BEFORE THE ADDITIONAL BENCH DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT MYSURU.
Consumer Complaint (C.C.)No. 1231/2016
Complaint filed on 24.05.2016
Date of Judgement.23.12.2016
PRESENT : 1. Shri Ramachandra M.S., B.A., LL.B.,
PRESIDENT
2. Shri Thammanna,Y.S., B.Sc., LL.B.,
MEMBER
Complainant/s : Sri. Seetharamu
S/o Late Krishnegowda,
M 1234, 2nd Main, Vivekanandanagar,
Mysusu.
(Sri K.S. Maanu., Advocate)
V/s
Opponent /s : 1.Star Health and Allied
insurance co.Ltd., Registered
office No.1, New tank street,
Valluvar Kottam High Raod,
Nungambakkam,
Chennai-600034,
2. Start Health and Allied
insurance co. Ltd., Branch
office, Mysuru C 51, 1st Floor,
5th Cross, 8th main , Above
processional couriers,
Saraswathipuram, Mysuru-
570008, rep by its Authorized
signatory.
(Sri. B.N. Shashidhar., Advocate)
Nature of complaint | : | Deficiency in service |
Date of filing of complainant | : | 24.05.2016 |
Date of Issue notice | : | 28.07.2016 |
Date of Order | : | 23.12.2016 |
Duration of proceeding | : | 4 Months 26 days |
SHRI RAMACHANDRA . M.S., PRESIDENT
JUDGEMENT
The complainant filed the complaint Under Section 12 of Consumer Protection Act, 1986 against the opposite party.
2. The brief facts of the complaint is that he had purchased /obtained a medical insurance policy from the opposite parties company at the 2nd opposite party’s office on 27.03.2015 and got insured himself under the policy no. P/141116/01/2015/006169 under the product name senior citizens red carpet health insurance policy which was valid for a period from 28.03.2015 to 27.03.2016 and the sum insured was Rs. 1,00,000/- for cashless hospitalization and medical treatment and for reimbursement of medical expenses of the complainant that may be occasioned during the policy validity period.
3. The complainant further states that during the first week of January 2016 the complainant was suffering from severe fever and drowsiness and severe head ace for a period of one week. The immediately he was hospitalized to JSS Hospital on 13.01.2016 and on various medical check ups and upon CT Scan being done it was diagnosed that he was suffering from right fronto parietal chronic subdural hemorrhage and the doctors had advised the complainant to under to operation for which the medical expenses was estimated to the tune. Rs 75,000/-and asked the complainant to deposit the same. At that time, the complainant and his son had intimated to the hospital that he has taken the health insurance policy from the opposite parties and asked the hospital authorities to send claim to the opposite parties for cashless treatment.
4. The complainant further submits that the hospital authorities collected the details of the policy and made by submitting pre authorization request form by sending the details of the disease and the treatment to be undergone by the complainant along with other investigation reports and the same was registered by the opposite parties in claim intimation no. CLI/2016/14116/0305822 However the branch office of opposite parties situated at Bangalore rejected the claim made by the complainant for pre authorization for cashless treatment by giving a reason that the said disease from which the complainant was suffering was a outcome of pre-existing disease which existed since for a period of over 12 months preceding from the date of policy and as per exclusion clause no.1 of the policy, the complainant is not entitled for cashless treatment through letter dated 17.01.2016. Thereafter the doctors who were treating the complainant again sent a request letter dated 20.01.2016. to the opposite parties to reconsider the claim made by the complainant for sanction of pre authorization for cashless treatment along with a certificate that the disease suffered by the complainant is not an outcome of pre-existing disease and the same can occur over a span of couple of weeks. However the same was again rejected by the opposite party branch situated at Bangalore giving the same reason. Then the complainant and his son by raising loan made arrangements for money and got the same deposited and got the operation done by spending a sum of Rs. 75,000/-.
