By Sri. MOHANDASAN.K, PRESIDENT
1. The first complainant is an employee of Aryavaidhya Sala, Kottakkal and the second complainant is the wife of the first complainant. The complainants are covered with insurance policy issued by the first opposite party in the name of Aryavaidya sala, Kottakkal and the policy coverage extended to the complainant’s family. The policy number is 1004002818P109841016, which is issued through second and third opposite parties.
2. The submission of the complainant is that the complainant had remitted Rs.7500/- towards insurance premium during 2017 -2018 and at that time he was unmarried. The first complainant married the second complainant on 26/08/2017 and the second complainant delivered twins on 26/05/2018 as premature during 7th month itself and the female baby died within 3 days of delivery and the male baby still alive. The complainant claims Rs.3,00,000/- from the first opposite party towards the treatment expense.
3. The submission of complainant is that at the time of subscribing the policy the first complainant being unmarried the father and mother was covered and thereafter marriage the wife and the family has to be covered naturally. Subsequent to the marriage the complainant ought to have remitted Rs.9,200/- rupees towards the insource to cover his father and mother and in the absence of the same the complainants and the child are covered as per the policy. The complainant contended that to avail insurance coverage for the parents, the complainant is liable to pay additional insurance premium of Rs.9,200/- after the marriage. The complainant enquired the matter with the second and third opposite parties and they suggested that the wife and child includes within the insurance coverage and the parents naturally goes out of the coverage and if the coverage is required for the parents, the additional premium has to be paid and also said that it can be done at the time of renewal of the insurance policy. The complainant has not received any insurance benefit during the period 2010-2018.
4. The complainant spends Rs.38,526/- for the treatment of the child who died within three days of delivery. The complainant submit that the opposite party so far not paid the claim and even not denied the claim. The complainant submit that the opposite parties had said to the complainant that, the complainant is entitled for the benefit and the denial of the insurance by the opposite party is a mistake. The complainant spent Rs.2,09,752/- for the treatment of male child. The complainant submits the insurance transactions were done through the second and third opposite parties. Both the second and third opposite parties instructed the complainant to do the necessary things for availing insurance coverage. The complainant submits that as per the terms of the insurance policy, the family includes heads of the family and children. In the matter of unmarried people alone the parents include under the policy coverage. The specific allegation is that at the instance of marriage, the complainants and children begotten in the marital relation are the beneficiaries and the parents naturally exclude from the insurance coverage. But in this complaint opposite party denied the insurance coverage without any proper reason. The complainant alleges deficiency of service on the side of opposite party and attempt of the opposite party is to make illegal benefit which is definitely comes under the purview of consumer protection act and so the complainant prays the treatment expenses of Rs.38,566/- and Rs.2,09,752/- and also compensation of Rs.3,00,000/- on various heads along with cost of Rs.50,000/-.
5. On admission of the complaint notice was issued to the opposite parties and on receipt of notice the first opposite party entered appearance and filed version. The second and third opposite parties did not appear and so they called and set exparte.
6. The first opposite party filed version denying the averments and allegations in the complaint. The opposite party admitted that the complainant paid Rs.7,500/- as premium for the insurance coverage and there is insurance coverage for the complainant. The opposite party contended that the marriage of the complainant held on 26/08/2017 with the second complainant is not been intimated to the opposite party and was not paid additional premium to include the second complainant to be insured in the above policy. The policy which is issued to Kottakkal Arya Vaidya Sala with UDC number 4281, which is covered the first complainant and his parents. The opposite party submitted that the intimation regarding the marriage of the first complainant was received to the first opposite party only after the expiry of the policy and so no inclusion of any member can be made. The opposite party submitted that the allegation of the complainant that on 26/05/2018 the second complainant had a premature delivery on the 7th month and that too twins and the girl child in that delivery died on the third day itself and the boy is alive, is not known to the first opposite party till the expiry of the policy. The complainants have not intimated the fact of marriage and not paid additional premium to add the second complainant, the complainants are not at all entitled to get any amount as treatment expenses for the premature delivery and consequential expenses. As per the policy conditions there is a waiting period of 9 month in case of maternity expenses, after the inception of the name of his spouse in group policies. The opposite party admitted that the policy in dispute was done by the second and third opposite parties.
7. The opposite party admitted that before marriage the complainant has to pay only Rs.7,500/- as premium and the beneficiaries are the father and mother, but after the marriage the spouse will naturally be included is false and so denied. The opposite party contended that after marriage a premium of Rs.9,200/- is to be paid not to include the parents but to include spouse and for that additional premium is to be paid and only after the intimation and payment of additional premium the spouse will be added to the list of beneficiaries. The opposite party also denied the allegation that second and third opposite parties intimated the complainant that after marriage automatically the spouse will be included in the list of beneficiaries is absolutely false and in correct. The opposite party admitted that the complainant has not availed any Mediclaim during the period as contended in the complaint.
