SMT. RAVI SUSHA: PRESIDENT

This complaint has been filed by the complainant against opposite parties to pay an amount of Rs.27,548/- on the basis of the group health policy from the opposite parties  with interest cost and compensation of Rs.50,000/- .

Brief facts of the case are that the complainant is the , holder of “Group Health” Insurance policy of the 1^st OP with policy bearing No.4211-500301-15-500000-00-247(IDNo.5022035490) dated 24/12/2015 for an assured sum of Rs.2,00,000/- for a period from 24/12/2015 to 23/12/2016.  The complainant had paid a sum of Rs.1,529/- as premium for the policy and the policy is styled as TPA and was sold by M/s Muthootu Mini Financiers Pvt. Ltd., the 2^nd OP on the assurance, that the OPs will provide.  Medical assistance for a period of one year from 24/12/2015 to 23/12/2016.  The policy was issued after 4 months of receipt of premium.  As per the terms and conditions of the OP’s insurance policy, the company assured that, if during the period of the policy or during the continuance of the policy by renewal any insured person shall contact any disease or suffer from any illness or sustain any bodily injury through accident, the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person.  On 05/12/2016 the complainant was admitted with the complaint of “pilonidal sinus” to the Tely Medical centre Ltd. Thalassery and he underwent treatment  including Excision of Pilonidal Sinus from the said hospital.  The complainant submits that, as an insured person under the “Group Helath Policy of the OP, he is entitled to get insured sum from the OPs on account of the treatment made to him.  The complainant submit that a total sum of Rs.27548/- was incurred by him for the treatment during the above said inpatient period.  Immediately after the discharge from the hospital the complainant informed the insurance agent of  the OP about the treatment and surgery, and  as per his advice the complainant submitted the claim before the OP with all relevant documents required for disbursing the insurance claim.  But there was no response from the OP.  Whenever the complainant approached to the OP, they dragged the matter by saying lame excuses.  The complainant patiently waited for a reply from the OP but he did not get any result.  From the approach and attitude of the OP, made it clear that they have not intention to give the claim to the complainant as per the “Group health policy”.  Hence the complainant constrained to take legal action against the OP to get the clam amount from the OP.  Thereafter on 17/02/2017 the complainant was caused to send registered lawyer notice to the OP for considering his clam. The OP received  the notice  on 20/02/2017.  But no reply was send by them.  The complainant further submit  he filed a complaint before the insurance ombudsman Kochi as complaint NO.KOC-G-028-1718-0159 ON 05/06/2017 and the same was dismissed by insurance ombudsman Kochi as per the Award dated 28/01/2019.  The complainant further adds that the disease for which he took the treatment is not one coming within the preview of any of the exclusion clauses mentioned in the insurance policy issued by the OP.  Hence the rejection of the complaint by the Ombudsman is an unfair and is supporting to the insurance company.  The complainant is entitled to get a medical claim benefit as an insured  person for an amount of Rs.27,548/- on the basis of the “Group Health Policy” from the OP with interest, cost and compensation towards deficiency of service and unfair trade practice.  Hence this complaint.

            After receiving notices OPs 1 and 2 filed their version separately. OP NO.1 contended that the instant complaint is time-barred.  It is not filed within the stipulated period of two years.  That complainant has not sought the permission of this Honorable Forum U/s 11(2)(b) of Consumer Protection Act 1986 before instituting the present complaint against the answering OP.  The answering OP has no branch office in the Territorial Jurisdiction of this forum hence institution of complaint is not tenable in the eye of law.  OP is submitted that the policy issued subject to certain terms, conditions and exceptions.  Admissibility of any claim under the policy is governed by the terms of the contract.  Since the claim was contrary to the conditions of the policy, claim of the complainant was rejected.  It is submitted that the complainant submitted claim for reimbursement of expenses incurred by him towards hospitalization.  The complainant along with the claim form submitted the medical records.  The complainant was admitted to Tely medical Centre Ltd. for the period from 05/12/2016 to 09/12/2016.  The complainant was diagnosed with infected pilonidal Sinus and had to undergo Excision of the same with rhomboid flap repair.  On examination of the documents it was observed that the complainant was admitted to the Hospital with complaints of swelling, pain, discharge and itching perianal area since 8 months.  He also had past history of pilonidal sinus – I &D done 6 months back. Thus, from the documents submitted by the complainant it was evident that the ailment for which the complainant had undergone treatment had waiting period of 1 year as per terms of the policy.  The policy schedule filed by the complainant on its face has clear mention of the exclusion clausal. In view of the facts and circumstance of the case, the claim of the complainant was denied vide email dated 07/01/2017.

