CC No.1272.2014

Filed on 18.07.2014

Disposed on.21.10.2017

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU– 560 027.

DATED THIS THE 21^st DAY OF OCTOBER 2017

CONSUMER COMPLAINT NO.1272/2014

PRESENT:

Sri.  H.S.RAMAKRISHNA B.Sc., LL.B.

        PRESIDENT

              Smt.L.MAMATHA, B.A., (Law), LL.B.

                     MEMBER

                                         V/S

ORDER

BY SRI.H.S.RAMAKRISHNA, PRESIDENT

1. This Complaint was filed by the Complainant on 18.07.20174 U/s 12 of the Consumer Protection Act, 1986 and praying to pay Insurance amount of Rs.2,70,933/- along with 12% interest from 04.01.2012, to pay sum of Rs.2,00,000/- towards mental agony, to pay damages of Rs.2,00,000/- and other reliefs.

2. The brief facts of the complaint can be stated as under:

In the Complaint, the Complainant alleges that the Complainant had taken a Mediclaim Policy from the Opposite Parties with Policy No.42310014820112682 on 04.03.2011.  The Complainant has paid a Gross Premium of Rs.10,063/-.  The Complainant insured, his wife and two sons, including his son, Akshay Kurian who is the Claimant in respect of the policy.  According to the Policy, the policy shall pay the hospitalization expenses for surgical costs for an in-patient at any Nursing Hospital in India, the Complainant’s son Akshay Kurian met with an accident on 01.01.2012 and sustained facial injuries.  There were serious injuries on his face and he was bleeding heavily.  He was admitted to Manipal Hospital, Bangalore and was an inpatient there.  On 04.01.2012 the son of the Complainant underwent a surgery for wound debridement, suturing of facial wounds and ORIF of facial fractures was done under GA on 04.01.2012, on 07.01.2012 the son of the Complainant was discharged.  On 04.01.2012, the Complainant gave a representation to the 1^st Opposite Party that Complainant’s son met with an accident on 01.01.2012 and he was admitted to Manipal Hospital, Bangalore.  Since this hospital does not have tie-up with the 1^st Opposite Party, he would be submitting all the bills and documents to the Bangalore office for settlement.  On 04.01.2012 the Complainant got an acknowledgement from the 2^nd Opposite Party, stating that the claim intimation has been updated and the claim number is 55661112147165. After the discharge of the Complainant’s son, the Complainant filled up the “Hospitalization and Domiciliary Hospitalization Benefit Claim” Form on 11.01.2012 and submitted the same to the 2^nd Opposite Party, along with a covering letter and all the original documents.  He requested the 2^nd Opposite Party to reimburse him the amount of Rs.2,70,933/- which was the amount incurred for the treatment of the Complainant’s son Akshay Kurian.  On 19.01.2012, the 2^nd Opposite Party intimated the Complainant that some more documents were required to process the claim.  The Complainant by letter dt.06.02.2012, submitted all the original documents prayed for early reimbursement of the amount claimed.  All of a sudden on 15.02.2012, the 2^nd Opposite Party sent a letter stating that: As per Policy sub-limit, treatment charges related to complication of alcohol abuse are not payable.   Hence claim is rejected.  On 23.02.2012 and 12.03.2012 the Complainant had sent a reminder to the 2^nd Opposite Party stating “We would like to categorically state that Akshay Kurian was not under the influence of alcohol with the Bio-Chemistry Reports taken which supports as evidence that Blood Alcohol is Negative.   The Complainant also sent a letter to the 1^st Opposite Party, reiterating that there was no alcohol content in the blood of Akshay Kurian and requested the 1^st Opposite Party to intervene in the settlement of claim of the Complainant with Raksha the 2^nd Opposite Party at the earliest.  The Complainant got a reply to the letter dt.24.04.2012 received on 27.04.2012 from the 2^nd Opposite Party stating that “Based on previous requests, case was prioritized and team was advised to process the claim with utmost positive care.  Case was subjected to detailed investigation and investigator provided them all the supporting documents to come to a conclusion that beneficiary was under influence of alcohol at the time of accident.  Hence that case was denied”.  The Complainant requested the 2^nd Opposite Party to provide him with the documents proving that Akshay Kurian was under the influence of alcohol.  In reply to this letter the 2^nd Opposite Party sent a letter to the Complainant that confidential documents cannot be shared with the Complainant but can be forwarded to the insurance Company on their request.   The Complainant submits that the Claims Department of the 1^st Opposite Party sent a letter dt.30.04.2012 stating that the matter is being taken up with Raksha TPA.  The 2^nd Opposite Party for a thorough review of their decision.  “Once the decision is completed by the 1^st Opposite Party, we shall revert to you and hence kindly bear with them.  The 2^nd Opposite Party to scrutinize the claim considering the documentary evidence and the policy terms and conditions on priority and inform the insured Complainant.  The letter dt.14.05.2012.    Hence, this complaint. 

