DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 15th day of May 2017
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 09/04/2015
: Sri.V.P.Anantha Narayanan, Member
(C.C.No.50/2015)
J.Suresh alias Sureshkumar
S/o.Mani Embrathiri,
Ramanilayam,
Cherpulassery Post,
Ottapalam Taluk,
Palakkad. - Complainant
(Adv.P.Jayan)
V/s
The Manager
United India Insurance Co.Ltd.
IInd Floor, Parappurath Tower,
Main Road, Ottapalam – 679 101
Palakkad - Opposite party
(By Adv.A.Raji Vijayasankar)
O R D E R
By Smt.Suma.K.P. Member
The complainant in this case had taken a family Medicare policy from the opposite party as policy No.101203/48/14/06/00000460 on 9/7/2014 and is valid from 9/7/2014 till 8/7/2015. As per the terms of the policy the complainant and his family had a valid insurance coverage for all the ailments and accidents when undergone treatment under hospitalization for more than 24 hours. On 23/9/2014 the complainant was admitted at Perinthalmanna Moulana Hospital for treatment of bilateral inguinal Hernia. The doctors intimated that surgery is necessary since his ailment was severe. He was treated in the hospital till 25/9/2014 when the complainant intimated the opposite party about the treatment and the expenses. The opposite party informed that the discharge bill will be settled directly. But as promised, the opposite party did not settle the bills and accordingly the complainant contacted the office and they informed to pay the hospital bill directly and the expenses will be reimbursed after submitting the bills before the opposite party’s office. Accordingly complainant paid an amount of Rs.46,402.45/- paise as hospital charges and submitted the bills before opposite party for reimbursement. The opposite party has credited an amount of Rs.15,000/- towards the complainant’s account. The complainant alleges that the opposite party had not acted as per the terms of the policy and as promised and did not pay the entire amount spent for treatment. Again the complainant submitted an application before opposite party alongwith hospital bills and discharge summary and applied for the balance amount of Rs.31,402/-. But the opposite party had refused to pay the amount stating flimsy reasons. On 22/12/2014 complainant caused a lawyer notice to the opposite party stating to pay the balance amount but the opposite party refused to pay the balance amount or to sent a reply to the said notice. The complainant alleges that the opposite party is liable to pay the entire amount spent for treatment as per the terms of the policy. The denial of balance amount amounts to deficiency of service on the part of the opposite party. Hence he had approached before this Forum seeking an order to direct the opposite party to pay the balance amount of Rs.31,402/- which was spent by him for the treatment alongwith compensation of Rs.1 lakh for the mental agony suffered alongwith the cost of this litigation.
Notice was issued to the opposite party for appearance. Opposite party remained absent inspite of accepting notice hence he was called absent and set exparte.
Complainant filed chief affidavit alongwith documents. Ext.A1 to A5 was marked from the part of the complainant. Opposite party filed application as IA NO.246/15 to set aside the exparte order and another application as IA No.247/2015 to reopen the evidence. The application was heard and IA was allowed on cost of payment of Rs.500/- to complainant.
Opposite party filed version after payment of cost.
The opposite party contended that the complaint is not maintainable and there is no deficiency of service on their part. The risk involved in the coverage of policy was for the period 9/7/2014 to 8/7/2015 and the claim was for the treatment undergone by him on 23/9/2014. The present policy obtained by him was without disclosing the existing illness. The present policy is a different policy issued to him and also to his family members with limited coverage for each illness. As per the present policy to get coverage for inguinal hernia, is two years waiting period has to be observed. The claim was satisfied and obtained full and final settlement receipt. The remedy open to the complainant was to approach the higher authorities because this is not a claim which comes under deficiency of service.
The insured first policy was for Rs.1 lakh as sum insured. This policy expired on 8/7/2014. Then he took a policy for Rs.2 lakhs covering the entire family under the sum insured. The claim on these policies relating to same ailment like hernia and it has got a waiting period of two years. In the latter policy the insured made a claim. Since the claimant has policy coverage of Rs.1 lakh in the previous year this waiting period would not have applied to the extent of Rs.1 lakh in the present policy of Rs.2 lakhs. So his claim was honoured to the extent of Rs.1 lakh and as per the clause in the policy the hernia limit of Rs.15,000/- was paid. So the balance claim above 15,000/- is not payable. In the new policy the waiting period for inguinal hernia is two years. Since he was having old policy for the limit of Rs.15,000/- for hernia, by applying provisions in the individual policy taking the old policy limit, the maximum amount of Rs.15,000/- was given and receipt was obtained. The benefits for the enhanced limit are not admissible as per the policy conditions. The insured / complainant was fully satisfied at the time of passing the claim and accepted it under the policy by signing full and final settlement. Hence the present complaint is not acceptable. In order to file a petition he should have prove contractual violation and deficiency of service. Here the claim was satisfied. There is no condition in policy to pay the entire expenses for the family members of him to the full extent as contended by him. The rest of the allegations alleged in the complaint was denied by the opposite party. As soon as the opposite party receive the notice, the matter was informed to him immediately and this fact is noted in the receipt itself at the time of effecting the payment. The amount paid by the opposite party was as per the terms of the policy. There is no deficiency of service and he is not entitled to get Rs.1 lakh for the mental agony. Hence the complaint has to be dismissed with cost.
