IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM

Dated, the 28^th day of October, 2024

Present: Sri. Manulal V.S. President

  Smt. Bindhu R.  Member

Sri.K.M.Anto, Member

C C No. 106/2024 (Filed on 22.03.2024)

O R D E R

Sri. Manulal V.S. (President)

The complaint is filed under Section 35 of the Consumer Protection Act 2019.

The complainants are husband and wife, respectively. The complainants have had a health insurance policy from 08.11.2013 onwards with the opposite party.  The complainants have taken a health insurance policy valid from 05.12.2022 to 04.12.2023 vide policy No: P/181113/01/2023/1706851 with Family Health Optima Insurance Plan of the opposite party. Due to acute joint pain and difficulty in extension of the right leg, the second complainant underwent treatment for 26 days, including inpatient treatment for the period from 25.03.2023 to 27.03.2023 in Dheemahi Ayurvedic Center Neelimangalam, Perumbaikad P.O. Kottayam. The complainants have submitted bills for ₹ 22,231/- (Rupees twenty two thousand two hundred and thirty one only) and all required documents as per claim No. CIR/2023/181113/1706851 to get the amount. However, the opposite party repudiated the claim by letter dated 12.05.2023 stating that the intimation regarding hospitalization was not given within 24 hours of hospitalization.

The complainants did everything as per the directions of the opposite party. But the opposite party repudiated the claim of the complainants without any legal basis. There is a gross deficiency of service and unfair trade practices on the part of the opposite party. Undue hardship and agony have been caused to the complainants by the acts of the opposite party. The opposite party is liable to compensate the complainants. Hence, this complaint is filed by the complainants praying for an order to direct the opposite parties to pay ₹ 22,231/-(Rupees twenty two thousand two hundred and thirty one only) with interest and to pay compensation of ₹15,000/- (Rupees fifteen thousand only) for the deficiency of service and unfair trade practice on the part of the opposite parties.

Upon notice from this Commission, the opposite party appeared before the Commission and filed version contending as follows:-

The first complainant had taken a Family Health Optima insurance policy from the opposite party on 08.11.2013 and the same has been renewed up to 04.12.2023, covering the first and second complainants for a sum insured of ₹ 3,00,000/- (Rupees three lakh only) vide policy No. P/181113/01/2023/011117. The terms and conditions of the policy were explained to complainants at the time of proposing the policy and the same was served to the complainant along with the Policy Schedule.

During the aforesaid policy period, the second complainant was admitted on 25.03.2023 at Dheemahi Ayurvedic Center, Neelimangalam for the treatment of right knee joint pain and difficulty in extension of right leg. After the treatment, she was discharged on 27.03.2023.

After discharge from the hospital, the intimation regarding hospitalization was given only on 27.03.2023, i.e., after a lapse of 2 days from the occurrence of the event. As per the terms and conditions of the policy, in the event of hospitalization of the insured person, intimation should be given to the company immediately, within 24 hours from the time of admission. This condition is precedent to admission of liability under the policy. As per the terms and conditions of the policy, it is the duty of the insured to intimate the claim within the stipulated time. Hence, the claim was rejected on the ground of late intimation and the above fact was intimated to the complainants on 12.05.2023.

It is submitted that after the claim repudiation, the complainants approached the opposite party, seeking the return of documents submitted by the complainants for claim processing. Based on the request, the opposite party had returned the same vide letter dated 08.12.2023.

The claim of the complainant is not payable as per the terms and conditions of the policy. The complainant had submitted the claim for ₹ 22,231/-(Rupees twenty two thousand two hundred and thirty one only). Therefore, it is submitted that even though the claim is not payable as per policy terms and conditions, if this Commission finds any liability upon the opposite partie, then the liability of the opposite party may be limited to ₹ 10,000/- (Rupees ten thousand only) which is the maximum payable for Ayurvedic Treatment under the terms and conditions of the policy.

The opposite party had acted per the policy's terms and conditions. The opposite party has repudiated the claim based on the terms and conditions of the policy. There is no deficiency in service or unfair trade practice from the side of the opposite party.

Complainant filed proof affidavit In lieu of chief examination and marked Exhibits A1 to A7 from the side of the complainant. Balu.M. who is the Deputy General Manager-Legal of the opposite party filed proof affidavit in lieu of chief examination and marked Exhibits B1 to B4 from the side of the opposite partie.

We would like to consider the following points on the evaluation of the complaint and evidence on record.

1. Whether the complainant had succeeded to prove any deficiency in service on the part of the opposite party?
2. If so, what are the reliefs and cost?

Point number one and three together.

There is no dispute on the fact that the complainants have taken a health insurance policy valid for the periods from 05.12.2022 to 04.12.2023 vide policy No.  P/181113/01/2023/1706851 with Family Health Optima Insurance Plan of the opposite party. It was also admitted that the sum insured was ₹ 3,00,000/- (Rupees three lakh only). It is proved by A3 discharge summary that with a complaint of right knee joint pain and difficulty for extension of right leg, the second complainant underwent treatment for 26 days as inpatient treatment for the period from 25.03.2023 to 27.03.2023 in Dheemahi Ayurvedic Center, Neelimangalam, Perumbaikad P.O. Kottayam. Exhibit A4 series bills prove that the second complainant had spent ₹ 22,231/- (Rupees twenty two thousand two hundred and thirty one only) for her treatment at the hospital. Though the complainants lodged a claim for reimbursement of the treatment expenses under the policy, the opposite party repudiated the same vide Exhibit A5 letter dated 12.05.2023 stating that the intimation regarding hospitalization was not given within 24 hours of hospitalization.

