IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 15thday of February, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R, Member
Sri. K.M. Anto, Member
C CNo. 224/2018 (filed on 24-10-2018)
Petitioner : M C Suresh,
S/o. M P Chandrasekharan,
Madathinkal House,
Maalam P.O. Kottayam,
Pin – 686 019.
Vs.
Opposite Party : The Branch Manager,
M/s. Star Health & Allied
Insurance Co. Ltd. II Floor,
Puthenpurackal Complex,
MC Road, Kodimatha,
Kottayam – 686 013.
(Adv. Avaneesh V.N.)
O R D E R
Sri. Manulal V.S. President
The complaint is filed under Section 12 of Consumer Protection Act, 1986.
The case of the complainant is as follows,
The complainant is a consumer of the opposite party and paid premium to avail Senior Citizens Red Carpet insurance for his mother named Savithri. His mother was treated at J.K. Medicare hospital for mid zone pneumonia with sepsis, acute enteritis as IP from 28-07-2018 to 02-08-2018. He had spent total amount of Rs.15,092/- for the treatment. After discharge, the complainant submitted claim application to the opposite party along with all the documents. On 17-09-2018, the opposite party deposited an amount of Rs.8,626/- towards the full and final settlement. Later the opposite party issued a letter stating details of claim statement and it is seen from the bill assessment sheet that the oppo0stie party made arbitrary deduction for an amount of Rs.1,550/- as nursing charge without assigning any reason. The amount paid for medicines are seen deducted for the reason that it comes under consumables and deducted 30% of the amount as co-pay. It is averred in the complaint that earlier claims in respect of treatment as per policy were previously settled by the opposite parties before the Forum without deducting any amount as co-pay. The opposite party made deduction for an amount of Rs.6,466/-, out of total claim amount, which is not justified and arbitrarily made for undue gain for the opposite party. According to the complainant, there is a clear deficiency in service on the part of the opposite party by withholding Rs.6,466/- and the complaint is entitled for the same. Hence this complaint is filed for an order to direct the opposite party to pay Rs.6,466/- with interest and for compensation of Rs.10,000/-.
Upon notice, opposite party appeared and filed version contenting as follows.
The complainant had taken a policy of health insurance from the opposite party under the Senior Citizens Red Carpet Insurance policy bearing No.P/181113/01/2012/000818 which is valid for a period commencing from 28-06-2011 to 27-06-2012 and the sum assured was Rs.1,00,000/- and the same policy was renewed up to 29-06-2019. At the time of availing the policy, the complainant was supplied with terms and conditions of the policy. The complainant’s mother Savithri was admitted at JK Medicare & Diabetes Centre, Kottayam on 28-07-2018 for the treatment of Mid Zone pneumonia with sepsis and Acute Enteritis and after the treatment she was discharged on 02-08-2018. As per the terms and conditions of the Senior Citizen Red Carpet Insurance policy clause 5, the policy is subject to co-payment of 50% of each and every claim around within all preexisting diseases and 30% of each and every claim for all other claims.
As per the policy terms and conditions of the policy, the room, boarding and nursing expenses as provided by the hospital/nursing home at 1% of sum insured subject to maximum of Rs.10,000/-. In case on hand the wife was admitted for 5 days and complainant submitted total room rent and nursing expenses of Rs.6,550/- but as per the policy norms the complainant was eligible for Rs.5,000/- as room rent with nursing expenses and the opposite party allowed Rs.5,000/-. The complainant is not entitled for compensation or cost of the proceedings. There is no deficiency in service from the side of the opposite party.
The complainant filed proof affidavit in lieu of chief examination and marked Ext.A1 from their side. Padma Prabha P, who is the Chief Manager, Legal filed proof affidavit in lieu of chief examination and got marked Ext.B1 to B5 from their side.
On evaluation of complaint, version and evidence on record, we would like to consider the following points.
- Whether there is any deficiency in service from the part of opposite party?
- If so what are reliefs?
For the sake of convenience, we would like to consider Point No.1 and 2 together.
