This Complaint coming up before us for hearing on 02-11-11 in the presence of Sri P. Phani Raju, advocate for the complainant and of Sri Ch. Narasimha Reddy, advocate for opposite party, upon perusing the material on record after hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao,  President:-

The complainant filed this complaint under section 12 of the Consumer Protection Act seeking Rs.1,56,790/- towards his critical illness claim; Rs.50,000/- towards mental agony and costs.

1. The averments of the complaint in brief are hereunder:

The complainant on 05-10-10 took Varishta mediclaim policy bearing No.550500/42/09/2500000145 from the opposite party for the period from 09-10-09 to 08-10-10.   The complainant paid Rs.16,649/- as premium for himself and his wife.   The complainant on 04-04-10 got operated for heart ailment in Star Hospitals, Hyderabad and was discharged on 12-04-10. The complainant made claim with the opposite party for Rs.1,52,785/- towards critical sum insured and submitted necessary papers.  The opposite party subsequently renewed the said policy by collecting premium.   The opposite party paid amount under medical sum insured in January, 2010 for the treatment taken in Care Hospitals, Hyderabad.   But the opposite party did not pay the amount claimed under critical sum insured.    The complainant got issued notice on 08-01-11 for which the opposite party on 16-02-11 sent cheque for Rs.26,962/- only.   The conduct of the opposite party amounted to deficiency of service.

3.      The contention of the in nutshell is hereunder:

        As per terms and conditions of the policy a complainant suffering from critical illness has to submit notice with full particulars within 15 days from the date of diagnosis.  But the complainant informed the same to the opposite party on 22-10-10.   The complaint is barred by limitation as per the terms and conditions of the policy.   The opposite party repudiated the policy on the limitation ground.   The opposite party did not commit any deficiency of service.    However the opposite party paid Rs.26,962/- on the good health policy limited and settled the claim of the complainant.   The liability of the opposite party will be limited to 20% for coronary artery surgery.   The complaint therefore be dismissed.

4.   Exs.A-1 to A-9 were marked on behalf of the complainant.   The opposite party though granted more than sufficient time did not argue the matter.   Hence judgment is pronounced on the material available.

5.  Now the points that arose for consideration in this complaint are:

1. Whether the opposite party committed deficiency of service?
2. Whether the complainant is entitled to claim compensation?
3. To what relief?

6.   Admitted facts in this case are these:

1.  The complainant took the subject policy from the                                opposite party (Ex.A-1).

                2.  The opposite party paid premium of Rs.16,649/-

                        (Ex.A-2).

                3.  The policy under Ex.A-1 covered the claims of the                               complainant and his wife (Ex.A-3).

                4.  The opposite party sent cheque for Rs.26,962/- along                          with covering letter (Ex.A-9).

7.    POINT No.1:-   The opposite party in para 6 of its version mentioned that it repudiated the policy on the limitation ground as the complainant failed to submit the claim forms in time as per terms and conditions of the policy.  Ex.A-9 is the covering letter sent by M/s Good Health Plan Limited along with cheque for Rs.26,962/-.   Nowhere in Ex.A-9 the opposite party mentioned that it repudiated the critical illness claim of the opposite party for not submitting relevant papers in time. 

8.   Along with its version the opposite party filed the letter dated 20-12-10 addressed by the complainant to it, letter dated 27-12-10 addressed by M/s Good Health Plan Limited to it, repudiation letter dated 25-10-10 by the Medical Officer and terms and conditions of the said policy.   The repudiation is not by the opposite party but by its third party agency i..e, M/s Good Health Plan Limited.   In Ex.A-9 letter it was mentioned “please find enclosed payment towards full and final settlement for the treatment of the National Insurance Company Limited”.   Nothing prevented either the opposite party or M/s Good Health Plan Limited to mention the reasons for payment of Rs.26,962/- only.  The letters dated 27-12-10 and 25-10-10 filed by the opposite party along with its version were not referred to in Ex.A-9. 

9.   10.2 Section 2 of the terms and conditions of the policy says that notice with full particulars shall be sent to the company within 15 days from the date of diagnosis of the disease upon detection of any critical illness.   In this case the complainant was diagnosed as suffering from “CAD.DVD, NSTEMI, Good LV function, HTN, Bronchial Asthma, S/P TURF, and was operated “CABG X3 Grafts (LIMA -> LAD, AO -> SVG-> Ramus & AO -> SVG-> Distal LCX (Sequential) on beating heart.   Target artery stabilization was achieved by using octopus IV TSS.   Patient tolerated the procedure well and shifted to CTICU in stable hemodynamic status and ventilated electively”  as seen from Ex.A-6.   It can therefore be said that the complainant suffered from critical illness.      

10.      The contention of the complainant is that the opposite party cannot sit upon the aspect of delay having considered part of the claim.  Ex.A-9 revealed that the opposite party sent cheque for Rs.26,962/- for the treatment taken in M/s Star Hospital, Hyderabad.    Since the opposite party paid part of the claim it is not open to it to bank upon the aspect of delay as rightly contended by the complainant.   The opposite party cannot approbate and reprobate.  The above conduct of the opposite party in our considered view amounted to deficiency of service.  The contention of the opposite party is that the complainant, if at all is entitled to 20% for coronary artery surgery.   The same does not hold water that the compensation for coronary artery surgery will be limited to 20% of the sum assured under this section and it is in addition to the compensation, if any available under section 1 above.    Under those circumstances, we opine that the opposite party has to pay Rs.1,52,785/- as per Ex.A-5 bill issued by M/s Star Hospitals, Hyderabad.   We therefore answer this point against the opposite party.

11.   POINT N.2:-    The complainant claimed compensation of Rs.50,000/- for the delay in settling the claim.  The complaint was silent when he submitted claim to the opposite party.   The complainant also relied on the letter dated 20-12-10 filed by the opposite party along with its version.  It is the complainant who made the claim at a belated stage.   Therefore the claim of the complainant for damages of Rs.50,000/- is not justified.   In view of the conduct of the complainant awarding Rs.5,000/- towards damages will meet ends of justice.   We therefore answer this point accordingly.

12.   POINT No.3:-   In view of above findings, in the result the complaint is allowed partly as indicated below:

1.  The opposite party is directed to pay Rs.1,25,823/- (Rupees one lakh twenty five thousand eight hundred and twenty three only) together with interest @9% p.a., from the date of complaint till payment.

        2.   The opposite party is directed to pay Rs.5,000/- (Rupees five               thousand only) towards mental agony and Rs.1,000/-                     (Rupees one thousand only) towards costs to the                             complainant.

        3.  The amounts ordered above shall be paid within a period of                  six weeks from the date of receipt of the copy of the order.

Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 8^th day of November, 2011.

MEMBER                                  MEMBER                        PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite party:   NIL

PRESIDENT