BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM RAICHUR.
COMPLAINT NO. (DCFR) CC. 72/2012.
THIS THE 28th DAY OF FEBRUARY 2013.
P R E S E N T
1. Sri. Pampapathi B.sc.B.Lib. LLB PRESIDENT.
2. Sri. Gururaj, B.com.LLB. (Spl) MEMBER.
3. Smt. Pratibha Rani Hiremath,M.A. (Sanskrit) MEMBER.
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COMPLAINANT :- Somanath Pattansetty S/o. Siddalingappa
Pattanashetty, aged about 54 years, Occ: Advocate and notary, R/o. Siddeshwar Nilaya, Hirejanthkal road, Gangavathi- 583227, Dist: Koppal,
//VERSUS//
OPPOSITE PARTIES :- 1. The Branch Manager, LIC of India, Branch,
Gangavathi, Dist: Koppal.
2. The Manager, (Health Insurance) LIC of India,
Divisional Office, Jeevan prakash- P.B.No.43 station road, Raichur- 584 101.
3. The Branch Manager, (claims) Family Health Plan (TPA) Ltd., Ground floor, Srinilaya, Cyber Banjara Hills, Hyderabad
CLAIM :- For direct the opposites to pay a sum of Rs. 1,70,000/- with 12% interest, to direct them to pay an amount of Rs. 50,000/- towards mental agony, harassment for to deficiency in service and to direct them to pay a sum of Rs. 10,000/- towards cost of litigation with other reliefs as deems fit to the circumstances of the case
Date of institution :- 04-09-12.
Notice served :- 21-09-12.
Date of disposal :- 28-02-13.
Complainant represented by Sri. TM. Swamy, Advocate.
Opposite Nos.1 to 3 to represented by Sri. S. Basappa Advocate.
This case coming for final disposal before us, the Forum on considering the entire material and evidence placed on record by the parties passed the following.
JUDGEMENT
By Sri. Gururaj, Member:-
This is a complaint filed by the complainant Somanatha Pattanshetty S/o. Siddalinga Pattanashetty against the Opposite 1 to 3 U/sec. 12 of Consumer Protection Act for direct the opposites to pay a sum of Rs. 1,70,000/- with 12% interest, to direct them to pay an amount of Rs. 50,000/- towards mental agony, harassment for to deficiency in service and to direct them to pay a sum of Rs. 10,000/- towards cost of litigation with other reliefs as deems fit to the circumstances of the case.
2. The brief facts of the complainant case are that, he has purchased Health Insurance Policy bearing No. 664357775 dt. 15-02-2008 from the opposite covered under LICs Health Plus with profit issued by Opposites through Opposite No- 1 by agreeing to pay Rs. 9,000/- as yearly premium till its expiry by 15-02-2022 by appointing his wife as a nominee. That in the month of October-2011 the complainant had been to Raichur and at that time he had a chest pain accordingly, he had treatment at Raichur and after submitting entire records in respect of said treatment, opposite Nos. 1 & 2 have reimbursed the amount spent for treatment. Subsequently the complainant approached Narayana Hrudayala Hospital, Bangalore for better checkup and treatment on 26-03-2012 and as per the doctors of said hospital it was diagnosed as CAD-AWMI,S/P CAG double vessel disease and advised the complainant for immediate coronary angio plasty. The complainant got admitted on the same day in the said hospital and under went for angio plasty i.e, adhoc PTCA + STENT TO MID LAD and he was discharged on 27-03-2012 with the follow up treatment. In all he has spent Rs. 1,70,000/- for the said treatment.
That, after the said treatment the complainant submitted all relevant papers along with intimation dt. 03-04-2012 for claim purpose and thereafter as per the advise of the opposite No-1 he has also submitted hospital treatment form with all details. But instead of settling the claim opposite No-3 has sent claim repudiation letter dt. 28-04-2012 by intimating denial of complainant claims on the ground that, the said treatment is not covered under purview of policy condition. The act of the opposite No-3 is illegally and uncalled for because only on the basis of the policy condition the claim has been repudiated but such conditions are not made known to complainant either expressly or impliedly at the time of issuing the policy or during the course of the policy till the submission of claim.
