D.O.F:20/10/2020
D.O.O:20/07/2023
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.139/2020
Dated this, the 20th day of July 2023
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
Mahesh Kumar.V, aged 37,
S/o Balakrishnan. P,
Aravath House,
Thachangad, P.O Panayal : Complainant
And
Authorized Signatory,
Cholamandalam MS Gneral
Insurance Company Ltd,
2nd floor, Dare house,
2NSC Bose Road, Chennai – 600001 : Opposite party
(Adv: Balagopalan.M)
ORDER
SRI. KRISHNAN.K : PRESIDENT
The case of the complainant is that he has obtained a Health Insurance Policy from Opposite Party for himself and his spouse covering the period from 24/10/2018 to 23/10/2019 by paying Rs. 5645/- for the coverage of two lakhs. Medical expenses for treatment is also covered by the policy. Complainant suffered a fall, caused injury on his left knee on 03/07/2019 admitted in Vinay hospital Mangalore, Medical Expenses incurred is more than Rs. 1,00,000/- insurance policy is not shown prior to admission. Bills are paid in cash. Complainant applied for insurance benefits on 01/11/2019 produced all original documents. The Opposite Party sent a letter informing sanction of Rs. 85816/- but not paid. So complainant sent a notice but not replied. Thus complaint is for payment of insurance claim and compensation for deficiency in service and negligence and cost of litigation.
2. The Opposite Party appeared and filed written version. The Opposite Party admitted the policy but denied liability to pay insurance benefits since required documents are not produced. The Opposite Party insisted following documents they are
1) Certificate by treating doctor confirming nature and circumstances of the case.
2) If the injury was on account of road traffic accident to produce copy medico legal report.
3) To produce MRI report supporting the diagnosis report.
4) Certificate from treating doctor to clarify if any history of alcohol abuse at the time of injury.
Inspite of several requests complainant did not produce nor sent any reply. Thus there is no deficiency in service or negligence and claim rejected for the reason. And prayed to dismiss the complaint.
Complainant filed chief affidavit and cross examined as Pw1, Ext A1 to A3 and Ext X1 marked from complainant side. The Opposite Party produced Ext B1 to B4 documents. Ext A1 policy copy Ext A2 letter from Opposite Party, Ext A3 is copy of lawyer notice, Ext X1 document summed. Ext B1 is health claim query, Ext B2 is reminder, Ext B3 is closure letter. Issued to complainant Ext B4 copy of repudiation letter.
3. Following points raised for consideration :
a) Whether repudiation of the insurance claim by Opposite Party is justifiable?
b) Whether there is any deficiency in service from Opposite Party? Whether complainant entitled for compensation? If so for what reliefs?
All the points are discussed together for convenience.
It is very clear that entire documents were with Opposite Party produced by complainant. Opposite Party has no case that there was no fall or complainant did not suffer any injury due to fall. So there is no question of producing a certificate by treating doctor confirming the nature and circumstances of the case.
Now reason No:2. If the injury was an account of road traffic accident to produce copy of medical legal report.
In the claim it was made very clear that injured has a fall and sustained injury to knee joint and hence no scope to claim as a road traffic accident.
Reason No:3, MRI report is produced as a documents, Reason No:4, stated is to produce. Certificate from treating doctor to clarity it any history of alcohol abuse at the time of injury. Medical records already produced did not refer to or mention any history of alcohol abuse at the time of accident. So a separate certificate from the doctor to clarity any history of alcohol abuse at the time of injury does not arise at all.
Unless and until there is medical evidence that the injured had suffered from any of diseases and was hospitalized no injured can be deprived of the rightful claim towards medical claim expenses.
It is not a case where injured had been admitted or hospitalized for any diseases resulting from his being alcoholic or use of intoxicating drugs or alcohol or suffered knee joint injury.
Considering the nature and circumstances of the case, complainant is entitled for insurance benefits covered by the policy. Despite producing all medical records in the absence of any contra evidence we hold that repudiation of policy benefits is not as per mandate of law. Reasons given in rejecting the claim is not as per law and hence repudiation is unjustifiable for the reason aforesaid. Complainant is entitled for insurance benefit covered by the policy on the basis of the documents produced and evidence adduced.
Thus the insurance benefits are not paid in time in spite of production of all medical records. There is no justification for not accepting the same and thus there is deficiency in service and negligence from Opposite Party hence complainant is entitled for compensation. Taking not all the circumstances of the case we her by award a sum of Rs. 25,000/- towards deficiency in service and negligence and cost of litigation Rs. 5000/- .
In the result complaint is allowed in part Opposite party is directed to pay Rs.85,816/- being the insurance benefits with 8% interest from the date of repudiation till it payment payable to the complainant and Rs. 25,000/- (Rupees Twenty five thousand only) for deficiency in service and Rs. 5000/- (Rupees Five thousand only) as cost of litigation within 30 days of the receipt of the order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1- Health certificate of insurance.
A2- Letter from Opposite party.
A3- Lawyer notice.
B1- Health claim query letter.
B2- Health claim query reminder letter.
B3- Health claim query reminder cum closure letter.
B4- Health claim repudiation letter.
X1- Documents.
Witness Examined
Pw1- Mahesh Kumar.V
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Ps/ Assistant Registrar