Point No.1 and 2
There is no dispute on the fact that the complainant had availed a Senior Citizens Red Carpet Insurance Policy for his mother Savithri vide policy No.P/181113/01/2012/000818. It is also admitted by the both parties that the complainant’s mother was treated at J.K. Medicare Hospital for mid zone pneumonia with sepsis, acute enteritis as IP from 28-07-2018 to 02-08-2018. According to the complainant, he had spent Rs.15,092/- for her treatment. The specific case of the complainant is that out of total amount of Rs.15,092/-, the opposite party allowed only Rs.8,626/- for her treatment expenses. It is alleged by the complainant that the opposite party illegally deducted an amount of Rs.1,550/- as nursing charge and deducted 30% of amount from the amount paid for medicine as co-payment. According to him, the opposite party had illegally made a deduction of Rs.6,466/-, out of total claim without any justification. The complainant was resisted by the opposite party on the ground that as per the terms and conditions of the policy, the complainant is entitled only 1% of sum assured per day for the room and nursing expenses. In the case on hand the sum assured was Rs.1 lakh and the complainant is entitled only Rs.1,000/- per day under the head of room and nursing charges. And opposite party further contents that as per clause 5 of the terms and conditions of the policy, the policy is subject to co-payment of 50% of each and every claim around out of all pre-existing diseases and 30% of each and every claim for all other claims. Ext.A1 proves that opposite party had deducted Rs.6,466/- from the total claims under various heads. Ext. B2 which is the policy schedule proves that the policy was continuously renewed by the complainant from 28-06-2011 onwards. Ext.B1 is the terms and condition of Senior Citizens Red Carpet insurance policy. On perusal of Ext.B1, we can see that room paid and as provided by the hospital/nursing home @1% of sum insured subject to maximum for Rs.4,000/- per day. On perusal of Ext.B1, we can see that in clause 5 of exclusion clause it is stated 50% of each and every claim arising out of all preexisting diseases as defined and 30% in all other claims which are to be borne by the insured. During the course of argument, the complainant submitted the opposite party had not provided the terms and conditions of a policy to him. On perusal of Ext.B1, we can see that there is no evidence to show that Ext.B1 terms and conditions of the policy was in respect of Ext.B2 insurance policy schedule. The opposite party admits that the date of inspection of the 1st policy was during the year 2011 and the policy was continuously renewed without any interruption. According to the complainant, at the time of 1st inspection of the policy, there was no condition of co-payment, 1% of sum insured to the room paid and nursing expenses. Though the opposite party contented that the change in terms and conditions of the policy was duly informed to the complainant they did not produce any evidence to show the same. It is pertinent to note that this Commission vide in IA No.25/2020 direct the oppositeparty to produce the postal receipt or documents relating to courier delivery to show that the terms and condition of the policy was duly intimated and served to the complainant at the time of renewal of policy. But the opposite party failed to produce the same. The opposite party did not produce the terms and conditions of the policy at the time of the 1st inception of the policy.
Hon’ble Supreme Court in Jacob Punnan Vs. United India Insurance Company Limited (2021 (6) KLT Online 1185 ) (SC) has held that insurer was under a duty to disclose any alternation in the terms and condition of the contract of insurance at the formation stage (or as in this case, the stage of renewal), the insurer cannot be heard to say that the insurer were under an obligation to satisfied themselves, if a new term had been introduced. The Hon’ble Supreme Court further held that the insurer was clearly under a duty to inform the appellant policy holders about the limitation which was imposing in the policy renewed. Its failure to inform the policy holders results deficiency of services.
As discussed earlier, the opposite party had failed to prove that they had duly informed the change in the terms and conditions in respect to the expense regarding boarding, room and nursing charges and with the condition of co-payment of medical expenses to the complainant. Therefore, we are of the opinion that the opposite party has committed deficiency in service by non-disclosure about the introduction of clause of limitation in the terms and conditions of the policy. In the version and evidence, the opposite party had admitted that though they have paid an amount of Rs.8,626/- to the complainant as medical expenses there was an amount of Rs.289/- is due to the complainant as per the statement of account. It is very interesting to note that though the opposite party claims that they have processed the claims of complainant with due diligent there is an amount of a 289/- is due to the complainant. It is clearly shows that the manner in which the opposite party process the claim of the policy holders to honour their legally entitled claims. The irresponsible and negligent conduct of the officials of the opposite party amounts to dereliction in duty and thereby caused much hardship and loss to the policy holders. Any fault, imperfection or inadequacy in the quality and nature of the services amounts to deficiency in service under ConsumerProtection Act. Therefore, we are of the opinion that the opposite party has committed deficiency in service by not fully honoring the medical claim of the complainant as agreed by the opposite parties under contract of insurance. No doubt due to the deficient act of the opposite party, the complainant had suffered much loss and mental agony for which opposite parties are liable to compensate. In the light of above discussion and evidence on record we allow this complaint and pass the following Order.
- We hereby direct the opposite party to pay Rs.6,466/- to the complainant ie. the amount which is incurred by the complainant for his medical treatment.
- We hereby direct the opposite party to pay Rs.5,000/- as compensation to the complainant for the mental agony and hardship suffered by him due to the deficiency in service of the opposite parties.
The Order shall be complied within a period of 30 days from the date of receipt of Order.If not complied as directed, the award amount will carry 9% interest from the date of Order till realization.
Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Commission on this the 15th day of February, 2022.
Sri. Manulal V.S. PresidentSd/-
-
Sri. K.M. Anto, Member Sd/-
Appendix
xhibits marked on the side of the complainant
A1 -Letter dtd.18-09-18 issued by opposite party to petitioner
Exhibits marked from the side of opposite party
B1 – Original policy conditions issued by opposite party
B2 – Copy of policy schedules
B3 – Discharge summary dtd.02-08-18 from Medicare & Diabetes Centre
B4 – Copy of payment voucher dtd.18-09-18 by opposite party
B5 – Copy of authorization for enhancement of amount dtd.30-08-16 by opposite party
By Order
Assistant Registrar
