By Smt.  Bindu. R,  President:

          This complaint is filed by Thomas. P.V @ Stephen,  Pukudiyil House, Padichira P.O,  Pulpally,  Wayanad District  against  The Officer in Charge,  United India Insurance Company Ltd.,  and two others as Opposite Parties alleging deficiency of service and unfair trade practice and therefore  praying to issue direction to them to pay a sum of Rs.89,648/-  with  interest  at the rate of 12% per annum and for other reliefs.

          2. The Complainant states that the Complainant is an agriculturist and joined in the Medi claim  Insurance Policy Scheme of the  1^st and 2^nd  Opposite Parties from the Office of 1^st Opposite Party at Pulpally with policy No.3005832819P113312862 for a sum assured  for  2 Lakhs.   The period  of insurance was from 16.01.2020 to 15.01.2021.  The Complainant had paid Rs.13,436/-  towards the premium.  According to the Complainant, the Complainant and his wife Sali were covered  as per the policy.  The Complainant states that the Opposite Parties assured that the Complainant or his wife Sali can  jointly or severally  avail the treatment benefit for a sum of Rs.2,00,000/- and the Complainant states  that the Complainant is having Medi claim Insurance Policy from 2008 onwards.

          3. The  Complainant  further states that Sali, wife of the Complainant,  was admitted in the DM WIMS,  Medical College Hospital, Meppadi in connection with  Uterus problems on 25.11.2020 and she had undergone surgery on 01.12.2020 and  the Complainant had incurred a bill of Rs.1,09,648/-  for the treatment.  At the time of joining the insurance policy the Opposite  Parties were offered  cashless treatment for Rs.2,00,000/- and  the Complainant made a request for cashless treatment with the hospital but the Opposite Parties granted only 20,000/-  towards the cashless treatment. The Complainant was asked to pay the balance amount stating that the  3^rd  Opposite Party is processing the claim submitted by the Complainant.  The Complainant further states that believing the words of the Opposite Party that the balance amount will be paid to the Complainant directly,  the Complainant deposited the expenses in the hospital.  But after paying  the amount,  the hospital authorities informed the Complainant that the claim was rejected by the Opposite Parties.  The Complainant states that when he enquired with the hospital authorities it was informed that the Opposite Parties rejected the claim and  3^rd  Opposite Party had given  communication showing that only an amount of Rs.20,000/-  is allowed and the cashless treatment request is rejected .  According to the Complainant the cashless  claim was rejected on invalid grounds and hence the Complaint.

