IN THE KODAGU DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MADIKERI

ORDER DELIVERED BY HON’BLE MEMBER

SMT. GOWRAMMANNI

1. This complaint filed under section 35 of Consumer Protection Act, 2019 The Complaint Prays the following relief against the opposite party:-

1. Pay 3,00,000/- for Mediclaim Reimbursement, 50,000/towards mental and physical agony and Pay Rs.2,000/- for cost of the proceedings and such other relief as the Court deems fit in the interest of justice and equity.

2.  Brief facts of the complaint of the complainant is as under;

1. The complainant aunty Vinitha Joyappa during her lifetime she had taken health insurance policy from 2nd Opposite party under No.141136/01/2024/000327 27/09/2023 valid from 28/09/2023 to 27/09/2024 and she was eligible for health insurance upto 3,00,000/- and nominated the complainant as her nominee in the said policy. Vinitha Joyappa suffered left prominal fracture and she was admitted on 03/11/2023 for which she underwent operation at DRM Hospital Mysore on 08/11/2023 and she was discharged from the said hospital on 13/11/2023 and hospital bills were cleared complainants aunts passed away on 15/12/2023 due to other health issues. Thereafter the opposite party have rejected the claim of the complainant on the ground she was suffering from free existing decease (Cold agglutinin). Further the complainant alleged in their complaint that Opposite parties initially promised approval but later on refused to reimburse the claim of the complainant. Complainant alleged in their complaint that the opposite party had given flimsy reason for rejecting the rightful claim of the complainant and hereby deprived the claim of the complainant. The Opposite party committed a deficiency of service in this regard complainant has been put to lot of financial hardship, mental agony and physical agony due to the negligence attitude of the opposite party. Hence this complaint.
2. After registration of the complaint, notice was issued to opposite party. In response to the notice, Opposite parties appeared through their counsel and filed their version.

3.  Brief Facts of the Version filed by the Opposite parties:-

1.  The averments made in the complainant are hereby denied. Except those that are admitted hereunder and the complainant is put to strict proof thereof. The complainant is not maintainable either in law or on fact and is liable to be dismissed in limline.

2. On perusal of claim documents from the Hospital records and discharge summary dated 13/11/2023 states that the insured is a known case of Cold agglutinin Hence query was raised to submit the required documents related to the said decease vide letter dated 07/12/2023 subsequently reminder was sent on 22/12/2023. In spite of several intimation the insured had failed to submit the above said documents. Hence The claim was rejected due to non submission of documents and the same was communicated to the insured vide letter dated 13/12/2023.

3. The opposite party further took a contention in their version it is settled law that terms of the policy shall given the contract between the parties they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy. That without prejudice to whatever has been stated earlier in this written statement even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance issued the claimant. It is respectfully submit that maximum quantum of liability under the terms of the policy.

4. There is no cause of action for the complaint. The various relief sough for at Rs.3,00,000/- towards hospitalization expense and other charges are not payable as per the policy terms and the same is not payable by the opposite parties. Further claim towards mental agony, harassment, stress and inconvenience caused to the complainant highly exaggerated and without any basis. There is no deficiency of service on the part of the opposite party hence it is prayed that the complaint may be dismissed with costs.

5. In this case complainant filed her examination-in- chief by way of affidavit evidence as CW-1 with 05 documents marked as exhibits C-1 to C-5. And The Opposite party has filed their examination-in-chief by way of affidavit evidence taken as RW-1. Complainant filed their written arguments and also addressed the oral arguments. Heard the Oral Arguments of the respondent and posted for orders.

6. The points that would arise for our consideration are as under;

1. Whether the complainant proves the deficiency in service by the opposite parties and thereby they are entitled for the reliefs sought ?
2. What order ?

7. Our findings on the above points are as under;

1. Point No.1 :-Affirmative
2. Point No.2:- As per the final order for         
   13031.  

R E A S O N S

1. Point No.1:-  In this case 1^st Opposite party is the registered and corporate office of Star Health And Allied Insurance Company. 2^nd OP is the Branch office of the 1^st Opposite party. There is no dispute with regard to insurance policy opposite parties were admitted the facts of the complaint. One Vinutha Joyappa who is the complainant aunty during her lifetime she took health insurance policy from 2^nd Opposite party on 27/09/2023 The said polcy was valid from 28/09/2023 to 27/09/2024. The said policy cover upto 3,00,000/-.
2. In this case complainant alleged that the opposite party without sufficient cause and reason reject the claim of the complainant on the ground that she was suffering from pre existing decease Cold agglutinin. Perused the contents of the affidavit evidence and documents produced by the complainant we carefully observed those documents Vinutha Joyappa suffered Left Proximal Fracture and she was admitted on 03/11/2023 for which she underwent operation at DRM Hospital, Mysuru On 08/11/2023 and Discharged from the said Hospital on 13/11/2023. Complainant produced the all medical expense bills, discharge summary before the commission.
3. In this case the said policy holder nominated the  complainant as a nominee in the said policy and Vinutha Joyappa was passed away on 15/12/2023 due to other health issues. The main dispute arose in this case whether Opposite party have given flimsy reason for rejecting the rightful claim of the complainant?
4. The opposite party admitted the facts of the complaint there is no dispute with regard to the policy and they admitted that insured raised request for cashless treatment for the diagnosis. On receipt of request made by the insured initially Rs.60,000/- was approved later on scrutiny of documents further evaluation was required hence cashless claim was rejected and withdrawn and same was communicated to the insured. Further OP took a specific contention that on perusal of claim documents from the hospital records and discharge summary stated that the insured is a known case of (Cold agglutinin). Hence query was raised to submit the required documents related to the said decease in spite of several intimation to the insured but they have failed to submit the above said documents. Hence the claim was rejected due to Non Submission of documents. There is no deficiency of Service on the part of Opposite Party. The various reliefs sought for Rs.3,00,000/- towards Hospitalization expenses and other charges are not payable as per the policy terms.
5. In this case complainant counsel vehemently argued that the opposite party have given flimsy reason for rejecting the rightful claim of the complainant. Further they argued that complainant father had sent E-mail on 19/01/2024 and registered letter on 10/01/2024 requesting to settle the claim. But his request was not considered and the opposite party have failed to settle the claim and whatever documents which was in the possession of Vinutha Joyappa she has handed over to the said documents to the Star Health Insurance Representative of One Officer by name Mr.Nithin who wrongfully assured that her claim of Rs.3,10,000/- will be settled soon. But they never made any sincere effort to settle the claim amount. Without sufficient ground opposite parties have repudiated the claim of the complainant and avoid to deprive the complainant rightful claim. In support of their arguments they cited,

