IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA
Dated this the 8th day of July, 2014
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member-I)
Smt. Sheela Jacob (Member-II)
C.C.No.38/2014 (Filed on 21.03.2014)
Between:
K.G. Prasad,
Pranavam,
Elavumthitta.P.O.,
Pathanamthitta Dist. ….. Complainant
And:
The New India Assurance Co. Ltd.,
Branch Office,
Kunnithottathil Tower,
Ring Road, Pathanamthitta. ….. Opposite party
O R D E R
Smt. K.P. Padmasree (Member):
Complainant filed this complaint against the opposite party for getting a relief from the Forum.
2. Brief facts of the case is as follows: Complainant is a policy holder of the opposite party. Opposite party introduced a policy namely ‘Universal Health Insurance Policy’ with the co-operation of the Akshaya Centre. Complainant remitted Rs.548/- as premium amount for joining the scheme. The validity period of the said policy is from 30.04.2013 to 29.04.2014. The said policy offered insurance coverage upto Rs.30,000/- including hospitalization expenses for the insured and his family members.
While so on 02.01.2014, complainant’s wife Smt. Radhamani is admitted in Kozhencherry Muthoot Health Care Hospital due to viral fever. She is discharged on 08.01.2014. The total hospital bill is Rs.15,100/-. Complainant submitted a claim application with all relevant documents and medical bills before the opposite party. But the opposite party rejected the claim stating the reason that her ailment is pre-existing.
3. In the discharge summary it was mentioned that she was on treatment since 8 months. Even if the ailment is existing for the last 8 months, it will be covered as the policy was taken 8 months prior to the date of complainant’s admission. Moreover, after getting the claim form opposite party rejected the claim after one and half months. The above said act of the opposite party is a clear deficiency in service which caused financial loss and mental agony to the complainant. Hence this complaint for getting the medical bill of Rs.15,100/- along with compensation of Rs.15,000/-
4. Opposite party entered appearance and filed version with the following contentions. Opposite party admitted that complainant is a policy holder of the opposite party and as per the terms of the policy his family members are included in the policy for a period from 30.04.2013 to 29.04.2014. Complainant’s wife Radhamani was admitted in Muthoot Hospital on 02.01.2014 and discharged on 08.01.2014 and submitted the medical records and claim papers for payment of medical expenses. On verifying the document it is revealed that T.R. Radhamani was suffering from the ailment for the last 8 months. It is noted in the discharge summary that ‘she was on treatment since 8 months’. As per the terms and conditions of Universal Health Insurance Policy the disease is considered as pre-existing since it is within one month from the inception of the policy, and claim on such pre-existing diseases are excluded from the insurance coverage. Therefore, the claim of the complainant was repudiated on valid grounds and strictly in accordance with the stipulations contained in the policy. Therefore there is no deficiency in service from the part of the opposite party. With the above contentions, opposite parties prays for the dismissal of the complaint with their cost.
5. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
6. The evidence of this complaint consists of the oral testimony of PW1, DW1, Exts.A1 to A5, B1 and B1(a). After closure of the evidence, both sides were heard.
7. The Point:- Complainant’s case is that he and his family members were insured under the policy namely ‘Universal Health Insurance Policy’ introduced by the opposite party. Complainant remitted the premium amount of Rs.500/- and policy period is from 30.04.2013 to 29.04 2014. The said policy offered insurance coverage up to Rs.30,000/- for the treatment expenses of the insured. While so, complainant’s wife was hospitalized and incurred hospital expenses of Rs.15,100/-. Complainant submitted a claim application before the opposite party with all relevant records. But they rejected the claim stating that the ailment of the complainant is pre-existing. The repudiation of the claim by the opposite party is a deficiency in service and therefore opposite party is liable to the complainant.
8. In order to prove the complainant’s case, complainant was examined as PW1 and the documents produced were marked as Exts.A1 to A5. Ext.A1 is the policy document dated 30.04.2013 issued by the opposite party to the complainant. Ext.A2 is the discharge summary of Muthoot Health Care dated 08.01.2014 in respect of the treatment of the insured. Ext.A3 series are the Medical bills (20 bills) of the Muthoot Health Care issued to the complainant. Ext.A4 is the claim form along with the medical certificate dated 15.01.2014. Ext.A5 is the repudiation letter issued by the opposite party to the complainant.