4. Upon notice the Opposite Parties entered into  appearance and filed their versions.

          5.  1^st and 2^nd  Opposite Parties in their  joint version,  contented that a Family Medicare Policy No.3005832819P13312862 for a period  from 16.01.2020 to 15.01.2021 was issued to the Complainant with sum assured of Rs.2,00,000/-.  As per the policy the Complainant  and Smt. Sali were covered  for the above period.  It is stated by 1^st and 2^nd  Opposite Parties that the  1^st policy was taken by the Complainant on 16.01.2016 for Rs.1,00,000/- and later enhanced the sum  insured as  Rs.2,00,000/-  from 16.01.2019.  1^st  and 2^nd  Opposite Parties denied the allegation that the Complainant had  mediclaim policy from 2008 onwards.  The admission of Complainant’s wife in the hospital and the statement regarding the surgery etc are admitted by  1^st and 2^nd  Opposite Parties.  The 1^st  and 2^nd  Opposite Parties contented that the patient was admitted in the DM WIMS  Medical  College Hospital with a  history of “known case of  2^nd  degree UV  Prolapse  with Cyctocele and Rectocele,  Diabetes, Mellitus,  Cardic Dysfunction (Moderates LV Dysfunction/Mild MR/Sclerotic AV/ mild pah/T4PCI LVDD) presented with mass descending per vagina since 5 years.  History of difficulty of passing stool.  History of constipation  since 2 months and history of heavy menstrual bleedings since 2 months”.  The illness of the patient was pre existing.  It is contented  by the 1^st and 2^nd  Opposite Parties that  the claim submitted by the Complainant was processed by restricting  the sum insured to Rs.1,00,000/-  which is the sum insured under  the   policy in favour  when the ailment contracted  since  5 years from the inception of policy.  The ailment is contracted prior to the enhancement date of policy and hence as per policy condition “claim in respect of ailment disease or injury contracted or suffered during a proceeding  policy period,  liability of the company shall be only to the extent of sum insured order the policy in force at the  time when it was contracted or suffered during the currency of such  renewed policy or  any  subsequent renewal there of”.   As per  the family Mediclaim Policy issued for the period form 16.01.2016 to 15.01.2017  the sum insured was  1,00,000/-.  Hence as per family medicare policy  floater,  the expense in respect of hysterectomy  is restricted  to 20% of sum insured fixing maximum amount at Rs.1,00,000/- as per condition coverage.  The  1^st and 2^nd  Opposite Parties  contented that in view of the policy conditions,  the  1^st  and 2^nd   Opposite Parties paid Rs.20,000/- to the Complainant and the Complainant is not entitled to get further amount as claimed in the complaint.    1^st and 2^nd  Opposite Parties denied the statement of the Complainant that 1^st and 2^nd  Opposite Parties offered cashless treatment for the pre existing  disease and it is  contented that the denial of balance claim is purely based on policy condition and on valid grounds.  There is no deficiency or unfair trade practice from the side of the  1^st  and 2^nd  Opposite Parties and prays for dismissal of the  complaint  with compensatory costs.

          6. The 3^rd  Opposite Party  in their version contented that the  complaint is filed on  an experimental basis.  The contention of the 3^rd Opposite Party are similar to that  of 1^st and 2^nd  Opposite Parties and  it is  contented  that the claim submitted by the Complainant was processed by restricting  the sum insured as Rs.1,00,000/- which  is the sum insured under the policy infavour  when the ailment contracted since 5 years from the inception of policy.  As per  policy conditions the Opposite Parties paid  Rs.20,000/-  considering the sum insured as 1,00,000/-.  The statement regarding the offer of cashless treatment in the complaint is denied by the  3^rd Opposite Party and  it is  contented that there is no deficiency or unfair trade practice from the part of the  3^rd  Opposite Party and prays for dismissal of the complaint with compensatory costs.

          7. Evidence in this case consist of the oral testimony of PW1 the Complainant and Ext.A1 to A4 are produced from  the side of the Complainant.  From the side of the  Opposite  Parties,  OPW1 was examined  and Ext.X1 series is marked.

          8.  The following are the points  to be analysed in this complaint to derive into an inference of the facts.

1.  Whether the Complainant had sustained to any deficiency  of service or   

unfair trade practice from the side of the Opposite Parties?

2.  If so the quantum of compensation and costs to be awarded to the 
3.  

          9. Heard both sides  and  perused the entire evidence and records in detail.

10. In this case Ext.A1 is the copy of  Family Medicare Policy  2014 bearing No.3005832819P113312862 in the name of the Complainant for a period 16.01.2020 to 15.01.2021 issued by 3^rd  Opposite Party in the case.  Ext.A2 is the copy of Inpatient Final Bill of Mrs Sali Thomas which shows  the net amount as Rs.109648.00.  Ext.A3 is the copy of Letter from 3^rd  Opposite Party to the Administrator/Medical Superintendent DM WIMS regarding  rejection of the request for enhancement of  cashless claim.  Ext.4 is the copy of cash receipt dated 02.12.2020 with reference to the payment of Rs.89,648/-.

          11. Ext.X1 series is the discharge  summary of Mrs. Sali Thomas with MRD No.348327  dated 27.11.2020,  which is produced  as per direction in IA386/2023.

