THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C. 432/2012
Dated this the 14th day of February 2017
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
Present: Beena Joseph, Member:
This petition was filed on 09.10.12. The above complaint was filed against the illegal repudiation of the Medi claim Insurance.
The complainant’s husband P.Raju joined a Medi claim policy of the opposite parties which numbered as P/181300/01/2012/002053 this was a family health plan for Rs.2 lakh. As per the policy complainant and her family covered by the insurance. The petitioner is the wife of Mr.Raju who met with an accident on 20.06.2012. And she was admitted at National Hospital, Calicut. On examination it is found that her left hand sustained a fracture to radius so the hospital authority conducted a surgery to her left hand and she was discharged on 23.06.2012. Complainant incurred a total expense of Rs.24,315/- at the time of discharge. Complainant also purchased medicines worth Rs.34,852/-. The complainant intimated the claim to the opposite party through toll free number within 24 hours of hospitalization. Then he was asked to reveal policy numbers etc. the complainant subsequently filed claim statement in the prescribed form to the opposite party on 09.07.2012, along with all the documents. But thereafter no response from the opposite parties. Complainant herein issued a lawyer notice to the opposite parties. There after opposite parties issued a letter stating that her claim was repudiated due to the non compliance of condition No.3 of the terms and conditions contained in document number 4. Rejecting a valid claim made by complainant on a frivolous ground is against the principles and amounts to deficiency in service. Thus complainant sustained substantial mental agony, financial difficulties and pain. So the opposite parties are liable to compensate the complainant by paying the full amount of expense incurred by her. Thus opposite parties are liable to pay Rs.59,167/- towards hospital expense and to pay Rs.10,000/- towards mental agony and to pay Rs.10,000/- towards cost of the proceedings. The non compliance of condition No.3 of contract is not material and time was not essence of the contract. But the opposite parties treated it as a material condition. The automatic rejection of the claim on the basis of delay is nothing but a case unequal bargaining leading to an unfair term in a standard form of contract. Therefore the above complaint is filed claiming Rs.79,167/-.
In this matter notice were issued to both parties, both of them appeared and filed version.
Opposite party filed version stating the following contentions. Opposite party admitted the existence of the policy and stated that it was valid up to 30.07.2012. The complainant was admitted on 20.06.2012 at National Hospital, Calicut for the treatment of closed fracture L/3 radius for which ORIF with DCP+K wire fixation was done and discharged on 23.06.2012. The opposite party admitted the incident, admission in hospital and discharge. Further they submitted that the intimation regarding hospitalization received by them only on 06.07.2012 after a lapse of 15 days from the date of occurrence. As per policy condition No.3 specifically states that, upon happening of any event which may give rise to a claim under this policy, notice with full particulars shall be send to the company within 24 hours from the date of occurrence of the event. This is a condition precedent to admission of liability under the policy. The opposite party has been denied an opportunity to satisfy whether the person who underwent treatment is the same person who is covered under the policy. Since the complainant had not intimated the hospitalization in time, that is within the 24 hours from the date of admission in the hospital, the claim falls outside the scope of the coverage.
The opposite party herein admitted that the complainant submitted claim form with medical certificate discharge summary bills and lab reports but it was rejected by the opposite party due to the non compliance of condition No.3 and it was informed to the complainant on 06.08.2012.
Complainant herein has availed claim benefits thrice in various hospitalizations, so she is aware of the procedure of intimation. The liability under the insurance policy is subject to the terms and conditions, exclusion and definition. It is a settled Law that the terms of policy have to be construed as it is the court cannot add or substract something beyond the policy terms and conditions. The opposite party herein, dealing with the public money and functioning under the guidelines of IRDA controlled by govt. of India. So the company must abundant caution in dealing with the claims by all conditions correctly. The opposite party has not caused any mental agony or sufferings to the petitioner hence he is not entitled to get any prayer in the petition. Opposite party has not committed any deficiency of service or unfair trade practice as alleged. Hence petition is liable to be dismissed.
In this matter complainant filed chief affidavit and examined as PW1and Exts. A1 to A8 marked. Ext.A1 is the policy. Ext.A2 is the medical bills copy and discharge summary. Ext.A3 is the total amount and copy of bills submitted by complainant to opposite party. Ext.A4 is the terms and conditions of the policy. Ext.A5 is the claim form for medical insurance. Ext.A6 is the receipt of the claim documents which signed by the representative of the opposite party No.2. Ext.A7 is the Lawyer notice. Ext.A8 is the repudiation letter issued by opposite parties.
Opposite party filed affidavit and examined as RWI. Ext.B1 to B6 marked. Ext.B1 is the model of family health optima Insurance plan. Ext.B2 is the policy schedule. Ext.B3 is the copy of the claim form. Ext.B4 is the repudiation letter. Ext.B5 is the letter given by the complainant to the opposite party. Ext.B6 is the total bill amount submitted by the complainant to the Insurance Company.
