D.O.F:12/11/2020
D.O.O:12/07/2022
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.No.153/2020
Dated this, the 12th day of July 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Sudheesh Kumar,
R/at 103/39, Sai Shakthi Layout Road,
Near Sri Narayan Guru Temple
Mylasandra,
Bangalore, Karnataka. 560068 : Complainant
(Adv: T.C. Narayanan)
And
1. Chief Manager,
Head Office, United India Insurance
Company Ltd, Head Office 24,
Whites Road, Chennai, 600014 : Opposite Parties
2. United India Insurance Company Ltd,
Tiger Hills, Post Box No. 19,
Muncipal Office Road
Kasaragod – 671121
(Adv: K. Vinod Kumar OP1 & 2)
3. Medi Assist Insurance TPA Private Ltd,
Tower D, 4th Floor, IBC Knowledge Prk,
4/1, Bannerghatta Road,
Bangalore - 560029
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed for compensation on the ground of service deficiency
On the part of the Opposite Parties.
The facts of the case in brief is that the complainant took the lnsurance policy, namely, Criti Care Health policy of the Opposite Parties by remitting the premium amount of Rs-3177/- on 27.12.2018. and the Opposite Party No.2 issued the policy No.1020002818P112414814. The period of in insurance coverage is from 27.12.2018 to 26.12.2019.The sum insured under the policy is for a total sum of Rs.5,00,000/-and at the event of the insured person being diagnosed with one of the critical illness defined in the policy, the company shall pay the sum insured. Cancer of specified severity , first heart attack of specified severity, coronary artery surgery, heart valve replacement, coma specified severity, kidney failure, stroke resulting in permanent symptoms, major organ /bone marrow transplant multiple sclerosis, motor neuro disease with permanent symptoms, permanent paralysis of limbs are covered in the policy.
The complainant was admitted at the insurer’s net work Hospital namely, Narayana Hridayalaya, Banglore on 29-06-2019 and he had detailed diagnosis from there and it was found that he had features of left upper limb and lower limb weakness, sudden onset, high blood pressure, right lentiform and right corona radiata acute infract and Cardio Electro Physiologist advised to follow up in OPD for one month continuous Holter monitoring for further management etiology of stroke was likely. As per the policy the complainant informed the Opposite Party about the hospitalization and requested for the sum insured as per the terms of the policy and promises .But the Opposite Parties repudiated the claim as per the letter dated 31-01-2020, stating the reason that the patient was admitted with possible diagnosis of TIA as per summary and there is no permanent neurological deficit lasting more than three months. But the complainant was admitted with possible diagnosis of TIA but it was not confirmed. The actual illness was Cerebral Vascular Hyper tension and it has no connection with TIA and he could not move a bit during the last 10 months and he was completely bed ridden and was suffering from permanent neuro logical deficit lasting more than three months Further there is no exclusion clause, in the policy hand book of the Opposite Parties The denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony. The complainant asses his damages to a tune of Rs. 10,00000/- Hence this complaint is filed for direction to the Opposite Parties to pay Rs.10,00000/- towards the compensation and also the costs.
The opposite party No.1 and 2 entered appearance and filed written Version.
As per the written version of the Opposite Party No.1 and 2, the complaint is false and not maintainable either in law or on facts. It is admitted that the Opposite Parties they have issued Criti Care Health policy by receiving the premium amount of Rs-3177/- on 27.12.2018, and the Opposite Party No.2 issued the policy No.1020002818P112414814. The period of in insurance coverage is from 27.12.2018 to 26.12.2019. The coverage under the policy is limited as per the endorsements, conditions and limitations of the policy. It is also admitted that. Cancer of specified severity , first heart attack of specified severity, coronary artery surgery, heart valve replacement, coma specified severity, kidney failure, stroke resulting in permanent symptoms, major organ /bone marrow transplant multiple sclerosis, motor neuro disease with permanent symptoms, permanent paralysis of limbs are covered under the policy. It is true that the complainant submitted a claim dated 20.08.2019 claiming an amount of Rs.5,00,000/-. But the Discharge summary and the other documents submitted revealed that the complainant was admitted with possible diagnosis of TIA (Transient Ischemic Attack )and started on dual antiplatelets and strain and he was discharged on improved condition. As per the policy condition No.7 any cerebro vascular incident producing neurological sequel , which include infraction of brain tissue, thrombosis in intra carnieal vassal hemorrage and embolization excluding the 1) Transient Ischemic Attack, 2)Traumic Injury of the brain and vascular disease effecting only eye or optic or vestibular functions are only covered by the policy. For getting coverage for stroke under the policy, diagnosis has to be confirmed by a specialist medical practitioner and evidence by typical clinical symptoms as well as typical findings in CT scan or MRI of brain . As the documents produced by the complainant did not show any such disease covered by the conditions of the policy, the Opposite Parties rightly decided to repudiate the claim and hence the claim is closed treating it as no claim and intimated the same to the complainant as per the letter dated 31.01.2020.
There is no service deficiency or unfair trade practice on the part of the Opposite Parties. The Opposite Parties are not liable to pay any amount to the complainant and the complaint is liable to be dismissed .
The Opposite Parties NO.3 did not appeared nor filed any version.
A witness namely Mr.Siby Mammen,the brother in law of the complainant filed proof affidavit in lieu of chief examination and documents produced by he complainant were marked as Ext.A1 to A4. He witness was cross examined as PW1. The Ext - A1 is the Criti Care Policy issued by the Opposite Parties., Ext. A 2 is the Policy Prospectus. Ext. A3 is Policy Handbook, Ext.A4 is the copy of the Medical Records.