Anitha Gupta V/s HDFC Standard LIC Co., Ltd., Decided in CC No.696/2018 Before the Hon’ble National Commission, New Delhi.

6. Herein the above case question for consideration before us is whether the opposite party committed the deficiency to provide service to the complainant. Section 2(II) of the Consumer Protection Act, 2019 define “Deficiency” means  any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained by or under any law for the time being in force or has been undertaken to  be performed by a person in pursuance of a contract or otherwise in relation to any service and includes-

1. Any act of negligence or omission or commission by such person which causes lose or injury to the consumer; and
2. Deliberate withholding of relevant information by such person to the consumer.            

The consumer protection act came into being in order to protect the Interest of consumers who are affected by the acts of the service providers who in order to attract the consumers tend to make attractive offers but when it comes to actually providing the offered service they take a step back.

7. In the present case the deceased assured was suffered left proximal fracture which he underwent operation. Due to other health issues she was passed away on 15/12/2023. But opposite party denied the claim of the complainant for the reason insured was suffering free existing decease and she suppressed the matter with regard to the deceased. The opposite party they never established the evidence and the contention of that Cold agglutinin the burden of proving the said facts which was shifted to the opposite party but there was no evidence led before the commission. Hence the contention taken by the opposite party does not hold by the commission.
8. Retraining to the facts of the present complaint it is clear that the complainant aunty Vinutha Joyappa has availed the service of the opposite party by purchasing said insurance policy thereafter demise of the complainant aunty the complainant approached the OP for sum assured. However the same was rejected by the opposite party at the First Initially they promised to reimburse the mediclaim bills expenses thereafter they were tried to evade the claim and escape their liability without Genuine grounds. In their version also indirectly they admitted to resolve the claim but they never made sincere effort to settle the matter. The act of the opposite party is Highly negligent and irresponsible. The complainant being the Nominee of the Deceased Vinutha Joyappa there was no doubdt and she produced the All sufficient documents to prove her case she is entitled the assured amount of Rs.3,00,000/- from the opposite parties. The 2^nd Opposite party is the branch agent of the 1^st Opposite party after the registration of the complaint also they never made any sincere effort to settle the claim amount. For the aforesaid facts and circumstances of the case opposite party they cannot escape from their liability hence we opined that complainant is entitled Policy sum assured amount of Rs.3,00,000/- along with 10,000/- for Deficiency of Service and 3,000/- for cost of the proceedings from the Opposite parties. Hence we answer Point No.1 in Affirmative.

9.  Point No.2:- From the discussion made above and conclusion  arrived at, we pass the following order;

O R D E R

1. The complaint of the complainant under section 35 of Consumer Protection Act 2019 is allowed.
2. The Opposite Party No.1 & 2 are jointly or severally is liable to pay the Policy No. 141136/01/2024/000327 sum assured of Rs.3,00,000/-(Three Lakh Rupees) to Complainant from the date of 15/12/2023 at the rate of 6% per annum and directed to comply the aforesaid order within 45 days from the date of receipt of this order.  Failing which opposite parties are directed to pay interest at 12% per annum with said amount till the realization of this order.
3. The Opposite Party No.1 & 2 Jointly or Severally is further liable to pay the compensation of Rs.10,000/-  (Rupees Ten Thousand only) towards  deficiency in service, and Rs.3,000/- (Rupees Three thousand only) towards cost of proceedings.
4. Copy of this order as per statutory requirements be forwarded to the parties free of cost and file shall be consigned to record room.

 (Dictated to the Stenographer, transcribed, corrected and pronounced in the open Commission on this 08^th DAY OF AUGUST, 2024)

                (GOWRAMMANNI)                      (RENUKAMBA.C)                                                     

                      MEMBER                             PRESIDENT(I/C)                      

Witnesses examined on behalf of the complainant

CW-1-  Miss.Saakshi Vivek, D/o Vivek Joyappa, aged 21 Years, badaga Banangala Village.

Documents marked on behalf of the complainant

Ex.C-1 : Certificate of Insurance (Original)

Ex.C-2:  Medical Bill (Xerox)

Ex.C-3 : Reply Letter received to the complainant Account( Xerox Copy)

Ex.C-4:- Discharge Summary (Original)

 Ex.C-5:-Death Certificate of Vinitha Joyappa

Witnesses examined on behalf of the opposite party

          RW-1-  C.M.Bopanna, aged 42 Years, S/o Machaiah, Branch Manager, Star Health  

                        & allied insurance company, Madikeri

Documents marked on behalf of the opposite party:  NIL

(GOWRAMMANNI)

Dated: 08/08/2024                                     MEMBER