KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No.261/2015

JUDGEMENT DATED: 05.11.2024

(Against the Order in C.C.No.128/2012 of CDRF, Wayanad)

PRESENT:

APPELLANTS:

(by Adv. G.S. Kalkura)

Vs.

RESPONDENTS:

(by Adv. P Raj Mohan)

JUDGEMENT

SRI. K.R. RADHAKRISHNAN  :  MEMBER

          This is an appeal filed under Section 15 of the Consumer Protection Act, 1986 by the 2^nd and 3^rd opposite parties in C.C.No.128/2012 on the files of the District Consumer Disputes Redressal Commission, Wayanad (the ‘District Commission’ for short).  As per the order dated 21.01.2015 the District Commission partly allowed the complaint and directed the opposite parties to pay Rs.24,390.50/-(Rupees Twenty Four Thousand Three Hundred and Ninety and Fifty paise) to the complainant towards hospital expenses with 12% interest from the date of filing of the complaint till realisation.  The opposite parties are also directed to pay Rs.5,000/- (Rupees Five Thousand only) as compensation and Rs.2,000/-(Rupees Two Thousand only) as costs of the proceedings.  For the sake of convenience, parties are referred as per their original status in the complaint.

          2.       The complaint in brief, is as follows: The complainant had taken a medical insurance policy called ‘medi family package plan’ from the 2^nd and 3^rd opposite parties for himself and his family members.  The first policy was taken for the period from 05.01.2009 to 04.01.2010 which was renewed for the period from 07.01.2010 to 06.01.2011.  The third policy was for the period from 07.01.2011 to 06.01.2012 covering his wife and daughter only.  The subsequent renewal of the policy also covered only his wife and daughter.  The complainant had undergone treatment at PVS Hospital, Kozhikkode during the period of the policy No.P-181314/01/2011/05378 for the period from 07.01.2011 to 06.01.2012.  He was admitted for upper uretary calculus and admitted in the hospital on 26.05.2011 and undergone surgery on 27.05.2011.  He was discharged on 31.05.2011.  He incurred an amount of Rs.24,390.50/-(Rupees Twenty Four Thousand Three Hundred and Ninety and Fifty paise only) towards the treatment expenses as per bill No.1112/00/1997.  The complainant submitted the claim to the opposite parties.  They rejected the claim on the ground that the policy does not cover the complainant. According to them this policy is meant for persons aged up to 45 years only and as he was more than 45 years at the time of renewal of the policy, he was not included in this policy.  Only his wife and daughter are covered under the policy.  As he was not covered under the policy, his claim was repudiated by the insurance company.  Aggrieved by the decision of the insurance company, the complainant filed a complaint claiming the treatment expenses of Rs.24,390.50/-(Rupees Twenty Four Thousand Three Hundred and Ninety and Fifty paise only) with compensation of Rs.50,000/-(Rupees Fifty Thousand only).

          3.       Notice was issued to the opposite parties and second and third opposite parties entered appearance and filed their version.  The 1^st opposite party is the agent of the insurance company, who did not appear before the Commission and filed his version.    According to the 2^nd and 3^rd opposite parties, the first and second policies covered the complainant, his wife and daughter.  But the 3^rd policy, covering the period during which the claim is related, does not cover the complainant as he exceeded 45 years of age at the time of renewal.  The medi family package covers persons from the age of five months to 45 years only.  This is already stated in the brochure given to the complainant.  As he is not covered under the policy, the claim was repudiated.  Hence, they prayed for dismissal of the complaint.

          4.       The evidence in the complaint consists of proof affidavit of the complainant and oral and documentary evidence on both sides. The complainant was examined as PW1 and `Exhibits A1 to A5 were marked on his side.  The 2^nd opposite party was examined as OPW1 and Exhibits B1 to B4 were marked on their side.  On the basis of the evidence adduced, the District Commission passed the impugned order.  Aggrieved by the said order, the 2^nd and 3^rd opposite parties have filed this appeal.

          5.       Heard both sides.  The learned counsel for the appellant submitted that the policy ‘Medi Classic Insurance Policy’ (Medi Family package plan) issued to the complainant is meant for persons aged between 5 months and 45 years.  This was explained in the brochure given to the insured at the time of taking the policy.  As he was aged more than 45 years, he was not covered under the policy for the period from    07.01.2011 to 06.01.2012, during which period he was hospitalised.  The complainant took a separate policy in his name alone thereafter.  As the complainant is not covered under the policy, the insurance company is not liable to pay any claim and hence repudiated the claim of the complainant.  Therefore, the learned counsel prayed for allowing the appeal and setting aside the order of the District Commission.

          6.       The learned counsel for the respondents submitted that the complainant was taking the policy continuously from 05.01.2009 onwards and that he was not aware of the fact that he was excluded from the policy for the period from 07.01.2011 to 06.01.2012.  The insurance company never informed him that they cannot cover persons aged beyond 45 years under this policy.  The respondent has paid the premium as demanded by the insurance company on getting the renewal notice.  Repudiation of the claim is not justified. Hence, he prayed for dismissal of the appeal and confirming the order of the District Commission.

