BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM PRESENT: SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER C.C. No: 161/2001 Filed on 05..04..2001 Dated: 30..06..2010
Complainants: COINPAR, Centre of Indian Consumer Protection & Research, Mudavanmugal, Thiruvananthapuram, represented by its Secretary General, M.A. Vahab hereinafter called COINPAR. J. Jeswin Vetha Jeyasingh, Scientist/Engineer-SE, CAD/MEE, VSSC, ISRO P.P., Thiruvananthapuram. Y. Justus Chellapaul, 86F, Joedaniel Street, Nagercopil – 629 003.
Opposite parties:
M/s United India Insurance Co. Ltd., Regd & Head Office, 24, Whites Road, Chennai – 600 014 represented by its Managing Director. (By Adv. R. Jagadish Kumar) M/s. United India Insurance Co. Ltd., Divisional Office No.1, LMS Compound, Thiruvananthapuram – 695 033. Represented by its Divisional Manager.
This O.P having been heard on 22..04..2010, the Forum on 30..06..2010 delivered the following:
ORDER SMT. S.K.SREELA, MEMBER:
The facts of the complaint are as follows: Initially 2nd complainant subscribed to a Group Medical Insurance Policy having the master policy No. 100400/48/37/229/98-99 and as per certificate No. 0038 dated 26/03/99 for an insurance stake of Rs.15,000/- for himself and members of his family consisting of five individuals including the 3rd complainant. The period of insurance runs from 26/03/99 to 25/03/2000. Out of the policy sum of Rs. 15,000/- insured, claim emerged and was preferred for an amount of Rs. 11,535/- during May 1999 itself and the opposite party paid the claim without any hesitation. The insurance rules permit enhancement/renewal of the medical coverage on mutually agreeable terms and the 2nd complainant was accordingly advised by the opposite party to do so at his will. Accordingly, the consumer again subscribed for a further Group Medical Insurance policy for Rs. 1,50,000/- by paying Rs.2,873/- which resulted in the issuance of a Mediclaim Insurance Master Policy No. 100400/48/37/229/98-99 and certificate No. 239 dated 22/06/1999 which is valid from 22/06/1999 to 21/06/2000 and included six members of the family for the coverage including the 3rd complainant. This facility was open as part of a Group Insurance Scheme through arrangement with Space Centre Employees Co-operative Society, Thiruvananthapuram in which the policy holder was a member and his father stands as insured. Subsequently, 3rd complainant Mr. Y. Justus Chellapaul fell ill at Madras and was admitted in Malar Hospital, Chennai on 20/9/1999, he had to undergo Heart Bye-pass surgery and the 2nd complainant insured incurred an expenditure of Rs. 1,25,184/- towards the hospital charges including surgery charges. A claim was prepared by the 2nd complainant and submitted to the 2nd opposite party who issued the policy on behalf of the 1st opposite party on 22/06/99. The 2nd opposite party to whom the claim was preferred have failed to respond to the claim so far. The delay in admitting the claim is a deficiency in service and willful negligence which has caused irreparable injury, undue hardships and loss in addition to severe mental agony to the policy holder and 3rd complainant. Any amount of compensation will be insufficient to heal the injury and damages caused to the 2nd & 3rd complainants. In this regard the complainants are entitled to claim huge and punitive damages for the deficiency and willful negligence in service. However the claim amount is limited at Rs. 10,000/- in addition to Rs. 1,25,184/- actually due to the 2nd & 3rd complainants and interest at the rate of 12% per annum till discharge. As the opposite parties failed to resolve the issue, 2nd & 3rd complainants contacted COINPAR the 1st complainant organization to espouse his cause. The 1st complainant issued a notice to the opposite parties calling upon the opposite parties to pay the compensation and the insurance claim with interest due to the consumer within 30 days but the opposite parties did not respond admitting their liabilities. These complainants were left with no option rather than invoking the provisions of Consumer Protection Act 1986 to redress the grievances of the 2nd & 3rd complainants. Hence this complaint. 