Tamil Nadu

South Chennai

971/2009

A.L.Bindumadhavan - Complainant(s)

Versus

Administrative Officer,United India Insurance Company Ltd - Opp.Party(s)

C.V.Kumar

04 Sep 2015

ORDER

                                                                                     Date of Complaint  : 13.11.2009

                                                                                     Date of Order      : 04.09.2015

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT :    THIRU. B. RAMALINGAM, M.A.M.L.,                         :  PRESIDENT                     

                      TMT.K. AMALA, M.A. L.L.B.,                                         :  MEMBER I

                   TR. T.PAUL RAJASEKARAN, M.A PGDHRDI, AIII,BCS : MEMBER II

 

C.C.No. 971 / 2009

THIS FRIDAY  THE 4^th   DAY OF SEPTEMBER  2015

 

A.L Bindumadhavan,

NO.7, Ganesha Street,

Gnanamurthy Nagar,

Ambattur,

Chennai 600 053.                                              .. Complainant.

- Vs- 1. Administrative Officer, United India Insurance Company Ltd., Corporate Cell, 98 A Dr. Radhakrishnan Salai, Chennai 600 004. 2. The Manager, United India Insurance Company Ltd., 24, Whites Road, Chennai 600 014.                                      .. Opposite parties.		.. Opposite party.

For the complainant                     :  M/s. C.V.Kumar     

For the opposite parties                       :   Mr.S.K.Krishnamurthy

      Complaint under section 12 of the Consumer Protection Act, 1986 for a direction to the opposite parties  to pay a sum of Rs.1,71,000/- with interest and also to pay a sum of Rs.1,00,000/-  as compensation for  mental agony and also to pay cost of the proceedings to the complainant.

ORDER

THIRU. B. RAMALINGAM,  PRESIDENT            

1.The case of the complainant is briefly as follows:-

          The complainant has taken Health Insurance Policy for his father namely A.V. Lakshmanan and Mother L.Mahalakshmi.   The said policy was renewed and was in force from 14.10.2008  to 13.10.2009.  The policy mentioned complainant’s mother Mahalakshmi was fell ill and she was admitted in Kuppuswamy Naidu Memorial Hospital at Coimbatore for treatment.    She was admitted and taken inpatient treatment for the period from 23.10.2008 to 11.11.2008 and after she was discharged from the hospital on 11.11.2008.  The complainant has made claim for the said reimbursement of the said claim as per the policy and submitted claim form on 12.11.2009.  Whereas the opposite party have repudiated the said claim stating that the claim made was within a period of 30 days from the date of inception of the policy and previous policy was not furnished by the complainant, as such the opposite party is not liable to compensate the medical expenses of the deceased Mahalakshmi and it is not covered by the policy.    The complainant has issued a notice through his counsel calling upon the opposite parties to settle the claim was also went in vein.     The 1^st opposite party with ulterior motive has refused to settle the claim of the complainant.  The act of the opposite parties amounts to deficiency of service and which caused lot of mental agony and hardship to the complainant.   As such the complainant has sought for a sum of Rs.1,71,000/- with interest and also to pay a sum of Rs.1,00,000/-  as compensation for  mental agony and also to pay cost of the proceedings to the complainant  Hence the above complaint.   

2.  Written version of  opposite parties  is   as follows:-

   The opposite parties does not admit any of the allegations contained in the complaint except those that are expressly admitted herein.      The Health Insurance policy taken by the complainant was renewal of the earlier policy is totally erroneous and misleading.   It is pertinent to mention that while issuing the new Health Insurance Policy to the complainant by mistake discount was given to the complainant taking the advantage of the same the complainant falsely stated that it is a renewal policy.   The opposite parties had specifically connoted in their reply notice that the Health Insurance Policy taken by the complainant was not a renewal of the earlier policy, but a new policy.  As the claim raised by the complainant within first 30 days from the commencement of date of policy falls under the policy exclusions and hence the claim was repudiated.    Hence there is no deficiency of service on the part of the opposite parties and prays to dismiss the complaint. 

3.     Complainant has filed his Proof affidavit and  Ex.A1 to Ex.A4 were marked on the side of the complainant.   Opposite parties have filed their   proof affidavit and Ex.B1 & Ex.B2 were marked on the side of the opposite parties.

4.         The points that arise for consideration are as follows:-

1.    Whether there is any deficiency in service on the part of the opposite parties?

 

2. To what relief the complainant is entitled to?

 

 

5.  Point Nos.1 & 2: 

        Perused the complaint filed by the complainant, written version filed by the  opposite parties,  the  proof  affidavit filed by complainant and opposite parties and Ex.A1 to Ex.A4  filed on the side of the complainant and Ex.B1 and Ex.B2  filed on the side of the  opposite parties  and considered both side arguments.

6.     There is no dispute that the complainant has taken Health Insurance Policy for his father A.V. Lakshmanan and Mother L.Mahalakshmi.   The said policy was renewed and was in force from 14.10.2008  to 13.10.2009 the said Health Insurance policy filed as Ex.A1.  The policy mentioned complainant’s mother Mahalakshmi was fell ill and she was admitted in Kuppuswamy Naidu Memorial Hospital at Coimbatore for treatment.    She was admitted and taken inpatient treatment for the period from 23.10.2008 to 11.11.2008 and after that she was discharged from the hospital on 11.11.2008.  The complainant has made claim for the said reimbursement of the said claim as per the policy and submitted claim form on 12.11.2009.  Whereas the opposite party have repudiated the said claim stating that the claim made was within a period of 30 days from the date of inception of the policy and previous policy was not furnished by the complainant, as such the opposite party is not liable to compensate the medical expenses of the deceased Mahalakshmi and it is not covered by the policy.

