This C.C. is coming on before us for hearing; in the presence of Sri. H. Sree Rama Rao, Advocate for complainant; and of Sri. S. Muralidhar Rao, Advocate for Opposite parties 1 & 2; upon perusing the material papers on record; upon hearing and having stood over for consideration, this Forum passed the following:-

O R D E R

(Per Smt.V.Vijaya Rekha, Member)

This complaint is filed under section 12(1) of the Consumer Protection Act, 1986. 

2.       The brief facts as mentioned in the complaint are that the complainant obtained Medi Claim Health Insurance Policy from the opposite parties for the period 2000-2001, since then, the policy was renewed from time to time till 17-08-2011.  During the existence of policy, the complainant went into ‘coma’ and admitted in the Cure Hospital, Khammam by his family members, from there, he was shifted to Kamineni Hospitals, Hyderabad and had taken treatment from 30-11-2010 to 01-01-2011 as in patient vide in-patient No.201014423 for Ischemic Encephalopathy, Bilateral Multiple Infarcts, Sepsis with Septic Shock with ARF, Pseudomonal Infection (Central Line) Grade III to IV, Decubitus Ulcer, Anemia, Diabetes Mellitus Type II and Ischemic Heart disease.  After discharging from the hospital, claimed the opposite parties vide claim petition No.25783 but the opposite parties repudiated the claim by stating that the insured is a case of Bilateral Multiple Infarcts with Ischemic Encephalopathy, Diabetic and Hypertensive, which are the strong / risk factors and as such as per exclusion 4.1 of policy schedule, the expenses incurred on pre-existing diseases are not payable.  Thereafter, the complainant addressed a letter on 16-05-2011 to the opposite party No.2, stating the facts and details by requesting to settle his claim.  Again the complainant received another letter from the opposite party No.2, wherein, the opposite party No.2 stated that the claim was repudiated by M/s. Good Health Plan Ltd., basing on the reasons that according to discharge summary, the cause of hospitalization was Ischemic Encephalopathy, Bilateral Infarcts, Septicemia but as per case sheet it is a case of ingestion of CLONASEPAM (30-40 tablets) and the insured got intubated before coming to the Kamineni Hospital, Hyderabad and there are no investigation reports in support of present ailment, therefore, as per exclusion 4.8 of policy, the expenses incurred on ailment due to ingestion of intoxication drugs are not payable.   Upon which, the complainant addressed a letter dt. 09-08-2011 by furnishing required documents along with the certificate, issued by Dr. E. Srikanth Reddy, D.M., (Nimhans), Consultant Nero Physician, Kamineni Hospitals, Hyderabad regarding the cause of hospitalization.  The complainant further submitted that the allegation of the opposite parties regarding the consuming of ‘CLONAZEPAM’ tablets is not correct, only it is the suspicion of the family members, who found one empty strip of ‘CLONAZEPAM’ tablets underneath the cot of the complainant at the time of complainant went into ‘coma’  and they informed the same to the hospital authorities at the time of taking of initial treatment, the same was carried out in the case sheet while referring the complainant to the Kamineni Hospital.  The complainant also submitted that he approached the Consumer Affairs, IRDA, Hyderabad on his grievance, though, there is no response in settling the claim, therefore, approached the Forum as there is no hope of settlement and prayed to direct the opposite parties to settle the claim and to pay an amount of Rs.2,00,000/- with future interest at 18% per annum from the date of complaint and to pay Rs.5,000/- towards damages and costs.

3.       In support of his case, the complaint filed affidavit and some documents; those were marked as Exhibits A1 to A11.

4.       On being noticed, the opposite parties appeared and filed counter.  

5.       In the counter, the opposite parties admitted the issuance of policy bearing No. 051701/48/10/97/00000373 in the name of complainant from the period 19-08-2010 to 18-08-2011 and averred that the complainant failed to give immediate information regarding the hospitalization to find out the real facts.  The complainant is a known case of type II DM and has hypertension since past 10 years, which are the strong and risk factors.  According to section 4.1, the expenses incurred on pre-existing disease are not payable.  The opposite party No.2 further submitted that the present situation was developed due to ingestion / consumption of 30-40 “CLONAZEPAM” tablets and as such as per exclusion No. 4.8, repudiated the claim and also alleged that after receipt of repudiation letter the complainant created concocted, irrelevant documents and as such prayed to dismiss the complaint with costs as the complainant failed to place investigation reports in support of his case.  

