Kerala

Idukki

CC/15/2019

Dileep k p - Complainant(s)

Versus

Oriantel Insurance Co ltd - Opp.Party(s)

27 Apr 2023

ORDER

 

DATE OF FILING : 25/01/2019

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 27^th day of April 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.15/2019

Between

Complainant                            :   Dileep K.P.,

                                                     Kandananickal House,

                                                     Muthalakkodam P.O., Thodupuzha.

                                                          (By Adv.K.M.Sanu)

                                                           And

Opposite Party                  :   1 .  The Regional Manager,

                                                    Oriental Insurance Co.Ltd., Regional Office,

                                                    Jyothi Super Bazar, Thodupuzha P.O.

                                               2 . The Manager,

                                                    Oriental Insurance Co.Ltd.,

                                                    Kadavanthra P.O., Kochi 20.

                                                    (Both by Adv.Watson A.Mazhuvannoor)

                                               3 . The Manager,

                                                     M/s Good Health TPA Series Ltd.,

                                                     1HK Building, Opposite Vidyanikedhan  

                                                     College, Providence Road,

                                                     Ernakulam – 682 018.

                                                             

O R D E R

SMT.ASAMOL P., MEMBER

 

Facts of the case is discussed hereunder:-

 

1 . Complainant is an account holder in Punjab National Bank.  He has been taking   mediclaim   policies   for   many   years.    Opposite  parties   have

(Cont.....2)

 

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implemented health insurance policy as PNB-Oriental Royal Medicalim policy jointly with Punjab National Bank and they assured that more coverage with less premium.  Accordingly, since an account holder of this bank, complainant was a member in this policy.

  2 . Thus, complainant has taken this policy for the period from 06/12/2017 to 05/12/2018 with paying the premium of Rs.6070/-.  As per this policy, insurance coverage was Rs.4 Lakhs for treatment expenses of complainant and his family members.

3 . During the validity period of this policy, on 30/10/2018, complainant has gone to Kolencheri Medical College since he was suffering from severe stomach pain and on detailed examination, it informed that surgery is necessary because he has kidney stone and accordingly, from 02/11/2018 to 06/11/2018, he was admitted there and surgery was done and Rs.33,000/- was incurred for the treatment.

4 . It was informed to opposite parties that complainant was admitted in hospital and he had claimed cashless facility as per the policy.  But opposite parties were not ready to give it due to the reason that Kolencheri Medical College Hospital was not in their list.

5 . After discharging from hospital, complainant had submitted claim application along with necessary documents to opposite parties.  But,  opposite parties were not ready to give claim amount.  Complainant has taken this mediclaim policy which is having cashless facility, as he was unable to meet unforeseen medical expenses.

6 .  Denial of the claim amount as per the policy is deficiency in service on the part of opposite parties.  Therefore, complainant is entitled to get compensation from opposite parties.  Hence he has prayed the following 

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reliefs.

1. Opposite   parties may be directed to pay Rs.33,000/- as treatment expense along with 18% interest to complainant.
2. Opposite parties may be directed to pay Rs.50,000/- as compensation and Rs.10,000/- as litigation cost to complainant.

Upon notice served from the Forum, 1^st and 2^nd opposite parties have appeared and filed written version.  3^rd opposite party has not appeared before the Forum.  Hence 3^rd opposite party was set exparte.  The contentions of 1^st and 2^nd opposite parties are briefly discussed hereunder:-

1 . This complaint is not maintainable either in law or on facts of this case against this opposite parties.  This complainant has no cause of action against this opposite parties.

2 . It is admitted that this opposite party issued a Medi-claim policy No.440202/48/2018/7638 for the period from 06/12/2017 to 05/12/2018 in the name of Deelep K.P, Kandananickel, Muthalakodam P.O., Thodupuzha.  The complaint, his wife Mini K.S., and dependent child, Gourinandanad covered by this  policy subjected to terms and conditions in the policy and sum insured is Rs.4,00,000/-.

3 . As per the conditions of policy that the above claim is not admissible on the following reasons.  It is a case of Right Mid Ureteric Calculus.  As per records the patient is covered in the policy since December 2017.  As per clause 4.2, calculus decease is not covered under the policy for first two years.  The policy is fresh one and hence claim is not payable under clause 4.2.  The complainant admitted in the Hospital on 02/11/2018 and discharged on 06/11/2018.  The inception of the policy is on 06/12/2017 and the patient admits in the Hospital is on 02/11/2018.  Therefore the disease         

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contracted by patient within two years of inception of the policy. Therefore, the expenses on treatment for disease contracted by patient is not covered by policy, claim is not payable under the policy.  The claim of the complainant is not covered by the policy.  Hence the complaint is not maintainable as per the conditions of the policy.  It is true that the complainant had preferred a claim.  But 1^st  opposite party has given a reply repudiating  his claim stating the reason on 22/02/2018.

4 . To prove the terms and conditions of the contract of insurance, a certified true copy of policy No.440202/48/2018/7638 is filed.

5 . The allegation of deficiency in service are wholly misconceived, groundless, false, untenable in law besides being irrelevant having regard to the facts and circumstance.  The claim of the claimant is repudiated on the ground that the claim is not covered as per clause 4.2 of the policy.  So there is no deficiency in service on the part of the opposite parties in repudiating the claim Rs.33,000/- claimed towards treatment expenses is excessive and the opposite parties are not liable to pay the said amount as per the conditions of the policy.  The claimant is not entitled to interest at the rate of 18%.  Since here is no deficiency in service, the opposite parties are not liable to pay compensation of Rs.50,000/-.  Therefore the complainant is not entitled to get Rs.33,000/- under the Medi-Claim policy, Rs.50,000/- as compensation for the deficiency in service and Rs.10,000/- as costs from the opposite parties.