Complainant and opposite party filed their respective chief affidavit. The matter was referred to mediation for settlement. But it was not settled.
Complainant was cross examined as PW1. Ext.B1 to B3 was marked from the part of opposite party and Ext.B4 was marked with objection. Complainant also filed application seeking permission to cross examine the opposite party. Since no specific reason was made out for cross examination the forum directed the complainant to file interrogatories. Accordingly complainant filed interrogatories and opposite party filed answers for the same.
Evidence was closed ad matter was heard.
The following issues are considered in this case are.
1.Whether there is any deficiency in service from the side of opposite party ?
2.If so, what are the reliefs entitled to the complainant ?
Issues 1 & 2
We have perused documents as well as affidavit filed before the Forum. The complainant has stated that he is claiming the amount as per Ext.A3 which was also marked as Ext.B2(family health medicare policy). The opposite party alleges that as per Ext.B2 the limit for the treatment of hernia is Rs.15,000/- to Rs.30,000/- rupees. Ext.B3 is the claim form submitted by the complainant before the opposite party. In Ext.B3 there is medical certificate attached which was filled by the doctor in which it is stated that in col.6 the patient was suffering from the illness since 3 months. The opposite party alleges that as per Ext.B2 there is a waiting period of two years for the existing illness and the complainant is not eligible for the claim as per Ext.B2. The claim paid towards the complainant was under Ext.B1 policy(individual health insurance policy). So as to prefer the claim under the family medicare (Ext.A3) policy the complainant had to wait for two years from the date of the policy. However the opposite party has honored the claim of the complainant to the extent of Rs.1 lakh as per the clause of the previous policy. But the previous policy ends on 9/7/2014 and as a continuation the policy under Ext.B2 commences from 9/7/2014 onwards. Hence insurance company cannot wash off their liability since they had entertained his claim during the period of the Ext.B2 policy. As per the clause Ext.B2 policy, the maximum limit by which the complainant is eligible is Rs.30,000/-. Since the opposite party has entertained his claim during the period in which Ext.B2 was in force, they are bound to compensate the complainant as per the clause in Ext.B2 and the maximum amount that can be granted to the complainant is Rs.30,000/-. The opposite party ought to have paid the maximum limit at the time of settling the claim itself. Without doing so, they had committed deficiency of service on their part. From the above discussions, we are of the view that the case of the complainant is to be allowed.
Hence the complaint is allowed in part and we direct the opposite party to pay the balance amount of Rs.15,000/- (Rupees Fifteen thousand only) to the complainant with interest @ 9% interest per annum from 25/9/2014 onwards. We also direct the opposite parties to pay Rs.5,000/-(Rupees Five thousand only) as compensation towards mental agony suffered by him alongwith Rs.2,000/-(Rupees Two thousand only) as cost of this proceedings.
The aforesaid amount shall be paid within one month from the date of receipt of this order, failing which complainant is entitled to realize 9% interest per annum for the whole amount from the date of order, till realization.
Pronounced in the open court on this the 15th day of May 2017.
Sd/-
Shiny.P.R.
President
Sd/-
Suma.K.P.
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 – Photocopy of discharge card issued by Moulana Hospital & Scanning Centre,
Perinthalmanna
Ext.A2 – Photocopy of discharge bill dated 25/9/14 issued by Moulana Hospital
Perinthalmanna
Ext.A3 – Copy of Family medicare policy insurance policy in the name of J Suresh
from 9/7/14 to 8/7/15
Ext.A4 - Copy of individual health insurance policy in the name of J Suresh from
9/7/13 to 8/7/14
Ext.A5 series – Advocate notice dated 22/12/14 alongwith postal receipt and
acknowledgment card.
Witness examined on the side of complainant
PW1 – Sureshkumar
Exhibits marked on the side of Opposite parties
Ext.B1 – Copy of individual insurance policy in the name of J.Suresh from 9/7/13 to
8/7/14
Ext.B2 – Copy of family medicare policy in the name of J Suresh from 9/7/14 to
8/7/15
Ext.B3 – Claim Form
Ext.B4 – Settlement advise memo (with objection)
Witness examined on the side of opposite party
Nil
Cost Rs.2,000/- allowed as cost
