Kerala

Idukki

CC/165/2021

Rajesh K K - Complainant(s)

Versus

TATA AI G General Insurance co,ltd - Opp.Party(s)

Adv.K M Sanu

26 Jul 2023

ORDER

 

DATE OF FILING : 22/11/2021

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 26^th day of July 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.165/2021

Between

Complainant                             :   Rajesh K.K., S/o Krishnankutty,

                                                      Kalluvayalil House, Thodupuzha East P.O.,

                                                      Thodupuzha.

                                                           (By Adv.K.M.Sanu)

                                                   And

Opposite Parties :                 :1 . The Manager,

                                                   TATA AIG General Insurance Co.Ltd.,

                                                   3^rd Floor, Grnad BNay, Kattukkara Junction,

                                                   Opp.Bismi Super Market, Kaloor, Cochin – 682 020.

                                                    (By Adv.Thomas Sebastian)

                                              2 . The Manager,

                                                   Axis Bank, Thodupuzha Branch,

                                                   Thodupuzha P.O.

                                                            (By Adv.Biju P.Sebastian)

 

O R D E R

SRI.AMPADY K.S., MEMBER

This complaint is filed under S.35 of Consumer Protection Act, 2019.  Complaint averments are as under.

1 . Complainant is an account holder in 2^nd opposite party bank.   1^st and 2^nd opposite parties jointly introduced a General Insurance Medi Claim Policy Scheme.  As an account holder 2^nd opposite party insisted the complainant to take a policy.  As a result complainant joined in the policy in

(Cont.....2)

 

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2019 and in the second year complainant renewed this policy for the period from 17/08/2020 to 16/08/2021 by paying a premium of Rs.14,612/- and along with the renewal complainant enhanced the coverage by 5 Lakhs by paying an additional premium of Rs.4,449/-.  Then the total coverage of the policy became 20 Lakhs.  Under the policy, complainant, wife and two children are covered.

2 . While the policy is live complainant’s son Sooraj R.Krishna aged 21, was consulted at Chazhikattu Hospital for back pain on August 2020.  Some medicines were given and advised to take rest.  Thereafter in March 2021 same problem again repeated and again consulted the same doctor.  The Ortho Specialist doctor advised either for a surgery or complete bed rest for a long period of time.  Complainant and son was not convinced to this advice and they decided to take Ayurvedic treatment.  The complainant’s son admitted in Dhanwanthari Ayurvedic and Research Centre, Thodupuzha and treated as inpatient there from 21/05/2021 to 05/06/2021.  An amount of Rs.33,367/- was paid as hospital bills.

3 . After the treatment complainant given the claim application to opposite party with relevant documents without any delay.  But they are prolonging the claim application unreasonably by demanding some documents of previous treatment.  All available records are handed over to the 1^st opposite party.  They are demanding records of treatment which is actually not done.  Complainant’s son treated only at Chazhikattu Hospital and Dhanwanthari Ayurvedic Centre for Back Pain.

(Cont.....3)

 

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4 . 1^st opposite party caused extra ordinary delay in processing the claim.  This is against the claim processing norms of IRDA.  1^st  opposite party is duty bound to obey the direction of IRDA.

5 . Extra ordinary delay in processing claim application amounts to deficiency in service and unfair trade practice.  They are duty bound to settle the claim within a reasonable time.  So the complainant is entitled to get the bill amount as per the policy.   He is entitled to get Rs.33,367/- with 12% interest from the date of treatment.  More than that, he is entitled to get compensation for deficiency in service and unfair trade practice on the part of opposite party.

6 . The cause of action arose on 05/06/2021 the date on when the complainant’s son get discharged from the hospital and thereafter continuously within the jurisdiction of this Hon’ble Commission.

Hence he prayed for the following reliefs.

1 . 1^st opposite party may be directed to give Rs.33,367/- as treatment expenses.

2 . Opposite parties may be directed to give Rs.50,000/- as compensation for deficiency in service and unfair trade practice.

