DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,KOZHIKODE

PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB: PRESIDENT

Smt. PRIYA.S, BAL, LLB, MBA (HRM) :  MEMBER

Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER

Tuesday 30^th day of January 2024

CC.96/2018

Complainant

Sandesh. N.K,

Prime Syndicate,

17/1661, Pavamani Road,

Calictu – 673 004.

(BY Adv. Sri. Pavithran.K)

Opposite Parties

1.         Divisional Manager,

The Oriental Insurance Co. Ltd,

Divisional office –II,

11/127, 2^nd floor, Pramod Building,

Cherooty road, Calicut – 1, 673001 (PIN).

2.        The oriental Insurance Co Ltd,

Head Office – A 25/27,

Asaf Ali Road,

New Delhi – 110002

(By Adv. Sri C.K Umasanker for OP1 and 2)

                                                                           ORDER

By Sri. P.C. PAULACHEN  – PRESIDENT

            This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.

2.  The case of the complainant, in brief, is as follows:

The complainant is the holder of Happy Family Floater Policy - 2015 of the opposite parties. The policy covers among other things, the health insurance for the complainant, his wife and 2 children.  The period of the policy was from 26/07/2016 to 25/07/2017. The sum insured was Rs. 3,00,000/- . The insurance cover has been in force since 2009.

3. During the period of the policy, the complainant’s wife Swapna had back pain and she consulted the doctors in Iqraa hospital, Kozhikode. As she had no relief of pain, she was admitted and treated in Sukrutham Ayurveda Chikilsalayam, Mankavu, Kozhikode from 13/12/2016 to 09/01/2017. The total treatment expenses in that hospital was Rs. 81,176.50/-. The complainant preferred a claim with the opposite parties. But the claim was repudiated by the opposite parties without valid reasons as per letter dated 20/03/2017.
4. Thereafter on 28/04/2017 the complainant issued a letter to the insurance company, to which, a reply was sent on 2/05/2017 with untenable contentions. Later, on 19/06/2017 a lawyer notice was issued to the insurance company, which evoked no response. The act of the opposite parties amounts to unfair trade practice and deficiency of service. The complainant is entitled to get reimbursement of the amount claimed for ayurvedic  treatment of his wife and in addition Rs. 15,000/- towards the mental, physical and economic hardship undergone by him.
5. The opposite parties have filed written version wherein they have admitted the policy. According to the opposite parties, the treatment of Swapna was in a private ayurvedic chikilsalayam, contrary to the policy terms and conditions and that was the reason for repudiating the claim. As per the policy terms and conditions, ayurvedic treatment expenses are admissible only when the treatment is taken as an inpatient in a Government hospital or in any institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health. On repudiation of the claim, a letter was received from the complainant citing clause 2.1 of the policy terms and conditions seeking reimbursement. Clause 2.1 mentioned in that letter pertains to the terms and conditions applicable to the policies prior to 28/12/2015 ie before the revision of the terms and conditions of the policy. The claim preferred is based under policy commencing from 26/06/2016 to 25/06/2017 and hence the terms and conditions of the policy revised after 28/12/2015 are applicable and this fact was informed to the complainant. The lawyer notice has been duly replied with. There is no unfair trade practice or deficiency of service on the part of the opposite parties. The complainant has suppressed material facts and has approached the Commission with unclean hands to make unjust enrichment. With the above contentions, the opposite parties pray for dismissal of the complaint.
6. The points that arise for determination in this complaint are:
   1. Whether there was any unfair trade practice or deficiency of service on the part of the opposite parties, as alleged?
   2. Reliefs and costs.
7. Evidence consists of the oral evidence of PW1 and Exts A1 to A14 on the side of the complainant.  RW1 was examined and Exts B1 to B4 were marked on the side of the opposite parties.
8.  Heard.   Brief argument note was filed.
9. Point No.1:  The complainant  has approached this Commission with a grievance that the claim put in by him in connection with the  treatment of his wife was repudiated by the opposite parties without valid reason.
10. The complainant is the holder of Happy Family Floater Policy - 2015 under Silver Plan of the Oriental Insurance Company Ltd. The above policy covers the health insurance for the complainant, his wife and 2 children. The period of the policy was from 26/07/2016 to 25/07/2017. The said insurance cover has been in force since 2009. The sum insured is Rs. 3,00,000/-. On 13/12/2016 the complainant’s wife Swapna was admitted and treated as an inpatient in Sukrutham Ayurveda Chikilsalayam, Mankavu, Kozhikode for back pain and was discharged on 09/01/2017. The total amount spent for the said ayurvedic treatment was Rs. 81, 176.50/-. The complainant preferred a claim for reimbursement of the amount spent for ayurvedic treatment for his wife. The claim was repudiated by the insurance company as per Ext A9 letter dated 20/03/2017.
11. Ext A9 shows that the claim was repudiated for the reason that as per the terms and conditions of the policy, ayurvedic treatment expenses are admissible only when the treatment is taken as an inpatient in a Government hospital or in any institute recognised by the Government and /or accredited by Quality Council of India/National Accreditation Board on Health, whereas, Sukrutham Ayurveda Chikilsalayam does not satisfy the above conditions.
12. The complainant got himself examined as PW1, who has filed proof affidavit and deposed in terms of the averments in the complaint and in support of the claim. Ext A1 is the copy of the policy, Ext A2 is the terms and conditions of the policy, Ext A3 is the copy of the bill dated 25/11/2016 issued by Iqraa Hospital, Kozhikode, Ext A4  is the copy of the MRI scan report dated 26/11/2016, Ext A5 is the copy of the discharge card of the Sukrutham Ayurveda Chikilsalayam, Ext A6  is the copy of the discharge bill, Ext A7 series are the copies of the bills, Ext A8 is the copy of the medical certificate, Ext A9 is the repudiation letter dated 20/03/2017, Ext A10 is the copy of the registration certificate issued by the Kozhikode Corporation, Ext A11 is the copy of the receipt issued by the Kozhikode Corporation, Ext A12 is the letter dated 02/05/2017 issued by the opposite parties, Ext A13 is the copy of the lawyer notice dated 19/06/2017 and Ext A14 is the postal receipt and postal acknowledgment card.
13. The Administrative Officer of the insurance company was examined as RW1 and he has filed proof affidavit and deposed in support of the contentions in the written version. Ext B1 is the copy of the policy with the terms and conditions, Ext B2 is the copy of the letter dated 28/04/2017 issued by the complainant, Ext B3 is the copy of the conditions of the policy and Ext B4 is the copy of the reply notice dated 03/07/2017.
14. PW1 has admitted that he has been continuously taking the policy from the year 2009 onwards and on all occasions while renewing the policy, he was served with the terms and conditions of the concerned policies. So it is not disputed that the complainant was  served with the terms and conditions of the policy covering the period from 26/07/2016 to 25/07/2017. As per the terms and conditions of the said policy produced as Ext B1 in case of Ayurvedic/ Siddha/Homeopathic/Unani treatment, hospitalisation expenses are admissible only when the treatment is taken as an inpatient in a Government Hospital or in any institute recognized by Government and/or accredited by Quality Council of India/National Accreditation Board on Health. Nothing is produced by the complainant to show that Sukurtham Ayurveda Chikilsalayam is an institute  recognised by the Government and /or accredited by Quality Council of India / National Accreditation Board on Health. The complainant has produced Ext A10, which is the copy of the registration certificate issued by the Kozhikode Corporation to Sukurtham Ayurvedic Chikilsalayam. But Ext A10 is not in compliance with the policy conditions above stated. PW1 has admitted in the cross examination that he was under the impression that the said chikilsalayam was having the certification as stated in Ext A9 repudiation letter. Ext A10 will not suffice to prove that Sukurtham Ayurveda Chikilsalayam is a Government hospital or an Institute recognised by the Government and /or accredited by Quality Council of India/ National Accreditation Board on Health. That being the position, the insurance company has rightly repudiated the claim.
15.  The complainant has relied on clause 2.1 of Ext A2 policy conditions. But Ext A2 pertains to policies issued prior to 28/12/2015. The claim is preferred under the policy which commenced from 26/07/2016 and ended on 25/07/2017. So what is applicable is the terms and conditions attached to Ext B1 policy. Ext A2 pertains to earlier policy.
16. Since hospital from where complainant’s wife Swapna had taken treatment does not satisfy the conditions of the policy, the opposite parties is not bound to honour the claim. That being the position, no unfair trade practice or deficiency of service can be attributed against the opposite parties in repudiating the claim. The claim was validly repudiated by the insurance company and consequently the complaint must fail.
17. Point No.2: In view of the finding on the above point, the complainant is not entitled to claim and get any relief as prayed for.

