Present: 1. Sri.P.K.Sasi, President.
2. Smt. Sheena.V.V, Member.
3. Sri.M.P.Chandrakumar, Member
7th day of March 2015
C.C.153/11 filed on 23/3/11
Complainants: 1. Anoop antony, Akkara House,West Bazar,
Ollur.P.O.
2. Lincy.M.V., W/o.Anoop Antony, Akkara
House,West Bazar,Ollur.P.O.
(By Adv.A.D.Benny, Thrissur)
Respondents: Manager, Divisional Office, National Insurance Co.
Ltd., Kollannur Devassy Smarak, Round East,
Thrissur.
(By Adv.M.Sathyanadhan, Thrissur)
O R D E R
By Sri.P.K.Sasi, President :
The 2nd complainant is the wife of 1st complainant. The case of complainants are that they have incepted Gramin Suswasthya Micro Insurance Policy (Medi claim policy) with the opposite party on 21/7/10. The policy covers upto 20/7/11. During that period the 2nd complainant was admitted and treated at Amala Institute of Medical Sciences, Thrissur from 9/10/2010 to 21/10/2010. The 2nd complainant was pregnant at the time of incepting the policy. She was taken to the hospital for periodical check up but the doctor found that she was having high BP which was associated with pregnancy and she had post partum eclamp-sia and the 4th day her child died and a claim for Rs.43,000/- was submitted before opposite party. The claim was repudiated by opposite party stating that as per the policy condition No.1.3 a waiting period of nine months is a must. That was not complied in this case. Hence the claim is not admissible. Against that repudiation this complaint is filed.
2. Opposite party enters appearance and filed a detailed version by admitting the policy and denying all other allegations. It is clearly stated in the version that repudiation was proper and legal, since condition No.1.3 in the terms and conditions of the policy strictly denies the admission of complainants claim. The 2nd complainant was in an advance stage of pregnancy when she has taken the policy. The delivery has taken place on 14/10/10 and as 9 months waiting period in respect of maternity was not complied. The expenditure stated in the complaint is for Rs.43,000/-. But the claim submitted by complainant was only for Rs.38,705/-. There was no deficiency in service on the part of opposite party in repudiating the claim of complainants. Hence the complainants are not entitled to get the amount and compensation as prayed in the complaint.
3. Points for consideration are that :
1) Whether there was any deficiency in service on the part of opposite party?
2) What costs and reliefs ?
4. The case was posted for evidence and from the complainants side the 1st complainant was examined as PW1 and Exhibits P1 to P5 documents were marked. Exhibits R1 to R7 marked on the side of opposite party and no oral evidence adduced from their side
5. The complainants filed proof affidavit stating all the facts stated in the complaint. 1st complainant was cross examined by opposite party’s counsel. He admitted that his wife was pregnant while taking the policy. The incident happened in the 6th month of her pregnancy. The treatment conducted was not in related to the delivery. Their claim is not for delivery benefits but for the treatment conducted during the period of hospitalization. He also stated that the repudiation is not proper and is illegal.
6. By perusing the documents produced from both sides it is seen that the 2nd complainant has hospitalized from 9/10/10 to 20/10/10 for some treatment related to her pregnancy. There is no evidence adduced before us to show that it was a premature birth. It was a caesarian case and the child was dead. But as per the policy the medi claim sum insured for each family is Rs.25,000/- and personal accident sum insured for each family also Rs.25,000/-. Here as per Exhibit R2 medi claim medical report only blood investigation was conducted to the patient. No other details stated. In Exhibit R1 the policy claim form the room rent for the period of treatment shown as Rs.5,160/-, expenses for anesthesia Rs.3,850/-, for medicines and diagnostic tests Rs.21,797.83 and as a total of Rs.30,807.83.
7. There is nothing stated in the complaint regarding the treatment underwent by the 2nd complainant during the period of hospitalization. And nothing is stated for which they are claiming the amount and under what head they are claiming the amount. If it is for the delivery expenses, as per the policy condition they are entitled to get only a maximum amount of Rs.3,500/-. Here in this case the treatments conducted are relating to the caesarian delivery. So the maximum amount entitled to get by the complainant is Rs.3,500/- only.
8. However, the claim is submitted before the waiting period mentioned in the policy condition, considering the unavoidable circumstances humanitarian consideration under which the 2nd complainant has under gone caesarian delivery, we are of the opinion that she is entitled to get the benefits for the caesarian delivery as per the policy. At the same time it cannot be say that the claim was repudiated illegally. So we find no deficiency in service on the part of opposite party.
9. In the result we allow the complaint in part and the opposite party is directed to pay Rs.3,500/- (Rupees Three thousand and five hundred only) to the complainant with 12% interest from the date of complaint with a cost of Rs.2,000/- (Rupees Two thousand only) within one month from the date of receiving of copy of this order.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 7th day of March 2015.
Sd/- Sd/- Sd/-
M.P.Chandrakumar Sheena.V.V. P.K.Sasi, Member Member President.
Appendix
Complainant’s Exhibits
Ext.P1 Copy of insurance policy
Ext.P2 Copy of repudiation letter
Ext.P3 Copy of lawyer notice
Ext.P4 Acknowledgement card
Ext.P5 Copy of discharge summary card
Complainants witness
PW1 – Anoop Antony
Opposite Party’s Exhibits
Ext.R1 Policy claim form
Ext.R2 Mediclaim Medical report
Ext.R3 Discharge summary card
Ext.R4 Medical bills
Ext.R5 Lr. dt. 14/12/10
Ext.R6 Lr. dt. 27/10/10
Ext.R7 Copy of policy with terms and conditions
Id/-
President
