DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the 24^h day of February 2018

Present   : Smt.Shiny.P.R. President

              : Smt.Suma.K.P. Member                                          Date of filing:  19/05/2017

              : Sri.V.P.Anantha Narayanan, Member

(C.C.No.79/2017)

Baby Girija,

W/o Unni,                                                                 -        Complainant

Residing at “Krishna Kripa”,

Jawahar Nagar, Pudussery (PO),

Palakkad.

(By.Adv.P.C.Sivadas)

 V/s

1. M/s United India Insurance Co.Ltd,                        -        Opposite parties

    11/82, 3^rd Floor,

    Malabar Fort,

    Opp.G.B Road, Palakkad.

2.  M/s Medi Asst.India Pvt, Ltd,

    4^th Floor, Chickago Plaza,

    Rajaji Road, Ernakulam – 682 035.

    Rep.By its Manager.

O R D E R

Smt.Suma.K.P. Member

          The case of the complainant is that from the year 2000 onwards her husband had joined a group insurance medi claim policy of the 1^st opposite party.  After retirement, from 2006 onwards he had taken the policy individually.  During 2016 he renewed the policy and the complainant is also a beneficiary under the policy.  The 2^nd opposite party is the claim settlement agency.  Complainant suffered pain in the left leg knee and during the month of February 2017, he consulted in Ganga Hospital, Coimbatore.  The hospital authorities suggested knee replacement surgery.  The surgery was conducted on 03.02.2017.  After the surgery the hospital issued a bill to the tune of Rs.1,58,110/-.  According to the complainant the policy covers treatment expenses, hence they sent the claim form to the opposite parties.  The claim was settled only for Rs.87,500/-.  Balance amount of Rs.70,610/- was paid by the complainant.  The complainant submits that the policy coverage is for 2 lakhs, and when expired about the part settlement, there was no explanation from the part of the opposite parties.  Hence there is deficiency of service on the part of the opposite parties.  Hence this complaint. 

Notice was issued to the opposite parties for appearance.  Opposite party entered appearance and filed version stating the following contentions. 

     The complainant had purchase the UIIC Individual Health Insurance Policy 2010 Gold effective from 13.12.2017 having a sum assured of Rs.1,25,000/-.  The sum insured in the year 2012-13 was for Rs.1,25,000/- which was enhance to Rs.1,50,000/- vide policy renewal in the year 2013-14.  The policy was further enhanced to Rs.1,75,000/- by vide policy renewal, in the year 2014-15 and finally the sum insured was enhanced to Rs.2 lakhs in 2015-16 and the total sum insured is Rs.2 lakhs under the policy renewal in the year 2016-17.  During the subsistence of the policy term effective from 14.12.2016 to 13.12.2017 the complainant made a re-imbursement claim for amount of Rs.1,58,110/- due to major procedure of total knee replacement undergone by his spouse Mrs.Baby Girija.  As per the claim record the panel experts processed the claim subject to policy norms.  On verification of all investigation papers and discharge summary, it is divulged that the beneficiary was admitted at Ganga Medical Centre and Hospital Pvt.Ltd, Coimbatore for knee joint replacement surgery done on 02.07.2017 due to de-generative condition resulting in osteoarthritis.  The investigators carried out by the panel reveals that the claim, is partly admissible as per policy clause No.4.4 and 1.2 and 1.b respectively. 

