IN THE KODAGU DISTRICT CONSUMER DISPUTES REDRESSAL FORUM MADIKERI

SRI. C.V. MARGOOR,PRESIDENT

O R D E R

1. This complaint filed by Smt. Rani.C.S w/o. M.S. Appaiah, resident of Madikeri Town, Kodagu District against the opponents with a prayer to direct the opponents to pay the balance insured amount of Rs.27,500/-, Rs.10,000/- cumulative bonus amount, Rs.500/- towards x-ray and ECG charges paid by her.  Rs.2,00,000/- as compensation for physical and mental pain and cost of this proceedings.

2. The opponent no.1 is the Divisional Manager, New India Assurance Company Ltd, Mysore and opponent no.2 is the Branch Manager, New India Assurance Company Ltd., Madikeri.  The complainant has taken Janatha Mediclaim policy from the opponent no.2 on 01/08/2001 for a sum of Rs.50,000/- and the policy covered the mediclaim of her and her husband. 

3. The complainant had undergone hysterectomy on 18/04/2018 in Mangalore Nursing Home at Mangalore and she was inpatient for three days.  The complainant has paid medical expenses of Rs.92,743/- including the pharmacy and laboratory charges.  The complainant after discharge from the hospital has submitted claim application but the opponents have settled the claim to a meager amount of Rs.22,500/- much against the policy terms and conditions.  The complainant is entitled to claim a sum of Rs.50,000/- which is the insured amount for year and accrued cumulative bonus of Rs.10,000/-.  It is alleged in the complaint that she had paid the premium amount continuously for the last 17 years without questioning the enhancement of the premium amount.  The opponents have never revealed the restriction and limitation whatever may be till such date of settlement of the claim amount made.   The complainant and opponents have not entered any such agreement for such terms and conditions or  limitations and the same has been purposefully suppressed by the opponents.  The complainant has got issued legal notice through her Advocate on 10/07/2018 but the opponent has given reply reiterating their stand already taken which is against the terms of the policy.  Hence, this complaint.

4. The opponent resisted the complaint by filing written statement.  The opponent admitted that the complainant is a holder of Janatha Mediclaim Policy.  The opponent further admitted that the complainant preferred a claim for undergoing the hysterectomy treatment on 18/04/2018.  The opponent is liable to pay a sum of Rs.22,500/- as per the terms and conditions and limitation of the policy.  Accordingly the opponent settled the claim of the complainant at Rs.22,500/-.  Therefore, there is no deficiency of the service on the part of the opponent.  The opponent denied that the terms and conditions of the policy was not explained or suppressed the same.  The complainant is not entitled for any of the amount claimed in the complaint.

5. The complainant filed her affidavit in lieu of oral evidence and got marked exhibits P1 to P8 documents.  On behalf of opponents Smt.K.B. Yeshoda w/o. Dr. P.C. Bolka, the Assistant Manager of Madikeri Branch filed affidavit in lieu of oral evidence and got marked exhibits R1 and R2 documents.

6. The learned counsel for the complainant and opponent have submitted their written arguments  and the points that would arise for determination are as under;

1. Whether the complainant proves that the act of opponent not allowing her application for Rs.50,000/- amounts to deficiency in service?

2. Is complainant entitled to the relief sought for?

3. What order?

7. Our findings on the above points is as under;

• Point No.1:- In the Affirmative
• Point No.2:- In the partly Affirmative
• Point No.3:- As per final order for the below

R E A S O N S

8. Point No.1 to 3:- The learned counsel for the complainant contention is that the act of opponent rejecting part of the claim of the complainant is arbitrary and unscientific and the opponent has intentionally suppressed so called terms and conditions and never revealed the same till the same produced as evidence in this case.  The opponent has not issued the brochure or explained the limitations or the terms and conditions of the policy.  As against this the learned counsel for the opponent argued that the settlement for Rs.22,500/- is proper as per the terms and conditions of the policy as such there is no deficiency of service on the part of opponent.  The opponent has paid the claim amount as per clause 2.10 of the policy terms and conditions.

9. In this case the opponent has not disputed the Janatha mediclaim policy taken by the husband of complainant to him and his wife on 01/08/2001 and the same has been renewed continuously for a period of 17 years.  Janatha Mediclaim Policy has taken by the husband of complainant for sum of Rs.50,000/- each and during the time of claim the policy was in force.  The opponent has not disputed the fact that the complainant had undergone hysterectomy on 18/04/2018 in Mangalore Nursing Home at Mangalore and she was admitted as inpatient for three days.  Exhibit P2 is medical bill dated 20/04/2018 issued by the Mangalore Nursing Home at Mangalore for giving treatment to the complainant for Hysterectomy disease and according to this the complainant was admitted on 17/04/2018 and discharged on 20/04/2018.   Exhibit P2 bill is for Rs.92,264/- and the same has been paid by the complainant.  Exhibit P4 is intimation given by the opponent No.2 for settling the bill amount of Rs.22,500/-.  The opponent has disallowed many charges contrary to exhibit P2 medical bill and approved for Rs.22,500/-.