In the result, the complaint is dismissed.However, no order as to costs.

Pronounced in open Commission on this, the 30^th day of  January, 2024.

Date of Filing:   27/03/2018

                                  Sd/-                                                           Sd/-                                                              Sd/-

                          PRESIDENT                                              MEMBER                                                   MEMBER

APPENDIX

Exhibits for the Complainant :

Ext A1 - Copy of the policy.

Ext A2- Terms and conditions of the policy.

Ext - Copy of the bill dated 25/11/2016 issued by Iqraa Hospital, Kozhikode.

Ext A4-Copy of the MRI scan report dated 26/11/2016.

Ext A5 - Copy of the discharge card of the Sukrutham Ayurveda Chikilsalayam.

Ext A6- Copy of the discharge bill.

Ext A7 series - Copies of the bills.

Ext A8 is- Copy of the medical certificate.

Ext A9 -Repudiation letter dated 20/03/2017.

Ext A10 - Copy of the registration certificate issued by the Kozhikode Corporation.

Ext A11 - Copy of the receipt issued by the Kozhikode Corporation.

Ext A12 - Letter dated 02/05/2017 issued by the opposite parties.

Ext A13 - Copy of the lawyer notice dated 19/06/2017.

Ext A14 - Postal receipt and postal acknowledgment card.

Exhibits for the Opposite Party

Ext B1 – Copy of the policy with the terms and conditions.

Ext B2 – Copy of the letter dated 28/04/2017 issued by the complainant.

Ext B3 – Copy of the conditions of the policy.

Ext B4 - Copy of the reply notice dated 03/07/2017.

Witnesses for the Complainant

PW1 -     Sandesh. N.K, (Complainant)

Witnesses for the opposite party

 Nil

                              Sd/-                                                           Sd/-                                                         Sd/-

                       PRESIDENT                                              MEMBER                                              MEMBER

                               True copy,

                                                                                                                     Sd/-                                            

                                                                                                                   Assistant Registrar