7.     The bill for hospital  expenses and the discharge summary of the hospital and other document relating to the treatment taken by the deceased  Mahalakshmi has been filed as Ex.A2.  The legal notice issued by the complainant to the opposite party and the repudiation letter  given by the opposite party to the complainant dated 2.12.2008 is filed as Ex.A3. 

8.     The learned counsel appearing for the complainant would argue that, since the policy Ex.A1 is of the renewal health policy, as such the rejection of the claim by the opposite party stating that the policy was taken on 14.6.2008, whereas the insured person is the mother of the complainant was admitted for treatment within 30 days from the date of inception of the policy is not covered under the policy is not valid objection as per the policy and the repudiation of the claim by the opposite party is not sustainable.   Whereas the learned counsel appearing for the opposite party would argue that though Ex.A1 policy relating for the claim is renewal policy and the complainant has not produced the particulars of previous policy to the opposite party  has required by the condition of the policy and the renewal policy issued by the opposite party is due to mistake without verifying the previous policy and bonus deduction of premium was also given to the said renewal policy as mentioned in Ex.B1 are given by mistake.  Therefore since the complainant has not produced the previous policy and particulars Ex.A1 policy is to be considered a new policy as such from the date of inception of the policy, claim was made within 30 days, as such the claim cannot be settled by the opposite party as per the policy as it is not covered.

9.     However as contended by the learned counsel appearing for the complainant since the opposite party has issued a renewal policy Ex.A1 with mentioning of previous policy No. and particulars there on in it and also given a bonus premium discount i.e. no claim discount of premium for Rs.3668.25  and issued the said policy, contrary to this fact the contention raised by the opposite party that the said renewal health policy Ex.A1 was issued by mistake on the representation made by the complainant cannot be acceptable as valid one and the said contention raised  by the opposite party is to be rejected as not sustainable is acceptable.

10.    Therefore we are of the considered view that the reason stated by the opposite party for repudiation of the said claim of the complainant is not valid and sustainable, since the opposite party have received premium and issued renewal health policy Ex.A1 to the complainant with particulars mentioning the previous policy and also giving no claim bonus of deduction of premium in the said policy.  After claim was made by the complainant the opposite party attitude of repudiating the said claim stating that no document of particulars of previous policy was furnished by the complainant as such the Ex.A1 policy was issued by mistake by the opposite party is not acceptable.

11.    The complainant has filed hospital record and bills etc for the treatment of deceased Mahalakshmi / insured for a sum of Rs.1,71,825/-.  The opposite party have not raised any objection or dispute with regard to the above hospital expenses claimed by the complainant.  Therefore we are of the considered view that the opposite party is liable to reimburse the said claim of Rs.1,71,825/- towards the medical expenses incurred by the complainant’s deceased mother treatment.  The said claim was not settled by the opposite party till this date as such by retaining the said amount by the opposite party without making payment to the complainant on invalid reason would have benefited out of the said amount, which amounts to deficiency of service on the part of the opposite party and which caused mental agony and hardship to the complainant is acceptable. 

12.    Therefore we are of the considered view that the opposite parties are  jointly and severally liable to pay a sum of Rs.1,71,825/- for the reimbursement of the medical expense  with interest at the rate of 9% p.a. from 12.11.2009 to till the date of payment   and also to pay a sum of Rs.20,000/- as compensation for mental agony and also to pay  a  sum of Rs.5000/- as cost of the complaint  to the complainant and as such the points 1 & 2 are answered in favour of the complainant.

In the result, the complaint is partly allowed.   The opposite parties are jointly and severally   directed to pay a sum of Rs.1,71,825/- (Rupees One lakh Seventy one thousand Eight hundred and twenty five only) for the reimbursement of the medical expense  with interest at the rate of 9% p.a. from 12.11.2009 to till the date of payment   and also to pay a sum of Rs.20,000/- (Rupees twenty thousand only) as compensation for mental agony and also to pay  a  sum of Rs.5000/- (Rupees Five thousand only) as cost of the complaint  to the complainant within six weeks from the date of receipt of copy of this order failing which the compensation amount of (Rs.20,000/) shall carry interest at the rate of 9% per annum from the date of order  passed till the date of realization.

   Dictated to the Assistant  transcribed and typed by her corrected and pronounced by us on this the 4^th    day of  September  2015.

 

MEMBER-I                                         MEMBER-II                                            PRESIDENT.

Complainant’s side documents :

Ex.A1- 15.10.2008    - Copy of Renewed Policy.

Ex.A2-           -                 - Copy of Discharge summary and bills.

Ex.A3- 2.12.2008      - Copy of replied by the opposite party.

Ex.A4- 6.10.2009      - Copy of notice by complainant through counsel with A.D.

 

Opposite parties’  side documents : -    

 

Ex.B1-           -                 - Copy of the policy condition.

 

Ex.B2- 18.11.2009    - Copy of the reply notice of the opposite parties.   

 

 

MEMBER-II                                       MEMBER-II                                PRESIDENT.