KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD THIRUVANANTHAPURAM

APPEAL NO.273/10

JUDGMENT DATED 16.4.2011

PRESENT

JUSTICE SHRI.K.R.UDAYABHANU                --  PRESIDENT

United India Insurance Company Ltd.

Head office, Chennai &

Branch Office, Kottayam.

Reptd. by Dr.Mohan Shanker                            --  APPELLANT

Sr.Divisional Manager,

United India Insurance Company,

LMS Compound, Trivandrum.                                                                 

     (By Adv.R.Jagadish Kumar)

                   Vs.

1.      Jacob Punnen

Paraekulam House,

Manganam, Muttambalam P.O,

Kottayam.

2.      Maria Punnen                                            --  RESPONDENTS

     Residing at Paraekulam House,

Manganam, Muttambalam P.O,

Kottayam.

JUDGMENT

JUSTICE SHRI.K.R.UDAYABHANU,PRESIDENT

          The appellants are the opposite parties in CC.166/09 in the file of CDRF, Kottayam.  The appellants are under orders to pay to the complainant a sum of Rs.1,75,000/- being the balance amount payable as per Ext.A2 policy and also Rs.5,000/- as compensation.   It is also mentioned that amount will carry interest at 9%.

          2. It is the case of the complainants’  ie; husband and wife that they had availed medi-claim (GOLD POLICY) of the opposite parties and the same has been renewed periodically up to 2008-09.  The total coverage was Rs.8 lakh (ie; Rs.4,25,000/- for the first petitioner and Rs.3,75,000/- for the second petitioner).  The premium as demanded was paid every year.  The second petitioner underwent Angioplasty at Appolo Hospital, Chennai.  The expenses was incurred amounting to Rs.3,82,705.27.  The opposite party paid only Rs.2 lakh.  The contention of the opposite parties that they are liable    to pay Rs.70% for the sum insured or maximum of 2 lakh for Angioplasty cannot be approved.  It is also alleged that the opposite parties have unilaterally varied  the terms of the existing policy without the knowledge and consent of the petitioners. 

          3. It is the case of the opposite parties  that the sum insured  is Rs.4,25,000/- for the first petitioner and Rs.3,75,000/- for the second petitioner   and that as per   the prior policy the  sum insured for each was Rs.3 lakh.  It is also mentioned that the payment of Rs.2 lakh is legally valid and correct and that the complainant is entitled to get the said amount above.

          4. The evidence adduced consisted of the proof affidavits filed by the respective sides and Exts. A1 to A9,  & B1.

5. The Forum has held that the terms of the policy have been varied without the knowledge and consent of the complainants.

6. We find that the Forum has also noted the Condition No.1.2 (d) in the policy  wherein expenses with respect to major surgery -  Angioplasty is limited to 70% of the sum insured or maximum of Rs.2 lakhs.  Ext.A1 policy produced is for the period from 28.3.06 to 27.3.07.  Ext.A1 would not show that it is “GOLD POLICY”/ medi-claim as is mentioned in Ext.A2.  Further, Ext.A1 was with respect to the complainants and their son whereas Ext.A2 is with respect to the complainants alone.  It has also to be noted that Ext.A2 was produced by the complainants themselves.   Hence they cannot plead ignorance of the conditions in Ext.A2.  The opposite parties as per Ext.A6 has intimated the complainant in response to the letter of the complainant that as per clause 1.2 of the policy, the claim is  restricted to 70% of the sum insured or maximum 2 lakh and that they can only pay Rs.2 lakh.  The contention of the counsel for the respondent/complainant that the opposite parties had no such case is without merits.  We find that the parties are bound by the terms of the agreement/contract.  Hence, we find that the liability of the appellant is limited to the amount mentioned in clause 1.2 (d) of the policy.

7.  In the circumstances, the order of the Forum is set aside and the appeal is allowed.

Office will forward the LCR along with the copy of this order to the Forum.

JUSTICE  K.R.UDAYABHANU --  PRESIDENT