D.O.F:21/06/2021
D.O.O:18/07/2022
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.No.99/2021
Dated this, the 18th day of July 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Devasia.A
S/o . Antony,
Kollammarukunnel – House,
Padippu, Shankarampady
Chengala – (Via) Kasaragod - : Complainant
(Adv: T.C Narayanan)
And
1. Chief Manager,
Regd. And corporate Office,
Star Health and Allied Insurance
Insurance Company Ltd,
1, New Tank Street, Nungampakkam,
Chennai – 600034
2. The Branch Manager,
Star Health and Allied Insurance
Insurance Company Ltd,
2nd Floor, Aramana Arcade,
Bank Road, Kasaragod 671121
(Adv: K. Vinod Kumar)
ORDER
SRI.KRISHNAN.K :PRESIDENT
The Complaint is filed under section 35 of Consumer Protection Act 2019
The case of the complainant in short is that he is a L.I.C agent and also attends coolie work. The agent of Opposite Party introduced a family health insurance policy. Accordingly he paid Rs. 16827/- on 25/08/2020 and policy is issued to his name covering supersaver plan which covers preexisting diseases, impatient hospitalization, specified diseases, with all types of treatment.
The Complainant was admitted at MIMS Hospital Kannur on 03/03/2021 for treatment of ASGOS. And he applied for cashless treatment on 04/03/2021. The request is rejected. He got discharged on 05/03/2021. Again re admitted on 18/03/2021. Surgery was conducted for the same illness, he requested for insurance benefit treatment continued for 8 days. The waiting period for pre-existing illness is over. Opposite Party unlawfully repudiated. The relief sought in the complaint is for the claims damages, medical expenses and for mental pain and agony and monitory loss.
The Opposite Party filed written version denying the allegations but admitting the insurance policy during the period Opposite Party admitted hospitalization of the complainant and report received as congenital heart disease. As per exclusion clause, congenial internal disease shall be excluded until expiry of 24 months of continues coverage after inception date other allegations are denied. The Opposite Party submits that complainant is not entitled for any reliefs and policy terms are final. Policy is termed by Govt. of India. Therefore complaint may be dismissed.
The complainant filed chief examination affidavit and was cross examined as Pw1. And produced Ext A1 to A3 documents were marked. Ext A1 is original policy, Ext A2 is hospital bills, Ext A3 repudiation letter. The Opposite Party has no oral evidence but produced documents marked Ext B1 to B3. Ext B1 is the original policy, Ext B2 ECHO report and B3 is TEE report.
Points for considerations:-
- Whether there is any deficiency in service from the Opposite Party is repudiating the claim of insurance reliefs?
- Whether complainant is entitled for compensation? If so for what reliefs?
The insurance policy is obtained to alleviate the sudden and un-expected illness and to meet the expenses thereof and denying its benefits or coverage later is not in accordance with law. The principle of law is well-settled by the reported decision in Jacob Punnen Vs united India Insurance Co. ltd, 09/12/2021- 2021-4-CPR 400-2021 O Supreme (SC) 783 it is held as follows:-
S. RAVINDRA BHAT, KM JOSEPH JJ Insurance Act, 1938 – section 45 –contract Act 1872, section 22 – Insurance, Medi claim Policy partial payment of expenses incurred on Angioplasty there can be said to be no consensus ad idem on introduction of cap on coverage by insurer, as appellant was not informed that they had paid premium for a new policy, but were led to believe that they had in fact renewed pre – existing policy on some terms with only differences being removal of their son as a beneficiary and a higher coverage (from Rupees 6 lakh to Rupees 8 lakh in total) for appellants, which was accepted by insurer – General Rule of acceptance of any insurance proposal by assured involves unconditional acceptance of all terms-cap-on coverage placed by insurer without prior intimation to assured and without providing an opportunity to assured to seek alternative insurance policies that were more favourable to their needs was restrictive, and thus not enforceable. If renewed contract is agreed, inall respects, by both parties fresh terms (with restrictions) would be binding. However that would not be case when a new term is introduced unilaterally, about which policy holder is in dark (para 18,19, and 26).
Consumer protection Act 2019 section 67- Insurance Act, 1938 – sections -45 guidelines on standardization of General terms and clauses in Health Insurance policy contracts dated 11/06/2020 clauses 10 and 14- insurance –medi claim policy- partial payment of expenses incurred on Angioplasty – Relief declined by for below. As principal insurer is liable for acts of its agent. In order to demonstrate deficiency, it is not necessary that same emanates only from a law or a contract principle of uberrima files involves prior intimation of change in terms in insurance contracts deficiency in service assumes even more significance in present case, as it pertains to senior citizens medi claim holders were kept in dark, and asked to renew a policy terms of which had undergone a significant change in that, its cover was radically different, and imposed limitations on insures liability insurer was clearly. Under a duty to inform appellant policy holders about limitations which it was imposing in policy renewed for 2008 – 2009. Its failure to inform policy holders resulted in deficiency in service. Impugned order NCDRC as well as order of State commission set aside (Para 33,34,35,36,37,39 and 40)
In view of settled law, insurer was duty bound to disclose any alternation in the terms of contract of insurance at the formation stage it cannot say that insured was under obligation to satisfy themselves if a new terms introduced..
There is, thus serious deficiency in service and pure negligence in repudiating the insurance benefits and hence complainant is not only entitled to compensation but also payment of medical bills and litigation costs. Total medical bill comes Rs. 1,87, 839/- rounded to Rs 1,88,000/- . Considering the nature of dispute and circumstances of the case, CDRC hereby award a sum of Rs. 10,000/- as compensation for deficiency in service and cost of litigations as Rs.5000/-.
In the result complaint is allowed in part directing the Opposite Party to pay Rs. 1,88,000/- towards medical bills with 6% interest per annum from the date of complaint till its payment and Rs. 10,000/- (Rupees Ten thousand only) for deficiency in service and Rs. 5000/- (Rupees Five thousand only) to cost of litigation within 30 days of the receipt of the order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Original Policy
A2 series- Hospital bills
A3- Rejection letter
B1- Policy
B2- Echo report
B3- Tee report
Witness Examined
Pw1- K.A. Devasia
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
