BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 23^rd  DAY OF JANUARY 2023

ORDER

SMT.JYOTHI N., MEMBER

1. The complaint has been filed under Section 17 of C.P. Act (hereinafter referred as an “Act”) against the OPs for the following reliefs against the OP:-

1. To direct the OP-1 & 2 to reimburse the claim amount of Rs.2,47,955.10p with 18% interest from the date of payment by the complainant.
2. To direct the OPs to pay compensation of Rs.5,00,000/- towards mental agony undergone by the complainant.
3. Grant such other relief deems fit and proper under the circumstances of the case in the interest of justice and equity.

2. The facts of the complaint in brief is as under:-

The complainant husband Late Mr.Sathish Patil had taken a policy bearing no.67160234172800000449 for Rs.8,00,000/- (Rs. Eight lakhs only) from OP-1 having branch office at Bengaluru i.e. 2^nd of OP.

It is contended by the complainant her husband has been regularly paying the yearly premium has availed the policy for the last more than 15 year from OP-2  branch and also the complainant stated that, her husband has  premium i.e. paid and  renewed from 28.03.2018 and valid upto 27.03.2019.

The complainant husband  on 13.07.2016 name Mr.Sathish Patel was admitted to M.S.Ramaiah Memorial Hospital and was the under the treatment for kidney ailment. That on 17.07.2018 Doctors gave a declaration that Mr. Satish Patel died due to kidney failure that after the  complainant claimed medical coverage of insured  Mr.Satish Patel from OP-1 & 2. That of hospital raised bill for Rs.2,77,514.10p and non-medical bill of Rs.4,542/-.

The complainant claimed the said amount from OP as insured Satish Patel had the medical coverage and which was in existence at the time of death. However, to the shock and surprise the complainant received only Rs.29,559/- out of Rs.2,77,514.10P and Rs.4,542/-. The complainant states that OPs has not given the entire amount claimed by the complainant through M.S.Ramaiah Hospital which has a tie up with 2^nd OP, where complainant husband Mr.Satish Patel was admitted which is very unfortunate.

The OPs is being a government organization, the act of OPs  is not reimbursing all the medical expenses is totally uncalled for and deplorable. That the complainant had to borrow money from others to pay the entire medical bill at hour of grief. That despite the complainant had to suffer mentally and physically for deplorable act caused by the OPs is not paying the entire claimed amount.

The complainant after the part payment has orally requested the 2^nd OP to pay the entire hospital charges and medical expenses, but till today there is absolutely no response from the OP-1&2 branch.

That the complainant also issued legal notice to OPs on 26.12.2018 wherein the OP-1 & 2 received the legal notice but did not give any reply. That the complainant on 16.12.2019 approached the OPs requesting the OP to reimburse the balance medical bills.  However, there was no positive response from the OP-2.

According to the complainant the cause action has arose on 31.12.2018 and also when OP refused to give any reply and did not give any response on 06.12.2019. Being aggrieved by the said act of the OPs the complainant has filed this  complaint.

3. Even though the complainant has taken the notice, OP-1 & 2 filed appeared through their counsel and filed their version. Even thought notice served on OP-3, but  has not turned up and remained absent and placed exparte.

4.     As per contention of OP-1 &2  that the complaint filed by the complainant is not maintainable either under law or facts and liable to be dismissed. Further contended that  there was no deficiency of service on the part of this OPs and no cause of action has arisen in favour of complainant to file the present complaint against the OP-1 &2. That OP-2 had issued floater mediclaim policy bearing no. 671602/34/17/28/00000449 for  the period from 28.03.2018 to 27.03.2019 in the name of Satish D.Patel covering Mrs.Satish D.Patel his spouse Ms.Praveena S.Patel and children Mittal S.Darshan & Darsahn.S.Patel for a floater sum  insured of Rs.8,00,000/-. However, it is submitted that the floater sum insured under the previous policy bearing no.671602/34/15/28/ 00000382 for the period from 28.03.2016 to 27.03.2017 was for the floater sum insured of Rs.3,00,000/- only. The husband of complainant has enhanced the floater sum insured from Rs.3,00,000/- to Rs.8,00,000/- under the policy  bearing no.671602/34/16/28/00000396 for the period from 28.03.2017 to 27.03.2018 and further renewed the policy under no.671602/34/17/28/ 00000449 for the period from 28.03.2018 to 27.03.2019 under which the complainant has lodged the present Fifth claim seeking reimbursement of Rs.2,77,514/- . This OP may kindly be permitted to file the certified copy of the policy bearing no.671602/34/15/28/00000382, 671602/34/16/28/00000396 and 671602/ 34/17/28/00000449 during the course of the proceedings.