3 . Rs.10,000/- may be allowed as litigation expenses.

4 . Such other reliefs that are found to be just by the Commission.

1^st and 2^nd opposite parties entered appearance.  They have filed written version belatedly which cannot be accepted as per S.38(3) of Consumer

(Cont.....4)

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Protection Act, 2019 and in the light of judgement of Hon’ble Supreme Court in New India Assurance Co. Ltd., Vs Hilly Multipurpose Cold Storage (P) Ltd., (2020) 5 SCC.757.  Complainant produced copy of 5 documents which were marked as Ext.P1 to P5 as follows.

1 . Ext.P1 Group Medicare certificate of insurance master policy No.0238178373 in the name of complainant and his family.

2 . Ext.P2 – Discharge summary dated 05/06/2021 of Dhanwanthari Ayurveda Hospital.

3 . Ext.P3 -  Treatment certificate dated 11/06/2021 with clinical notes, procedures, medicines prescribed etc.

4 . Ext.P4 – Request letter dated 09/01/2021 issued to complainant by 1^st opposite party seeking additional information/documents etc.

Ext.P5 – Discharge bill No.133 dated 05/06/2021 issued by Dhanwanthari Hospital.

On submission by counsel for 1^st opposite party, 6 documents were seen marked on their side by mistake.  In the light of legal bar mentioned above, those documents cannot be acted upon.

Heard both sides,

On a perusal of the averments in the complaint and documents produced by complainant, following points arise for consideration.

1 . Whether there is any deficiency in service or unfair trade practice on the part of 1^st opposite party?

 

(Cont.....5)

 

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2 . If so, for what reliefs complainant is entitled to?

3 . Reliefs and costs?

Point Nos. 1 and 2 considered together.

On going through the averments of complainant and evidence produced, it is seen that 2 policies were taken by complainant.  One for Rs.15 Lakhs and another for Rs.5 Lakhs.  Claim was raised in respect of treatment done to his son Sooraj R.Krishna at Dhanwanthari Ayurvedia Hospital, Thodupuzha from 25/05/2021 to 05/06/2021.  As per Ext.P2, main complaints reported to Doctor are low back pain since one year.  Shoulder pain radiating to both UL Gastritis.  As per diagnosis, ailment shown is a “Katigraham”.  We understand that it is  a condition where the lower back region is afflicted with vitiated ‘Vata’ and present with symptoms such as pain with stiffness. Ext.P1 contains 2 certificates ie, (1100915219 for Rs.15 Lakhs and certificate No.00915206 for Rs.5 lakhs.  Above certificates were seen issued under master policy No.0238178373 issued by 1^st opposite party  company.  Master policy holder is Axis Bank Ltd., Intermediary is also shown Axis Bank Ltd.  From this, it is clear that 2^nd opposite party is only an intermediary and they are not directly involved in settlement of claim.  So liability cannot be fastened on them.  Ext.P1 was for the period from 17/08/2020 to 16/08/2021.  Treatment was done during the above period.  Treatment expenses as per Ext.P5 is Rs.33,367/-.  As per Ext.P4, 1^st opposite party sought following further documents from complainant.

(Cont.....6)

 

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( 1 ).   Treating doctors certificate for details and circumstances of injury with fall from bike one year ago and treatment records for the same.

( 2 ) .   Treating doctors certificate for past history duration, etiology of back pain /when diagnosed for the first time, first consultation papers and past medical records.  Though complainant stated in complaint that he joined in the policy in 2019, no evidence is produced thereof.  His contention is that in August, 2020, his son consulted at Chazhikkattu hospital for back pain and some medicines were given and advised to take rest.  While the same ailment occurred again in March 2021 and he consulted the same doctor.  As the doctor advised surgery or complete bed rest for a long period of time, his son was admitted in Dhanwanthari hospital and availed treatment.

