BEFORE THE TELANGANS STATE CONSUMER DISPUTES REDRESSAL COIMMISSION: AT HYDERABAD

                                                            FA 150 of 2014

Between:

Nayeem Ghori

R/o 12-2-790/A/7,

Ayodhya nagar colony,

Mehadipatnam,

Hyderabad – 500 028                                  .                       Appellant/complainant

And

The Manager,

Star Health & Allied Insurance Co., Ltd

1-8-167 to 179  besides Usha Kiran complex,

Ground floor, S.D. road, Near paradise circle

Secunderabad – 500 003                                                   Respondent/opposite party

Counsel for the Appellant                                     :           Party in person

Counsel for the Respondent                                 :           Sri G. S. G. Radhakrishna

Coram :         HON’BLE SRI JUSTICE B. N. RAO NALLA,  PRESIDENT

                                                                        And

                                                Sri Patil Vithal Rao, Member

Friday, the Second Day of September

TWO THOUSAND SIXTEEN

            Oral order: ( Per Hon’ble Sri Justice B. N. Rao Nalla, Hon’ble President )

                                                            *******

1.  This appeal is  filed by the dis-satisfied complainant  U/s 15 of the Consumer Protection Act, 1986 challenging the impugned order dated 30.01.2014   passed by the District Forum II, Hyderabad   in CC No.415 of 2012 awarding Rs.3,000/- towards damages, Rs.2,000/- towards compensation and Rs.1000/- towards costs.
2. For the sake of convenience, the parties are described as arrayed in the complaint before the District Forum.
3. The case of the complainant before the District Forum in brief is that the complainant obtained Medi Classic Health Insurance Policy on 2.12.2006 for a sum insured limit of Rs.1,00,000/- and that the said policy was continuously renewed from time to time without any break with enhancement of Rs.50,000/- on 21.12.2010 and another sum of Rs.50,000/- on 21.12.2011, thereby, the total sum insured limit was Rs.2,00,000/-. During the subsistence of the policy, the complainant  underwent treatment in Sunshine hospital, Secunderabad from 27.10.2012 to 29.10.2012 for pain in the left rib cage due to accidental fall. The claim made by the complainant on 07.12.2011   was repudiated  by the opposite party on the ground that the complainant suppressed the fact   that he had on and off pain in the left rib at the time of taking policy in the year 2008 and denied cashless treatment. The complainant wrote to the opposite party stating that his first policy was from 2006 and not from 2008 and requested to verify the records and settle his claim. As there was no response from opposite party for his correspondence, he lodged a complaint with IRDA( Insurance Regularity and Development  Authority). The IRDA registered his complaint and fixed the time  of Redressal of his grievance on or before 06.03.2012.  On 09.03.2012, representative of the insurer handed over a cheque for Rs.14,688/- as a full and final settlement of the claim which fell  short of Rs.8,815/- of his claim. Again, the complainant approached the Insurance Ombudsman for full claim and compensation for unnecessary delay in settlement of his claim. Thereafter the insurer settled his claim for a further sum of Rs.7365/- which was again short of Rs.1450/-. The Ombudsman after hearing both sides granted Rs.300/- to the complainant and expressed his inability to pass an order for compensation for the delay as it does not come under its jurisdiction. Hence the complaint  to grant compensation of Rs.4,00,000/- towards mental agony due to deficiency in service, to direct the opposite party to update their records of the complainants’ Med Claim policy
4. The opposite party resisted the claim contending that during the processing of the claim, the complainant approached IRDA they have worked out the quantum of claim payable in terms of Insurance policy and handed over a cheque for Rs.14,688/- in full and final settlement of his claim. Thereafter, on approaching the Insurance Ombudsman, the Claims Review Committee further reviewed the claim and settled for Rs.7,365/- rejecting balance amount of Rs.1450/- since room rent for pre hospitalization expenses at Rs.1100/- and Regn. Fee of Rs.50/- not payable. Further declined Rs.300/- claimed under pre hospitalization expenses for medicines as there was no break up. The claim was submitted on 7.12.2011, information was called, break up details furnished and query replied by the complainant in February 2012 and claim was settled on 2.3.2012. The opposite party also settled Rs.300/- as per the orders passed by the Insurance  Ombudsman and hence there was no deficiency in service on their part. There is no cause of action in filing the complaint and the complaint is not maintainable and hence prayed for dismissal of the complaint.

5. During the course of enquiry before the District Forum, on behalf of the complainant affidavit evidence was filed and Ex A-1 to A-6   are marked . On behalf of the opposite party affidavit evidence of Sri Ch. Raghavaiah, Zonal Manger of the opposite party  was filed and Ex.B-1 to B-5 are marked.

6. After considering  the material available on record and after hearing on both sides, the District Forum passed the impugned order directing the opposite party to update the records of the complainant’s Mediclaim policy, to pay Rs.3,000/- towards damages, Rs.2,000/- towards compensation for mental agony and trauma and costs of Rs.1,000/-.