That as regard to the enhancement of sum insured, attention is drawn to clause-5.11 of the policy condition.

The OPs further submits that the continuous cover for the complainant’s husband is available only for Rs.3,00,000/- and not Rs.8,00,000/- which  we enhanced only on 28.02.2017. As per above clause no.4.1 above, the increased sum insured of Rs.5,00,000/- would be available only after 48 months from the date of inception of the continuous coverage of new floater sum insured form 28.03.2017 i.e. with the reference 28.03.2021. As the current Fifth claim was reported during the 2^nd year from the date of enhancement of new insured, the previous floater sum insured of Rs.3,00,000/- only is applicable for the claim reported during the period from 28.03.2018 to 27.03.2019.

The OPs contended that the present claim of Rs.2,77,514/- was processed by the OP-3, who are the IRDA approved TPA who are appointed by OP-1 & 2 for the processing of claim as per policy terms and conditions. While processing paper, it was noted that the complainant’s husband has already availed the benefit of settlement  04 of previous claims. The complainant’s husband was already paid 04 claims  and 5^th claim was paid Rs.29,559/- again the floater sum insured of Rs.3,00,000/-.  On further verification of records OP-3 has paid a total amount of Rs.3,17,990/- towards all the 05 claims, but together instead of floater sum insured of Rs.3,00,000/- in other wards the OP-3  in adversely paid Rs.29,559/- inspite of only Rs.11,569/- which resulted in excess payment of claim at Rs.17,990/- more than the entitlement.  The OPs have taken up the matter separately with OP-3 with regard to recovery of Rs.17,990/- paid in extra of the sum insured.

The medical expenses for the treatment of complainant’s husband had been reimbursed as per mentioned above. It is submitted that non-medical bills of Rs.4,542/- is not admissible under the scope of policy condition. Out of the total bill of Rs.2,77,514/- the 5^th claim was paid at Rs.29,559/- in fact the complainant’s husband have already taken 04 more claims earlier under the same policy. It is respectable submitted that being the government organization the company to pay the claim clearly based on terms and conditions of the policy.

OPs stated that the complainant’s husband were duly informed about the processing and settlement of claims from time to time as per terms and conditions of the policy. The claim amount under the current 5^th claim was paid less as the floater sum insured of Rs.3,00,000/- was exhausted.  Hence, OPs contend that there is absolutely no deficiency of service and prays to dismiss the complaint with the cost in the interest of justice and equity.

5. The complainant filed her affidavit evidence  and got marked Ex.P1 to P7. The Deputy Manager, Regional office of OP has filed her affidavit evidence and got marked Ex. R1 to R13.

6.  Heard the arguments of advocate from the complainant and OP. Both complainant and OP have filed written arguments. Perused the written documents.

7. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

08.   Our answers to the above points are as under:

       Point No.1:  Affirmative

      Point No.2: Affirmative in part

      Point No.3: As per final orders

REASONS

09.   Point No.1 AND 2: It is admitted by the both the parties that the complainant’s husband Mr.Satish Patel has taken the policy for a sum of Rs.8,00,000/- from the OP-1 branch office and obtained policy from OP-2 and it is also admitted that the complainant is a regular payer of the premium from the past 15 years and recently complainant’s husband taken the policy renewed the policy from 28.03.2018 and valid upto 27.03.2019. During that period complainant husband admitted for the treatment of kidney ailment. On 17.07.2018 the complainant’s husband died due to kidney failure and doctor also given declaration of this effect i.e. Ex.P3. After which legal representative of complainant’s husband has claimed medical coverage of her husband from OP-1 & 2. But the OPs after perusing the raised  bill of the complainant’s husband for the sum of Rs.2,77,514/-, but the OP have reimbursed only Rs.29,559/- out of Rs.2,77,514/- and also admitted that Rs.4,542/- was given by Ramiah Hospital and now complainant is claiming remaining amount from OP. After which complainant is frequently following up with OP for getting their legitimate claim towards medical expenses, but still today there is no response from OP and complainant have issued legal notice to the OP on 26.01.2018 i.e. Ex.P6 and sent notice is duly served, but the OPs have not responded for the said legal notice.