          12. During  cross examination of PW1 he deposed that “kmen tXmakv Fsâ  `mc-y-bm-Wv. kmen tXma-kn\v  Akp-J-ap-­m-b-Xns\ XpSÀ¶v 2020 \hw-_À 25 \mWv NnIn-Õn-¨-Xv,  Hm¸-td-j³ \S-¯n-bXpw  A¶p-X-s¶-¶-bm-Wv.  AXn\p ap¼v Ak-z-Ø-X-IÄ  ]d-ªn-cp-¶p.  bq{S-knsâ  complaint  BWp-­m-bn-cp-¶p.  bq{Skv XÅn hcp-I-bp-­m-bn-cp-¶p ae aq{X hnkÀP-\-¯n\pw _p²n-ap-«p-­m-bn-cp-¶p.  »oUn§v D­m-bn-cp-¶p.  ta¸mSn WIMS hospital   Bbn-cp¶p  NnIn-Õn-¨-Xv.  `mc-ybv¡v diabetes   sâ Akp-J-ap-­m-bn-cp-¶p.  tUmIvS-tdmSv Akp-J-s¯-¡p-dn¨v hni-Z-ambn  ]d-ªn-cp-¶p”.   OPW1 was a summonsed witness and  as Ext.X1 series  were marked through him deposed that “ kmen F¶  patient s\ Rm³ NnIn-Õn-¨n-«p­v .   25.11.2020 \mWv  admit BbXv.  AhÀ¡v KÀ`]m{Xw Xmtgbv¡v Cd-§n-h-cp¶ {]iv\-am-bn-cp-¶p.  Ct¸mÄ Fs¶ ImWn¨v kmen F¶ patient  sâ  discharge summary bptSbpw case sheet sâbpw ]IÀ¸mWv.  Marked as Ext.X1 series  CXn F\n¡v th­n Fsâ  Assistant BWv H¸n-«n-cn-¡p-¶-Xv.  Rm\mWv treat   sNbvX-Xv.  51 hb-Êp-ff Lady  BWv.  KÀ`-]m{Xw Cd-§n-h-cp-Ibpw aq{X-k-©nbpw Cd§nh¶n-cp-¶p.  A©v hÀj-ambn AkpJw D­m-bn-cp-¶p. IqSmsX c­p-am-k-ambn  heavy menstrual bleeding D­m-bn-cp-¶p”.  According to OPW1,  the doctor who treated  Sali, W/o. Thomas,   the duration of the said disease is  5 years.  She was also having  heart disease and diabetics  and the only solution was  surgery which was done from the hospital.  Nothing was brought out challenging the credibility of  deposition of the witness during cross examination.

          13. In this case, apart from the  deposition of OPW1.  Ext.X1 series is the crucial document which is the discharge summary of the patient.  Ext.X1 shows that Mrs. Sali Thomas was admitted in Dr.  Moopen’s, Medical College on  25.11.2020 and   she was discharged on 02.12.2020.  Diagnosis is stated as “SECOND DEGREE UV PROLAPSE WITH CYSTOCELE AND RECTOCELE - DIABETES MELLITUS - MODERATE LV DYSFUNCTION/ MILD MR/ SCLEROTIC AV/MILD PAH/TYPE 1 LVDD”.  HISTORY shows “ 51 year old  patient,  she is  a known case of  2^ND DEGREE UV PROLAPSE WITH CYSTOCELE  and  RECTOCELE,  DIABETES MELLITUS, CARDIAC DYSFUNCTIONS (MODERATE LV DYSFUNCTION/MILD MR/SCLEROTIC AV/MILD PAH/TYPE 1 LVDD).   Presented with mass descending per  Vagina since  5 years.   H/O difficulty in passing stool.   H/O  constipation since  2 months  and H/O heavy menstrual bleeding since 2 months”.   

          14. On going through the documents submitted from both  sides and after making a through analysis of the deposition  from  either side including that of OPW1 the Commission comes to the following conclusion.