5. The complainant further submits that after discharge from the hospital the complainant again submitted the request along with all medical bills and other investigation reports and hospital discharge summary and other necessary documents and claimed for reimbursement of the medical expenses incurred by the complainant and sent the letter of repudiation to the complainant by giving the same reason on 08.04.2016. The complainant had obtained the said medical policy by paying heavy instalment with an intention to keep himself indemnified as against any medical emergencies as he is alone at home and that nobody is there to take care of himself in his old age. Earlier to this hospitalization he had a sudden fall at his house in bathroom as he skidded due to presence of slippery content which was not visible and had suffered minor injuries to his body and also head from inside. Since there was no body at home he did not take any medical treatment and took rest at home itself. Due to said injury, sometimes he used to suffer drowsiness and head ace for few days. Thereafter he suffered from the above said disease. The said inside injury might have been the cause for the above said disease.
6. The complainant further states that the opposite parties have not processed the claim made by the complainant correctly and without observing the nature of the disease caused to the complainant and the treatment given to the complainant, the opposite parties have repudiated the claim made by the complainant by wrongly interpreting the disease suffered by the complainant as intracerebral haemorrhage instead of right fronto parietal chronic subdural hemorrage which was not caused due to any of the pre existing disease of the complainant. That apart before repudiating the claim made by the complainant, the opposite parties ought to have gone through the cause of such disease in detail with the help of medical experts team under the guidelines of various medical texts and also ought to have gone through the nature of the operation undergone by the complainant. The nature of the operation undergone by the complainant clearly demonstrates that the disease which the complainant suffered was not caused inside the brain but it was outside the brain and the cause was no due to hypertension.
7. The complainant states that the said repudiation of the claim made by the complainant is an illegal, arbitrary and malicious act done by both the opposite parties just to illegal enrichment by avoiding payment of treatment expenses in violation of the agreed terms of the Policy. The said repudiation of the doctor of JSS Hospital Certifying to the effect that the disease suffered by the complainant, occasioned not due to pre-existing disease, the opposite parties just to avoid making payment to the complainant and to reimburse him, has repudiated the said claim and thereby the opposite parties have been indulged in exercising unfair trade practice and also committed deficiency in service as per the terms of the policy. Due to the rejection of the claim made by the complainant, the complainant had to face unforeseen financial crisis during his medical emergency apart from suffering pain and mental agony.
8. The complainant further states that for no fault on the part of the complainant the claim made by the complainant could not have been repudiated as he ever suppressed any material facts before the opposite parties or before the hospital authorities. Despite of repeated requests made by the complainant and also producing medical certificate issued by the doctors, the opposite parties have repudiated the claim made by the complainant which is highly illegal giving raise a legal right to the complainant to set the law into motion. Under such circumstances being unsatisfied with the conduct of the opposite parties in repudiating the claim of the complainant, the complainant got issued the legal notice dated 29.04.2016 to the opposite parties claiming for reimbursement of claim of the complainant as it is the duty on the part of the opposite parties being the insurers to settle the claim made by the insured properly. The said notice had been sent to the opposite parties though RPAD the said notice have been duly served on the opposite parties. Despite of service of the said notice, the opposite parties have neither replied to the said notices nor settled the claim of the complainant.
9. Notice to the opposite parties the served in person they engaged the counsel they have not filed version only memo and affidavit filed form their side. In the memo the opposite parties have stated that a sum of Rs. 40,000/- is transferred through neft on 09.06.2016 to the complainant account towards the insurance claim amount. In view of the same is submits the matter is settled the complainant is not maintainable. For the memo the complainant has filed objection that the transfer of amount to his account is only part payment of insurance claimed amount. The opposite party has to pay balance claim amount of Rs 35,000/- as such complainant reserving his right to claim the same from the opposite party. This facts is also reiterated in affidavit filed by the opposite party.
10. Heard arguments.
11. The points that arise for our consideration are;
- Whether the complainant establishes that the opposite party are liable to pay the claim amount and compensation for the deficiency in service and unfair trade practice by opposite party and thereby he is entitle for the relief?
