IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Friday the 27th day of May, 2016
Filed on 15.11.2014
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt.Jasmine.D. (Member)
in
C.C.No.302/2014
between
Complainant:- Opposite Party:-
Sri. Sasikumar Cherukole The Oriental Insurance Company Ltd.
Cherumuttathu House, Cherukole A-25/27, Asaf Ali Road
Mavelikara – 690 101 New Delhi – 110 002
(By Adv. Varghese. K. Samuel) (By Adv. C. Muraleedharan)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant is a Happy Family Floater policy holder of Oriental Insurance Company under policy No.443290/48/2014/750 for the period from 07.02.2014 to 06.02.2015. He was admitted to St. Gregarious Hospital, Parumala for chest pain on 4.5.2014 and underwent Coronary Angioplasty on 4.5.2014. For getting cashless facility, the request was sent in advance by the hospital, the details of the total bill of Rs.1,17,925.94/- was sent by the hospital to the opposite party. The opposite party denied the cashless facility and sent letter on 14.07.2014 rejecting the medi-claim of the complainant. Alleging deficiency in service on the part of the opposite party the complaint is filed directing the opposite parties to pay the insured amount of Rs.1 lakh with interest and compensation of Rs.25,000/- along with costs.
2. The version of the opposite party is as follows:-
The opposite party issued a Happy Family Floater policy to the complainant for a period up to 6.2.2015 for total sum of Rs.1 lakh. Complainant submitted his expenses incurred of his treatment for Rs.1,17,925.94/-, but the investigator appointed for investigating the genuineness of the claim submitted, reported that the complainant had first time consulted the doctor for CAD on 28.9.2012 as per his Id No.13899 of the hospital and the present treatment is in continuation of the pre-existing treatment. The complainant is not entitled to get any of the reliefs prayed for in the complaint. There is no deficiency in service on the part of the opposite party.
3. Complainant was examined as PW1. Doctor was examined as PW2. Documents produced were marked as Exts.A1 to A7. Opposite party was examined as RW1. One witness was examined as RW2. The documents produced were marked as Exts.B1 to B4.
4. The points came up for considerations are:-
- Whether there is any deficiency in service on the part of the opposite parties?
- If so the reliefs and costs?
5. It is an admitted fact that complainant is the holder of Happy Family Floater policy for a period from 07.02.2014 to 06.02.2015. The policy covers hospitalization expenses for maximum amount of Rs.1 lakh. According to the complainant he was admitted to the St. Gregarious Hospital, Parumala for chest pain on 4.5.2014 and underwent Coronary Angioplasty on 4.5.2014. The total bill for the treatment was Rs.1,17,925.94/-. Ext.A2 series are the bills and discharge card of the complainant. The discharge card shows that he was admitted on 4.5.2014 and the PTCA with DES to LAD was done on 5.5.2014. The opposite party rejected the claim submitted by the complainant stating that the complainant had first time consulted the doctor for CAD on 28.9.2012 and the present treatment undergone on 4.5.2014 is in continuation of the pre-existing ailment. The point to be considered is whether the complainant had any pre-existing disease. According to the opposite party as per the report of the investigator, the complainant had first time consulted the doctor for CAD on 28.9.2012 as per Id No.13899 of the hospital. So the opposite party repudiated the claim as per clause 4.1 of the policy condition which stipulated that pre-existing health condition ailment/disease, injuries of the insured person are excluded for such insured person up to 4 years of the policy being in force continuously. According to the opposite party, the complainant had made consultation as per Id No.13899 of the hospital. But the opposite party had not taken any attempt to produce those files from the hospital authority. In order to succeed in its plea, the onus lies heavily on the opposite party to prove that the complainant had pre-existing disease. While cross examining the RW2 the investigator, he was asked by the counsel of the complainant that, “lmPcm¡nbncnbv¡p¶ dnt¸mÀ«n\v Dt]mZv_eIambn tlmkv]näen \n¶pÅ tcJIsfs´¦nepw lmPcm¡nbn«ptm? (Q) Cà .(A)” So there is no documents to prove that the complainant was suffering pre-existing disease and also that there is suppression of the material fact by the complainant. Ext.A6 is the Medical Report of the complainant. In Ext.A6 it is clearly stated that the patient approached the doctor for the first time in connection with the disease like chest pain on 4.5.2014. The doctor who issued Ext.A6 document was examined as PW2. While cross examining the doctor, he categorically stated that before signing the document he had examined the case sheet of the patient. More over to the question about the duration on the present disease, the answer by the doctor is ‘only hours.’ The opposite party has not produced any document to convert to be adduced by the complainant. In the absence of any documents, we are unable to come to the conclusion that the complainant was suffering from pre-existing disease and there is suppression of material facts. Therefore we are of opinion that there is deficiency in service on the part of the opposite party in repudiating the claim of the complainant.
In the result, complaint is allowed. The opposite party is directed to pay an amount of Rs.1,00,000/- (Rupees one lakh only) being the insured amount with 8% interest from the 8.5.2014 till realization. The opposite party is further directed to pay an amount of Rs.2,000/- (Rupees two thousand only) towards costs of the proceedings. Since the primary relief is granted no further amount as to compensation. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the 27th day of May, 2016.
Sd/- Smt. Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt. Jasmine. D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Sasikumar (Witness)
PW2 - Dr. Anand Srinivasan.K. (Witness)
Ext.A1 - Copy of the Universal Health Insurance Policy Schedule
Ext.A2 - Copy of the medical bills
Ext.A3 - True copy of the Certificate dated 13.5.2014
Ext.A4 - True copy of the registered letter dated 14.7.2014
Ext.A5 - True copy of the letter dated 12.8.2014
Ext.A6 - True copy of the medi-claim medical report
Ext.A7 - True copy of the letter dated 1.9.2014
Evidence of the opposite party:-
RW1 - Subha. G. Panicker (Witness)
RW2 - Saurabhan. P. (Witness)
Ext.B1 - Happy Family Floater Policy Schedule
Ext.B2 - Copy of the terms and conditions
Ext.B3 - Investigation report dated 8.7.2014
Ext.B4 - Letter dated 1.10.2014
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite party/S.F.
Typed by:- pr/-
Compared by:-
