By Smt. Padmini Sudheesh, President:
The complaint is filed by Power of Attorney Holder for and on behalf of the insured. The insured was one of the insurance policy holders Pravasi Suraksha Kudumba Arogya Scheme introduced and implemented by respondent company. The intention of the scheme was to extend assistance to the treatment expenses to the non-resident Indian and their family members. The insured joined the scheme vide policy No.2000/47/761400/85173 for a period from 31.10.2000 to 30.10.2005 for which the respondent company collected a sum of Rs.2250/- from complainant. In March 2004 the complainant undergone ayurvedic treatment for varicose veins – right lower limb at Oman but later he came to native place for further treatment. He admitted in Amritha Institute of Medical Science and Research Centre, Ernakulam and treated as inpatient therein and spent a considerable amount for treatment. After the treatment he approached the respondent company with all medical records and raised the claim. But the company did not make any attempt to make payment and prolonged the matter under one pretext or other. The company was reluctant to grant policy benefit by stating that he was suffering from the disease for last several years. This is unreasonable and deficiency in service. So a legal notice was sent. Hence the complaint.
2. The counter averments are that the respondents admit that a Pravasi Suraksha Kudumba Arogya policy is issued in the name of Ramachandran vide policy No. 761400/47/00/85173 valid from 30.10.2000 to 30.10.05. The limit of liability is subject to the terms and conditions of the policy. The respondents deny the averments that the complainant underwent the treatment in the month of March 2004 for varicose vein right lower limb. The complainant has submitted a claim to the respondents stating that the disease was pre-existing for two years under clause 5(B) of the claim form. A medical report was submitted by Dr. Ragunadhan Pillai and Dr. Rajeswaran Pillai, Professors of AIMS Hospital Cochin on 11.12.04 stating that the disease was pre-existing for a period of two years. The discharge summary issued from AIMS hospital showed that the complainant was having the illness since two years which gradually increased to present size with bleeding episode once. As per Clause 6(B) of the claim form it was stated that the disease was first consulted with a doctor on 11.3.04 at Muscat. Accordingly these respondents called for previous treatment records and the complainant instead of sending the treatment records furnished to the company only the cash receipt No.1679 dt. 11.9.04. So the first respondent sent a letter to complainant on 19.1.05 requesting him to submit the related document of previous treatment for processing the claim. But the complainant has not submitted the relevant papers. So the company informed the complainant that company cannot rule out the possibility of pre-existing illness and was not in a position to proceed further. No deficiency in service committed by the respondents. For the legal notice the respondents sent a reply stating the correct facts. The respondents deny the expenses, charge towards air ticket, bystander expenses etc. Hence dismiss.
3. The points for consideration are:
(1) Was there any deficiency in service from respondents?
(2) If so reliefs and costs.
4. The evidence consists of Exts. P1 to P11 and Ext. R1 to R11.
5. Points: The complaint is filed to get mediclaim expenses from the respondents by the insured Ramachandran through Power of Attorney Holder. It is his case that he has undergone treatment for Varicose Vein right lower limb and incurred expenses for treatment. Being a policyholder he is entitled to get policy benefits along with compensation. The company rejected the claim of complainant stating pre-existence of the disease before the inception of the policy.
6. It is the case of company that in the claim form submitted by complainant it is stated in clause No.5(b) that the disease was pre-existing for two years. It is also stated that the doctors from AIMS Hospital submitted medical records stating that the disease was pre-existing for a period of two years. It is further stated that the discharge summary issued by the Department of General Surgery, AIMS hospital showed that the complainant was having the illness since two years which gradually increased to present size with bleeding episode once. It is also their contention that as per Clause 6(b) of the claim form it was stated that the disease was first consulted with a doctor on 11.3.04 at Muscat.
7. The claim form is produced by the company and marked as Ext. R1. The complainant has written the date of injury sustained or the date of disease/illness first detected as two years. For the answer towards clause 6(b) it is stated that the first consultation of a doctor for this disease as 11.3.04 at Muscat. It is admitted by the company also that the validity of the policy from 30.10.2000 to 30.10.05. The claim form is dated 17.12.04 and the history of two years will be in the year 2002. The first consultation of a doctor for the disease was 11.3.04 and if that be so it is also within the policy period. The policy starts from 31.10.2000 and the pre-existence of two years will be in the year 2002.
8. The copy of discharge summary from AIMS hospital produced and marked as Ext. R3 in which the history and physical findings stated that tortuous veins right lower limb since 2 years, gradually increased to present size. It is also stated that history of bleeding episode once spontaneously. It is to be noted the date of admission at AIMS hospital was on 1.12.2004 and definitely the pre-existence of two years will be in the year 2002. There is no history stated at all in Ext. R3 that years will be taken to increase to present size. It is definitely stated in Ext. R3 that since two years gradually increased to present size. So it is to be realized that the pre-existence was 2002 onwards.
9. It is the case of respondents that as per clause No.6(b) of the claim form it was stated that the disease first consulted with a doctor on 11.3.04 at Muscat. According to them the respondents called for previous treatment records but complainant failed to submit the same. It is true that the respondents produced copy of letters sent to complainant requesting to furnish previous treatment records. There are several communications done by company to get previous treatment records at Muscat. But no such records are seen submitted to company by the complainant. Ext. R12 is a medical certificate issued by Kottakkal Ayurvedic Health Centre wherein it is stated that the patient Ramachandran was examined and treated by the doctor and found to suffer from Varicose Veins on right leg. The date mentioned by the doctor is 11.3.04. So from the records produced by company there is nothing to believe that the complainant was suffering from the disease prior to the joining of policy. The Learned Counsel for respondents filed an argument note in which it is stated that the claim could not process since no earlier treatment records were produced by the complainant in spite of repeated demands made by the respondents. But as per Ext. R12 the disease was not cured from the treatments in Oman and the doctor advised to go to India for further treatment and as stated by the complainant the further treatments were in India.
10. The complainant produced documents which are marked as Exts. P1 to P11. The copy of documents submitted by company also marked. The complainant produced the air ticket and marked as Ext. P11. The Counsel for complainant also filed argument note and stated that the insurance scheme starts from the year of 2000 and ended at the year of 2005. According to the complainant if at all the disease of the complainant is pre-existing from the year of 2004 as claimed by company which is occurred during the valid period of the policy. As stated in the argument note by complainant the respondent company has no case that the disease was pre-existing before the year of 2000 from which policy is commenced. The version of complainant is totally true and correct. So there is serious deficiency in service on the part of respondent company in repudiating the claim of complainant. So the company is liable to pay compensation also.
11. In the result the complaint is allowed and the respondents are directed to pay Ext. R10 series amount and compensation of Rs.5000/- (Rupees five thousand only) with costs Rs.500/- (Rupees five hundred only) within two months from the date of receipt of copy of this order. If the amount is not paid within the stipulated period the respondents will be liable to pay interest at the rate of 12% per annum for the bills amount from the date of complaint till realization.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 30th day of September 2011.