          7.       We have considered the submissions on both sides and perused the records.  This is a complaint in which the insurance company repudiated the claim on the ground that the respondent/complainant is not covered under the policy as he exceeded the age of 45 years at the time of renewal of the policy.  The insured has been taking the policy from 05.01.2009 onwards for himself, wife and daughter.  The first policy No.P-181314/01/2009/001864 (Exhibit A1) was for the period from 05.01.2009 to 04.01.2010 (Exhibit A1) and he has paid a  premium   of  Rs 2,238 + Service Tax 277/- totalling  Rs.2,515/-(Rupees Two Thousand Five Hundred and Fifteen only). The policy was renewed for the period from 07.01.2010 to 06.01.2011 vide policy No.P-181314/01/2010/003823 (Exhibit A2) by paying a premium of  Rs.2,238/- + service tax Rs.231/- totalling Rs.2,469/-(Rupees Two Thousand Four Hundred and Sixty Nine only).

8.       Exhibit A3 is the renewal policy No.P-181314/01/2011/005378 for the period from 07.01.2011 to 06.01.2012 which is relevant in this complaint. The complainant was treated in the hospital and claimed reimbursement of treatment expenses during this policy period. The premium paid was Rs.2,391 (Gross premium 2,168 + ST 223) for renewal of the policy. In this policy, though the complainant’s name is mentioned as proposer, only his wife and daughter have been included as insured persons. The contention of the appellant is that the policy can be issued to persons aged upto 45 years only and the complainant was excluded from the policy as he exceeded 45 years of age. It is contended that this restriction is stated in the brochure given to the insured. The appellants have produced a part of the brochure (Exhibit B1) in which it is stated that any person aged between 5 months and 80 years are eligible for the policy which is applicable for individuals.  In case of family package, which is applicable for family, the eligible age is from 5 months to 45 years.   It is to be borne in mind that a brochure is only a tool for promotion of a product and not forming part of the policy issued to the respondent/complainant. As brochure is not a part of the insurance contract, conditions stated there in are not applicable and relevant in this case.  We also observe that nothing is stated in the policy issued to the complainant, restricting issuance of the policy to those who are only in the age group of 5 months to   45 years.

9.       The complainant is covered under the first and second policies (Exhibits A1 and A2).  The date of birth of the complainant is 21.05.1964 and he attained the age of 45 years on 21.05.2009, during the currency of the first policy itself.  Exhibit A2 is the second policy issued by the insurance company after he has attained the age of 45 years.  Hence, the arguments of the appellants that they are not issuing the policy for persons aged 45 years and above is untenable and cannot be accepted. Moreover, age restriction for issuing the policy is not stated in the terms and conditions of the policy. Hence, unilaterally excluding the complainant from the policy on renewal amounts to deficiency in service on the part of the insurer.

10.     Exhibit B2(4) is the renewal notice issued by the insurance company regarding renewal of the policy expiring on 06.01.2011(Exhibit A2).  The renewal notice states as under:

          “We wish to inform you that your policy No.P-181314/01/2010/003823 is coming up for renewal on 06.01.2011.  Premium based on the expiring policy works out to Rs.2,391/- (Rupees Two Thousand Three Hundred and Ninety One only) including Service Tax.  The cheque/demand draft for renewal premium favouring “Star Health and Allied Insurance Co. Ltd.” indicating the policy number of the cheque/demand draft may be mailed to our branch for the issue of the renewal policy”

11.     From the renewal notice it is clear that, the insurance company has not stated anything about the exclusion of the complainant from the insurance policy consequent on his attaining the age of 45 years.  It is clearly stated that the premium based on the expiring policy was Rs.2,391/-(Rupees Two Thousand Three Hundred and Ninety One only) which was paid by the respondent/complainant vide receipt No.11-01/1133005536 dated 15.12.2010.  Thus the respondent’s /complainant’s bonafide belief was that the policy was renewed on the same terms and conditions, covering himself, wife and daughter. The individual policy {(Ext B3(1)}was taken by him only after his hospitalisation, i.e. from 20.06.2011. There is no case by the appellant that the respondent/complainant wanted to add or delete any of the members covered in the expiring policy, on the basis of renewal notice.  Moreover, there is no evidence to show that the complainant was given an opportunity to migrate to another policy on expiry of the policy. Hence, there is no substance in the contention of the appellant that the respondent was not covered under the policy issued for the period from 07.01.2011 to 06.01.2012, which covers his period of hospitalisation.  We are of the view that Exhibit A3 policy was wrongly issued, arbitrarily excluding the respondent/complainant from the policy. The complainant has paid the renewal premium for himself and family as demanded by the insurer in the renewal notice, and hence he is deemed to have been covered under Exhibit A3 policy.

          12.     In view of the above, we concur with the finding of the District Commission that there was deficiency in service on the part of the 2^nd and 3^rd opposite parties. We find no grounds to interfere with the order of the District Commission and hence the appeal is liable to be dismissed and the order of the District Commission is to be confirmed.

13.     In the result, the appeal is dismissed and the order dated 21.01.2015 in C.C.No.128/2011 of the District Commission is confirmed.  There shall be no order as to costs.

14.     The statutory deposit of Rs20,065/- (Rupees Twenty Thousand and Sixty Five only) made before this Commission by the appellants at the time of filing this appeal shall be disbursed to the complainant/respondent, on proper acknowledgement. The balance amount due as ordered shall be paid by the appellants within one month from the date of receipt of a copy of this judgment, failing which the respondent is at liberty initiate appropriate proceedings for executing the order.

SL