IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI
BEFORE : Hon’ble Thiru Justice R. SUBBIAH PRESIDENT
Tmt Dr. S.M.LATHA MAHESWARI MEMBER
F.A.NO.161/2016
(Against order in CC.NO.14/2015 on the file of the DCDRC, Thiruvallur)
DATED THIS THE 24th DAY OF SEPTEMBER 2021
Mrs. A. Lavanya Satheesh
W/o. A. Satheesh
No.214, Bazaar Street
Palavakkam Village and Post M/s. A. Satheesh
Uthukottai Taluk Counsel for
Thiruvallur District Appellant / Complainant
Vs.
- The Manager
Heritage Health Services Ltd.,
Prince Centre, S-206, 2nd Floor
No.709-710, Mount Road
Thousand Lights, Chennai – 600 006
- The Branch Manager
United India Insurance Co. Ltd.,
No.153, J.N.RoadServed and called absent
Thiruvallur- 602 001Respondent/ Opposite parties
The Appellant as complainant filed a complaint before the District Commission against the opposite parties praying for certain direction. The District Commission allowed the complaint. Against the said order, this appeal is preferred praying to enhance the award amount passed in the order of the District Commission dt.27.7.2016 in CC.No.14/2015.
This appeal coming before us for hearing finally today, upon hearing the arguments of the counsel appearing on bothside and on perusing the documents, lower court records, and the order passed by the District Commission, this commission made the following order in the open court:
ORDER
JUSTICE R. SUBBIAH, PRESIDENT (Open court)
1. This appeal has been filed by the appellant/ complainant as against the order dt.27.7.2016 in CC.No.14/2015 passed by the District Consumer Disputes Redressal Commission, Thiruvallur, by directing the Respondent/ opposite parties herein to pay a sum of Rs.9505/- towards balance claim amount as per the terms and conditions of the policy alongwith compensation of Rs.5000/- and cost of Rs.5000/-, on the ground that the District Commission had partly allowed the complaint and thus praying for allowing the complaint fully as prayed for.
2. The brief facts which are necessary to decide the appeal is as follows:
The complainant had taken an individual Health Insurance Policy from the 2nd opposite party on 26.3.2007, and renewing the policy periodically. The latest policy No.012002/48/13/97/00000911 was taken for the period covering from 26.3.2014 to 25.3.2015 for a sum insured at Rs.2,00,000/-. While so due to swelling around the right ear, her elder son A.Keerthivardhan was admitted in the Vijaya Hospital, Vadapalani on 3.12.2014 at 9.00 am., and he was operated on the same in the right ear. After the operation he was shifted to ICU and after to the ward. At the time of admission itself she submitted the insurance details to the Hospital authorities. But at the time of discharge, the hospital authorities informed her that Heritage Health Services Pvt. Ltd., has only approved Rs.28000/- out of the final bill of Rs.53579/- which was billed by M/s. Vijaya Health Centre. The 1st opposite party informed that as per the policy conditions the complainant is eligible for that amount only. She was left with no other alternative, but to pay a sum of Rs.25579.50/- in cash and to get discharged from the hospital. Since she had taken policy for a sum of Rs.2,00,000/- she wanted to know the reasons for the lesser sum settled by the insurance company towards the medical bill. Hence she made a representation to the opposite parties on 12.12.2014. But the said letter to 1st opposite party was yet to be returned and the letter to the 2nd opposite party was served. But till now there is no reply received from the opposite parties. Thus alleging deficiency on the part of the opposite parties, the complainant filed a complaint before the District Commission praying to settle the balance claim of Rs.25579/- alongwith 12% p.a., from 4.12.2014 alongwith compensation of Rs.50000/- and cost of Rs.5000/-.
- The said complaint was resisted by the insurance company by filing counter stating that the Insurance company has to follow the rules and regulations of the policy. As per New Rule 6 of the said policy the complainant is eligible for only 70% of the claim amount. Thus they prayed for the dismissal of the complaint.
- Before the District Commission, proof affidavits were filed by both parties. The documents filed by the complainant, were marked as Ex.A1 to A11. There was no document filed by the opposite parties.
- The District Commission after evaluating the submissions made on bothsides and on perusal of the documents had come to the conclusion that as submitted by the opposite parties the complainant is eligible for 70% of the total claim amount. But the opposite parties had settled only a sum of Rs.28000/-. But actually 70% of the total claim of Rs.53579.50/- works out to Rs.37505/-, the opposite parties are liable to pay a further sum of Rs.9505/- to the complainant. Thus alleging deficiency on the part of the opposite parties, passed an order directing the opposite parties to pay a sum of Rs.9505/- towards the balance claim amount alongwith compensation of Rs.5000/- and cost of Rs.5000/-. Aggrieved over the said order, the complainant had filed this appeal, praying for enhancement of the amount awarded as prayed for in the complaint.
- Before this commission, the insurance company though served, remained absent. Hence we have heard the learned counsel for the appellant/ complainant and passed the following order:
- The learned counsel for the appellant/complainant had submitted that the District Commission had come to the conclusion that the complainant is entitled for 70% of the claim amount only based on the version of the opposite parties, without assigning any valid reason except the New Rule 6 of the policy. It is the specific contention of the complainant that the New Rule 6 will be applicable only for the present policy. But the policy was taken by the complainant in the year 2007, much earlier to the inclusion of the New Rule 6. Therefore, it is not proper on the part of the insurance company to reject the claim quoting the New Rule 6. Thus prayed for awarding the entire claim amount.
- In this connection a perusal of the policy copy issued to the complainant would show that there is no clause or column printed/ shown stating that the complainant is entitled only for 70% of the claim amount as seen from Ex.A1. Whereas the copy of terms and conditions of the policy submitted by the opposite parties in the connected appeal in FA.No.159/2016, the said Rule 6 was shown. This would go to show that when the policy was issued to the complainant the said Rule 6 was not there, and it must have been subsequently introduced. Therefore, the stand of the opposite parties that the complainant is not eligible for the entire claim cannot be accepted. Furthermore the insurance company also has not chosen to appear before this commission to explain the rule position. Therefore we are of the considered opinion to allow the appeal, by directing the Respondents/opposite parties to pay the entire claim amount.
- As far as the claim of compensation is concerned, the opposite parties if at all has to pay the full claim, they have to pay a further sum of Rs.25579/- only as claimed by the complainant. Therefore for the non-payment of balance claim amount of Rs.25579/- the claim of Rs.50000/- towards compensation seems to be exorbitant. Therefore, we are of the considered opinion that the amount awarded by the District Commission @ Rs.5000/- towards compensation and Rs.5000/- towards cost would meet the ends of justice.
- In the result, the appeal is allowed in part by modifying the order of the District Commission in CC.No.14/2015 dt.27.7.2016, by directing the 1st and 2nd Respondents/ 1st and 2nd opposite parties jointly and severally to pay a sum of Rs.25579/- towards the claim amount instead of Rs.9505/-. The award made towards compensation and cost is hereby confirmed. There is no order as to cost in this appeal. Time for compliance one month, from the date of receipt of copy of the order, failing which the above amount shall carry interest @9% p.a., from the date of default till realization.
S.M.LATHAMAHESWARI R. SUBBIAH
MEMBER PRESIDENT
