By. Sri. Chandran Alachery, Member:
The complaint is filed U/s 12 of the Consumer Protection Act 1986 for an Order directing the opposite parties to pay to the complainant Rs.20,086/- as the balance amount of his claim with an interest at the rate of 12% per annum from the date of hospitalization to till the date of payment and for compensation of Rs.4,000/- and cost of the proceedings.
2. Complainant's case in brief is as follows:- The case of the complainant is that, he took a medical Insurance policy from the 1st opposite party in the year 2008 and it was renewing on every year in order to cover the risk of medical expenses which may occur in future. The last renewed policy had valid coverage from 11.02.2011 to 10.12.2012. On 13th October 2011, the complainant was admitted for treatment in the MIMS Hospital, Kozhikode due to Bilateral Direct Inguinal Hernia and a surgery was suggested for him. On 14.10.2011, the surgery was done from the Hospital and the complainant was discharged on 16.10.2011. As per policy conditions, the complainant informed the 2nd opposite party about Hospitalization on 13.10.2011 and a claim case was lodged vide No.CCN-1916253. The complainant incurred Rs.32,586/- towards Hospital rent, medicine and treatments. When the complainant submitted claim form, the complainant received a letter dated 14.11.2011 from 2nd opposite party requesting him to submit his Bank Account details to transfer the claim amount. As per the request, the complainant sent his Account details and a canceled cheque to the 2nd opposite party. Later, the complainant received a cheque for an amount of Rs.12,500/- from the 2nd
opposite party in December 2011, even though the claim of the complainant was for the whole medical expenses amounting to Rs.32,586/-. Aggrieved by this the complainant filed this complaint for the redressal of his grievances.
3. On receipt of complaint, Notices were issued to the opposite parties and the opposite party No.1 appeared before the Forum and filed version. But opposite party No.2 not appeared before the Forum and is set Ex-parte on 25.02.2012. Thereafter the complainant filed proof affidavit and he is examined as PW1 and Exts.A1 to A8 is marked. The opposite party No.1 also filed proof affidavit and examined as OPW1 and marked Ext.B1 document. On perusing the evidence and documents of both parties, the Forum raised the following points for consideration:-
1. Whether there is any deficiency in service on the part of the opposite parties?
2. Relief and Cost.
4. Point No.1:- Ext.A1 series are the Policy Certificates. Ext.A2 is the Prospectus issued by the opposite parties. Ext.A3 is the Discharge Bill and Ext.A4 is the Discharge Summary. Ext.A5 is the Notice regarding the document required to the Insurance company (NEFT DETAILS REQUIREMENT) and Ext.A6 series 2 in numbers are the Premium Receipts and Ext.A7 series is also Premium Receipts. Ext.A8 is the prospectus issued by the Insurance company under Gold Policy. The case of the complainant is that he is entitled for the full amount of Rs.32,586/- as medical reimbursement. He received only Rs.12,500/-, So he should get the balance amount of Rs.20,000/- from the opposite party No.1. Moreover, the complainant rely on Ext.A8, the prospectus of Medi-claim Policy Gold. In Ext.A8, for Hernia, the reimbursement limit is restricted to 15% of the Sum insured or Maximum of Rs.30,000/-. The opposite party No.1 produced a document and is marked as Ext.B1. According to opposite party No.1, as per clause 1:2 of schedule of Ext.B1 policy, the liability is only Rs.12,500/- that is 25% of sum insured. So the complainant is entitled for reimbursement only for Rs.12,500/-. The opposite party already paid the amount to the complainant. Here on analyzing the evidence, the Forum found that the opposite party No.1 admits Ext.A2 and Ext.A8 prospectus issued by them to the complainant.
