Andhra Pradesh

East Godwari-II at Rajahmundry

CC/65/2015

K.T.N.V.N. Prasad - Complainant(s)

Versus

Star Health and Allied Insurance Co, Ltd., Rep. by its Manager - Opp.Party(s)

D.V.K.Ramesh

22 Aug 2016

ORDER

 

                                                                                                Date of filing:   04.11.2015

                                                                                                Date of Order: 22.08.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

          PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

              Monday, the 22^nd day of August, 2016

 

C.C.No.65 /2015

Between:-

 

1)  K.T.N.V.N. Prasad, S/o. Veera Swamy, Hindu,

     Aged 52 years, Business, D.No.9-25-31, Gunduvari

     Street, Rajahmundry.

 

2)  Smt. Kancherla Mahalakshmi, W/o. K.T.N.V.N. Prasad,

     Hindu, Aged 49 years, Housewife, D.No.9-25-31,

     Gunduvari Street, Rajahmundry.                                                               …  Complainants

 

                                    And

 

1)  Star Health and Allied Insurance Co. Ltd., Rep. by its

     Manager, D.No.46-7-27/2, Opp. Green Park Hotel,

     Danavaipeta, Rajahmundry.

 

2)  Star Health and Allied Insurance Co. Ltd., Rep. by its

     Authorized Signatory, KRM Centre, VI Floor, No.2,

     Harrimgton Road, Chetpet, Chennai – 600 031.                                        …  Opposite parties

  

 

            This case coming on 09.08.2016 for final hearing before this Forum in the presence of Sri D.V.K. Ramesh, Advocate for the complainants and Sri S.S. Chalam, Advocate for the opposite parties, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.H.V. Ramana, President(FAC)] 

This is a complaint filed by the complainants U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties 1 and 2 to pay the claim amount of Rs.5,847/- with interest at 24% p.a. from 17.10.2014; to pay Rs.5,000/- towards compensation and damages and pay Rs.1,000/- towards legal notice charges.

2.         The case of the complainants is as follows:- It is submitted that the 1^st complainant having believed the representation of the agent of the 1^st opposite party took Family Health Optima Insurance Policy bearing No.P/131124/01/2015/00383 code 3562036 of Rajahmundry Branch code No.131124. A premium amount of Rs.10,000/- was collected from the 1^st complainant on the policy covers from 24.5.2014 to 23.5.2015. The total coverage of risk is for 3 lakhs for two persons by name K.T.N.V.N. Prasad and K. Maha lakshmi i.e. the complainants. At the time of the policy, the 1^st opposite party, represented by its Branch Manager assured that the company will allow the claims without giving any problem to the policyholders.  Recently, the 2^nd complainant was hospitalized and admitted in a reputed Orthopedic Hospital, M/s. Arvindam Orthopedic Physiotherapy Center. The 2^nd complainant submitted the claim form and the same was signed by the hospital authority. In the said claim form, the doctor mentioned the date and time of admission and the date and time of discharge. The time of admission is at 6 AM on 15.10.2014 and the time and date of discharge is 11 AM on 16.10.2014. The doctor mentioned the same in the claim form Part B. The insurance company will rely upon the doctor certificate and will settle the claim. In this case, the time of admission was understood as 6 PM and the company repudiated the claim vide their letter dt.19.1.2015. Under the above circumstances, the complainant got issued notice dt.27.3.2015 and having received the same, the 1^st opposite party addressed a reply letter dt.15.4.2015 with false averments. Hence, the complaint.

