D.O.F:22/02/2022
D.O.O:02/09/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.39/2022
Dated this, the 02nd day of September 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT. BEENA. K.G : MEMBER
Joseph Danial, aged 49 years,
Kalikkal House,
Thannir Panthal,
Kanhirapoil – Post
Anandashram – Via : Complainant
(Adv: T.C Narayanan)
And
1. The Manager,
Bajaj Alliance Life Insurance Company Ltd,
City Centre, Bank Road, Kasaragod 671121.
(Adv: Vinod Bhattathiripad)
2. Bajaj Alliance Life Insurance Company Ltd,
2nd Floor, Bengacherry Complex, TB Road Junction,
Opposite Vyapara Bhavan, Kanhangad,
Kasaragod. 671315.
3. Bajaj Alliance Life Insurance Company Ltd,
2nd Floor, United Chambers, Sathy Road,
Ganapathy, Coimbatore, Tamilnadu. 641006. : Opposite Parties
4. The Health India TPA Services Pvt limited,
Neelkanath Corporate Park, 4th Floor, Kinol Road,
Vidya Vihar Society, Vidya Vihar Society West,
Mumbai. 400080.
ORDER
SRI. KRISHNAN.K : PRESIDENT
The complaint is filed under section 35 of consumer protection act 2019.
The case of the complainant is that he obtained an insurance policy from opposite party named Bajaj Alliance Family care Health policy by paying Rs. 10, 795/- on 28/12/2021. The period of the coverage is up to 28/12/2015. The complainant regularly renewed the policy. The sum insured of the policy is Rs. 2 lakh in the event of anyone in the policy is diagnosed of any disease and the event of hospitalization for 24 hours continuously, the hospital expense will be covered by the policy.
The complaint’s son Sharon Joseph was admitted in KMC Hospital Manglore on 14/07/2021 and discharged on 16/07/2021. The total bill charged is Rs. 69403. The complainant submitted all documents and bills to Opposite party for reimbursement of the amount. But Opposite party repudiated the claim the reason that Sharon Joseph admitted the hospital for only investigation purpose no treatment was done. The act of opposite party is deficiency in service and complainant claims compensation for Rs. I,00,000/-and hospital bills of Rs. 69403/- and cost of litigation.
The opposite party appeared and filed written version. The case of Opposite party is that Opposite party received the claim application upon receipt Opposite party processed the same in accordance with the terms and conditions of the policy. The Opposite party rejected the claim for the reason that Sharon Joseph taken treatment for Bilateral Ulnar Entrapment Neuropathy during scrutiny of claim file hospitalization is mainly of diagnostic and evaluation purpose and complainant is not entitled for the insurance benefit as per the terms of the policy.
Further states that contracts of insurance are contracts and once entered into the contract is binding both parties. There is no deficiency in service from opposite party and Opposite party acted upon the conditions of the policy and prayed to dismiss the complaint.
The complainant filed chief affidavit and cross examined as Pw1, Ext A1 to A5 documents marked from their side Ext A1 is policy, Ext A2 is certificate issued by doctor, Ext A3 discharge summary , Ext A4 lab records and Ext A5 is hospital bills Opposite party not adduced any evidence.
Following points arised for consideration in this case are:-
- Whether repudiation of the insurance benefit to the complainant is legally justifiable?
- Whether there is any deficiency in service from Opposite party?
- Whether Complainant entitled for compensation? If so for what reliefs?
All issues taken together for convenience. The case of the complainant is that he obtained Family Care health policy paying premium of Rs. 10795/- on 28/12/2012. He renewed the policy up to 27/12/2021 evidenced by Ext A1 policy. The policy coverage is Rs. 2,00,000/- including the payment of hospital expenses that the complainant ‘s son Sharon Joseph admitted in KMC Hospital, net work hospital of Opposite Party No:1. He was an inpatient from 14/07/2021 to 16/07/2021 evidenced by Ext A2 certificate.
The total hospital bill came to Rs. 69403/- ,all records submitted for claim on 14/08/2021. But Opposite party wrongly repudiated the claim stating that hospitalization was for diagnosis and evolution purposes. The Opposite party No:1 claims no treatment done to the child except bills. After collecting the premium when claim submitted rejecting is abusing process of law. There is no dispute regarding genuinely of the treatment.
When there is a valid insurance policy is favour of a person claim for re-imbursement of expenses incurred must be paid vides order in 2023 3) KCJ 475.
There is no evidence to justify that admission is made for investigation and evaluation purpose and therefore Commission finds that repudiation unjustifiable and un acceptable. There is no suggestion to Pw1regarding admission as for as evaluation is only. The burden is on opposite party to adduce evidence by examining the doctors who treated the child to prove that the admission is only for evaluation. Issue No: 1 and 2 found in favour of complainant. The complainant is entitled for recover hospital bill as policy coverage. Since repudiation is unjustifiable not as per law there is deficiency in service in rejecting valid insurance claim. Hence complainant is entitled for compensation. The Commission finds a sum of Rs. 25,000/-is reasonable compensation for deficiency in service and complainant also eligible for cost of litigation.
In the result complaint is allowed in part directing opposite party No:1 to pay Rs. 69403/- covered by hospital bill along with 8% interest per annum from date of filing complaint till payment and also pay Rs. 25,000/-(Rupees Twenty five thousand only) as compensation for deficiency in service and Rs. 5000/- (Rupees Five thousand only) as cost of litigation to the complainant within 30 days of the receipt of the order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1- Policy
A2- Certificate issued by Doctor
A3- Discharge summary
A4(series) - Lab records
A5- Bill Settlement receipt
Witness Examined
Pw1- Joseph Daniel
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