3. In response to the notice, the Opposite Party No.1 put their appearance through their counsel and filed their version.  In the version pleaded that after the occurrence of the accident Complainant son Akshay Mathew was initially taken treatment at Sathya Hospital and later on at 1.30 a.m the Complainant’s son was shifted to Manipal Hospital.    As per the Initial Assessment Form, referring to the Manipal Hospital, it is specified that the patient was restless, not obeying under influence of Alcohol.  As per the said Report the Opposite Party No.2 has rightly repudiated the claim.  The documents No.K and K-1 are created for the said case.   The Opposite Party No.2 has intimated the repudiation on 15.02.2012 itself then also due to the several requests made from the complaint the Opposite Parties made thorough investigation and then the Opposite Party have taken the same stand supra vide letter dt.15.02.2012.  It is pertinent to note that the Complainant has violated the terms and conditions of the Policy No.4, 8, as agreed by him.  The Complainant has suppressed the material fact that his son was drunken at the time of accident.  On 31.12.2011 and the rider of the vehicle was Akshay Mathew who was aged about 17 Years and his date of birth is 21.02.1994.  At the time of accident without DL he has driven the vehicle, the same is bad.  Therefore, the Complainant has violated the terms and conditions of the policy.  Subsequent to the repudiation of the claim the Complainant has represented the Opposite Party NO.2 to reconsider the claim, and informed that the letter issued from a Dr.Satish R of Manipal Hospital, stated that patient was not under the influence of Alcohol.  The opinion given by the doctor for not having alcohol is from a different doctor of the Manipal Hospital.   The case sheet and initial reports of the Manipal Hospital, clearly shows the patient was under the influence of alcohol.   The Opposite Party No.2 is rightly repudiated the claim.  Hence prays to dismiss the complaint against Opposite Party No.1.

4. Eventhough notice was served on Opposite Party No.2, the Opposite Party No.2 fails to put their appearance.  Hence placed ex-parte. 

5. The Complainant, Sri.Kurian Mathew, filed his affidavit by way of evidence and closed his side.  On behalf of the Opposite Party No.1, the affidavit of one Sri.R.S.Arasu has been filed.   Heard the arguments of both parties.

6.      The points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Parties ?
2. If so, to what relief the Complainant is entitled?

7.     Our findings on the above points are:-

                POINT (1):-  Affirmative

POINT (2):-  As per the final Order

REASONS

8. POINT NO.1:- As looking into the allegations made in the complaint and the version of the Opposite Parties, it is not in dispute that the Complainant had taken a Mediclaim Policy from the Opposite Party with Policy No.42310014820112682 policy period from 21.03.2011 to 20.03.2012 and the said policy was covered for the complainant, wife and his two sons. 

