D.O.F:30/09/2023
D.O.O:27/03/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.293/2023
Dated this, the 27th day of March 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
Lathika Ramesh
Ambadi Acheri
Post - Kalanad,
Kasaragod Taluk and District.
(Adv: Jithesh Babu P.K.) : Complainant
And
The Divisional Manager,
Oriental Insurance Company,
Beauty Plazha, Balmatta Road,
Mangalore, Karnataka. 575001-KAR 01. : Opposite Party
ORDER
SMT.BEENA.K.G : MEMBER
The complainant is a policy holder under Oriental Insurance Company Ltd, having policy No. 422200/48/2023/1119. The above said policy covers the period in between 24/09/2022 to 23/09/2023. The above said Insurance Policy covers several benefits as mentioned specifically in the policy including several diseases. In the meanwhile, the complainant was hospitalized at Indira Hospital, Falneer, Mangalore and the disease was diagnosed as gastritis, fissure-in-ano for colonoscopy and other. The above disease is also covered by the said Insurance Policy which is admitted by opposite party. The complainant was hospitalized and was subjected to several medical checkup and was finally operated for the above said disease. The total expenses for the treatment has comes to a tune of Rs. 24,677/- of which a claim form for health insurance policy was submitted for Rs. 22,224/-. The claim form was submitted to the opposite party through the hospital authorities and the opposite party without any valid reason rejected the claim on the ground that, the complainant was hospitalized as an impatient for less than 24 hours. The allegation of the complainant is that, the rejection of the claim by opposite party was without any valid ground and the opposite party has violated policy conditions and thus refused the legal claim of the complainant. The attempt of the opposite party is to make unlawful gain at the expense of the complainant which is not permitted under law. Due to the rejection of the policy claim, the complainant has to arrange money for the medical bills from his friends and relatives, which has put her under great mental pain and agony. The complainant issued a lawyer’s notice dated 25/06/2023 calling upon the opposite party to accept the claim of the complainant and reimburse Rs. 22,224/- with 12% interest with an amount of Rs. 50,000/- as damages for mental agony and monitory loss due to unlawful rejection of claim. The denial of the claim amounts to gross negligence and service deficiency due to which the complainant suffered great mental agony and monitory loss.
Notice of opposite party served, but they remain absent. Name called absent, set exparte.
The complainant filed proof affidavit in lieu of chief examination. Ext. A1 to A3 marked. The main issued raised for consideration are;
- Whether there is any deficiency in service on the part of opposite party in rejecting the claim of the complainant?
- Whether the complainant is entitled for relief?
- If so, what is the relief?
The grievance of the complainant is that, he is a policy holder of opposite party and the policy covers in between 24/09/2022 to midnight 23/09/2023. Ext.A1 is produced to prove that he is a policy holder. The policy covers several benefits as mentioned in the policy form. In the meanwhile, the complainant was hospitalized for fissure-in-ano. After several checkup she was finally operated for the above said disease. The total expenses for the treatment was comes to a tune of RS. 24,677/- for which a claim was submitted. The claim form submitted to the opposite party through the hospital authorities was rejected on the ground that she was hospitalized as an inpatient for less than 24 hours. The allegation of the complainant is that, the opposite party has violated the policy conditions and repudiated the claim. The complainant caused to sent a registered lawyer notice dated 25/06/2023 calling upon the opposite party to accept the claim. The lawyer notice is produced and marked as Ext.A2. Ext.A3 is the postal acknowledgment of the notice. Even after receiving the notice also, the opposite party was not ready to settle the matter. Both parties are bound to obey the policy conditions. If the complainant is a policy holder and the treatment comes within the policy period, the opposite party is bound to allow the claim amount. In the absence of rebuttal evidence, the opposite party is liable to allow the claim of the complainant, as the disease is covered by the policy and the reason for the rejection is illegal. The complainant had paid the policy premium. Hence the complainant is entitled for the claim amount. The prayer of the complainant is Rs. 22,224/- with interest at 12% and an amount of Rs. 50,000/- towards damages. The complainant is entitled for cost of litigation also. Interest is not allowed as the date of treatment, date of rejection of claim are not mentioned.
In the result, complaint is partly allowed, directing the opposite party to pay the claim amount of Rs. 22,224/- (Rupees Twenty Two thousand Two hundred and Twenty Four only) with 9% interest from the date of complaint till realization and a compensation of Rs. 50,000/- (Rupees Fifty thousand only) along with a cost of Rs. 5,000/- (Rupees Five thousand only) to the complainant within 30 days from the date of receipt of copy of this order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 – Copy of the claim form
A2 – Copy of the lawyer notice
A3 – Postal acknowledgement
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
JJ/
