IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 31stday of March, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member,
Sri. K.M. Anto, Member
C C No. 130/2019 (filed on 01-08-2019)
Petitioner : Avaneesh V.N.
Vinu Bhavan,
Vempally P.O.
Kottayam.
(Adv. Shaji Varghese)
Vs.
Opposite parties : New India Assurance Company
Limited, Ettumanoor Branch,
Rep. by Manager,
Ettumanoor P.O.
Kottayam.
(Adv. Anie C. Kuruvilla)
O R D E R
Smt. Bindhu R. Member
The complaint is filed under Section12 of the Consumer Protection Act,1986.
The complainant contracted with the opposite party and secured a Health Insurance Policy for himself and his family after remitting Rs.8142 /- for the year 2018-19.vide policy number 76250234182700000022 for a total sum insured Rs.3,00,000/-.
The complainant got admitted in Bharath hospital, Kottayam due to severe chest infection on 9.7.2019and was discharged on 19.7.2019.Though the hospital authorities submitted a bill for Rs.56,791/- the opposite party approved only Rs.41,109/- The petitioner had to pay Rs.14,417 to the hospital. The complainant is entitled for a reimbursement of balance amount of Rs.13,442/- after deducting the consumable items. Rs.635, the expense of discharged medicines was also deducted. The TPA of the opposite party in the repudiation letter stated that the room rent was deducted as excess room rent and all other amounts were deducted proportionately. As per the policy condition, clause 3.1.1., the petitioner is entitled for 1% of the sum insured as the room rent, which includes nursing charges also. According to the complainant the bill submitted is for room rent of Rs.2000/- and nursing charges for Rs.1000/- in total Rs.3,000/- which is in the limit of 1% of the sum insured, as the sum insured is 3,00,000/-.Also as per clause 2.32 of the policy condition, the petitioner is entitled for the cost of post hospitalization medical expenses. The expenses for the discharge medicines also is payable. The partial denying of the claim by the opposite party amounts to deficiency in service. So the complaint is filed for the payment of the balance claim amount with interest and compensation.
Upon notice, the opposite party appeared through counsel and filed version contending that the complaint is filed without bonafides. Admittedly the complainant was admitted in Bharath Hospital, Kottayam and diagnosed with lower lobe pneumonia, diabetes mellitus, Rhino sinusitis with polyp and underwent flexible nasopharyngoscopy and settled the claim of the complainant for an amount of Rs.41,109/- out of the claim amount of Rs.56,972/-. The claim was processed by restricting the sum insured to Rs.2,00,000/- since the ailments of DM and Rhino sinusitis with polyp were having a waiting period of 24 months. The sum insured was enhanced from Rs.2,00,000/- to Rs.3,00,000/- commencing from 14.9.2017 onwards subject to condition 5.12,R/w condition nos 4.3.1 and condition no 3.1(d) of the policy.
The claim was processed with proportionate deductions, since the insured opted higher rented room than the entitled category of room and nursing care per day. The claim was processed by considering the sum assured as Rs.2,00,000/- as per condition no.3.1.(d) of the policy as the disease for which he was admitted comes under the purview of condition 5.12 r/w condition 4.3.1.Since the enhancement was made only on 14.9.17, and as the policy is treated as a fresh policy, the deceases which have two years waiting period is exclusively applicable for that amount. The authorised room rent and nursing charges per day is calculated by taking 1% of the sum assured i.e.2,00,000/- but the petitioner availed room rent and other services for Rs.3,000/-. So the excess room rent and nursing charges is calculated as Rs.2,000/- Excess room rent and nursing charges of Rs.10,000/- is deducted from the claim amount. Along with that the bills for the non-medicals and discharge medicines also were deducted. Thus the claim was settled for Rs.41,109/-The insured complainant is not entitled to get the discharge medicine through the claim put forward by him instead he has to make a separate claim after discharge before this opposite party. The complainant is not eligible for the post discharge medicines as that amount is not payable as the policy covers only hospitalisation expenses as per condition no 1 of the policy. If a subsequent claim was made for that amount it would have been obtained. So the complaint is liable to be dismissed.
Towards the evidence part the complainant filed Exhibits A1 and A2 whereas the opposite party filed Exhibits B1 and B2.
We have evaluated the pleadings and evidence on record and would frame the following points:
- Whether the complainant is eligible for the claim placed under the enhanced sum insured?
- Whether there is any deficiency in the deducted payment made by the opposite party?
- Reliefs?
All the 3 points are considered together.
The complainant submitted a claim of Rs.56,972/- for his hospitalisation and treatment against his policy with the opposite party.The opposite party paid only 41,109/- after deducting amounts for the consumables and discharge medicines. The complainant alleges that this deduction for the discharge medicine is not correct and the opposite party is liable to pay that amount. Moreover, the opposite party calculated the room rent and nursing charges as the sum insured is Rs. 2,00,000/- as the claim arose within the exclusion period of 24 months of the enhancement. The complainant’s dispute is that the calculation of the room rent and nursing expenses should have done upon the sum insured of Rs.3,00,000/- as the original amount was enhanced to that and the exclusion period should be calculated from the inception of the original policy.
