BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.1316/2016

DATED ON THIS THE 7^th October 2016

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                                          B.E., LLB.,    - MEMBER

Sri Devakumar.M.C.

Member

1.     The complainant filed the complaint under section 12 of the C.P.Act, against the opposite parties, alleging deficiency in service and unfair trade practice by opposite parties and seeking a direction to pay Rs.99,668.64 amount claimed under opposite parties “Senior Citizens Red Carpet Insurance” policy and Rs.3,00,000/- compensation for mental agony and hardship caused with such other reliefs.
2.     The complainant taken the opposite parties product by name “Senior Citizen Red Carpet Insurance” policy in favour of his mother on 31.01.2015, on payment of premium of Rs.9,500/-.  During the subsistence of the policy, the insured suffering from her illness admitted to the hospital and took treatment as in patient, while discharging from the hospital on 31.12.2015, the hospitalization charges of Rs.99,668.64 was demanded and the opposite parties repudiated the claim under the policy.  Hence, aggrieved complainant filed the complaint, seeking reliefs.
3.     Both the opposite parties represented through their counsel but not filed their version.  In turn filed a memo along with a cheque for a sum of Rs.61,749/- towards the full and final settlement of the eligible amount as per the terms and conditions of the policy and also an affidavit towards their evidence and prays for dismissal of the complaint.
4.     The complainant lead his evidence by filing affidavit.  Written arguments not filed.  Both counsel submitted oral arguments and on perusing the material on record, the matter posted for orders.
5.     The points arose for our consideration are:-

1. Whether the complainant establishes that the opposite parties are liable to pay the claim amount and compensation for the deficiency in service and unfair trade practice by opposite parties and thereby he is entitled for the reliefs?
2.  What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- Partly in the affirmative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant purchased a health insurance policy called “Senior Citizens Red Carpet Insurance”, on 31.01.2015, in favour of his mother by deposited premium of Rs.9,500/-.  The policy was valid from 31.01.2015 to 30.01.2016.  The sum assured was Rs.2,00,000/-.  The opposite party assured complainant that in case of hospitalization for treatment, they reimburse the claim amount to the extent of sum assured.  The complainant revealed all the medical history relating to his mother in the proposal form.
8.    Considering the particulars furnished in the proposal form and on payment of the premium amount, the opposite party No.1 issued the insurance policy for a sum assured of Rs.2,00,000/-.
9.    The complainant got admitted his mother on 25.12.2015, for her ailments, duly informing the opposite party No.1, to Apollo Hospitals, Mysore and obtained treatment until 31.12.2015.  The hospital issued a bill for a sum of Rs.99,668.64 to opposite party, for payment, but same denied.  As such, the complainant was forced to make the payment to the hospital.  The complainant with great difficulty arranged money and paid to the hospital to get his mother discharged.  The complainant enquired with opposite party No.2, regarding repudiation of his claim, by submitting all the relevant documents, but the opposite parties never gave any explanation, resulted in mental agony and hardship. Hence, the complainant alleging deficiency in service and unfair trade practice and sought for the reliefs. 
10. The opposite parties contended that, it took some time to investigate with its panel doctors and in accordance with the exclusion clause of the terms and conditions of the policy, considering all the applicable factors, it has arrived and decided to pay Rs.61,749/- towards full and final settlement and deposited the same vide cheque bearing No.130552 dated 31.08.2016 drawn on HDFC Bank in favour of the complainant.  Hence, contended there is no deficiency in service and unfair trade practice by them and not liable to pay any compensation as claimed.  As such, prays for dismissal of the complaint.  
11. It is apparent on the record that after calculation of all the applicable conditions as per the policy, the opposite parties have arrived and deposited a sum of Rs.61,749/- towards the full and final settlement of the claim to the complainant on 31.08.2016.
12. However, on refusal to pay the hospital charges at the time of discharge of the policy holder on treatment, the complainant was put to great hardship to settle the hospitalization charges by borrowing or arranging the money.  Further, the amount was not paid until filing of the present complaint, which has certainly caused mental agony and hardship to the complainant.  Hence, the opposite parties are liable to pay compensation for the sufferings of the complainant. Accordingly, the point No.1 is answered partly in the affirmative.   
13. Point No.2:- In view of the above discussions, we proceed to pass the following

:: O R D E R ::

1. The complaint is allowed in part.
2. The opposite parties are hereby directed to pay Rs.3,000/- towards compensation for the mental agony and hardship caused and Rs.2,000/- towards costs of the proceedings to the complainant, within 60 days of this order.
3. In default to comply, the opposite parties shall pay interest at 12% p.a. on the said total sum of Rs.5,000/-, from the date of the complaint, until payment made.
4. In case of default to comply this order, the opposite parties shall undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
5. Give the copies of this order to the parties, as per Rules.

(D