3.         The 1^st opposite party filed its written version and the same was adopted by the 2^nd opposite party and denied the allegations made by the complainant and the complaint is not maintainable either under law or on facts. The allegation that the 2^nd complainant alleged to have been admitted in the hospital at 6 AM on 15.10.2014 and was discharged on 16.10.2014 at 11 AM is not true and correct. In fact the 2^nd complainant was admitted in the hospital on 15.10.2014 at 6 PM and was discharged on the next day at 11 AM i.e. 16.10.2014. The said fact was clearly indicated in the claim form Part-B as per the treatment undergone by the 2^nd complainant which was duly certified by the doctor with the seal of the doctor and signature. The opposite party therefore confirms that the stay of the complainant in the hospital is less than 24 hours. The opposite party submits that as per the terms and conditions of the policy ‘patient’ means an insured person who is admitted in the hospital and stay there for a minimum period of 24 hours for the sole purpose of receiving treatment. Since the 2^nd complainant in the present case had stayed in the hospital for less than 24 hours, she will not come under the preview of ‘Patient’, as defined in the terms and conditions of the family health optima insurance policy and hence policy has no application in the present case and the opposite party rightly repudiated the claim of the complainants. The opposite party submits that the submission of another certificate issued by the doctor with necessary modifications regarding alteration of time of admission in order to suits to the terms and conditions of the policy and the affidavit duly executed by the doctor are inadmissible since the same are submitted after the repudiation of the claim by the opposite party. The opposite party submits that insurance is a contract based on utmost good faith. There is need and requirement and compulsion on the part of the insured to be truthful and transparent in the proposal to enable the insurer to take and make a conscious decision to under write the risk or not. Failure on the part of the insured complainant in this regard would vitiate the very contract of insurance, hence the opposite party rightly repudiate the claim of the 2^nd complainant and the same was communicated vide letters dated 27.2.2015 and 3.3.2015. Therefore, there is no deficiency of service on the part of the opposite party in repudiating the claim of the 2^nd complainant and the complaint is liable to be dismissed with costs.

4.         The proof affidavit filed by the 1^st complainant and Exs.A1 to A6 have been marked for the complainants. The proof affidavit filed by the 1^st opposite party and Exs.B1 to B6 have been marked for the opposite parties.

5.         Heard both sides. The opposite parties filed written arguments.

6.         Points raised for consideration are:

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

            2. Whether the complainants are entitled for the reliefs asked for?

            3. To what relief?

 

7.  POINT Nos.1 & 2:  The admitted facts of the complaint are that complainants obtained Family Health Optima Insurance Policy bearing No.P/131124/01/2015/00383 code 3562036 of Rajahmundry Branch code No.131124 and paid an amount of Rs.10,500/- as premium and the sum assured is.3 lakhs for both wife and husband and the said policy was in force vide Ex.A1. The 1^st complainant submitted that his wife was hospitalized in a reputed Orthopedic Hospital i.e. M/s. Arvindam Orthopedic Physiotherapy Center on 15.10.2014 at 6.00 AM and she was discharged on 16.10.2014 at 11.00 AM. The complainants also submitted that the opposite parties understood the 2^nd complainant was admitted at 6.00 PM and the company repudiated the claim vide Ex.A2 letter dt.19.1.2015 and mentioned that the 2^nd complainant stayed in the hospital for less than 24 hours. He also submitted that in Form-B of the claim form, the doctor who noted the time was considered by the opposite parties as 6.00 PM instead of 6.00 AM. He also submitted that the doctor gave a clarification with regard to the time and informed the opposite parties to consider the claim. The opposite parties further wrote a letter to the complainants with regard to the repudiation vide Exs.A3. When the opposite parties failed to settle the claim, the complainants got issued a legal notice through their advocate dated 27.3.2015 vide Ex.A4. The said notice was received by the opposite parties and gave a reply vide Ex.A5 and stated that the 2^nd complainant has to be hospitalized for a minimum period of 24 hours. In this case, the doctor who gave the treatment to the claimant, himself gave an affidavit vide Ex.A6 that the patient Smt. Kancherla Mahalakshmi joined as inpatient No.61/2014 on 15.10.2014 at 6.00 AM and was discharged on 16.10.2014 at 11.00 AM. He also mentioned in his affidavit, the said information is available in his registers such as admission register and discharge register.     

