IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 27th day of April, 2023
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 68/2022 (Filed on 30-03-2022)
Petitioner : (1) Babykutty Varghese,
W/o. M.I. Varghese,
Murickanattu House,
Vadavathoor P.O.
Kottayam.
(2) M.I. Varghese,
Murickanattu House,
Vadavathoor P.O.
Kottayam.
(Adv. C.J. Jomi)
Vs.
Opposite party : (1) Bajan Allianz General Insurance Co. Ltd.
Represented by its Manager,
3rd Floor, YMCA Building,
Kottayam – 686001
(Adv. Lithin Thomas)
(2) Canera Bank Ltd.
Rep. by its Manager cum Branch Head,
Manarcadu Branch, Arackal Building,
Manarcadu, Kottayam.
(Adv. Dominic D. Vallavassery)
O R D E R
Sri. K.M. Anto, Member
The complaint is filed under section 35 of the consumer protection Act 2019
The brief of the complainant’s case is as follows. The second complainant is an account holder of the second opposite party. In 2015 the first complainant had
taken Medi-claim insurance policy of Apollo Munich Insurance company for the
period from 24/01/2015 to 23/01/2016 for a sum insured of Rs.1,00,000/- which was continued till 30/01/2021 without break. Just before the expiry of last of such policy, the complainants were directed by the second opposite party to port the policy with the first opposite party as the second opposite party had stopped tie-up with Apollo Munich Insurance Company and started tie-up with the first opposite party. They assured that all the benefits of the prior policy will be transferred to the new policy of the first opposite party such as cumulative bonus and conditions regarding locking period etc. Accordingly, the complainant had agreed to purchase the policy from the first opposite party and a new policy was issued to the complainant as policy No. OG 2116066021000011035 for the period 31/01/2021 to 30/01/2022 for sum insured of Rs.1,00,000/- by the first opposite party. The first complainant got admitted in Bharat Hospital, Kottayam for treatment for HYDRONEPHROSIS LEFT. She underwent inpatient treatment from 18/08/2021 to 20/08/2021 and had spent an amount of Rs.4,308/- for diagnoses and initial treatments. Rs.59,462/- as inpatient bill and also paid Rs17,391/- for removal of Catheter etc. After discharge on 29/08/2021, the complainant had submitted the claim for reimbursement of medical bills of Rs.59,463/- and pre hospitalization bills Rs.4,308/-.to the first opposite party.
The 1’st complainant had submitted the Doctor’s certificate separately followed by another certificate from the Doctor as demanded by the first opposite party. On 29/10/2021 the first opposite party received an E-mail to produce the old history of the treatment. Since there was no prior treatment, the complainant had given the replay. Then the complainant got another email to furnish the bank account detail with MICR and IFSC number which was also furnished. But the first opposite party had not paid the insurance amount to the first complainant. This act of the first opposite party is deficiency in service and unfair trade practice. The non processing of the claim of the first complainant had caused much mental agony and financial crisis to the first complainant. Hence this complaint.
On admission of the complaint copy of the complaint was duly served to the
opposite parties. The opposite parties appeared and filed separate versions.
The version of the second opposite party is that in 2015 the complainants had taken medical policy from Apollo Munich through the second opposite party.
Later Apollo Munich cancelled the tie-up with the second opposite party and the first opposite party agreed to offer portability facility to the complainants. It is clearly mentioned in the policy document issued by the first opposite party that the Medi-claim policy of Apollo Munich health insurance and continuity is extended from 24/01/2015. There is no mis selling or omission from the part of the second opposite party and it is well ensured that the complainant is getting continuation on porting the policy to the first opposite party. There is no deficiency in service on the part of the second opposite party.
The version of the first opposite party is as follows. The first opposite party never engaged the second opposite party to pursue any person for availing Medi claim policy from the first opposite party. The averment that the complainant was directed by the second opposite party to port the policy with the first opposite party before the expiry of the alleged policy taken from Apollo Munich is false. It is also false that the opposite parties made believe the complainants that the all the benefits of the prior policy will be transferred to the new policy of the first opposite party such as cumulative bonus and conditions regarding locking period etc.
It is against the fact that a new policy was issued to the first complainant for the sum insured of Rs.1,00,000/- and policy number OG 2116066021000011035 with effect from 31.01.2021 to 30.01.2022.
The averments that the first complainant got admitted for Hydronephrosis Left and underwent inpatient treatment and spent an amount of Rs.4,308/- for diagnoses and initial treatments, Rs.59,462/- as inpatient bill and paid Rs.17,391/- for removal of catheter are false. It is also false that after discharge on 29/08/2021 the complainant had submitted the claim for reimbursement of medical bills through the website, followed by physical submission at the office and submitted the medial bills and treatment records. The allegation that as per the demand of the first opposite party, the first complainant submitted the Doctors Certificate separately, followed by another certificate from doctor. It is untrue that the complainant got an email to furnish bank account details with MICR and IFSC number etc. The complainant is not an insured with the first opposite party and hence not a consumer as per the provisions of Consumer protection Act. There is no deficiency in service on the part of the first opposite party. The first opposite party never adopted unfair method or unfair or deceptive practice.
