DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

Civil Station, Palakkad 678001, Kerala

Dated this the 30^th day of September, 2009

Present: Smt.Seena.H, President

Smt.Preetha.G.Nair, Member

Smt.Bhanumathi.A.K, Member

C.C.No.129/2007

Mrs.Lakshmi Sreenivasan,

W/o.T.S.Sreenivasan,

“Seenus”, S.K.Puram Road,

Ganesh Nagar,

Palakkad – 678010. - Complainant

(By Adv.C.Balachandran)

Vs

1. Oriental Insurance Company Ltd.,

Divisional Office,

Palakkad.

(By Adv.P.Ramachandran)

2. Yagnapriya Bharath,

Officer on Special Duty,

Insurance Regulatory and Development Authority,

IRDA, Parishrama Bhavanam,

5-9-58B, Basheerbagh,

Hyderabad 500 004.

3. M/s.Family Health Plan Ltd.,

No.39/496 G.Uznaz Tower,

5^th Floor, Medical Trust Junction,

Pallimukku, M.G.Road, Ernakulam,

Kochi. - Opposite parties

O R D E R

By Smt.Preetha.G.Nair, Member

The complainant is the wife of Sri.T.S.Sreenivasan, who is the holder of individual mediclaim policy No.442000/48/07/00039 for an amount of Rs.50,000/- . Complainant being the spouse was insured for an amount of Rs.15,000/- initially and was enhanced to an amount of Rs.50,000/- from 19-04-06 to 18-04-07. The mediclaim policy was first taken by the complainant for the period from 07-04-99 to 06-04-2000 and it is being renewed every year. The complainant was admitted as an in-patient in Lakshmi Hospital on a complaint of pain in the abdomen on 25-05-06. She was subjected to extensive medical check up and on 29-05-06 on the basis of a report of scan test it was recommended for post vaginal

hysterectomy. Immediately based on the recommendation of scan report the complainant was operated at Lakshmi Hospital on 29-05-06. After the operation the complainant had a BP fall and shock, that again led to a second operation conducted on the complainant on 29-05-06. The second surgery was emergency and unexpected. The complainant was discharged on 05-06-06. Based on the mediclaim policy the complainant submitted a claim for an amount of Rs.36,029/48 to the 3^rd opposite party. There was undue delay on the part of 3^rd opposite party in considering the claim of the complainant. This necessitated the complainant to address through her husband to the 3^rd opposite party. Based on such representation the 3^rd opposite party called for the details and informing her that they have been appointed as a third party administrator to administer the mediclaim policy of 1^st opposite party. The particulars requested by the 3^rd opposite party were furnished by the complainant. Thereafter by letter dtd.30-08-06 a cheque for Rs.15,750/- drawn on the UTI bank was forwarded to the complainant. The complainant received the same after three months, on 24-11-06 under protest. On 25-11-06 the complainant’s husband addressed to the 2^nd opposite party to look into the issue and take appropriate decision in the matter. Thereafter the 2^nd opposite party informed the husband of the complainant that on receiving the complaint, they took up the matter with 1^st opposite party, which informed that enhancement of sum insured from Rs.15,000/- to Rs.50,000/- during renewal. And the claim during renewal was pre-existing so far as enhanced sum insured is concerned attracting provisions of conditions of No.4.1, 4.2 and 4.3 and the claim for Rs.15,000/- plus Rs.750/- can be considered. The inaction on the part of the insurance company to settle the entire claim amounts to deficiency in service and it has caused much mental agony to the complainant. The complainant is eligible to be compensated by payment of Rs.21,000/- being the balance claim amount together with a sum of Rs.1 lakh as compensation for the delay in payment in part and for not settling the entire claim after accepting the premium and further sum of Rs.1 lakh for causing mental agony to the complainant.

2. After admitting the complaint, notice was issued to opposite parties. 1^st opposite party filed version through counsel. But 2^nd and 3^rd opposite party absent. Hence 2^nd and 3^rd opposite parties set ex-parte. 1^st opposite party filed version stating the following contentions. The 1^st opposite party stated that the allegation of the inaction, on the part of insurance company to settle the entire claim amounts to deficiency in service and it has caused mental agony to the complainant is not correct. The complainant is not entitled to get the compensation claimed for the delay in payment in part and for the alleged mental agony. The amount settled by the opposite party is the sum, the complainant is legally

