Advocate A.S.Dhobale for the complainant
Advocate S.A.Maheshwari for the opponents
*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-**-*-*-*-**-**-*-*-*-**-*-**-
Per Hon’ble Shri. V. P. Utpat, President
:- JUDGMENT :-
Date – 17th December 2013
This complaint is filed by consumer against insurance company for deficiency in service u/s 12 of the Consumer Protection Act, 1986. Brief facts are as follows-
[1] Complainant is resident of Vadgaon (Bk), Pune. She has obtained Hospitalization Medical Policy from the Opponents for the period 29/9/2011 to 28/9/2012. She had paid premium of Rs.1157/-. Complainant has renewed the policy 10 days before the due date for third year. On 27/9/2011 she was admitted in the hospital of Dr. Shivdikar. She was suffering from heavy bleeding. She was hospitalized till 3/10/2011 and thereafter she was discharged. On 12/10/2011 she had submitted her mediclaim alongwith documents but that was repudiated by the Opponent No.2 vide letter dated 9/12/2011. According to the Opponents complainant is not eligible for the claim as the policy coverage is for two years for surgery of Multiple Myomas as per policy exclusion clause 4.3. It is also contended that the duration of the present disease was since 2-3 months and i.e also ground for rejection of the claim. Complainant had spent Rs.80,538/- for medical treatment. Hence, she has filed present complaint and claimed Rs.80,538/- towards main claim, compensation of Rs.50,000/- for mental agony and Rs.10,000/- as cost of the litigation.
[2] Opponents resisted the claim by filing written version in which they have denied the contents of complaint in toto. The have contended that there is no deficiency in service as the claim was rightly repudiated. As per the policy exclusion clause 4.3 expenses incurred for disease like heavy bleeding i.e. Multiple Myomas is not covered for the first two years policy. Secondly, as per the discharge summary the said disorder was there for three months hence the said illness is not covered. The claim is therefore rejected. The Opponents have prayed for dismissal of the claim.
[3] After scrutinizing the documentary evidence, hearing argument of both counsel and considering the pleadings of both parties, following points arise for my determination. The points, findings and reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1 | Whether the Opponents have rightly repudiated medical insurance claim of the complainant ? | In the negative |
2 | Whether there is deficiency in service on the part of the Opponents ? | In the affirmative |
3 | What order ? | Complaint is partly allowed. |
Reasons
As to the Point Nos. 1 to 3-
[4] The admitted facts in the present proceeding are that the complainant has obtained insurance policy from the Opponents. It is not in dispute that she has obtained two policies one after one. But it reveals from the same that the second policy is obtained by the complainant after the expiration of first policy. The first policy was obtained for the period of 29/9/2010 to 28/9/2011 and the second policy was obtained from 29/9/2011 to 28/9/2012. The learned Advocate for the Opponents argued that as per clause 4.3 in the policy as the said disease occurred during the period of first two years, complainant is not eligible for the said medical claim and it is rightly repudiated by the Opponents. It is convenient to refer clause 4.3 which is laid down as follows-
“4.3 Treatment of diseases such as Cataract, Benign Prostatic, Hyperthropathy, Hysterectomy, Herina, Hydrocele, Congenital Internal Diseases, Fissures / Fistula in anus, Piles, Sinusltis and related disorders, Polycystic ovarian diseases, Non – infective arthritis, Undiscended testis, Sugery of gall baldder & bile duct excluding malignancy, Sugery of Genito-urinary systems, excluding malignancy, Pilonidal Sinus, Gout & Rheumatism, Hypertension, Diabetes, Calculus diseases, Surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy.”
[5] It is significant to note that complainant has not obtained term policy and she has obtained polices one by one. Then the restriction for claiming compensation if the disease occurred within period of two years cannot be made applicable for the complainant and the clause 4.3 to that extent appears to be redundant and inconsistent with the policy. So also, clause as regards occurrence of disorder within period of three months, it is the opinion of the Forum that, clause 4.3 is inconsistent with the policy for first year, and on that ground the claim cannot be rejected. In such circumstances, this Forum held that the Opponents have wrongly repudiated the claim. It reveals from the documentary evidence i.e. bills, case papers that the complainant was admitted in the hospital when the policy was valid and she had spent Rs.80,538/-. As per the terms and conditions of the policy she is entitled for that amount. She is also entitled to receive compensation on the ground of mental and physical sufferings to the tune of Rs.10,000/- and Rs.2,000/- as cost of litigation.
In the light of the above discussion, this Forum answer points accordingly and pass following order-
:- ORDER :-
1. Complaint is partly allowed.
2. It is hereby declared that opponents have caused deficiency in service.
3. Opponent Nos. 1 and 2 jointly and severally directed to pay Rs.92,538/- (Ninety Two Thousand Five Hundred and Thirty Eight only) to the complainant within six weeks from the date of receipt copy of order.
4. If the amount is not paid or deposited within the stipulated period, it shall carry interest @ 9% p.a. from the date of filing of complaint till its realization.
5. Both parties are directed to collect the sets which are provided for the Members within one month from the date of order. Else those will be destroyed.
Copy of order be supplied to both the parties free of cost.
Place – Pune
Date – 17/12/2013
