DATE OF FILING : 23.3.2011
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 29th day of August, 2011
Present:
SRI.LAIJU RAMAKRISHNAN PRESIDENT
SMT.BINDHU SOMAN MEMBER
C.C No.61/2011
Between
Complainant : P.N. Prakash, S/o Neelakandan,
Souparnika House,
Ambalapady, Adimali P.O.,
Idukki District.
(By Adv: Naiju Raveendran)
And
Opposite Parties : 1. The Manager,
New India Assurance Company Ltd.,
Munnar Branch,
Munnar P.O.,
Idukki District.
2. The Manager,
Medi – Assist India Pvt. Ltd.,
No.406, Chandralayam,
Kurisupalli Road,
Temple Lane, Ravipuram,
Cochin – 682015.
(Both by Adv: K. Pradeepkumar)
O R D E R
SRI. LAIJU RAMAKRISHNAN (PRESIDENT)
The complainant availed a mediclaim policy from the 1st opposite party for his family on 20.3.1999 and it was renewing continuously without break. On 20.3.2008, the complainant enhanced the sum insured per person from Rs.40,000/- to Rs.1 lakh. On 20.9.2009 the 2nd insured happened to be admitted in the Vaidya Madhom Vaidyasala and Nursing Home, Mezhathoor, Trithala Hospital for the treatment of “Rakthavatham and Piles” and incurred an expense of Rs.32,983/-. Thereafter the complainant submitted a claim form along with the bills from the hospital for the said amount to the 1st opposite party through the 2nd opposite party for and on behalf of the 2nd insured. But the 1st opposite party refused to accept the claim and allowed a nominal amount of Rs.10,000/- raising untenable arguments. Further on 21.9.2010 the 2nd insured was admitted in the same hospital for the treatment of Rakthavatham and Neck pain and incurred an expense of Rs.30,952/-and submitted a claim form along with the bills from the hospital for the said amount to the 1st opposite party
(cont.....2)
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through the 2nd opposite party for and on behalf of the 2nd insured. But the 1st opposite party again refused to accept the claim and a nominal amount of Rs.10,000/- was allowed. The 1st opposite party is liable to pay the balance amount of Rs.22,983/- with 12% interest per annum for the 1st claim and Rs.20,952/- with 12% interest per annum for the 2nd claim to the 2nd insured and also Rs.5,000/- as compensation to the complainant.
2. As per the written version filed by the opposite party, the 1st opposite party is an independent thirty party administrator of mediclaims appointed as per the directions of IRDA. The 1st opposite party's liability to reimburse the expenses incurred by the insured for hospitalisation, treatment and related expenses incurred is strictly as per the contract of insurance policy only. It is admitted that the complainant availed mediclaim policy with the sum insured of Rs.40,000/- and the same was enhanced in the year 2008, to Rs.1 lakh. One of the beneficiaries of the policy named Sathi Prakash, wife of the complainant was hospitalised in Vaidyamadham Vaidyasala and Nursing Home, Palakkad from 20.9.2009 to 12.10.2009 towards the treatment of Rakthavatham. Complainant submitted a claim for reimbursement of Rs.32,983/-, out of which an amount of Rs.10,000/- was approved and the same was paid vide cheque bearing No.634601 dated 1.2.2010. Again she was hospitalised for Rakthavatham and Neck pain and submitted a claim of Rs.30,952/-. The claims were restricted to Rs.10,000/- (25% of initial sum insured of Rs.40,000/-) as per clause 2.7 of the insurance policy which stated expenses incurred for Ayurvedic/Homeopathic/Unani treatment are admissible upto 25% of the sum insured. As this being the claim for ayurveda, this opposite party paid 25% of Rs.40,000/- sum insured. The complainant is not eligible for the enhanced insured sum of Rs.60,000/- as there is already one claim settled towards the same ailment (Piles and Rakthavatham) in the year 2007-2008 making the ailment pre-existing disease for the enhanced sum insured. So the benefit of the enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy period. Hence the settlement made under the present claim is in order and the petition is liable to be dismissed.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to?
