By Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite parties to pay Rs.3,00,000/- to the Complainant as covered under the policy taken by the Complainant from Opposite Parties, to pay One Lakh as compensation and cost of the proceedings.
2. Complaint in brief:- The Complainant's husband later Babu Mathew had insured his family under Family Health Optima New Policy with Opposite Party's Company wide policy No. P/181314/01/2014/002333 for the policy period from 06.09.2013 to 05.09.2014. The total sum assured was Rs.3,00,000/-. Due to abdominal pain, the Complainant's husband was initially treated at Amrutha Hospital Ernakulam and all original Bills are produced to Opposite Parties after discharge along with claim application. After that the Complainant's husband was admitted Baby Memorial Hospital at Kozhikode on 18.05.2014. On diagnosis, Cirrhosis of liver portal HTN(L) upper limp cellulite was found and an amount of Rs.1,80,000/- had been spent for treatment. Later the Complainant's husband had expired on 31.05.2014. The Complainant approached the Opposite parties with all original bills and claim application was submitted. But it was repudiated by the Opposite Parties stating that the death was caused due to the use of intoxication of drug/alcohol which was not covered under policy. But no such medical records to show the cause. The Complainant send lawyer notice to Opposite Parties on 01.08.2014 but there was no reply. The Opposite Parties are deliberately repudiated the claim and the act of Opposite Parties are deficiency of service from their part. Aggrieved by this, the complaint is filed.
3. On receipt of complaint, notices were issued to Opposite parties and Opposite parties appeared before the Forum and filed version. In the version of Opposite Parties, the Opposite Parties contended that they have not repudiated the claim numbers 6039, 34692 and 2642. Hence there is no deficiency of service. The Complainant had accepted a sum of Rs.42,000/- as full and final settlement towards claim and no objection had raisen by the Complainant. The cheque for Rs.42,000/- was accepted by Complainant on 13.09.2014 for the period 09.04.2014 to 17.04.2014 admission and treatment. Family Health Optima policy was taken for the period 06.09.2013 to 05.09.2014. The Complainant intimated three claims such as 34692, 6039, 2642 to the Opposite parties. The Complainant had submitted the original bills and documents is claim No.6039 and the same is settled as full and final settlement. The Opposite Parties deny the admission alleged by the complainant on 18.05.2014 at BMH. There was intimation for claim 34692, but has not submitted original documents and bill to prove the admission at BMH. The expenses was alleged as Rs.1,80,000/-. In lawyer notices, only claim 6039 is stated. But no notice or claim form with bills and documents are submitted by the Complainant with regard to the claim No.34692 and claim No.2642. The Opposite Party had send letter dated 08.09.2015 to the Complainant asking for production of the discharge summary. But the Complainant not replied and produced discharge summary. Hence the claim is repudiated. The same was intimated to the Complainant on 01.02.2016. There is no deficiency of service from the Part of Opposite parties.
