PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 27th day of August 2011
Filed on :30/09/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 519/2010
Between
E.M. Paul, : Complainant
Edakkattukudy house, ( By Adv. Tom Joseph,
Kuthukuzhy P.O., Court road, Muvattupuzha)
Kothamangalam.
And
1. M/s. New India Asurance Co. Ltd., : Opposite parties
Ravipuram Divisional Office, (By adv. Lakshmanan T.J.,)
Raman Centre, Penta Queen, Padivattom,
Valanjamabalam, Kochi-16. Kochi-24)
2. M/s. Medi Assist Pvt. Ltd.,
No. 406, Chandralayam,
Kurisupally road, Temple Lane,
Ravipuram, Kochi-682 016.
O R D E R
C.K. Lekhamma, Member.
The case of the complainant is as follows:
The complainant has taken a family medi claim policy with the opposite party since 2004. While so, the sum assured was enhanced as Rs. 1,00,000/- (One lakh) in the year 2008 to 2009.
During March 2010 complainant has lodged a claim for Rs. 42,460/- (No. 505716) before the opposite parties in connection with the treatment of the complainant’s wife. But the opposite parties allowed only Rs. 25,000/- and denied the balance claim amount stating, the reason ‘sub limit exhausted’. The reason given for deduction of the claim amount is unsustainable. The opposite parties are liable to pay the entire claim amount since the sum assured during the period of treatment is one lakh. The act of the opposite parties amounts to deficiency of service. According to the complainant he is entitled to get Rs. 17,460/- together with interest . Hence this complaint.
2.Version of the opposite parties.
The present dispute between the complainant and the 1st opposite party is a quantum dispute and the same is not coming within the purview of a consumer dispute hence the above complaint is not maintainable under the Consumer Protection Act. The claim of the complainant was settled by the opposite party for a sum of Rs. 25,000/- and the complainant had accepted the said amount as full and final settlement of his claim and the same was acknowledged without any protest and now the present complaint for the balance amount is not maintainable either in law or on facts. Initially the sum insured was Rs. 25,000/- each. During the period 2008-2009 the complainant enhanced the sum insured to Rs. 1,00,000/- each. The complainant had submitted a new proposal form before the insurance company for the policy commencing from 05-04-2008 to 04-04-2009. The medi-claim policy for the period from 05-04-2008 to 04-04-2009 contains a specific term on the face of the policy itself that the increased sum insured shall be treated as a fresh insured for all the purposes. Moreover, condition No.6 (d) clearly specify that if the policy is to be renewed for enhanced sum insured then the restriction as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for the difference. The complainant’s wife was admitted in the hospital on 15-03-2010 and discharged on 16-03-2010. In the discharge summary it is also stated that permanent pace maker implantation done DDDR (2007) and the history of the patient was also stated. The insured is not entitled for the benefit of enhanced sum insured since the sum insured was enhanced during 2008-2009 and the treated ailment had contacted even during earlier policy period. The opposite party had acted only in accordance with law relying on the policy condition and their action cannot be termed as a deficiency in service on their part. The complainant is not entitled for the relief’s as prayed in the complaint.
3. The complainant and the opposite party represented through counsel. Ext. A1 to A3 were marked on the side of the complainant. Ext. B1 to B4 were marked on the side of the opposite parties. Thereafter, we have heard the counsel.
3. The points that arose for determination are as follows:
i. Whether the complaint is maintainable?
ii. Whether the complainant is entitled to get entire claim amount from the opposite parties?
iii. Compensation and costs if any
4. Points Nos. i, ii & iii. The opposite parties contended that this complaint is not maintainable since the dispute is only a quantum dispute. It is stated that the settled claim amount of Rs. 25,000/- has been received by the complainant as full and final settlement of the claim and the same has acknowledged without any protest. But there is no evidence to substantiate such contention. In the absence of evidence we are of the firm view that the complaint is maintainable.
There is no dispute with regard to the issuance of the policy. The complainant enhanced the sum insured from 25,000/- to 1 lakh each for the period of 2008 – 2009. The reason for repudiation mentioned in Ext. A1 letter is that “sub limit exhausted”. Ext. A2 is the copy of the request letter issued by the complainant to the opposite parties. The complainant’s wife Smt. Jalaja Paul was admitted in Lakeshore Hospital on 15/03/2010 and discharged on 16/03/2010. The complainant submitted mediclaim for Rs.42,460/-, to the opposite parties in connection with the treatment of his wife. The opposite parties contended that it is mentioned in Ext. B4 discharge summary, that “the insured is a known case of sick sinus syndrome with complete Heart Block under permanent pacemaker implanted in the year 2007”. In the year of 2007 the sum insured was Rs. 25,000. The disease was known before the enhancement of the sum insured. Therefore the claim restricted to Rs. 25,000/-. These opposite parties informed this to the complainant through Ext. A3 letter. To substantiate their contention opposite parties relied Ext. B3, clause 6 (d) Renewal of policy in which it is stated that in the case of renewal of policy with enhanced sum insured the restriction is applicable to a fresh policy.
In order to overcome the said clause the learned counsel for the complainant relied on the decision of the Hon’ble National Commission in Oriental Insurance Co. Ltd., Vs. Madankumar Dutta II (2008) CPJ 366 (NC) The Hon’ble Commission observed that reference to the ‘first year’ in clause 4.3 of the policy would mean the period for which the policy was initially purchased.
The Hon’ble Supreme Court held in Biman Krishna Bose Vs. United India Insurance Company Ltd. (2001 (6) SCC-477). In the case of the renewal of old policy a new contract comes into being, but the said contract on the same terms and conditions as that of the original policy.
5. In view of the said findings we are of the opinion that the complainant is entitled to get mediclaim pertaining to the treatment of his wife as per the enhanced sum insured. In the facts and circumstances of the case we are not ordering any compensation and costs of the proceedings.
6. Accordingly we partly allow the complaint as follows:
The 1st opposite party shall pay the insurance claim amount to the complainant, in accordance of the enhanced sum insured, as per norms.
The above said order shall be complied with within a period of one month from the date of receipt of copy of this order, failing which the amount shall carry interest at the rate of 6% p.a. till realization.
Pronounced in the open Forum on this the 27th day of August 2011.
Sd/- C.K. Lekhamma, Member.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s Exhibits :
Ext. A1 : Copy of letter dt.11/06/2010
A2 : Copy of letter dt. 28-07-2010
A3 : Copy of letter dt. 03-09-2010
Opposite party’s Exhibits :
Ext. B1 : Copy of Proposal form for
ediclaim (Janatha/family
floater/group/medi claim 2007
B2 : Copy of Insurance policies
B3 : Copy of specimen of
policy condition
B4 : Copy of discharge summary
