IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 14th day of September, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 37/2020 (Filed on 17-02-2020)
Petitioner : (1) P.A. Abraham,
Pattani House,
Kuravilangad P.O.
Kottayam.
(2) Elsamma Abraham,
W/o. P.A. Abraham,
Pattani House,
Kuravilangad P.O.
Kottayam.
(Adv. Nithin Sunny Alex and
Adv. Jaimon Jose)
Vs.
Opposite party : Branch Manager,
United India Insurance Company
Ltd, City Branch Office No.1,
Jose Trust Building,
Chittur Road, Ernakulam,
Pin - 682035
(Adv. P.G. Girija)
O R D E R
Sri. Manulal V.S. President
The case is filed under Section 12 of Consumer Protection Act, 1986.
The case of the complainants is as follows:
The second complainant is the wife of the first complainant. The first complainant subscribed the health insurance policy of the opposite party vide policy number 1002032816P113459761 for the period of 16-1-2017 to 15-1-2018. The complainants are covered under the policy. The previous policy no was 1002032815P111122519893.In November 2017 the second complainant had undergone a mammogram at Caritas hospital Thelleakom. Since some malignancies are found she got treatment from Rajagiri hospital, Aluva and after that Medicity hospital Ernakulam. When it is confirmed that it is cancerous, the second complainant got admitted in RCC Thiruvanthapuram for treatment and surgery was done for the removal of both breasts. The claim submitted for the expenses incurred for the treatments in Caritas hospital, Rajagiri hospital and Aster Medicity was illegally rejected by the opposite party. It is averred in the complaint that the complainant is subscribing the policy for last 10 years and never made any silly claims. This is the first claim put forward for the second complainant from the first policy which was subscribed about 10 years back. According to the complainants the repudiation of the claim by the opposite party amounts to deficiency in service. Hence this complaint is filed by the complainants praying for an order to direct to pay Rs.90,000/- as claim amount and compensation.
Upon notice opposite party appeared before the commission and filed version as follows:
The complainants have availed an Individual Health Insurance policy with policy number 1002032816P113459761 for the period of 16-1-2017 to 15-1-2018 under the plan Gold. The complainants have to prove the treatments undergone at Caritas hospital, Rjagiri hospital and Aster Medicity. The complainants have not submitted any document to show that surgery was done at RCC Thiruvanthapuram for removal of breasts, The complainant have also not submitted any bill regarding the surgery done at RCC Thiruvanthapuram. The complainants have submitted the bills related to the investigations done primarily for diagnosis of an illness. Documents showing any active line of treatment are not submitted by the complainants to the opposite party. Hence the complainant’s claim was repudiated as per the clause 4.11 of the insurance policy; there is no deficiency in service on the part of the opposite party.
First complainant filed proof affidavit in lieu of chief examination and marked exhibits A1 to A4. M.R.Sreekumar who is the Divisional Manager of the opposite party filed proof affidavit and marked exhibit B1 and B2 from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points,
- Whether there is any deficiency in service on the party of the opposite party?
(2)If so what are the reliefs?
Point number 1 and 2
The specific cases of the complainant that the second complainant who is the wife of the first complainant had undergone a mammogram at Caritas hospital Thelleakom during November 2017. Since some malignancies are found she got
treatment from Rajagiri hospital Aluva and after that Medicity hospital Ernakulam. When it was confirmed that it was cancerous, the second complainant got admitted in RCC Thiruvanthapuram for treatment and surgery was done for the removal of both breasts. Her claim was illegally repudiated by the opposite party. It is proved by exhibit A4 that the second complainant is under the treatment at RCC Thiruvanathapuram since 22-11-2017 for Carcinoma Breast. Exhibit A3 proves that the second complainant was admitted in Regional Cancer Centre, Thiruvanthapuram on 28-5-2018 and got discharged on 30-5-2018. On perusal of exhibit A3 we can see that the second complainant had undergone surgery for bilateral modified radical mastectomy on 29-5-2018.
The complaint is resisted by the opposite party on the ground that that there was no active line of treatment and the bills submitted by complainants are related to the investigations done primarily for diagnosis of an illness only.
As per clause 4.11 of Exhibit B1 policy, charges incurred at hospital primarily for diagnosis, x-ray or laboratory examination or either diagnostic studies not consistent with or incidental to the diagnosis and treatment of existence or presence of any ailment, sickness or injury for which confinement is required at a hospital/nursing home is not payable.
On a mere reading of exhibit b2 bill details we can see that the complainants have not produced any bill for the expenses incurred at RCC Thiruvanathapuram for the treatment of second complainant. The only bill produced by them from the RCC Thiruvanthapuram for an amount of Rs.150/- which is remitted towards the consultation and registration fee. Moreover it can be seen from going through Exhibit B2 that though complainant produced bill from 6-11-2017 to 22-11-2017 all these are related to the investigation, lab charges, and registration charges. It is pertinent to note that the complainants have not produced the treatments records from Caritas hospital, Rjagiri Hospital and Aster Medi city. Admittedly the claim was rejected by the opposite party vide exhibit A1 which is dated 19-2-2018. Thus it is clear from exhibit A1 that the complainants lodged the claim before the surgery which was performed on 29-5-2018.
The Hon’ble Supreme Court in a recent Judgment dtd. 06th October 2021 i.e. in “SGS India Limited v/s Dolphin International Limited”, categorically held that the onus of proof that there was deficiency in service is on the complainant.
Here in this case as discussed above we are of the opinion that the complainant has failed to prove any deficiency in service on the part of the opposite party. Thus the complaint is dismissed.
Pronounced in the Open Commission on this the 14th day of September,2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of letter dtd.19-02-2018 issued by opposite party to 1st complainant
A2 – Copy of lawyers notice dtd.29-06-2018 issued by 1st complainant to The Grievance Redressal Cell, United India Insurance Co. Ltd.
A3 –Copy of discharge summary dtd.30-05-18 from RCC, Thiruvananthapuram
A4 – Copy of treatment certificate dtd.07-07-14 by Dr.Beela Sarah Mathew
Exhibits marked from the side of opposite party
B1 – True copy of policy No.1002032816P113459761by opposite party
B2 – Copy of bill details in the name of 2nd complainant by HealthIndia Isnurance TPA Services Ltd.
By Order
Sd/-
Assistant Registrar
