BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 25/01/2012

Date of Order : 31/12/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 56/2012

Between

And

O R D E R

A. Rajesh, President.

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

The complainant availed himself of a Bajaj Allianz Family Care First Policy from the opposite party for the period from 26-02-2009 to 26-02-2012. On 28-11-2009, the complainant's wife was diagnosed with Otorrhoea illness, when she consulted the doctor with acute infection of ear. Since there was no improvement, in spite of administration of medicines, the doctor advised her to take Mastoidectomy with Tympanoplasty operation. The complainant approached the opposite party for cashless payment of operation expenses. The opposite party called for report from the doctor on 21-11-2011. On 22-11-2011, additional information was called for. The opposite party informed the complainant on 22-11-2011 that they cannot ascertain the medical expenses due to the insufficient information given by the hospital and requested the complainant to bear the medical expenses and claim the same from the opposite party. The complainant's wife underwent treatment at Ernakulam Medical Centre from 23-11-2011 to 25-11-2011, she incurred a sum of Rs. 32,595/- towards treatment expenses. The opposite party repudiated the claim of the complainant stating that the ailment of the complainant is not covered during the waiting period. The above conduct of the opposite party amounts to deficiency in service. So, the complainant is entitled to get the insurance amount together with interest along with a compensation of Rs. 50,000/- and Rs. 2,000/- towards costs of the proceedings. This complaint hence.

2. The version of the opposite party is as follows :-

The opposite party issued a Bajaj Allianz Family Care First Insurance Policy in favour of the complainant and his family. The wife of the complainant was admitted to Ernakulam Medical Centre Hospital for Mastoidectomy with Tympanoplasty operation. As per Clause 8 of the terms and conditions of the policy, the company shall be liable to make payment for the illness only from the renewal date or date of renewal whichever is later. In this case, the complainant's first renewal will be after 3 years from the policy commencement date that is, 26-02-2009. That means the policy does not cover the disease of the complainant's wife for 3 years and the opposite party legally repudiated the claim of the complainant. There is no deficiency in service on the part of the opposite party. The complaint is devoid of any merit and is liable to be dismissed.

3. The complainant was examined as PW1 and Exts. A1 to A7 were marked on his side. The witnesses for the opposite party were examined as DWs 1 to 3. Ext. B1 was marked on their side. Heard the learned counsel for the parties.

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

1. Whether the complainant is entitled to get the insurance claim from the opposite party?

2. Whether the opposite party is liable to pay compensation and costs of the proceedings to the complainant?

5. Point No. i. :- The complainant availed himself of a Bajaj Allianz Family Care First Policy from the opposite party with effect from 26-02-2009 to 26-02-2012. During the currency of the policy, the complainant's wife underwent treatment at Ernakulam Medical Centre from 23-11-2011 to 25-11-2011. Her disease was diagnosed as right chronic suppurative otitis media and which called for Mastoidectomy with Tympanoplasty operation. Thereafter, the complainant submitted insurance claim application before the opposite party. The opposite party demanded information from the complainant by Ext. A4 and A5 letters. The complainant submitted the documents as demanded by the opposite party. Since there was no response, the complainant caused Ext. A6 letter to the opposite party. Thereafter the opposite party repudiated the claim of the complainant by Ext. A7 letter dated 13-12-2011, which reads as follows :

“On detailed scrutiny of the same, we find that the claim does not fall under the purview of the policy for reasons given below :

Verification of claim documents reveals aforesaid claimant was hospitalized for treatment of Right Chronic Suppurative Otitis Media and undergone Tympanoplasty. We regret to inform you claim stands repudiated as policy does not extend coverage for Tympanoplasty for three years Kindly note the above stated illness shall not be covered under subsequent year policies as the policy excludes any illnesses which are diagnosed during the waiting period.

The relevant clause of the policy is given below for your reference :

Exclusions : 6 b

The Company shall not be liable to make any payment if Hospitalisation or Medical Expenses or claims are attributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following : Hospitalisation and/or treatment within the Waiting Period and Hospitalisation and/or treatment following the diagnosis within the Waiting Period;

Illness covered only after first renewal 8

The company shall be liable to make payment for the following illnesses only from the first Renewal Date or date of Revival, whichever is later, provided these Illnesses are diagnosed or Hospitalisation or Medical Expenses incurred after the first Renewal Date or date of Revival, whichever is later; Tympanoplasty, Valve Replacement, Valvotomy, Cerebral Haemorrhage; Anglographies, Angoplasty (with or without stent), Coronary Artery Bypass Graft unless post Accident. The first Renewal will be due after three years from the Policy Commencement Date.

Hence we regret to inform you that the claim is inadmissible and thus repudiated. We have retained the claim docket for future reference.”

6. According to the complainant, the rejection of the cashless facility at the hospital and the subsequent repudiation of the insurance claim amounts not only to unfair trade practice but also deficiency in service on the part of the opposite party. In spite of that the opposite party vehemently contended that they have repudiated the insurance claim of the complainant on the basis of exclusion clauses 6B and 8 in the terms and condition of the policy. According to them, at the outset, they have as necessitated in legal terms they have served a copy of the terms and conditions of the insurance policy to the complainant. The opposite party claims that they have despatched the terms and conditions to the complainant by post. To substantiate the same, they have examined DWs 1 to 3 the officials of the Postal Department who could not prove the veracity of such. Had the opposite party been successful in serving a copy of the terms and conditions of the policy to the complainant, which has proven not to be done. The denial of such a right to the complainant is against the IRDA Rules. The above conduct of the opposite party amounts to deficiency in their service. So, the complainant cannot be disentitled in law to get the insurance claim for the treatment of his wife at Ernakulam Medical Centre Hospital.

7. It is only to be fairly noted that an insurance policy is taken only as a precaution not necessarily out of fear. Truly, if not every insurance company seems to have some clause within their formidable legal terms something to repudiate even the most earnest sincere and honest claim. This seems to show that the insurance and assurance given by the companies of such looks like a farce, which if true puts a consumer in a fools paradise. With malice towards none, we are constrained to hold so in the experience of its vast nature. If the true spirit of promises were to be kept such situations let alone be kept aside would not even arise. It cannot be contended that every consumer approaches the company with a falsified claim, though the opposite parties would have legal but not ethical concerns in their favour were such things to be noted may such claims and concerns could easily be avoided.

8. Point No. ii. :- In factual law, this is a case as many others were an award of compensation would see no limits. But, which we sincerely feel the award of the same would see the day lights in company policies. We deliberately refrain from awarding the same, however granting a cost of Rs. 2,000/-.

9. In the result, we partly allow the complaint and direct as follows :-

1. The opposite party shall pay the insurance claim of the complainant with interest at the rate of 12% p.a. from the date of complaint till realisation.

2. The opposite party shall also pay Rs. 2,000/- to the complainant towards costs of the proceedings.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in the open Forum on this the 31^st day of December 2012.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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