10. Exhibit P1 is Janatha Mediclaim Policy (Hospitalization Benefit Policy) issued by opponents in the name of husband of complainant for the period from 24/08/2017 to 23/08/2018.  Exhibit P1 reveals the date of issue of first policy as on 01/08/2001.  As already observed that the husband of complainant has renewed Janatha Mediclaim Policy every year from the year 2001 till 2018.  The husband of complainant has paid Rs.4,354/- as premium for the year 2017-18.  According to exhibit P1 policy covers the complainant and her husband for Rs.50,000/- each per year.  The opponent has produced exhibit R1  true copy of policy of exhibit P1 issued to the husband of complainant.  The opponent has enclosed terms and conditions of policy of exhibit P1 about 24 pages which runs from page no.5 to 28.  Clause no.2.10 of the Janatha Medicalim policy deals with schedule of payment for specific disease.  According to this schedule maximum amount for hysterectomy is Rs.22,500/- which inclusive of Room /ICU/OT charges/Surgeons, Doctor’s fee, medicines, internal appliances  and other charges incurred during hospitalization period.  The terms and conditions of the policy said to have been issued in the year 2013-14 that can be find on every page of document i.e. IRDA/NL – HLT-NIA/P-H/V.I/336/13-14.

11.  The learned counsel for the complainant contention is that the terms and conditions of the policy have not been explained to the complainant while issuing policy in the year 2001 or subsequent years including while issuing exhibit P1 policy during the year 2017.  It is bounden duty  of the opponent to serve the terms and conditions or limitations of the policy to the insured.  The opponent has produced 24 pages terms and conditions of Janatha Mediclaim policy along with exhibit R1.  Exhibit R1 contained only 2 pages that can be found on at the end of each page as page 1 of 2 and page no.2 of 2.  Even the same can be found in exhibit P1 policy issued to the complainant.  The terms and conditions runs from page no.5 to 28 a separate annexure to Janatha Mediclaim Policy and the opponent has not produced any document to show that they have furnished or supplied to the complainant’s husband at the time of issuing exhibit P1 policy.  The opponent in surprise while rejecting part of the mediclaim has intimated the limitations of the policy and further produced annexures along with exhibit R1 at the time of evidence i.e. on 16/02/2019.  It shows that the opponent has not explained the terms and conditions or limitations of the policy to the complainant while renewing Janatha Mediclaim Policy on 24/08/2017 or subsequent date.  The complainant though she has paid medical bill of Rs.92,264/- for hysterectomy disease vide exhibit P2 bill but she has restricted her claim for the insured amount of Rs.50,000/-.  The opponent instead of allowing claim for Rs.50,000/- has approved for Rs.22,500/- by assigning the limitations of the policy.  The opponent has not served the terms and conditions and limitation of the policy to the complainant and her husband while issuing exhibit P1 policy.  Therefore, the act of opponent not allowing the claim for Rs.50,000/- amounts to deficiency in service.

12. The complainant has asked for bonus  a sum of Rs.10,000/-.  The husband of complainant has taken mediclaim policy and the same has been renewed every year.  Insurance company is liable to pay bonus on the accrued premium amount but in this case the policy has been renewed every year and at the end of the term the premium amount will not be accrued as such the complainant is not entitled for any bonus on the premium amount which has been paid every year.

13. The complainant has asked for Rs.2,00,000/- as compensation for physical and mental pain.  The complainant has not produced any material to show that she has suffered physically due to rejecting her part of the mediclaim.  The complainant might have suffered mental agony since the opponent has rejected part of her claim though her husband has been renewing medicalim policy for the last 17 years.  Therefore, the opponents shall liable to pay a sum of Rs.10,000/- towards mental agony to the complainant.  In addition to that the opponents shall liable to pay Rs.10,000/- as cost of this proceedings.  For the above reasons, we proceed to pass the following ;

O R D E R

1. The complaint filed by Smt. Rani C.S w/o. M.S. Appaiah, resident of Madikeri is partly allowed directing the opponents no.1 and 2 shall jointly and severally liable to pay a sum of Rs.50,000/- towards medical expenses for the hysterectomy disease.  If the opponents have already paid Rs.22,500/- to the complainant or her husband then the same shall be adjusted out of Rs.50,000/.
2. The opponent shall pay the said amount within two months from the date of order otherwise it carries interest at the rate of 12% per annum from 20/04/2018 till the date payment.
3. It is further ordered that the opponents shall pay a sum of Rs.10,000/- as compensation  and Rs.10,000/- as cost of this proceedings within two months from the date of order. Otherwise, it carries interest at the rate of 12% per annum from the date of filing of the complaint till its payment.
4. Furnish copy of order to the complainant and opposite parties at free of cost.

(Dictated to the Stenographer, got it transcribed, corrected and pronounced in the open Forum on this 02^ndday of MARCH, 2019)

                                                      (C.V. MARGOOR)

                                                          PRESIDENT 

                                                    (M.C. DEVAKUMAR)

                                                             MEMBER