cccccPBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of October 2012
Filed on : 27/12/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 721/2011
Between
Preejo Peter, Staff Nurse, : Complainant
S/o. Peter E.P., Edakkalthur House, By Adv. K.G. Sunil Kumar
Marathakkara, Thrissur. Thottungal house,
Thrikkumaramkudam,
Thrissur-3)
And
1. Managing Director, : Opposite parties
Paramount Health services (TPA) (absent)
Pvt. Ltd., Kankathuparambu,
Chittoor road, Kacheripadi,
Kochi-682 018.
2. Managing Director,
Paramount Health Service (TPA)
Pvt. Ltd., D 39 Okhla Industrial Area,
New Delhi-110 020.
3. Manaing Director,
United India Insurance Co. Ltd.,
Okhla Road, New Delhi-110025.
4. Manager,
United India Insurance Co. Ltd.,
Round North, Thrissur-680 001.
(O.Ps. 3 & 4 impleaded as per
order in I.A. No. 329/2012
dt. 26/05/2012)
O R D E R
A Rajesh, President.
The facts of the complainant’s case are as follows:
The complainant availed a family medi calim policy of the 4th opposite party for the period from 19-11-2010 to 18-11-2011. While so the father of the complainant had to undergo treatment for heart disease at Trichur Heart Hospital, Thrissur. The complainant had to spend Rs. 1,39.444/- towards treatment expenses. The complainant submitted insurance claim application before the 1st opposite party. Since there was no response the complainant caused to issue a lawyer notice dated 29-09-2011 to the 1st and 2nd opposite parties only when the opposite parties opted to reply stating untenable contentions. Thus the complainant is before us seeking direction against the opposite parties to pay the insurance claim together with compensation of Rs. 25,000/- and costs of the proceedings.
2. In spite of receipt of notice of this complaint from this Forum the opposite parties 1 to 3 opted not to contest the matter for their own reasons. Proof affidavit has been filed by the complainant. Exts. A1 to A6 were marked. Heard the counsel for the complainant.
3. The points that arose for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim
from the opposite parties?
ii. Whether the opposite parties are liable to pay compensation
and costs of the proceedings to the complainant?
4. Point No. i. Admittedly the complainant was holding valid insurance policy of the 3rd opposite party for the period from 19-11-2010 to 18-11-2011 evident from Exts. A1 and A6. It is not in dispute that during the currency of the policy the complainant’s father had undergone treatment for acute AWMI/ PRIMARY PTCA WITH STENT TO OCCULED LAD DONE from 31-03-2011 to 05-04-2011 evidenced by Ext. A2 discharge summary. It is also not in dispute that the 1st opposite party has repudiated the claim of the complainant as per Ext. A6 letter dated 01-11-2011 stating as follows:
The Mediclaim documents of Mr. Preejo E Peter on 13-04-2011 were received. However no intimation was received within 24 hours from the date of admission i.e., 31-03-2011. As per policy terms and condition no. 5.3,”Upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to TPA named in the schedule immediately and in case of emergency hospitalization with in 24 hours from the time of hospitalization / Domiciliary hospitalization”. Since this condition is not complied is not complied with, the claim of the insured has been repudiated.”
5. Neither the complainant nor the opposite parties did produce the terms and conditions of the policy in this Forum. It is the duty of the insurance company to substantiate the reasons for the repudiation of the insurance claim, in this case not forthcoming. The clause that the complainant has intimated the insurance company within 24 hours from the date of admission can only be taken as directory not mandatory because at such a time and circumstances were the insured is critically hospitalized. No such probabilities can possibly be entertained by the close relatives who might even be unaware of such an insurance policy let alone the family members. The situation leaves us with no other option but to allow this complaint.
6. In the above circumstances we are of the firm view that the 3rd opposite party is contractually and legally liable to pay the insurance claim of the complainant. However nothing is on record to show the sum insured as per the policy. In that view of the matter we find that a direction to the 3rd opposite party to pay the insurance claim of the complainant subject to the sum insured as per the policy is enough to abate the agony of the complainant.
7. Point No. ii. The primary complaint of the complainant having been met squarely no question of compensation and costs necessarily arises.
8. In the result, we partly allow the complaint and direct that the 3rd opposite party shall pay the insurance claim of the complainant subject to the sum insured as per the insurance policy together with interest @ 12% p.a. from the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of October 2012