            The opposite parties also admitted that the complainants took the policy and the same was in force vide Ex.B1 & B2. The main contention is that the 2^nd complainant stayed in the hospital only 17 hours and it is clearly indicated in the claim Form-B vide Ex.B3. He also submitted that as per the terms and conditions, it is clearly mentioned under clause-2 definitions as defined the inpatient under Ex.B2 policy. The opposite parties also filed the declaration letter given by the 1^st complainant vide Ex.B4, in which he clearly mentioned about the admission and discharge of the 2^nd complainant and requested the opposite parties to settle the claim.  Dr. Arvindam, who treated the 2^nd complainant gave a letter that the 2^nd complainant was admitted in their hospital on 15.10.2014 at 6.00 AM and discharged on 16.10.2014 at 11.00 A.M. Even then, they sent repudiation letter to the complainant vide Ex.B6.

            After perusing the material on record, it is observed that the complainants obtained the policy and paid the premium to the opposite parties. The 2^nd complainant underwent the surgery in the hospital of Dr. Arvindam on 15.10.2014 and she was admitted at 6.00 A.M. on the same day. It is also observed that the doctor, who conducted the surgery himself gave an affidavit and also wrote a letter vide Exs.A6 & B5 that the 2^nd complainant was admitted in their hospital at 6.00 AM of 15.10.2014 and was discharged on 11.00 A.M. on 16.10.2014. The said information was mentioned in his admission and discharge registers. The opposite parties repudiated the claim by relying on Ex.B3 in which it is mentioned that the 2^nd complainant was admitted on 15.10.2014 and the time is at 6.00 PM, but as per our observation it is noticed that the time is not clearly visible to us. As per Exs.A6 and B5 the doctor who did the surgoery also gave an affidavit that the 2^nd complainant was admitted in their hospital on 15.10.2014 at 6.00 AM and also discharged on 16.10.2014 at 11.00 AM. The concerned doctor also submitted that the said information is available in his admission register and also discharge register. When the doctor himself categorically stated with regard to the admission and discharge, the opposite parties should have enquire the said information in the hospital and settle the claim of the 2^nd complainant, but the opposite parties failed to do so and they have not made any efforts with regard to verification of time of admission. They merely relied on the information furnished in the claim form part-B and which is not clearly written in the said form about the date of admission. Therefore, we opined that there is a deficiency in service on the part of the opposite parties in not settling the claim, even though the doctor gave an affidavit with regard to the admission of the 2^nd complainant. Hence, the 2^nd complainant is entitled for the medical claim amount as mentioned in the claim form. The opposite parties are also directed to give the damages to the complainants for mental agony in not settling the claim even inspite of furnishing the information required by the opposite parties.             

8.   POINT No.3:  In the result, the complaint is allowed in part, directing the opposite parties to pay the claim amount of Rs.5,847/- and  pay Rs.2,000/- towards damages for mental agony for non-settlement of claim of the 2^nd complainant and also direct the opposite parties to pay Rs.1,000/- towards costs of the complaint to the complainants. Time for compliance is two months from the date of this order.   

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the 22^nd day of August 2016.

    

                   Sd/-                                                                                            Sd/-      

              MEMBER                                                                              PRESIDENT(FAC)

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANTS: None.                                      FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANTS:

 

Ex.A1    Copy of the Policy issued by the opposite party.

Ex.A2    Claim Form.

Ex.A3    Repudiation letter dt.19.1.2015.

Ex.A4    Office copy of the notice dt.27.3.2015.

Ex.A5    Reply by the opposite party dt.15.4.2015.

Ex.A6    Notarized Affidavit of Dr. G. Aravindam.

 

 

FOR OPPOSITE PARTIES:-  

 

Ex.B1    dt/24.5.2015    Proposal form along with family health optima Insurance policy.

Ex.B2    dt/24.5.2015    Terms and conditions of the policy issued.

Ex.B3    dt/15.10.2014  Claim form Part-B.

Ex.B4    dt/29.1.2015    Declaration letter by the complainant.

Ex.B5    dt/                  Certificate issued by the doctor.

Ex.B6    dt/28.2.2015    Letter of repudiation by the opposite party.           

 

                   Sd/-                                                                                            Sd/-

                MEMBER                                                                             PRESIDENT(FAC)