Allegation of complainant is that 1^st opposite party was demanding records of treatment which were not available as the illness was only back ache and they are prolonging the claim application unreasonably.  His contention is that he had submitted all available records.  As per Ext.P3 issued from Chazhikkattu Hospital, it is revealed that complainant’s son visited the hospital for the treatment of contusion right side chest.  He came on 07/09/2020 with complains of pain back of chest, X -Ray done showed straightening of cervical spine.  He was advised bed rest.  As per clinical notes appended to Ext.P3, previous visits were on 28/04/2020, 01/04/2018.  On 28/04/2020, consultation was  done in general medicine department. 

(Cont.....7)

 

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Present treatment done as per Ext.P2 cannot be treated as continuation of earlier ailments occurred due to accident.  It is the duty of opposite parties to prove that present treatment related to earlier ailments.  Opposite parties could have collected any such evidence from Chazhikkattu Hospital as the complainant had filed treatment details from the said hospital which is marked as Ext.P3.  Medication is seen advised for 1 week only in respect of bike accident as evidenced by above document.  Opposite party’s demand for additional documents can only be considered as a delay tactics for not honouring the claim in time.  Ordinarily, nobody would keep previous treatment records of minor ailments.  It is a futile attempt on the part of opposite parties to deny the rightful claim of an insured.  The very purpose of taking medical insurance policy is to meet any unforeseen future medical expenses.  It is the duty of an insurer to honour genuine claims, which is not done in this case.  This is deficiency in service on the part of 1^st opposite party.  In the above circumstances, we find that 1^st opposite party is responsible to pay the treatment expenses claimed Rs.33,367/- with interest 9% per annum from the date of complaint ie, from 22/11/2021 along with compensation of Rs.5000/- and litigation costs Rs.3000/- and complainant is entitled to recover the same from 1^st opposite party.  Hence point Nos.1 and 2 are answered as above.

 

 

(Cont.....8)

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Point No.3

 

In the view of the above discussions and our findings on points Nos.1 and 2, we order the following.

1 . 1^st opposite party is directed to pay Rs.33,367/- (Rupees Thirty Three Thousand Three Hundred and Sixty Seven only) being treatment expenses with simple interest @ 9% per annum from the date of complaint ie, 22/11/2021 to the complainant till realisation.

2 . It is further directed 1^st opposite party shall pay compensation of Rs.5000/-(Rupees Five Thousand only) for deficiency in service with interest @ 9% per annum from date of this order till realisation and litigation costs Rs.3000/- (Rupees Three Thousand only) to complainant.

Above amounts should be paid by 1^st opposite party within  45 days of receipt of this order.  We find that 2^nd opposite party is not responsible to pay any amount.  Point No.3 is answered accordingly.

In the result, complaint is allowed in part as indicated above.

Parties shall take back extra copies without delay.

Pronounced by this Commission on this the   26 ^th  day of July 2023.

 

                                                                                                Sd/-

                                                                            SRI.AMPADY K.S., MEMBER

                                                                                            Sd/-

                                                                 SRI.C.SURESHKUMAR, PRESIDENT 

                                                                                            Sd/-

                                                                        SMT.ASAMOL P., MEMBER

 

  (Cont.....9)

 

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APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1-  Group Medicare certificate of insurance master policy

            No.0238178373 in the name of complainant and his family.

Ext.P2 – Discharge summary dated 05/06/2021 of Dhanwanthari Ayurveda

               Hospital.

Ext.P3 -  Treatment certificate dated 11/06/2021 with clinical notes,

               procedures, medicines prescribed etc.

Ext.P4 - Request letter dated 09/01/2021 issued to complainant by 1^st

              opposite party seeking additional information/documents etc.

Ext.P5 – Discharge bill No.133 dated 05/06/2021 issued by Dhanwanthari

                Hospital.

 On the side of the Opposite Party :

Nil

                                                                                              Forwarded by Order

 

                                                                                        ASSISTANT REGISTRAR