9. On the other hand, the contention of the opposite party is that complainant is a policy holder of the opposite party and getting the claim application of the complainant, they verified the same and found that insured’s ailment is pre-existing. As per the terms and conditions of the policy pre-existing diseases are excluded from the insurance coverage. Therefore, the claim of the complainant was repudiated. Hence there is no deficiency in service from the opposite party.
10. In order to prove the case of the opposite party, Manager of the opposite party was examined as DW1 and documents produced were marked as Ext.B1 and B1(a). Ext.B1is the policy schedule of the Universal Health Insurance Policy. Ext.B1(a) is the exclusion clause in the prospectus of the policy.
11. On the basis of the contentions, arguments and materials on record it is seen that the parties have no dispute with regard to the issuance of the policy in question and its validity. The only dispute is that the complainant’s wife’s ailment is a pre-existing one and as per the terms and conditions of the policy, complainant is not entitled to get the treatment expenses. On going through the evidence adduced by both parties it is seen that complainant joined the policy on 30.04.2013. Opposite party rejected the claim on the basis of Ext.A2 discharge summary. In Ext.A2, it is mentioned that complainant’s ailment is 8 months old. Opposite party rejected the claim on the basis of this. As per the records it is clearly revealed that the complainant joined the scheme with a coverage period starting from 30.04.2013. The patient was admitted and treated at Muthoot Health Care on 02.01.2014. Even if she is contracted with the ailment prior to 8 months from the date of her admission, she is not aware of her ailment on 30.04.2013 and as such there is no suppression from her side on the date of taking the policy. Any person can affect any disease at any time. From Ext.A2 it is clear that the ailment which the complainant had undergone the treatment is not a pre-existing one. Further, there is no evidence from the side of opposite party for showing that the complainant had undergone treatment before 02.01.2014. Moreover, opposite party had no case that the complainant had taken the policy for defrauding the opposite party. Therefore we find that the allegation of pre-existing disease raised by the opposite party is not sustainable. In the circumstances, the repudiation of the claim by the opposite party will not stand and it is a clear deficiency in service. Therefore, this complaint is allowable.
12. In the result, this complaint is allowed thereby the opposite parties are directed to pay the medical expenses of Rs.15,100/- (Rupees Fifteen Thousand One hundred only) as per Ext.A3 series along with compensation of Rs.2,500/- (Two Thousand five hundred only) and cost of Rs.1,000/- (Rupees One Thousand only) to the complainant within 30 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount ordered herein above with 9% interest from today till the realization of the whole amount.
Declared in the Open Forum on this the 8th day of July, 2014.
(Sd/-)
K.P. Padmasree,
(Member I)
Sri. Jacob Stephen (President) : (Sd/-)
Smt. Sheela Jacob (Member II) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : K.G. Prasad
Exhibits marked on the side of the complainant:
A1 : Policy document dated 30.04.2013 issued by the opposite
party to the complainant.
A2 : Discharge summary of Muthoot Health Care dated
08.01.14.
A3 series : Medical bills (20 bills) of the Muthoot Health Care
issued to the complainant.
A4 : Claim form along with the medical certificate dated
15.01.14
A5 : Repudiation letter issued by the opposite party to the
complainant.
Witness examined on the side of the opposite party:
DW1 : Habeeb Muhammed
Exhibits marked on the side of the opposite party:
B1 : Policy schedule of the Universal Health Insurance Policy. B1(a): Exclusion clause in the prospectus of the policy.
(By Order)
Copy to:- (1) K.G. Prasad, Pranavam, Elavumthitta.P.O.,
Pathanamthitta Dist.
(2) The New India Assurance Co. Ltd., Branch Office,
Kunnithottathil Tower, Ring Road, Pathanamthitta.
(3) The Stock File.
