SMT. ELIZABETH GEORGE (PRESIDENT) The case of the complainant is as follows:- The complainant is a business man and had taken an individual health insurance policy in the year 2005. The policy was renewed without break till now. The policy covers the risk of health insurance of the complainant and his dependants. In connection with Lumbar disc disease the insured person-Reena George taken treatment at Sree Agasthya Medical Centre (Ayurvedic & Allopathic Clinic Tripunithara, Ernakulam from 13.06.2013 to 30.06.2013. The total hospitalization expenses came Rs.27,550/-. The complainant submitted entire set of medical records including original bills within stipulated date to the opposite party and demanded policy benefits. But there was no response from the opposite party till 10.11.2013 and on 12.11.2013 received notice from opposite party showing the rejection of the claim under the reason. No.3. As per the rejection letter, since the ayurvedic treatment received from the non-government hospital, the complainant was not eligible for the claim reimbursement. The stated condition is not binding to the complainant and which was completely against the policy. Hence the complaint is filed.
2. The version of the opposite party is as follows:- The complainant had firstly approached the Insurance Ombudsman, Ernakulam and after hearing from both sides, the Insurance Ombudsman dismissed the complaint. Opposite party had issued an individual health insurance policy to the complainant for the period from 6.8.2012 to 5.8.2013. The opposite party rejected the claim as the complainant violated the policy conditions. The complainants wife was treated in the Sree Agastya Medical Centre, Tripunithara, Ernakulam, it is a private hospital. In the policy it is specifically stated that for ayurvedic treatment hospitalization expenses are admissible only when the treatment is taken inpatient in a Government hospital/Medical College hospital. There is no deficiency in service on the part of the opposite party.
3. The complainant was examined as PW1. The documents produced were marked as Exts.A1 to A8. The opposite party was examined as RW1 and one document produced marked as Ext.B1.
5. The points came up for considered are:- Whether there is any deficiency in service on the part of the opposite party? If so the reliefs and costs?
6. It is an admitted fact that the opposite party had issued an Individual Health Insurance policy to the complainant for the period from 6.8.2012 to 5.8.2013. The allegation of the complainant is that his wife was treated at Sree Agastya Medical Centre, Tripunithara, Ernakulam from 13.6.2013 to 30.6.2013 and the claim for the hospital expenses was repudiated by the opposite party. According to the opposite party, the complainants wife was treated in the private hospital and as per the conditions of the policy for Ayurvedic/Homeopathic/Unani treatment hospitalization expense are admissible only when the treatment is taken as inpatient in a Government hospital. Ext.A3 is the insurance policy produced by the complainant. As per the policy period of insurance was 6.8.2010 to 5.8.2011. According to the complainant from 2005 onwards he was renewing the policy in time without any documentation by remitting the premium amount. Hence the main allegation of the complainant is that the condition incorporated in the renewed policy is not binding to him. But while cross examining the complainant he admitted that he had filed a complaint against the opposite party before the Honble Ombudsman for the similar matter on 22.2.2012 and had received the claim amount in that case as per the order of Ombudsman. Now the complainant again renewed the policy. He again undergone the treatment at Ayurvedic private Hospital. The award copy of the Insurance Ombudsman produced by the complainant marked as Ext.A8. Honble Ombudsman discussed the matter in detain and stated that, While in the first case the claim was allowed as the change in conditions was not informed to the policy holder, it is not so in the present case as the complainant is very well aware of the conditions especially after the last claim was rejected by the Insurer and he had to file a complaint with the Ombudsman. Therefore it is amply proved that the complainant was very well in the in the know that admissibility of Ayurvedic claims are limited by conditions and he is also aware of the conditions. The complainant again filed claim application before the opposite party. But it was repudiated. So he filed complaint before the Ombudsman, Honble Ombudsman dismissed the complaint. Hence we are of opinion that the special condition was incorporated without the knowledge of the complainant is not seen as a genuine allegation. For the treatment that he had undergone during the year 2012 he had raised the same allegation and received the claim amount after that he again undergone treatment during the year 2013 and he is stopped from raising the same allegation before the opposite party. The learned counsel of the complainant produced a decision of Honble National Commission reported in 2011(1) CCC page No.350 and vehemently argued that no unilateral action on part of any party to the contract could be binding on the other. On going through the said decision we came to see that Honble National Commission opined that, The bald defence made by Corporation that inclusion of Exclusion clause in the policy when it was renewed for the period from 22.1.2001 to 21.1.2002 was made within the knowledge of petitioner would not impress us in absence of any clinching evidence put on the record by Corporation. In the instant case, the opposite party proved that the complainant had knowledge about the inclusion of Exclusion clause during the period from 2012 onwards. Hence that decision is not applicable in this case. The repudiation of the claim by the opposite party is justified. In the result, complaint is dismissed. Dictated to the Confidential Assistant transcribed by her corrected by me an pronounced in open Forum on this the 31 day of August, 2016.st Sd/- Smt.Elizabeth George (President) Sd/- Sri.Antony Xavier (Member) Sd/- Smt.Jasmine. D. (Member) Appendix:- Evidence of the complainant:- PW1 - K. George Mathew (Witness) Ext.A1 - Copy of Insurance Policy for the period from 6.8.2012 to 5.8.2013 Ext.A2 - Copy of Insurance Policy for the period from 6.8.2009 to 5.8.2010 Ext.A3 - Copy of Insurance Policy for the period from 6.8.2010 to 5.8.2011 Ext.A4 - Copy of Health Insurance Claim Form Ext.A5 - Copy of Medical Report Ext.A6 - Copies of Cash Bills Ext.A7 - Copy of Repudiation letter Ext.A8 - Award copy of Insurance Ombudsman :- Evidence of the opposite party RW1 - Bindu. B. (Witness) Ext.B1 - Copy of Policy // True Copy // By Order Senior Superintendent Complainant/Opposite party/S.F. Typed by:- pr/- Compared by:- [HON'BLE MRS. Elizabeth George] PRESIDENT [HON'BLE MR. Antony Xavier] MEMBER [HON'BLE MRS. Jasmine. D.] MEMBER