DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 18th day of December, 2023
Present : Sri.Vinay Menon V. President
: Smt. Vidya.A., Member
: Sri. Krishnankutty N K, Member
Date of filing: 17/03/2020.
CC/45/2020
Vijaykumar P V - Complainant
S/o Madhavam
Padinjare Valappil House
Karinganadu, Vilayur P.O.
Koppam, Pattambi Taluk,
Palakkad - 679 309
(By Adv. Shiju Kuriakose)
V/s
1. The Manager - Opposite Parties
Federal Bank
Koppam, Palakkad - 679 309
2. The Manager,
Federal Bank Ltd., Regional Office,
Ground Floor,
Saikrishna Residency
Kunnathurmedu, Palakkad - 678 013
(OPs 1&2 by Adv. Randhir Kumar)
3. The Manager
MaxBupa Health Insurance Co.Ltd,
7B, Puthuran Plaza, KPCC Junction
40/483-M.G Road, Kozhi - 682 011
(By Adv. Saji Isac K J)
O R D E R
Prepared by Sri. Krishnankutty N K, Member
- Pleadings of the complainant in brief
The complainant subscribed to the Group Health Insurance Policy of OP3 through the opposite party 1 & 2. The sum assured was Rs 2,00,000.00 and the policy was valid from 28/9/2018 to 27/9/2019. During the period from 31.01.2019 to 04.02.2019, the complainant was admitted to EMS Memorial Co-operative Hospital Perinthalmanna for the treatment of Coronary Artery Disease, but his insurance claim for Rs 1,45,416/- was repudiated by OP3. Aggrieved by this, the complainant approached this Commission seeking direction to opposite parties for payment of the claim amount apart from a compensation of Rs 100,000.00 and cost of Rs 25000/-.
- Notices were issued to the opposite parties. They entered appearance and filed their version. The contention of OP 1 & 2 is that they are only commission agents of OP3 and hence they have no role in deciding on the settlement of claim by the OP3. According to OP3 the rejection of claim is only on account of non-production of necessary documents inspite of repeated reminders sent by them to the complainant.
- The complainant filed Proof Affidavit and marked Ext.A1 to A10 as evidence. Ext A1 is the certificate of insurance issued by the OP3, A2 is the claim denied mail sent by the OP3, A3 is the discharge bill, Ext.A4 is the discharge summary, Ext.A5 is the certificate issued by the Cardiologist, Ext A6 is the Coronary Angiogram +PTCA Report issued by the Hospital, Ext A7 is the memo filed by the OP3, Ext A8 is the copies of original Claim form and related documents submitted to the OP3, Ext A9 is the copy of claim reimbursement checklist, and Ext. A10 series are the bills/invoices submitted by the complainant to OP3.
All the exhibits were objected on the ground that they are photocopies, but the objection was overruled as there was no allegation that they are forged/concocted ones. The OP3 filed Proof Affidavit and marked Ext B1 to B4 as evidence. Ext B1 is the certificate of insurance along with terms & conditions, Ext B2 & B3 are the e-mails sent to the complainant by OP3 asking him to submit additional documents and B4 is the mail from OP3 denying the claim. OP1 And OP2 did not file Proof Affidavit.
4. The issues involved in this case are
(a) Whether the repudiation of claim by OP3 is as per the terms & Conditions of the policy.
(b) Whether there is any deficiency in service or Unfair Trade Practice as the part opposite parties.
(C) Whether the complainant is entitled to the reliefs sought for
(d) Any other reliefs / cost.
Issue.1
5. From the Proof Affidavit filed by the complainant and OP3 and the documents adduced as evidence, we can draw the following information for deciding the merits of the case.
(a) As per Ext. B4 (Also Ex.A2) the reason for disallowance has been mentioned as clause 9.3 whereas the Ext B1 does not contain such a clause.
(b) As per the version and Proof Affidavit filed by OP3 the reason for repudiation of the claim is non submission of some additional records/documents called for vide Ext B2 & B3. In para 11 of the Proof Affidavit, it is mentioned that the complainant was a known case of “diabetes mellitus and was on medication” and hence it is clear that the documents sought were related to the past treatment of Diabetes mellitus. What the opposite party want to argue here is that the complainant was having a pre existing disease ie, Diabetes mellitus and hence his eligibility of claim cannot be adjudicated without the past treatment records of the disease.
