IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, ALAPPUZHA
Wednesday the 15th day of December, 2021.
Filed on 07.01.2020
Present
- Sri.S.Santhosh Kumar BSc.,LL.B (President )
- Smt. Smt.C.K.Lekhamma, B.A, LLB (Member)
In
CC/No.5/2020
between
Complainant:- Opposite party:-
Sri.Peethambaran Smt.Asha Manwara
S/o Purushothaman Care Manager
Kochuparambu Aditya Birla Capital Health
Pallana P.O. Insurance Co., 13th floor,
Kumarakodi R Tech park Nirion Company
Thrikkunnapuzha-690515 of Western Express Highway
(Party in Person) Gurgaon East, Mumbai-400063
(Adv. Saji Issac.K.J )
O R D E R
SRI. S.SANTHOSH KUMAR (PRESIDENT)
Complaint filed under Sec.12 of the Consumer Protection Act, 1986.
1. Material averments briefly stated are as follows:-
On 19.01.2019 complainant and his wife Indira joined a health insurance policy of the opposite party. Monthly premium of Rs.853/- was being deducted on 5th of every month from the account of the complainant. On 29.07.19 wife of the complainant became unconscious and when contacted with M/s Huda trust hospital where it was informed that the insurance company had tie up they denied the same. On enquiry with M/s Souhridaya hospital, M/s Deepa Hospital Karuvatta and M/s KVM hospital also it was informed that they have no tie up with the opposite party. Thereafter wife of the complainant was admitted at Mathery Medial Mission hospital on 29-7-19. She was treated for one week and discharged after that. Opposite party was not available over phone. When contacted at the health insurance department they assured to reimburse the amount accordingly all the documents were sent by post and by courier service. The last document was sent on 19-12-19. Though it was assured that bill amount of Rs.9498/- will be credited in his account within 5 working days it was not paid. Hence the complaint is filed for realizing the bill amount and for Rs.16,000/- as compensation.
2. Opposite party filed a version mainly contenting as follows:-
The complaint is an abuse of the process of law and the complainant has approached this Commission with unclean hands. The averment that admission of Indira at Mathery Medical Mission Hospital on 29-7-19 is false and hence denied. The averment that complainant had forwarded all necessary documents to the opposite party is denied. Opposite party had requested the complainant by letter dated 30-11-19 to provide all original investigation reports for Rs.1640/- in main bill. Since the complainant did not submit the documents required again opposite party requested to forward the records on 2-12-19. Another letter was also sent on 28-12-19.
3. The averment that all the documents were sent by post and by courier service and the last documents were sent on 19-12-19 is false. The original investigation report and case papers and supporting diagnosis were not sent. As per the conditions of the policy if there are any deficiencies in the necessary claim documents which are not met or are partially met. Opposite party will send a maximum of 3 remainders following which a rejection letter will be sent. Opposite party had not received the deficiency documents after 45 days from the date of initial request of such documents. Opposite party sent letters on 30.11.19, 02.12.19, and 28.12.19. Thereafter another letter was sent on 05.03.2020 intimating the complainant of the inability to approve reimbursement of the claim as the documents were not submitted. The contention that a staff of the opposite party had contacted complainant and assured to credit Rs.9,498/- within 5 working days is false. As per the discharge certificate from the Mathery Medical Mission hospital the final bill is only Rs.3564/- out of which an amount of Rs.1640/- remains unexplained. There is no deficiency of service and unfair trade practice on the part of the opposite party. The rejection of claim was due to the default of the complainant himself. Hence the complaint may be dismissed with cost.
4. On the above pleadings following points were raised for consideration:-
- Whether there is any deficiency of service on the part of opposite party?
- Whether the complainant is entitled to realize an amount of Rs.9,498/- as prayed for?
- Whether the complainant is entitled to realize an amount of Rs.16,000/- as compensation?
- Reliefs and cost?
5. Evidence in this case consists of the oral evidence of PW1 and Exts.A1 to A5 from the side of the complainant. Opposite party has not adduced any evidence Ext.B1 to B4 were marked from their side.
6. Pw1, the complainant along with his wife joined a health insurance policy with the opposite party on 19/1/2019. An amount of Rs. 853/- was being deducted from the account of the complainant on the 5th of every month. While so on 29/7/2019 complainant’s wife was admitted at M/s Matheri Medical Mission Hospital, Thottappally due to fever and the hospital bill was Rs.9498/-. PW1 filed a claim form before the opposite party. Inspite of repeated communications the claim was not honoured and hence the complaint is filed for realizing an amount of Rs. 9498/- along with cost. Opposite party filed a version admitting the claim. There only contention is that there was no bill for Rs. 1640/- Submitted along with the claim form and inspite of repeated demands it was not furnished. They sent letters on 30/11/2019, 2/12/2019 and 28/12/2019. Inspite of that the necessary documents were not submitted. Complainant gave evidence as PW1 and marked Ext.A1 to A5. Opposite party has not adduced any oral evidence Ext.B1 to B5 were marked from their side.
