By Sri.P.K,.Sasi, President
The case of the complainant is that he has taken a medi claim family package policy with the opposite party from 2001 onwards. He used to renew that policy till this date. As per that policy if the complainant or his family members are treated as inpatient for more than 24 hours in any hospital the treatment expenses will be reimbursed by the opposite party.
2. The complainant admitted at Ernakulam Lissie hospital for the treatment of removing stones from kidney. He has undergone treatments on five occasions in between 13/9/10 to 29/12/10. Total 23 days he has treated as inpatient and he has also incurred an amount of Rs.50,000/- for the treatments. A claim was submitted with all supporting treatment records. But the opposite party denied and repudiated the claim, by stating that the policy period is not completed 2 years, hence excluded as per 4.3 of the policy condition. The rejection of the claim is illegal which amounts to deficiency in service on the part of the opposite party. Hence this complaint is filed for getting the treatment expenses with compensation.
3. Being noticed on the complaint, the opposite party entered appearance through counsel and filed detailed version. The opposite party has admitted that a medi claim policy was issued in the name of complainant for the period from 11/8/10 to 10/8/11. But the opposite party has denied all other allegations stated in the complaint against the opposite party. It is also admitted by the opposite party that the complainant has preferred five claims for different periods of hospitalization for the treatment of same disease. The claims were verified by the third party administrator and reported that all the treatments were pertaining for calculus disease, which is excluded from the scope of the policy for the first 2 years as per clause 4.3 of the policy. The opposite party has stated the details of the policies issued by them to the complainant. According to the opposite party there were breaks between the periods of policies. Therefore, the policies cannot be considered as continuous policy. Hence the policies were treated as fresh policies. The opposite party specifically denies that the complainant was a policy holder continuously, for the last 12 years. According to the opposite party they have not committed any deficiency in service or unfair trade practice towards the complainant and prayed for the dismissal of the complaint with cost.
4. Then the case was posted for evidence and the points for consideration are that :
1) Whether the complainant was entitled to get any benefit under the policy ?
2) Whether the opposite party has committed any deficiency in service ?
3) If so what costs and reliefs ?
5. From the side of complainant, he has filed proof affidavit, in which he has affirmed and narrated all the averments stated in the complaint in detail. He has also produced six documents which are marked as Exts.P1 to P6. Ext.P1 is brochure of medi claim insurance; Ext.P2 to P6 are different pre-repudiation statement.
6. From the side of opposite party, the Divisional Manager filed counter proof affidavit in which he has affirmed and explained all their contentions raised in the version in detail. He has also produced eight documents which are marked as Exts.R1 to R8. Ext.R1 series (4Nos.) are policy certificates with terms and conditions, Ext.R2 is letter issued by the complainant dated 27/4/11, Ext.R3 is repudiation statement dated 8/2/11, Ext.R4 series(2 Nos.)are claim rejection/repudiation statement dated 22/1/11, Ext.R5 is copy of medi claim medical report dated 20/10/10, Ext.R6 is copy of claim form, Ext.R7 is copy of medi claim medical report and Ext.R8 is copy of claim form. Both sides filed detailed argument notes and we heard in detail also.
7. The case of the complainant is that, being a medi claim insurance policy holder, he is entitled to get the medical expenses incurred for his treatments from the opposite party. But the opposite party has denied the claim without any genuine reason and cause. According to the opposite party the main contention raised is that there was no continuation of the policy, hence the claim submitted by the complainant is excluded as per clause 4.1,4.2 and 4.3 of the policy condition.
8. We have gone through the contents of the affidavits as well as the contents of the documents produced from both sides. A chart of four policies are stated in the version as well as in the counter proof affidavit filed by the opposite party. It would go to show that there are breaks happened in the renewal of the policies. We have thoroughly examined Ext.R1 series. The latest policy among Ext.R1 bears previous policy No.828. The period of that policy was 11/8/10 to 10/8/11. Previous policy was for the period 11/8/09 to 10/8/10. That policy bears policy No. as 828 and previous policy No. shown as 567. Another policy was for the period 10/7/08 to 9/7/09 which bears policy No.567, whereas no previous policy No. is stated. It would go to show that the latest policy numbered 938 is a continuation of policy No.567. Since this policies are continuation of that policy the previous policy numbers are specifically mentioned on those policies. That means the policy can be considered as effective from 10/7/08 to 10/8/11. Here the opposite party has considered the policy is valid from 11/8/09 only instead of considering 10/7/08. That is why the claim was happened to fall under the exemption clause 4.1 to 4.3. The continuity of the renewal of the policies are maintained with the same company. Therefore, we are of the opinion that however, the complainant undergone treatment for calculus disease, he is entitled to get the policy benefits.
9. The case of the complainant is that he has undergone treatment for removing stones from the kidney on five occasions and he submitted five claims before the opposite party. It is also admitted by the opposite party that the complainant has submitted five claims. But only two claim forms are seen produced before the Forum and marked as Exts.R6 and R8. The reason for non-production of other claim forms is best known to the opposite party alone. The claim of the complainant is that he has incurred an expense of Rs.50,000/- for his treatments. But there is no supporting evidence produced before us. Ext.R6 is for an amount of Rs.9,000/- and Ext.R8 is for an amount of Rs.8,000/-. In total claim for Rs.17,000/- is seen submitted by the complainant, as per the materials available before us.
10. The main argument raised from the side of complainant is that if the opposite party has considered the policies as a separate and fresh policies, separate proposal forms also would have been signed and submitted by the complainant and that is not seen produced by the opposite party. That itself would go to show that these policies were continuous policies and only for denying the claim, the opposite party has raised an objection by stating that there was break in renewal of the policies. Since, there is no contra evidence adduced from the side of opposite party regarding this point of argument raised by the complainant, we are inclined to accept the claim of the complainant that the policy was a continuous policy for more than two years and he is entitled to get the benefit of the policy. The denial of that amounts to deficiency in service on the part of the opposite party.
11. In the result we allow this complaint in part and the opposite party is directed to pay Rs.17,000/- (Rupees Seventeen thousand only) covered under Exts.R6 and R8 with 9% interest from the date of complaint to the complainant within one month from receiving copy of this order. Failing which, he is entitled to get 9% interest till realization.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 29th day of February 2016.
