Per Mr.H.K.Bhaise, Hon’ble Member
1) The Complainant No.1 is a voluntary consumer organization which has been espousing the cause of consumers. The complainant No.2 is the actual aggrieved consumer who has taken mediclaim policy under which she and her husband are both covered. The O.P.No.1 is the claim processing agent of O.P.No.2/Insurance Company which has issued the mediclaim policy to the Complainant No.2. The complaint is in respect of the deficiency in service and the unfair trade practice of partially settling the claim instead of making full payment.
2) The Complainant No.2 and her husband are insured for Rs.2,50,000/- each with the O.P.No.2 under a mediclaim policy since the past several years and the policy has been renewed from the time to time. At the material time, the policy was in force and Policy No.020681/48/12/97/00000317 for the period from 6th August, 2012 to 5th August, 2013.
3) During the policy period, the husband of the complainant No.2, aged 74 years, had an accidental fall at home due which he suffered a head injury as well as eye and teeth injury. He was hospitalized from 24th January, 2012 to 12th February, 2012 at the Parsi General Hospital for Contused Lacerated Wound (CLW) and contusion over chin, swelling over right eyebrow.
4) The hospitalization bill for the treatment of the traumatic head injury with contused lacerated wound and maxillary haematoma with thin subdural haematoma over the brain on the right side came to Rs.66,858/-. Besides this, there were additional costs of medicines etc. and the total expenses came to Rs.71,158/-. Accordingly, a claim was lodged with the O.P.No.1 for Rs.71,158/- along with all supporting documents.
5) Though the total claim was Rs.71,158/-, the O.P.No.1 merely sanctioned Rs.13,858/- and rejected the balance amount of Rs.57,300/- by O.P.No.1 vide his payment reference advice dated 28th February, 2012. The complainant made enquiries as to a substantial part of claim had been rejected, she was verbally informed that hospitalization for was not required for sixteen days and that only four days hospitalization would be adequate and hence the claim had been processed accordingly. The Complainant No.2 therefore approached the hospital which issued a certificate clarifying that hospitalization was necessary for sixteen days as there was haematoma over the brain on the right side. A copy of said certificate dated 3rd April, 2012 issued by the hospital was forwarded by the Complainant No.2 to the O.P.No.1 along with the representation for considering the payment of claim for entire hospitalization. The Complainant No.2 has also registered a grievance to the Grievance Cell of the O.P.No.2. There after, the O.P.No.1 asked for certain clarification by sending a letter dated 9th April, 2012. The necessary information was furnished thrice as evident from the letter dated 4th April, 2013. However, the opposite parties failed to respond further and the review of the claim for the balance amount has still date neither been admitted nor rejected. Since, the settlement of the balance claim has been pending for an unduly long time, the present complaint has been filed for deficiency in service and for unfair trade practice. Therefore, the complainant has filed this complaint for balance amount of Rs.57,300/- along with interest. The complainant has also claimed compensation of Rs.20,000/- for physical and mental harassment.
6) The O.P. No.1 & 2 were duly served with notices along with copies of complaint and documents. Online tracking report from the site India Post filed by the complainant shows that the said notices were properly delivered to the O.P.No.1 & 2 on their address which were given by the complainant. The opposite parties failed to appear before this Forum. Therefore, the opponents were proceeded ex-parte. The claim of the complainant is supported by the documents on record. The complainant has filed affidavit in support of his claim. The opponents have not challenged the contention of the complainant and claim of the complainant. The claim was already submitted to the opponents by the complainant with due compliance of the clarifications asked by the opposite parties along with necessary certificates for hospitalization etc. The complaint was also lodged with the grievance cell of the O.P.No.2 and claim was resubmitted with certain clarifications. The necessary information was furnished thrice. However, the opponents failed to respond complainant and review of the claim for the balance amount has till date neither admitted or rejected. The expert doctor from the B.D.Petit Parsee General Hospital Mumbai who has provided the treatment has given the justification for 16 days of hospitalization and certified that patient had to be kept under observation for 16 days in hospital and therefore patient did not need neurosurgery. We hold that the rejection of the claim made by the opposite party is unjustified.