7. In the version policy is admitted by the opposite parties. There only contention is that inspite of Ext.B1 to B3 reminders necessary document were not submitted and so the claim was kept pending. The dispute is with respect to a bill amounting Rs. 1640/-. Ext.B1 dtd. 30/11/2019, Ext.B2 is dtd.2/12/2019 and Ext.B3 is dtd. 28/12/2019. In all these letters addressed to PW1 opposite party demanded certain documents mainly original bill for Rs. 1640/-. It was contented by the learned counsel appearing for the opposite party that if necessary documents are not produced inspite of three reminders they are entitled to repudiate the claim. Here in this case though Ext.B1 to B3 letters are sent the claim is not repudiated and learned counsel appearing for the opposite party frankly admitted that if PW1 produces the bill for Rs. 1640/- they are ready to entertain the claim. The learned counsel appearing for the opposite party relied upon a ruling of the Hon’ble Supreme Court in Export Credit Guarantee Corpn of India Ltd Vs. M/s Garg Sons International ( 2013 KHC 4040). It was held by the Hon’ble Supreme Court
“Terms of Insurance policy have to be strictly construed in order to determine the extent of the liability of the insurer – It is not permissible for the Court to substitute terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance.”
8. Here as discussed earlier from Ext.B5 it is revealed that the total claim amount is only Rs. 9498/-. Opposite party admitted the insurance policy and there only grievance is that a bill for Rs. 1640/- was not furnished inspite of sending Ext.B1 to B3 reminders. It is true that as per the ruling referred above, the terms of insurance policy had to be construed strictly. The opposite party as per their conditions is entitled to repudiate the claim. If inspite of repeated reminders to produce the necessary documents and this commission cannot interfere with the same. However it is to be noted that the total bill amount is only Rs. 9498/- and according to PW1 he has furnished all the necessary documents. As held by the Hon’ble Supreme Court in Om parakash Vs. Reliance General Insurance on 4/10/2017 in Civil Appeal No. 15611 of 2017.
“Rejection of the claim on purely technical grounds in a mechanical manner will result in loss of confidence of policy – holders in the insurance industry. It needs no emphasis that the Consumer Protection Act aims at providing better protection of the interest of consumers. It is a beneficial legislation that deserves liberal construction. This laudable object should not be forgotten while considering the claims made under the Act.”
9. Here in this case as stated earlier the claim amount is only Rs.9498/-. It is not honoured by the opposite party, on a contention that bill for Rs. 1640/- is not produced. It is true that inspite of Ext.B1 to B3 reminders the same is not produced by the complainant. Since the bill amount is only Rs. 9498/- and so that the complainant is regularly remitting the premium on every month, opposite party had to take a lenient view and even if the bill is not available they can entertain the claim since PW1 is a regular customer. In said circumstance we are of considered view that a direction can be given to the opposite party to honour the claim for Rs. 9498/- submitted by complainant. According to PW1 the date of admission with the hospital was on 29/7/2019 and still he has not received the claim though he was regularly remitting the premium of Rs. 853/- every month. Per contra the contention of learned counsel appearing for the opposite party is that they have not entertained the claim for want if necessary document. As stated earlier complainant will produce all necessary documents if available within a short time and the opposite party will entertain the claim thereafter. It appears that dispute is only with regard to bill amounting Rs. 1640/-. Even if it is not available being a regular customer opposite party will entertain the claim. Complainant is claiming compensation on an allegation that there was deficiency of service from the part of opposite party. Per contra the learned counsel appearing for the opposite party contented that the claim was not entertained for want of necessary documents which they are authorized as per terms and conditions of the policy (Ext.B4). In said circumstance no compensation can be awarded. These points are found accordingly.
10. Point No.4:-
In the result, complaint is allowed in part.
A) Opposite party is directed to entertain the claim of Rs. 9498/- of the complainant without much delay.
B) Complainant is allowed to realize an amount of Rs.2000/- as cost from the opposite party.
The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant, transcribed by him corrected by me and pronounced in open Commission on this the 15th day of December, 2021.
Sd/-Sri.S.Santhosh Kumar(President)
Sd/-Smt.C.K Lekhamma (Member)
Appendix:-Evidence of the complainant:-
PW1 - Peethambaran (Complainant)
Ext.A1 - Copy of Policy Certificate
Ext.A2 - Discharge Summary
Ext.A3 - Mail Copy of Query Letter dtd. 12/12/2019
Ext.A4 - Copy of Mail dtd. 10/12/2019
Ext.A5 - Health Insurance Card
Evidence of the opposite parties:-
Ext.B1 - Reminder dtd.30/11/2019
Ext.B2 - Reminder dtd. 2/12/2019
Ext.B3 - Reminder dtd. 28/12/2019
//True Copy ///
To
Complainant/Oppo. party/S.F.
By Order
Assistant Registrar
Typed by:- Br/-
Compared by:-
