Date of Filing : 23.11.2010
Date of Order : 20.03.2012
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLAR
Dated 20th MARCH 2012
PRESENT
Sri. H.V. RAMACHANDRA RAO, B.Sc., BL, ……. PRESIDENT
Sri. T.NAGARAJA, B.Sc., LLB. …….. MEMBER
Smt. K.G.SHANTALA …….. MEMBER
Consumer Complaint No. 230 / 2010
Sri. B.S. Ramesh, S/o. late Seenappa,
Aged about 42 years,
R/at: Banahalli Village, Tekal Post, Malur Taluk,
Kolar District.
(By Sri. M. Venkataramanappa, Adv.) ……. Complainant
V/s.
1. The Zonal Manager,
L.I.C of India, Safiabad,
Hyderabad, Andhra Pradesh.
2. The Manager, Health Insurance
Divisional Office, Jeevan Jyothi,
P.B. No. 3829, Indira Nagar II Stage,
Bangalore – 560 038.
3. The Senior Manager, Health Insurance,
K.G.F Branch,
L.I.C of India, K.G.F,
Kolar District.
(By Sri. Samarangappa, Adv.) …… Opposite Parties
ORDER
By Smt. K.G. SHANTALA, MEMBER
This Complaint is filed by the Complainant u/s. 12 of the Consumer Protection Act, 1986 seeking decree against the Opposite Parties for health insurance claim of Rs.1,00,000/- alleging.
That the complainant is a policy holder of health plus, covering himself and his two children with his wife being nominee and the policy bearing No. HO36/364514110/01 dated 22.08.2008 would expire on 22.08.2032 of the OP. The complainant is regularly paying the premium. On 21.01.2009 he approached Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore and was diagnosed to be suffering from “deviated nasal septum” and was advised Septoplasty. The complainant got admitted to hospital and underwent surgery and got discharged on 08.05.2009. After discharge, he made correspondence with Opposite Parties requesting them to pay a sum of Rs.1,00,000/- as per terms and conditions of the policy, but the Opposite Parties have issued reply notice on 11.11.2009 which is nothing but deficiency in service. Hence, the Complaint.
2. The Opposite Parties in the version admitted the policy and its duration. Further contended that the liability under the claim for “septoplasty surgery” was rejected as the claim was submitted after 15 days from the date of discharge from hospital. However the delay in making the claim was condoned, but the claim could not be considered for payment as the present ailment falls under pre-existing disease. The Opposite Parties further contended that the surgery did not fall under major surgery and therefore the policy benefit could not be extended to cover the claim of the complainant.
3. From the averments in the complaint and version, affidavits of the parties and the documents produced, the points that arise for our consideration are:
(A) Whether the complainant has proved the alleged deficiency in service by the OP?
(B) If so, to what relief/s the complainant is entitled?
(C) What Order?
4. Our findings to these points are as hereunder:
(A) Negative
(B) Negative
(C) As per detailed order for the following reasons.
REASONS
5. Point Nos. A to C - The complaint averments do not coincide with the documents produced by the complainant. The complainant has averred in the complaint and affidavit that he was admitted on 21.01.2009 to Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore for treatment where he was detected to be suffering from deviated nasal septum for which an operation of Septoplasty was necessary, accordingly he has undergone for the said surgery in the said hospital and got discharged on 08.05.2009 and during the said period of treatment he has incurred more than Rs.1,00,000/- towards his treatment. The discharge summary marked as Ex. P2 reveals that the date of admission is 15.04.2009 and the date of discharge is 21.04.2009 and that he underwent Septoplasty with partial B/L inferior turbinectomy on 17.04.2009. The claim form shows the date of admission as 30.04.2009 and date of discharge as 03.05.2009 and the claim amount column is blank. The complainant has produced one more discharge summary pertaining to the same hospital with regard to pain during defecation for which lateral sphinterotomy was performed on 29.04.2009 to treat chronic fissure in anus with sentinal tag. The date of admission to hospital is shown as 25.04.2009 and date of discharge is shown as 08.05.2009. The claim form was sent to Opposite Party on 10th July 2009 and his claim was rejected showing the reasons for rejection as:
1. Claim submitted after 15 days from the date of discharge from hospital.
2. Present ailment falls under pre-existing disease.
Clause II (ii) deals with pre-existing condition, any medical condition or any related condition (e.g. illnesses, symptoms, treatments, surgery, pains) that have arisen at some point prior to the commencement of this coverage, irrespective of whether any medical treatment or advice was sought. Any such condition or related condition about which the Principal Insured or Insured dependant know, knew or could reasonably have been assumed to have known, will be deemed to be pre-existing.
6. However, in the instant case, the date of commencement of policy is 22.08.2008, the date of detection of illness is 21.01.2009 i.e. 150 days after the Complainant got admitted in the Hospital for deviated Nasal septum. He submitted claim form on 20.07.2009. The claim was repudiated on the ground that “present ailment falls under pre-existing disease”. In the present case, the illness was detected 150 days after the commencement of coverage of Policy and the complainant underwent treatment (surgery) three months after detection of illness i.e., during April-May 2009. Therefore, the illness cannot be termed as pre-existing. However, the surgery that the complainant underwent does not fall in the category of major surgery. As such it is not covered under the Health Policy.
7. Similarly, the Complainant underwent another surgery in the same Hospital for Sphincteretomy for which Discharge Summary has been filed. However, both the surgeries undergone by the Complainant do not fall under the category of major surgery. As such, the Complainant is not entitled to any benefit under the Health Policy. The Ops were right in repudiating the claim on the ground that it did not fall within the policy terms & conditions. Since Point Nos. 1 & 2 are held in the negative, the Complaint is liable to be dismissed and hence we proceed to pass the following:
ORDER
1. The Complaint is dismissed. No costs.
2. Return extra sets to the parties concerned under the Regulation 20(3) of the Consumer Protection Regulations 2005.
3. Send copy of the Order to the concerned, free of costs.
(Dictated to the Stenographer, got it transcribed and corrected and pronounced in the open Forum on this the 20th day of March 2012)
T. NAGARAJA K.G.SHANTALA H.V.RAMACHANDRA RAO
Member Member President
SSS
