DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  16^th day of  June, 2023 

Present      :    Sri. Vinay Menon V., President

                  :   Smt. Vidya A., Member                       

                  :   Sri. Krishnankutty N.K., Member                               Date of Filing: 27/07/2022  

                         CC/81/2020

Kannan Thampi,

S/o. Thampi Chandran,

Mandumpala House, Near Sreekrishna Temple,

Kunnathurmedu, Palakkad – 678 013                        -                       Complainant

(By Adv. M/s K.Sindhupriya & Arun Krishnan R.)

                                                                                                Vs

1. The Managing Director & CEO Branch Manager,

Reliance General Insurance Company,

Reliance Centre, South Wing, 4^th Floor,

Western Express Highway, Santhacruz East,

Mumbai – 400 055

2. The Manager,

Reliance General Insurance Company,

3^rd Floor, Urumbil Signature Tower,

Behind KR Bakery, Kanjikuzhy,

Kottayam – 686 004

3. Jubilee Mission Medical College Hospital,

Bishop Alappatt Road, P.B.No.737,

Thrissur – 680 005

Rep.by Managing Director                             -                       Opposite parties

(O.P.s 1 & 2 by Adv. K.K. Jaidip

O.P. 3 by Adv. M/s Abhilash G. & Sujesh K.)

O R D E R

By  Sri. Vinay Menon V., President

1. Complainant pleads that he and his wife are beneficiaries under a health insurance policy issued by the opposite parties 1 & 2. Complainant’s wife was diagnosed with endometriotic cyst during the coverage period of the policy in the 3^rd O.P. hospital and had to undergo an urgent surgery. The O.P.s 1 and 2 repudiated the claim for cashless treatment stating that the treatment for cyst/polyps was not covered for first 24 months from the date of inception of the policy. Alleging the ground for repudiation to be illegal and alleging connivance between the O.P.s 1 & 2 and 3, to betray benefits of the policy to the complainant, this complaint is filed.
2. O.P.s 1 and 2 filed version contenting that the condition suffered by the complainant would be covered only after the first 24 months and as on the date of surgery, there was no coverage as the condition suffered was still in the waiting period.
3. O.P. 3 filed version contenting that the treatment rendered was effectual and that there was no connivance between them and the Insurance Company.
4. Pleadings and counter-pleadings considered, we frame the following issues for adjudicating the dispute:

1. Whether the ailment suffered by the complainant was within the waiting period as contemplated under policy conditions?
2. Whether there is any deficiency in service on the part of the O.P.s?
3. Whether the complainant is entitled to any of the reliefs sought for?
4. Any other reliefs?

5. (i)         Complainant issued Power of Attorney in favour of his wife. Attorney filed proof affidavit and marked Exts. A1 to A8 and was examined as PW2.

Marking of Ext. A1 was objected to on the ground it is a policy schedule unaccompanied by terms and conditions. Ext. A8 is a copy of the entire policy documents submitted by the O.P.1. at the instance of complainant. Therefore reliance need not be made on Ext. A1.

Ext. A5 was objected as the said certificate can be marked only though the doctor who issued it. Therefore the doctor concerned was examined as PW1. Therefore objection can be overruled.

            (ii)        O.P.s filed proof affidavits; no documents were marked.   

            Issue No. 1

6.         Repudiation of the complainant’s claim was made by the 1^st O.P. on the ground that the treatment covered is subject to a waiting period of 24 months from the Policy Commencement Date. Grand pleadings by the complainant and evidence apart, crux of the dispute can be ascertained by answering the question ‘whether the treatment evidenced by Ext. A4 Discharge summary is within the waiting period of 24 months contemplated under Section 5(b)(i) & (vi) of the Exclusion Clause in Ext. A8’.

7.         Impression shown in Ext. A3 US Report is that the complainant was suffering from “LEFT OVARIAN CYST – LIKELY ENDOMETRIOTIC ON FOLLOW UP”.

8.         Ext. A4, as already stated supra, is a Discharge summary of the treatment and surgery underwent by the complainant in O.P.3 hospital. She was having “left sided cystic mass 7x8 cm palpable with nodules in POD”. Procedure carried out is “LAPROSCOPIC CYSTECTOMY UNDER GA ON 22/05/2020”.

8.         Ext. A8 is the complete copy of  policy documents pertaining to the Insurance coverage of the complainant. Section 5 of Ext. A8 deals with ‘Exclusions’.

Clause (b) deals with Specific waiting period. Sub - Clause b(i) reads as follows:

S. 5(b)(i) -  “Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first Policy with us. This exclusion shall not be applicable for claims arising due to an accident.”

            List is scheduled under Sub clause (vi).  2^nd item in this schedule relates to Gynaecological issues. Conditions in the 1^st exclusion deals with Cysts, polyps including breast lumps.

9.         Policy schedule of Ext.A8 shows that first policy inception dated is 31/1/2020.

Hence it can clearly be seen that the treatment rendered as shown in Ext.A4 is within the waiting period of 24 months as contemplated under Ext.A8. Accordingly Issue No. 1 is decided in favour of O.P.s 1 & 2.        

            Issue No. 2 to 4

10.       Resultantly we hold that repudiation of claim by the opposite parties 1 & 2 is in order and there is no deficiency in service on the part of OPs. Complainant is not entitled to any of the reliefs sought for.

11.       In the facts and circumstances of the case, parties are directed to suffer their respective costs.

12.       Accordingly this complaint is dismissed.

                  Pronounced in open court on this the  16^th  day of June, 2023.      

                                                                                                                              Sd/-

                                                                                                            Vinay Menon V

                                                                President

                    Sd/-

              Vidya.A

                                   Member        

      Sd/-                                              Krishnankutty N.K.

                                                                                                                     Member

APPENDIX

Exhibits marked on the side of the complainant :

 Ext.A1 –  Original policy schedule bearing policy No.220622028240000243

Ext.A2 –  Copy of rejection letter dated 23/5/2020

Ext.A3  –  Original ultra sound report dated 8/5/2020

Ext.A4 –  Copy of discharge summary dated 25/5/2020

Ext.A5 – Original certificate dated 8/6/2020

Ext.A6 – Bill dated 26/5/2020

Ext.A7 –  Original Power of Attorney dated 18/2/2020

Ext.A8 – Copy of policy document bearing policy No.220622028240000243

Exhibits marked on the side of the opposite party:   Nil

Court Exhibit:  Nil

Third party documents:  Nil

Witness examined on the side of the complainant:

PW1 – Dr.Neetha George

PW2 – Varsha P Varghese

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.