D.o.F:13/02/2012
D.o.O:10/3/2014
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.NO.244/12
Dated this, the 10th day of March 2014
PRESENT:
SMT.P.RAMADEVI : PRESIDENT
SMT.BEENA K.G : MEMBER
SMT.SHIBA.M.SAMUEL : MEMBER
K.Balakrishnan, S/o Late Sri.P.Koman,
Appooghar, Po.Ramdas Nagar,
Kasaragod.
(Adv.K.V.Prabhakaran)
1.The Divisional Manager,
United India Insurance Co.Ltd,
Tiger Hills, Muncipal Office road,
Kasaragod.
2.M/s good Health Plan Ltd,
Door No.CC41/1064C,Golden Plaza Annex Complex,
Chittor Road, Opp. My moon Theatre,
Pullapady Junction, Ernakulam 682018.
- M/s good Health Plan Ltd
Plot No.49,Nagarjuna Hills,
Panjagutta,Hyderabad-82.
4. Dr.Prasad Menon, Administrator,
Kasaragod Institute of Medical Science,KIMS,
Ashwini Nagar,Kasaragod.671121.
(Adv.C.Damodaran,Kasaragod)
ORDER
SMT.SHIBA.M.SAMUEL : MEMBER
The gist of the complainants case is that the complainant had taken individual health Insurance policy for self and his wife from Ist opposite party. On 17/2/12 the complainant’s wife admitted in KIMS for treatment of bilateral varicose veins and undergone surgery. On 17/2/12 Rs.15,000/- was sanctioned for surgical management by the 2nd opposite party. But on 22/2/12 4th opposite party herein informed the complainant that the initial amount of Rs.15000/- was cancelled by 2nd opposite party in fax message to KIMS and the same created grave mental agony and frustration. The complainant thereafter on 27/2/2012 submitted medical reimbursement claim for 49.230/- to 2nd opposite party. Evenafter repeated phone calls and personal enquiry Ist opposite party herein failed for a settlement within reasonable period. Opposite parties herein without any written communication allowed only Rs.9738/- against the total claim of 49230/-. The opposite parties 1 to 3 denied the right of cashless facility and repudiated Rs.40,000/- from reimbursement claim, acted in an extraordinary negligent and irresponsible manner which resulted heavy financial crisis and mental sufferings and thereby filed this complaint claiming Rs.40,000/- with interest and Rs.50,000/- as compensation.
2. Opposite parties 1&4 appeared and filed version. Opposite party No.3 filed memo adopting the version of Ist opposite party and 2nd opposite party has not filed any version. According to opposite parties 1&3 the repudiation is as per the policy condition since the disease varicose vain does not occur suddenly and the complainant availed policy by suppressing material facts ie her preexisting disease and further averred that complainants’ wife was under treatment for a long time as the disease is gradual and time consuming in curing . The complainant knowing fully well the terms and conditions of the policy made an attempt to get the doctors bill included in the hospital bill and contended that there is no deficiency of service on the part of the opposite parties and hence the complaint is liable to be dismissed. 4th opposite party herein contended that he is unnecessarily dragged in this matter and he is not having any role in the dispute between the complainant and opposite parties 1 to 3 prayed for a disposal on merit and according to them there is no deficiency in service on their part.
3. Complainant filed proof affidavit and examined as PW1 in support of his claim. Exts.A1 to A20 marked through him and he was cross examined by the counsel for the opposite party. For opposite parties counsel represented that they have no oral evidence and Ext.B1 marked. Both sides heard and the documents carefully perused.
4. The points for consideration are
- Whether there is any deficiency in service on the part of the opposite parties 1 to 3?
- What order as to relief and costs.
5. Point No.1: While considering this point it is absolutely necessary to evaluate the evidence tendered by PW1 while examining him. Through PW1 Ext.A1 to A20 marked. While perusing Exts.A1& A2 it is crystal clear that the complainant had availed individual health Insurance Policy for himself and his wife. Ext.A3&A5 would prove that the wife of complainant had undergone surgery for varicose vain. Ext.A5 is the fax message which shows that an amount of Rs.15000/- was sanctioned as initial authorization for surgical management and the Ext.A6 is the document which shocked the complainant by cancelling the cashless facility of initial authorization dated 22/2/12. Moreover the same is not intimated to the complainant, but it was communicated to the KIMS. The complainant herein who is the policy holder were not even asked to prefer reimbursement of claim. Even though the opposite parties had a specific case of preexisting disease, in the cross examination the complainant denied all the suggestion put forwarded to him and opposite party failed to prove their case by bringing any evidence in contrary to that effect. Due to the act of the opposite parties complainant had grave mental agony and frustration in his old age and found it very difficulty to manage liquid cash hurriedly for settling the hospital charges. We are of the opinion that the complainant might have suffered a lot especially in his advanced age of 66 years and he being a retired government servant who lives on his monthly pension taken the Health Insurance Policy with the hope that it would be of help in his future. The Hon”ble National Disputes Redressal Commission in the case of National Insurance Co. Limited Vs. Bipual Kundu reported in NC&SC on consumer cases part VI 1985-2005 page No.9695 held that the insurance company cannot avoid consequence of insurance contract by simply showing inaccuracy or falsity of the statement made by policy holder and burden of proof on insurer to show that the statement on a fact had been suppressed which was material for the policy holder to disclose. By relying upon this dictum we are of the opinion that the repudiation of Rs.40,000/- from the reimbursement claim amounts to deficiency of service and negligence on the part of the opposite parties Nos1 to 3.
6. Point No.2: While considering the mental agony and difficulties sustained to the complainant especially in his advance age , we are of the opinion that he is entitled for an amount of rs.40,000/- and to pay an amount of Rs.15,000/- as compensation for mental agony deficiency in service from the side of opposite parties 1 to 3 with a cost of Rs.3000/- . Time for compliance is limited to 30 days from the date of receipt of copy of order , failing which opposite parties 1 to 3 shall be liable to pay interest @9% for Rs.40,000/- from the date of complaint till the date of actual payment to the complainant by Opposite parties 1 to 3. Opposite party No.4 is exempted from the liability.
Exts:
A1-copy of insurance ID
A2- copy of policy
A3-copy of discharge notes
A4-copy of RFA vericose veins post procedure orders
A5-copy of fax message
A6-copy of denial of cashless access
A7-copy of inpatient advance receipt
A8-copy of discharge bill
A9toA11-copy of receipts
A12-copy of letter from PW1 to OP.2
A13-copy of claim form
A14-copy of expenses bill
A15-copy of letter from PW1 to OP.1
A16-letter from OP.1 to PW1
A17-certificate issued by KIMS
A18-letter from OP.1 to PW1
A19-copy of additional information request form
A20-copy of letter from OP.2 to PW1
B1- Health insurance policy
PW1-K.Balakrishnan-complainant
Sd/ Sd/ Sd/
MEMBER MEMBER PRESIDENT
eva
/Forwarded by Order/
SENIOR SUPERINTENDENT