- What order?
12. Our answer to the above points is as follows;
- Point No.1: In the Partly Affirmative.
- Point No.2: As per final order for the following;
REASONS
13. Point No.1:-It is not disputed fact that complainant has obtained an health insurance policy from the opposite party on 27.03.2015. on the policy number P/141116/01/2015/006169 under the scheme “Senior citizen Red carpet health insurance policy “’ it is valued from 28.03.2015 to 27.03.2016 and sum assured was Rs. 1,00,000/- for cash less Hospitalization and medical treatment. This facts is not disputed by the opposite party the same is also proved by the complainant with supporting documents.
14. The complainant in the month of January 2016. Was suffering from severe fever and drowsiness and severe head ace when he was hospitalized on 30.01.2016. Upon medical check up and CT scan , it was diagnosed and he was suffering from right fronoto parietal chronic subdural hemorrhage and doctor advised to under go operation and the cost of the operation and treatment was estimated tune of Rs. 75,000/- complainant informed the hospital that he has taken the health policy with facility of cashless service. When the hospital authority try to get the sanction of insurance amount from the company. The company has rejected the claim of insurance amount by assigning reason that the complainant has not disclosed pervious decease that reason under pre existing decease they are not liable to pay insurance claim amount to the complainant. These facts is not at all disputed by opposite party, here the only fact that goes to the crux of the case is that whether the opposite party proves that complainant was suffering from any pervious decease which leads to the present problem. The opposite party has by voluntarily paying party claim amount has admitted that whatever defence taken by him is only in order to defeat the claims of compliant.
15. Further once again when the complainant has approached for reimbursement of the insurance amount the opposite parties have rejected the claim for the 2nd time the complainant has again approached the opposite party for the settlement of claim amount which result in the rejection of claim for the 3rd time when the complainant approached the opposite party for settlement of claim amount again it came to be rejected by giving the same reason on 08.04.2016 his claim came to be repudiated by the opposite party. The legal notice of complainant is neither replied nor complied by opposite party this attitude shows that how careless and negligent they are towards complainant.
16. Further the settlement of claim amount of Rs. 40,000/- by the opposite party after filing the complainant is clear admission of liability of the opposite party towards the claim of complainant. Here the opposite party by paying part payment of claim amount has admitted that his earlier repudiation is illegal. Thereby he clearly admits the deficiency of service towards the complainant. and another point the opposite party has failed to explain how the quantum of claim amount of Rs 40,000/- is fixed and when there is no condition in the policy regarding deduction which was made by the opposite party, these facts is neither explained nor answered by the opposite party.
17. Further the rejection of claim amount of complainant for the three consecutive times by the opposite party is a gross negligence on his part. When the deduction of the claim amount is made by opposite party is not explained in his statement and is also not supported by any condition of the policy which is issued by opposite party. The very rejection of the claim of the complainant amounts to violation of condition of policy. Here at the first instance the opposite party rejects the claim of the complainant to settle the claim amount and thereafter for the three consecutive times again the opposite party repudiated the claim and the reason given for rejection is a pre existing decease, when such being the case why, and how all of sudden the opposite party has settled the complainant claim in part to the tune of Rs. 40,000/- instead of actual claim amount of Rs. 75,000/- These facts of opposite party shows the double standard attitude of opposite party towards complainant. it is nothing but a contradiction to earlier rejection of claim of complaint. It is also crystal clear that when the complaint is filed soon after the receipt of court notice opposite party transfers the part claim amount to complainant account. The conduct of opposite party is evident that the earlier rejection of claim is only in order to escape the liability of payment. When complainant approached the fora for the relief immediately the opposite party chooses to pay the claim amount. This shows that in order to evade the order of this fora and any other award of amount. The opposite party has voluntarily paid the part claim amount.
