Complainant: Beena Shaju, Kallukaran House, P.O.Alagappa Nagar,
Amballoor, Thrissur.
(By Adv.K.Arunkumar Kaimal, Thrissur)
Respondents: 1. United India Insurance Co. Ltd., UIBO Chalakudy,
Srikumar Building, South Junction, Kochi.
2. United India Insurance Co. Ltd., Thrissur Branch,
Thrissur.
(By Adv.Sija Rajan, Thrissur)
O R D E R
By Smt.Padmini Sudheesh, President:
The case of complainant is that the complainant had taken a medi claim policy from the respondents and the policy has family coverage. After the policy the complainant had to undergo thyroid operation. After the operation it became known that the complainant has cancer in thyroid and so advised to remove the portion affected by cancer. So she had to undergo another operation for removal of cancer affected part of thyroid. After the second operation the complainant preferred for the medical charges of the 2nd operation. She submitted claim and the same was repudiated by respondents stating it to be pre-existing. This act of respondents is deficiency in service. Hence the complaint.
2. The counter is filed by respondents to the effect that in this complaint the complainant is not specified the details of the disease and what type of treatment advised by the doctor, even the amount of medical bills are not stated in the complaint. Hence the complaint is vague and incomplete. Some of the diseases are excluded from the coverage of medi claim. The treatment is for thyroid and it is not a sudden disease, it may develop after a long period. So it is preexisting and will not come under the coverage. Hence dismiss.
3. Points for consideration are that:
1) Whether there was any deficiency in service committed by respondents?
2) If so reliefs and costs?
4. Evidence consists of oral testimony of PW1 and Exhibits P1 to P9.
5. Points: The complaint is filed to get reimbursement of medical expenses. The complainant was a medi claim insurance policy holder of respondents and during the policy period the complainant had undergone operation for removal of cancer affected part thyroid. After the operation she preferred claim for medical charges. But it was not honoured by stating pre-existence of the disease. According to complainant this act of respondents is deficiency in service. The respondents filed a nominal counter stating that the details of the disease and treatment are not stated in the complaint. It is also the contention that since the treatment is for thyroid it is not a sudden disease and may develop after a long period. So the disease is a preexisting disease and complainant is not entitled for any amount.
6. The complainant was examined as PW1 and according to her Rs.30,000/- was the expense for the treatment. It is the contention of respondents that medical expenses are not stated in the complaint. According to PW1 the expenses come to Rs.30,000/-. It can be seen that there is no document at all to show the amount of expenses. IA.636/12 was filed by complainant to bring the medical bills by respondents. But no documents or affidavit filed by respondents. So an adverse inference can be taken. The respondents taken the case in a silly manner and no claim file produced to peruse the documents. It is the duty of respondents to prove the contention of pre-existence of the disease. It is also the duty of respondents to prove the case of complainant as untrue and she is not entitled to get the amount claimed. There is lack of evidence in the case. It is found that deficiency in service committed by respondents. According to PW1 Rs.30,000/- is the treatment expenses. Since there is no other evidence we are under the impression to order this amount.
7. In the result the complaint is allowed and the respondents are directed to pay Rs.30,000/-(Rupees Thirty thousand only) as treatment expenses and Rs.5,000/- (Rupees Five thousand only) as compensation with costs Rs.750/- (Rupees Seven hundred and fifty only) within a month from the date of receipt of copy of this order.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 29th day of November 2014.
Sd/-
Padmini Sudheesh, President.
Sd/-
Sheena.V.V, Member.
Sd/-
M.P.Chandrakumar, Member
Appendix
Complainant’s Exhibits:
Ext.P1 Discharge summary
Ext.P2 Histopathology report
Ext.P3 Discharge summary
Ext.P4 Histopathology report
Ext.P5 Scan report
Ext.P6 Lab report
Ext.P7 Copy of repudiation letter
Ext.P8 Identity card
Ext.P9 Policy copy
Complainant’s witness :
PW1 – Beena.M.V
Id/-
President
