IN THE KODAGU DISTRICT CONSUMER DISPUTES REDRESSAL FORUM MADIKERI

SRI. C.V. MARGOOR,PRESIDENT

O R D E R

1. This complaint filed by Sri.Ravi.P.M s/o.Mani, aged 29 years, resident of Nellihudikeri Village, Siddapur, Kodagu District against the New India Assurance Company Limited, Madikeri branch with a prayer direct the opponent to pay a sum of Rs.54,671/- with interest at the rate of 18% per annum from the date of complaint till the date of realization.

2. The complainant had obtained a Universal Health Insurance Policy from the opponent bearing No.67240234171900000048 to him, his wife Smt. Arathi and children Rakshith and Rohith for health and medical requirements.  The policy was in force from 21/07/2017.

3. It is stated in the complaint that the complainant has fell ill and took treatment at Sacred Heart Hospital, Siddapur and then at Kasturaba Medical College Hospital at Mangalore.  The complainant was treated in the said hospital from 02/08/2017 to 14/08/2017 and spent Rs.24,671/-.  The complainant has submitted claim application for reimbursement of the medical expenses but the opponent has repudiated the claim on untenable reason.  The complainant has sought total sum of Rs.54,671/-  which includes medical expenses, travelling, attendant, miscellaneous and cost of this proceedings. 

4. The opponent filed written statement/ version admitting that the complainant had obtained a Universal Health Insurance Policy from this opponent which was in force from 21/07/2017.  The opponent further admitted that the complainant has preferred the claim application for reimbursement of medical expenses but the opponent has repudiated the claim on the exclusion clause of the policy that all diseases contracted during the first 30 days of commencement of the policy from 21/07/2017 and admitted to hospital on 02/08/2017 within 12 days of the commencement of policy for the treatment of Leptospirosis with Klebsiela pneumonia with Pyelonephritis.  Therefore, the opponent has repudiated the claim of the complainant and repudiation is proper.  On the above grounds, the opponent prays to dismiss the complaint.

5. The complainant filed his affidavit in lieu of evidence and got marked exhibits P1 to 9 documents.  On behalf of opponent its Manager K.C. Chandran s/o. late Chappan filed affidavit evidence and got marked exhibits R1 and R2.  Heard the arguments advanced by the learned counsel for both the sides and points that would arise for determination are as under;

1. Whether the complainant proves that the act of opponent repudiating his claim is improper and amounts to deficiency in service?

2. What order?

6. Our findings on the above points is as under;

• Point No.1:- In the Affirmative
• Point No.2:-  As per final order for the below

R E A S O N S

7. The learned counsel for the complainant  submitted that disease mentioned in the version is not a disease but the complainant was suffering from fever two days prior to admitting as inpatient in Kasturba Medical College Hospital, Mangalore.  The opponent without any justifiable cause has repudiated the claim.  As against this the learned counsel representing the opponent vehemently argued that the complainant has contacted disease within 30 days from the date of taking health policy as such he is not entitled for medical claim since his claim falls under exclusion clause of the policy condition.  The learned counsel for the opponent made alternative submission that the complainant is not entitled for entire medical expenses of Rs.24,000/-,travelling and other expenses in terms of policy condition.

8. The opponent in the written statement as well as affidavit evidence admitted the fact that the complainant has obtained Universal Health Insurance policy covering from 21/07/2017 to him, his wife and kids.  The opponent has not disputed taking treatment by the complainant for the alleged disease from 02/08/2017 to 14/08/2017 at Kasturba Medical College Hospital, Mangalore.  Exhibit P1 is policy document issued by the opponent covering the health of the complainant, his wife and kids from 21/07/2017 to 20/07/2018.  Exhibit P2 is discharge summary issued by KMC Hospital, Mangalore.  According to this the complainant was admitted on 02/08/2017 and discharged on 14/08/2017 and history of the patient is that the complainant was suffering from fever since two days  prior  to 02/08/2017, intermittent, progressive, associated with chills and rigor, associated with decreased appetite and with throat pain.  No history of burning micturition, vomiting, pain abdomen, decreased urine out put, malena and bleeding manifestation.  Doctor has finally diagnosed that the complainant has leptospirosis with Klebsiella Pneumonia with  Pyelonephphritis.  Exhibit P7 is medical bill issued by Kasturaba Medical College Hospital for a sum of Rs.24,671/- for the treatment to the complainant from 02/08/2017 to 14/08/2017.

