By Smt.Rajani.P.S., Member
The complainant’s case is that she had joined in the Medicare- chit JM05 conducted by the New Trichur Company Limited and as per the terms and conditions of the kuri, the kuri subscriber and the family members (4Nos.) are included in the mediclaim policy issued by the respondent insurance company. According to this the complainant and her son Jerry and daughter Sheri are joined in the policy as per No.100606/48/03/03826 for the period 26/3/04 to 25/3/05. On 21/10/04 while she was in Ollur St.Vincent De Payl Hospital where her son was admitted she felt chest pain and got admitted in the same hospital and treated upto 27/10/04. She never felt the chest pain earlier. She submitted the claim before the respondent. But it was repudiated by stating that the treatment was for a pre-existing disease. The complainant never suffered any cardiac diseases earlier and hence the respondent is liable to pay the claim amount. The complainant spent Rs.4,323.75 for her treatment. The repudiation of the claim is a deficiency in service on the part of the respondent. Hence the complaint.
2. The counter filed by the respondent is that the complainant was suffered from chest pain while she was take caring of her son in the hospital is denied. As per the documents submitted by the complainant, she was having some cardiac problems prior to this policy date. So the respondent repudiated the claim stated as pre-existing disease. So this respondent is not liable to give any compensation to the complainant. The mere existence of the mediclaim policy does not ipso facto attach any liability with this respondent. The complainant has no right to file any complaint against this respondent. The complainant is only a beneficiary of the policy holder. As per the terms and conditions of the mediclaim policy there are some diseases which are excluded from the liability and as per Clause 4(1) also the pre-existing diseases are also excluded from the liability. There is no deficiency in service and unfair trade practice from the part of this respondent. Hence dismiss.
3. The points for consideration are :
1) Is there any deficiency in service on the part of respondent?
2) If so reliefs and costs?
4. The evidence consists of Exhibits P1 to P4 series and Exhibit R1. No other evidence for both.
5. Points: The complaint is filed to get the treatment expenses as per the mediclaim policy issued by the respondent. The complainant had chest pain while she was taking care of her son at St.Vincent De Paul hospital, Ollur and admitted and treated in the same hospital from 21/10/04 to 27/10/04. The respondent repudiated her claim by stating the disease treated as a pre-existing disease. The complainant’s case is that she never suffered any cardiac disease earlier and hence the act of the respondent is an unfair trade practice and deficiency in service. The respondent in their counter stated that they repudiated the claim as per the terms and conditions of the policy. As per the documents submitted by the complainant and Section 4(1) of the policy pre-existing diseases are excluded from the policy.
6. The respondent”s main contention is that the disease treated was for a pre-existing one. Among the documents produced by the complainant, the Exhibit P3 is the only document which reveals the details regarding the treatment. Exhibit P3 would show that the diagnosis as CAD, Non ST Elevation MI and HTN, Hyperlysidemia. Other than this nothing is mentioned about the history of the cardiac problems. If the complainant is having any pre-existence of the earlier said disease, the treated doctor will surely mention it in the discharge summary. The respondent only produced Exhibit R1 the policy conditions which is not a relevant document to prove their contention about the pre-existing disease of the complainant. No piece of paper is produced to prove their contention. No oral evidence has taken to prove the same. The repudiation of a valid claim by stating pre-existence of the disease is a serious negligence and deficiency in service on the part of the respondent.
7. In the result the complaint is allowed and the respondent is directed to pay the Exhibit P4 series bills amount with 12% interest from the date of claim and Rs.500/- (Rupees Five hundred only) as costs within one month from the date of receipt of copy of this order.
Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 9th day of September 2010.