The first complainant filed proof affidavit and marked documents Exhibits A1 to A6. Even though the first and second opposite parties filed their version, they
failed to adduce any further evidence to defend their case.
On the basis of the complaint, version of the opposite parties and evidence
adduced we would like to consider the following points
- Whether there is deficiency in service or unfair trade practice on the part of
the opposite parties?
2 If so, what are the reliefs and costs?
Point 1 and 2
Ongoing through the complaint, version of the opposite parties and evidence on record it is evident that the first complainant is having a Mediclaim insurance policy from the first opposite party with customer ID No.205374566 and Master policy number OG-20-9999-9960-00000092 and child certificate number OG-21-1606-6021-00001035 for the period from 31/01/2021 to 30/01/2022 with sum insured Rs.1,00,000/-.
Ext A1 is the Mediclaim Policy schedule issued by the first opposite party. The name of insured is the first complainant. Policy is issued on 10/02/2021, for the period from 31/01/2021 to 30/01/2022 with sum insured 1,00,000/- No. of persons; self and risk covered is Inpatient Hospitalization and premium paid is Rs.3,473/0. The scope of coverage is given as all terms and conditions are as per group Mediclaim policy of Canara Bank customers. Previous policy No.120/100/12586/2018/A016898/653 and additional remarks given as “ it is agreed and understood that the mediclaim insurance policy is issued with portability benefit from mediclaim policy of Apopolo Munich Health Insurance Co. Ltd and continuity is extended from 24 Jan 2015.The continuity for continuity for 6 years is extended on sum insured of Rs.1,00,000/- for Mrs. Babykutty Varghese C B for 0. All other terms, conditions, coverage and exclusions of the policy remain unaltered, all waiting periods apply as fresh on enhanced sum insured, any disease/injury contracted during breaking period will not be payable”.
The Agency code in Ext A1 Policy schedule is the second opposite party Canara Bank with code No.10045514. Ext A3 is the Inpatient bill issued to the first complainant from Bharat Hospital, Kottayam on 20/08/2021 which shows that the patient’s name Babykutty Varghese, treated by DR. Manu V.S, MBBS, MS, MCH admitted on 18/08/2021 and discharged on 20/08/2021. Total bill amount Rs.59,462/-. Ext A4 is the copy of the claim form Submitted by the first complainant on 29/08/2021 claiming Rs.59,462/ as Hospital Bill and Rs.4,308/- pre–Hospital Bills. Ext A5 is the inpatient bill of the first complainant dated 23/09/2021 for Rs.3695/-. It is seen that the first complainant is admitted on 5.44am on 23/09/21 and discharged at 10.01 am on the same day.
On the basis of the above discussed findings, it is evident from Ext A1 Policy schedule and the version of second opposite party that the first opposite party had issued the Ext A1 Mediclaim policy with a sum assured of Rs.1,00,000/- for the period from 31/01/2021 to 30/01/2022 to the first complainant. It is also clear that they had given the portability cover of the previous Mediclaim Policy Apollo Munich Insurance Co Ltd from the year 2015.
Even though the first opposite party totally denied the claim of the complainant and stated that they have not issued any Mediclaim Policy to the first complainant it is evident from Ext A1 and the Version of second opposite party that the first opposite party had received the premium amount of 3473,/- and they had issued the Ext A1 Policy schedule on 10/02/2021 with Sum assured Rs.1,00,000/- for the Period From 31/01/2021 to 30/01/2022 with risk cover Hospitalization expenses to the first complainant. As per Ext A1 the Mediclaim insurance policy is issued with portability benefit from Mediclaim policy of Apollo Munich health insurance Co. Ltd and continuity is extended from 24 Jan 2015. The continuity for 6 years is extended on sum insured of Rs.1,00,000/- for Mrs. Babykutty Varghese. The act of total denial of the issuance of the Ext A1 Policy and the receipt of the claim form and other treatment records from the first complainant is unfair trade practice on the part of the first opposite party. Moreover, the non-processing of the Ext.A4claim filed by the first complainant is deficiency in the service on the part of the first opposite party. Hence point No 1 is found in favor of the complainants. We allow the complaint and pass the following orders.
- The first opposite party is directed to give Rs 59,462/- to the first complainant.
- The first opposite party is directed to pay Rs25,000/- to the first complainant as compensation for the mental agony and sufferings with cost RS 5,000/-.
The order shall be complied within 30 days from the date of receipt of the copy of this order failing which the award amounts will carry 9 % interest from the
date of this order till realization.
Pronounced in the Open Commission on this the 27th day of April, 2023
Sri. K.M. Anto, Member Sd/-
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1- Copy of policy issued by opposite party
A2 – Copy of medical certificate dtd.25-10-21
A3 – Copy of medical bills issued by Bharath hospital
A4 – Copy of claim form dtd.29-8-21
A5 – Cash bill dtd.23-09-21 issued by opposite party
A6 – Copy of discharge summary issued by Bharath Hospital,
Exhibits marked from the side of opposite party
Nil
By Order
Sd/-
Assistant Registrar