Hence, the complaint may be dismissed against these opposite parties.

Thereafter, the case was posted for evidence of complainant.  Complainant has filed proof affidavit and documents.  Exts.P1 to P7 were

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marked.  Complainant was examined as PW1.  Proof affidavit of 1^st and 2^nd opposite parties were filed.  DW1 was examined.  Exts.R1 and R2 were marked. 

Heard the counsels for both sides.  Thereafter, it was taken for orders.  Now the points which arise for consideration are:-

1. Whether there is any deficiency in service on the part of opposite parties?
2. If so, what reliefs the complainant is entitled to?

 

Points are considered together

 

We have perused the proof affidavit and evidence on record.  It is proved that complainant has taken mediclaim policy from opposite parties for the period from 06/12/2017 to 05/12/2018 with premium amount of Rs.6,070/- under Exts.P1 and R1 documents.  Complainant was admitted in MOSC Medical College Hospital, Kolenchery on 02/11/2018 and he was discharged on 06/11/2018 ie, within the validity period of this policy.  As per Ext.P3, it is seen that complainant was diagnosed with Right MID Ureteric Calculi, AKI and surgery was done during this admission period.  Complainant has produced  discharge bill ie, marked as  Ext.P4.  as per this document,  complainant has paid total bill amount Rs.32,150/-.  Complainant alleges that opposite parties have neither given cashless facility nor claim amount  thereafter also as per the policy.  According to opposite parties, they have repudiated the claim amount because of a case of Right Mid Ureteric calculus diseases  is not covered in the policy for two years as per policy conditions clause 4.2 .  Complainant’s policy  is  new  and  the  claim  is  not  

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payable  under  Clause  4.2.   Policy condition was produced and marked as Ext.R2.  We have perused it and seen   as per this exclusion clause that the expenses on treatment of calculus diseases for 2 years are not payable if contracted or manifested during the currency of the policy and if the continuity of the renewal is not maintained with the company, then subsequent cover shall be treated as fresh policy and clauses 4.1, 4.2 shall apply unless agreed by the company and suitable endorsement passed on the policy.  It is mentioned in Ext.P1 that portability from other policies is not available and previous policy number is not stated also.  Therefore, it can be considered as a new policy.  Even though complainant has produced Ext.P6 for proving the continuity of the policy, it is seen that these earlier policies were for the period from 25/11/2015 to 24/11/2017.  The ending period of this previous policy was 24/11/2017.  Thereafter, complainant has taken the current insurance policy for the period from 06/12/2017 to 05/12/2018.  From this, we have understood that this current policy was not being continued of the earlier policy.  Moreover, complainant alleges that since he was an account holder of Punjab National Bank, on the assurance of them that more coverage with less premium, he was inspired to join this policy.  Here complainant has not added Panjab National Bank as a party in this complaint and also it is not proved that, the bank had given such assurance to him.  Even though complainant has produced Ext.P6 and P7, there is no evidence adduced to prove the contents of these documents and the issuing authority ie, manager was neither listed as a witness nor he examined before this Commission.  Therefore, it is not proved that on the basis of which of the records he perused and issued these Exts.P6 and P7 certificates.  Moreover, as per these documents, it is not proved that this policy was in continuous period from the earlier policies.  According to opposite parties, they have

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issued Ext.R1 ie, a letter to complainant that informed the claim is not admissible because, calculus disorders are not covered in the policy for first two years as per clause 4.2.  On the basis of perused documents, we can only consider this policy as a fresh policy.  Accordingly, claim was repudiated by opposite parties.  Therefore, we are of the opinion that there is no deficiency in service on the part of opposite parties.  Hence, as per this policy complainant is not entitled to get the claim amount from opposite parties.  In the light of the above circumstances, complaint is dismissed without costs.

Extra copies to be taken back by parties without delay.

 Pronounced by this Commission on this the 27^th  day of April, 2023.

 

                                                                                        Sd/-

                                                                                SMT.ASAMOL P., MEMBER                                                                                                           

                                                                                                  Sd/-                                                                        

                                                                        SRI.C.SURESHKUMAR, PRESIDENT                                                                                                

                                                                                                   Sd/-                                                                             

                                                                                 SRI.AMPADY K.S., MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

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APPENDIX

Depositions :

On the side of the Complainant :

PW1 – Dileep K.P.

On the side of the Opposite Party :

DW1- Jimmy Mathew

Exhibits :

On the side of the Complainant :

Ext.P1  -  PNB –Copy of Oriental Royal Mediclaim Policy Schedule.

Ext.P2  -  Copy of  the Oriental Insurance Co.Ltd card

Ext.P3  -  Copy of discharge summary of Urology department.

Ext.P4  -  Discharge Bill dated 06/11/2018

Ext.P5  - Copy of Claim Form

Ext.P6  - To whomsoever it may concern dated 04/06/2019

Ext.P7  - Certificate of Indian Overseas Bank dated 10/06/2019

Ext.P8 – Copy of Happy Family Floater -2015 Policy Schedule

On the side of the Opposite Party :

Ext.R1 – The oriental Insurance Co.Ltd., without prejudice dated 22/12/2018.

Ext.R2 – Copy of PNB- Oriental Royal Mediclaim Policy Schedule

 

 

                                                                                               Forwarded by Order  

 

 

                                                                                          ASSISTANT REGISTRAR