DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE
PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB : PRESIDENT
Smt. PRIYA.S, BAL, LLB, MBA (HRM) : MEMBER
Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER
Friday the 18th day of November 2022
C.C. 77/ 2016
Complainant
P.T. Jose,
Panamattom,
33/6016-‘C’,
Chevayoor p.o.,
Kozhikode-673017.
(By Adv. Sri. Pavithran. K. )
Opposite Parties
- The Manager,
Andhra Bank,
Parco complex,
Kallai Road,
Kozhikode-673003.
(By Adv. Sri. K.S. Rajagopalan)
- The Manager,
United India Insurance Co. Ltd,
Divisional Office, 7th Floor,
United India Towers, Basheer Bagh,
Hyderabad-500029.
(By Adv. Sri. T. V. Hari)
- The Manager,
Good Health Plan Limited,
Maniyattukudy Asfa Building,
Mavoor Road, Calicut-4,
673004.
- The Managing Director,
Malabar Institute of Medical Science Limited,
Mini Bye pass Road, Govindapuram-p.o.,
Calicut-673016.
ORDER
By Smt. PRIYA. S - MEMBER
This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.
2. The complainant took Health Insurance Policy of the 2nd opposite party through the 1st opposite party by paying a sum of Rs. 1581/-. The policy was an exclusive one for those who have account in Andhra Bank. The opposite party is the Manager of Andhra Bank, the 2nd opposite party is the Manager of United India Insurance Co. Ltd, the 3rd opposite party is the Manager of Good Health Insurance Co. Ltd and the 4th opposite party is the Managing Director of Malabar Institute of Medical Science Limited.
3. Policy duration was for a period of 1 year (09/06/2014 to 08/06/2015) and the sum insured was Rs. 1,00,000/-. As per the policy the complainant and his wife is having policy eligibility. Arogyadaan Policy Number of the complainant is 0504002814P101905064. He had renewed the policy by paying an amount of Rs. 1,763/- for the period from 09/06/2015 to 08/06/2016.
4. On 30/09/2015 the complainant’s wife was admitted to the opposite party hospital due to uterus related disease. On 01/10/2015 uterus surgery was done. She was treated in oncology department. Review date was on 12/10/2015. In total Rs. 1,14,502/- was the expense. But the complainant got only Rs.20,000/- from the opposite parties. This is nothing but the unfair trade practice of the opposite parties which caused hardships of the complainant. So the complainant wants to get back Rs. 94,502/-(ie 1,14,502 – 20,000) from the opposite parties. Rs.50,000/- for the mental and physical agony of the complainant.
5. The 1st, 2nd and 4th opposite parties filed their version separately. The 3rd opposite party was set ex-parte.
6. The 1st opposite party in their version stated that the complainant as an account holder of Andhra Bank had joined the group mediclaim Insurance launched by the 2nd opposite party. The premium amount of Rs.1,763/- was collected by the 2nd opposite party by debiting the same from the account of the complainant, maintained with this opposite party. The renewal of the policy is done automatically every year by debiting their accounts with the premium, to the credit of the 2nd opposite party. The facility offered is exclusively to the account holder of the 1st opposite party. The terms of insurance are as directed by the opposite party and accepted by the complainant. The 1st opposite party is a 3rd party to the contract between them. Consideration by way of premium is collected by the 2nd opposite party. The 3rd opposite party is acting as the 3rd party administrator was selected and accepted by the opposite parties 2,3 and the complainant. There is no privity of contract between the complainant and the 1st opposite party and hence an unnecessary party to the proceedings. If at all the complainant has sustained any loss, due to the violation of the policy conditions, the opposite party is neither liable nor responsible. If at all the Forum finds that complainant is entitled to any compensation, the same may not be directed against the 1st opposite party. The amounts claimed under various heads in the complaint is exorbitant, excessive, disproportionate and not valid and binding on the 1st opposite party. So the 1st opposite party wants to dismiss the complaint with costs to them.
7. The 2nd opposite party in their version says that the hospitalization of the complainant’s wife was for a period from 30/09/2015 to 06/10/2015 was for Hysterectomy (uterus removal surgery). The Arogyadaan Policy enrolled under Andhra Bank Policy No: 0504002815P103075013 is subject to terms and conditions embodied in the policy of Insurance. The policy coverage as per terms and conditions of the policy hospitalization expenses for hysterectomy are limited to 20% of sum insured. As the sum insured is Rs.1,00,000/- this claim has been settled for Rs.20,000/- (20% of 1,00,000/-) and the same was communicated to the insured and paid. The complainant is not entitled for any further amount from the hands of this opposite party. The bill of Rs. 1,14,502/- is not maintainable as this complainant is entitled for a maximum amount of Rs. 20,000/- alone as per policy conditions. The averment in the petition that the complainant had no knowledge of terms and conditions is totally false. The 2nd opposite party had not adopted any unfair trade practice as alleged by the complainant. The 2nd opposite party prays to dismiss the complaint with cost to the opposite party.
