DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD

Dated this the 28^th day of May 2019

Present: Smt.Shiny.P.R. President

               : Sri.V.P.Anantha Narayanan, Member                  Date of filing: 12/10/2018

                                                              (CC.No.127/2018)            

1. E.T.Venugopal,                                                      

    (S/o.late P.A.Menon)

    “Prabha” Convent Road,

     Thottakkara Post,

     Ottapalam – 679102,

     Palakkad Dist.                                                             -     Complainants

2.  Prabha Venugopal,

    (D/o.late K.Raman Nair)

    “Prabha” Convent Road,

     Thottakkara Post,

     Ottapalam – 679102,

     Palakkad Dist.

    (By party in Person only)     

Vs 

1. The Manager,                                                                   

    Oriental Insurance Company Ltd.,

    Kingsway Buildings(First Floor),

    Mavoor Road Junction,

    Kozhikode, Kerala – 673 001.

2. The Manager,

    Punjab National Bank,

    Post Box No.9,                                                                 -       Opposite Parties

    Palakkad Road,

    Ottapalam – 679 101.

    (By Adv.K.Krishnakumar)

3. The Manager,

    Oriental Insurance Company Ltd.,

    3^rd Floor, Builtech Foundations,

    Chittoor Road, Palakkad – 678 013.

    (By Adv.A.R.V.Sankar for Opposite parties 1 & 3)

O R D E R

By Smt. Shiny.P.R,  President.

Brief facts of complaint.

1^st Complainant had taken a PNB Oriental Royal Medicalim policy on            25-09-2015 from the 1^st and 3^rd opposite parties through the 2^nd opposite party. The above medicalim policy was further renewed on 25-09-2016, 25-09-2017 and       25-09-2018 without any break. 2^nd complainant was also insured in the above mediclaim policy. On 29-05-2018 a knee replacement surgery was done to the 2^nd  complainant at Divine medical Centre, Wadakkanchery. 1^st complainant submitted that he had informed about the above said surgery to the 1^st and 3^rd opposite parties on 20-05-2018 through e-mail. They had spend an amount of Rs.1,69,096/- for the surgery and all the bills along with discharge summery were sent to the 1^st opposite party. But the opposite parties rejected the claim on 04-07-2018 for the reason that the arthritis related complaints were excluded for first three years under exclusion clause of the policy. Then they approached Ombudsman for the redressal of his grievances, but no reply. Hence the complaint. Complainant submitted that repudiation of mediclaim is illegal and the reason given by the opposite parties is unjustified and devoid of any merit. They are making unlawful enrichments. Complainant further submitted that a privilege must to given to the senior citizens. Complainant prays for an order directing opposite parties to pay an amount of Rs.1,69,096/- and 12% interest thereupon from 31-05-2018 till realization along with cost of proceedings.

Complaint was admitted and notices were issued to opposite parties. Opposite parties entered appearance and filed their separate version contending the following:-

1^st and 3^rd opposite parties contended that the complainant was having an Oriental Royal Mediclaim policy No.441003/482018/2221 valid from 25.09.2017 to 24.09.2018 and the sum insured was Rs.5 lakhs (floater based).  Before completing the prescribed period of 3 years 2^nd complainant had undergone knee replacement surgery for left leg for osteoporosis and osteoarthritis.  As per Exclusion Clause 4.3(xxii) of the policy expenses on treatment for joint replacement due to degenerative conditions are not payable for 3 years.  Hence the claim was repudiated by the 1^st and 3^rd opposite parties by their letter dated 08.08.2018 with liberty to approach the higher forums if necessary. Then the complainants approached Ombudsman but without waiting for the reply of Ombudsman they approached this Forum for getting the hospital expenses.  The original policy taken by them was on 25.09.2015 for the year 2015-2016 which was renewed on 2016-2017 and further renewed from 25.09.2017 to 24.09.2018.  As per the terms of the policy the risk coverage is after 3 years from the inception of the policy for the specified illness mentioned in 4.3(xxii).  But on 28.05.2018 he came with a claim of his wife.   As per the policy conditions no privilege is given to senior citizens and old people.  As per clause No.4.3(xxiii) of the policy expenses on treatment for joint replacement due to degenerative processes or conditions not payable for 1^st three years. The duty of the company is only to honor genuine claims and not on concessions basis.  The complainant is aware of the fact that the surgery conducted to her was before 3 years.  There was hardly 4 month’s deficit to get the benefit of the policy.  So there was no deficiency of service on the part of these opposite parties.    Hence complaint has to be dismissed with cost of these opposite parties.

 2^nd opposite party contended that this opposite party is not a necessary party in the above complaint.  This opposite party is unnecessarily dragged to court, which has resulted in loss and injury to this opposite party.  This opposite party is not the ‘insurer’ and was never responsible for the consideration and disposal of any mediclaim.  This opposite party and the oriental insurance company Ltd. have entered into an insurance scheme effective from 30.11.2014 to provide medical insurance for its employee and persons having any type of accounts at this opposite party’s Bank branched under the name – PNB Royal Mediclaim policy.  For this purpose a corporate agreement was entered into between this opposite party and the above said insurance company.  This agreement clearly specifies that on remitting the premium, this opposite party Bank’s responsibility under the agreement would be over and that the bank will not be responsible for settlement of claim or any other liability relating to the policy.  It is also stated therein that for all or any of the liabilities the insurer ie. the insurance company alone is liable to the insured.  This opposite party only acted as a collection centre of the premium and the bank customers enjoyed the privilege of lesser premium amount, while compared with direct health insurance policies. Hence complaint is to dismissed with the cost of this opposite party.  

