SMT. RAVI SUSHA  : PRESIDENT

     Complainant  filed this complaint  U/S 35 of the  Consumer Protection Act 2019 seeking to get  an order directing opposite parties to pay an amount of Rs.150,000/- as the  amount incurred by the complainant for the treatment  of her husband  Mr.Joseph Thekkeyil and Rs.1,00,000/- towards compensation.

        The brief facts of the complaint is that  complainant had taken an Arogya Sanjeevani policy  from  OPs on 13/1/2021 covering her husband also.  The  sum insured is  Rs.3,00,000/-. It is stated that due to some health problem  the complainant’s husband Mr.Joseph was admitted in Anamaya Medical Institute,Payyanur on 17/1/2023 and was discharged on 26/1/2023.  Further a surgery was conducted on Mr.Joseph and incurred an expense of Rs.137254/- and spend some other  amount in connection with the treatment. Further submitted that the hospital authority were not  ready to accept the policy and   the complainant is constrained to pay the bill.  Further the complainant  preferred a claim before  the OPs submitting original medical bills but the claim  was rejected  by OP. Complainant sent lawyer notice to OPs  demanding the claim, they received the  notice but neither send  any reply  nor paid the amount.  Hence  this complaint.

    After receiving notice, OPs entered  appearance through their counsel and  filed version admitting the  policy of complainant and her husband. It is submitted  that during the aforesaid policy period, OP had received a request for cashless hospitalization from Anamaya Medical Institute, Payyanur, the complainant’s husband Mr.Joseph was admitted at the hospital on 17/1/2023 and was provisionally diagnosed with disease COPD and CVA.  Along with request for cashless hospitalization, the hospital has forwarded the OP record dtd.17/1/2023 and  nurses initial assessment sheet, where it is observed that the patient is a known case of old CVA/COPD on medicine.  The OP had  issued a letter to the above hospital  to submit  letter from treating doctor stating the duration of COPD,CVA,circumstance of injury, submit first consultation, treatment records, any prior  history of hospitalization if so its discharge summary.  But the hospital has failed to submit  first consultation paper. It is further submitted that  as the letter of OP, she produced prescriptions dtd.30/3/2021 from Dr.Jose.P.Antony,Dr.Jose’s clinic,Kannur and prescription dtd.2/8/2011, 3/9/2022 from Dr.M.Mathews, Kannur.  Along with the same,  the complainant had submitted case record from Anamaya  Medical Institute,Payyanur.  As per the  prescriptions submitted by the complainant the patient has been consulting for COPD since 30/3/2021 and on medication.  But the duration was not mentioned.  The OPs after perusing the submitted documents had again issued a query letter dtd.3/3/2023 to the complainant to submit previous discharge summary of CVA and COPD with diagnosed PFT report and MRI report. But the complainant had failed to furnish previous discharge summary.  Without the  required documents sought for, the OPs were not able to decide the admissibility of the claim.  Hence the OPs having no other option , had repudiated  the claim for  the reason “Non submission of required documents and informed the complainant vide letter dtd.17/3/2023. There is no  deficiency of service  from the OPs.  The claim of the complainant was repudiated for reasonable  grounds.  Hence prayed for the  dismissal of the complaint.

         Complainant filed chief affidavit and  documents. Examined as PW1 and marked the documents as Exts.A1 to A4 series.  PW1 was cross-examined for  OP and marked Exts.B1 to B12.  On the side of OPs, Deputy Legal Manager of  OP filed his chief affidavit and was examined as DW1 . After that the learned counsel of complainant filed argument note.

   The undisputed facts in this case are that the complainant had taken an Arogya Sanjeevani policy  from  OPs on 13/1/2021 covering her husband also.  The  sum insured is  Rs.3,00,000/-.  Further the complainant’s husband Mr.Joseph was admitted in Anamaya Medical Institute,Payyanur on 17/1/2023 due to a fracture and was discharged on 26/1/2023.  Further a surgery was conducted on Mr.Joseph and incurred an expense of Rs.137254/-.  Further the complainant  preferred a claim before  the OP company and it was rejected through Ext.B12 letter dtd.17/3/2023  due to the reason of “Non submission of required documents”.  OP directed the complainant to submit previous discharge summary of CVA and COPD with diagnosed PFT report and MRI report.  In the absence of the above said documents, OP denied the claim of complainant. According to OP as per policy condition No.10.4, the insured person has to submit  all the  required documents and details called for  by OP insurance company.