9. Further to substantiate this, the Complainant in his sworn testimony, he has reiterated the same and produced the Individual Mediclaim Policy Schedule.  As looking into this document, it clearly reveals that this policy is in the name of the Complainant Sri.Kurian Mathew policy bearing No.42310014820112682 covering from 21.03.2011 to 20.03.2012 and the said policy was covered for the Complainant’s wife Malini Kurian sum insured is Rs.2,50,000/-, the Complainant’s son Nitin Kurian sum insured is Rs.1,25,000/- and another son Akshay Kurian sum of Rs.1,25,000/-.  This evidence of the Complainant has not been challenged by the Opposite Party.    To discard the evidence of the Complainant, there is no other contra evidence.  Therefore, it is proper to accept the defence taken by the Complainant.  The Complainant has taken mediclaim policy from the Opposite Party with policy No. 42310014820112682 policy period from 21.03.2011 to 20.03.2012 and the said policy was covered for the Complainant’s, his wife and two sons including Akshay Kurian.
10. It is further case of the Complainant, the Complainant’s son Akshay Kurian met with an accident on 01.01.2012 and sustained facial injuries.  There were serious injuries on his face and he was bleeding heavily.  He was admitted to Manipal Hospital, Bangalore as an inpatient.  On 04.01.2012 the son of the Complainant underwent a surgery for wound debridement, suturing of facial wounds and ORIF of facial fractures was done under GA on 04.01.2012, on 07.01.2012 the son of the Complainant was discharged from Manipal Hospital.  Even this fact is also not been denied or disputed by the Opposite Party.  Further to substantiate this, the Complainant in his sworn testimony, he has reiterated the same and produced Discharge Summary.  As looking into this document, it is very clear that the Complainant’s son Akshay Kurian had taken treatment in Manipal Hospital, Bangalore as an inpatient from 01.01.2012 to 07.01.2012 for Facial Laceration and also it reveals that the alleged Facial Laceration is due to Road Traffic Accident on 01.01.2012 and sustained facial injuries.  This evidence of the Complainant has not been challenged by the Opposite Party.    To discard the evidence of the Complainant, there is no contra evidence.  Therefore, it is proper to accept the contention of the Complainant that the Complainant’s son met with an accident on 01.01.2012 and sustained facial injuries, as a result, he was admitted to the Manipal Hospital and had taken treatment as an inpatient on 04.01.2012 the Complainant’s son underwent surgery for Wound Debridement + suturing of facial wounds + ORIF of facial fractures.
11. It is further case of the Complainant, the Complainant on 04.01.2012, the Complainant gave a representation to the 1^st Opposite Party that Complainant’s son met with an accident on 01.01.2012 and he was admitted to Manipal Hospital and submitting all the bills and documents with Opposite Party No.2.  After discharge of the Complainant’s son, the Complainant filled up the “Hospitalization and Domiciliary Hospitalization Benefit Claim” Form on 11.01.2012 and submitted to the 2^nd Opposite Party requested the 2^nd Opposite Party to reimburse a sum of Rs.2,70,933/-.    On 15.02.2012, the 2^nd Opposite Party sent a letter stating that: As per Policy sub-limit, treatment charges related to complication of alcohol abuse are not payable.  The Complainant requested with Opposite Party No.2 to reconsider the claim.   Inspite of that the Opposite Parties were repudiated the letter addressed by the Complainant dt.04.01.2012 informing the Opposite Party, the Complainant’s son Akshay Kurian was hospitalized in Manipal Hospital from 01.01.2012 for treatment and the Claim Form submitted with Opposite Party No.2, it reveals that the Complainant submitted the Claim Form No.55661112147165 for a sum of Rs.2,70,933/- along with Medical bills and other documents.  Further he has produced the letter addressed by the Opposite Party No.2 to the Complainant dt.19.01.2012 seeking some more documents for processing the claim of the Complainant.  To this letter, the Complainant reply on 06.02.2012 and furnishing additional documents as sought by the Opposite Party No.2 i.e., 1. MLC, 2. Treating Doctor’s Certificate mentioning detailed circumstances and mode of incidence. 3.Reports supporting treatment taken Discharge Summary-given earlier to Raksha (Ref:Our earlier letter dt.11.01.2012).  4.Treating Doctor’s Certificate mentioning non-influence of alcohol in patient’s blood.  5.Original Investigation Reports of Blood and Radiology.  6. Documents of Age Proof-Passport Copy. 7. Certificate for Implants used in the surgery and also produced a letter addressed by the Opposite Party to the Complainant informing that the claim has been untenable.  On the ground that the treatment charges related to complication of alcohol abuse are not payable.  Even thereafter the Complainant made several requests to reconsider the same and this is further very clear that the Complainant also produced the Certificate issued by the Dr.Sathish of Manipal Hospital dt.02.02.2012 certifying that Akshay Kurian met with an accident on 01.01.2012 he was under the influence of alcohol.  Further this is also supported by Bio-Chemistry Report issued by Dr.Vijay S.Bhat of Manipal Hospital that the Blood Alcohol is influence of alcohol is Negative.  In spite of furnishing all these materials, the Opposite Parties fails to honour the claim.  From this evidence, it is very clear that the Complainant’s son met with an accident on 01.01.2012 and he was hospitalized and taken treatment as an inpatient in Manipal Hospital on 04.01.2014 he was underwent surgery after discharge from the Hospital filed a Claim Form by producing all the relevant documents.  But in spite of that the Opposite Parties have repudiate the claim.   On the ground that the Complainant’s son was under influence of alcohol.  Eventhough there was no evidence to show that the Complainant’s son was under Influence of alcohol. 
12. The defence of the Opposite Party is that the repudiation of the claim of the Complainant is due to Complainant’s son was under Influence of Alcohol and documents No.K and K-1 are created for the said case   and the Complainant has violated the terms and conditions of the Policy No.4,8.  On that ground, the Complainant’s claim was repudiated.   To substantiate this, Sri.R.S.Arasu, Deputy Manager of Opposite Party No.1 Company, he has reiterated the same and produced the Initial Assessment Form of Manipal Hospital.  As looking into this document is with reference to the Complainant’s son Akshay Kurian and as per this document Akshay Kurian admitted the Manipal Hospital with a History of Road Traffic Accident on 01.01.2012.  He was brought to the Manipal Hospital from Sathya Hospital was under Influence of Alcohol.  The Opposite Parties have not examined doctor who has issued this initial Assessment Form.  On the other hand, the Doctor who have treated the Akshay Kurian, son of the Complainant have clearly issued Certificate that the Complainant’s son was not under Influence Alcohol at the time of accident.  As per letter dt.02.02.2012 issued by the Dr.Satish R and also Bio-Chemistry Report submitted by Dr.Vijay Bhatt the influence of alcohol was Negative.  Thereby, the Opposite Parties have fails to substantiate their defence that the claim of the Complainant was rejected.  Due to violation of Clause-4.8 of the policy.  But, the repudiation of the claim of the Complainant is not proper and correct.  Eventhough as per the terms of the policy, ought to have honour the claim of the Complainant and has to reimburse for a sum of Rs.1,25,000/- which was sum insured.  Inspite of that the Opposite Parties have repudiated the claim, thereby it clearly amounts to deficiency of service on the part of the Opposite Parties No.1 & 2 as well as the Opposite Parties No.1 & 2 are adopting unfair trade practice.  Hence, this point is held in the Affirmative. 

