IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
DATED THIS THE 3rd DAY OF DECEMBER 2019
Present: - Sri. E.M.Muhammed Ibrahim, B.A, LLM. President
Smt.S.Sandhya Rani. Bsc, LLB ,Member
Sri.Stanly Harold, B.A.LLB, Member
CC.No.236/2016
Rajeev, 52 years,
S/o Raghavan,
Kochupurakkal Veedu,
Kuzhithura P.O.,Karunagappally, : Complainant
Kollam.
(By Adv.C.Sajeendrakumar) V/S
- The Manager,
HDFC ERGO
General Insurance Company Ltd., 6th Floor,
Bishop Jerome Nagar, Kollam.:Opposite parties
(By Adv.S.Dileepkumar)
- The Manager,
HDFC ERGO,
General Insurance Company Ltd.,
HDFC House 1st Floor,
165-166 Back bay Reclamentation,
H.T.Parekh Marg Church gate
Mumbai-400020.
(By Adv.S.Dileepkumar)
FAIR ORDER
Sri.Stanly Harold, B.A.LLB, Member
This is a case based on a consumer complaint filed under section 12 of the Consumer Protection Act 1986.
The averments in the complaint in short are as follows.
The complainant is a customer of the opposite parties since 2013. In the year 2016 the opposite parties contacted the complainant through telephone and explained about their Health Suraksha Top up policy and its benefits and coverage details. Believing the words of the opposite parties the complainant expressed his willingness to avail the said policy . On 17. 04.2016 an amount of Rs.34624/- was
paid to opposite parties by the complainant through his credit card facility available in HDFC bank. At the time of availing the policy the opposite parties made the complainant to believe that the tenure of the policy is two years ie.16.04.2016 to 15.04.2018 . Thereafter complainant was admitted as impatient in Valiyath Institute of Medical Sciences from 07.06.2016 to 13.06.2016 in relation with a stomach complaint .
According to the complainant he had made a claim before the opposite parties for releasing the treatment expenses incurred in the Valiyath Institute of Medical Sciences, Karunagapally. Thereafter the complainant had duly filled and signed the claim form and countersigned by the hospital authorities and also produced treatment certificate, discharge certificate, and a certificate showing about the rest period of one month adviced from the hospital to the opposite parties. However the opposite parties repudiated the claim on flimsy grounds. According to the complainant the said act of the opposite parties is gross violation of assurance made in the policy and hence there is deficiency in service on the part of opposite parties.
The opposite parties filed version resisting the averments in the complaint. However the opposite parties would admit Ext.P1 policy and its condition and its validity. But would contend that they had issued Health Suraksha Top up policy to the complainant after explaining all the benefits conditions and coverage of the said policy. The complainant is fully aware of the terms and conditions of the policy and exclusion clauses applicable to the policy which are specifically mentioned in the policy issued to the insured by the insurance company. According to the opposite parties Health Suraksha Top up policy issued to the complainant is for a sum insured of 7,15000/- with a deductable limit of 3 lakhs under the policy. As per the policy issued by the opposite parties the policy has a deductable limit of Rs.3 lakh as per the concluded terms of contract. According the opposite parties they would be liable for medical expenses and other benefits under the policy only when the expenses incurred by the complainant exceeds agreed deductable amount of Rs.3 lakh and the complainant is not entitled to make any claim under the above policy, the medical expenses incurred by him if the particular claim is less than 3 lakhs. It is further contend that the opposite parties have issued the insurance policy to the complainant along with the full policy wordings showing the terms and conditions governing the policy. According to the opposite parties the insurance policy, being a contract of insurance, the terms and conditions of the concluded, contract is perfectly binding on the contracting parties in deciding the rights and liabilities arising under the insurance policy and the insured complainant once having accepted the terms and conditions of the policy is legally estopped from raising a dispute against the terms and conditions of the insurance contract at a later stage. It is also contended that the policy terms and conditions of Health Suraksha Top up policy including the deductable limits up to Rs.3,00000/- were properly explained to the complainant and the complainant had accepted the same while submitting the proposal form.
According to the opposite parties complainant had preferred a claim with the opposite parties claiming a sum of Rs.94992/- as benefits eligible to him under the policy for the treatment taken by him in Valiyath Institute of Medical Science at Karunagapally. But as per the records from the said hospital the expenses incurred is only Rs.43922/- . However the definition clause 13 of the policy wordings the company is not liable for any payment unless the medical expenses exceeds the deducted limit of Rs.3,00000/- .According to the opposite parties operation of the policy starts only when the expenses incurred for the treatment exceed the deductable limit of Rs.3,00000/- but in the instant case the medical expenses incurred for the complainant is only to the tune of Rs.43922/- which is within the deductable limit under the policy and as such the opposite parties are not liable to make any payment under the policy. Hence the opposite parties repudiated the claim of the complainant vide repudiation letter dated 31.07.2016.
In the light of the above pleadings the points that arise for consideration are:-
- Whether the complainant is entitled to get the claim amount as per the policy conditions in Health Suraksha Top up policy?
- Whether there is any deficiency in service on the part of the opposite parties?
- Reliefs & costs?
Evidence on the side of complainant consists of oral evidence of PW1 and Ext.P1 to P12 documents. Evidence on the side of the Opposite parties consist of the oral evidence of DW1 and Ext.D1 to D3 documents.
The learned counsel for the complainant has not filed any argument notes. The learned counsel for the opposite party filed notes of argument.
Heard both sides.