Further, it is also contended that, opposites have already admitted the claim at the first instance when he has taken the treatment at Raichur and paid Rs. 3,450/- vide cheque No. 898622 of Axis Bank dt. 11-08-2012. But now repudiating the claim without any intimation is illegal in the eyes of law and thereby caused deficiency in service, as such he filed this complaint for the reliefs as prayed in it.
3. Opposites have appeared in this case through their Advocate and filed written version by contending that, this Hon’ble Court has got no jurisdiction to try the case as the policy has been issued by opposite No-1 Gangavathi Branch of Koppal District, as per the terms and conditions of the policy the present policy is benefit type policy, eligible benefits will be paid in the form of HCB (Hospital Cash Benefit) and MSB (Major Surgical Benefit). The HCB is payable for each day of hospitalization in excess of first 48 hours if, part of days is less then four hours it will be ignored. If part of day is four hour or more it will be treated as full day for deciding eligible days for payment of HCB. Therefore minimum hospitalization of 52 hours is required for payment of HCB subject to policy conditions and privileges. Major surgical benefit is available for specified listed 49 surgical procedures only. Specified percentage of MSB sum assured will be payable for listed 49 surgical procedures as per policy conditions and privileges.
Further, it is contended that, there is no link to the actual expenditure incurred by the complainant since our health insurance policies are benefit type of policy and not indemnity type of reimbursement of policy. No doubt we have given the first payment for the first treatment for an amount of Rs. 3,450/- through cheque No. 898622 dt. 14-05-2012 to the complainant as it was not any surgery only for the treatment, further the complainant was hospitalized only 26 hours 48 minutes minimum hospitalization required is 52 hours. It is also contended by the opposites that, the complainant is not resident of this Hon’ble court jurisdiction; hence this forum has no territorial jurisdiction to entertain the complaint. As such there is no deficiency in their services, the complainant is not entitled for any of the reliefs and prayed for to dismiss the complaint among other grounds along with cost.
4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that:
1. Whether the complainant proves that, he obtained LICs Health Plus with profit policy of opposites vide policy No. 664357775 through opposite No.1 and thereafter he has admitted in Narayana Hrudalaya Hospital Bangalore on 26-03-12 and under went for angio plasty i.e, Adhoc PTCA + STENt TO MID LAD and discharged on 27-03-2012 with the follow up treatment spent upto Rs.1,70,000/- thereafter he forwarded his claim petition along with necessary medical bills to the opposites but all the Respondents shown their negligence in settling his claim, inspite of his request and thereby all the opposites found guilty under deficiency in their services.?
2. Whether complaint is entitled for the reliefs as prayed in the complaint.
3. What order?
5. Our findings on the above points are as under:-
(1) In the affirmative
(2) As discussed in the body of this judgement and as noted in the final order.
(3) In-view of the findings on Point Nos. 1 & 2, we proceed
to pass the final order for the following :
REASONS
POINT NO.1 & 2:-
6. To prove the facts involved in these two points, affidavit-evidence of the complainant was filed, he was noted as PW-1. The documents Ex.P-1 to Ex.P-18 are marked.
7. On the other hand affidavit-evidence of Manager (L&HPF) of Opposite Insurance Company was filed, he was noted as RW-1. One document was filed as same was marked as Ex.R-1.