            OP No.2 submitted that  all the allegations in complaint are denied. The complainant was enrolled into the Live Health plan of 1st OP for one year.  The 2^nd OP do not provide any medical assistance.  Claim settlement and similar services are exclusively within the jurisdiction of 1^st OP and the company only co-ordinates with the insurance company and customers. The other allegation that the enrolled policy was issued on the same day itself, the allegation made in contravention is specifically denied.  The application was made on 23/12/2015 and the policy started from 24/12/2015.  All pertaining documents are supplied on the same day itself.  The policy comes with exclusions and those exclusions are not covered in the 1^st year which was clearly mentioned to the customer when the policy was issued.  The complainant is aware about the said exclusion.  The complainant was admitted to Telly Medical centre, Thalassery, and was treated “Pilodial Sinas” for one of the disease which is in the exclusion of the policy.  Claim settlement and similar services are exclusively within the jurisdiction of 1^st OP and policy holder.  Complainant has to approach OP1 for all claim settlement related issues. The OP 2 is not aware about the communications between OP1 and complainant. There is no violation of the terms of the insurance policy, negligence or deficiency in service as alleged by the complainant.  The Insurance ombudsman has rightfully dismissed the complaint as the ailment and consequential hospitalization falls in the exclusion clauses of the insurance policy.  The OP2 is not liable to compensate the complainant for any of the claim made in his prayers. .  It is submitted that since there is no deficiency in service on his part, prays for the dismissal of complaint.

            At the evidence stage complainant has filed chief-affidavit and documents.  He has been examined as Pw1 and marked Ext.A1 to A13.  Pw1 has been cross-examined for OP No.1.  OP No.1 submitted  documents  and were marked as Ext.B1 to B7.  After that the learned counsels of complainant and OP No.1 filed written argument notes.  We have perused the documents terms and conditions of OP No.1 in the insurance policy issued to the complainant and the submissions of the parties in this case.

            The learned counsel for the OP No.1 submitted that present complaint is not maintainable as it is time-barred.  OP 1 submitted that the complaint was filed after the stipulated time of two years.  Further submitted the since the OP No.1 has no branch office within the territorial jurisdiction of this commission, this commission does not have territorial jurisdiction to adjudicated this case.  Another plea of OP No.1 is that as per the terms of the policy the ailment for which the complainant had undergone treatment had waiting period of 1 year.  The learned counsel of OP NO.1 submitted that due to the above said contentions, this compliant is liable to be dismissed.  On the other hand, learned counsel for the complainant submitted that the disease for which he took the treatment is not one coming within the purview of any of the exclusion clauses mentioned in the insurance policy issued by the OP.  Hence the rejection of the claim of complaint is deficiency in service and unfair trade practice.  Complainant claims that he is entitled to get the medical claim benefit for his treatment. 

            It is not disputed that the complainant had undergone treatment for Pilonidal sinus for a period from 05/12/2016 to 09/12/2016.  The 1^st plea raised by the learned counsel of OP is that the present complaint is a time-barred one.  It is not filed within the stipulated period of two years.

            On perusal of the record, it is revealed that the cause of action for filing the consumer complaint arose on 05/12/2016, the date on which the complainant was admitted to the Tely medical center for the treatment of excision of pilonidal sinus.  The insurance claim was made on 17/12/2016 and it also stood repudiated by the OP vide e-mail dated 07/01/2017.  Consumer complaint was filed on 10/05/2019 ie after a period of two years prescribed under Consumer Protection Act.  Thus the consumer complaint filed without any application for condonation of delay, no cognizance could have been taken.  Hence complaint is liable to be dismissed on that account.  Next question to be decided is whether the disease to which complainant availed treatment comes under the exclusion clause?  As per the policy terms and conditions submitted from the side of OP No.1 part III Exclusions 3 as “During the 1^st year of the operation insurance cover of the Insured person (s) with Us, the expenses on treatment of diseases such as Cataract, benign Prostatic Hypertrophy, Henrnia, Hydrocele, Fistulain anus, piles, Sinusitis and related disorders, Fissure Gastric and Duodenal ulcers, gout an rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); Hysterectomy/myomectomy for menorrhagia or fibromyoma or prolapsed of uterus, polycystic ovarian diseases ; sinusitis and related disorders and skin tumors unless malignant benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&c); Congenital Internal Diseases, Joint Replacement due to Degenerative condition, surgery for prolapsed intervertebral disc unless arising from accident, Age related osteoarthritis and Osteoporosis, Surgery of varicose veins and varicose ulcers, Calculus diseases of Gall bladder and Urogenital system.”

            Considering the terms and conditions of the policy, the disease of complainant comes under the waiting period of one year as stipulated in the policy.  Hence the repudiation of claim made by OP NO.1 is justifiable and hence there is no deficiency in service on the part of OPs.

So as far as the other aspect is concerned, there is no deficiency of service on the part of OP No.2.

            In the result complaint fails and hence it is dismissed.  No order as to cost.

Exts

A1-Claim forms

A2- Acknowledgement card dated 23/12/2017

A3-Postal receipt

A4(series)- Acknowledgement card

A5- Reply notice

A6- Ombudsman order

A7- Dismissal order of ombudsman

A8- General Insurance policy

A9- Terms and condition

A10- Discharge summary

A11- Claim form part A

A12- Lawyer notice

Pw1-Complainant

Pw2-Father of the complainant

B1-    Claim form

B2-Certificate of insurance

B3-Medi Assist Insurance  denial of claim

B4- Discharge summary  (Tely Mdical centre Ltd.)

B5-  Attested copy of the Grup Health policy

B6-Ombudsman complaint

B7-Self contained note

      Sd/                                                                          Sd/                                                     Sd/

PRESIDENT                                                                   MEMBER                                                   MEMBER

Ravi Susha                                                               Molykutty Mathew                                     Sajeesh K.P

(mnp)

/Forward by order/

Assistant Registrar