KERALA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM
C.C. 18/2009
DATED. 02/05/2012
PRESENT:-
SHRI.S.CHANDRA MOHAN NAIR : MEMBER
SMT. A. RADHA : MEMBER
COMPLAINANTS
1. A. Hyma,
W/o P.N. Pradeep Kumar(Late),
Krishna Nivas, Chevarambalam P.O.,
Calicut – 673 017
2. P.N. Abhinav Krishan,
S/o P.N. Pradeep Kumar(Late)
Aged 8 years, Krishna Nivas, Chevarambalam P.O.,
Calicut – 673 017
Minor represented by his mother and
natural guardian, A. Hyma
( Rep. by Adv. Sri. T.G. Rajendran & others)
OPPOSITE PARTIES
1. Tata AIG Insurance Company Ltd.,
Registration No. 110,
Registered and Corporate Office at Peninsula Towers, 6th Floor, Peninsula Towers, 6th Floor, Peninsula Corporate Park,Ganpatrao Kadam Marg, Lower Parel(W), Mumbai – 400 013
Rep. by its Managing Director
2. The Manager, (Claims), Tata AIG Life Insurance Company Ltd., 2nd Floor, S.L. Plaza,
Palarivattom, Kochi – 25
3. The Senior Executive Operations (Claims),
Tata AIG Life Insurance Company Ltd, 2nd Floor,
S.L. Plaza, Palarivattom, Kochi – 25
4. The Manager,
Tata AIG Insurance Company Ltd., Bank Road, Calicut
(Rep. by Adv. S. Reghukumar)
JUDGMENT
SHRI.S.CHANDRA MOHAN NAIR : MEMBER
This is a complaint filed against non payment of the insured amount by the opposite parties.
1. The brief facts as recapitulated from the complaint are that the first complainant is the wife of one deceased P.N. Pradeepkumar and the second complainant is the son of the deceased Pradeepkumar who are the legal heirs and that the said Pradeepkumar was an insured of the opposite parties. It is the case of the complainants that the deceased Pradeepkumar had taken an insurance policy from the first opposite party in the year 2006 and that he had renewed the policy in the subsequent year and also that the insured when faced with a critical illness inclusive of coronary artery decease had applied for a sum of Rs. 3,90,000/- for the treatment as assured by the opposite parties and as contained in the policy conditions. It is alleged that though the insured had produced necessary certificates for the treatment, the opposite parties did not pay the sum consequent to which the surgery was prolonged and finally on 4.9.2008 the insured was taken to Malabar Institute of Medical Science Ltd, Kozhikode and though the surgery was fixed to be done on 5.9.08 by 6 A.M., On 5.9.08 the insured succumbed to his illness. The very case of the complainants is that if the opposite parties had disbursed Rs. 3,90,000/- at the appropriate time, the surgery could have been done and the complainant’s life could have been saved. It is further alleged that even after the death of the insured and though necessary papers were given to one Renjith, the agent of the opposite parties, the death claim was also denied by the opposite parties, Alleging deficiency in service the complainants prayed for directions to the opposite parties to pay the sum of Rs. 5,90,000/- being the amount covered under the policy towards treatment expenses and death benefit and also another sum of Rs. 25,lakhs as compensation for the mental agony caused to the complainants due to the deficiency in service committed by the opposite parties.
2 Resisting the complaint the opposite parties filed version wherein it was contended that there was no deficiency in service on the part of the opposite parties in not paying any amount to the complainant. It is submitted that though the complainant had applied for the treatment expenses of Rs. 3.90,000/- the complainant had not proved the claim to the satisfaction of the opposite parties. However it was admitted that the first complainant’s husband had taken a Health Protector policy from the opposite parties and that though the policy contained the payment of treatment expenses amounting to Rs. 3,90,000/-, the insured did not satisfy the conditions required for the payment. It is further submitted that 3 conditions were to be satisfied for the said payment whereas the complainant had satisfied only one the condition and did not come under the condition Nos. 2 and 3. It is also submitted that the death benefit was not paid as the complainants did not file an application before the opposite parties by submitting the necessary documents. According to the opposite parties there is no cause of action against the opposite parties and the allegations are baseless and unsustainable. Pleading for the position that there is no deficiency in service, the opposite parties prayed for the dismissal of the complaint.
