THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.277/2015
Dated this the 11th day of December, 2017
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, M.A., L.L.B. : Member
ORDER
Present: Rose Jose, President:
This petition is filed by the petitioner under Section 12 of Consumer Protection Act, 1986 for getting an order directing the opposite parties to allow his claim and to reimburse the hospital charges of Rs.25,200/- along with 12% interest per annum and also compensation for his sufferings and cost of the proceedings.
Petitioner’s case is that he had taken a Mediclaim Policy of the 1st opposite party vide Policy No, 441003/48/2015/2081 in his and his wife Laila name. While the policy is alive he experienced some difficulties in his left eye vision and consulted in Comtrust Eye Hospital, Calicut. The ailment was diagnosed as Retinopathy complaint due to blockage of blood in left eye. For removing the blockage he had undergone a small surgery. As a part of surgery he has to take an injection in his left eye which cost Rs.25,000/-. Thereupon he informed this fact to the 2nd opposite party through Hospital Authority for availing cashless treatment. The 2nd opposite party advised him to undergo surgery and claim medical re-imbursement. Accordingly he was admitted at the hospital on 01/04/2015 and injection was done to his left eye retina. He was stayed at the hospital for observation and on the next day at 2 pm after check-up he was discharged with advise to come for check-up after 10 days.
The petitioner further stated that as per the advise of the 2nd opposite party, he had prepared the medical reimbursement claim in the prescribed form and submitted before the 2nd opposite party with medical report and cash bill of Rs.25,200/- for getting reimbursement. After some days he received 2 phone messages but it was incomplete and not convincing. So he contacted the 2nd opposite party and they told him that he will be given a detailed reply soon. But so far he has not received any reply. The inordinate delay on the side of the opposite parties in allowing his claim and in giving a reply is a deficiency in service on their part and this caused much mental pain, heavy financial loss and such other difficulties to him. Hence this petition seeking reliefs.
The 1st and 3rd opposite parties filed a combined version. The 2nd opposite party didn’t appear or filed version. Hence they set ex-parte.
The 1st and 3rd opposite parties admitted the issuance of the said policy to the petitioner and his wife with an assured amount of Rs.2,00,000/- for the period from 10/12/2014 to 09/12/2015 subject to the terms and conditions in the policy. The submission of claim for getting hospital expenses of Rs.25,200/- towards treatment of retinal vein occlusion with cystoids macular oedema and surgical operation to left eye underwent by the petitioner on 01/04/2015 in Comtrust Eye Hospital, Kozhikode was also admitted by them. But it is contended that as per Exclusion Clause No. 4.1 of the Policy Conditions, they are not liable to make any payment in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of pre-existing health condition or disease or ailment/injury which are pre-existing (treated or untreated, declared or not declared in proposal form) in case of any of the insured person of the family when the cover incepts for the 1st time are excluded for such insured person upto 3 years if the policy being in force continuously. The said exclusion will also apply to any complication arising from pre-existing ailments (diseases) injuries. Such complications shall be considered as a part of the pre-existing health condition or diseases. Since the ailment of the petitioner was one under the Exclusion Clause No. 4.1 of the policy, they had no option but repudiate the claim and this matter has been intimated to the petitioner through a letter also.
They further contended that all the policy conditions were explained to the petitioner at the time of issuance of the policy and the petitioner was aware of the conditions also. So they are rightly repudiated the claim and hence there is no deficiency in service or any unfair trade practice on their part as alleged and they are not liable to reimburse the hospital expenses of the petitioner as per the policy condition or to pay any compensation to him. Hence prayed to dismiss the petition with cost of them.
The matters for determinations are:
Whether there is any deficiency in service on the part of the opposite parties?
Reliefs and costs if any?
Evidence consists of the affidavit filed by both the parties, Ext.s A1 to A8, B1 to B3 and testimonies of PW1 and RW1.
Point No. 1: There is no dispute with regard to the policy. The petitioner averred that, he had undergone surgery for removing the blockage of blood in his left eye and for that surgery an injection was necessary costing Rs.25,200/-. He produced the copy of the hospital bill for the said amount and was marked as Ext. A3. It is stated that before the surgery he contacted the 2nd opposite party through the hospital authority for reimbursement of the treatment charges and they advised him to undergo treatment and then claim medical reimbursement. As such after the surgery he had submitted a claim for Rs.25,200/- as per Ext. A3 hospital bill, but there was no reply from the 2nd opposite party for a long time and so he again contacted them but even then there was no reply till filing this petition on 05/06/2015. It is stated that only after filing of this petition he received a letter from the 2ne opposite party dated 05/06/2015 intimating the repudiation of his claim due to the reason “Pre-existing disease under Clause 4.1 of the Policy Conditions.” The said letter was marked as Ext. A6. In Ext. A6 it is stated that “Complaint starts since 4 months from 28/03/2015, denied under 4.1, hence this claim needs denial under pre-existing condition.”