On the basis of documents evidence and rival contentions of parties following issued are framed.
Points to be considered.
- Is there any service deficiency or illegal trade practice adopted by opposite party?
- Whether the repudiation of claim is proper or not?
- What are the reliefs?
This is the case against the repudiation of medical insurance by the opposite party. The petitioner herein is the wife of P.Raju who is the policy holder of star health and allied insurance Ltd as per the policy number P/181300/01/2012/002053 for the period of 31.07.11 to 30.07.12. The petitioner is the wife of policy holder and the policy covers insurer, his wife and two children. So petitioner is entitled for Policy benefits during the insurance period. Regarding this fact there was no dispute by the opposite parties. The petitioner herein met with an accident on 20.06.12 and she sustained fracture to radius so she was admitted in National hospital, Calicut on the same day. She underwent a surgery on her left hand. The hospital authorities conducted closed fracture radius surgery on her left hand. Thus the petitioner has paid Rs.24,315/- as hospital expenses in addition to that she had purchased medicines worth Rs.34,852/-.
In this matter petitioner’s son had given intimation to first opposite party through toll free number regarding the hospitalization of the insured on 21.06.2012. Later he had given detailed statement as on 09.07.12, even then the claim was repudiated by the opposite parties stating that, the claim was out of time as per clause No.3 & 4 of the policy condition. On verifying the records and evidence it is found that there was the only existing difference with respect to the intimation of hospitalization given by the parties. The petitioner says that she had intimated the hospitalization to the opposite parties by toll free number. As per the version of opposite parties and policy conditions the insured ought to have intimated the hospitalization within 24 hours of hospitalization.
Considering the rival contentions of the parties the only point to be considered is whether the hospitalization was intimated in time or not. The complainant stated in her petition that, she had intimated regarding the hospitalization to the opposite parties through the toll free number of the opposite parties. But there was no reply to this aspect by the opposite parties in their version or affidavit. While examining Respondents as RW1, she had admitted that the opposite party having a toll free number to register the hospitalization. So it can be presumed that intimation can be given through the toll free number.
In this matter specific case of complainant is that she had intimated the hospitalization through toll free number. This was not disputed by the respondents at any point of time, on the other hand opposite party had produced a letter alleged to be written by the complainant seeking excusing the delay of intimation of hospitalization which marked as Ext.B5, which objected by the petitioner. On verifying Ext.B5 with B6, it is found that B5 is not genuine. Because the handwriting, signature are different on both documents. So we cannot place reliance on Ext.B5. More over Ext.B5 is a copy of letter.
On the basis of the policy conditions there was a clause stating that hospitalization has to be intimated within 24 hours. Considering these conditions there was no whisper anywhere in the agreement that, time is the essence of the contract. If an ordinary man gets hospitalized, he will be running pillar to post in order to save the life of the injured. Then there will not be any preference to claim the insurance. The opposite parties herein did not dispute the identity of the insured hospitalization, injury and medical bills of the claim put forwarded by the complainant. Where in their version opposite party stated that they did not get any opportunity to satisfy or check whether the person who underwent the treatment is the same person, who is covered under the policy. The documents were admitted by the opposite parties, so it can be seen that the contentions in the version and documents are contradictory.
So we found that the repudiation of claim of the petitioner is illegal and unsustainable. Even then the claim lodged by the petitioner before the Insurance and the Forum are having wide difference. So we are not inclined to grand the entire claim of the petitioner. The actual claim of the petitioner before opposite party was Rs.34852/- only. In the result petition is allowed.
Therefore we direct the opposite parties to pay Rs.34852/- to the complainant and Rs.2500/- as cost of the proceedings. Comply the order within one month from the date of receipt of this order.
Dated this 14th day of February 2017.
Date of filing: 09.10.2012..
SD/- MEMBER SD/- PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1.Original premium certificate for the hospitalization benefit policy dtd.30.07.2011.
A2. Medical bills copy and discharge summary.
A3. Total amount and copy of bills submitted by complainant to opposite party (8 No. in series)
A4. The terms and conditions of the policy.
A5. Claim Form for medical insurance.
A6. Receipt of the claim documents which signed by the representative of the opposite party
No.2.
A7. The Lawyer notice.
A8. The repudiation letter issued by opposite parties.
Documents exhibited for the opposite party:
B1. Model of Family Health Optima Insurance plan.
B2. Family Health Optima Insurance policy- schedule.
B3. Copy of the claim Form
B4. Repudiation of Claim letter dtd.06.08.2012.
B5.Letter given by the complainant to the opposite party dtd.09.07.12.
B6. Total bill amount submitted by the complainant to the Insurance company.
Witness examined for the complainant:
PW1. Pushpalatha (Complainant)
Witness examined for the opposite party:
RW1. Mridula, Madathil meethal PO.Vengeri, Calicut-10.
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
