Karnataka

Bangalore 4th Additional

CC/16/255

Sri. Shankaraiah.M.V, S/o. late Veerabhadraiah, - Complainant(s)

Versus

The Oriental Insurance Company Limited & Others, - Opp.Party(s)

22 Oct 2019

ORDER

Complaint filed on: 12.02.2016

Disposed on: 22.10.2019

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027

 

CC.No.255/2016

DATED THIS THE 22^nd OCTOBER OF 2019

 

PRESENT

 

SMT.PRATHIBHA. R.K., BAL, LLM, PRESIDENT

SMT.N.R.ROOPA, B.A., LLB, MEMBER

 

	Complainant/s	V/s	Opposite party/s
	Shankaraiah.M.V., S/o Late Veerabhadraiah, Aged about 51 years, R/at No.7, Ajantha Vihar Apartments, 3rd Floor, Yelahanka New Town, Industrial Area, Bangalore   By.Adv.G.M.Shivakumar	1	The Oriental Insurance Company Limited. CBO 17, No.12, Bellary Road, Next to Canara Bank, Hebbala, Bangalore-560 024. Rep by its Managing Director
		2	Medi Assist India TPA Pvt. Ltd., Tower-D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore-560 029. Rep by its Manager.   By.Adv.Prathima.V

 

ORDER

SMT.PRATHIBHA. R.K., PRESIDENT

 

            1.        This complaint is filed by the Complainant against the Opposite party No.1 & 2 (herein after called as OPs), under section 12 of the Consumer Protection Act, 1986. The Complainant prays to direct the OPs jointly and severally to pay Rs.1,32,624/- towards the claim made by him under the mediclaim insurance policy, to pay Rs.1,00,000/- as compensation towards anxiety, pain and annoyance, to pay interest at the rate of 9% from 20.10.2015 on Rs.1,32,624/- till the date of realization, to pay costs of Rs.25,000/-.

 

2. The brief facts of the complaint is as under:

The Complainant submits that, he had availed a mediclaim policy bearing No.421504/48/2016/763 from the OP-1 through OP-2. The said policy is valid from 1.6.2015 to 31.5.2016. The OP-2 is the third party administrator of OP-1. The marketing representative of OP-1 represented the complainant that the policy is comprehensive policy which includes all types of diseases. Believing the words of the marketing representative, the complainant had obtained the above said policy.

 

2a.      The complainant further submitted that on 13.10.2015, the complainant has admitted to the M S Ramaiah Memorial Hospital, there he was diagnosed as open Cholecytectomy and the complainant was discharged on 20.10.2015. After discharging from the hospital, the complainant submitted the claim form before the OP-2 for reimbursement of the bill amount of Rs.1,32,624/-. The OP-2 has deliberately rejected the claim of the complainant on 19.1.2016 informing him by sending a mail citing a reason that the ailment cholelithiasis and procedures related to that are not covered under the policy for two years from the date of its inception.

 

2b.      The complainant further submitted that during the inception of the policy, the representatives of the OPs have not informed to the complainant any such time period to effectuate the policy. Further submitted that prior to treating for the ailment of Cholelithiasis, the complainant was diagnosed to have Cholelithiasis with obstructive jaundice at M.S.Ramaiah Memorial Hospital. The complainant underwent ERCP+stenting on 12.9.2015. The complainant towards the treatment and medical charges preferred a claim before OP-2 for Rs.66,288/- and the OP-2 reimbursed a sum of Rs.61,808/- to the account of the complainant.

 

2c.      The complaint further submitted that the OP deliberately rejected the claim of the complainant on flimsy grounds with also intention to avoid the payment of amount claimed by the complainant. Hence, the complainant has filed this complaint.

 

3. Notice was served to OP.1 & 2. Though notice served on OP.2, he did not appear before this forum, hence, placed exparte. The OP.1 appeared before this forum and filed objection. In the objection, the OP.1 submits that, the complaint is not maintainable either on law or on facts.

 

3a.      The OP-1 submitted that the he is a public sector undertaking wholly owned by the Government of India and is engaged in non-life insurance.  The OP had issued the mediclaim policy vide 421504/48/2016/763 and the same was valid from 1.6.2015 to 31.5.2016. The same is for one year which is extendable every year with prescribed premium. The said policy also includes both inclusion and exclusion clauses also.

 

3b.      The OP-1 further submitted that the complainant had diagnosed as open Cholecytectomy at M S Ramaiah Memorial Hospital on 13.10.2015. The complainant had lodged a claim before the OP-2 and the same was repudiated on the ground that the treatment underwent by the complainant is comes under the exclusion clause No.4.2 of the policy and the same could be covered only after the continuation renewal period of two years. Hence, the claim of the complainant was rightly repudiated as per the policy terms and conditions and warranty.