8. From the pleadings of the parties and their respective evidences it is a fact that opposites have not disputed regarding the treatment taken by the complainant in Narayana Hrudalaya Hospital, Bangalore, while his medi claim policy is in-force. The points required to decide in this case are that, the treatment taken by the complainant at the second instance at Narayana Hrudalaya by undergoing Angio Plasty by admitting himself on 26-03-2012 is covered under the policy are not as contended by the opposites. Admittedly, No doubt the said treatment i.e, surgical procedure undergone is not covered under the listed surgical procedures and coronary angio plasty with stent implementation (two or more coronary arteries must be stented) as per Page No-25 of the booklet produced under Ex.R-1. Further it is also correct that, the complainant is admitted in the hospital only 26 hours 48 minutes which is less then 52 hours as contended by the opposites. But the important point for our consideration is that, whether all these terms and conditions are made known to the policyholder clearly in the policy and whether they have been clearly shown to the complainant while obtaining the policy, or at the time of payment of first instance and any further subsequent dates. Further it is also important to note here that, whether such intimation which are made available on the policy are clearly visible and easily understandable to the policyholder and it is also pertaining to note that all these terms and conditions are made available on the policy are not.
10. As per Ex.P-1 the policy in question is not properly visible as contended by the complaint. Further, the conditions what they have opposites have raised are also not cleared in the policy. The said policy is of three pages and the words or the size of the alphabets are not properly visible. Under such circumstances, it cannot be said that, the terms and conditions of the policy cannot be said that, they are fully visible and made known to the policyholder and it is also fact that, the contents of the policy is properly made known to the policyholder. Under such circumstances, the rejection of the claim by the opposites without any proper advise, or proper method to inform the policyholder about the terms and conditions of the policy or the contents of the policy is made known to the policyholder is holds no good. In this regard we have referred the judgment of the Hon’ble National Commission ruling cited in 2010 CJ 190 NC wherein, the Hon’ble National Commission clearly held that, being aware of existence of policy is one thing and being aware of contents and meaning of clause of policy is another. Un-explained or un-noticed exclusion clauses would not be binding to insure. Exclusion clauses are required to be ignored if, insurance company or its agent or intermediary does not adhere to mandatory requirement of explaining exclusion clause before issuance of insurance cover. Further, the Hon’ble National Commission in the case of National Insurance Company Ltd., V/s. DP Jain iii 2007 CPJ 34 NC clearly held that, an insurer or its agent or the intermediary shall provide material information in respect of proposed cover to the prospect to decide on the best cover that would be any or interest.
11. Further, we have also referred the another ruling cited by the Delhi State Consumer Disputes Redressal Commission in (2010) CJ 520 (Delhi) in ICICI Prudential Life Insurance Co. Ltd., V/s. Anil Kumar Jain case wherein, it has clearly held that, it is not open to insurance company to place conditions which are unlikely to be fulfilled with a view to create a devise to escape payment of compensation it amounts to defrauding and cheating customer. It is not open to insurance company such particulars and details of decease which quite often do not appear and which may provide symptoms appearing in all kinds of heart ailment cannot always be the same and merely because all symptoms are not 100% the same. Insurance company cannot avoid compensation. Ailments suffered by Respondent/complainant of this case was highly serious and life threatening and spirit and support of agreement must be assumed to be such as to provide for such serious deceases of heart. Further we have also referred another ruling of Chandigarh National Commission cited in 2010 CJ 261 (Punjab). So in this case also it is clearly held that, when insurance company wants to apply exclusion clause to deny insurance claim they have to provide that, exclusionary clause was duly communicated to insure and it was duly signed by him. Further, we have also referred the another case of our Hon’ble National Commission cited in 2009 CJ 147 NC wherein, the Hon’ble National Commission categorically held that, insurance__ policy document __ printing in very small letter__ same requiring magnifying glass to read__ such practice held to be not appreciable.
In any angle if, we gone through the above said rulings they are definitely and amply applicable to the case of the complainant. Because the policy, the contents of the policy and the alphabets of the policy are not particular and they are not properly visible. The exclusion clause is also properly made available in the policy. Hence, the complainant counsel rightly contended all these facts in his complaint and arguments. On the other hand, the contents of the opposites about exclusion clause about the non covering of the said decease of the complainant and method of treatment are not according to the policy terms and conditions. Further, regarding the technical point about the time of hospitalization are not acceptable as they were not properly made available to the policyholder. No doubt they are in separate book which is made availed before this forum. Further it is not the case of the opposites that, the said Ex.R-1 made available to the complainant at the time of obtaining the policy. Under such circumstances the contents of the opposites cannot be accepted.