4. The evidence consists of oral testimony of PW1 and Exts. P1 to P6 marked on the side of the complainant and oral testimony of DW1 and Ext.R1(series) marked on the side of the opposite parties.
(cont....3)
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5. The POINT :- The complainant produced evidence as PW1. As per PW1, he availed a mediclaim policy as policy No.760406/34/08/11/00000153 with the 1st opposite party. The conditions of the mediclaim policy is produced and marked as Ext.P3. The policy was availed on 20.3.1999 and after that it was continuing without break. The amount was enhanced on 20.3.2008 from Rs.40,000/- to Rs.1 lakh. Two claims were filed by the complainant for the treatment of his wife, one for an amount of Rs.32,983/- for the treatment of Rakthavatham and piles, on 20.9.2009 and the opposite party paid only Rs.10,000/- another claim was filed for the treatment of his wife on 21.9.2010 for Rakthavatham and neck pain for an amount of Rs.30,952/-. But the opposite party paid only Rs.10,000/- for the same. A letter was issued by the complainant against the same for the settlement of the balance amount to the opposite party, copy of the same is marked as Ext.P1. The reply was issued by the 1st opposite party to the complainant stating that she is liable for only 25% of the sum insured because the same was enhanced for Rs.1 lakh and it was a pre-existing disease and the complainant is entitled for the claim only after the completion of 2 years. As per the clause 2(7) of the policy conditions, for ayurvedic treatment expenses incurred are admissible upto 25% of the earlier sum insured which is of Rs.40,000/-. The letter is marked as Ext.P2. As per PW1, while he joined in the policy, there was no condition such as 25% of the sum assured is entitled for Ayurvedic expenses. He already received claim for ayurvedic expenses. On cross examination of the learned counsel for the opposite party, the complainant submitted that more than 5 times he has claimed for the treatment expenses and all the claims were received from the opposite party. Ext.P4 is the mediclaim policy conditions issued to the complainant at the time of availing the policy. Ext.P5 is the discharge summary issued from Vaidyamadham Vaidyasala and Nursing Home in which the wife of the complainant named Sathi Prakash was admitted as inpatient from 20.9.2009 to 12.10.2009. Copy of the claim form of complainant's wife Sathi Praksh dated 6.1.2011 is marked as Ext.P6. The opposite party produced evidence as DW1. DW1 deposed that as per clause 2(7) of the contract of the insurance, the claims were restricted to Rs.10,000/- that is 25% of the initial sum insured and as per clause 4(3) waiting period for specified diseases. As per clause 6(d), if the policy is to be renewed for enhanced sum insured then the restriction as applicable to a fresh policy, will apply to additional sum insured as if a separate policy has been issued for the difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy periods. In this case it is revealed that the disease in dispute is pre-existing. The true copy of the policy along with the policy conditions are marked as Ext.R1(series).
As per the complainant, he is continuously renewing the policy and no break has been occurred during the period. The sum insured enhanced for an amount of Rs.1 lakh by paying on 20.3.2008. The 2nd insured was admitted in Vaidya Madhom
(cont.....4)
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Vaidyasala and Nursing Home, Mezhathoor, Trithala on 20.9.2009 for the treatment of Rakthavatham and piles and a claim was filed for Rs.32,983/-, but the opposite party restricted the claim to Rs.10,000/- with raising untenable arguments and the cheque was issued. After that on 21.9.2010, again the 2nd insured admitted in the same hospital for neck pain and Rakthavatham and incurred expenses for an amount of Rs.30,952/- and a claim was filed for the same, but the opposite party was sanctioned Rs.10,000/- only. As per the opposite party, while the insurance amount was enhanced by the complainant, one claim was already settled towards the same ailment, piles and rakthavatham and so it is a pre-existing disease for the enhanced sum insured. So he is not eligible for the enhancement amount of Rs.60,000/- and it is as per Ext.R1 policy conditions. As per clause 2.7 of the insurance policy conditions, the complainant is eligible for 25% of Rs.40,000/- and that is Rs.10,000/- and it was received by the complainant. The expenses incurred for Ayurvedic/Homeopathic/Unani treatment are admissible upto 25% of the sum insured. Being this the claim for Ayurveda, the opposite party paid 25% of the sum insured.
