PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 29th day of February 2012
Filed on : 18/07/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 375/2011
Between
P.N. Prakasan, : Complainant
S/o. Narayanan, (By Adv. George Varghese Nareyan-
Panakkattampilly Thundy house, parampil, Adv. & Notary,Sayeed
Kuthappady, Thammanam P.O., Complex, Doraiswamy Iyer road,
Ernakulam, Cochin-682 032. Ernakulam, Kochi-35)
And
1. The Oriental Insurance : Opposite parties
Company Ltd., Regional Office, (1st O.P. by Adv. MGK Menon,
Paramara road, Ernakulam North, CC/39/1521, Ernakulam, South
Cochin-16. Railway Station road,
Kochi-682 016)
2. TTK Health Care Services (party-in-person)
Pvt. Ltd., 39-4130, 1st Floor,
Mareena Buildings, M.G. Road,
Ernakulam, Kochi-681 016.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is an employee of Kalyan Silks, Thrissur. The employer insured their employees under a group insurance policy of the 1st opposite party for an amount of Rs. 15,000/- each. The wife of the complainant is an Advocate Clerk who has an insurance policy with a coverage of Rs. 30,000/-. The facts being so on 07-07-2009 the complainant was admitted in Amrita Institute of Medical Sciences and Research Centre, Kochi for the medical complaint namely “small irregularity felt over the right lower Jaw” and he had undergone radio therapy treatment. He was treated at the hospital for the period from 08-07-2009 to 13-07-2009. The complainant had to expend more than Rs. 2 lakhs towards his treatment expenses. The complainant duly submitted claim application before the opposite party. But the same was rejected by them for their own reasons. Complainant is entitled to get insurance claim together with interest and costs of the proceedings. This complaint hence.
2. Version of the 1st opposite party.
The complainant is one of the beneficiaries of the mediclaim policy issued for the period from 06-06-2009 to 05-06-2010 in favour of the employees of Kalyan Silks, Thrissur. The sum insured was Rs. 15,000/-. The 2nd opposite party processed the claim application of the complainant and they came to a finding that the complainant’s claim was not payable as per clause No. 4.1 of the policy . The said clause states that treatment of pre existing disease is not covered and payable. The complainant is not entitled to get any of the reliefs as claim for.
3. In spite of receipt of notice from this forum the 2nd opposite party did not respond to the same for their own reasons. The complainant was examined as PW1 and Exbts. A1 to A5 were marked on the side of the complainant. Witness of the opposite party was examined as DW1. Heard the counsel for the contesting parties.
4. The points that came up for consideration.
i. Whether the complainant is entitled to get insurance claim
from the opposite parties?
ii. Whether the opposite parties are liable to pay costs of the
proceedings to the complainant
5. Admittedly the policy was valid for the period from 06-06-2009 to 05-06-2010. Exbt. B1 is the treatment certificate issued from AIMS, Kochi. As per Ext. B1 the disease of the complainant was diagnosed as carcinoma alveolus recurrence. The complainant was treated from 08-07-2009 to 13-07-2009. The opposite party vehemently relied on clause No. 4.1 in Exbt. B2 policy which reads as follows:
“ Pre existing health condition or disease or ailment/injuries. Any ailment/disease/injuries/health condition which are pre-existing(treated/untreated, declared/not declared in the proposal form ) when the cover incepts for the first time are excluded up to 4 years of this policy being in force continuously.”
6. To support the argument of the 1st opposite party the learned counsel relied on the history of the ailment as stated in Ext. B1 medical certificate which is as follows:
“ 51 year old Mr. Pakashan presented with history of excision of ulcerative lesion one year back. On regular follow up in other hospital, recently developed right level I Lymphnode, FNAC outside reported as squamous cell carcinoma. Came here for further management.”
7. Apart from the history as stated in Ext. B1 no independent medical evidence is on record to substantiate the contention of the 1st opposite party that the disease of the complainant was pre-existing at the time of inception of the policy. The opposite parties ought to have taken steps to produce the medical records to prove their contentions in this Forum, wherein they failed. So concessions can not be called for. The Hon’ble National Consumer Disputes Redressal Commission in LIC of India Vs. Shri. AnilKumar Rashtogi 2009 (4) (CPR 130 NC has held in para 13 as follows:
“Except a memo noting that has been made in the discharge summary regarding respondent’s history and the diagnosis nothing on record has been shown as to what medication the respondent was taking for any of the ailments for which he took treatment in the year 2002.” Therefore in the instant case the complainant is entitled to get insurance claim from the 1st opposite party.
8. The complainant has not produced any document to substantiate the quantum of expenses incurred by him. The opposite party failed to sustain their contentions that such an amount as claimed by the complainant has been expended.
9. In the result, we allow the complaint and direct that the 1st opposite party shall pay the insurance claim of the complainant for reasons stated above provided the complainant submits necessary documents to substantiate his quantum of expenses for his treatment.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order failing which the above amount shall carry interest @ 12% p.a. till payment.
Pronounced in the open Forum on this the 29th day of February 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 the card
A2 : Copy of discharge summary
A3 : Copy of certificate dt.11-10-2010
A4 : Copy of medical certificate
dt. 09-12-2009
A5 : Lawyer notice. Dt. 04-05-2011
Opposite party’s Exhibits : :
Ext. B1 : Copy of certificate
dt. 09-12-2009
B2 : Copy of mediclaim insurance
policy (Group)
B3 : Copy of letter dt. 25/01/2010
B4 : Copy of medi claim
Computation
B5 : Copy of radiation treatment
Summary
Deposition:
PW1 : P.N. Prakasan
DW1 : Jagadish H.
