BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 28/10/2011

Date of Order : 31/05/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 600/2011

Between

And

O R D E R

A. Rajesh, President.

1. The facts of the complainant's case are as follows :

The complainant availed an insurance policy of the 1^st opposite party on 19-01-2009 with sum assured to the tune of Rs. 50,000/-. The policy was continued upto 19-01-2010 to 18-01-2011, the complainant was admitted to the Medical Centre Ernakulam on 28-08-2010 for left Otorrhoea and was treated for (L) SCOM-Tuboptympanic. She underwent surgery on 30-08-2010 and incurred a sum of Rs. 27,454/- towards treatment expenses. The claim for insurance was repudiated by the opposite parties by their letter dated 16-11-2010 stating that the ailment of the complainant was a complication of chronic sinusitis. Thus, the complainant is before us seeking direction against the opposite parties to pay the insurance claim together with compensation of Rs. 10,000/- and Rs. 3,000/- by way of costs of the proceedings. This complaint hence.

2. The opposite parties filed version stating as follows :

The policy of the complainant was commenced for the first time from 19-01-2009. The illness for which the complainant was treated in the hospital was a complication of chronic sinusitis and as per exclusion clause 4.3 of the policy, sinusitis and related disorder will be payable only after two years from the commencement of the 1^st policy. In this case, the above clause is applicable. There is no deficiency in service on the part of the opposite parties in repudiating the claim of the opposite parties.

3. No oral evidence was adduced by the parties. Exts. A1 to A8 and B1 and B2 were marked on the side of the complainant and the opposite parties respectively. Heard the counsel for the parties.

4. The points that arose for consideration are :-

1. Whether the complainant is entitled to get the insurance claim from the opposite parties?

2. Whether the opposite parties are liable to pay compensation and costs of the proceedings to the complainant?

5. Point No. i. :- Admittedly, the complainant availed herself of an insurance policy from the 1^st opposite party with effect from 19-01-2009 and renewed the same till 18-01-2011. During the currency of the policy, the complainant had undergone treatment at Ernakulam Medical centre from 28-08-2010 to 30-08-2010 evident from Ext. A2 discharge summary. The opposite parties repudiated the insurance claim by Ext. A5 letter dated 16-11-2010 which reads as follows :

“Please be informed that the above claim does not qualify for settlement as per policy terms and conditions, on the following grounds :

CSOM – tubotympanic type – In the opinion of our panel of doors, ailment is complication of Chronic Sinusitis – Policy incepts from 19/01/2009 only – Sinusitis and related disorders are not payable during the first two years, under clause 4.3 of the policy.”

6. Subsequently, the complainant caused Ext. A7 letter dated 16-04-2011 to reconsider the decision in Ext. A5 to which the opposite parties sent Ext. A8 reply dated 09-05-2011 which reads as under :

“The competent Authority has re-examined the matter and observed that you have been covered under the Mediclaim Policy from 19-01-2009 onwards only. The expenses incurred for the treatment of (L) CSOM Tubotympanic Type is a complication of chronic sinusitis and as per the mediclaim policy, the Sinusitis and related disorders will be payable only after two years of the policy i.e. from 19-01-2009. Since the treatment occurred was within the two year limit, we observe that the repudiation of the claim done by the TPA M/s. TTK Healthcare TPA Pvt. Ltd. as per Exclusion No. 4.3, is found to be in order and no grounds exist for a review. Hence, we are treating your grievance as closed.

If you are not satisfied with our decision you may approach the Hon'ble Insurance Ombudsman, Pulinat Building, 2^nd Floor, Opp. Cochin Shipyard, M.G. Road, Cochin – 682 015.”

7. However, nothing is on record to show the nexus between sinusitis and the present ailment of the complainant neither has it been unproved for want of ample medical evidence which for reasons of their own the opposite parties have not produced in this Forum. The complainant here is squarely a consumer and it is the bounden duty of this Forum to upheld her legitimate right which for no reasons however, frivolous cannot be backed away from. Ext. A3 is the final bill issued by the complainant, the complainant had to incur Rs. 25,744/- towards hospital and treatment expenses. The complainant is entitled to get the amount from the opposite parties with 12% interest p.a. from the date of complaint till realisation.

8. Point No. ii. :- The complainant has been put to unnecessary litigation and inconvenience which calls for necessary costs, we fix it at Rs. 1,000/- and primary grievance of the complainant having been met adequately. We feel no compensation is called for.

9. In the result, we partly allow the complaint with the observations and to the extend above.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 31^st day of May 2012

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

=========