The opposite party resisted the complaint, contending that as per the terms and conditions of the policy, in the event of hospitalization of the insured person, intimation should be given to the company immediately, within 24 hours from the time of admission. The opposite party relied on condition No. 4 (2) (D)  of Exhibit B1 terms and conditions, which states explicitly that "Upon the happening of the event, notice with full particulars shall be sent to the Company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not."

On going through Exhibits B3 repudiation letter, we can see that the intimation regarding the admission was given to the opposite party on 27.03.2023. It is proved by Exhibit  A2, which is the certificate issued by the treating doctor, that the second complainant was advised to complete rest with internal medication for 7 days from 03.04.2023.

If there is some delay, we have to see what prejudice has been caused to the opposite party. It has been so held in the  judgment of the Hon'ble Haryana State Consumer Disputes Redressal Commission, Panchkula "Shriram General Insurance Company Limited versus Rajesh Kumar," 2014(2) CLT 390. After relying upon the Circular dated 20.09.2011 issued by the Insurance Regulatory and Development Authority, which was regarding delay reads as under:-

"Re: Delay in claim intimation/documents submission with respect to i. All life insurance contracts, and ii. All Non-life individual and group insurance contracts the Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.

The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers to effect various post-claim activities like investigation, loss assessment, provisioning, claim settlement, etc. However, this condition should not prevent settlement of genuine claims, particularly when there is a delay in intimation or in the submission of documents due to unavoidable circumstances."

9. In view of this circular issued by the I.R.D.A., contractual obligation passing the condition that the claim should be intimated within the specified period is necessary for insurers for offering various post claim activities. However, this condition should not prevent the settlement of the genuine claim. The claim of the complainant is genuine, then it should not be repudiated merely for one day delay given in intimation to the insurance company. Therefore, we are of the opinion that the order so passed by the learned District Forum is correct order. We affirm the findings so recorded by the learned District Forum."

In circular no: IRDA/ HLTH/ MISC/ CIR/ 216/ 09/ 2011 dated September 20^th, 2011, issued by the Insurance Regulatory Development Authority, stated that even if there was a condition in the policy regarding delay in intimation, the insurer could not take its shelter to repudiate the claim, which is otherwise proved to be genuine.

Therefore, the opposite party cannot repudiate the claim of the complainant merely relaying the delay caused in giving intimation of hospitalisation to the opposite party. On going through the Exhibit A5 repudiation letter, we can see that the opposite party repudiated the claim of the complainant, relaying on the delay caused in giving intimation to the opposite party and has not stated any other reason for rejecting the claim of the complainant. Therefore, we are of the opinion that the opposite party has committed deficiency in service by repudiating the claim of the second complainant.

Section 2 of the terms and conditions of Exhibit B1 policy deals with the coverage under the policy. As per clause (s) of Section 2, the liability of the opposite party is limited to ₹ 10,000/- (Rupees ten thousand only) for the Ayurvedic treatment if the sum assured is up to ₹ 4,00,000/- (Rupees four lakh only). Therefore, the opposite party is liable to pay ₹ 10,000/- (Rupees ten thousand only) to the complainants. Non payment of this eligible sum to the complainants amounts to a deficiency in service on the part of the opposite party. Considering the nature and circumstances of the case and keeping in mind the salutary principles of the Consumer Protection Act, we allow this complaint and pass the following order.

1. We, hereby, direct the opposite party to pay ₹ 10,000/- (Rupees ten thousand only) to the complainants with interest @ 9 % from 12.05.2023, i.e., the date of repudiation to the date of realization.
2. We hereby direct the opposite party to pay ₹ 10,000/- (Rupees ten thousand only) as compensation to the complainants for their service deficiency.

The opposite party is directed to pay the amounts to the complainant within 30  days from the date of receipt of a copy of this Order, failing which, the compensation amount shall carry interest  @ 9% p.a. from the date of this order till its realization.

Pending Application(s), if any, automatically stand disposed of as having been rendered infructuous.

Pronounced in the Open Commission on this the 28^th day of October, 2024

Sri. Manulal V.S, President  Sd/-

    Smt. Bindhu R.  Member    Sd/-

Sri. K.M. Anto, Member      Sd/-

APPENDIX :

Exhibits from the side of the Complainant :

A1    -       Copy of customer ID card.

A2    -       Treatment certificate dated 15.04.2023

A3    -       Discharge summery.

A4    -       Medical bill dated 21.03.2023

A4(a)        -       Medical bill dated 04.06.2023

A4(b)        -       Medical bill dated 15.04.2023

A4(c)        -       Medical bill dated 15.04.2023

A5    -       Letter issued by opposite party  dated 12.05.2023

A6    -       Copy of advocate notice dated 27.02.2024

A7    -       Postal acknowledgement card

Exhibits from the side of the Opposite Parties :  

B1    -       Copy of policy schedule and condition

B2    -       Copy of discharge summary

B3    -       Copy of letter repudiating claim dated 12.05.2023

B4    -       Copy of letter returning

By Order,

      SD/-                                                                                           Assistant Registrar