KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAD, THIRUVANANTHAPURAM
FIRST APPEAL 346/2010
JUDGMENT DATED: 16..7..2011
PRESENT
JUSTICE SRI.K.R.UDAYABHANU : PRESIDENT
SRI.S.CHANDRAMOHAN NAIR : MEMBER
1.TATA AIG Life iNsurance Co.Ltd. : APPELLANTS
2nd floor, Foto Fast House, M.G.Road,
Kochi-682 035, rep.by its Manager.
2. TATA AIG, Aban Towers,
Pathanamthitta, Rep.by its Manager.
(By Adv.Mathew B.Kurian)
Vs.
1. Shiju Sebastian, : RESPONDENTS
Maliakal Thudiyil House,
Near CANA, Thuruthy.P.O.,
Changanachery.
(By Adv.R.Suja, counself or R1)
2. M/s Bajaj Capital Insurance Broking Ltd.,
(Agency Office CO01), Rubicon Building,
SA,Road, South Over Bridge,
Valanjambalam, Cochin -16 rep.by
Its General Manager.
3. Khaleel.P.K., Parekkattu House,
Veroor.P.O., Changanachery.
JUDGMENT
JUSTICE K.R.UDAYABHANU : PRESIDENT
The appellant is the 1st opposite party/Tata AIG Life insurance Co.Ltd. in CC.109/08 in the file of CDRF, Pathanamthitta. The appellants are under orders to pay a sum of Rs.3750/- towards daily hospitalization benefit and Rs.375/- for post hospitalization benefits and Rs.22,056/- towards surgical benefits and Rs.5000/- as compensation and Rs.2000/- as cost with interest at 9%.
2. The case of the complainant is that he was covered by Health First Policy of the opposite party as per which there was a coverage upto 3,75,000/- including surgical benefits of Rs.37500/-. The complainant had met with an accident and he sustained extensive craniofacial injuries. He was admitted St.Thomas Hospital Chethipuzha and from where referred to Pushpagiri Medical college hospital on 30.11.06. He underwent surgery on 30.11.2006 and discharged on 21.12.06. He had incurred a sum of Rs.Rs.22,056/- for treatment. Opposite party allowed only Rs.4125/-.
3. The case of the opposite parties is that as per the terms of the policy the complainant is entitled only at the rate of Rs.250/- per day as daily hospitalisation benefit and Rs.125/- per day as post hospitalization benefit and also surgical benefits of Rs.12500/- with respect to the surgeries covered by the policy.
4. According to the opposite parties the surgery that the complainant underwent is not covered by the policy.
5. The evidence adduced consisted of the testimony of PW1, DW1; Exts.A1 to A9 and B1 to B11
6. The appellant has relied on the decision of the Supreme Court in Bharathi Knitting Company Vs. DHL1996 (4) SCC 704 in support the contention that the parties are bound by the terms of the contract. We find that the fact situation in the above stated case is entirely different and has no relevance to the facts of the present case.
7. We find Forum has directed to pay at the rate of Rs.750/- for 5 days towards hospitalization and Rs.375/- for one day for post hospitalization benefit and Rs.22500/- towards the surgical benefit.
8. The counsel for the appellant has no dispute with respect to the amounts awarded ie, Rs.3750/- and Rs.375/-. The complainant has purchased 3 units of the policy. According to the appellant the hospitalization benefit is at the rate of Rs.250/- per day and post hospitalization benefit Rs.125/- per day. As the complainant has purchased 3 units the amount for hospitalization would be Rs.750/- per day, and for post hospitalization Rs.375/- per day. The main dispute is with respect to the surgical benefit. The appellant is relied on Ext.B2 policy conditions wherein there is a list of surgeries that are covered. On an examination of Ext.B2 document we find that surgeries specified therein are very rare surgeries which any assured would not have to undergo in case of normal illnesses. For example orthopedic surgeries mentioned are plastic repair of cranium, prosthetic replacement of bone, replantation of upper limb, replantation of lower limb, implantation of prosthesis for limb, amputation of arm, amputation of hand, amputation of leg or foot. We find that the surgeries covered are deviced in such a manner that normal Surgeries are not covered by the policy. The above scheme amounts to fraud perpetuated on the customer. We find that the opposite party should not be allowed to get away which such a scheme. We find that as per Ext.A9 bill the complainant has been charged for hospitalization expenses for a sum of Rs.15,404/-. He was impatient for 6 days. He underwent surgeryuuunder general anesthesia. He also underwent CT scan for which Rs.2000/- has been charged at the above hospital. Hence we find that the complainant would be entitled for inpatient treatment a sum of Rs.18500/-(rounded). He will be entitled for a sum of Rs.3500/- for OP treatment which can be taken reasonable as 10 days. Altogether he will be entitled for a sum of Rs.22500/-. The complainant will also be entitled for cost of Rs.5000/-. The complainant will be entitled interest at 12% from the date of complaint ie, 25.7.08. The order of the Forum is modified accordingly. The amounts are to be paid within 2 months from the date of receipt of this order failing which the complainant will be entitled for interest at 15% from 16..7..2011 the date of this order.
Office will forward the LCR to the Forum alongwith the copy of this order.
JUSTICE K.R.UDAYABHANU : PRESIDENT
S.CHANDRAMOHAN NAIR : MEMBER
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