    Complainant submitted that she made a written pre authorization request for cashless facility, but the request was turned down by the  insurer on the reason that the husband of the complainant provisionally diagnosed with disease COPD and CVA.  Along with request for cashless hospitalization, nurses initial assessment sheet was forwarded to the OP insurance, where it is observed that the patient is a known case of old CVA/COPD on medicine. It is also submitted that  as the letter of OP, she produced prescriptions dtd.30/3/2021 from Dr.Jose.P.Antony,Dr.Jose’s clinic,Kannur and prescription dtd.2/8/2011, 3/9/2022 from Dr.M.Mathews, Kannur which are marked as Ext.B10.  It is pertinent to note that the policy was issued to the complainant on 13/1/2021.  The symptoms related to the disease COPD,CVA clinically found only on diagnosis on 30/3/2021.  The complainant is unaware of the existence of disease prior  to consultation.  Complainant’s husband had never been admitted to the hospital for treatment of COPD or CVA.  He was treated as an outpatient for these disease.  The  complainant can only submit the documents that are available and cannot be expected to produce documents that do not exist, especially since the diagnosis was made after policy issuance.  In this respect the complainant herewith produce  the  judgment of Hon’ble High Court of Kerala reported in 2019 ICO 2681 observed that  “Rejection of medical insurance claim for the reason that insure contracted disease within 30 days of commencement of policy-A disease can be said to be contracted for the purpose of insurance claim, only when after diagnosis it is clinically found that the patient  is suffering from disease.  The symptoms related to the disease may be in existence for long periods prior to the diagnosis and they symptoms may be within the knowledge of the patient.  For the purpose of an insurance claim, a disease can be said to be contracted only when it is diagnosed by a competent physicians and confirmed.  In the instance cse the burden of proving the fact, which excludes the liability of the insurer to pay compensation lies on the insurer.

     Here OP failed to prove their contention.  Not a piece of medical records produced by  OP to establish that the complainant’s husband was suffered from COPD and CVA prior to the taking of the policy or diagnosed by  a competent medical  practitioner   prior to 13/1/2021.  In  the medical records as available  here, the treating doctor has stated that patient is a  known case of old CVA/COPD on medicine.  But the date of diagnosis of said disease is not seen mentioned.  The patient had taken disputed treatment for the fracture of proximal tibia.

     So as per the  judgment of Hon’ble High Court of Keala as referred above, complainant is entitled to get the treatment expense incurred to her for the treatment of her  husband Mr.Joseph taken from Anamaya Medical Institute, Payyanur.  Ext.B7 shows the total treatment expense was Rs. 137254.00. Here without any cogent medical records, denial of  eligible claim of the insured amounts to deficiency in service on the part of insurance company.  So the complainant is entitled to get relief from the OPs.

          In the result, complaint is allowed in part.  Opposite parties 1 &2 are directed to  pay Rs.137254.00/-  to the complainant.  The OPs are also directed to pay Rs.25000/- towards compensation and Rs.10,000/- towards cost of the proceedings of this case.  Opposite parties  shall comply this order within one month after receiving certified copy of this order.  Failing which the awarded amount  except cost portion, will carry interest@9% per annum from the date of order till realization.  Complainant can execute the order as per provision in Consumer Protection Act 2019.

Exts:

A1- Policy

A2-copy of lawyer notice

A3series-Postal receipt(2 in No)

A4 Series- Acknowledgment card(2 in No)

B1- copy of proposal form

B2-Copy of request for cashless hospitalization for  health insurance through Anamaya  Medical institute,

B3-copy of treatment records

B4- copy of query letter issued by OP

B5- copy of denial of pre authorization request

B6-original discharge card

B7-Inpatient bill

B8-lab reports

B9& B11-copy of query letter sent by OP

B10-copy of prescription dtd.2/8/22,3/9/22,30/3/21

B12- copy of repudiation letter issued by OP

PW1- Valsamma-  Complainant

DW1- Balu.M-witness of OPs

Sd/                                                              Sd/                                                          Sd/

PRESIDENT                                       MEMBER                                                MEMBER

Ravi Susha                                       Molykutty Mathew                                          Sajeesh K.P

eva                                                                           

                                                                                 /Forwarded by Order/

                                                                                   ASSISTANT REGISTRAR