Karnataka

Gadag

CC/49/2016

Sri Amaresh S/o Basavantappa Kannari - Complainant(s)

Versus

The General Manager, Appollo Munich Health Insurance Co Ltd., - Opp.Party(s)

M.SKaradagi

17 Jun 2017

ORDER

JUDGEMENT DELIVERED BY

SMT.C.H.SAMIUNNISA ABRAR, PRESIDENT:

The complainant has filed this Complaint against the Opposite Parties (herein after referred in short as OPs) u/s 12 of Consumer Protection Act, 1986.

 

2.    The brief fact of the case is that the Complainant purchased a Health Insurance Policy with Ops on 21.09.2013 under the name “EASY HEALTH INSURANE GROUP” and paid the installments premium to OP No.1, Policy Certificate was issued on 21.09.2013 under policy NO.140300/1201/2013/A003368/648 with customer I.D. No.F3265/53/S/26072014 and Member I.D. No.1000736758. The Complainant paid the second installments premium on 13.08.2014 of Rs.1,353.62 to the OP No.2. The said policy is valid from 26.07.2014 to 25.07.2015. The above said policy was insured both individually and family members also. As per the conditions, the Complainant has insured with both. The said policy is for accidental death coverage upto Rs.1,00,000/- also life risk coverage on illness and accidental injuries.

 

3.      Further Complainant submits that on 01.08.2014, the Complainant met with a road accident between Hubli-Koppal Road, near Haligundi village, Gadag District and the same has been informed to the concerned police. The FIR has been lodged under the Crime No.125/2014, immediately Complainant was shifted to Govt. Hospital, Gadag and Complainant took treatment 3 months in the said hospital and he has spent Rs.1,00,000/- for his treatment and Rs.50,000/- of future treatment.

 

4.      Further, the Complainant submits that after his treatment he had approached to OP No.1 through OP No.2 with a consent documents, but Ops have not heeded request of Complainant and go on postponing the same on one or the other pretext and Complainant has communicated and correspondent application claiming the said expense which was incurred to him, but Ops still today not shows interest and not paid the amount and made deficiency in service.

5.      Further, Complainant stated that Ops being   reputed Company they have not rendered proper service and by the illegal act of the Ops, Complainant had sustained mental and economical torture finally fed up with the unwanted act of Ops, Complainant got issued a legal notice on 08.07.2016 calling upon to pay the amount, but the notice of OP No.2 returned without any endorsement on 22.07.2016 and the legal notice of OP No.2 has not returned back till today. Hence, Complainant prayed to order for Rs.1,00,000/- along with interest and Rs.50,000/- towards future treatment and RS.20,000/- towards compensation and other relief that this Forum deems fit.

 

6.       The Forum registered a case and issued a notice to the OPs. After receipt of notice, OPs have appeared through their advocates and filed their respective Written Version.

The brief version of OP No.1 and 2 are as hereunder:

           Both the Ops have denied that averments made in the Complaint and further OP No.1 submits that the policy was admitted but the policy is subjected to terms and conditions of the Health Insurance Policy. Further submits that the Complainant had approached to him and submitted claim proposals along with some documents. After that on 24.03.2015 OP No.1 issued a quarry letter and as per mandatory documents like treating doctor certificate mentioning the date details of injuries, date and time, mode of injury, how it happened. But, the Complainant has failed to comply the same. Further, OP No.1 submits that 20.07.2015 the Complainant has wrote a letter to OP No.2 and submits that “his claim has been cancelled so he needed original documents which he has submitted in Gadag, Mulagund Circle Branch as soon as possible” and as per request of the Complainant all the documents were returned to the Complainant. The claim was rejected as all the original documents returned to the member (as letter submitted by the member to return the original documents) Hence, question of deficiency in service does not arises and pray to dismiss the case. On the other hand, OP No.2 denied all the contents of the Complainant and prayed to dismiss the Complaint with cost.    