3 The issues that come for our consideration are :
1) Whether the complainant is a consumer?
2) Whether there is deficiency in service or unfair trade practice on the part of the opposite parties?
3) Relief and costs
4 The evidence consists of the oral testimony of the first complainant as Pw1 and Exts. A1 to A16 on her side. On the part of the opposite parties the 3rd opposite party is examined as Dw1 and Exts. B1 to B4 are marked on his side.
5. Issue No. 1 : Though the opposite parties have raised a contention that the complainant is not maintainable, there is no specific pleading regarding the issue of maintainability of the complaint. Since the issues regarding payment or non payment of insurance amounts come within the ambit of the Consumer Protection Act we find that the complaint is perfectly maintainable before this Commission.
6 Issue No. 2 : The complainants have a case that the insured was not paid the amount of Rs. 3,90,000/- for the treatment even though the insured had produced all the necessary documents for payment of the same. The complainants have stated that they had produced the doctor’s certificate requiring treatment for the Coronorary Artery Disease of the insured after investigations like Coronory Angeogram, the opposite parties have rejected the claim on a baseless and untenable ground that the insured did not satisfy the 2nd and 3rd conditions of the policy for payment of treatment expenses. It is also the case of the complainant that the insured had renewed the policy on 19.12.2007 and it was consequent to the gravity of the illness that he required admission to the IQRA hospital, Malaparamba where Dr. Muhemmad Cholackal had treated him and conducted various tests like E.C.U., C.X.R. Echo, T.M.T, CAG, and blood investigations. The learned counsel for the complainants have argued before us that the treatment was so essential and so unavoidable that he had applied for the amount of Rs. 3,90,000/- and the opposite parties had rejected the payment on flimsy grounds. He has also submitted that the opposite parties committed grave deficiency in service in not paying even the death claim of Rs. 2lakhs with the associated benefits even after the death of the insured and even after submitting the papers through the agent of the opposite parties Mr. Renjith.
7 On the otherhand the learned counsel for the opposite parties vehemently opposed the above submissions of the learned counsel for the complainants. It is submitted that the policy contains 3 conditions for payment of the treatment expenses of Rs. 3,90,000/- and the complainant had to satisfy all the 3 conditions for getting the amount. In the written version, it is stated that the claim did not satisfy the 3 criteria for qualification in the head” Heart attack” of the critical illness benefit laid down in the policy.
The three conditions are as follows:
1) A history of typical chest pain
2) The occurrence of typical new acute infarction changes on the electrocardiograph progressing to the development of new pathological Q waves, and
3) Elevation of cardiac Troponin(T or I) to atleast 3 times the upper limit of the normal reference range or an elevation in CKMB to atleast 200% of the upper limit of the normal reference range.
8. The learned counsel argued that the second and 3rd conditions were not satisfied in the case of the complainant though the first condition was satisfied. He has also a case that the opposite parties had informed the complainant that as per Ext. B2 , it was specifically informed that the opposite parties would review the case once the CABG is done. It is also argued by the learned counsel that death claim was not sanctioned for the sole reason that the complainants did not make an application accompanied by the required documents.
