Date of Filing:15-12-2015
Date of Order: 26-2-2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. D.NIRMALA, B.Com., LLB., MEMBER
Tuesday, the 26th day of February, 2019
C.C.No.24 /2016
Between
Gottipai Srinivasu
S/o.G.V.GKrishna,
Aged about 47 years,
Occ: Business, R/o.flat No.9,
Kanaka Durga Apartments,
Opp: road to Meera Medicals,
Secunderabad - 500003 ……Complainant
And
M/s. Bajaj Allianz General Insurance Co.Ltd.,
Rep.by its Branch Manager,
1st floor, Flat No.115, Bhuvana Towers,
S.D.Road, Secunderabad – 500003,
(As per Memo amended as a M/s. Bajaj Allianz General
Insurance Co.Ltd.,) ….Opposite Party
Counsel for the complainant : M/s.Gopi Rajesh & Associates
Counsel for the Opposite Party : M/s. M.V.R.Suresh
O R D E R
(By Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint is preferred under Section 12 of C.P. Act of 1986 alleging that repudiation of claim submitted by the complainant to the opposite party amounts to deficiency in service hence a direction to the to pay a sum of Rs.7,46,426/- with interest at 18% P.A towards reimbursement of the amount spent by the complainant for treatment and further direction to pay Rs.5,00,000/- towards compensation for causing mental agony by repudiating the claim and a sum of Rs.5,000/- towards costs of this complaint.
- Complainant’s case in brief is that he has taken health insurance policy from the opposite party in 2005 and the renewed every year till 13-11-2015. The last renewal of policy was on 14-11-2015 covering the period from 14-11-2014 to midnight of 13-11-2015 and the policy was known as Health Guard Insurance policy premium and paid was Rs.10,130/-. In the month of November, 2014 complainant was suddenly hospitalized with fever and abdomen pain and got admitted KIMS hospital, Secunderabad and the same was communicated to the opposite party. He was informed by the opposite party to pay the hospital bill and submitted claim for reimbursement. Complainant after treatment discharged from hospital on 16-11-2014 and submitted a claim for Rs.25,333/- for reimbursement of the hospital bill.
The complainant was again fell sick and got admitted in the KIMS hospital and after treatment got discharged on 8-12-214 by paying a bill amount of Rs.28,646/- to the hospital and thereafter submitted the claim for the said amount to opposite party. Again he was hospitalized on 29-12-2014 and after three days treatment was discharged on 30-12-2014 and paid hospital bill amount of Rs.15,280/- and submitted the claim to that effect to opposite party. Again he got admitted in the same hospital on 05-01-2015 with the complaint of Abdominal distension and was discharged on 9-01-2015 and bill amount of Rs.54,237/- was paid at the time of discharge and submitted a claim to opposite party. Again on 18-1-2015 he was got admitted in the same hospital with the complaint of increasing distension of abdomen and decreased urine output and after treatment for three days was discharged on 15-02-2015 and after payment of bill amount of Rs.6,22,930/- and later submitted the claim for reimbursement of the same to opposite party.
After submitting of the above said claims opposite party neither repudiated the claim nor accepted. Originally he took the policy in the year 2013 and continuously renewed without any break and till 2013 for a period of 8 years he has not submitted any claim. First claim submitted in the month of October, 2014 for Rs.25,333/- which amount was paid by opposite party. After renewal of the policy on 13th November, 2014 opposite party has not paid the amount claimed. On 27-11-2014 opposite party addressed a letter asking him to submit some documents for processing the claim. The opposite party on receipt of the documents submitted informed that the claim is under process he will be communicated in a week’s time. The complainant has made several phone calls, sent emails and personally visited the office but there was no response. Finally on 27-10-2015 he received a mail from the opposite party informing that claim is repudiated and addressed letters that effect on 11-2-2015 and 27-02-2015 stating that the documents examined shows treatment taken was for chronic liver disease and portal hypertension caused due to alcohol intake and the coverage does not extend for the said treatment. The said intimation was received after lapse of 8 months from the date of submission of the claim. The opposite party did not explain as to why it has taken 8 months time to intimate repudiation of the claim and also and why it has accepted a claim earlier in the month of October, 2015 for the same problem and rejecting of the 5 claims by the opposite party amounts to unfair trade practice and deficiency of service.
The complainant has taken medi claim policy from the opposite party with an apprehension that if any sudden illness arises to him and his family members will be covered for all the illnesses and surgeries. Opposite party without any justification repudiates the claim intentionally and thereby caused mental agony and loss to him. Hence the present complaint.
- Opposite party while admitting issuance of Mediclaim policy to the complainant in the year 2005 and renewal of the same till 2014 and payment of the amounts spent for the first time in October, 2014 denied the rest of the complainant’s version. The defense set out by the opposite party is that under the subject policy liability of the company will not be more than sum insured amount of Rs.2,00,000/- if the claim is admissible in terms and conditions of the policy. The company cannot go beyond the terms and conditions and exclusions of the policy. The policy is a contract between the parties and insurer undertook to compensate the insured for the loss suffered on account of risks covered in the policy. The complainant claims that he suddenly collapsed and got admitted on 14-11-2014 and thereafter again on 6-12-2014 and 29-12-2014, 5-1-2015 and 18-1-2015 spent the amount for the hospitalization. He was hospitalized for treatment of chronic liver disease and portal Hypertension caused due to alcohol intake. The complainant is consuming alcohol since 20 years and besides smoking for 10 to 15 years and there is nexus between Alcohol consuming and smoking to the present illness. As per the clause 13 of terms and conditions of subject policy the above claim is excluded under the exclusion clause hence the claim submitted for reimbursement of the amounts spent was repudiated. The clause 13 of the terms and conditions of the policy reads that “ailments requiring treatment due to use or abuse of any substance drug or any alcohol and treatment for De-addiction is not covered. Hence the claim of the complainant is not maintainable in the present complaint. Even otherwise the insured cannot claim anything more than what is mentioned in the policy. As there is no deficiency of service on the part of the company the complainant cannot maintain the present complaint and same is liable to be dismissed.