The opposite party's did not adduce any oral evidence nor produced any documents
Based on the pleadings and evidence of the rival parties in this case the following
issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of any of the opposite party?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainant is that he took the insurance policy, namely, Criti Care Health policy of the Opposite Parties by remitting the premium amount of Rs-3177/- on 27.12.2018 and the Opposite Party No.2 issued the policy No.1020002818P112414814. The period of in insurance coverage is from 27.12.2018 to 26.12.2019. The sum insured under the policy is for total sum of Rs.5,00,000/-and at the event of the insured person being diagnosed with one of the critical illnesss defined in the policy, the company shall pay the sum insured. The complainant was admitted at the insurer’s net work Hospital namely, Narayana Hridayalaya, Banglore on 29-06-2019 and he had detailed diagnosis were made from there and it was found that he had features of left upper limb and lower limb weakness, sudden onset, high blood pressure, right lentiform and right corona radiata acute infract and Cardio Electro Physiologist advised to follow up in OPD for one month continuous Holter monitoring for further management etiology of stroke was likely. As per the policy the complainant informed the Opposite Parties about the hospitalization and requested for the sum insured as per the terms of the policy and promises. But the Opposite Parties repudiated the claim as per the letter dated 31-01-2020 stating the reason that the patient was admitted with possible diagnosis of TIA as per summary and there is no permanent neurological deficit lasting more than three months. But the complainant was admitted with possible diagnosis of TIA but it was not confirmed. The actual illness was Cerebral Vascular Hyper tension and it has no connection with TIA and he could not move a bit during the last 10 months and he was completely bed ridden and was suffering from permanent neuro logical deficit lasting more than three months. Further there is no exclusion clause in the policy hand book of the Opposite Parties.
The Opposite Parties admitted that they have issued Criti Care Health policy
by receiving the premium amount of Rs.3,177/- on 27.12.2018 and the Opposite Parties No.2 issued the policy No.1020002818P112414814. The period of in insurance coverage is from 27.12.2018 to 26.12.2019.
The coverage under the policy is limited as per the endorsements, conditions and limitations of the policy. It is true that the complainant submitted a claim dated 20.08.2019 claiming an amount of Rs.5,00,000/-. But the Discharge summary and the other documents submitted revealed that the complainant was admitted with possible diagnosis of TIA (Transient Ischemic Attack )and started on dual antiplatelets and strain and he was discharged on improved condition. As per the policy condition No.7, any cerebro vascular incident producing neurological sequel , which include infraction of brain tissue, thrombosis in intra carnieal vassal hemorrage and embolization excluding the 1) Transient Ischemic Attack, 2)Traumic Injury of the brain and vascular disease effecting only eye or optic or vestibular functions are only covered by the policy. For getting coverage for stroke under the policy, diagnosis has to be confirmed by a specialist medical practitioner and evidence by typical clinical symptoms as well as typical findings in CT scan or MRI of brain. As the documents produced by the complainant did not show any such disease covered by the conditions of the policy, the Opposite Parties rightly decided to repudiate the claim and hence the claim is closed treating it as no claim and intimated the same to the complainant as per the letter dated 31.01.2020.
So the main argument of the Opposite Parties is that as per the policy condition No.7, any cerebro vascular incident producing neurological sequel , which include infraction of brain tissue, thrombolysis in intra carnieal vassal hemorrage and embolization excluding the 1) Transient Ischemic Attack, 2)Traumic Injury of the brain and vascular disease effecting only eye or optic or vestibular functions are only covered by the policy.
The complainant argue that even though the complainant was admitted with possible diagnosis of TIA , it was not confirmed. The actual illness was Cerebral Vascular Hyper tension and it has no connection with TIA and he could not move a bit during the last 10 months and he was completely bed ridden and was suffering from permanent neuro logical deficit lasting more than three months. Further there is no exclusion clause in the policy hand book of the Opposite Parties.
The Opposite Parties did not care to prove their case by adducing reliable evidence. Therefore it can be held that the complainant is entitled for insurance benefit and the denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties.
Therefore considering the facts and circumstances of the case and in the absence of rebuttal evidence this commission is of the view that there is service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony. Therefore the Opposite Party is liable to pay compensation for that The complainant asses his damages to a tune of Rs. 10,00,000/- But there is no evidence for such a huge loss or damage in this case. Admittedly the sum insured in the Criti Care Policy of the complainant is Rs. 5,00,000/- Hence this commission is inclined to allow that amount of Rs.5,00,000/-. Since the Opposite Parties repudiated the claim without valid reason, there is service deficiency on their part due to which the complainant suffered mental agony and hardships and hence Opposite Parties are liable to pay compensation. This commission hold that Rs. 50,000/- would be a reasonable compensation in this case.
ln the result, the complaint is allowed in part and the Opposite Parties are directed to pay a total amount of Rs. 5,00,000/- with 8% interest per annum from 12.11.2020, the date of complaint till payment, to the complainant .The Opposite Parties are also directed to pay Rs. 50,000/-(Rupees Fifty Thousand only) towards compensation and Rs.5,000/- (Rupees Five thousand only) towards the costs to the complainant.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Criti care policy
A2- Policy Prospectus
A3- Policy Handbook
A4- Medical Records
Witness Examined
Pw1- Sibby Mammen
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