9. The opponent has produced exhibit R1 Universal Health Insurance Policy document to the complainant and clause 4.2 of exclusions says that any disease other than those stated in clause 4.3, contracted by the insured person during the first 30 days from the commencement date of the policy.  Note to clause 4.2 says that these exclusions 4.1 and 4.2 shall not however apply, if ;

1. In the opinion of Panel of Medical Practitioners constituted by the Company for the purpose, the Insured person could not have known of the existence of the Disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the Company, AND

2. Insured had not taken any consultation, treatment or medication in respect of hospitalization for which claim has been lodged under the policy prior to taking the insurance.

On plain reading of exclusion clause 4.2 it is not applicable to the complainant.  Firstly the opponent has not got examined the complainant by the panel of Medical Practitioners constituted by the company.  Secondly, the complainant had not taken any consultation, treatment etc in respect of hospitalization prior to taking the insurance policy.  The discharge summary of KMC Hospital indicates that the complainant was admitted to the hospital with history that since two days prior to his admission he was suffering from fever etc.  It is nowhere mentioned in the discharge summary that prior to taking policy on 21/07/2017 or admitting in the hospital the complainant was suffering from any disease or took treatment. Therefore, the said exclusion clause is not at all applicable to the case on hand.

10.  The learned counsel for the opponent brought to the Forum notice the benefits which are available to the complainant under this policy.  According to Section 1 of policy terms total expense incurred for any one illness is limited to Rs.15,000/-.   Companies liability in respect of all claims admitted during the period of insurance shall not exceeds the sum insured of Rs.30,000/- per person or family as mentioned in the schedule .  According to exhibit R1 policy details coverage i.e. hospital benefits Rs.30,000/- .  In view of terms and conditions of exhibit R1 policy the complainant is entitled to the maximum extent of Rs.15,000/- though he has incurred Rs.24,000/- for his treatment at KMC Hospital, Mangalroe.  Therefore, the opponent shall liable to pay a sum of Rs.15,000/- as medical expenses to the complainant.

11. The opponent in the written statement para No.3 admitted that the complainant preferred the claim for reimbursement of medical expenses who has taken medical treatment in Kasturaba Medical College Hospital, Mangalore from 02/08/2017 to 14/08/2017 claiming reimbursement of Rs.24,671/- along with claim form dated 30/08/2017.  It shows that the complainant has submitted claim form within 10 days from the date of discharge from the hospital.  Further the complainant has sent reminders to the opponent on 31/08/2017 and 05/09/2017 through Courier vide exhibits P9 and P9A document.  The opponent insurance company inspite of the claim form and reminders sent by the complainant did not take any action.  Therefore, the complainant has approached this Forum on 29/01/2018.  Even after filing the complaint and receipt of this complaint notice by the opponent on 21/02/2018 neither paid the claim amount nor intimated action taken on the claim form. 

12. The opponent in the written statement paragraph no.6 has come up with a plea that it has repudiated the claim of the complainant and intimated him vide exhibit R2 letter dated 16/03/2018.  The opponent has repudiated the claim 48 days after filing the complaint and nearly one month after the receipt of notice from this Forum.  The complainant has submitted claim form on 30/08/2017 and the opponent did not take action five months from the date of submitting claim form then the complainant has to approach this Forum.  This shows the utter negligence on the part of opponent in discharging service to the complainant.  Therefore, the opponent shall liable to pay a sum of Rs.15,000/- as cost of this proceedings to the complainant.  For the above reasons, we proceed to pass the following;

O R D E R

1. The complaint filed by Mr. Ravi. P.M s/o. Mani is partly allowed directing the opponent to pay a sum of Rs.15,000/- as medical expenses to the complainant with interest at the rate of 15% per annum from 15/08/2017  till its realization.  
2. In addition to that the opponent shall liable to pay a sum of Rs.15,000/- as cost of this proceedings within two months from the date of order.  In case the opponent fails to pay the said amount of Rs.15,000/- it carries interest at the rate of 15% per annum from the date of filing the complaint till realization.
3. Furnish the copy of the order to the complainant and opponent at free of cost.

(Dictated to the Stenographer, got it transcribed, corrected and pronounced in the open Forum on this 19^th day of JANUARY, 2019)

                                                  (C.V. MARGOOR)

                                                      PRESIDENT 

                                                (M.C. DEVAKUMAR)

                                                        MEMBER