8. The 4th opposite party in the version avers that the complaint is regarding non-payment of benefits as per the health insurance policy taken by the complainant from the 2nd opposite party through the 1st opposite party for treatment availed for his wife from the 4th opposite party hospital. As per the complaint itself, the complainant’s wife was admitted in MIMS Hospital on 30/09/2015 and was discharged on 06/10/2015. All the necessary treatments were provided to her according to the accepted medical protocol. It is also stated in the complaint that on discharge from the hospital, the complainant’s wife was provided with discharge summary, laboratory details, CT scan report, histopathology report, bills etc. There is absolutely no complaint against the 4th opposite party hospital regarding the treatment given to her or the service rendered to her from the hospital. Hence the 4th opposite party is not at all a necessary party in the case. The presence of the 4th opposite party is only for the purpose for providing that the complainant had undergone treatment in the hospital. The 4th opposite party has also supplied all the necessary documents in connection with the treatment. It is therefore just and necessary to close the matter against the 4th opposite party with costs.
9. The points that arise for determination in this case are:
(1) Whether there was any deficiency of service on the part of opposite parties?
(2) Reliefs and costs.
10. Evidence in this case consists of the oral evidence of PW1 and Exts A1 to A24 on the side of the complainant and Ext B1 on the side of the opposite parties.
11.Heard. Complainant filed argument note.
12. Point No.1: The complainant has approached this Commission with a grievance that the claim put in by him in connection with the treatment of his wife was only partially allowed by the Insurance company stating flimsy reason.
13. The complainant filed proof affidavit and was examined as PW1. He testimonied in tune with the averments in the affidavit. Exts A1 to A24 were marked. Ext A1 is the copy of Arogyadaan renewal authorization letter. Ext A2 is the copy of certificate of Insurance policy. Ext A3 is the copy of certificate of Insurance policy dated 09/06/2015. Ext A4 is the copy of AB Arogyadaan Mender Guide Book. Ext A5 is the policy details. Ext A6 is the copy of Discharge summary. Ext A7 is the copy Laboratory results. Ext A8 is pharmacy bill statement. Ext A9 is the histopathology report. Ext A10 is the discharge bill. Ext A11 is the pharmacy bill payment details. Ext A12 is the medical report of attending Doctor. Ext A13 is the copy of Letter written by the complainant to the 3rd opposite party dated 13/10/2015. Ext A14 is the copy of check list of Mandatory Documents to be collected with claim. Ext A15 is the reply letter given to the complainant by the 3rd opposite party having a Number CCN : 140276 dated 01/12/2015. Ext A16 is the copy of reply letter issued by the 2nd opposite party. Ext A17 is the copy of postal receipt and acknowledgement card. Ext A18 is the copy of the letter sent by the complainant to the 3rd opposite party. Ext A19 is the newspaper advertisement regarding insurance companies’ health news dated 12/09/2016. Ext A20 is the request to issue terms and conditions of AB Arogyadaan Medical Insurance Policy made by the complaint to the 1st opposite party. Ext A21 is the terms and conditions of Insurance policy issued by the 1st opposite party. Ext A22 is the histopathology report of CPC Medical Laboratory. Ext A23 is the letter given by department of surgical Oncology. Ext A24 is the surgical details of the complainant’s wife. Ext B1 is the Health Insurance Details.
14. The complainant is a holder of Arogyadaan Policy of the 2nd opposite party enrolled under Andhra Bank, the 2nd opposite party herein. The above policy covers the health Insurance of the complainant and his wife Omana. The sum assured is Rs. 1,00,000/-. The policy was renewed for the period from 09/06/2015 to 08/06/2016. On 30/09/2015 the wife of the complainant Smt. Omana was admitted in the MIMS Oncology Centre Calicut. The final diagnosis was Carcinoma Endometrium. The operative procedure executed was Total Abdominal Hysterectomy (TAH) with Bilateral Salpigo Oophorectomy (BSO). She was discharged on 06/10/2015. Ext A6 is the copy of the discharge summary. The total hospitalization and medical bills amounted Rs. 1,14,502/-. A claim was preferred by the complainant before the 2nd opposite party, but only an amount of Rs. 20,000/- was allowed. There is no serious dispute in the above aspects.
