since the IVDP other than caused by an accident is only excluded and the OPW1 also deposed that the IVDP may come on a fall.
11. On analysing all the evidence above, we are in the opinion that there was no misrepresentation of facts, and on allegation of these grounds, repudiation of claim is an unfair trade practice and it amounts to deficiency of service. The point No.1 is found accordingly.
12. Point No.2:- Since the point No.1 is found against the Opposite Parties are liable to pay the claim amount with interest and cost and compensation. The Complainant is entitled for the same.
Hence the complaint is partly allowed and Opposite parties are directed to pay Rs.42,855/- (Rupee Forty Two thousand Eight hundred and Fifty Five) only with 12% interest from 08.11.2013 as claim amount and also directed to pay Rs.5,000/- (Rupees Five thousand) only as compensation and Rs.3,000/- (Rupees Three thousand ) only as cost of the proceedings to the Complainant. The Opposite Parties are directed to comply the order within one month from the date of receipt of this order. There after the Complainant is entitled for an interest at the rate of 15% per annum for whole the amount.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 10th day of April 2015.
Date of Filing:08.11.2013
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. P.M. Johny. Complainant.
Witness for the Opposite Parties:
OPW1. Manu Mohan Executive Officer, Star Health.
Exhibits for the complainant:
A1.(3 pages) Medi Classic Health Insurance Policy (Individual) Schedule.
A2.(2 pages) Repudiation of Claim. dt:30.07.2013.
A3. Copy of Letter. dt:06.06.2013.
A4. Copy of Certificate. dt:06.06.2013.
A5. Letter. dt:28.05.2013.
A6. Copy of Discharge Summary. dt:06.05.2013.
A7(a & b) Copy of the particulars of Treatment and expected
amount of treatment. dt:06.05.2013.
Exhibits for the opposite Parties.
B1.(6 pages) Copy of Medi Classic Insurance Policy (Individual).
B2. Certificate. dt:06.06.2013.
B3. Copy of Letter. dt:05.08.2013.
B4. Discharge Summary. dt:06.05.2013.
B5. Claim Form For Medical Insurance. dt:06.05.2013.
B6. Letter. dt:06.06.2013.
B7. Authorisation Letter. dt:04.03.2015.
X1. Prescription. dt:21.04.2013.
X2. Case Sheet. dt:23.04.2015