2. Opposite party has filed their version contending as follows: The complainant is not a consumer as defined in Section 2(d) of the Consumer Protection Act. It is true that the 2nd complainant had subscribed to the Group Medical Insurance Policy Nos. 100/400/48/37/229/98/99. The period of insurance runs from 26/3/1999 to 25/3/2000. The policy sum was for Rs.15,000/-. The insured took the certificate of the insurance for a sum insurance of Rs.15,000/- initially. The initial policy was partially exhausted a new certificate was taken in 6/99 for a sum insured of Rs.1,50,000/- and the present claim in dispute pertains to the certificate. The 2nd policy and its facilities taken by the complainants 2 & 3 is exclusively not applicable for general public. It was exclusively for the members of the Space Centre Employers' Co-operative Society, Trivandrum with whom an agreement was made by the opposite party. Since, most of the members could not enroll in time enrollment facility was exteded to those persons who could not avail the facility. This was misused by the complainants 1 & 2. While the 1st complainant could insure for any amount he initially took a policy for Rs.15,000/- and he got his claim under the 1st policy. The 2nd policy was taken concealing the disease of the 2nd complainant and thereby knock off money which he was not legally entitled to under the policy. Here a facility was misused by the complainants when the same was extended to facilitate the colleagues who had not initially enrolled. Even the name given for enrollments in the 2 policies were twisted by the 1st complainant and thereby mis-lead the opposite party and took the 2nd policy it is not permissible under law. The 2nd insured complainant had first joined the insurance scheme for Rs.15,000/- and claimed Rs.11,500/- and the complainant again joined the scheme for Rs.1,50,000/- on 22/6/1999 and has lodged the claim on 22/10/1999. The 2nd & 3rd complainants knew very well of the existing disease and they have taken the 2nd policy with an eye on bye-pass surgery. Under the terms of the insurance policy the 2nd enrollment is a mis-use of the enrollment facility. The premium collected for the 2nd enrollment which is under the terms of policy which was not entitled to be paid by the complainant and which is not permissible for Rs.2,873/- was asked to be collected by the VSSC Space Centre Employers' Co-Operative Society by the opposite party by voucher and the same has not been collected till date. The balance of Rs.3,500/- which is a balance amount of the policy was sent to the 3rd opposite party for reimbursement of medical expenses by voucher dated 27/4/2001 has also not been returned. Thus, the amount due of Rs.6,373/- ie., to say Rs. 3,500/- to the complainants and Rs.2,873/- the excessive premium paid not permissible have been distributed by vouchers and which has not been collected till date. Hence there is no deficiency of service on the part of this opposite party.
Complainant has filed affidavit and marked Exts. P1 to P8. Exts. D1 to D14 were marked on behalf of the opposite parties.
The following issues arise for consideration: Whether there is any deficiency in service on the part of the opposite parties? Whether the complainant is entitled for the reliefs sought for in the complaint?
3. Points 1 & 2: The allegations in the complaint are that the claim preferred by the 2nd complainant has not been admitted or responded by the opposite parties and according to the complainants the delay in admitting the claim is a deficiency in service. The opposite parties have filed their version stating that the premium collected for the 2nd enrollment which the complainant was not entitled to pay and which is not permissible for Rs. 2,873/- was asked to be collected by the VSSC Space Centre Employer's Co-operative Society by this opposite party and the same has not been collected till date and hence there is no deficiency in service on their part. 4. We have gone through the records produced by both parties. Ext. P4 Claim Form has been submitted on 22/10/1999 and as per Ext. P5, the sum insured opted is Rs.1,50,000/- wherein a total amount of Rs.1,25,184.05/- has been claimed for the expenses incurred by the claimant. The complainants plead that the opposite parties never responded to it. Ext. D8 is the claim note produced by the opposite parties and Ext.D9 is the copy of the claim form which show that the opposite parties were informed about the same. The observation of ADM as per Ext. D8 is that "The Group Policy to members of the VSSC Employer's Co-operative Society was issued in 26th March 1999 where existing