          15. The Complainant had been admitted to DM Medical College on 25.11.2020 as an inpatient and was discharged on 02.12.2020 for the treatment of 2^nd  degree UV PROLAPSE with CYSTOCELE and RECTOCELE Diabetes Mellitus.  MODERAT LV DISFUNCTION / MILD MR/ SCLEROTIC AV/MILD PAH/TYPE 1 LVDD.

          16.  On noticing this the Commission examined  as to whether the Complainant had a valid insurance policy during this period and seen that the Complainant was covered by the insurance policy from 16.01.2020 to  15.01.2021 as per  Medicare Policy No. 3005832819P13312862 which is  accepted by the Opposite Parties.  The Complainant had stated that the Complainant is having mediclaim insurance policy for  Rs.2,00,000/- from 2008 onwards which is  denied by the Opposite Parties and the Opposite Parties upheld that the Complainant  is having policy coverage only from 16.01.2016 and the sum insured  was Rs.1,00,000/- only.  It is further stated by the Opposite Parties that this amount was enhanced to Rs.2,00,000/-  by the Complainant from  16.01.2019 onwards. 

          17. Even if by accepting the statement of  the Opposite Party that the Complainant had enhanced the insurance coverage only from 16.01.2019 to the tune of  Rs.2,00,000/-,  it is accepted by the Opposite Party that the Complainant had taken the insurance policy on 16.01.2016.  The Opposite Party had not produced any document to the effect that they had conducted   a medical  check   up  of   the wife   of   the

Complainant at the time of issuing policy and therefore merely by relying on the  statement of OPW1 alone it cannot be ascertained with certainty that the duration of the ailment is  5 years and above that it  is not the out come of  proof with any medical records of diagnosis but the mere understanding of a human doctor.  More over it is not fair  to think that  a patient with ailment having this much of difficulties and  miseries have fore planned to avail the insurance  coverage for her treatment years after it is detected.  Another notable  point  to be taken into  account at this juncture is that even if  the argument of the Opposite Party that there was no coverage for  Rs.2,00,000/-, the Opposite Parties themselves admits that there is a coverage for insurance policy for Rs.1,00,000/-

          18. Under circumstances described above denying the coverage amount  of  Rs.1,00,000/- by the Opposite Parties in this case amounts to deficiency of service  and unfair trade practice from the side of  Opposite Parties.  Therefore  the Commission is of the view  that the Complainant had established  point No.1 in their favour and    there fore point No.2 is also decided  accordingly.

1.  The Opposite Parties shall  disburse an amount of Rs.80,000/- (Rupees Eighty thousand only) to the Complainant being the balance amount of  the assured amount of Rs.1,00,000/-  (Rupees One Lakh only)  within  30 days  from the date of receipt of a copy of this order.
2. An amount of Rs.20,000/-  (Rupees Twenty  thousand only)  shall be paid as compensation and Rs.10,000/-  as cost of proceedings to the Complainant.

If the amount  ordered above are not paid to the Complainant within  30 days  the same shall attract interest at the rate of 6% from the date of order till  realization except for the amount ordered as costs.

          CC Partly allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 20^th  day of December 2023.

          Date of filing:17.03.2021.

                                                                             PRESIDENT    :  Sd/-

                                                                                       MEMBER        :   Sd/-                                                                                         MEMBER        :   Sd/-

APPENDIX.

Witness for the Complainant:

PW1.          Thomas. P.V.                           Complainant.         

Witness for the Opposite Parties:

OPW1.        Dr.  Nazar. T.                           Doctor.                

Exhibits for the Complainant:

A1.      Copy of  Family Medicare Policy 2014.

A2.       Copy of In-Patient Final Bill.                            

A3.       Copy of Letter.                                         dt:02.12.2020.

A4.        Copy of Cash Receipt.                                      dt:02.12.2020.

X1 series   Copy of Discharge Summary and Case Sheet.                            

Exhibit for the Opposite Parties:

  Nil.

                                                                                                PRESIDENT:   Sd/-

                                                                             MEMBER    :   Sd/-

                                                                             MEMBER    :   Sd/-