Karnataka

Bangalore 4th Additional

CC/3075/2017

Smt.P.S.Sarika Devi, - Complainant(s)

Versus

M/s Star Health and Allied Ins. Co.Ltd., - Opp.Party(s)

29 Oct 2018

ORDER

Complaint filed on: 28.11.2017

                                                      Disposed on: 29.10.2018

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

 

 

CC.No.3075/2017

DATED THIS THE 29^th OCTOBER OF 2018

 

PRESENT

 

 

SRI.S.L.PATIL, PRESIDENT

SMT.N.R.ROOPA, MEMBER

 

Complainant/s: -                           

1. Smt.P.S.Sarika Devi,

W/o Sri.N.S.Anand,

Aged about 31 years,

 

2. Sri.N.S.Anand

S/o Sri.G.Narayana Murthy,

Aged about 38 years

 

Both are R/at

no.330, 22^nd cross,

III block, Jayanagar,

Bengaluru-11

 

Inperson     

 

V/s

Opposite party/s

Respondent/s:-

 

1. M/s.Star Health and

Allied Ins. Co., ltd.,

Rep by its Branch Manager,

No.1, New Tank Street,

Valluvar Kottam High Road, Nungambakkam,

Chennai-34.

 

Also at no.48/2, I floor,

8^th main, 13^th cross,

Opposite to Canara Union, Malleswaram,

Bengaluru-03.

 

By Adv.Sri.Y.P.Venkatapathi

 

2. Sri.Naveen,

Insurance Agent,

M/s.Star Health and

Allied Ins. Co., ltd.,

no.48/2, I floor,

8^th main, 13^th cross,

Opposite to Canara

Union, Malleswaram,

Bengaluru-03.

 

Ex-parte

 

 

PRESIDENT: SRI.S.L.PATIL

 

 

            This complaint is filed by the Complainant no.1 & 2 (hereinafter referred to as Complainants) against the Opposite party no.1 & 2 (hereinafter referred to as Op.no.1 & 2 or Ops) seeking issuance of direction to pay a sum of Rs.50,000/- with interest at 18% p.a.; to repay the 2 years premium amount of Rs.14,350/-; to pay Rs.25,000/- for travelling expenses, mental agony; to pay cost and to grant such other reliefs deem fit for which the Complainants are entitled to.

 

          2. The brief facts of the case of the Complainants are that, Op.no.1 insurance company sent an agent by name Sri.Naveen who is Op.no.2. He gave them the information on various aspects of the policy. He informed that Family Health Optima Insurance Plan is the best suited for Complainants. Complainant no.1 asked if they will get the insurance benefit on the maternity purpose also. He informed that it will be given only to the customers who complete 2 years of policy with different plan. They were not satisfied about it. He informed that the Op.no.1 gives the maternity benefit in the very first year of the policy and then he tried to convince saying that instead this policy has the advantage of one feature wherein gives the medical cover for the new born baby. He showed the policy coverage which reads as follow: New Born Baby Cover – Hospitalization expenses for treatment of new born baby. This covers starts from 16^th day after birth and is subject to a limit of 10% of sum insured or Rs.50,000/- whichever is less. Complainants further submit that, they considered the policy for some time and then took the policy for the first time on 16.02.16. Op.no.1 gave the policy for first year and Complainant paid an amount of Rs.7159/- for first year policy.  In second year also they took policy by paying Rs.7159/-. Complainants further submit that, in the last week of Feb 2017, Complainant no.1 conceived. Their son was born on 15.09.17. He was due to be born on 27.11.17. But he was born much earlier on 203^rd day.  Since birth he had different medical problems due to preterm and underweight. On 02.10.17, he was admitted to NICU hospital. The doctors at the hospital diagnosed various disorders including: preterm (29+4) weeks, low birth weight (1.06 kgs), Respiratory distress syndrome, late onset sepsis and neonatal hyperbilirubinemia. Since Complainant’s son was finding difficult in inhaling, he was also given oxygen for two days. He was hospitalised for 19 days between 02.10.17 to 20.10.17. For the purpose of claiming the insurance amount, they called insurance agent Op.no.2 to hospital. They gave him the birth certificate and medical papers also. He took the papers and stopped taking our calls. On personal visit to Op.no.1, they realized that he had not even informed the company regarding the birth of son and a possible claim.  They have incurred more than Rs.2 lakhs for medical expenses. Due to the irresponsible behavior of Op.no.2, Complainant personally visited the Op.no.1 Company. Then the Branch Manager of Op.no.1 has declined to pay and settle them the insurance claim as the Op.no.1 had no mood to pay money. He also issued a letter in writing which mentions that the company will not settle the claim as the child was born pre term and low birth weight. The Complainant asked the Manager if the policy given to them mention any such conditions for declining the claim. He failed to explain satisfactorily. He also refused to take any claim application from Complainant for the said reason. In this context, Complainant issued legal notice, but Op not given any reply.  Hence prays to allow the complaint.