 

3c.      The OP-1 further submitted that the complainant admittedly underwent treatment on 13.10.2015 and also the policy was first time incepted on 1.6.2015. Therefore, the claim of the complainant was repudiated and the same is valid under the law. The OP-1 has furnished the terms and conditions of the policy.  The OP-1 further submitted that the complainant has opted for the policy then he has to abide by the terms and conditions of the policy. The complainant cannot pretend that he was not aware of the exclusion clauses and the same is not acceptable. Hence, there is no deficiency of service on the part of the OP-1.  Hence, prays this forum to dismiss the complaint.

 

4. In the course of enquiry into the complaint, the Complainant and the OP.1 has filed their affidavit reproducing what they have stated in their respective complaint and objection. The Complainant and the OP-1 has filed their written arguments. Both parties have produced documents which were marked. We have heard the arguments of both sides and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.  

 

5. Based on the above materials, the following points arise for our consideration;  

1. Whether the Complainant has proved that there is deficiency in service on the part of the OPs, if so, whether he is entitled for the relief sought for ?

2.  What order?

 

6. Our findings on the above points are as under:

Point No.1:  In the negative

Point No.2:  As per the order below

REASONS

7. Point No.1: On perusal of the pleadings, objection, evidence and documents of both the parties, it is an admitted fact that the complainant has availed the mediclaim policy bearing No.421504/48/2016/763 / Ex-A1 from the OP-1. The said policy was valid from 1.6.2015 to 31.5.2016 and the said policy is for one year. It is also an admitted fact that on 13.10.2015, the complainant had admitted at M.S.Ramaiah Memorial Hospital and he was diagnosed for open Cholecytectomy and he was discharged on 20.10.2015.

 

8.        The contention of the complainant is that after discharge from the hospital, the complainant submitted the claim form before the OP-2 for reimbursement of the amount of Rs.1,32,624/-. The OP-2 has deliberately rejected the claim of the complainant on the ground that the said treatment was exempted from the clause. At the time of inception of the policy, the OP’s representative informed the complainant that the said policy includes all types of diseases.

 

9.        On the other hand, the OP submitted that the complainant was diagnosed as open Cholecytectomy. The said treatment undergone by the complainant comes under the exclusion clause No.4.2 of the policy. Hence, the OPs have rightly repudiated the claim of the complainant.

 

10.      On perusal of the discharge summary / Ex-A3, as it could be seen that the complainant admitted to the hospital on 13.10.2015 at M S Ramaiah Memorial Hospital.  In the hospital, they have diagnosed as S/P LAP –OPEN CHOLECYSTECTOMY. Further, ongoing through the google website i.e. www.google.com, Open Cholecystectomy means “removal of the gallbladder.” Further, on perusal of the Clause 4.2/ Ex-A1, which reads as hereunder:

4.2 The expenses on treatment of following ailment/ diseases/surgeries for the specified periods are not payable if contracted and / or manifested during the currency of the policy.

4.2. xiii  is mentioned as “ surgery of gallbladder and bile duct excluding malignancy”. The said treatment covers after 2 years.  

Admittedly, the complainant admitted to the hospital for open Cholecytectomy on 13.10.2015. The Policy was incepted for first time on 1.6.2015. As per the terms and conditions of the said policy, the said treatment covers after 2 years. The complainant admitted to the hospital for the said treatment within a year. Hence, the said treatment taken by the complainant is not covered under the Clause 4.2 of the policy terms and conditions. Hence, on the above, the OP has rightly repudiated the claim of the complainant. Further, the complainant submitted that at the time of obtaining the policy, OP-1’s representative informed the complainant that the policy includes all types of diseases. At the time of obtaining the said policy, the complainant himself has read over the terms and conditions and obtained the policy. Hence, the complainant is estopped from taking such contentions. In view of the above discussions, we come to the conclusion that there is no deficiency on the part of OPs by not settling the claim amount to the complainant.  Accordingly, we answer the Point No.1 in the negative.

 

11. Point No.2: In the result, for the foregoing reasons, we proceed to pass the following order.

ORDER

The complaint filed by the Complainant is hereby dismissed. No order as to costs.  

            Supply free copy of this order to both parties. 

(Dictated to the Stenographer, transcribed and typed by her, corrected and then pronounced by us in the Open Forum on this, the 22^nd October 2019)

(ROOPA.N.R)     MEMBER

(PRATHIBHA.R.K)  PRESIDENT

 

 

1. Witness examined on behalf of the complainant/s by way of affidavit:

 

Sri.Shankaraiah M.V. who being the Complainant was examined. 

 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Mediclaim of the policy
Ex-A2	Identity card of the policy holder
Ex-A3	Discharge summary dt.20.10.2015
Ex-A4	Medical bills for having paid amount towards the treatment
Ex-A5	Reject the claim sent through the mail to complainant
Ex-A6	Discharge summary dt.14.9.2015
Ex-A7	Total medical bill

 

1. Witness examined on behalf of the OP/s by way of affidavit:

 

R.S.Arasu, who being the Deputy Manager of OP.1 was examined. 

 

 

Copies of Documents produced on behalf of OP.1:

 

Doc-1

Copy of the google website

 

 

 

(ROOPA.N.R)     MEMBER

(PRATHIBHA.R.K)  PRESIDENT