6.       Both the parties filed Written Arguments by reiterating the same averments as mentioned in the complaint and counters.  Along with a petition, the opposite parties filed certified true copy of policy bearing No.051701/48/10/97/00000373, got marked as Exhibit B1, the same was marked as Exhibit A2 on behalf of complainant is photocopy.

7.       During the pendency of proceedings the complainant filed a petition by seeking direction to appoint an Advocate / Commissioner to record the evidence of treated Doctor and to collect the original Reports and Medical Bills.  Thereafter, filed another petition to direct the RMO of Kamineni Hospitals, Hyderabad to submit the Original Medical Records.  After service of notice, concerned authorities of Kamineni Hospitals, Hyderabad produced the original documents before this For a, those were marked on behalf of complainant as exhibits A9 to A15.  

8.       In view of the above circumstances, now the point that arose for consideration is,

Whether the complainant is entitled to the relief as prayed for?

Point:-        

          According to the aforesaid averments, the complainant obtained Medi Claim Health Insurance policy from the opposite parties for the period 2000-2001 till 2010-2011, every year it was renewed by the opposite parties on payment of premium amount.  During the subsistence of policy bearing No. 051701/48/10/97/000000373, the complainant went into ‘coma’ and had taken treatment as in patient from 30-11-2010 to 01-01-2011 at Kamineni Hospital, Hyderabad and claimed the opposite parties by submitting relevant documents.  On the other hand the opposite parties resisted the case of the complainant by taking a plea that the complainant is a known case of Diabetes and having Hypertension for the last 10 years, which are the strong and risk factors to the present ailment as alleged and also raised another objection regarding the consumption of “CLONAZEPAM” tablets and repudiated the claim by sending two repudiation letters by raising different versions.  But failed to file any documentary proof in this regard and could not file any previous medical / treatment record to prove that the policy holder having pre-existing disease before the policy was came into existence i.e. prior to the effective date of policy.  According to the premium receipts, marked under exhibit A2 initially, the complainant paid the premium amount for obtaining Medi Claim Health Insurance Policy on 02-08-2002, thereafter, he paid the premium on 12-08-2005 and after that, the premiums were paid continuously from year to year till the date of hospitalization.  The opposite parties did not raise any objection in this regard, it seems that the policy was in existence since its inception. As far as the objection raised by the opposite parties regarding the pre-existing disease is concerned, while considering the discharge summary, marked under exhibit A8, we have observed that the doctors of Kamineni Hospitals, Hyderabad did not mention anything regarding the previous history of Diabetes and Hypertension, only they mentioned the diagnosis report while providing treatment from 30-11-2010 to 01-01-2011.  It seems that there is no record in support of averments of the opposite parties.  Moreover, the entire treatment, given by the Doctors of Kamineni Hospital, Hyderabad was only for Ischemic Encephalopathy, Bilateral Multiple Infarcts and Septic Shock with ARF, therefore, it is clear that the objection raised by the opposite parties regarding the ingestion / consumption of “CLONAZEPAM” tablets is not sustainable.  And the Certificate issued by the treating Doctor of Kamineni Hospitals, Hyderabad, evidenced under exhibit A6 speaks that the consumption of “CLONAZEPAM” tablets was only a suspicion and it was not proven on detail evaluation.  The MRI Reports and other relevant reports reveals that the complainant was diagnosed to have Encephalopathy Ischemic, Bilateral Multiple Infarcts  Sepsis with Septic Shock with ARF, Pseudomonal infection (Central Line) Grade II to IV Decubitus Ulcer, Anemia, DM type II, Ischemic Heart disease.  Therefore, it is clear that the complainant/policy holder was obtained treatment for his health problems as stated supra. not due to consumption of any intoxicated tablets and as such the opposite parties cannot escape from their liability in settling the claim, therefore, the point is answered accordingly in favour of the complainant by holding that the opposite parties are liable to pay the Medi Claim expenses according to the policy schedule as the liability is limited up to Rs.1,75,000/-.

8.       In the result, the complaint is allowed in part, directing the opposite parties to pay an amount of Rs.1,75,000/- under policy bearing No. 051701/48/10/97/00000373 to the complainant together with interest @9% per annum from the date of repudiation i.e. 16-05-2011 till realization.  Further directed to pay Rs.1,000/- towards costs.

           Typed to dictation, corrected and pronounced by us in the open forum, on this the  26^th day of June, 2015.

                                                  FAC President               Member      

                                           District Consumer Forum, Khammam

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant                                                       For Opposite party  

       None                                                                             None

DOCUMENTS MARKED:-

For Complainant                                                       For Opposite party

FAC President               Member

     District Consumer Forum, Khammam