15. The stand taken by the Insurance company is that as per the policy, the hospitalization expenses for Hysterectomy is limited to 20% of the sum assured. Going by Ext A21, which is the terms and conditions of the policy, it is seen that for hysterectomy the hospitalization expenses is limited to 20% of the sum insured subject to maximum of Rs. 50,000/-. But Ext A21 further provides that for specified major surgeries hospitalization expenses is limited to 80% of the sum insured subject to a maximum of Rs. 4,00,000/-. It is also specified that surgery for cancer is a major surgery. Now coming to the case of Smt. Omana Jose, it is a case of Carcinoma Endometrium and TAH &BSO was done. TAH & BSO is removal of uterus, cervix and both fallopian tubes and ovaries. It is not a case of mere hysterectomy. The above surgical procedure was necessitated due to cancer which is a specified major surgery as per the policy terms and conditions. Hence according to us, 80% of the sum insured should have been allowed to the complainant. The contention of the insurance company that only 20% of the sum insured can be granted cannot be sustained.
16. From the above discussion, we hold that the claim was wrongly limited by the insurance company to Rs. 20,000/-. The act of the insurance company in wrongly limiting the claim to Rs. 20,000/- and thereby denying the legitimate claim amounts to gross deficiency of service. The complainant is entitled to get Rs. 60,000/- more from the insurance company apart from Rs. 20,000/- already disbursed. It goes without saying the act of insurance company has caused mental agony and hardship to the complainant for which he is entitled to be compensated adequately. Considering the entire facts and circumstances, we are of the view that a sum of Rs. 10,000/- will be reasonable compensation in this case. The complainant is also entitled to get Rs. 5,000/- as cost of the proceedings.
17. Point No. 2: In the light of the finding on the above point the complainant is disposed of as follows:
a) CC 77/2016 is allowed in part.
b) The 2nd opposite party is directed to pay a sum of
Rs.60,000/- (Rupees sixty thousand only) to the
complainant.
c) The 2nd opposite party is directed to pay Rs. 10,000/-
(Rupees ten thousand only) as compensation to the
complainant.
d) The 2nd opposite party is directed to pay Rs. 5,000/- as cost
of the proceedings to the complainant.
e) The payment as aforestated shall be made within 30 days of
the receipt of copy of this order, failing which, the amount of
Rs. 60,000/- shall carry an interest of 6% p.a. from the date of
this order till actual payment.
Pronounced in open Commission on this, the 18th day of November, 2022.
Date of Filing: 08/02/ 2016.
Sd/-
PRESIDENT
Sd/-
MEMBER
Sd/-
MEMBER
APPENDIX
Exhibits for the Complainant :
Ext. A1 – Copy of the AROGYADAAN renewal authorization letter.
Ext. A2 – Copy of certificate of Insurance Policy.
Ext. A3- Copy of certificate of Insurance Policy dated 09/06/2015.
Ext. A4 – Copy of AB AROGYADAAN mender Guide Book.
Ext. A5- Policy details.
Ext. A6- Copy of discharge summary.
Ext. A7- Copy of laboratory result.
Ext. A8- Pharmacy bill.
Ext. A9 - Histopathology report.
Ext. A10 –Discharge bill.
Ext. A11- Pharmacy bill payment details.
Ext. A12- Medical report of attending Doctor.
Ext.A13- Copy of letter worth by the complainants of the 3rd opposite
party dated 13/10/2015.
Ext.A14- Copy of checklist of Mandatory documents to be collected
with claim.
Ext.A15- Reply letter given to the complainant by 3rd opposite party
having a number CC:140276 dated 01/12/2015.
Ext.A16- Copy of Reply letter issued by the 2nd opposite party.
Ext.A17- Copy of postal receipt and acknowledgement card.
Ext. A18 –Copy of the letter sent by the complainant to the 3rd opposite
party
Ext. A19 –Newspaper advertisement regarding Insurance Companies
health news dated 12/09/2016.
Ext. A20 –Request to issue terms and conditions of AB AROGYADAAN
Medical Insurance Policy.
Ext. A21 –Terms and condition of Insurance Policy.
Ext. A22 –Histopathology report of CPC medical laboratory.
Ext. A23 –Letter given by the department of surgical Oncology.
Ext. A24 –Surgical details of the complainant’s wife.
Exhibits for the opposite parties
Ext. B1- Health Insurance details.
Witnesses for the Complainant
PW 1 – P.T. Jose (Complainant)
Witnesses for the opposite parties
NIL.
Sd/-
PRESIDENT
Sd/-
MEMBER
Sd/-
MEMBER
Forwarded/ By Order
Sd/-
Assistant Registrar
