PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 27th day of September 2012
Filed on : 25/06/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 336/2011
Between
M.M. Mathew, : Complainant
Menacheril house, (By Adv. Abey Tom, Alappattu
390/6, Palace road, Buildings, Market road,
Alwaye-683 101. Ernakulam)
And
The Oriental Insurance Co. Ltd., : Opposite party
Pattamana buildings, (By Adv. M.G.K. Menon,
Railwlay Station Road, CC/39/1521, Ernakulam,
Alwaye-683 101. South Railway Station Road,
Kochi-682 016)
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is a subscriber of medi-claim policy issued by the opposite party for coverage of Rs. 3 lakhs for the period from 07-08-2009 to 06-08-2010. The policy is being renewed thereafter. The complainant was admitted in Karothukuzhi hospital, Aluva from 14-12-2009 to 15-12-2009 for treatment of dislocation, sprain, and strain of joint, synovitis, posterior muscle teer (Arm). Thereafter he was admitted in medical Mission Hospital, Kolenchery from 22-12-2009 to 24-12-2009 for Hepetetis Mylits, GBS. The complainant was again referred to medical trust hospital, Ernakulam and underwent treatment till 31-12-2009. The preliminary diagnosis according to the doctors was that he was suffering from unspecified diabetes mellitus. Though the opposite party allowed insurance claim of the complainant for his treatment at Karothukuzhi, Hospital and Medical Mission Hospital, they have not paid treatment expenses of Rs. 57,743/-, the complainant had to spend at Medical Trust Hospital. The complainant had no history of diabetes mellitus. Against the repudiation of the insurance claim the complainant approached the Regional Manager of the opposite party and as per his instance the complainant approached the Insurance Ombudsman. But there was no positive response. So the complainant is before us seeking direction against the opposite party to pay the insurance claim of Rs. 57,743/- together with costs of the proceedings.
2. The version of the opposite party is as follows:
The opposite party had issued an insurance policy for the period from 07-08-2009 to 06-08-2010 in favour of the complainant. On the basis of the insurance policy the complainant submitted an insurance claim application. But it was rejected as per exclusion clause No. 4.3 in the policy. Since diabetes mellitus is excluded for 2 years from the inception of the policy which commences with effect from 07-08-2009. Moreover the opposite party is not liable to pay expenses incurred by the complainant for diagnostic procedure and investigations if there were no active line of treatment. There is no deficiency in service on the part of the opposite party. The opposite party is not liable to pay any insurance amount to the complainant.
3. The complainant was examined as PW1 and Exts. A1 and A2 were marked on his side. No oral evidence was adduced by the opposite party. Exts. B1 to B7 were marked on the part of the opposite party. Heard the learned counsel for the parties.
4. The points that came up for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim
from the opposite party?
ii. Whether the opposite party is liable to pay costs of the
proceedings to the complainant?
5. Point No. i &ii. According to the complainant he has been holding insurance policy of the opposite party continuously for the last 30 years. During evidence the complainant who was examined as PW1 deposed that he is ready to produce the policy immediately prior to 2 years from the disputed policy for the period from 07-08-2009 to 06-08-2010. The opposite party maintains that they have issued only Ext. B3 to B5 policies to the complainant for the following period.
Sl. No. | Exhibits | Period of policy |
1 | B3 | 10/09/2007 to 09/09/2008 |
2 | B4 | 07/08/2010 to 06/08/2011 |
3 | B5 | 07/08/2009 to 06/08/2010 |
6. The opposite party repudiated the insurance claim of the complainant vide Ext. B2 repudiation letter dated 19-05-2010 which reads as follows:
“This is regarding the claim lodged by you for patient, M.M. Mathew under Medi-claim policy No. 441500/48/10/01176 details mentioned above. Our panal of Doctors have scrutinized the claim documents submitted by you.
The observations are as follows:
1. Policy coverage for MM Mathew is for 1 Year/Years.
2. Current policy is in First Year/Years.
3. Current illness DIABETES MELLITUS + CELLUSITIS + SEZIURE DISORDER is since few Days as per Discharge Summary
4. Current illness is a complication of DIABETES MELLITUS which is since as per
5. As per policy terms & conditions, DM excluded for 2 years from the scope of the policy. As per policy copy received policy is in 1st year
6. As per Policy terms and conditions, claim is not payable, Under Clause No. 4.3 (Please refer to policy copy for details)
7. Admittedly the present claim of the complainant is based on Ext. B4 policy for the period from 07-08-2009 to 06-08-2010. Ext. B6 is the discharge summary which goes to show that the complainant had been suffering from diabetes mellitus. As per clause 4.3 of Ext. B4 policy terms and conditions diabetes is excluded for two years from the date of inception of the policy. Admittedly B3 would show that the complainant is holding valid policy immediately prior to Ext. B4 policy . In short as per the terms and conditions in Ext. B1 the complainant is not entitled to get insurance claim especially since the diabetes mellitus of the complainant was pre existing. However the complainant unequivocally stated before this Forum that he has been holding insurance policy for the last 30 years. However the same has not produced before the opposite party while processing the claim application or during evidence in this Forum though he agreed to produce the same in this Forum. In that view of the matter in meeting ends of justice we think that an apartment should be given to the complainant to prove his contentions that he had been holding valid policy immediately prior to 2 years from Ext. B4 policy.
7. In the result, we pass the following orders.
i. The opposite party shall process the insurance claim application of the complainant if the complainant submits the details of the policy which he said to have been holding for 2 years prior to Ext. B4 policy for the period from 07-08-2009 to 06-08-2010.
ii. The complainant is directed to produce the above details of the policy to the opposite party within 30 days from the date of receipt of a copy of this order. The opposite party shall process the insurance application of the complainant within 30 days from the date of receipt of the above document as directed above.
The above said order shall be complied with as stated above.
Pronounced in the open Forum on this the 27th day of September 2012.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : copy of diagnostic report dt. 05/11/2010 A2 : copy of clinical report dt. 03/07/2011
Opposite party’s Exhibits :
Ext. B1 : Copy of Happy family floater policy
B2 : Copy of claim rejection/repudiation
Statement
B3 : Copy of individual medi claim policy
schedule
B4 : Copy of Happy family floater policy
Schedule dt. 16-04-2012
B5 : Copy of Happy family floater
policy schedule dt. 13-04-2012
B6 : Copy of discharge certificate
dt. 09-01-2010
B7 : Copy of details of expense incurred
by the claimant.
Depositions:
PW1 : M.M. Mathew