The opposite party No.1 in cross examination admitted that Ext.B1 is an incomplete document. Ext.A1 is a part of Ext.B1, but that is missing in Ext.B1 produced by the opposite party No.1. So the Forum found that Ext.B1 cannot be relied upon in deciding the quantum of medical reimbursement, Nothing prevented the opposite party No.1 to produce sufficient documents to prove their claim. But that is not done in this case. Ext.A1 is the Medical Insurance Policy having coverage from 11.02.2011 to 10.12.2012. The surgery was done on 14.10.2011 within the period of coverage. Ext.A8 is the prospectus of Ext.A1 policy ie Health Insurance Policy Gold in which it is stated that for Hernia decease the company will entertain the claim at the rate of 15% of the sum insured or a maximum of Rs.30,000/-, but opposite party says that the conditions of the Ext.A8 is already changed and the conditions of the policy is changing periodically. In this case the inception of the policy starts in the year 2008 at that time the Ext.A8 was supplied to the complainant, and thereafter the complainant renewing the policy continuously. When it was renewed in the year 2011 also only Ext.A1 is given to the complainant and not supplied the original of Ext.B1. Hence, the complainant is under the impression that the policy condition could not be changed at all. Any way the opposite party
No.1 supplied the Ext.A8 and it contains no period or expiry date. In the circumstances any policy holder renewed the policy under the impression that the policy conditions are not changed, cannot be ignored, unless and until an estoppal is published by the opposite party. In this case, the opposite party have not produced the estoppal and not adduced any evidence to show that the Ext.A8 is for a fixed periods. Hence the opposite party No.1 shows Ext.A8 to the complainant and enrolled him in that policy in the conditions as stated in Ext.A8. In cross examination of OPW1, OPW1 deposed that “Gold policy conditions Cu t]mfnkn¡v _m[IamWv F¶mWv AXnsâ AÀ°w, Gold Policy prospectus BWv Fs¶ ImWn¨Xv, marked as Ext.A8”. The opposite party No.1 produced Ext.B1, the document which they relied on in fixing the amount of medical reimbursement. In the document list it is shown that Ext.B1 document is a copy. On perusal, it is seen that it is only a copy, but not a certified copy. The opposite party No.1 in his cross examination admitted that Ext.B1 is not a complete one. Therefore, the Forum cannot rely in Ext.B1. In the circumstances, this Forum found that there is deficiency of service from the part of opposite parties in allowing the medical reimbursement to the complainant. The Point No.1 is found accordingly.
5. Point No.2:- Since the Point No.1 is found in favor of the complainant, the complainant is entitled to get the reimbursement of Rs.17,500/- being the balance amount calculated at the rate of 15% of the sum insured or a maximum of Rs.30,000/- as per Ext.A8 document. Here the opposite party already paid Rs.12,500/- as medical reimbursement, the balance amount is Rs.17,500/-. The Point No.2 is decided accordingly.
In the result the complaint is partly allowed and the opposite parties are directed to pay Rs.17,500/- (Rupees Seventeen Thousand and Five Hundred) only as balance amount of medical reimbursement and Rs.1,500/- (Rupees One Thousand and Five Hundred) only as compensation and Rs.1000/- (Rupees One Thousand) only as cost of the proceedings. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order. Thereafter the complainant entitled for an interest @ 12% per annum from the opposite parties till payment.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 14th day of February 2014.
Date of Filing:11.01.2012.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. T. P. Aliyas. Complainant.
Witness for the Opposite Parties:
OPW1. Sajeevan. Manager, United India Insurance Company.
Exhibits for the complainant:
A1(Series). Copy of Policy Documents.
A2. Prospectus.
A3(Series). Copy of Discharge Bills.
A4. Copy of Discharge Summary.
A5. Copy of Notice. Dt:14.11.2011.
A6(Series). Premium Receipts (2Nos).
A7 (Series). Premium Receipts (2 Nos).
A8. Prospectus of Insurance Policy.
Exhibits for the opposite Parties:
B1. Individual Health Insurance Policy Document (Duplicate).
Sd/-
PRESIDENT, CDRF, WAYANAD.
