IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 28th day of January, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 70/2021 (Filed on 30.03.2021)
Complainant : Annamma Joseph,
13 D, Skyline Hill View, Manganam,
Muttambalam P.O, Kottayam, Kerala, Pin-686004
Phone-9947344441
(By Adv.Anish Ramakrishnan)
Vs
Opposite parties :1. Branch Manager,
HDFC Ergo General Insurance Co.Ltd
2nd Floor, W-Mall, K.K.Road
Near K.F.C Kanjikuzhy, Kottayam
Kerala-686004, 04812-573367
(By Adv.Lithin Thomas)
2. Branch Manager,
Bandhan Bank Ltd, Ground Floor
Century Tower, Near Y.W.C.A
M.C.Road, Kottayam-686001
04812585467, 7594817901
(By Adv.Joby Joseph)
O R D E R
Sri.Manulal.V.S, President
The Complaint is filed under section 35 of the Consumer Protection Act 2019.
Case of the complainant is as follows: Complainant is maintaining a savings bank account with the second opposite party. Complainant has availed an insurance policy from the first opposite party. On 28-09-2020 the complainant consulted the doctor at S.H.Medical Hospital Kottayam due to blood in cough. After one month a biopsy was done by collecting samples from lungs of the complainant by admitting her in the hospital. When the complainant contacted the first opposite party for reimbursement it was informed that the reimbursement would be done after confirming the Cancer. It was further informed that the expenses incurred for MRI, PET scan, Blood test would be refunded at the time of admitting her for surgery under the heads of pre and post hospitalization. Thereafter the complainant underwent a surgery at Caritas hospital. Though the complainant lodged a claim with the first opposite party for an amount of Rs.1,38,415/- the first opposite party allowed only Rs.34,931/-. Further on 28-02-2021 the complainant lodged claim with the first opposite party for an amount of Rs.15,482/- for post hospitalization amount. Despite the repeated request of the complainant the opposite parties did not care to reimburse the balance amount to the complainant. According to the complainant the above said act of the opposite parties amounts to deficiency in service and caused much hardship to the complainant. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to refund Rs.1,03,484/- along with a compensation of Rs.1,00,000/- and cost of this litigation.
Upon notice opposite parties appeared before the commission and filed separate version.
First opposite party filed version contending as follows:
Complainant was issued Group Assurance Health Plan Policy vide policy no. 150700/2020/A020484/PE02166757 having coverage for a period from 08-05-2020 to 07-05-2020 having multiple converges as specified in the policy schedule against a total sum insured of Rs.2,00,000/-. The policy coverage shall be restricted to the coverage /benefits as mentioned in the certificate of insurance. Admittedly hospital expenses in connection with surgery were covered by the insurer. The complainant received all the benefit for which she is entitled to receive on the policy. The complainant is not entitled to get any additional claim from the first opposite party. An act of non settlement of claim or failure of the complainant to provide complete information for verification and settlement of claim can no stretch be termed as deficiency in service. There is no deficiency in service on the part of the first opposite party.
Second opposite party filed version contending as follows:
The second opposite party has no authority in settling the disputes pertaining to insurance claim. The second opposite party merely acted as a facilitator and the contract of insurance is essentially between the insurance company and the insured. Second opposite party acts as a facilitator for insured and insurance company and its main function is to provide assistance in transaction with respect to collection and remitting of premium amount and it has no discretion towards the disputes related to insurance claim.
The complainant is maintaining a savings account bearing no.501800237111453 at the Kottayam Branch of the second opposite party since September 2018. At her own will and consent, complainant has also availed an insurance policy from HDFC ERGO Health Insurance Limited (formerly known as Appollo Muich Health Insurance Company). The second opposite party duly explained the terms, conditions and benefits of the various policies to the complainant. The complainant after being satisfied with the terms and conditions signed and filled up the proposal form for the insurance policy and also executed necessary documents for payments for the premiums. After receipt of the duly filled up and signed proposal form together with premium, the second opposite party duly forwarded the same to the first opposite party.
As per the account statement of the complainant it appears that the first opposite party has settled an amount of Rs.26,931/- on 10-03-2021, Rs.8,000/- on 20-03-2021, Rs.24,041/- on 04-04-2021 and Rs.75,546/- on 15-05-2021. There is no deficiency in service on the part of the second opposite party and the complainant is not entitled for any reliefs.
Complainant filed proof affidavit in lieu of chief examination and marked Exhibit A1 to A6 from the side of the complainant. No oral or documentary evidence on the part of the opposite a parties.
On the basis of the contention of the rival parties we framed the following issues for consideration.