In the enquiry the complainant has got filed his evidence affidavit and substance of the same in line with the complaint version. He also got exhibited sixteen (16) documents in support of his version. Similarly for the Opposite Party evidence affidavit of Sri R.Laxmminarayana stated to be Authorized signatory of opposite party and one Dr. Peddina S.K.Prasanna Kumar stated to be Deputy Manager of it are filed and the substance of their evidence affidavit are also in support of defense set out in the written version . Opposite party also got exhibited four (4) documents. Both sides have filed written arguments and made oral submissions.
On a consideration of material available on the record the following points have emerged for consideration .
- Whether repudiation of the entire claim submitted by the complainant is in terms of policy conditions ?
- Whether the complainant is entitled for the amount claimed in the complaint?
- To what relief?
Point No.1: Taking of the Mediclaim policy by the complainant in the year 2005 and its renewal regularly till 2014 are not being disputed by the opposite party. Similarly hospitalization of complainant for the Liver serosis and related complaints is also not being disputed by the opposite party. The only ground urged by the opposite party for repudiating the claim is as per Clause 13 of terms and conditions of subject policy ailments requiring treatment due to use or abuse of any substance Drug or any Alcohol and treatment for de-addiction are excluded in the subject policy. Though the complainant has filed the policy document as Ex. A1 it does not contain the terms and conditions incorporated therein. However the opposite party filed it as Ex.B2. The exclusion clause at page 4 of Ex.B2 and the clause 13 under which opposite party is taking shelter reads as ailments requiring treatment due to use or abuse of any substance Drug or any Alcohol and treatment for de-addiction is excluded. The complainant has filed entire medical record as Ex.A2 to A11 but none of these documents says the ailment for which the complainant got admitted in the KIMS hospital was result of intake of either Alcohol or tobacco for continuous period. The opposite party also have not got filed evidence of any medical officer who is competent to speak about this ailment and cause of disease. In the absence of medical expert evidence that the ailment of chronic liver and portal hyper tension will be caused due to Alcohol intake or on account of tobacco smoking it is difficult to accept. Nothing prevented to opposite party to examine a medical officer to speak these aspects. Hence this ground urged by the opposite party for repudiating the claim cannot be countenanced.
The other ground urged by the opposite party is sum assured under the subject policy is only 2,00,000/-. Since health Guard policy is a contract between the policy they are bound by the terms and conditions hence even if the disease with which the complainant got admitted in the hospital for treatment is also covered under the policy, the liability of company is limited Rs.2,00,000/- and company cannot be made liable to pay the entire amount spent by the complainant for treatment of ailment. A reading of Ex.B2 policy shows the maximum of liability of the company in the event of hospitalization of insured is Rs.2,00,000/- hence this ground urged by the opposite party is sustainable. Even according to the complainant first claim submitted by him was for a sum of Rs.25,333/- was accepted and paid. Subsequent 5 claims were repudiated. Maximum liability of the company under the subject policy is Rs.2,00,000/- and out of it the company paid to the insured Rs.25,333/- and now liable to pay the remaining amount of Rs.1,74,667/- as its liability is restricted. Accordingly the points is answered.
Point No.2: in view of the findings that the opposite party is liable to pay a sum of Rs.1,74,667/- and by denying the same it has caused mental agony hence liable to pay interest on this amount at 18% P.A from the date of repudiation to the date of payment and further directed to pay a sum of Rs.25,000/- as compensation for causing inconvenience and mental agony by repudiating the entire claim itself.
Point No.3: In the result, the complaint is partly allowed directing the opposite party
- To pay to the complainant a sum of Rs.1,74,667/- with interest at 18% P.A from the date of repudiation to the date of payment
- The opposite party is further directed to pay a sum of Rs.25,000/- as compensation for causing inconvenience and mental agony by repudiating the entire claim.
- The opposite party is liable to pay a sum of Rs.5,000/- towards costs of this complaint.
Time for compliance : 30 days from the date of service of this order
Dictated to steno transcribed and typed by her pronounced by us on this the 26th day of February , 2019
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Exs. filed on behalf of the Complainant:
Ex.A1 is policy schedule
Ex.A2 is discharge summary
Ex.A3 is in patient final bill for Rs.25,333/-
Ex.A4 is discharge summary dt.8-12-2014
Ex.A5 is final bill for Rs.28,646 dt.8-12-2014
Ex.A6 is discharge summary
Ex.A7 is final bill for Rs.15,280/- dt.30-12-2014
Ex.A8 is discharge summary
Ex.A9 is final bill for Rs.54,237/- dt.09-01-2015
Ex.A10 is discharge summary
Ex.A11 is final bill for Rs.6,22,930/- dt.15-2-2015
Ex.A12 is letter dated 27-11-2014
Ex.A13 is bank letter
Ex.A14 is bank pass book
Ex.A15 is repudiation letter dt.11-02-2015
Ex.A16 is repudiation letter dt.27-02-2015
Exhibits filed on behalf of the Opposite party
Ex.B1 is claim form of the complainant
Ex.B2 is policy schedule
Ex.B3 is proposal form
Ex.B4 is repudiation letter dated11-02-2015
MEMBER PRESIDENT
