DATE OF FILING : 03.02.2010
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI Dated this the 31st day of July, 2010
Present: SRI.LAIJU RAMAKRISHNAN PRESIDENT SMT.SHEELA JACOB MEMBER SMT.BINDU SOMAN MEMBER C.C No.33/2010 Between Complainant : Joseph.J.Olickal, Olickal House, Kanjar P.O, Thodupuzha, Idukki District. (By Advs: K.M.Sanu & Johny Alex) And Opposite Parties : 1. The Manager, KNK Life Care, XVII 595, Kanjiramattom Junction, Thodupuzha P.O, Idukki District. (By Adv: M.M.Lissy) 2. The Manager, Reliance General Insurance Company Limited, Elizabath Alexander Memorial Building, Shanmugham Road, Kochin – 31. (By Adv: K.Pradeepkumar) O R D E R SRI. LAIJU RAMAKRISHNAN(PRESIDENT)
The complainant availed two medi-claim policies for himself and for his wife as "Reliance Health Wise Policy(Gold)" from the 2nd opposite party through the Ist opposite party, who is the authorised agent of the 2nd opposite party in 2007. The policy period was from 5.10.2007 to 4.10.2008. As per the policy the opposite party offered a coverage of Rs. 1 lakh each for medical expenses on different head. At the end of the Ist year of the policy on 3.10.2008, the complainant entrusted the renewal premium of Rs.3,600/- for renewing both the policies without break. The renewal forms were also signed. The Ist opposite party issued the receipts and two policies as policy No.282510134450 and 282510134456 for the complainant and his wife respectively on 3.12.2008. On perusing the same, he understood that the policy issued were not the renewals of the old policy. They were fresh policies commencing from 21.11.2008 and moreover the issued policies were of 'Silver' category and not of "Gold' category. So the complainant immediately contacted the opposite parties to issue renewed policy because he had remitted the premium for renewing both the policies in Gold plan. Complaints were also sent to the 2nd opposite party in registered post. After several communications and telephone calls, the 2nd opposite party assured that if any claim arises, they would make good the mistakes at the time of settling the claim by considering the policy as renewal in gold plan. During the policy period in September 2009, the complainant was admitted at Samaritan Hospital, Pazhanganadu for repeated fever. The test results showed the performance of a bacteria in blood and was treated there as inpatient for 7 days. After discharge, diagnostic tests were done at Medical College Hospital, Kottayam and Amritha Hospital, Kochi. After that he was admitted at Dr.Naushad's Hospital at Vytila, a surgery was conducted for Sinosal Poliposes and discharged after 3 days. The complainant incurred an expense of Rs.59,000/- for the treatment. The complainant submitted claim application before the opposite parties with all relevant records and medical bills. But the opposite party repudiated the claim on the ground that the policy receipt was only on 21.11.2008 and the ailment in question was in the Ist year of commencement of the policy. So they are not liable to pay the same. The opposite parties wilfully avoided to renew the policy after receiving the premium and issued a new policy under a different plan, which is a deficiency from the part of the opposite party. So this petition is filed for getting the medical treatment expenses for the complainant to the tune of Rs.59,000/- and also for compensation. 2. As per the written version filed by the Ist opposite party, it is admitted that the date for renewing the policy was on 3.10.2008. But the complainant was not made payment on that day because his mother was admitted in hospital. So he approached the Ist opposite party only on 10.10.2008 with Rs.3,600/-. The complainant made the payment to the Ist opposite party's agent Mr.Praveen on 10.10.2008, but the date shown on the receipt is 3.10.2008, because the previous policy expired on 3.10.2008 and the date for renewing the policy was on 3.10.2008. But the payment was done only on 10.10.2008 by the complainant. The complainant never signed any renewal forms to say that the complainant renewed both the golden plan policies. In the beginning complainant's policies were Gold plans and the sum assured was Rs.1 lakh. But subsequently the complainant not paid the premium in time and not renewed the same. So it caused break in Gold plan policy. When the Ist opposite party consulted with the complainant about the break in Gold plan, the complainant accepted the Silver plan sum assured as Rs.2 lakhs instead of Gold plan sum assured Rs.1 lakh. On 19.11.2009 the complainant renewed the silver plan policy. The complainant never arised any objection about the silver plan policy at the time of accepting the Silver plan and renewing the Silver plan policy. The Ist opposite party collected the premium and sent to the 2nd opposite party. The Ist opposite party is only an agent of the 2nd opposite party and also there is a condition in that policy that if the party committed any break in payment, there is no need to renew or accept the policy. Because it is a one year agreement between the 2nd opposite party and the complainant. So there is no deficiency in the part of the Ist opposite party.
