CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present Sri. Santhosh Kesavanath P. President Smt. Bindhu M. Thomas, Member CC No. 13/2006 Thursday, the 29th day of April, 2010 Petitioner : Jose Joseph Thengupalliparambil Memury P.O, Kottayam (By Adv. S. Pradeepkumar) Vs. Opposite parties : 1) National Insurance Co. Ltd. Mydhily Mandiram, Janatha Junction, Palarivattom, Kochi. (By Adv. C.J. Jomi) 2) TTK Health Service Pvt. Ltd. Kochi. O R D E R Smt. Bindhu M. Thomas, Member. The crux of the petitioner’s case is as follows: The petitioner has taken a policy named Hospitalization and Domiciliary Hospitalization Benefit policy on 14.. 3..2003 and valid up to 13..3..2004 vide No. 570105/48/02/8502797.The said policy was renewed by the petitioner on 15..03..2004 for further one year and the second policy numbers is 570105/48/03/8503085. The proposal form and declaration date of second policy is 14..3..2003 and the second policy is the continuation of the first policy. On 11..1..2005 wife of the petitioner Molly Jose was admitted in Matha Hospital for a disease “Fibroid Uterus” and underwent a major surgery on 12..1..2005 and discharged on 18..1..2005. Petitioner paid Rs. 17,271/- as treatment expense. Immediately after discharge petitioner filed claim form along with relevant medical document and bills before the first opposite party and the first opposite party sent the said documents for verification to their agent T.T.K, the second opposite -2- party. On 5..3..2005, the second opposite party rejected the claim stating reason that second policy was rejected due to the reason that there is a break of three days. The policy premium was given to the agent on 13..03..2004 and the policy was renewed only on 15..3..2004. The proposal form and declaration date of second policy is 14..3..2003 that itself shows that the second policy is the continuation of the first policy. The petitioner alleged that the act of opposite party is a clear case of deficiency in service and filed this complaint praying to direct the opposite parties to allow the claim amount of Rs. 17,271/- with 18% interest Rs. 10,000/- as compensation along with cost. Notice was served to first and second opposite parties. Second opposite party called absent hence set ex-parte. First opposite party entered appearance and filed version with the following main contention. i) The complaint is not maintainable either in law or on facts. ii) The policy No. 570105/48/03/8503085 is not the continuation of the first policy. The first policy expired on 13..3..2004 and the second policy was taken only on 16..3..2004 after a break of three days. The allegation that the complaint has entrusted the premium amount on 14..03..2004 is false. iii) This opposite party has no knowledge about the claim form filed by the complainant. The surgery for Fibroid Uterus cover will be available if the policy is renewed without break for another year. Since there was a break of three days the claim might have been repudiated by the above said company. The bonus was given only as an incentive and not as an acknowledgement for continuation of policy -3- iv) The opposite party never acted against the terms of contract. Since there is a break, the complainant is not entitled to get insurance amount. Hence the first opposite party prayed to dismiss the complaint with costs to them. Points for considerations are: i) Whether there is any deficiency in service e or unfair trade practice on the part of opposite parties? ii) Reliefs and costs? Evidence consists of affidavits filed by the petitioner and first opposite party and Exts. A1 to A5 series. Point No. 1 According to the first opposite party, the claim of the petitioner was repudiated by the second opposite party stating reason that the policy was renewed with a break of three days and the present policy is a fresh policy. The first opposite party contented that the surgery for fibroid uterus covers only if the policy is renewed without break for another year. Whereas the counsel for the petitioner argued that the proposal form and declaration for the alleged policy is Dtd: 14..3..2003. The policy period for the policy under dispute is 16..3..2004 to 15..3..2004. The learned counsel for the petitioner further argued that cumulative bonus is allowed for the alleged policy and therefore the said policy is a continuing policy. The petitioner produced the original policy schedule for the period 14..3..2003 to 13..3..2004 and it is marked as Ext. A1. As per Ext. A1 the proposal form and declaration is dated 14..3..2003. The original policy schedule for the -4- period 16..3..2004 to 15..3..2005 is also produced and marked as Ext. A2. On perusing Ext. A2 it is found that the proposal form and declaration is dated 14..3..2003. From Ext. A1 and A2 it is clear that there is no fresh proposal and declaration for the alleged policy. If the policy under dispute is a fresh policy, there must be a fresh proposal form and declaration. But as the proposal form and declaration for the disputed policy is Dtd: 14..3..2003, we are of the opinion that the disputed policy is the continuation of the first policy. The first opposite party averred that the cumulative bonus was given only as an incentive and not as an acknowledgement for continuation of policy. But nothing is produced on record to prove that the first opposite party give cumulative bonus as an incentive and not as an acknowledgement for continuation of policy. In our view cumulative bonus is allowed to those policy holders who has not made any claim during the previous policy period. Since cumulative bonus is allowed in the alleged policy and as the declaration and proposal for the said policy is dated 14..3..2003, we come to the conclusion that the policy under dispute is a continuing policy and it covers the treatment expenses of the surgery for fibroid uterus. In our view the act of opposite parties in repudiating the insurance claims on flimsy reasons is a clear case of deficiency in service. Point No. 1 is found accordingly. Point No. 2 There is no dispute in the claim amount made by the petitioner. So, in view of the findings in point No. 1, we allow the petition. -5- The first opposite party is ordered to pay the claim amount of Rs. 17,271/- to the petitioner with interest @ 9% p,.a from the date of repudiation, 05..03..2005 till realization. The second opposite party is ordered to pay the litigation cost of Rs. 5000/- to the petitioner. As interest is allowed no compensation is ordered. This order will be complied with within one month of receipt of its copy failing which the above mentioned litigation cost also will carry interest @ 9% p.a. till realization . Smt. Bindhu M. Thomas, Member Sd/- Sri. Santhosh Kesavanath P., President Sd/- APPENDIX Documents of the petitioner: Ext. A1: Policy Certificate original vide No. 570105/48/02/8502797 Ext. A2: Original policy certificate vide No. 57105/48/03/8503005 Ext. A3: Claim Form Ext. A4: Discharge summary Ext. A5 to A5c Medical bills issued by Matha Hospital. Documents of the opposite party: Nil. By Order, Senior Superintendent amp/ 5 cs.
| | HONORABLE Bindhu M Thomas, Member | HONORABLE Santhosh Kesava Nath P, PRESIDENT | , | | 