8. The opposite party specifically contended that the complainant has not intimated the fact of marriage and has not paid any additional premium to include the wife as a beneficiary. The complainant without intimating the above said fact, claim form was submitted on 10/09/2018, intimating regarding the marriage, premature delivery, death of girl child and expenses incurred for treatment. The submission of the opposite party is that in the absence of intimation of marriage, non-payment of additional premium and 9 months waiting period of maternity benefit make the complainant not entitled to get any medical expenses or compensation as the second complainant is not a beneficiary as on the date of the policy. Hence the submission of the opposite party is that the allegation that the opposite party has not paid any amount as claimed is true, but has not rejected the claim is incorrect and false. The opposite party submitted that if a policy holder gets married the above fact is to be intimated and the additional premium is to be paid and then only the spouse come in to the fray of the policy cover. The opposite party submitted that they have not cheated the complainant and no deficiency of service caused from the side of opposite party. It is submitted that the contract of insurance is a contract of indemnity and it is the duty of the insurer to indemnify the insurer. But for a contract of indemnity both parties to the contract should be genuine and bonafide. In this complaint the insured has not acted bonafide and genuine. The complainant neither intimated about the marriage nor paid any additional premium but intimated the fact of marriage as well as pre mature delivery and other details after the expiry of the policy. Hence the submission of the opposite party is that the present complainant is filed by the complainant on an experimental basis to get compensation of which the complainant clearly knows that they are not entitled for any benefit or any compensation as prayed in the complaint.
9. The complainant and first opposite party filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A4 and the documents on the side of opposite party marked as Ext. B1. Ext. A1 is copy of insurance policy number 1004002817P109271712 from 30/07/2017 to 29/07/2018. Ext. A2 is copy of claim form. Ext. A3 is discharge bill dated 29/05/2018. Ext. A4 is discharge bill dated 23/06/2018. Ext. B1 is copy of insurance premium with the list of employees covered by the policy.
10. Heard complainant and first opposite party. Perused affidavit and documents.
The following points arise for consideration: -
1) Whether the claim of the complainant is covered by the policy?
2) Whether there is deficiency in service on the part of the opposite parties?
3) Relief and cost?
11. Point No.1 &2
The first opposite party admitted issuance of policy number 100400281P109841016 in favor of Kottakkal Arya Vaidya Sala which in turn covered UDC number 4281, the first complainant and his parents. But the Ext.B1 shows the policy number as 1004002817P109271712 from 30/07/2017 to 29/07/2018. The contention of the opposite party is that the insurance coverage extends to the complainant and his parents only. The intimation regarding the marriage of the first complaint is received by the first opposite party only after the expiry of the policy and as the policy has expired no inclusion any member can be made. The opposite party further contended that the second complainant had a premature delivery on the 7th month that too for twins and the girl child in that delivery died on the third day and the boy is alive is not known to the first opposite party till the expiry of the policy. It is submitted that the complainant has not intimated the fact of marriage as well as has not paid additional premium to add the second complainant, the complainants are not at all entitled to get any amount as treatment expenses for the premature delivery and consequential expenses.
12. The contention of the first complainant is that he married the second complainant on 26/08/2017 and she delivered on 26/05/2018 that too twins and the female baby died after three days and the male baby still alive. The complainant spent Rs.2,48,318/- rupees for the treatment of the babies. The grievance of the complainant is that at the time of subscribing the policy he was unmarried and so his parents were covered under the policy. But after the marriage the wife and children are naturally entitled the insurance protection. If the parents are part of the insurance coverage during the marriage of the first complainant naturally, they will go outside the protection of insurance policy and the wife and children being part of the policy coverage. The submission of the complainant is that for the insurance protection of the parents after the marriage of the first complainant, he is bound to pay insurance premium as additional. But the opposite party do not admit the version of the complainant and submitted that the complainant was not informed the marriage to the insurance company and the parents of the first complainant will not go outside the insurance coverage automatically. The opposite party also contended that the complainant informed about the marriage and delivery after expiry of the insurance policy.
13. In this complaint, complainant and opposite party produced copy of the policy and they are marked as Ext. A1 and B1 respectively. The Commission has gone the averments of Ext. B1 copy of the insurance policy which comprises 200 pages. In page 3 of the Ext. B1 document specifically mentioned as follows: -
14. Underwriter Remarks: - 2133 employees (self + spouse + children) covered with 2.5 Lakhs floater. Parents of unmarried employees are covered. Coverage for spouse is from date of marriage. Room rent limited to Rs.2,000/- per day (APPL only for room rent & Nursing Exp & other associated charges has to be paid extra, proportionate clause will apply. ICU restricted to Rs.4,000/- per day, (Appl only for ICU charges & not for associated charges). Proportionate clause will apply pre hospitalization 30 days post hospitalization 60 days, maternity not covered, baby coverage including all expenses of babies from day one for full sum insured. Corporate buffer (floater) Rs.10 lakhs, Max Rs.1Lac /case /employee & buffer amt extended to family members of those employees, who have not claimed consecutively for 5 years, Ayurveda hospitalization treatment -50% copay on admissible amount. Dental coverage for injury due to accidents only. 5% copay for all cashless claims, capping on ailment – angioplasty limit Rs.1.20 lakhs per claim, Cataract - Rs.22,000 per claim, proportionate clause applicable. TPA fees reduction by 1.5%.