3. As per the written version of the 2nd opposite party, it is stated that the complainant paid the premium only on 10.10.2008 which is Rs.3,600/- for renewing the policy. Even though the complainant received the policy certificates immediately after issuing the same, till the repudiation, the complainant did not make any complaint regarding the type of policy received by him or regarding the commencement of the policy. The complainant opted for a silver category policy that is why he was issued the same. No oral assurance was given by the opposite party that they will make good the mistake at the time of settling the claim by considering the policy as renewal in Gold plan. There is no such amount Rs.59,000/- has been incurred for the treatment expenses of the complainant. As per the terms and conditions of the policy, the treatment of the ailment in question was excluded. So the opposite party was constrained to repudiate the claim and so there is no deficiency in service on the part of the 2nd opposite party.
4. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to? 5. The evidence consists of the oral testimony of PW1 and Exts.P1 to P12 marked on the side of the complainant and the oral testimony of DWs 1 and 2 and Exts.R1 to R3(series) marked on the side of the opposite parties. 6. The POINT :- The petition is filed for getting the treatment expenses of the complainant from the opposite parties for his medi-claim policy. The complainant is examined as PW1. PW1 availed two Reliance Health Wise Policy(Gold) from the 2nd opposite party through the Ist opposite party in the name of PW1 and his wife. As per the policy, the sum assured is Rs.1 lakh and the policy period was from 5.10.2007 to 4.10.2008. On 3.10.2008 PW1 paid Rs.3,600/- to the Ist opposite party for renewing the policy. Ext.P1 is the receipt issued by the Ist opposite party for the same. The opposite party issued two number of policies on 3.12.2008, but later it was revealed that the policies were not the renewed ones but they were fresh policies commencing from 21.11.2008 and also in the category of Silver and not in the Gold. When PW1 complained about the same, the opposite party assured that the defect can be cured and it can be considered as Gold if any claim arises, Ext.P5 is the copy of the complaint given to the Ist opposite party about the same. Complainant filed complaint to the 2nd opposite party also. Copy of the same with postal AD card is marked as Ext.P7(series). The copy of the complaint dated 2.12.2008 given to the Reliance General Insurance Company's office at Mumbai and its postal AD card are marked as Ext.P8(series). The copy of complaint dated 10.12.2008 given to the 2nd opposite party at their Cochin office and its postal AD card are marked as Ext.P9(series). The copy of complaint dated 10.12.2008 given to the 2nd opposite party's office at Mumbai and its postal AD card are marked as Ext.P10(series). Ext.P6 is the copy of the Gold policy issued by the 2nd opposite party on 18.10.2007. In September 2009 the complainant was admitted at Samaritan Hospital, Pazhanganadu for repeated fever and treated there as inpatient for 7 days. Later several tests were conducted at Medical College Hospital, Kottayam and Amritha Hospital, Kochi. Then he was admitted at Dr.Naushad's Hospital at Vytila for 3 days and surgery for Sinosal Poliposes was conducted there. The treatment expenses incurred Rs.59,000/-. So a claim form was given to the opposite party for getting the treatment expenses with relevant documents and bills. But the same was repudiated by the opposite party by a letter dated 10.11.2009, copy of the same is marked as Ext.P2. The reason for repudiation is that the treatment of the complainant was during the first year of the operation of the insurance cover, so the claim stands declined under exclusion clause No.3 of the medi-claim policy. The Treatment Summary from the Samaritan Hospital is marked as Ext.P3 and the Medical Bills from Dr.Naudhad's Hospital, Cochin is marked as Ext.P4(series).
7. The Ist opposite party is examined as DW1. As per DW1, the complainant approached the office of the Ist opposite party and paid Rs.3,600/- as premium to the staff of the Ist opposite party, Mr.Praveen. The renewal date of the premium was on 3.10.2008. So as per the request of the complainant, the date was written in the receipt as 3.10.2008. But the complainant never signed the renewal forms on that day. As per the request of the complainant, the policy was changed to Silver plan from the Gold pan because of the non-payment of the premium in the due date. Without the consent of the policy holder the category of the plan cannot be changed. Ext.R1(series)are the copy of the certificates issued to the complainant and his wife for silver plan. As per the cross examination of the learned counsel for the complainant, DW1 deposed that no request was given by the complainant for changing the policy. It was done as per the consultation of the agent Mr.Praveen. The amount was given to the agent Mr.Praveen, the said agent delayed the payment of the customer, it is a mistake from the part of the agent. So they have terminated the service of the said agent. But there is no difficulty caused to the customer. The policy coverage was changed from Rs.1 lakh to Rs.2 lakhs. The 2nd opposite party is examined as DW2. The policy copy is marked as Ext.R2(series). DW2 deposed that the policy of the complainant was in Silver category. Without the consent of the policy holder the policy cannot be changed to any other category. But the policy was renewed after changing to silver category by the complainant. DW2 also deposed that the Ist opposite party is the authorised agent of the 2nd opposite party and they are still continuing the agency. It is also admitted that if any mistake happened from the part of the Ist opposite party, the 2nd opposite party is also liable for the same. No investigation has been done by the 2nd opposite party as per the complaints received from the complainant. It is also admitted that the opposite party is liable to give the claim of the complainant if the receipt of the premium was on 3.10.2008. 