7. Aggrieved by the  above impugned order of the District Forum, the complainant  preferred this appeal contending that the District Forum passed the impugned order without appreciating the facts and circumstances of the case in proper perspective and thereby came to wrong decision. Complainant   filed the claim seeking a total compensation of Rs. 4 lakhs for deficiency in service on the part of the opposite party Star Health and Allied Insurance Co. Ltd and to update their records of the complainant’s Medi claim policy and costs . However, the District Forum erroneously awarded paltry amount of Rs.3,000/- towards damages, Rs.2,000/- towards compensation and Rs.1,000/- towards costs/
8. Now, the points that arise for consideration of this Commission are

1. Whether the impugned order as passed by the District Forum suffers from any error, irregularity or the same is liable to be set aside,  modified   or interfered with in any manner ?
2. To what relief ?

9. There is no dispute that the complainant obtained Medi Classic Health Insurance Policy for a sum insured limit of Rs.1,00,000/- from the opposite party. There is also no dispute that the complainant had taken treatment for his ailment  and he submitted his claim to the opposite party in that regard  and it was repudiated. There is also no dispute that  after approaching IRDA the insurer handed over a cheque for Rs.14,688/- and again after approaching the Insurance Ombudsman a further sum of Rs.7365/- was paid to the complainant. The Insurance Ombudsman after hearing both sides passed order vide Ex.A-5 granting Rs.300/- to the complainant but without any compensation for deficiency in service.
10.  The complainant filed the complaint against the respondent/opposite party before the District Forum seeking compensation of Rs.4 lakhs for deficiency in service and to update their records of the complainant’s Medi Claim policy. The District Forum after considering  contentions and evidence on record of both sides directed the opposite party to update the records of the complainant’s Medi claim policy,  to pay Rs.3,000/- towards damages and Rs.2,000/-towards compensation and Rs.1000/- towards costs. Dis-satisfied with the said order the complainant preferred this appeal.
11. The counsel for the respondent/opposite party in the appeal submitted that the original claim of the appellant was settled out of Court to the satisfaction of the appellant/complainant by paying the insured amount to him.  That the appellant claimed some compensation/damages for mental agony before the District Forum and the same was considered by the District Forum and awarded as stated in the impugned  order. That the claim of the appellant was also dismissed by the Insurance Ombudsman which was filed challenging the original settlement of the claim. In view of the settlement of his original claim by the Insurance company and also in view of the compensation, damages and costs as awarded by the District Forum are in keeping with his prayer in CC and hence the appeal deserves no consideration and the same may be dismissed with costs.
12. The District Forum already directed the opposite party  to update the records of the complainant’s Mediclaim policy. Hence, now, the only point for our consideration is as to the enhancement of compensation.
13. The dispute arose when the opposite party repudiated the claim of the complainant vide Ex. A-3  on the ground that he  suppressed his pre-existing rib pain problem  at the time of taking the policy and the policy was taken in the year  2008.  Ex. A-1 Medi claim policy shows that the said policy was taken on 21.12.2006 and it was renewed from time to time till  20.12.2012 and it was in force at the time of his medical claim. NO evidence was adduced that the complainant had pre-existent rib pain at the relevant time. Further, in the written arguments filed on behalf of the opposite party, it is submitted that  due to re-organization of branch offices and consequent decentralization of issue of policies from Zonal office to branch offices, proper updation of policy records could not be updated  in the formative years, resulting in declining of cashless treatment to the complainant. In addition to that, the opposite party paid the said amounts only after he approached the appropriate authorities for the  reliefs. These averments show that  without going through the record the respondent/opposite party  simply repudiated the claim of the complainant  with callous and negligent attitude which amounts to deficiency in service as rightly held by the District Forum. Therefore the District Forum  directed the opposite party to update the records of the complainant’s Mediclaim policy and awarded Rs.2,000/- towards  compensation. However, claiming Rs.4 lakhs towards compensation by the appellant/complainant appears to be  exorbitant and on higher side.

14. Point No. 1 :

After considering the foregoing facts and circumstances and also having regard to the contentions raised on behalf of the appellant/complainant  and the respondent/opposite party  this Commission is of the view that the respondent/opposite party  is liable to pay Rs.12,000/- ( Rupees Twelve Thousand) only to appellant/complainant  towards compensation. The impugned order of the District Forum is accordingly modified.  This Commission answered Point No. 1, accordingly.

15. Point No. 2 :

In the result, the appeal is allowed in part modifying the order of the District Forum and directing the Respondent /opposite party  to pay an amount of Rs.12,000/- (Rupees Twelve Thousand) only to the appellant/complainant  towards compensation enhancing it from Rs.2,000/-awarded  by the District Forum  while confirming the rest of the impugned order. There shall be no order as to costs in this appeal .  Time for compliance four weeks.                                               

                                                            PRESIDENT                                    MEMBER                                                                                           Date  :  02.09.2016.