          As per policy clause no.4.4, the full sum insure for the above treatment is payable only after four policy renewals post last enhanced sum insured and as per clause No.1.2 and 1.b expence for knee joint replacement surgery are limited to 70% of the sum insured, hence the sum insured for Rs.1,25,000/- which was in force before four years was considered and approved for Rs.87,500/- (70% of 1,25,000) against the estimated bill amount of Rs.1,58,110/-. As evident from records, the claims was submitted during the 2^nd year of policy renewal post enhanced sum insured, it was not complied with the prerequisite condition of 4 years of waiting period to avail the benefit for claiming full sum insured which squarely fall within the policy Exclusion clause No.4.4 & 1.2, 1.b, clause No.4.4 and 1.2, 1.b is replicated below for reference.  Exclusion No.”4.4 during the first 4 years of the operation of the policy, the expenses related to treatment of joint replacement due to Degenerative Condition and are related Osteoarthritis @ Osteoporosis are not payable”.  Exclusion 1.2 “ Expenses in respect of the following specified illness will be restricted as detailed below; b. major surgeries actual expenses incurred or 70% of the sum insured which ever is less.  Major surgeries include cardiac surgeries, brain tumour, surgeries, pace maker implantation for sick sinus syndrome, cancer surgeries, hip knee joint replacement surgery, organ transplant”.  For the purpose of applying these conditions subsequent dates of enhancement of sum insured under the renewal policy has been considered.  Now against non settlement of his claim, the complainant has approached this Forum for part realization of his claimed amount.  There is no deficiency of service on the part of the opposite party.  The opposite party has paid the eligible amount to the complainant as per the terms and condition contained in the policy.  The complainant has forgotten the conditions in the policy to get the enhanced amount.  The settlement effected by the company was as per the conditions contained in the policy as agreed by the complainant.  The policy enhancement made by the complainant was only from the period 2016-17 and to get that enhanced amount he should wait for four years ie. pre-requisite in the policy.  Immediately after enhancing the policy amount, he came with expense bill, similarly to the policy amount.  There was no provision to sanction that amount because both the parties are bound to act in terms of the contract. 

          There is no deficiency of service on the part of the opposite party and the complainant is not entitled to get any sum more than the one already paid by the opposite parties.  Hence the complaint had to be dismissed. 

          Both complainant and opposite parties filed the respective chief affidavits.  Opposite party filed application as IA 328/2017 seeking permission to cross examine the complainant.  Further the opposite party submits that cross examination of the complainant is not necessary.  Exts.A1 to A6 was marked from the part of the complainant.  Exts.B1 to B4 was marked from the part of the opposite parties.  Evidence was closed and the matter was heard. 

The following issues that arise for consideration are.

1. Whether there is any deficiency of service from the part of opposite parties?

2. If so, what are the relief and cost?

Issues No.1 & 2

          We have perused the affidavits and documents produced before the Forum.  As per Ext.B1 it is viewed that clause No.4.4, the full sum insured for the above treatment is payable only after four policy renewals cost last enhanced sum insured and as per policy clause No.1.2, 1.b expenses for knee joint replacement surgery are limited to 70% of the sum insured, hence the sum insured for Rs.1,25,000/- which was in force before four years was considered and approved for Rs.87,500/- against the estimated bill amount of Rs.1,58,110/-.  To avail the benefit for claiming full sum insured will squarely fall within the policy exclusion clause No.4.4 and 1.2 and 1.b.  There is no provision to sanction that amount because both parties are bound to act in terms of the contract.  Hence we cannot attribute deficiency of service on the part of the opposite parties.  In the light of the above discussion the complaint is dismissed without cost. 

Pronounced in the open court on this the 24^th day of February 2018.

   Sd/-

                  Shiny.P.R

                   President 

                        Sd/-        

                   Suma.K.P

                    Member

     Sd/-

    V.P.Anantha Narayanan

                    Member

Appendix

Exhibits marked on the side of complainant

Ext.A1          -  Photo copy Individual Health Policy Schedule issued by opposite party

Ext.A2          -  Photo copy of complainant sent a request letter to opposite party

             dated.26.01.2017 for cashless treatment

Ext.A3          -  Photo copy of Discharge summary dated.07.02.2017 issued by Ganga

              Medical Care & Hospital (P) Ltd

Ext.A4          -  Photo copy of credit bill issued by Ganga Hospital, Coimbatore to the

             complainant

Ext.A5          -  Acknowledgement Receipt No.Adv.27264/2016-17 dated.07.02.2017 issued by

             Ganga Hospital, Coimbatore to the complainant

Ext.A6          -  letter sent by the complainant dated.07.03.2017 to 1^st opposite party

Exhibits marked on the side of Opposite parties

Ext.B1 -  Policy copy for the period from 14.12.2013 to 13.12.2014 -

   policy no.1010222813P142013381

Ext.B2 -  Policy copy for the period from 14.12.2014 to 13.12.2015 -

             policy no.10102002814P107448136

Ext.B3 -  Policy copy for the period from 14.12.2015 to 13.12.2016 -

             policy no.10102002815P110644711

Ext.B4 -  Policy copy for the period from 14.12.2016 to 13.12.2017 -

             policy no.10102002816P1120124225

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost   

           Nil