- Whether the opposite parties committed any deficiency in service as alleged?
- Regarding the relief and costs?
Point No.1 & 2: For the sake of convenience we would like to consider Point No.1 & 2 together.
Admittedly complainant availed Group Assurance Health Plan Policy of the first opposite party vide policy no. 150700/2020/A020484/PE02166757 having coverage for a period from 08-05-2020 to 07-05-2021. On going through the Exhibit A5 certificate of insurance policy we can see that the sum assured was Rs.2,00,000/-. According to the complainant she had undergone surgery at Caritas hospital after detecting cancer on her lungs. Exhibit A1 proves that the complainant was treated at Caritas hospital as inpatient from 15-12-2020 to 24-12-2020 she had undergone for the procedure ‘Right Bilobectomy (Middle and Lower lobs).’ According to the complainant she had spent Rs.2,05,742/- for the treatment. However against her claim for the said amount the first opposite party approved Rs.1,93,069/-. The specific case of the complainant is that the first opposite party is liable to honor her claim for Rs.69,287/- as post hospitalization and Rs.58,128/- as pre hospitalization and Rs.1,100/- as hospital cash benefits. Though she is entitled for Rs.1,38,415/- as mentioned above the opposite party only allowed Rs.43,931/- under these heads.
The complaint is resisted by the opposite parties that the complainant received all the benefit for which she is entitled to receive on the policy. The complainant is not entitled to get any additional claim from the first opposite party. According to the second opposite party as per the account statement of the complainant it appears that the first opposite party has settled an amount of Rs.26,931/- on 10.03.2021, Rs.8,000/- on 20.03. 2021, Rs.24,041/- on 04.04.2021 and Rs.75,546/- on 15.05.2021.
In Export Credit Guarantee Society v. Garg Sons International (2014) 1 SCC 686 wherein Hon’ble Supreme Court held as under:
“The insured cannot claim anything more than what is covered by the insurance policy.” The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely." The clauses of an insurance policy have to be read as they are. Consequently, the terms of the insurance policy that fix the responsibility of the insurance company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonise the terms thereof, keeping in mind that the Rule of contra proferentem does not apply in case of commercial contract, for the reason that a Clause in a commercial contract is bilateral and has mutually been agreed upon.”
As discussed above the sum assured was Rs.2,00,000/- and the first opposite party allowed a claim of Rs.1,93,069/- during the policy period of 08-05-2020 to 07-05-2021. Thus remaining amount for which the complainant is entitled for the said period of coverage is only Rs.6,931/-. On going through the exhibit A2 series of bills we can see that the same were the bills of medical expenses incurred by the complainant for pre hospitalization treatment from 20-11-2020 to 14-11-2020. Similarly Exhibit A3 series bills are the bills for the post hospitalization from the period from 30-12-2020 to 19-03-2021. On going through the evidence of this case we can see that the complainant is entitled for Rs.6,931/- only against the claims for pre and post hospitalization. The first opposite party did not adduce any evidence to prove the reason for not allowing Rs.6,931/- to the complainant against her pre and post hospitalization claims. On the basis of the above discussed evidence we are of the opinion that non allowing of Rs.6,931/- to the complainant is inadequacy and imperfection in service by the first opposite party and amounts to deficiency in service on the part of the first opposite party. No doubt the deficient act of the first opposite party caused much mental agony and hardship to the complainant.
Considering the nature and circumstances of the case we allow the complaint against the first opposite party
And pass the following order:-
We herby direct the first opposite party to pay Rs.6,931/- to the complainant along with 9% interest from 30-03-2021 ie the date on which the complaint is filed till realization.
We hereby direct the first opposite party to pay Rs.20,000/- as compensation to the complainant for the deficiency in service on the part of the first opposite party.
Order shall be complied within 30 days from the date of receipt of the copy of this order, failing which the compensation amount will carry 9% interest till the date of realization.
Pronounced in the Open Commission on this the 28th day of January,2023.
Sri.Manulal.V.S, President sd/-
Smt.Bindhu.R, Member sd/-
Sri.K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant.
A1- Copy of the discharge summary dated 24/12/2020 from Caritas Hospital, Thellakom, Kottayam.
A2- Copy of the pre-hospitalization expenses.
A3- Copy of the post-hospitalization expenses.
A4- Copy of the claim repudiation letter dated 18.05.2021 from HDFC ERGO General Insurance Co.Ltd.
A5- Copy of the Group Assurance Health Plan- certificate of insurance.
A6- Biopsy report dated 12.12.2020 issued from Regional Cancer Centre, Trivandrum.
By order
sd/-
Assistant Registrar
