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.30,000/- being the balance amount of treatment expenses along with Rs.25,000/- as compensation and Rs.5,000/- as cost of the proceedings.
2. Brief of the complaint:- The complainant took a mediclaim policy from the 1st opposite party through agent. At the time of joining the policy, the agent promised the complainant that the complainant and other three members of his family will get treatment expenses upto one lakh in case of any admission and treatment in a hospital. The agent also promised that if treatment is taken f rom Wayanad, the bill amount must be send t o the company and the company will pay the amount and in case of treatment from Baby Memorial or MIMS, the complainant need not pay any amount but the company will directly pay the amount. The wife of complainant got severe headache and on 19.11.2013 she was admitted in MIMS Hospital, Calicut and taken treatment. This was informed to the agent and agent told the complainant to remit the amount since the TPA of 1st opposite party changed. The complainant then remitted Rs.1,52,437/- towards hospital expenses. Thereafter, claim is given to the company through agent. The 1st opposite party gave only Rs.70,000/- towards Hospital Bill. On 07.12.2013, the wife of complainant is again admitted in MIMS and a sum of Rs.1,12,185/- is remitted towards hospital expenses. The 2nd claim is not considered by 1st opposite party at all since the 2nd treatment is within 45 days of the 1st treatment. Aggrieved by this the complaint is made.
3. On receipt of complaint, notices were issued to opposite parties and notices were served to opposite parties. 1st opposite party appeared before the Forum and filed version. Even though the notice of 2nd opposite party is served on 30.06.2014, the 2nd opposite party did not appear before the Forum and hence the 2nd opposite party is set ex-parte.
4. In the version of 1st opposite party, they stated that the complainant had joined Individual Health Policy for a sum of Rs.1,00,000/-. In which his family members are also included as stated. The period of policy is 15.08.2013 to 14.08.2014. As per Clause 3.0 of the policy, the occurrence of illness after a lapse of 45 days will be considered as a fresh illness for the purpose of the policy. Since the earlier claim for the treatment date from 19.04.2013 to 29.04.2013, was settled for the maximum amount of Rs.70,000/- being 70% of the sum insured and the subsequent treatment availed within 45 days, this opposite party cannot settle the claim for the treatment availed from 07.12.2013. This opposite party already discharged the contractual obligation with the complainant and there is no deficiency of service from the part of opposite party.
5. On going through the complaint, version, and document, the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and Cost.
6. Point No.1:- The complainant filed proof affidavit and is examined as PW1 and Ext.A1 to Ext.A4 is marked. The opposite party is also filed affidavit and opposite party is examined OPW1 and Ext.B1 to Ext.B5 is marked. Ext.A1 is the policy schedule given to the complainant by opposite party which did not contain policy conditions. In Ext.A1 document it is written as "Terms, conditions and clauses attached as per the respective individual Schemes". Even if it is written likewise, the policy conditions was not attached to the Ext.A1 document. The specific allegation of the complainant is that he do not know what are the policy conditions and opposite parties No.1 and 2 did not send him the policy certificate which contains terms and conditions. On perusal the Forum found that there is no document produced by opposite parties to prove that policy terms and conditions were served to complainant or send to the complainant during the policy period of 15.08.2013 to 14.08.2014. The case of the complainant is that the sum assured is one lakh and only 70% of sum assured is given to him by the opposite parties. There is specific rule to the effect that the liability of Insurance Company is limited to only 70% of the sum assured. And more over, if second treatment comes within 45 days of first treatment, the company is not liable to pay any expenses towards second treatment. But here the claim of complainant is only to the extent of 30% of the balance amount of the 1st policy. As per clause 1.2 of the policy, the company is liable to pay only the actual expenses incurred or 70% of the sum assured which ever is less. But opposite parties are failed to inform this aspect to the complainant either orally or by sending the policy conditions to the complainant. The Forum is of the opinion that non-sending and non-disclosing the policy conditions to the complainant is a deficiency of service from the part of opposite parties. The Point No.1 is found accordingly.
7. Point No.2:- Since the 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 Rs.30,000/- (Rupees Thirty Thousand Only) to the complainant as compensation to the deficiency of service from the part of opposite parties and also directed to pay Rs.2,000/- (Rupees Two Thousand Only) as cost of the proceedings. The opposite party shall comply the Order within 30 days from the date of receipt of this order, failing which the complainant is entitled to get 12% interest for the whole sum thereafter.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 30th day of January 2015.
Date of Filing:24.06.2014.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. George. Complainant.
PW2. Reji. Insurance Agent.
Witness for the Opposite Parties:
OPW1. Naveen Palliyal. Manager, United India Insurance Company
Limited, Branch Kalpetta.
Exhibits for the complainant:
A1. Policy Schedule.
A2. Bill payment details.
A3. Additional Information Request Form. dt:17.12.2013.
A4. Mediclaim Repudiation Letter. dt:30.05.2014.
Exhibits for the opposite Parties.
B1. Individual Health Insurance Policy.
B2. Health Insurance Policy Claim Form. dt:05.12.2013.
B3. Medical Certificate/Attending Doctor's Certificate.
B4. Discharge Summary.
B5. Claim Process.
Sd/-
PRESIDENT, CDRF, WAYANAD.