18. The opposite party even though he is a insurer. He cannot dictate terms according to his whims and fancie he cannot determine the claim amount arbitrary without any guidelines and justification for it. Here it is a admitted fact the complainant has taken health policy for sum assured amount of Rs. 1,00,000/- when he paid the premium for the same and obtained the policy it is bound and duty of opposite party to honour the claim of the complainant. Here taking of policy between complainant and opposite party is a contract between these parties. The terms and conditions of the same has to be followed by both parties any violation of terms and conditions of policy it amounts to violation of policy by either of the party whoever violates conditions, They have to perform their part of duty as per the terms and conditions of policy.
19. Further the opposite party at 1st instance denied the claim of complainant. When complainant approached the fora for redressal of grievance, suddenly the opposite party in order to escape the order of fora he paid the part claim amount. This act of opposite party is nothing but unfair trade practice for which opposite party is liable to pay compensation to complaint.
20. However, the opposite party on refusal to pay operation and hospital charges at the time of operation, the complainant and his family member were put to great hardship to settle the hospital bill they were forced to borrow amount from financier and paid the same. Further claim amount was not settled until filing of the present complaint. Which has certainly caused mental agony and hardship to the complainant. Hence the opposite party are liable to pay balance claim amount along with compensation and other chargers. For the sufferings of complainant.
21.For above reasons by looking at the facts and documents produces by complainant has proved his case beyond reasonable doubt and also complainant proved that there is a deficiency of service on the part of opposite party.
22. According this forum we answered Point no.1 in the partly affirmative and pass the following:
ORDER
1. The complaint is hereby allowed in part.
2. The opposite party is herby directed to pay a sum of Rs. 35,000/-
to the complainant. within 30 days of this order. with interest
at the rate of 20% p.a from date 13.01.2016 till payment made.
3. The Opposite party is hereby direct to pay sum of Rs. 10,000/-
towards mentally agony and Rs. 3,000/- towards litigation
expenses and also a sum of Rs. 5,000/- towards unfair trade
Practice has to be paid to the complainant within 30 days of this
order. with interest at the rate of 15%. p.a from the date 13.01.2016
till payment made.
4. In case of default of this order the opposite party shall under go
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.
(Dictated to the stenographer transcribed , typed by her, transcript corrected by us and then pronounced in open court on the 23rd December 2016)
Shri Thammanna Y.S., Shri Ramachandra M.S.,
Member. President.
LIST OF WITNESSES EXAMINED AND DOCUMENTS MARKED ON BEHALF OF COMPLAINANT
Evidence by way of affidavit on behalf of complainant:
CW-1 : SEETHARAMU
Documents marked on behalf of complainant:
Annexure.1 : Proposal Form dated 27.03.2015
Annexure.2 : Insurance policy with receipt on 28.03.2015
Annexure.3 : Pre-authorisation request form
Annexure.4 : Insurance ID card
Annexure.5 : Election ID card
Annexure.6 : CT Scan report
Annexure.7 : Certificate issued by doctor
Annexure.8 : Rejection letter dated 17.01.2016
Annexure.9 : Rejection letter dated 21.01.2016
Annexure.10: Discharge summery issued by JSS Hospital
Annexure.11: Bill cum receipts issued by JSS Hospital
Annexure.12: CT Scan report
Annexure.13: Medical bills
Annexure.14: Letter issued by opposite party dated 13.02.2016
Annexure.15: Repudiation letter issued by OP dated 08.04.16
Annexure.16: Medical bills
Annexure.17: Legal notice with two postal receipts and two
acknowledgments.
LIST OF WITNESSES EXAMINED AND DOCUMENTS MARKED ON BEHALF OF OP.
Evidence by way of affidavit on behalf of OP:
RW-1 : UPENDRA KUMAR NAIK
Documents marked on behalf of Op.:
Annexure.1 : Bill assessment sheet
Shri Thammanna Y.S., Shri Ramachandra M.S.,
Member. President.
