By: Sri. Mohamed Ismayil C.V., Member
The complaint is filed under section 35 of the Consumer Protection Act.
1. On 28/11/2018 the complainant availed an insurance policy of the opposite party and remitted Rs 3446.42/- as annual premium. The policy is titled as LIC’s Jeevan Arogya and the said policy coverage commenced on 28/11/2018 and will be ended on 28/11/2042. As per one of the terms and conditions of the policy the complainant has to remit premium every year to the opposite party for keeping the policy alive. At the time of availing policy, the agent of the opposite party assured that said policy covers expense incurred for hospitalised treatment during the period of policy coverage. The complainant paid premium till the opposite party arbitrarily cancelled the policy. On 05/06/2020. The complainant was paralysed, immediately taken to the Medical College Hospital, Kozhikode and undergone treatment up to 11/06/2020. The complainant was again approached to the hospital after fifteen days and continued to take medicine as advised by the doctors. According to the complainant, she spent Rs 15,716/- as medical bill for her treatment. So the complainant submitted a claim application before the opposite party. During the pendency of claim application, on 09/03/2021 she was again admitted to Aster Mims Hospital, Kottakkal and discharged on 11/03/2021. According to the complainant she, spent Rs 23,537/- for her treatment in the above said hospital. Even there after the complainant continued treatment at Sri Chitra Hospital and also incurred expenses of Rs 18,525/-. The complainant filed a complaint before the Insurance ombudsman and same was dismissed on 01/12/2021. Later the complainant preferred a claim before the opposite party to get the benefit of the insurance policy. But the claim of the complainant was repudiated on 27/07/2021 stating the reason of pre existing illness irrespective of prior medical treatment or advice. The complainant contented that she is entitled to get insurance benefit as per the terms and conditions of the insurance policy. The opposite party repudiated the claim arbitrarily and reason stated for repudiation is illegal, unfair and against the principles of natural justice. The act of opposite party caused gross deficiency in service as well as unfair trade practice. The complainant has suffered mental agony, hardship and pain due to the act of the opposite party. So the complainant approached this Commission to get a direction to the opposite party to pay Rs 57,778/- with interest at the rate of 12% per annum to the complainant from the date of claim till realisation. The complainant also prayed to get a direction to the opposite party to pay Rs 1,00,000/- to the complainant as compensation for the mental agony, hardship and pain suffered due to the act of opposite parties. The complainant claimed Rs 25,000/- as the cost of the proceedings.
2. The complaint is admitted on file is issued notice to the opposite party. The opposite party received notice along with copy of documents on 25/04/2022 and appeared before the Commission through counsel on 23/05/2022. Later the opposite party filed version on 11/08/2022 i.e. after the expiry of statutory period as per the provision of the Consumer Protection Act. So the Commission need not consider the contention raised by the opposite party in the version.
3. The complainant filed affidavit and produced documents. Ext A1 document is the original policy schedule subscribed by the complainant from the opposite party numbered as 316669286 dated 28/11/2018. Ext A2 (series) documents are the copies of documents submitted along with claim form. Ext A3 document is the original repudiation letter dated 27/07/2021 issued by the opposite party to the complainant. Ext A4 document is the order of insurance ombudsman dated 01/12/2021. Ext A5 series documents are the bills of showing the amount spent for the treatment of the complainant.
4. Heard the complainant in detail. Perused affidavit and documents produced by the complainant. The points arisen for the consideration of the Commission are:
- Weather the opposite party committed any kind of unfair trade practices or deficiency in service towards the complainant?
- If yes, relief and cost.
5. Point No. (1) and (2).
The case of the complainant is that she subscribed an insurance policy named LIC’s Jeevan Arogya from the opposite party. The duration of the policy commenced from 28/11/2018 and will be ended on 28/11/2042. The complainant produced Ext A1 document to prove the insurance coverage undertaken by the opposite party. According to the complainant the subscribed policy is a health insurance policy and it cover cash benefit for hospital treatment to the insured. Unfortunately the complainant was paralyzed due to stroke and undergone medical treatment in different hospitals. As per the evidence adduced by the complainant, she spent total of Rs 57,778/- for her treatment and the opposite party was liable to indemnify the expenses Incurred for her treatment as per the terms and conditions of the policy. The complainant produced medical bills for the Commission and marked as Ext A5 series documents. It has come out in the evidence that the complainant approached the insurance ombudsman for settlement of claim. The complainant produced the order of the insurance ombudsman and same is marked as Ext A4 document by the Commission. Later the complainant submitted claim application before the opposite party. But it was rejected by the opposite party and the complainant produced all document submitted along with the claim application before the Commission and same is marked as Ext A2 document. The repudiation letter was also submitted by the complainant and marked as Ext A3 document. According to the contention of the complainant the repudiation of the claim was arbitrary, illegal and unfair. The affidavits and all documents produced by the complainant proved the contention made in the complaint. There was no contra evidence in the case. The Commission finds that the opposite party has committed deficiency in service towards the complainant by rejecting the claim application of the complainant. So the Commission allows the complaint in the following manner:
- The opposite party is directed to pay Rs 57,778/- ( Rupees fifty-seven thousand seven hundred and seventy eight only) to the complainant as the reimbursement of the medical bill incurred for her treatment.
- The opposite party is directed to pay Rs 50,000/- as compensation for the deficiency in service committed towards the complainant. The opposite party also directed to pay Rs 10,000/- as the cost of the proceedings to the complainant.
The opposite party shall comply this order within one month from the date of receipt of this order otherwise the entire amount shall carry 9% of interest per annum from the date of order till realisation
Dated this 5th day of December , 2022.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A5
Ext.A1: Original policy schedule subscribed by the complainant from the opposite
party numbered as 316669286 dated 28/11/2018.
Ext.A2 (series): Copies of documents submitted along with claim form.
Ext A3: Original repudiation letter dated 27/07/2021 issued by the opposite party to the
complainant.
Ext A4: Order of insurance ombudsman dated 01/12/2021
Ext A5: Bills of showing the expenditure for the treatment of the complainant.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Nil
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
