D.O.F: 26/04/2016
D.O.O: 14/03/2019
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.134/16
Dated this, the 14th day of March 2019
PRESENT:
SRI.ROY PAUL :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
Balakrishnan . T.K , S/o K.Ambu,
R/at Thonikkallu House, Paraklayi, : Complainants
Anandhashramam Via, Kasaragod.
(Adv: Babuchandran.K)
And
1. Manasije Mishra. Chief Executive Officer,
Max Bupa Health Insurance Co.Ltd,
B1/ 1-2 Mohan Co Operative Industrial Estate, : Opposite Parties
Mathura Road, New Delhi- 110044
2. Max Bupa Health Insurance co-Ltd,
Zonal Office, South Vaishnavi,Silieon Terrace,
1st Floor, Hosor main Road, Adugodi, Bangalore.
(Adv: Saji Issac. K.J)
3. Joshy. M, S/o Joseph,
Agent of Max Bupa Health Insurance Co.Ltd,
Mandapathil House, Belal P.O. Parappa, Kasaragod.
ORDER
SRI.ROY PAUL :PRESIDENT
This complaint under section 12 of Consumer Protection Act has been filed for an order directing the opposite parties to pay a sum of Rs. 97,000/- as the health insurance claim with interest compensation and cost to the complaint.
The gist of the complaint is that :-
As per the health insurance policy issued by the opposite party the complainant, his wife and two children were insured by receiving Rs.7326/- as premium. During the coverage of the policy the complainant’s younger son Bijith.T.K undergonefor a surgery for breathing difficulties, at Athena Hospital Mangalore on 13/05/2014 and got discharged on 20/05/2014. The claim of Rs.97000/- submitted by the complainant was rejected by the opposite party without any valid ground. There is deficiency of service on the part of the opposite party and the complaint has suffered much hardships, mental agony, loss of time and money. Hence the complaint.
The opposite party No: 1 and 2 entered appearance before the For a and submitted their written version contending that the surgery was for Adenoidectomy. So as per the terms and condition of the policy the opposite party is not liable to pay the claim Sleep related breathing problems also excluded in the policy. There is a waiting period of 24 months. Dental/Oral treatments excluded in the policy. So there is no deficiency of service on the part of the opposite party and complaint may be dismissed with cost. The opposite party 3 was set exparte.
On the basis of the rival contentions in the pleadings the following issues were framed for consideration.
1. Whether there is any deficiency of service on the part of the Opposite Parties?
2. Whether the complaint is entitled for any reliefs?
3. Reliefs and costs?
The evidence consists of the oral testimony of Pw1 and Ext A1 to A3 documents marked on his part. No oral evidence was adduced from the side of opposite party. Exts B1 to B7 documents were marked.
ISSUE No:1
The complainant adduced evidence by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. He was cross examined as Pw1 by the opposite parties and he relied on exhibits A1 to A3 documents also to substantiate his case. According to him as per the terms and conditions of the policy the complainant is entitled for the claim amount, but the opposite parties denied the claim without any valid ground. There is deficiency of service on the part of the opposite party and complainant suffered much hardships, inconvenience, mental agony, loss of time and money.
The learned counsel for opposite parties vehemently argued that there is no deficiency of service on the part of the opposite parties as alleged in the complainant. As per the terms and conditions of Exhibit B1 policy the complainant is not entitled for the claim since the treatment was for sleep disorders Adenoidectomy. As per exclusion clause 4© there is waiting period of 24 month also. Dental/Oral treatments are excluded in(4 (e) (ix) in the policy.
On perusal of the pleadings, documents and evaluation of the evidence we hold that as per the Ext A3 the patient was undergone treatment in order to increase the pharyngeal space advancement of maxilla. The said treatment is not shown in exclusion clause 4 of B1 policy and not comes under the waiting period of 24 months also . so we hold that the complainant is rightly entitled for claim as per the policy and denial of claim amounts to deficincy of service on the part of the opposite parties. We the Fora referred the citation CPJ 2014 (III) NC 268 – Rajendra Singh Vs L.I.C of India. The Honourable National Commission averred that when two reasonable interpretations of terms of policy are possible, interpretation in favour of the consumer should be taken. From the foregoing discussions and findings we are of the considered view that there is deficiency of service on the part of the opposite parties. Hence the issue No: 1 found against the opposite parties and answered accordingly.
ISSUE No: 2&3
As discussed above the complainant is reasonably entitled for the insurance claims from the opposite parties. It is in evident that the complainant has suffered much hardships, inconvenience, mental agony, loss of time and money. As per Ext B5 part medical bill the complainant is entitled for Rs.92911/- as insurance claim from the opposite parties. so we hold that the opposite party No:1 and 2 are liable to pay a sum of Rs.92911/- as insurance claim with interest @ 8% from the date of complaint (26-04-2016) to the complainant along with Rs.5000/- as compensation and Rs.2000/- as litigation cost. Thus the issue No: 2 and 3 are also accordingly answered.
In the result the complaint is allowed directing the opposite party No:1 and 2 pay a sum of Rs.92911/- with interest @ 8% per annum from the date of complaint (26-04-2016) to the complainant along with Rs.5000/- (Rupees Five Thousand only) as compensation and Rs. 2000/- (Rupees Two thousand only) as litigation cost within 30
days of receipt of the order. Failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 1986.
Sd/- Sd/-
MEMEBR PRESIDENT
Exhibits:
A1- Copy of the Insurance Certificate dated: 30-06-2013.
A2- Copy of the Authorization cancellation letter dated: 20-05-2014.
A3- Copy of the Certificate issued by the te Dr. Jagadisha Chandra dated: 18-09-2014.
B1-Copy of the policy document dated: 30-06-2013.
B2-copy of pre- authorization Form.
B3- Copy of denial of authorization.
B4- Copy of discharge summary.
B5- Copy of claim Form.
B6- Copy of letter dated: 05-07-2014.
B7- Copy of Denial letter.
Witness Examined:
PW1 - Balakrishnan. T.K.
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