13. POINT NO.2:- Eventhough the Complainant made several requests to reconsider his claim, but the Opposite Parties fails to reconsider the claim of the Complainant and as per the terms of the policy, the Opposite Parties ought to have reimburse the assured sum of Rs.1,25,000/-.  On the other hand, the Opposite Parties without assigning proper and valid reason rejected the claim of the Complainant and also fails to reconsider the request of the Complainant it causes mental agony and loss to the Complainant, thereby the Complainant is entitled for compensation for causing mental agony.  Hence, we proceed to pass the following order:

ORDER

The Complaint is allowed holding that there is deficiency of service by the Opposite Parties.

The Opposite Parties are directed to reimburse of Rs.1,25,000/- out of the medical expenses and further directed to pay a sum of Rs.50,000/- as compensation for causing mental agony.

The Opposite Parties are also liable to pay a sum of Rs.5,000/- as cost. 

The Opposite Party is directed to pay the aforesaid amount within 30 days from the date of receipt of this Order.   Failing which the aforesaid amount will carry interest at 12% p.a. from the date of order, till the date of payment. 

Supply free copy of this order to both the parties. 

   (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, 21^st day of October 2017)

        MEMBER                                             PRESIDENT

LIST OF WITNESSES AND DOCUMENTS

 Witness examined on behalf of the Complainant:

1. Mr.Kurian Mathew, who being the Complainant has filed his affidavit.

 List of documents filed by the Complainant:

1. Individual Mediclaim Policy schedule
2. Policy
3. Receipt of the Gross Premium of Rs.10,063 to Oriental Insurance Company          
4. The copy of the Discharge Summary
5. The Claim Intimation has been updated and claim number is 55661112147165
6. The claim intimation has been updated and claim number is 55661112147165
7. The amount incurred for the treatment of the Complainant’s son Akshay Kurian at Manipal Hospital, Bangalore for the period of 01.01.2012 to 07.01.2012
8. On 19.01.2012, the 2^nd Opposite Party intimated the Complainant that more documents were required to process the claim
9. The Complainant prayed for early reimbursement of the amount
10. The letter of the treating doctor
11. The copy of the letter
12. The copy of letter dt.23.02.2012, 12.03.2012, 23.04.2012 24.04.2012, 14.05.2012, 12.06.2012, 16.06.2012, 06.11.2012, 08.11.2012, 02.01.2013, 24.01.2014 and 22.04.2014.
13. The mails dt.24.04.2012 and 25.04.2012, 30.04.2012, 01.05.2012. 

Witness examined on behalf of the Opposite Parties:

1. Sri.R.S.Arasu, Deputy Manager of the Opposite Party No.1 by way of affidavit.

List of documents filed by the Opposite Party:

1. Certified copy of the Initial Assessment Form, referring to the Manipal Hosptial.

       MEMBER                                                                      PRESIDENT