10. The crux is to see that whether the complainant has enhanced from Rs.3,00,000/- to Rs.8,00,000/- on 28.03.2017 vide policy no.671602/34/16/28/00000392. The above said policy tenure the deceased husband of the complainant was admitted to hospital for 11 time and availed her claim amount of Rs.7,25,693/- and same was settled by OPs No.1 to 3. The subsequent renewal of above said policy on 28.03.2018 by policy no. 671602/34/17/28/ 00000449 for the same sum insured of Rs.8,00,000/-. OPs are denied the claim of the complainant on the ground that the policy issued to the complainant is governed by terms and conditions under the policy included a specific clause 5.11 with regard to pre-existing diseases are not covered in enhancement of sum insured in the earlier policy no.671602/34/16/28/ 00000396. The OPs have settled full claim of Rs.7,75,693/- all through OP in their version have claimed the eligible limit is only for Rs.3,00,000/- and in the present policy no.671602/34/17/28/ 00000449. The OPs have settled an amount of Rs.3,17,990/- in 5^th claim and in 5^th claim is partially paid i.e. Rs.29,559/-.

    11. The OPs did not conduct any medical examination of complainant’s husband Mr.Satish Patel before issuing Mediclaim floater policy no.671602/34/16/28/00000396 and subsequent policy. The OP is estoppled from taking the contention and clause no.5.11 for the enhancement of sum insured.

    12.       Further the contention taken by OP that no claim will be payable under clause no.4.1 for the treatment of any pre-existing condition/disease until 48 months of continuous coverage of such person have lapsed, from the date of inception of his/her 1^st policy has mentioned in the schedule is also not applicable to opposite party, since OP No.1 to 3 have already paid entire policy amount of Rs.7,75,693/- (Rs.Seven Lakh Seventy Five Thousand Six hundred and Ninety Three only) under the policy no.671602/34/16/28/00000396 as per the document produced by OP dt.22.09.2022. In the present policy no.671602/34/17/28/00000449 also OP no.1 to 3 have paid Rs.3,17,990/-. Despite taking the contention that the claimant was not eligible as per clause no.4.1. The OP No.1 to3 are bound to pay the balance claim amount of Rs.2,47,955.10p.

13.   As per the specific clause-5.11 the insured should have been examined by Medical practitioner before issuing mediclaim floater policy No. 671602/34/16/28/00000396 and subsequent policies.  In instant case the complainant’s husband had taken Kidney treatment for the 1^st time. But OPs have contending that it is pre-existing disease as mentioned in clause 4.1 and  not produced any cogent evidence to eliciting   the complainant’s husband was suffering from kidney ailment. The OPs have not repudiating this claim of the complainant on reasonable grounds. The OPs have contended the excess amount of Rs.7,75,693/- was paid against  insured amount for Rs.3,00,000/- claim. But which the complainant has  claimed the 5^th claim after enhancement of the policy premium of the sum insured for Rs.5,00,000/-. The OP should have settle the claim of the complainant for the 5^th claim i.e. the sum insured was Rs.5,00,000/- but OPs are contending that, while making the settlement of the 4^th claim that have paid excess amount which is not right, the OPs could have restricted their claim for the sum of Rs.3,00,000/- but while making for the settlement for the 5^th claim the OPs cannot contend that they have paid extra, as the sum insured for the 5^th claim was for Rs.5,00,000/-. A layman is going to take the insurance policy with intention that could help at the time of their necessity. When it does not come to rescue of the complainant the taking of the policy from the OP will be frustrated. Hence, all the reasons stated above is sufficient that OPs are not right in repudiating the claim of the complainant on false grounds. Hence, complainant has proved deficiency in service in the part of OPs. Under these circumstances, the complaint is to be allowed in part. Hence,  we answer point No.1 in affirmative and point No.2 affirmative in part.

13.   Point No.3:- In view the above discussion, the complaint is liable to be allowed in part. The OP directed to reimburse the claim amount of Rs.2,47,955/- with 9% p.a. interest from the date of complaint till realization. The complainant is also entitled for compensation of Rs.25,000/- for the mental agony suffered by them. The complainant is entitled for litigation expenses of Rs.25,000/-. Accordingly, we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. OP is directed to reimburse the claim amount of Rs.2,47,955/- with  interest at 9% p.a., from the date of complaint till realization.
3. OP is further directed to pay compensation of Rs.25,000/- for mental agony suffered by the complainant and a sum of Rs.25,000/- towards litigation expenses to the complainant.
4. The OP is further directed to pay entire amount within 60 days from the date of this order, if the OP fail to reimburse the amount Rs.2,47,955/- will carry interest at 12% p.a. after expiry of 60 days till the realization of the amount.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 23^rd day of JANUARY, 2023)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1: 

*SKA