(3) As per the policy terms & conditions “A Pre-existing Disease means any condition or injury or related conditions(s) for which you had signs or symptoms, and/or were diagnosed and/or received medical advice/treatment within 48 months prior to the first policy issued by the insurer”. (Ext.B1)
(4) If we scan through the documents marked, reference to blood sugar levels can be seen in Ext A4; the discharge summary which shows the blood sugar level of 315 mg/dl on 31/01/2019 and 142mg/dl on 01/02/2019. As per Ext. A5, the treating doctor has given a certificate to the effect that the patient was diabetic at the time of admission, but no previous records were available with the hospital. These two evidences are not sufficient to prove that the complainant was a “ known case of Diabetes mellitus and under medication” as claimed by the OP3. The OP3 has not adduced any evidence to show the past diagnosis or treatment for diabetes mellitus without which the statement in the Proof Affidavit can’t be taken as of any evidentiary value, but only as a wild guess. It is also possible that the body had this problem, but not exhibited by any symptoms hence not known to the complainant until it progressed to heart related problems which necessitated the treatment in question. Hence the repudiation of claim is against the spirit of the terms & conditions of the policy.
Issue 2
(6) Repudiation of claim without valid reason is a case of deficiency in service or unfair practice. Hence OP3 is liable to compensate the complainant.
Issue 3 & 4
(7). As the deficiency in service or unfair trade practice is proved against the OP3, the complaint is entitled to the compensation claimed. As per Page (2) of Ext A1 the disease specific limit for “ailments or procedures related to Ischemic Heart Disease has been mentioned as Rs 1,00,000.00, but the OP3 has not placed any arguments in this regard.
Resultantly the complaint is allowed and the following reliefs are ordered.
(1). The OP3 is directed to settle the claim for Rs 1,45,416.00 along with interest @ 10% pa. From 04.02.2019 till the date of final payment.
(2) The OP3 is also directed to pay Rs 50,000/- as compensation for mental agony suffered.
(3). The OP3 is also liable to pay Rs 25000/- as cost of litigation to the complainant.
As OP1 & OP2 are only commission agents under the bank assurance scheme they can’t be held responsible for the issues related to settlement of claim. Hence they are absolved off any liabilities.
The above amounts are to be paid within 45 days of receipt of this order, failing which the opposite parties are liable to pay Rs.500/-as solatium per month or part thereof till the date of final payment.
Pronounced in open court on this the 18th day of December, 2023.
Sd/-
Vinay Menon V
President
Sd/-
Krishnankutty N K
Member
APPENDIX
Documents marked from the side of the complainant:
Ext. A1 : Certificate of insured in the name of the complainant.
Ext A2 : E-mail dated 21/08/19 addressed by OP3 to the complainant.
Ext A3 : Discharge Bill dated 04.02.2019 issued by EMS Co-operative Hospital
& Research Centre, Perunthalmanna.
Ext A4 : Discharge summary dated 04/02/2019 issued by EMS, Coop Hospital
and Research Centre, Perinthalmanna
Ext.A5 : Certificate issued by EMS Co-op.Hospital & Research Centre,
Perinthalmanna dated 15/07/19.
Ext A6 : Coronary Angiogram + PTCA Report dated 31/01/19 issued by EMS
Coop. Hospital & Research centre, Perinthalmanna
Ext A7 : Memo filed by OP3 dated 27/5/23
Ext A8 : Copies of claim application & enclosures produced by OP3 as per the
above memo (Ext A7)
Ext A9 : Copy of claim reimbursement checklist produced as per memo (Ext A7)
Ext.A10 Series : Copies of Bills & invoices submitted along with claim
application produced by OP3 as per memo (Ext A7) .
Exhibits marked from the side of the opposite party :
Ext B1 : Certificate of Insurance dated 28/9/18 valid till 27/09/19 along with Terms & Conditions
Ext B2 : E-mail dated 05/07/19 from OP3 to the complainant
Ext B3 : E-mail dated 09/08/19 from OP3 to the complainant
Ext B4 : Claim Disallowance dated 29/06/20.
Witness examined from the side of the complainant : Nil
Witness examined from the side of the opposite party : Nil
Court Witness: Nil
Cost : 25,000/-
NB: Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out).