4. On perusal of complaint, version and documents, the Forum raised the following points for considerations.
1. Whether there is deficiency of service from the part of Opposite Parties?
2. Relief and cost.
5. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents are marked as Exts.A1 to A9. The Opposite Parties are also filed proof affidavit and is examined as OPW1 and Opposite Party's documents are marked as Exts.B1 to B5. Ext.A1 is the copy of policy schedule, Ext.A2 is the copy of customer identity card, Ext.A3 is the copy of lawyer notice, Ext.A4 is the postal receipts, Ext.A5 series are the A/D cards, Ext.A6 is the copy of claim form, Ext.A7 is the copy of calculation of medical bills, Ext.A8 also is the copy of calculation of medical bills, Ext.A9 series are the postal receipts and Acknowledgment card. Ext.B1 is the authorisation letter, Ext.B2 is the copy of policy schedule and terms and conditions, Ext.B3 is the copy of claim form. Ext.B4 is the copy of letter send to the Complainant by the Opposite Parties, Ext.B5 is the copy of repudiation letter. Admittedly, the Complainant's husband Babu Mathew had policy with Opposite parties named Family Health Optima Insurance Policy having validity period from 06.09.2013 to 05.09.2014. The case of Complaint is that the Complainant's husband had treated at AIMS Cochi and BMH at Calicut and submitted claims forms with Medical Bills. The Opposite Parties admitted that there are three claims which are numbered as 34692, 6039 and 2642. On 28.08.2014, claim No.6039 for the admission in AIMS is settled and Rs.42,000/- is paid to the Complainant. The Opposite Parties send notice to the Complainant asking her to produce relevant records ie Discharge Summary for entertaining the claims in 34692 and 2642 for admission at Baby Memorial Hospital, Calicut on 27.05.2014. That notice is marked as Ext.B4. On perusal of Ext.B4, it is seen that the notice is send on 08.09.2015 ie after one year of claim. Admittedly, there are three claims and one claim is already settled. As per Ext.B5 repudiation letter, the Opposite Parties stated that as per condition 4 of the policy, non-submission of additional documents is a violation of policy. Hence the claim is repudiated. According to the Forum, there is no justification for the delay in sending a notice by the Opposite Parties to the Complainant's husband after one year of receipt of claim. There is no dispute regarding the validity of policy during admission and treatment. Now all discharge summary and treatment records from Baby Memorial Hospital are produced before the Forum. Claim forms with relevant medical bills are already there with Opposite Party with respect to the admission and treatment at Baby Memorial Hospital, Calicut. Under humanitarian consideration especially when the policy holder is no more, the Opposite party should consider the claims after obtaining the relevent hospital records from the Forum. In a ruling reported in CPR September 2016 Part a Page 27 the Hon'ble NCDRC ruled that inordinate delay in repudiation of insurance claim does not speak well of conduct of Insurance Company. On an over all evaluation of the case, the Forum found that the there is deficiency of service from the side of Opposite Parties is dealing the matter. Point No.1 is found accordingly.
6. Point No.2:- Since point No.1 is found in favour of Complainant, the Complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the Opposite Parties are directed to pay the treatment Expenses as per claim No.34692 and 2642 for the admission and treatment of Late Babu Mathew at Baby Memorial Hospital by considering the Medical Bills and Hospital records. The Opposite Parties are at liberty to obtain the Hospital records from the Forum after proper endorsement. The Opposite Parties are also directed to pay Rs.3,000/- (Rupees Three thousand) only as compensation and Rs.2,000/- (Rupees Two thousand) only as cost of the proceedings. The Opposite Parties shall comply the order within 30 days from the date of receipt of this order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and
pronounced in the Open Forum on this the 14th day of December 2016.
Date of Filing:19.01.2016.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
Nil.
Witness for the Opposite Parties:
OPW1. Manu Mohan. Executive, Claims, Star Health,
Thiruvananthapuram.
Exhibits for the complainant:
A1. Copy of Family Health Optima Insurance Policy – Schedule.
A2. Copy of Customer Identity Card.
A3. Copy of Letter. dt:01.08.2014.
A4(1). Copy of Postal Receipt. dt:05.08.2014.
A4(1). Copy of Postal Receipt. dt:05.08.2014.
A5(1). Acknowledgment.
A5(2) Acknowledgment.
A6. Copy of Medical Certificate to be filled in by Treating Doctor.
A7. Copy of Calculation of Medical Bills.
A8. Copy of Calculation of Medical Bills.
A9(1) Postal Receipt. dt:20.08.2015.
A9(2) Acknowledgment
Exhibits for the opposite Parties:
B1. Authorisation Letter. dt:20.04.2016.
B2. Copy of Family Health Optima Insurance Policy – Schedule.
B2(a). Family Health Optima Insurance Plan.
B3(4 Pages) Copy of Claim form for Medical Insurance.
B4. Copy of Letter. dt:08.09.2015.
B5. Copy of Letter. dt:01.02.2016