 

          7.      The complainant has filed his Chief affidavit along with 30 documents which are marked as EX C1 to C27 in support of his case. The documents are as follows:

EX C1	Wound Certificate
EX C2	F.I.R. copy
EX C3	Complaint
EX C4	Charge Sheet,
EX C5	Mahajar,
EX C6	Policy Bond and premium receipt,
EX C7 to 23	Medical bills and receipts,
EX C24	Patient Discharge Card
EX C25	Certificate given by doctor,
EX C26	Letter given by Complainant to OP No.2,
EX C27	Legal Notice,
EX C28 and C29	Receipts.
EX C30	RPAD cover, notice and acknowledgement,

                                             

On the other hand, OP NO.1 and 2 filed chief affidavits.

8.      On the basis of above said pleading, oral and documentary evidence, the following points arises for adjudications are as follows:   

1.     2.	Whether the Complainant proves that OPs is made deficiency in service and unfair trade practice?   Whether the Complainant is entitled for the reliefs as sought?
3.	What Order?

 

Our Answer to the above points are:-

Point No.1 – Affirmative,

Point No.2 – Partly Affirmative,

Point No.3 – As per the final order.

                

R E A S O N S

     9.  POINT NO.1 and 2:  Since both the points are inter-link and identical, we proceed with both the points together.

 

     10.    From the above said pleadings, materials and contentions certain undisputed fact are to be noted, it is not in dispute that insured obtained policy marked as EX C6 and the said policy in question was valid from 26.07.2014 to 25.07.2015 and the Ops have received a premium from Complainant. The important point to take for discussion is that as per the pleading in a written version of OP No.1 is that he has made a quarry stating that to considered the claim proposal for Ops need documents such as, Certificate of treating doctor, details of injuries, dates, time, mode of injury and as per the OP No.1 Complainant has failed to furnish the same, hence the claim is rejected stated that as per all original documents returned to the member. Since fed up with attitude of Ops Complainant took back his all documents from the Ops. Such being the fact, as per the Ops will and wish we have to consider each document   as per the OP No.1 pleading they need the certificate of treating doctor which has been produced by the Complainant before the Forum i.e. EX C25. Moreover, the Complainant was treated in Government Hospital and another document i.e. they need the detail of injuries for that the Complainant had produced the Wound Certificate as EX C1 it reveals that the Dist. Hospital, Surgeon was treated him and other documents i.e. date and time. For that, the Complainant produced FIR and its enclosures like Charge Sheet and Mahajar Report to show the time and place of incident. As such, it is clear that the Complainant have all the document to show that the Complainant met with an accident and there is no ground to believe that he has not met with an accident and admitted in the Government Hospital and one more thing is that Complainant had filed all the receipts of the expenses incurred by him Rs.36,764/-. EX C18 which has been produced by the Complainant i.e. Receipt for Rs.8,081/-, but in this receipt the name of the patient has not been shown since this receipt is not considered. Such being the fact, OPs cannot refuse and escape from their responsible to pay the insured amount. Moreover, OP himself had admitted that if the above said documents is required to considered the claim form since Complainant as per the requirement of the Ops Complainant produced all the documents before the Forum. Hence, here we are in a view that Complainant is entitled for the partial relief sought by him. Since we answer Point No.1 in affirmative and Point No.2 in partly affirmative. 

11.   POINT NO.3:  For the reasons and discussion made above and finding on the above points, we proceed to pass following:  

//ORDER//

1. This Complaint is partly allowed with costs.
2. The OPs are directed to pay amount of Rs.36,764/- (Rupees thirty six thousand seven hundred and sixty four) towards the expenses incurred during the treatment of the Complainant along with interest at 9% p.a. from the date of filing this Complaint.

 

3. Further, OPs are directed to pay a compensation of Rs.5,000/- (Rupees five thousand) towards mental agony and Rs.1,000/- (Rupees one thousand) towards cost of litigation.

         

4. Further, OPs are directed to comply this Order within thirty days from the date of this Order, failing which OP has to pay interest at 12% p.a. on Rs.36,764/- from the date of order, till realization.

 

 

5. Send the copies of this Order to the parties free of cost.

 (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Court 17^th day of June, 2017)

 

 

Member

President