10th day of May 2012
CC.1080/05 filed on 2/11/05
Complainant : Sangeetha Satheeshkumar, Kandaramath Punchayil
House, Thriveni, Chalissery.P.O., Palakkad.
(By Adv.T.Bhaskaran, Thrissur)
Respondent : the new India Assurance Co. Ltd., rep. by its Divisional
Manager, 2nd floor, Collannoor Devassy Bldg, Palace
Road, Thrissur.
(By Adv.P.Sathishkumar, Thrissur)
ORDER
By Smt.Padmini Sudheesh, President
The case of complainant is that the husband of complainant had taken a policy named Pravasi Suraksha + Kudumba Aroghya Scheme of the respondent for self and his family. The period of the policy was from 4/9/2000 to 3/9/2005. On 18/8/03 the complainant consulted Dr.Krishnankutty of Krishna Assisted Reproduction and Endoscopy Center (KARE), Thrissur and on examination it was found that the petitioner was suffering from Multiple Fibroid Uterus. As directed by the doctor the complainant got admitted on 12/5/05 at West fort Hi-tech hospital Ltd., Thrissur and underwent operation. On discharge the complainant preferred claim to the insurance company. The company returned the claim application with the remark that as per PSKA Exclusion VII(1), the company shall not be liable to make payment under this scheme in respect of expenses whatsoever incurred in respect of diseases which have in existence at the time of proposing this insurance. The complainant verified the claim application and found that the date of first consultation was by mistake given as 18/8/99 instead of 18/8/03. So she approached the doctor and the date was corrected as 18/8/03 by the doctor. The doctor also issued a certificate dated 4/7/05. After correction the complainant resubmitted the claim. It was also returned citing the earlier reason. This is deficiency in service on the part of respondent . Hence the complaint.
2. The version of respondent is that the averments in the complaint that the respondent would have doubted the certificate issued by a very senior doctor, the veracity of which could be verified by anybody from the records kept by the hospital etc. are not correct and denied. On scrutinizing the claim submitted by the complainant it is seen that the complainant has undergone operation of the uterus and she admitted on 12/5/05 in West Fort Hi-tech hospital, Thrissur. She preferred a claim to respondent. While scrutinizing the claim documents it is seen the complainant had been suffering from multiple fibroid uterus since 18/8/1999. The policy coverage is commencing only from 4/9/2000. This respondent is not liable to indemnify the complaint as it is not payable under the policy. So the respondent repudiated the claim. The complainant has knowledge that she has been suffering from this disease since 18/8/1999. Hence dismiss.
3. Points for consideration are that :
1) Whether there was any deficiency in service from respondent ?
2) If so reliefs and costs ?
4. The evidence adduced consists of oral testimonies of PW1 and PW2, Exhibits P1 to P5 and R1 to R5.
5. The complaint is filed to get reimbursement of medical expenses from the respondent insurance company. The complainant was a policy holder of Pravasi Suraksha + Kudumba Aroghya Scheme of the respondent from 4/9/2000 to 3/9/2005. It is the case that the complainant consulted PW1 doctor on 18/8/03 for the disease Multiple Fibroid Uterus. She was admitted at West fort Hi-tech hospital, Thrissur and underwent operation during the policy period. The complainant claims Rs.48,365/- as treatment expenses. In order to get the same she has applied to the company by submitting the claim form. But the claim is returned by stating pre-existence of the disease.
6. The company contended that on scrutinizing the claim submitted by the complainant it was found that the complainant had been suffering from the Multiple Fibroid Uterus since 18/8/1999 and the policy coverage is commencing only from 4/9/2000. As per Exclusion VII(1) of the policy the company is not liable to indemnify the expenses for pre-existing disease.
7. The complainant is examined as PW1 and Exhibits P1 to P5 documents were marked on her part. She has deposed that consultation with PW2 was on 18/8/03. But Exhibit P2 the copy of claim form would show the date of 1st detection of the illness as 18/8/99. It is the version of PW1 that it is a mistake committed and the actual date is 18/8/03. It is also stated in Column 6(b) that on 18/8/99 she has first consulted doctor for this disease. It is the case of respondent that since the complainant has first detected the illness from 18/8/99 the respondent is not liable to make payment because there was no policy at that time.
8. The complainant also produced Exhibits P4 and P5 documents and in which it can be seen from Exhibit P4 that the date mentioned as 18/8/99 is strike off and written as 18/8/03. As per Exhibit P5 it is certified by PW2 doctor that the year of consultation was mentioned wrongly by the patient. The real dates are corrected. The respondent opposed the marking of this document through PW1 and PW2 is summoned to prove the documents. PW2 is the doctor who has issued Exhibits P4 and P5 documents. It is his version that on the request of patient Exhibit P5 was issued. He also deposed he has corrected Exhibit P4. During cross examination he has stated that the complainant has consulted him firstly on 2003. But it is his version that Exhibits P4 and P5 are issued for submitting to the insurance company. He is also the family doctor of complainant. PW2 categorically stated that he has recorded the date as 18/8/99 as per the information given by the party. Later the date was corrected only on the request of the patient. The doctor is deposing without referring the records and only by perusing Exhibits P4 and P5. It is his version that before 2003 PW1 has not the disease of Fibroid. So the evidence given by PW2 is not reliable.
9. In the claim form the complainant herself recorded that the first date of illness is 18/8/99. There is no correction made on this statement later. While examined as PW1 it was also asked to her. It is the version of PW1 that the records will be in the hospital. Since there is clarification in the date it is her duty to call for the records from hospital. It is the argument of complainant that when pre-existing disease is alleging by respondent it is the duty of respondent to prove the same. But in this particular case the circumstances would lead that the complainant is liable to prove the nonexistence of disease before the policy period. It is not done. So there is no deficiency in service on the part of respondent.
10. In the result the complaint stands dismissed.
Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 10th day of May 2012.
Sd/-
Padmini Sudheesh, President
Sd/-
Rajani.P.S., Member
Sd/- M.S.Sasidharan, Member
Appendix
Complainant’s Exhibits
Ext. P1 Copy of certificate of insurance
Ext. P2 Copy of claim form
Ext. P3 Copy of lr. dt.25/5/05
Ext. P4 Copy of medical certificate
Ext. P5 Copy of lr. dt. 4/7/05
Complainant’s witness
PW1 - Sangeetha Sathishkumar
PW2 – Dr.K.Krishnankutty
Respondents Exhibits
Ext. R1 Copy of claim form
Ext. R2 Copy of repudiation letter
Ext. R3 Copy of lr. dt. 4/7/05
Ext. R4 Copy of medical certificate
Ext. R5 Copy of certificate of insurance
Id/-
President
