ORDER
PER SH. RakeshKapoor, President
The complainant is holder of mediclaim insurance policy from OP1. He had started purchasing the said policy from OP1 w.e.f. 22.1.1999 and has been renewed the same year after year. The last policy purchased by him was effective for the period 22.1.2011 to 21.1.2011. On 8.3.2011 the complainant was hospitalized at Indraprastha Pvt Hospital Mathura Raod Delhi and was discharged on 12.1.2011. He has lodged a claim for a sum of Rs 3,74,337.30/- on account of the expensed incurred by him on the above treatment. The insurance company had paid a sum of Rs 2,33,600/- only and had refused to pay the balance amount. The complainant has alleged deficiency in service on the part of the Ops and has approached this forum for redressal of his grievance.
The OP has contested the complaint and has filed a written statement, it has denied any deficiency in service on its part and has claimed that the complaint is devoid of merits and is liable to be dismissed. It has admitted that the complainant had purchased mediclaim policy from it which was effective for the period 22.1.2011 to 21.1.2012. it has also admitted that it was renewal of the earlier policies which the complainant has been purchasing since the year 1989. It has admitted that it had received a claim for the reimbursement of a sum of Rs 3,74.337.30 from the complainant and that it had paid a sum of Rs 2,33,600/- to the complainant. It has justified its act on the plea that w.e.f. 1.4.2007 the maximum amount payable under the respective heads for which the claim had been lodged was 50% of the sum insured for one illness. It has claimed that it had acted in accordance of the terms and conditions of the policy purchased by the complainant and had , therefore, the dismissal of the complaint. Para 5 of its written statement reply on merits is relevant for the purposes of the decision of this case and is being reproduced as under:-
5.That the contents of Para no. 7 to 12 of the complaint is denied for want of knowledge and proof. The petitioner be put to strict proof of the allegation/ averments made in the paras under reply. It is submitted that the complainant was informed by the respondent vide letter dated 03.07.2011 was issued by the respondent to the complainant informing that your bill, an amount of Rs 3,32,462/- was claimed towards Anesthesia, Blood, Oxygen, OT Charges, Surgical appliances, Medicines, Drugs, Diagonstic Material & X-ray etc. As per the policy conditions, effective from 1.4.2007, maximum amount payable under this head is only 50% of the sum insured for one illness. Hence, irrespective of the amount of expenditure incurred, the maximum amount payable under this head is only 50% of the sum insured i.e. Rs 2,50,000/-. The respondents informed to the complainant that the payment made to is in order and governed within the terms and conditions of policy and the guidelines issued by the IRDA from time to time. That the payment advice/ calculation made by the respondent no. 2 was also sent by the respondent no. 2 to the complainant along with the letter dated 03.7.2011. The copy of the letter dated 03.07.2001 with payment advice are annexed collectively herewith and marked as Annexure R 1 and R 2 (colly).
The insurance company has , therefore, prayed that the complaint be dismissed.
We have heard arguments advanced at the bar and have perused the record.
It is admitted on record that the complainant had purchased the first mediclaim policy from the OP in the year 1999. The complainant has been renewing the said policy year after year and had last renewed it in the year 2011. A copy of the renewed policy has been placed on record by the complainant. It nowhere shows that there had been a change in the terms and conditions of the policy. The OP has not placed on record any document to show that it had at anytime conveyed to the complainant that the terms and conditions of the policy had undergone a change w.e.f. 1.4.2007. Since, it was a renewal of the earlier policy on year to year basis , it was imperative on the part of the OP to have placed on record a document showing that it had informed the complainant about the change in the terms and conditions of the policy. Since, the OP has failed to do so we are of the considered opinion that the OP insurance company cannot take any benefit of the changed conditions. In our opinion, the complainant had been put to a disadvantageous position and was prejudice by the non-supply of the changed terms and conditions. We , therefore, hold that the OP insurance company was deficient in rendering services to the complaint and direct it as under:-
- Pay to the complainant a sum of Rs 107837.30 along with interest @10% p.a. from the date of institution of this complaint i.e. 2.3.2012 till payment.
- Pay to the complainant a sum of Rs. 25,000/- as compensation for the pain and agony suffered by him.
- Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.
The above amount shall be paid by the OP to the complainant within 30 days from the date of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of this order till the date of payment. If OP fails to comply with the order within 30 days, the complainant may approach this Forum u/s 27 of the Consumer Protection Act, 1986.
Copy of the order be made available to parties free of cost as per law.
File be consigned to R/R.
Announced in open sitting of the Forum on_____________
( S N SHUKLA ) ( RAKESH KAPOOR )
MEMBER PRESIDENT