The opposite party has considered the claim as that of a sum insured of Rs.2,00,000/- which has commenced from 14/09/2015.All the deductable expenses are calculated on the basis of Rs.2,00,000/- sum insured. According to the opposite party “the claim was processed by restricting the sum insured to Rs.2,00,000/- since the ailments of DM and Rhino-sinusitis with polyp were having a waiting period of 24 months.”The complainant got admitted in the hospital on 9.7.19 and the claim was submitted on19.7.19 which is well out of the period of 24 months from the date of inception of the original policy 14.9.15. As the enhancement is only a process of increasing the policy coverage by the option of the insured and with the sanction of the insurer it shall not affect the original policy conditions and its coverage unless and until the insured is well educated about the change in policy if any by the insured at the time of enhancement. If a consumer of the policy intend to enhance his sum insured every year, he would be unable to claim any of the amounts as on each and every enhancement, the exclusion period of 24 months, 48 months and 30 days would start.Thus all the claims would be said to be excluded by the company. This is an unfair trade practice.
An insurance policy is meant to indemnify the insured on payment of premium as and when needed. Enhancement means only an increase in the amount not a new policy.
The insured when enhances the amount in the policy period, he has the intention to continue the policy with the enhanced amount as the sum insured. The insurance company cannot add new conditions on renewed/enhanced policies without proper communication to the insured.
In the policy condition exhibit B1, 5.1.2 “regarding enhancement of the sum insured exclusion 4.1,4.2,4.3.1 and 4.3.2 would apply to the additional sum insured from the date of such increase.”
But there is no evidence to prove that the opposite party has duly served the policy conditions to the insured. The insured enhances the policy in a bonafide belief that he would get the coverage for the original sum insured at the inception of the policy after the enhancement also. The counsel for the complainant argued that the complainant did not get separate policy conditions at the time of enhancement. The opposite party has not proved whether they had provided the policy conditions or not.
In Oriental Insurance Co. Ltd. vs M/S. Shraddha Traders on 10 April, 2019 Hon’ble National Consumer Disputes Redressal Commission held that:
“When the insured person is not provided any terms and conditions of the policy and not given any guidance to this effect, under that circumstances, if the insurance company repudiate the insurance claim taking base of this definition, then it would be considered as lapse in service. In view of all these facts and taking into account the judgments quoted, the Complainant becomes entitled to get the insurance claim under Shop Keepers Insurance Policy.”
In the light of above discussions, we find that the act of the opposite party in not educating the complainant about the terms and conditions at the time of the enhancement if there is any change in conditions. As in the case in hand, the opposite party company has not attempted genuinely to inform the complainant that he is not entitled for the enhanced amount of 1lakh for 24 months, is also a deficient act.
In United India Insurance Vs Jain Prakash Tayal (2010): The Hon’ble Delhi High Court held that no additional exclusion can be added in the renewal. Hence the claim is payable.
7 “ ………………………….The mere fact that a new policy document is issued upon each renewal, does not change the basic nature of the contract. Any unilateral insertion or change in the clause of the contract has to be with the consent of the insured, and there is no evidence on record to show that this clause was brought to the notice of the insured. Thus, there was no “consensus ad idem” on the exclusionary clause contained in PW-2/1. It is merely a unilateral insertion which would not bind the Plaintiff. E.8 ……”
So the contention of the opposite party that the sum insured can only be considered as Rs.2,00,000/- is not sustainable.
Further regarding the discharge medicine claim, the policy condition itself contains cl.2.32 of exbt B1 which states :
“Post hospitalization expenses means medical expenses incurred immediately after the insured person is discharged from the hospital, provided that:
- “Such medical expenses are incurred for the same condition for which the insured person’s hospitalization was required, ......” The complainant herein was advised to take particular medicines on the same date of discharge in continuation of the treatment for which he was hospitalised vide a bill on the same date. So the rejection of the discharge medicines is only arbitrary and hence cannot be admitted. If any other condition is there contrary to it, the construction of the wordings of the contract shall be construed in favour of the beneficiary.
Hence in the light of above discussion, we find that points no 1 and 2 are in favour of the complainant and that the complainant is eligible for the reliefs prayed for.
Thus the complaint is allowed
- Directing the opposite party to pay the amount of Rs.13,442/- along with interest at 9% p.a. from 19-07-2019 till realization.
- .Directing the opposite party to pay Rs.5,000/- towards compensation and no cost is ordered.
Order shall be complied within a period of 30 days from the date of receipt of Order. If not complied as directed, the compensation amount will carry 9% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 31st day of March, 2022
Smt. Bindhu R. Member, Sd/-
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of policy 76250234182700000022
A2 – Copy of cashless authorization letter dtd.19-07-19 by Medi Assist to Bharath
Hospital
Exhibits marked from the side of opposite party
B1 – Certified copy of policy 76010934162700000010with terms and conditions
B2 – Certified copy of policy 76250234182700000022
By Order
Assistant Registrar