entitled to get under the policy. As per the terms and conditions of the policy complainant is entitled to get the sum payable prior to the enhancement of the insured sum commences on the date of next renewal of the policy onwards provided the treatment for which the claim is preferred is not pre-existing to the date of enhancement. Hence the question of part payment does not arise. The complainant is not entitled to get enhanced insured sum because the ailment for which the claim was initiated is pre-existing to the date of enhancement of the insured sum. The medical reports produced by the complainant discloses that the insured had taken scanning for the ailment on 11-05-06 itself. That is within 22 days from the date of enhancement of the insured sum so it is clear that the insured was aware of the ailment and that the ailment was pre-existing. The contention that the second operation was after 8 hours and that it was a second event are not correct. The medical reports shows that bleeding was immediately after the surgery and it is a consequence of surgery. Arrest of bleeding at the spot of surgery cannot be considered as a second event. The alleged second event is only a continuous process of surgery. The further contention in the complaint that there was delay in settling the dispute and it caused mental agony to the complainant. The insured sum which the complainant is legally entitled to get was given to him without any undue delay. The claim application of the complainant was repudiated by the 3^rd opposite party. The 1^st opposite party is bound to follow the instructions and recommended actions of the 3^rd opposite party while settling the mediclaim policies. Hence the allegation of deficiency in service on the part of this opposite party is not sustainable. Therefore 1^st opposite party prayed that this complaint may be dismissed.

3. Complainant filed chief affidavit and documents. Exts.A1 to A11 marked on the side of complainant. 1^st opposite party filed affidavit and one document. Ext.B1 marked on the side of 1^st opposite party. Matter was heard.

4. Issues to be considered are:

1. Whether there is deficiency of service on the part of opposite parties?

2. If so, what is the relief and cost?

5. Issues I & II:

2^nd and 3^rd opposite party has not filed any version or affidavit. We perused relevant documents on record. It is not in dispute that the complainant is the wife of Sreenivasan, who is the holder of individual mediclaim policy No.442000/48/07/00039 for an amount of Rs.50,000/- each for himself, his wife and three children. According to

Ext.A9 after the operation the complainant had a Blood Pressure fall and shock, that again led to second operation conducted on the complainant. According to Ext.A1, the period of the mediclaim policy is from 19/04/06 to 18/04/07. The say of opposite party is that the ailment of the complainant which was pre-existing to the renewal of the policy was renewed for a higher insured sum. In the deposition of PW1-Dr.Kalyani.G.Menon stated that Fibroids are developed for a long time, complainant consulted her for continuous bleeding. PW1 adds that second operation was the continuation of the first. In the chief examination of PW1 deposed that she had conducted open surgery and it was unexpected and sudden. In short, the deposition of PW1 clearly shows that the ailment of the complainant was not pre-existing to the renewal of the policy. The 1^st opposite party orally stated that there was no delay in making payment of the insured sum. As per Ext.A5, the claim for an amount of Rs.36,029.48 to the 3^rd opposite party was submitted by the complainant on 15/06/06. According to Ext.A7 series the complainant received the cheque for Rs.15,750/- on 24/11/06. Therefore there was delay in making payment of the insured sum. We do not find any deficiency in service on the part of 2^nd opposite party. Hence they are exonerated. In the above discussions we hold the view that there is deficiency in service on the part of 1^st and 3^rd opposite parties. Hence complaint allowed.

6. We direct the opposite parties 1 & 3 jointly and severally to pay an amount of Rs.21,000/- (Rupees Twenty one thousand only) being the balance claim amount together with Rs.15,000/- (Rupees Fifteen thousand only) as compensation and Rs.2,000/- (Rupees Two thousand only) as cost of the proceedings. Order shall be complied within one month from the date of receipt of this order failing which the whole amount shall carry interest @ 9% p.a from the date of order till realisation.

7. Pronounced in the open court on this the 30^th day of September, 2009

Sd/-

Seena.H,

President

Sd/-

Preetha.G.Nair,

Member

Sd/-

Bhanumathi.A.K,

Member

Appendix

Witness marked on the side of complainants

PW1 – Dr.Kalyani.G.Menon

Witness marked on the side of opposite party

Nil

Exhibits marked on the side of complainant

Ext.A1 – Copy of mediclaim policy

Ext.A2 – Terms and conditions of policy

Ext.A3 – Report of scan test (photo copy)

Ext.A4 – Photo copy of certificate issued by Dr.Kalyani.G.Menon

Ext.A5 – Copy of letter sent by complainant to 3^rd opposite party

Ext.A6 – Letter dtd.29/07/06 sent by 3^rd opposite party to complainant’s husband

Ext.A7 (Series) – Copy of cheque and letter dtd.30/08/06 sent by 3^rd opposite party to

complainant’s husband,

Ext.A8 – Copy of letter dtd.25/11/06 sent by complainant’s husband to 3^rd opposite party

Ext.A9 – Letter dtd.19/02/07 sent by 2^nd opposite party to complainant’s husband

Ext.A10 – Copy of discharge summary issued by Lakshmi Hospital, Palakkad.

Ext.A11 (Series) - Copy of policies – 7 in Nos.

Exhibits marked on the side of opposite party

Ext.B1 – Copy of USG report dtd.11/05/06.

Costs (Allowed)

Rs.2,000/- (Rupees Two thousand only) as cost of the proceedings