12. Further it is worthwhile to note here that, they have paid some part of the amount to the complainant under the said policy for his first treatment at Raichur. Further, from the pleadings of the parties it shows that, it is the continuity of the treatment the complainant has took at Bangalore. Under such circumstances, the rejection of the claim of the complainant for the second treatment holds no good. Hence, we have rejected the claim of the opposites as there act is proper and according to the provisions of the policy.
13. Further, the opposites in their written version contended that, the complaint of the complainant is not maintainable as it is lacking from territorial jurisdiction to entertain the complaint. No doubt, the opposite No-1 office is at Gangavathi, the complainant is also the resident of Gangavathi, but the opposite No-2 is the resident of Raichur and who has rejected the claim of the complainant. Hence, the part cause of action was arised at Raichur. So, the complainant rightly approached to the Raichur Forum as it has got territorial jurisdiction to entertain the complaint. Hence we have rejected the contents of the opposites.
14. Further, it is the case of the opposite that, the claim of the complainant and his treatment and amount spent for it is not tallied. But we do not find any reason to believe that, how the opposites comes to such collusion in this regard. Because the complainant has produced all the relevant medical reports under Ex.P-3 to P-12 and Ex.P-15 to P-16 wherein, the doctor reports, bills and other details about the treatment and as well as expenditures are clearly speaks about the treatment and as well expenditures. Under such circumstances, the contents of the opposites in this regard are nothing but beating of dead horse. Under above circumstances, we hold that, the complainant has proved his case without any doubts. Therefore, we answered Point No-1 in affirmative.
15. As regards to the relief claimed by the complainant, he claimed total expenditure incurred in Narayana Hryudalaya Hospital Bangalore to the extent of Rs. 1,70,000/- vide Ex.P-9, Ex.P-11, Ex.P-12, and Ex.P-13. We are of the view that under the said medi claim policy the complainant is entitled to recover actual expenditure incurred by him towards his treatment in the said hospital. The claim of Rs. 1,75,000/- and odd is supported by records and bills of the hospital vide Ex.P-9, Ex.P-11, Ex.P-12, and Ex.P-13, as such complainant is entitled for to get an amount of Rs. 1,75,000/- towards medical expenditure of him.
16. Definitely there is a deficiency in service on the part of Respondents 1 to 3 by repudiating the legal claim of complainant, and same has made mental harassment to the complainant, as such we have granted lumpsum of Rs. 5,000/- which recoverable by the complainant on the Opposite Nos 1 to 3 for deficiency in their service etc.,
17. As regards to the cost of litigation is concerned, we have taken note of the entire litigation of the complainant and awarded a lumpsum amount of Rs. 2,000/- towards cost of the litigation. Accordingly the complainant is entitled to recover a total sum of Rs. 1,82,000/- from Opposite Nos. 1 to 3 jointly and severally. The complainant is entitled to recover future interest at the rate of 9% p.a. on the above total sum from the date of this complaint till realization of the full amount, accordingly we answered Point No.2.
POINT NO.3:-
18. In view of our finding on Point No-1 & 2 we proceed to pass the following order:
ORDER
The complaint filed by the complainant is partly allowed against Opposite Nos. 1 to 3 with cost.
The complainant is entitled to recover a total sum of Rs. 1,82,000/- from the Opposite Nos.1 to 3 jointly and severally.
The complainant is entitled to recover future interest at the rate of 9% p.a. on the above total sum of Rs. 1,82,000/- from the date of the complaint till realization of the full amount.
One month time is given to the opposite Nos. 1 to 3 to make the payment above total sum with interest.
Intimate the parties accordingly.
(Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 28-02-13)
Smt.Pratibha Rani Hiremath, Sri. Gururaj Sri. Pampapathi,
Member. Member. President,
Dist.Forum-Raichur. Dist-Forum-Raichur Dist-Forum-Raichur.
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