15. The perusal of the Ext. B1 regarding the coverage under the policy, it is apparent that the insurance policy naturally covers self, spouse and children. The wording parents of unmarried employees are covered is an addition and it is also specified that the coverage for spouse is from the date of marriage itself. So, the contention of the complainant that the complainant is entitled the benefit for the spouse from the date of marriage is evident from the document Ext. B1. The complainant has no case that they intimated the fact of marriage to the first opposite party immediately after the marriage. But the contention of the complainant is that the complainant had approached the second and third opposite parties to clarifying whether the complainant has to take any steps to get covered under the policy after the marriage. The reply of the second and third opposite party was that on marriage the complainant naturally becomes under the coverage of the policy and if at all is liable to pay additional premium that can be paid at the time of renewal of the policy/premium. The first opposite party admit that the third opposite party is the authorized agent of the first opposite party and through the third opposite party the policy was issued in the matter. In this complaint the notice was issued to the second and third opposite parties but they remained exparte in the matter. The complainant has got a case that the opposite party have not intimated the complainant regarding the repudiation of claim at any point of time. Though the opposite party contended in the version the claim was repudiated but no document is seen produced to establish the contention. So, the commission finds that in the absence of denial by the third opposite party regarding the intimation of marriage to the first opposite party and thereby lapse of taking required steps to avail the insurance coverage for the spouse is a default from the part of third opposite party and third opposite party is being the agent of the first opposite party is liable for the act of third opposite party. It is also evident that the first opposite party so far not issued repudiation notice to the complainant with proper explanation. It is also right to hold the marriage, delivery and treatment of babies were held during the valid period of insurance.
16. In the light of averments in Ext. B1, we accept the contention of the complainant that the complainants are entitled insurance coverage from the date of marriage and non-intimation of marriage and lapse of taking further steps from the side of complainant was occurred due to improper advice given by the third opposite party, the agent of the first opposite party and for that the complainant cannot be victimized. There is no doubt the complainant was married during the valid period of the insurance policy and the second complainant gave birth to twins as contended in the complaint. Hence the complainant is naturally entitled for the benefit of policy. The absence of intimation is not because of the fault of the complainant and so that cannot be considered as ground for repudiation of claim by the opposite party. The insurance legislation is a social welfare legislation and the object of the legislation cannot be defeated through raising hyper technical and flimsy reasons. The employer of the complainant subscribed the policy to protect the genuine interest of its employees. Hence, we find that there is deficiency in service on the part of first opposite party and defective service on the part of third opposite party. We hold the complainant is entitled the insurance benefit under the policy.
17. Point No.3
The complainant claims that he spends Rs.38,566/- for the treatment of the female baby who died within three days and the complainant claims Rs.2,09,752/- for the treatment expense of second male baby who still alive with interest at the rate of 12% per annum. The complainant also prayed compensation of Rs.2,00,000/- on account of deficiency in service and also Rs.1,00,000/- on account of difficulties, inconvenience and hardship and mental agony caused to the complainant due to the act of the opposite party. Complainant prayed Rs.50,000/- as cost of the proceedings. The contention of the opposite party is that the complainant is not entitled for the insurance coverage and so they are not liable to pay any amount to the complainant. But on perusal of the documents and affidavit it is already finds that the complainant is entitled insurance coverage as per the policy. The opposite party has not specifically denied the extent of compensation. So, there is no contra evidence against the quantum of expense met by the complainant for the treatment of children. So, it will be correct to hold that the opposite parties’ liable to pay the treatment expense of Rs.2,48,318/- to the complainant. The complainant claimed an amount of Rs.3,00,000/- as compensation on various counts and we find it is an exaggerate amount towards the compensation. We consider Rs.1,00,000/- as reasonable amount of compensation on account of deficiency in service and thereby caused inconvenience and hardship and mental agony to the complainant. We allow Rs.10,000/- towards the cost of the proceedings.
In the light of above fact circumstances we allow this complaint as follows: -
1) The opposite parties are directed to pay Rs.2,48,318/- to the complainant on account of treatment expenses.
2) The opposite parties are directed to pay Rs.1,00,000/- as compensation to the complainant on account of deficiency in service and thereby caused inconvenience, hardship and mental agony to the complainant
3) The opposite parties are directed to pay Rs.10,000/- as cost of the proceedings.
The opposite parities shall comply this order within one month from the date of receipt of copy of this order, failing which the complainant is entitled interest at the rate of 9 % per annum from the date filing this complaint till realization.
Dated this 2nd day of November, 2022.
Mohandasan K., President
Preethi Sivaraman C., Member
Mohamed Ismayil C.V., Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A4
Ext.A1: Copy of insurance policy number 1004002817P109271712 from 30/07/2017 to 29/07/2018.
Ext.A2: Copy of claim form
Ext A3: Discharge bill dated 29/05/2018.
Ext A4: Discharge bill dated 23/06/2018.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1
Ext.B1: Copy of insurance premium with the list of employees covered by the policy.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