Point No.1 &2
For avoiding repetition of discussion of materials these two points are considered together. PW1 is the complainant in this case who filed affidavit in lieu of chief examination by reiterating the averments in the complaint and got marked Ext.P1 to P12. Ext.P1 is the copy of Health Suraksha top up policy, Ext.P2 is Medical Bills, Ext.P3 cash Bills. Ext.P4 Discharge summary, Ext.P5 certificate issued from the hospital for taking rest Ext.P6 claim repudiation letter dated 31.07.2016. Ext.P7 is the requirement letter issued from HDFC ergo. Ext.P8 medical certificate. Ext.P9 medical Bill for Rs.9728. Ext.P10 policy wordings Ext.P11 copy of policy plan taken from the insurance companies site. Ext.P12 Booklet regarding the Health Suraksha top up policy.
The opposite parties strongly resisted the averments in the complaint and filed version and got examined DW1 and marked Exts.D1 and D2 documents Ext.D1 is the Health Suraksha Top up policy. Ext.D2 repudiation letter dated 31.07.2016.
However the opposite parties would admit the Ext.P1 policy its conditions and its validity. But would content that they had issued Health Suraksha top up policy to the complainant after explaining all the benefits conditions .
According to opposite parties, the complainant is having fully awareness regarding the terms and conditions of the policy as well as exclusion clauses applicable in the policy which are specifically mentioned. It is clear that the Health Suraksha top up policy issued to the complainant is for a sum of Rs.715000/- with a deductable amount limit of Rs.3 lakhs as per the concluding terms of the contract. The main contention raised by the opposite parties is that they are only liable to compensate for medical expenses including other benefits under the policy only when the expenses incurred by the complainant exceeds the deductable amount of Rs.3,00000/-. The counsel for the opposite parties points out that the in this case particular claim amount is less than 3,00,000/-. Though the complainant made a claim before the opposite parties for realizing the amount under the policy the same was repudiated by the opposite parties on the ground that medical expenses and other benefits does not exceeds the deducted amount of Rs.3,00000/-. The opposite parties has also not disputed the above case of complainant. But the opposite parties would content that complainant had failed to understand the full policy wording showing the terms and conditions governing the policy. According to the opposite parties the insurance policy being a contract of insurance, so the terms and conditions of the concluded contract is perfectly binding to contracting parties in deciding rights and liabilities arising under the insurance policy. The opposite parties would further content that the complainant once had accepted the terms and conditions of policy then he is legally estopped from raising against the terms and conditions of the insurance contract at a later stage. It is made clear by the opposite parties that the deductable limits up to Rs.3,00,000/- were properly explained to complainant and he had accepted the same and submitted the proposal form.
The opposite parties would contend complainant had preferred a claim of Rs.94492/- as benefits eligible to him under the policy for the treatment taken by him Valiyath Institute of Medical Science, Karunagapally. But on perusal of record it is reveal that the hospital expenses incurred is only 43922/-. According to opposite parties the definition clause 13 of policy wordings of Health Suraksha top up policy the company is not liable for any payment unless the medical expenses exceeds the deducted limit of Rs.3,00,000/-. But in the instant case the medical expenses incurred is only to the tune 43922/- which is less than the deductable limit as such the opposite parties not liable to make any payment under the policy. In the circumstance the repudiation of claim by the opposite party cannot be considered in proper or illegal .
It is true that the complainant had undergone the treatment for series abdominal disease interstitial pancreatitis . But simply because of the said treatment the forum cannot direct the opposite parties to pay the benefits covered under the policy by ignoring the terms and conditions of the policy. It is well settled that the terms of contract of insurance is to be strictly interpreted by the forum and while interpretating the terms and conditions the forum is not expected to add or subtract anything as contract of insurance is a ubarima-fide contract.
On evaluating the entire facts and circumstances available on the record we find no illegality, irregularity or impropriety in repudiating the claim by the opposite parties as the complainant is not eligible to any benefits or compensation under the Health Suraksha Policy for the medical expenses as the expenses does not exceed the deductable limit of Rs. 3,00,000. As the opposite parties have acted in tune with the terms and conditions of the policy one cannot infer deficiency in service on the part of opposite parties. The points answered accordingly.
Point No.3
In the result, we find no merit in complaint and same stands dismissed.
Parties are directed to suffer their respective costs.
Dictated to the Confidential Assistant Smt.Minimol S. transcribed and typed by her corrected by me and pronounced in the Open Forum on this the 3rd day of December 2019.
E.M .MUHAMMED IBRAHIM:Sd/- S.SANDHYA RANI:Sd/-
STANLY HAROLD:Sd/-
Sd/-
Senior Superintendent
INDEX
Witnesses Examined for the Complainant:- R.Rajeev
Documents marked for the complainant
Ext.P1:- copy of Health Suraksha top up policy
Ext.P2:- Medical Bills
Ext.P3:- Copy of other policy certificate
Ext.P4:- cash Bills
Ext.P5:- Medical certificate
Ext.P6:- claim repudiation letter
Ext.P7:- Deficiency letter
Ext.P8:-medical certificate
Ext.P9:-medical bill
Ext.P10:-policy wordings
Ext.P11:-Copy of policy plan from insurance companies site
Ext.P12:-Booklet Health Suraksha top up policy
Witness examined for the opposite party:-Aneesh Bhaskar
Documents marked for the opposite party
Ext.D1:-Health Suraksha Top up policy
Ext.D2:-Repudiation letter
