By Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite Party to pay Rs.35,000/- towards treatment expenses incurred by the complainant with 12% interest from 26.05.2013 till payment and also directing the Opposite Party to pay Rs.10,000/- as compensation to the Complainant for the deficiency of service of Opposite party.
2. Complaint in brief:- The Complainant on 26.03.2011 took a Health Insurance Policy from Opposite Party as per policy No.P/181314/01/2011/008553. As per policy conditions if the complaint, his wife, or children is admitted in Hospital for at least 24 hours as an inpatient and have taken treatment, the Opposite Party is liable to pay the treatment expenses. The Complainant there after renewed the policy on 26.03.2012 and on 23.03.2013 and the last policy have the validity from 26.03.2013 to 25.03.2014. The Complainant due to severe stomach ache admitted in Meppadi WIMS Hospital and undergone treatment for Hernia. The Complainant got discharged and thereafter the Complainant made claim application to the Opposite party. But the Opposite Party repudiated the claim with a reason that the disease is “pre-existing disease”. The case of Opposite Party is that the Complainant is suffering from Hernia since 3 years from the date of 26.04.2013. Aggrieved by the act of Opposite Party, the Complaint is filed.
3. On receipt of complaint, notice was issued to the Opposite Party and the Opposite Party appeared before the Forum and filed version. In the version, the Opposite party contended that there was no any deficiency in the service on the part of Opposite Party as the Complainant was suffering from inguinal Hernia since 3 years which is clear from the Hospital records of the Complainant who underwent treatment at DM Wayanad Institution of Medical Science. The Opposite Party admits the policy having validity. The policy is issued as per the terms and conditions of policy and the Complainant had signed the policy. The insured has not mentioned any disease in the health history column of the proposal form. Based on the declaration, the policy is issued. The Complainant was admitted at DM Wayanad institute on 26.04.2013 and diagnosed Left Direct Inguinal Hernia and was discharged on 01.05.2013. The Opposite Party conducted investigation and collected copy of the case records of the Complainant from DM Wayanad in which it was revealed that he was suffering from Left Inguinal Hernia more than 3 years. The treating doctor in order to help the patient had stated that the patient was suffering from the same since 1 ½ years. But no such records is found by Opposite Party. Since the Complainant has been suffering from Inguinal Hernia since 3 years, the claim falls under exclusion clause No.1 of the policy.
4. On perusal of complaint, version and documents, the Forum raised the following points for consideration.
1. Whether there is deficiency of service from the part of Opposite Party?
2. Relief and cost.
5. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents marked as Exts.A1 and A2 and Ext.X1 series. The Opposite Party also filed proof affidavit and is examined as OPW1 and Exts.B1 to B7 is marked. On going through Ext.B2 record ie Anesthesia record, it is stated in Relevant Past History column “L+1H – 3 years”. It means the patient is suffering Left Inguinal Hernia since 3 years. Ext.B2 is issued by Anesthesia doctor. Anesthesia doctor is not the doctor who treated the patient. The
Ext.B4 document is the claim form in which the treating doctor M. Nandeesh recorded that past History of patient with the duration of illness is one and half years. The Forum is of the opinion that the treating doctor can only state the past history of the illness better than Anesthesia doctor. In no other medical records it is stated that the patient is having Hernia illness since 3 years. On what basis, the Anesthesia doctor recorded that the patient is having Hernia illness since 3 years is not stated anywhere. The Forum can believe only the record of treating doctor. So the Forum found that since the policy is valid during the period of admission of the patient/Complainant in the Hospital and treatment, the patient/Complainant is entitled to get treatment expenses from the Opposite party. The repudiation of claim by the Opposite party is a deficiency of service from the part of Opposite Party. Point No.1 is found accordingly.
6. Point No.2:- Since point No.1 is found in favour of Complainant, the Complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the Opposite party is directed to pay Rs.35,000/- (Rupees Thirty Five thousand) only to the Complainant towards treatment expenses with 12% interest from 26.05.2013 till payment. The Opposite Party is also directed to pay Rs.10,000/- (Rupees Ten thousand) only as compensation and Rs.2,000/- (Rupees Two thousand) only as cost of the proceedings. The Opposite Party shall comply the order within 30 days from the date of receipt of this order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 25th day of May 2015.
Date of Filing:01.10.2013.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. Varghese Panachikkal. Complainant.
Witness for the Opposite Party:
OPW1. Manu Mohan Executive Officer, Star Health & Allied
Insurance Co. Ltd.,
Exhibits for the complainant:
A1. Copy of Letter. dt:27.07.2013.
A2. Medical Certificate. dt:06.05.2013.
X1 series Copy of Treatment Records.
Exhibits for the opposite Party.
B1 (14 pages) Copy of Star Tru Value Health Insurance Plicy Schedule.
B2. Proposal Form. dt:26.03.2011.
B3. Copy of Anesthesia Record. dt:26.04.2013.
B4. Claim form for Medical Insurance.
B5. Discharge summary.
B6. Copy of Letter. dt:27.07.2013.
B7. Authorisation Letter. dt:14.02.2015.
