DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE
PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB : PRESIDENT
Smt. PRIYA.S, BAL, LLB, MBA (HRM) : MEMBER
Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER
Thursday 30th day of November 2023
CC.606/2014
Complainant
Vineesh. T,
Thazhathayil (HO),
Edakkulam, Koyilandy,
Kozhikode – 673306.
Opposite Parties
- Apollo Munich Health Insurance Co. Ltd,
Apollo Hospitals Complex,
Jubilee Hills, Hydrabad,
Andrapradesh – 500033.
(By Adv. Sri. Saji Issac.K.J and Adv. Smt. Rakhi.K)
- Muthoot Fincorp Ltd,
Poonoor Branch,
Unnikulam Post,
Kozhikode -673 574.
(By Adv. Sri Sabu John Mathew)
ORDER
By Sri. P.C. PAULACHEN – PRESIDENT
This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.
- The case of the complainant, in brief, is as follows:
The complainant is the holder of Apollo Munich Health Insurance Policy. His son Vishal is also included in the policy coverage. As per the terms and conditions of the policy, an amount of Rs. 1,00,000/- can be claimed as medical expenses. On 11/9/2014 complainant’s son Vishal was admitted in the hospital with severe pain in the lower part of the abdomen and the doctors diagnosed it as BILATERAL RETRACTILE TESTIS. He had undergone a surgery and was discharged on 15/9/2014. An amount of Rs. 44,685/- was incurred as medical expenses for his treatment.
- The complainant preferred a claim with necessary documents. But the claim was repudiated by the first opposite party stating the reason that the ailment for which hospitalisation was sought was not covered under the policy coverage since it was under the category of congenital anomalies. Vishal had never shown any symptom related to the disease earlier and the doctor has confirmed that the disease was not under the category of congenital defect. He was cheated by the insurance company by denying the claim. He has spent a total amount of Rs. 50,000/-. Hence the complaint for directing the insurance company to settle the claim.
- The opposite parties resisted the complaint by filing written version separately.
- According to the first opposite party insurance company, the contract of insurance is a contract based on the terms and conditions of the policy and they are liable to compensate the complainant only according to the terms and conditions of the policy. The averment that the disease was not in the category of congenital defect is false and hence denied. They had received a request from the hospital for the patient Vishal Vineesh for diagnosis of bilateral retractile testis. But the request for cashless treatment was rejected as a claim was for the ailment, which was an external congenital condition. The claim was again submitted for reimbursement and it was also rejected for the same reason. As per the terms and conditions of the policy, any congenital internal or external diseases, defects or anomalies, genetic disorders are not payable. The claim falls under exclusions of the policy and hence the company is not liable to compensate the complainant. There has been no deficiency in service on their part. With the above contentions, the first opposite party prays for dismissal of the complaint.
- According to the second opposite party, they have only a role of insurance agent and they are not at all connected with the approval or denial of the claims by the insurance company. There is no deficiency of service on their part and they have nothing to do with the allegations in the complaint. They are unnecessary party to the proceedings and the complaint is only to be dismissed.
- The points that arise for determination in this complaint are: 1) Whether there was any deficiency of service on the part of the opposite parties, as alleged? 2) Reliefs and costs.
- Evidence was recorded by our learned predecessors-in-office which consists of the oral evidence of PW1 and Exts A1 to A6 on the side of the complainant. No oral evidence was let in by the opposite parties. Exts B1 to B3 were marked on the side of the first opposite party.
- The first opposite party has filed brief argument note.
- POINT No. 1 : The complainant has approached this Commission with a grievance that the claim put in by him in connection with the treatment of his son Vishal was repudiated by the first opposite party without valid reason. The complainant is the holder of Ext A1 Apollo Munich Health Insurance Policy. The above policy covers the health insurance for the complainant, his wife and son. The period of the policy is from 26/08/2014 to 28/05/2015. On 11/9/2014, the complainant’s son Vishal was admitted in the Malabar Hospital, Kozhikode with complaints of pain scrotum, often excruciating – few months. Occasional wetting. The finding was bilateral retractile testis. Bilateral orchiopexy and scopy was done on 12/09/2014 and he was discharged on 15/09/2014. Ext A4 is the copy of the discharge summary. The total bill amount was Rs. 44,685/-. Ext A5 series are the copies of the bills. The complainant preferred a claim before the first opposite party. The claim was repudiated by the first opposite party as per Ext A6 letter dated 14/10/2014. There is no serous dispute on the above aspects.
- Ext A6 shows that the claim was rejected for the reason that the claim was for an ailment which was an external incongenital condition and it falls under exclusions of the policy. Admittedly, the treatment undergone by Vishal was for bilateral retractile testis. As per Sec 2 Exclusions in Ext B1 policy, the insurance company will not make any payment for any claim in respect of any insured person for any congenital internal or external diseases, defects or anomalies; genetic disorders etc. Congenital anomalies are defined in the section on Interpretations and Definitions. Under definition 6 “Congenital anomalies refers to a condition(s) which is present since birth and which is abnormal with reference to form, structure or position. a) Internal Congenital Anomaly – which is not in the visible and accessible parts of the body. b) External Congenital Anomaly – which is in the visible and accessible parts of the body”.
- Here the ailment of Vishal was an external congenital anomaly condition. The learned counsel for the first opposite party produced the copy of the relevant page of the International Coding Diseases of WHO downloaded from the website, along with the argument notes. It is stated therein that retractile testis falls under the category of “other congenital malformations of testis and scrotum”.
- Nothing is produced by the complainant to show that bilateral retractile testis is not a congenital anomaly. It is stated in the complaint that the doctor has confirmed that the disease of Vishal was not under the category of congenital defect. But no steps were taken to examine the said doctor.
- As per the conditions of the policy any congenital internal or external diseases, defects or anomalies, genetic disorders are not payable. The ailment of Vishal was external congenital condition and the claim of the complainant falls under the exclusions of the policy. That being the position, the insurance company is not liable to honour the claim. The claim was repudiated by the insurance company for valid reasons and no deficiency of service can be attributed against the insurance company. Undoubtedly, the second opposite party has no role in the approval or denial of the claim by the insurance company and there is no allegation of deficiency of service on the part of the second opposite party and no relief is sought against them.
- To sum up, we hold that there is no proof of any deficiency of service on the part of the opposite parties and consequently the complaint must fail.
- Point No. 2: In view of the finding on the above point, the complainant is not eligible to claim and get any relief.
In the result, the complaint is dismissed. However, no order as to costs.
Pronounced in open Commission on this the 30th day of November 2023.
Date of Filing: 25/11/2014
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APPENDIX
Exhibits for the Complainant :
Ext A1 – Copy of Apollo Munich Health Insurance Policy.
Ext A2 – Copy of Apollo Munich Health Insurance premium receipt.
Ext A3 – Copy of Apollo Munich health Insurance ID Card.
Ext A4 – Copy of the discharge summary.
Ext A5 series - Copies of the bills.
Ext A6 –Letter dated 14/10/2014.
Exhibits for the Opposite Party
Ext B1 - Apollo Munich Health Insurance premium receipt.
Ext B2 - Apollo Munich Health Insurance Policy.
Ext B3 – Letter dated 14/10/2014
Witnesses for the Complainant
PW1 - Vineesh.T (Complainant)
Witnesses for the opposite parties
Nil
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