 

3. On receipt of the notice, Op.no.1 did appear and filed version denying the allegations made in the complaint. Inspite of notice served on Op.no.2, he did not appear, hence placed exparte. The sum and substance of the version of the Op.no.1 are that, the complaint filed by the Complainant is not maintainable either in law or on facts, hence liable to be dismissed.  All the related documents since will be there with the Chennai head office, as they will be sent to the head office, once the claim is either not made or not reported from the other offices. Hence, the presence of the head office is essential and the head office is necessary and proper party to the proceedings. Op.no.2 is fully aware of the risks assumed under different policies and the nature of risks and the terms & conditions of the policies. They obtained Family Health Optima insurance policy (hereinafter referred to as the said policy) covering Complainant no.1 & 2 for the period from 16.02.16 to 15.02.17 and subsequently renewed the policy for the period from 16.02.17 to 15.02.18. Op.no.1 submits that, the Complainant’s child is not covered under the policy, hence the medical expenses incurred for their child is not payable as per policy terms. There is no deficiency of services rendered by the Op, as to invoke the provisions of CP Act. The complaint is premature. They may kindly be directed with all the relevant documents to approach the Op, for scrutiny of the documents as per the contract and allow to take the decision. Hence, till then the complaint may kindly be kept pending to enable the Complainants to approach the Op.no.1. For any allegations, nothing had prevented the Complainants to approach the head office or Ombudsman. The Op further submits that, the transaction is purely contractual and the deciding of the facts will be only within the agreed scope of the contract, no independent or sympathetic farfetched view of the contract can be taken, contrary to the agreed terms & conditions of the contract and the rules, regulations and procedures enshrined in the insurance laws. Hence on these grounds and other grounds prays for dismissal of the complaint.

         

          4. To substantiate the case, both Complainant no.1 & 2 filed respective affidavit evidence and got marked the documents as Ex-A1 to A22. The Legal Officer of Op.no.1 filed affidavit evidence and got marked the documents as Ex-B1 to B6. Complainant filed written arguments. We have gone through the available materials on record. Heard.

  

5. The points that arise for our consideration are:

1. Whether the Complainant no.1 & 2 proves deficiency of service on the part of Ops, if so, whether they entitled for the relief sought for ?    
2. What order ?

         

           

 

6.  Our answers to the above points are as under:

 

Point no.1: In the Affirmative  

Point no.2: As per the final order for the following

 

REASONS

 

          7. Point no.1:  We have briefly stated the contents of the complaint as well as the version filed by the Op.no.1. The undisputed facts which reveals from the pleadings of the parties goes to show that, Complainants have availed the said policy and paid an amount of Rs.7,159/- in the month of Feb 2016. Then in the month of Feb 2017, Op.no.2 again called for the renewal of the policy for the second year. Hence, Complainants issued a new cheque bearing no.151837 for an amount of Rs.7,159/- drawn on ICICI bank, dtd.10.02.17, which can be seen on going through the contents of Ex-A2. It is also not in dispute that, in the last week of Feb 2017, Complainant no.1 conceived. Their son was born on 15.09.17. He was due to be born on 27.11.17. To substantiate this fact, Complainants produced Birth Certificate marked as Ex-A4. The birth of the said baby appears to be pre-matured, as he was born much earlier on 203^rd day. Since birth, he had different medical problems due to preterm and underweight. Hence, on 02.10.17, he was admitted to NICU, Rangadore Hospital, Shankarapuram, Bengaluru. The expert doctors in the said hospital treated the said baby for 19 days between 02.10.17 to 20.10.17. If the contents of these averments found at para 5 of the complaint are taken in to consideration that the said baby was admitted in the said hospital after 16^th day and got discharged on 20.10.17.

 

          8. The claim repudiated by Op.no.1 was marked as Ex-A11 which reads thus:

To,

Mr.N.S.Anand,

 

Sub: Rejection of Midterm Child Addition              

        P/141115/01/2017/012168

With reference to the above subject, we have not able to add the child cover in the policy due to pre term and low birth weight.

 

For rejection of the claim of the Complainant to the extent of Rs.50,000/-, the reason assigned by the Op.no.1 stating that, they are not able to add the child cover in the policy due to preterm and low birth weight. In this context, we placed reliance on the contents of Ex-A3 which is terms & conditions of the policy, wherein at clause J states that:

J. Hospitalization expenses for treatment of new born baby. This cover starts from the 16^th day after birth and is subject to a limit of 10% of the sum insured or Rupees Fifty thousand, whichever is less, subject to the availability of the sum insured. Note Intimation about the new born should be given to the company and policy has to be endorsed for this cover to commence.