9 On hearing the learned counsels and also on perusing the records it is found that both parties have no case that the first complainant’s husband and the second complainant’s father Dr. Pradeep Kumar did not take a policy from the opposite parties. The complainants would say that it was taken through one Mr. Renjith the agent of the opposite parties. Though the opposite parties would say that Renjith is no more in the company and the policy was issued to the complainant under health protector policy. The policy contains provision for payment of treatment expenses amounting to Rs. 3,90,000/- and if death occurs the amount will be 2 lakhs. It is found that though the opposite parties had denied the claim as per Ext. B2, the insured had not filed any case against the opposite parties with regard to the said denial of treatment expenses. However it is found that the insured had undergone treatment for the disease and was taken to the Malabar Institute of Medical Science for bypass surgery. It is also found that even before the by pass surgery, the complainant had unfortunately passed away. We find that atleast after the death of the insured the opposite parties ought to have paid the death claim of Rs. 2lakhs. Though they would argue that no claim was preferred by the complainants, it is to be found that at least after filing the complaint the opposite parties could have effected the payment. It is no excuse that no application was given by the complainants, especially when the complainants, have a case that the claim was made to the opposite parties through the agent Mr. Renjith and also that the opposite parties were aware of the death of the insured. We do not find any reasons to disbelieve the statement of the complainant that the necessary applications and documents were given through Renjit, the agent. We also find that the opposite parties have not chosen to examine the said Renjith though they would say that the agent Mr. Renjith is not in their service. In the above backdrop of the facts and circumstances we find that there is deficiency in service on the service of the opposite parties in not disbursing the death claim of the complainants.
10 Issue No. 3 : It is found that the opposite parties had committed deficiency in service in not paying the death claim amount of Rs. 2lakhs even though they were aware of the fact that the insured had passed away on 15.9.2008. We also hold that since no separate compensation for deficiency in service is ordered, the complainant is entitled for the payment of Rs. 2lakhs with 12% interest from the date of complaint till payment. The complainants are also eligible for payment of Rs. 5,000/- towards costs of the proceedings.
In the result, the complaint is allowed as above. Thereby the opposite parties are jointly and severally held liable for payment of Rs. 2lakhs with associated benefits to the complainants. The opposite parties are also liable for payment of interest @12%P.A. from the date of complaint till payment with costs of Rs. 5,000/-
S. CHANDRA MOHAN NAIR : MEMBER
A. RADHA : MEMBER
APPENDIX
Witnesses on the part of the Complainant
Pw1 : Hyma, W/o P.N. Pradeep Kumar(Late)
Exhibits produced by the Complainant
A1 : True Copy of the Insurance Policy dated.
28.12.2006
A2 : A copy of the receipt dtd. 2007.01.03 for
Rs. 6,564/-
A3 : A copy of the receipt dtd. 27.12.2007 for
Rs.6,571/-
A4 : A True copy of the critical illness claim submitted on
24.4.2008
A5 : A True copy of the filled questionnaire dated
10.5.2008
A6 : True copy of the filled questionnaire dtd. 10.5.2008
submitted by the husband of the 1st complainant.
A7 : True copy of the filled questionnaire
submitted by P.N. Sunil Kumar, the brother of the
insured
A8 : A True copy of the filled questionnaire
submitted by Dr. Muhammed Cholakkal
A9 : A True copy of the letter dtd. 13.6.2008.
A10. : A True copy of the letter dtd. 26.05.2008
A11 : A True copy of the letter dtd. 30.06.2008
A12 : A True copy of the acknowledgment card
evidencing acceptance of the notice dtd. 30.06.2008
by the 3rd opposite party.
A13 : A True copy of the acknowledgment card evidencing
acceptance of the notice dtd. 30.06.2008 by the
Customer Care Cell of the 1st opposite party
A14 ; A True copy of the letter dated 07.07.2008
A15 : A True copy of the death summary dated. 5.9.2008.
A16 : A Copy of the Cardiac O.P. Medical Report
Witnesses on the part of the Opposite party
Dw1 : Ramakrishnan P.V.
Exhibits produced by the Opposite party
B1 : Discharge summary dtd. 26.4.2008
B2 : Original of the resolution passed by the Board of
Directors.
B3 : Authority letter by P.V. Ramakrishnan.
B4 : Copy of the Board Resolution dtd. 14.1.2011
S. CHANDRA MOHAN NAIR : MEMBER
A. RADHA : MEMBER
ST