disease was also covered. The insured (the claimant) first joined the scheme on for Rs.15,000/- and claimed for Rs.11,500/-. He again joined the scheme for Rs.1,50,000/- on 22/6/1999 (Certificate No.239) and has lodged a claim on 22/10/1999. Since the S.I under normal Medi-claim can be enhanced during its period, I feel we may deem that the second enrollment as enhancement of S.I and consider for payment: Ext. D14 which has been marked subject to objection is seen sent to the Divisional Office at Thiruvananthapuram wherein they have been advised to cancel the second enrollment by refunding the premium collected for the same. Ext. D11 marked subject to objection is the copy of the letter dated 27/4/2001 seen sent to the claimant informing him regarding the enclosure of voucher for Rs. 3,500/- towards the reimbursement of medical expenses (maximum payable). But Ext. D11 is dated 27/4/2001 and the date of filing of this complaint is 5/4/2001. From the above itself it is evident that the same has been sent only after the complainant had approached this Forum for redressal of their grievance. The opposite parties have not explained the reason for non-payment to the claimant in time. The documents produced by the opposite parties are those in between the offices of the opposite parties and complainant has not been informed either about the approval of the claim or regarding the repudiation of the claim. No explanation is forthcoming for such long delay on the part of the Insurance Company in either settling the claim or repudiating the same. Had this complaint not been filed, the complainants would have been probably denied their claim. The insured were forced to pursue endlessly with the opposite parties and had to come with this grievance to this Forum for redressal. We consider this is a clear deficiency in service. As per Ext. D13, the Note to DM reads as 'since VSSC Group Medi-claim policy covers existing diseases and also the claim preferred during the policy period with adequate sum insured, we may pay the claim amount of Rs.1,24,901/- as per bills enclosed in the claim file'. 5. From the foregoing discussions we are of the view that the act of the opposite parties in not considering the claim, amounts to deficiency in service for which the complainants are to be compensated. The Insurance Company cannot escape from the liability for the non-settlement of the claim. In the result, complaint is allowed. Opposite parties are hereby directed to reimburse Rs.1,24,901/- along with a compensation of Rs.5,000/- and cost of Rs.1,000/- to the complainants 2 & 3 within a period of one month from the date of receipt of the order, failing which the entire amount shall carry interst @ 9%. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 30th day June, 2010.
S.K. SREELA, MEMBER.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI.A, MEMBER. ad.
C.C.No.161/2001 APPENDIX I. Complainants' witness : NIL II. Complainants' documents: P1 : Copy of Mediclaim Insurance Master Policy P2 : " proposer details P3 : " Mediclaim Insurance Master Policy P4 : " " P5 : " schedule of expenses incurred by the claimant P5(a) : " consolidated cadiac package statement dated 2/10/99 P5(b) : " receipt (c) : " receipt dated 2/10/99 (d) : " 23/9/99 & 30/9/99 (e) : " 21/9/99 & 24/9/99 (f) : " 25/9/1999 (g) : " prescription dated 23/9/1999 (h) : " 26/9/1999 (i) : " 26/9/1999 (j) : " 27/9/1999 (k) : " 28/9/1999 (l) : " 27/9/1999 (m) : " 30/9/1999 (n) : " 30/9/1999 (o) : " 01/10/1999 (p) : " post operative investigation (q) : " cash bill (r) : " investigation acquisition form dated 7/10/99 P6 : " letter dated 21/09/2000 P7 : " discharge certificate dated 3/10/1999 P8 : " discharge summary
III. Opposite parties' witness: NIL
IV. Opposite partis' documents: D1 : Copy of discharge summary D2 : " clinical findings D3 : " post operative investigation D4 : " discharge certificate D5 : " consolidated cadiac package statement D6 : " Terms and conditions of policy D7 : " period of Insurance dated 26/3/99 to 25/3/2000 D8 : " claim note D9 : " mediclaim insurance policy claim form D10 : " post operative investigation D11 : " letter dated 27/4/2001 D12 : " mediclaim note D13 : " note to DM dated 22/10/99 D14 : " claim under Tailor made mediclaim scheme of VSSC
PRESIDENT
| | [HONORABLE MRS. Smt. Beena Kumari. A] Member[HONORABLE MR. Sri G. Sivaprasad] PRESIDENT[HONORABLE MRS. Smt. S.K.Sreela] Member | | 