 

9. In the instant case, the baby was admitted after the 16^th day of the birth. So this clause will not come in the way to dishonour the claim of the Complainants. But the reasons assigned by Op.no.1 at Ex-A11 was on account of due to preterm and low birth weight. This condition is nowhere incorporated in the terms & conditions of the policy found at Ex-A3. When such being the fact, the very claim rejected by Op.no.1 is contrary to the decisions reported in:

i) 2009 (3) CPR 53 LIC of India and others vs. Kailash Chandra Kar, Held: Consumer Protection Act is a beneficial legislation and it cannot allow insurance company to escape liability on technical grounds to deprive the consumer of benefits to which he was entitled to.

ii) 2010 (1) CPR 114 National insurance company ltd., vs. Nand Lal, Held: insurance claim must be honestly settled without any delay

 

10. In the light of the decisions cited supra, we come to the conclusion that, the claim of the Complainants rejected by Op.no.1 assigning the reasons as stated in Ex-A11 stating that they are not able to add the child cover in the policy due to preterm and low birth weight have no legs to stand.

 

11. Now, the question that crops up for our consideration is, what is the liability of Op.no.1. Ongoing through the available materials on record, insured amount is Rs.3 lakhs and the policy has been renewed in the second year also. In this context, we confine the claim of the Complainants as sought for only to the extent of Rs.50,000/- with interest at 10% p.a. from the date of repudiation to till the date of realization. Due to non-application of mind, Op.no.1 has rejected the legally considerable claim of the Complainants. In this context, they issued legal notice, for which, there was no any response. Op.no.2 being the agent, though the said fact has been duly informed to him by the Complainants, but he did not respond. Hence, if an amount of Rs.5,000/- is awarded as compensation, we hope ends of justice would met sufficiently. Cost of litigation is fixed to Rs.5,000/-. Since the Op.no.2 is an agent, hence, we fastened the liability on Op.no.1 to realize the aforesaid amount. Accordingly we answered the point no.1 in the affirmative.

 

12. Point no.2: In the result, we passed the following:

 

ORDER

 

          The complaint filed by the Complainant no.1 & 2 is allowed.

 

          2. We direct Op.no.1 & 2 jointly and severally liable to pay Rs.50,000/- with interest at the rate of 10% p.a. from the date of repudiation to till the date of realization to the Complainants.

 

3. We also direct Op.no.1 & 2 jointly and severally liable to pay compensation of Rs.5,000/- and cost of litigation of Rs.5,000/- to the Complainants

 

4. We also direct the Ops to realize the aforesaid amount within six weeks from the date of receipt of this order, failing which the Complainants are at liberty to have the redress as per law.

 

5. Since the Op.no.2 is an agent, hence, we fastened the liability on Op.no.1 to realize the aforesaid amount.

 

          Supply free copy of this order to both the parties.

 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 29^th October 2018).

 

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT

                                                                        

1. Witness examined on behalf of the complainant/s by way of affidavit:

 

Sri.N.S.Anand, who being the complainant no.2 was examined. 

Smt.P.S.Sarika, who being the complainant no.1 was examined. 

 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Insurance policy
Ex-A2	Advance premium receipt
Ex-A3	Customer information sheet – family health optima insurance plan
Ex-A4	Birth certificate
Ex-A5	NICU discharge summary dtd.20.10.17
Ex-A6	Patient IP bill
Ex-A7	Medication prescription
Ex-A8  & A9	bills
Ex-A10	Claim form part A
Ex-A11	Rejection of midterm child dtd.16.11.17
Ex-A12	Legal notice dtd.20.11.17
Ex-A13	RPAD
Ex-A14	Microbiology Report
Ex-A15	Clinical pathology
Ex-A16 to A20	Photos of baby
Ex-A21	Doctor’s prescription
Ex-A22	Pharmacy bill

 

 

 

2. Witness examined on behalf of the Opposite party/s Respondent/s by way of affidavit:

 

Smt.Pushpavathi Sattigodru, who being the Legal Officer of Op.no.1 was examined.

 

Copies of Documents produced on behalf of Opposite party/s

 

Ex-B1	Insurance policy
Ex-B2	Proposal form
Ex-B3	Letter to Op dtd.02.11.17
Ex-B4	Birth certificate
Ex-B5	NICU discharge summary dtd.02.10.17
Ex-B6	Rejection of midterm child dtd.16.11.17

 

 

 

 

 

(ROOPA.N.R)     MEMBER

(S.L.PATIL)  PRESIDENT