DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD Dated this the 31st day of March 2010.
Present : Smt. H. Seena, President Smt. Preetha.G. Nair, Member Smt Banumathi.A.K, Member C.C.No.97/2009
Venkatesh Perumal S/o. Late. P. Sankara Subramaniam Proprietor M/s. P. Sankara Subramaniam Cycle Dealers G B Road Palakkad - Complainant (Adv. V.J. Vince) V/s
1. The Manager United India Insurance Co Ltd Branch Office Surya Complex T B Road Palakkad (Adv.A R V Sankar) 2. The Manager M/s. Medsave Health Care (TPA) Ltd 2nd Floore, Central Arcade Azad Road, Kaloor Kochi – 682 017. - Opposite parties
O R D E R Order by Smt. Seena.H, President
Case of complainant in brief:
Complainant has taken an individual health insurance policy vide policy No.101201/48/08/97/00000261 issued by the 1st opposite party. The period of insurance run from 23/04/2008 to 22/04/2009. As per the policy, complainants wife is also an insured. Complainant's wife was admitted in Ganga Hospital, Coimbatore on 30/10/2008 for treatment for umbilcal Hernia and fibroid uterus. She was discharged on 10/11/2008. Complainant spent an amount of Rs.85,724/- as treatment expenses. A claim was lodged - 2 - before the 2nd opposite party as per the advice of the 1st opposite party for the said amount. The 2nd opposite party vide letter dated 27/01/2009 informed the complainant that the claim is settled for Rs.21,680/-. According to the complainant, opposite parties has derived at the said amount without considering entire facts and circumstances . As per the policy conditions, complainant is entitled for Rs.80,000/-. The cheque for Rs.21,680/- was received by the complainant under protest. Hence complaint is filed claiming the balance amount of Rs.58,320/- along with compensation for deficiency in service.
Contentions raised by the opposite parties are as follows:-
2nd opposite party was set ex-parte. 1st opposite party filed version. 1st opposite party admits the policy. According to 1st opposite party as per condition No.12 in the policy, expenses in respect of hernia is restricted to 15% of the sum insured and for hysterectomy it is restricted to 20% of the sum insured ie, Rs.15,000/- and Rs.20,000/- respectively. If the expenses incurred exceeds Rs. One lakh, then the maximum amount payable is Rs.30,000/- in case of Hernia and Rs.50,000/- in case of hysterectomy. 1st opposite party contented that in this particular case operation was conducted simultaneously for the above stated diseases. Since both the above complications are repaired surgically through common procedure company applied 20% of Cap. By applying the same, company's liability is restricted to Rs.20,000/-. But the company has paid Rs.1680/- more towards pre & post hospitalization expenses. Claim is settled as per the terms and conditions of the policy and hence there is no deficiency in service on the part of opposite parties.
The evidence adduced consists of proof affidavits of both parties. Exhibit A1 to A3 marked on the side of complainant and Exhibit B1 series and Exhibit B2 marked on the side of 1st opposite party.
Issues for consideration are: Whether there is any deficiency in service on the part of opposite parties? If so, what is the reliefs and costs?
- 3 -
Issues 1 & 2 The undisputed facts of the complaint are that the complainant availed a policy issued by the opposite parties, that surgery was conducted for hernia and hysterectomy and that a sum of Rs.21,680/- was received by the complainant towards the claim amount.
The main contention of 1st opposite party is that since surgery for the two problems was rectified by a single operation, 1st opposite party by applying the maximum liability clause has issued Rs.20,000/- i.e, 20% of the sum insured. Pre & Post hospitalization charges to the tune of Rs.1680/- was also paid. Policy is marked as Exhibit B1. As per Exhibit B1, claim restriction for hernia is 15% of the sum insured or maximum Rs.30,000/-, and for hysterectomy 20% of the sum insured or maximum Rs.50,000/- It is no where stated in Exhibit B1 that if surgery is conducted for the two diseases by a common procedure, companies liability is limited to 20 % of cap. So the contention of 1st opposite party that the company is liable to pay only Rs.20,000/- is not substantiated by any documentary evidence.
Further learned counsel for the opposite party argued for the position that the claim restriction to 15% of the sum insured or maximum Rs.30,000/- means that if the amount exceeds Rs.1 Lakh amount payable is Rs.30,000/- similarly 20% of the sum insured or maximum Rs.50,000/- means that if the amount exceeds Rs.1 Lakh sum payable is Rs.50,000/- Here the amount spent by the complainant being less than Rs.1 Lakh, complainant is only entitled to 20% of the sum insured ie, Rs.20,000/-. All these contentions also do not find a place in Exhibit B1. According to our view, 15% of the sum insured or maximum Rs.30,000/- for hernia means that complainant is entitled to maximum amount of Rs.30,000/- producing the bills pertaining to the treatment. Similarly 20% of sum insured or maximum Rs.50,000/- means that the complainant is entitled to a maximum of Rs.50,000/- producing evidence of expenses incurred. Here complainant has produced documents for Rs.85,000/- Document marked as Exhibit A1 So the insurance company is bound to release the balance claim amount. The act of opposite parties in not releasing the same amounts to deficiency in service. - 4 - In view of the above circumstances of the case, we are of the view that complaint be allowed.
In the result complaint allowed. 1st and 2nd opposite parties are jointly and severally directed to pay an amount of Rs.58,320/- being the balance clam amount together with Rs.10,000/- as compensation and Rs.1,000/- as cost of proceedings.
Pronounced in the open court on this the 31st day of March 2010. PRESIDENT (SD) MEMBER (SD) MEMBER (SD)
APPENDIX Witness examined on the side of Complainant Nil Witness examined on the side of Opposite party Nil Exhibits marked on the side of the complainant Ext. A1 – Copy of schedule of Health Insuarance Policy - Gold Ext. A2 – Deduction Memo of Medsave Helathcare (TPA) Ltd, Kochi
3. Ext. A3 series - Acknowledgement card and receipts of Post office and copy of Lawyer notice dated 4th April 2009. Exhibits marked on the side of the Opposite Party Ext. B1 series – Claim process sheet of United India Insurance Company Limited Ext. B2 – Duplicate copy of Individual Health Insurance Policy of United India Insurance
Company Limited. Forums Exhibits Nil Costs Allowed
| | HONORABLE Smt.Bhanumathi.A.K, Member | HONORABLE Smt.Seena.H, PRESIDENT | HONORABLE Smt.Preetha.G.Nair, Member | | 