7) The opponents have not given reason for denying the claim of the complainant. The complaint has filed copy of health insurance policy on record. The same is not challenged by the opponents. The O.P.No.1 has received the premium for the policy therefore the complainant is entitled for his claim. There is no reason to reject the claim of the complainant. According to the complainant he has submitted the hospital bill of Rs.66,858/-. He has also incurred additional cost. Therefore, he submitted the claim of Rs.71,158/-. The hospital bill for the amount of Rs.66,858/- is on record. The complainant has not produced the bill for the additional cost. Therefore, the complainant is entitled only for the claim of Rs.66,858/-. Admittedly, the complainant received the claim of Rs.13,858/-. The complainant is entitled for the balance of Rs.53,000/-.
8) In spite of service of notice, the opponents failed to satisfy the claim of the complainant thereby complainant suffered from physical harassment and mental tension. The complainant is a senior citizen and had been put unnecessary mental agony and anxiety. We think compensation of Rs.10,000/- is reasonable for negligence, deficiency in service and mental agony suffered by the complainant, a senior citizen. Besides this, the complainant is entitled for the cost of proceeding Rs.5,000/-.
9) In para 10 of the complaint, the complainant has submitted that they have been given to understand that the O.P.No.2 contemplating to load the premium in view of the claim of the complainant. According to the complainant such loading of premium is illegal and contrary to the original policy condition. The complainant has not produced any evidence to show that the O.P.No.2 is going to load the premium. At this moment, this submission is on imagination. On this imaginary submission, the complainant has claimed the relief to direct the opponents to renew the policy as per original terms and conditions. We think it will not be proper to give relief on imaginary submissions. Therefore, the complainant is not entitled for such directions.
10) The complainant hasplaced reliance on the judgment of Hon’ble Supreme Court reported in reported in III (2001) CPJ 10 (SC) in the case of Biman Krishna Bose –Versus- United India Insurance Company Limited, in Civil Appeal No.2296 of 2000 decided on 2nd August, 2001. In this judgment, the Hon’ble Supreme Court has held as under :
“A renewal of insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force. In common parlance, by renewal, the old policy is revived and it is sort of substitution of obligations under the old policy unless such policy provides otherwise. It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as of the original policy”.
In the abovesaid judgment, cheque for premium amount was sent to the insurance company for renewal of the policy but the insurance company refused to renew the policy as the complainant approached the court. The Hon’ble Supreme Court held that rejecting to renew the policy on the ground that the complainant approached the court is not proper therefore the insurance company was directed to renew the policy for the expired period. In para 7 of the judgment, the Hon’ble Supreme Court has laid down as under :
“We, therefore, set aside the order of the High Court to the extent it directed the appellant to take a fresh mediclaim policy. We further direct that if the appellant applies for renewal of his mediclaim policy for the expired period and pays he premium, the respondent company shall renew the said mediclaim policy forthwith”.
The Hon’ble Supreme Court has given direction only for the expired period. In the instant complaint before us, the complainant is seeking direction to renew the policy in future on imaginary ground. Therefore, the abovecited judgment is not applicable in this complaint. Hence, we proceed to pass the following order.
O R D E R
1) Complaint is allowed.
2) The opponents are directed to pay to the Complainant No.2 Rs.53,000/- (Rs.Fifty Three Thousand Only) with interest at the rate of 9% per annum from 28th February, 2012 i.e. the date of partial settlement of the claim till its realization.
3) The opponents are also directed to pay Rs.10,000/- (Rs.Ten Thousand Only) towards compensation for negligence, deficiency in service and mental agony and Rs.5,000/-(Rs.Five Thousand Only) towards cost of the proceeding to the complainant No.2.
4) The above order shall be complied with within a period of one month from today.
5) Copies of this order be sent to the parties free of cost.
Pronounced dated 5th February, 2014