The petitioner produced the Medical Report dated 09/04/2015 issued by Dr. Ganadin, MBBS, MS, Fellow in Vitre Surgery, Comtrust Charitable Trust Eye Hospital, Calicut and was marked as Ext. A4. In Ext. A4 it is stated that “Mr. Ismail. S, aged 67 years old (as per OP No.1415/057846) presented to us on 06/01/2015 with complaints of defective vision in left eye of one week duration.” The policy period started from 10/12/2014 onwards. As per Ext. A4 the petitioner had first consulted the doctor on 06/01/2015 and at that time the ailment was only one week duration. From this it is clear that at the time of inception of the policy the ailment was not existed as stated by the opposite parties. So according to the petitioner the denial of his claim due to the reason stated in Ext. A6 is not sustainable and he is entitled to get the claim amount and the denial of his claim is deficiency in service on the part of the opposite parties.
The petitioner was examined as PW1 on 18/08/2016. After cross examination of the petitioner the 1st opposite party filed an additional version as per I.A.454/2016. In their additional version it is contended that as per Exclusion Clause 4.2 and 4.3 of the Policy Conditions also the insurance company shall not be liable to make any payments under this policy. They produced the policy copy and its terms and conditions and marked as Ext. B1. It is to be considered that the repudiation letter showing the reason for repudiation of a claim is the only document for an insured to evaluate whether his claim was genuine or not. Here there was much delay on the side of the opposite parties in sending the repudiation letter to the petitioner which forced him to approach this Forum for justice. The delay was admitted by RW1 in his deposition. The insured is legally entitled to know the exact reason for the repudiation of his claim within a reasonable time and the opposite parties are bound to inform the matter at the earliest also. The inordinate delay in sending the repudiation letter itself is deficiency in service on their part.
Here in this case as per Ext. A6 the only reason stated for the repudiation is pre-existing disease. It is also to be noted here that the opposite parties have not send a second letter showing any other reasons for their repudiation. So Ext. A6 only is applicable so far as the petitioner is concerned. Here Ext. A4 proved that the allegation of pre-existing disease was not true. Since the opposite parties are alleging pre-existing disease as the reason for repudiating the claim, they are bound to prove it by cogent evidence. Otherwise it will become a blind denial without any cause. Here the opposite parties have not produced any evidence to prove their contention that the disease was a pre-existing one. So it was better for them to allow the claim even at this later stage. But here instead of allowing the claim, they dared to come forward with new and untenable contentions that the claim was not admissible under Clause 4.2 & 4.3 of the policy conditions which was not mentioned in Ext. A6 repudiation letter. This shows that the opposite parties are acting prejudicially and are searching for one or other reasons to repudiate the claim in any way. This kind of activities cannot be accepted or tolerated.
Thus it seems that, the filing of additional version and raising of new contentions is the result of an afterthought with ulterior motive of avoiding payment of claim amount at any cost. It also makes reasonable doubt that the opposite parties are not even sure about the exact cause of the repudiation or is there any reason at all. It seems that firstly they are rejecting the claim, and thereafter searching out one or other reason only to justify their action. The insurance is a benevolent enactment intended to act as a helping hand to the poor and needy. People are taking policies after subscribing huge amounts as premium only with firm belief that it will be helpful for them when needed. But the indifferent and irresponsible attitude of the officials of the establishment will no doubt defeat the very purpose of the enactment itself. So this kind of irresponsible activities of the officials must be stopped by imposing heavy penalty.
Considering the facts stated and evidence on record it is found that the repudiation of the claim of the petitioner was without any sufficient reason and hence it is nothing but utter negligence and gross deficiency in service on the part of the opposite parties and so we are of the opinion that this is a fit care for imposing penalty on the opposite party. Point No. 1 found accordingly.
Point No. 2: In view of the finding in Point No. 1, this petition is to be allowed and the petitioner is entitled to get the claim amount and also compensation for the deficiency in service committed by the opposite parties and cost of the proceedings.
In the result, the following order is passed.
The opposite parties are ordered to pay the claim amount Rs.25,200/- (Rupees twenty five thousand two hundred only) along with 9% interest per annum from the date of filing this petition, Rs.20,000/- (Rupees twenty thousand only) as compensation and Rs.2,000/- (Rupees two thousand only) as cost of the proceedings to the petitioner within 3o days from the date of receipt of this order.
Dated this the 11th day of December, 2017
Date of filing: 01/06/2015
SD/-MEMBER SD/-PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. PNB-Oriental Royal Mediclaim Policy Schedule
A2. Copy of Discharge Summary of Comtrust Charitable Trust Eye Hospital
A3. Copy of Cash bill
A4. Copy of Medical Report issued by Comtrust Hospital
A5. Copy of Reimbursement claim form
A6. Copy of Repudiation letter
A7. Copy of screen shot of sms
A8. Policy Schedule
Documents exhibited for the opposite party:
B1. Copy of PNB-Oriental Royal Mediclaim Policy Schedule
B2. Copy of Proposal form
B3. Copy of repudiation letter
Witness examined for the complainant:
PW1. Ismail S. (Complainant)
Witness examined for the opposite party:
RW1. Ali Serbi, Athakassery House, Naduvannur Post
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