In this case, eventhough the opposite party enhanced the claim amount, they are considering the conditions of both policies, that is the policy availed at the time when the amount of Rs.40,000/- and also the policy availed for Rs.1 lakh. So the opposite parties are considering the conditions of both policies while considering the claim. As per the complainant, there is no such a restriction in the policy, nor such conditions or exclusions in the policy while it was provided to the complainant in the year 2003. But we think that the complainant was admitted in the hospital which is Vaidyamadham Vaidyasala and Nursing Home, on 20.9.2009 and as per the complainant, his wife availed treatment for Rakthavatham and piles and an amount of Rs.32,983/- was incurred for the same. But there is no bill produced by the complainant to show that such an expenses has been incurred for treatment of the complainant's wife. Sathi Prakash, the 2nd insured never produced any evidence before the Forum for the same. What prevented the 2nd insured to produce the bill for the treatment expenses incurred to her. Only the discharge summary produced by the complainant which is marked as Ext.P5 in which there is no statement regarding the expenses incurred by the complainant's wife for the treatment. No claim form produced by the complainant for the treatment in that period, before the Forum as evidence to show that the complainant incurred an amount of Rs.32,983/- for the treatment of his wife. If the opposite party sanctioned only Rs.10,000/- to the complainant, what made delay for filing the petition before the Forum because a delay of about near 1½ years has been expired after the same. Another claim is also filed by the complainant for the treatment for the 2nd insured on 21.9.2010. As per the complainant, she was admitted in the same hospital and Rs.30,952/- was incurred for the treatment. But no bill or treatment record produced by the complainant to show
(cont.....5)
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that the 2nd insured was admitted in the said hospital for treatment of rakthavatham and neck pain and such an amount was incurred for the treatment. So twice the complainant's wife was admitted in the same hospital for the treatment of rakthavatham. But not even a single bill has been produced by the complainant for the same. Any copy of the same is also not produced by the complainant if the original bills were produced before the opposite party. As per the complainant, he has received the claim from the opposite party more than 5 times and he knows all the formalities for receiving the claim. So that the complainant ought to have produced evidence before this Forum to show that such a treatment has been done for the 2nd insured. The petition is filed for getting the balance amount in two of the claims of the 2nd insured and both the claims were happened within an interval of one year. So the cause of action for this complaint is also not described by the complainant. So we think that the version of the complainant is not at all believable and the complainant failed to prove that such a treatment expenses has been incurred for the 2nd insured, the wife of the complainant.
Hence the petition dismissed.
Pronounced in the Open Forum on this the 29th day of August, 2011
Sd/-
SRI. LAIJU RAMAKRISHNAN (PRESIDENT)
Sd/-
SMT. BINDHU SOMAN (MEMBER)
(cont....6)
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APPENDIX
Depositions :
On the side of the Complainant :
PW1 - Prakash P.N.
On the side of the Opposite Parties :
DW1 - B. Satheesh.
Exhibits :
On the side of the Complainant :
Ext.P1 - Copy of the letter issued by the complainant to the 2nd opposite party
Ext.P2 - Copy of the letter issued by the 1st opposite party to the complainant
dated 8.4.2010.
Ext.P3 - The conditions of the mediclaim policy.
Ext.P4 - The mediclaim policy conditions issued to the complainant.
Ext.P5 - The discharge summary issued from Vaidyamadham Vaidyasala and
Nursing Home of the wife of the complainant.
Ext.P6 - Copy of the claim form of complainant's wife Sathi Praksh dated 6.1.2011.
On the side of the Opposite Parties :
Ext.R1 - The true copy of the policy along with the policy conditions.
