BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 30th of September 2010
PRESENT
SMT. ASHA SHETTY : PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
SRI. ARUN KUMAR K. : MEMBER
COMPLAINT NO.75/2010
(Admitted on 09.03.2010)
Zita Priya Fernandes,
Aged 28 years,
Wo Naveen Fernandes,
Resident at Niddel Gokarna House,
Kulshekar Post,
Mangalore. …….. COMPLAINANT
(Advocate for the Complainant: Sri.Naveen Kumar M.G.)
VERSUS
The Senior Branch Manager,
Reliance General Insurance Co. Ltd.,
Maximum Commercial Complex,
4 Floor, Light House Hill Road,
Hampankatta,
Mangalore 575 001. ……. OPPOSITE PARTY
(Advocate for the Opposite Party: Sri.B.Gangadhar)
ORDER DELIVERED BY PRESIDENT SMT. ASHA SHETTY:
1. This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party claiming certain reliefs.
The brief facts of the case are as under:
It is stated that, the Complainant has obtained a Medi Guard Insurance Policy from the Opposite Party bearing Policy No. 1404/382812100002 for the period commencing from 12.1.2008 to 11.1.2009. During the continuance of the policy, the Complainant admitted in the K.M.C. Hospital on 24.9.2008 for acute exacerbation of Bronchial Asthama with B/L Maxillo Ethmoidal Sinusitis and taken treatment, discharged on 26.9.2008 and spent Rs.15,000/- for the medical expenses. It is stated that, after discharge from the hospital, the Complainant approached the Opposite Party and requested to pay the amount, but the Opposite Party not paid the amount under the policy which amounts to deficiency in service and hence the above complaint filed under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Party to pay the aforesaid amount with interest at 12% per annum from date of claim made by the Complainant with the Opposite Party and also pay costs of the proceedings.
2. Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel filed version and admitted the policy but it is stated that, the claim of the Complainant is not admissible under exclusion clause 3 and condition No.8 of the Policy. It is contended that, as per the conditions and exclusion of the policy the claim of the Complainant is not maintainable and prayed for dismissal of the complaint.
3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the Complainant proves that the Opposite Party has committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
4. In support of the complaint, Mrs.Zita Priya Fernandes (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C8 were marked for the Complainant as listed in the annexure. One Mr.Chandrashekara Hosamani (RW1), Deputy Manager, Legal Department of the Opposite Party filed counter affidavit and answered the interrogatories served on him. Ex R1 and R2 were marked for the Opposite Party as listed in the annexure. The Opposite Party produced notes of arguments.
We have considered the notes/oral arguments submitted by the counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No.(i): Negative.
Point No.(ii) & (iii): As per the final order.
REASONS
5. POINTS NO. (i) to (iii):
From the outset of the records available on the file of this Forum, it is admitted that, the Complainant obtained a Medi Guard Insurance Policy from the Opposite Party for the period commencing from 12.1.2008 to 11.1.2009 bearing Policy No.1404/382812100002. It is also not in dispute that, during the continuance of the policy, the Complainant had admitted in KMC Hospital on 24.9.2008 for acute exacerbation of Bronchial Asthama with B/L Maxillo Ethmoidal Sinusitis and underwent treatment, discharged on 26.9.2008.
Now the point in dispute between the parties before the Forum is that, the Opposite Party despite of having the Insurance Policy and its coverage not paid/reimbursed the medical expenses. Hence came up with this Complaint.
On the contrary, the Opposite Party contended that, the treatment taken by the Complainant is excluded under the policy and hence, denied the claim of the Complainant.
On perusal of the oral as well as documentary evidence available on record, we find that, The Ex.C1 is the Insurance Policy bearing No.1404/382812100002 i.e. Medi Guard Insurance Policy valid from 12.1.2008 to 11.1.2009. The Ex.C5 is the Discharge Summary issued by the KMC Hospital shows that, the Complainant admitted on 24.9.2008 with the Complaints of acute exacerbation of Bronchial Asthama with B/L Maxillo Ethmoidal Sinusitis. However, we have perused the exclusion clause in the policy produced by the Opposite Party, wherein, page No.2 of the policy, Exclusion-3 reads thus:
“ 3. During the first year of operation of the insurance cover, expenses on treatment of diseases such as contract, benign prostates hypertrophy, hysterectomy or menorrhagia or fibromyoma, hernia, hydrocele, congenital internal diseases, fistula in anus, piles, sinusitis and related disorders are not payable. If these diseases are pre-existing at the time of proposal, they will not be covered even during period of subsequent renewals. Provided that the above exclusion shall not apply in case of the Insured Person having been covered under this scheme or a group insurance scheme with any of the Insurance Companies in India for a continuous period of preceding 12 months without any break.”
Further at Page No.1 definitions reads thus:
1. “Domiciliary hospitalization” means medical treatment for a period exceeding three days for disease/injury which in the normal course would require care and treatment at a hospital/nursing home but is actually taken whilst confined at home in India under any of the following circumstances:
i)……….
ii)…………….
Domiciliary hospitalization benefits shall be submit to the limit stated in the Schedule attached hereto and shall in no case cover:
a)…………………………
b) expenses incurred for treatment of any of the following
diseases:
i) Asthama
ii) Bronchitis
iii)…………
iv)………….”
From the above, exclusion clause as well as definitions under the policy made us very clear that the Asthma and Bronchitis and Sinusitis are not covered and excluded under the policy.
In the instant case, the disease suffered by the Complainant was acute exacerbation of Bronchial Asthama with B/L Maxillo Ethmoidal Sinusitis as per the discharge summary produced before this Forum. Hence, the claim of the Complainant is not covered under the policy and there is no deficiency on the part of the Opposite Party. In view of the above discussions, the Complaint filed by the Complainant has no merits deserves to be dismissed. No order as to cost.
6. In the result, we pass the following:
ORDER
The complaint is dismissed. No order as to cost.
The copy of this order as per the statutory requirements be forwarded to the parties free of charge and therefore the file be consigned to record.
(Page No.1 to 7 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 30th day of September 2010.)
PRESIDENT
MEMBER MEMBER
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 – Mrs.Zita Priya Fernandes – Complainant.
Documents produced on behalf of the Complainant:
Ex C1 – Certificate of Insurance bearing Policy
No.1404/382812100002.
Ex C2 – Medi Assist Card.
Ex C3 – Copy of Medi-Claim Insurance Policy Claim Form.
Ex C4 – 8.1.2009: Letter issued by the Respondent to the
Complainant.
Ex C5 – Copy of Discharge Summary.
Ex C6 – 26.9.2008: Xerox copy of the Discharge Bill.
Ex C7 – Xerox copy of the Pharmacy Bills.
Ex C8 – Xerox copy of the medical reports.
Witnesses examined on behalf of the Opposite Party:
RW1 – Mr.Chandrashekara Hosamani, Deputy Manager, Legal Department of the Opposite Party.
Documents produced on behalf of the Opposite Party:
Ex R1 – True copy of Reliance General Insurance Group Medi-Claim Insurance Policy.
Ex R2 – Original Discharge Summary.
Dated:30.09.2010 PRESIDENT