8. As per the complainant, the complainant paid Rs.3,600/- to the Ist opposite party for renewing the policy on 3.10.2008 itself. Ext.P1 is the receipt issued by the Ist opposite party for the same. But they have changed the category of the policy from Gold to Silver without the consent of the complainant and the complainant filed several complaints against the same to the opposite parties. As per the Ist opposite party, the amount was received only on 10.10.2008. But the date was written as 3.10.2008 as per the request of the complainant. So there is a break caused to the first policy period because of the non-payment of the premium in the due date. So without the consent of the complainant the policy category was changed as Silver. As per DW1, without the request of the policy holder the category of the policy cannot be changed. Here there is no written request has been received from the complainant to the opposite party. As per Ext.P1 bill the amount for the renewal of the policy is Rs.3,600/-. DW1 deposed that the renewal amount for golden category policy is Rs.3,600/- and the amount needed for renewing the silver policy is Rs.4,200/-. DW2 also admitted that without the consent of the policy holder the policy category cannot be changed. It is also admitted by DW2 that Exts.P7, P8, P9, P10 and P5 are the copy of the complaints received from the complainant to the opposite party against the renewal of the policy and the change of category of the policy done by the opposite parties. It is also admitted by DW2 that the complainant is entitled to get the claim amount from 3.10.2008 onwards, when the Ist opposite party received the policy premium. So we think that the complainant duly paid the premium amount Rs.3,600/- to the Ist opposite party on 3.10.2008 itself as per Ext.P1 bill. But the agent of the Ist opposite party delayed the payment and the category was also changed by the opposite party without the consent of the complainant. The complainant filed all the documents and bills for the treatment expenses incurred by him. But the opposite party repudiated the same which is a gross deficiency from the part of the opposite party. If any mistake happened to the Ist opposite party, who is the authorised agent of the 2nd opposite party, the 2nd opposite party is also liable for the same. It is also admitted by DW2 who is the 2nd opposite party. So the 2nd opposite party is entitled to give the policy amount as per Ext.P4(series) bills produced by the complainant. But in Ext.P4(series) bills, Ext.P4(13) and P4(14) are one and the same.
Hence the petition allowed. The 2nd opposite party is directed to pay an amount of Rs.42,213/- to the complainant as per Ext.P4(series) bills with 12% interest from the date of this petition and Rs.2,000/- as costs of this petition within 30 days of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default. Pronounced in the Open Forum on this the 31st day of July, 2010
Sd/-
SRI. LAIJU RAMAKRISHNAN(PRESIDENT) Sd/-
SMT. SHEELA JACOB(MEMBER) Sd/-
SMT. BINDU SOMAN(MEMBER) APPENDIX Depositions : On the side of Complainant : PW1 - Joseph.J.Olickal On the side of Opposite Parties : DW1 - K.R.Sudhakaran DW2 - Jaseela Ranjith Exhibits: On the side of Complainant: Ext.P1 - Receipt dated 3.10.2008 for Rs.3,600/- issued by the Ist opposite party Ext.P2 - Repudiation letter dated 10.11.2009 issued by the opposite party Ext.P3 - Photocopy of Treatment Summary issued from the Samaritan Hospital, Pazhanganad Ext.P4(series) - Photocopy of Medical Bills issued from Dr.Noushad's ENT Hospital, & Research Centre, Thammanam P.O, Cochin Ext.P5 - Photocopy of Complainant's complaint dated 10.12.2008 addressed to the Ist opposite party Ext.P6 - Photocopy of Reliance HealthWise Policy Schedule Ext.P7(series) - Photocopy of Complainant's complaint dated 2.12.2008 addressed to the 2nd opposite party's Cochin Office and its Postal AD Card Ext.P8(series) - Photocopy of Complainant's complaint dated 2.12.2008 addressed to the 2nd opposite party's Mumbai Office and its Postal AD Card Ext.P9(series) - Photocopy of Complainant's complaint dated 10.12.2008 addressed to the 2nd opposite party's Cochin Office and its Postal AD Card Ext.P10(series) - Photocopy of Complainant's complaint dated 10.12.2008 addressed to the 2nd opposite party's Mumbai Office and its Postal AD Card Ext.P11 - Postal AD Card Ext.P12 - Receipt dated 18.11.2009 issued by the Ist opposite party On the side of Opposite Parties : Ext.R1(series) - Photocopy of Reliance HealthWise Policy Schedules in silver Plan to the complainant and his wife Ext.R2(series) - Copy of Reliance HealthWise Policy Schedule with Terms and Conditions Ext.R3(series) - Reliance HealthWise Policy Claim Form with documents
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