Complainant filed chief affidavit and documents. Complainant was cross examined as PW1 and documents were marked as Exts. A1 to A19. Ext. A 20 marked with objection.  Opposite  parties 1 and 3 filed chief affidavits and documents which were marked as Exts. B1 to B8.  2^nd opposite party also filed chief affidavit.

The following are the issues that arises for consideration.

1. Whether there is any deficiency in service from the part of opposite parties? 
2. If so, what are the reliefs and cost? 

Issues 1 & 2

We have perused the affidavits and documents filed by both parties. Opposite parties admitted that complainant had taken Oriental Royal Medi claim policy from the opposite parties 1 and 3 on 25.09.2015 which was further renewed from time to time till 25-09-2018. Complainant submitted that his wife Prabha Venugopal was under gone knee replacement surgery on 29-05-2018 and all the bills of Rs.1,69,096/-  along with discharge summery were sent to the 1^st opposite party through e.mail but the opposite party repudiated claim. Opposite parties contended that the surgery was conducted on 29-05-2018. As per the terms and conditions of the policy the insured can claim for reimbursement only after three years from the date of first policy. As per clause No.4.3(xxiii) of the policy expenses on treatment for joint replacement due to degenerative processes or conditions not payable for 1^st three years.  Complainant had taken the policy on 25-09-2015. So the coverage would be started from 25-09-2018. In the present case the surgery of knee replacement was conducted on 29-05-2018 ie, four months before attaining 36 months. In order to get the insurance coverage he had to wait for four months as per the terms and conditions of the policy. On the perusal of Ext.B1 policy Exclusion clause 4 (1) and (2) xxii and xiii it is revealed that expenses incurred for knee replacement surgery if contracted/manifested after inception of policy are not payable during the waiting period of 36 months. Complainant deposed in cross examination that the surgery was conducted within three years from the date of first policy. In the complaint complainant pleaded that a privilege must be given to the senior citizens. While cross examination complainant deposed that t]mfnkn {]Imcw ko\nbÀ knänkWn\v Fs´¦nepw I¬kj³ D­v F¶v tcJs¸Sp¯nbn«nÃ.  I¬kj³ In«nbm \¶mbncp¶p F¶mWv Fsâ s{]bÀ. In United India Insurance Co.Ltd vs M/S.Harchand Rai Chandan Lal  IV CPJ 2004 15 Hon’ble SC held that  the terms of the policy have to be construed as it is and we cannot add or subtract nothing.  Hon’ble National Commission held in National Insurance Co.Ltd Vs Aparna Kahar that insurance claim can only be allowed within terms and conditions of policy (2014 NCJ 850(NC). Under the above discussions we are of the view that opposite parties 1 and 3 rightly repudiated claim. 2^nd opposite party is an unnecessary part to the complaint. Hence  we cannot attribute deficiency in service on the part of  opposite parties. In  the result complaint is dismissed.

Pronounced in the open court on this the 28^th day of May 2019.         

                                                                                                                        Sd/-

                  Shiny.P.R.

                   President            

Sd/-     

    V.P.Anantha Narayanan

                   Member

Appendix

Exhibits marked on the side of complainant

Ext.A1  - PNB Oriental Royal Mediclaim policy schedule No.441003/48/2016/1919

Ext.A2  - PNB Oriental Royal Mediclaim policy schedule No.441003/48/2017/2037

Ext.A3  - PNB Oriental Royal Mediclaim policy schedule No.441003/48/2018/2221

Ext.A4  - PNB Oriental Royal Mediclaim policy schedule No.441003/48/2019/1845

Ext.A5 – E-mail sent to opposite party dated 20/05/2018 by complainant.(with objection)

Ext.A6– Reply of E-mail to complainant by opposite party dated 21/05/2018(with objection)

Ext.A7– E-mail sent to opposite party dated 23/05/2018 by complainant.(with objection)

Ext.A8 – Reply of E-mail to 1^st complainant by opposite party dated 21/5/2018

                (with objection)

Ext.A9 – Letter dated 2/6/2018

Ext.A10 – Letter dated 5/6/2018

Ext.A11 – Letter dated 4/7/18 by 1^st opposite party to complainant.

Ext.A12 - Letter dated 11/7/18 by 1^st opposite party to complainant.

Ext.A13 – Letter dated 7/7/18 to Grievance Department by complainant.

Ext.A14 – Grievance Department letter dated 08/08/2018 to the complainant.

Ext.A15 – Letter dated 4/9/18 to Insurance Ombudsman by complainant.

Ext.A16 - Insurance Ombudsman’s office letter dated 20/9/2018.

Ext.A17 – Circular No.CIR/011/3/IRDA/Health/SN/09-10 dated 25/5/2009.

Ext.A18 – Gazette extra ordinary (Part III – Sec.4) insurance regulatory and development

                    authority notification dated 16/2/2013.

Ext.A19 – Discharge Summary of Max Care Hospital.

Ext.A20 – List of pre and post surgery expenses(with objection)

Exhibits marked on the side of Opposite parties

Ext.B1  - Copy of policy

Ext.B2  - Discharge Summary of Max Care Hospital.

Ext.B3 – Letter dated 25/06/2018 to complainant by 1^st opposite party.

Ext.B4 - Letter dated 04/07/2018 to complainant by 1^st opposite party.

Ext.B5 - Letter dated 11/07/2018 to complainant by 1^st opposite party.

Ext.B6 - Letter dated 08/08/2018 to complainant.

Ext.B7 - Letter dated 02/06/2018 to complainant.

Ext.B8 – Photo copy of agreement between Punjab National Bank and Oriental Insurance

 Company Ltd. dated 19/06/2015(7 pages)

Witness examined on the side of complainant

PW1 – E.T.Venugopal

Witness examined on the side of opposite parties

Nil

Cost :