By Sri. A.S. Subhagan, Member:-

            This Consumer Complaint is filed under section 35 of the Consumer Protection Act 2019.

            2.  Facts of the case in brief:-      The Complainant’s husband, Joshi Antony had taken a Family Insurance Medi-claim policy from the Opposite Party No.4 in the year 2012.  Opposite Party No.4 is the branch Office of Opposite Party No.3.  Opposite Party No.3 is an insurance broking company having tie up with different insurance companies.   After the receipt of the insurance premium from the consumers, the Opposite Party No.3 issued the policy of its tie up Companies.  The selection of the insurance policy was renewed by paying the premium amount in the branch office of the Opposite Party No.3 at Meenangady, Wayanad.  Towards the renewal of the policy, the husband of the Complainant paid Rs.7,360/- as premium on 05.05.2019.  After the receipt of the insurance premium, the Opposite Party No.3 renewed the policy and issued the insurance certificate of Opposite Party No.1. As per said insurance Certificate, the Master policy number is 0284956640, Certificate number is 024705180001329, Joshy Antony, Sumi Joshi, Aldion Joshy and Aldrin Joshi are the insured persons and insured sum was Rs.2,00,000/- per insured persons.  It was also stated that the Master Policy Holder is Muthoot Fincorp Limited and Intermediary name is Muthoot Risk Insurance and Broking Services Private Limited.  On 29.01.2019, the Complainant consulted Dr. Sr. Mary, Gynaecologist, Fatima Mata Hospital, Kalpetta and taken scan from the Karuna Diagnostics and Reseach Centre, Kalpetta due to abdominal pain.  As per the scan report, it was found that the Complainant was having cyst in the right ovary.  For better treatment, she was admitted in Baby Memorial Hospital, Kozhikode and the cyst was removed on 16.02.2019 and discharged on 18.02.2019.  For the surgery, the Complainant had spent an amount of Rs.1,04,963/-. After that the Complainant had submitted the claim form to the Opposite Party No.2 for the reimbursement of Rs.1,04,963/- which was the hospital expenses.  The Opposite Party No.2 is the department of Opposite Party No.1 dealing with medi-claims.  The claim form was received by Opposite Party No.2 on 06.03.2019.  But subsequently, the claim was repudiated by Opposite Party No.2 stating that the cyst was dermoid cyst.  In fact, the cyst was hemorrhagic.  But in the claim form it was mistakenly instead of hemorrhagic cyst stated as dermoid cyst.  It was a clerical mistake occurred at the time of filling the claim form.  After knowing the mistake, the doctor who treated the Complainant had issued a certificate stating that the cyst was hemorrhagic.  The said Certificate was issued on the basis of lab report.  After that the claim form was again sent along with the certificate to the Opposite Party No.2 for consideration.  But the Certificate of the Doctor was not considered by the Opposite Party No.2.  It is respectfully submitted that in past, the Complainant had undergone treatment for her two pregnancies at Assumption Hospital, Sulthan Bathery and had taken scan.  At that time, no cyst was detected in the scan.  If the cyst was dermoid, definitely the cyst should have been found a place in the scan report taken at that time.  Hence the repudiation of the claim is on baseless grounds.  Moreover, the policy was commenced in the year 2012.  At the time of taking the first policy, the Opposite Party No.4 had promised that after 4 years from the commencement of the policy, the policy would cover all the decease.  Hence the repudiation of the claim on the ground that the cyst was dermoid cyst is against the undertaking given by Opposite Party No.3 and 4.  Hence the Complainant approached Opposite Party No.4 and asked for the reimbursement of the claim amount.  But Opposite Party No.3 and 4 had not taken any steps to reimburse the amount.  It is clear evidence of deficiency of service on the Opposite Parties.  The repudiation of the claim against the terms agreed is a deficiency of service.  Opposite Party No.3 and 4 had never informed the Complainant that the deceases like dermoid cyst are not covered by the policy.  It is also a deficiency of service on the part of the Opposite Party No.3 and 4.  Due to the said act of the Opposite Parties the Complainant had suffered a great mental agonies, financial loss and hardships.  The Complainant is entitled to get an amount of Rs.1,04,963/- towards the claim and Rs.50,000/- towards mental agonies and hardships suffered by the Complainant.  Hence prayed to direct the Opposite Parties to pay an amount of Rs.1,04,963/- towards the claim amount and to pay an amount of Rs.50,000/- as compensation, cost and to grant such other relief as this Commission deems fit to grant.

            3.  Notices were served to the Opposite Parties for appearance.  Opposite Party No.1 filed version, complaint against Opposite Party No.2 was dismissed; Opposite Party No.4 filed version and Opposite Party No.3 adopted the version of Opposite Party No.4.

            4.  Contents of version filed by Opposite Party No.1:-  The Opposite Party admitted that the Complainant had taken a medi-claim/Health Care Policy No: 0284951875 for the period from 14.05.2018 to 13.05.2019. The allegation that the Opposite Parties are liable to cover, all treatment expenses during the validity of policy of Insurance issued to the Complainant is not fully correct.  It is submitted that  the Policy of Insurance issued to the Complainant specifically stipulated that '' if any insured person suffers an illness or accident during the policy period that requires insured persons hospitalization as an inpatient then the Company would pay for the expenses for the benefits mentioned below”.  Therefore hospitalization due to illness or accident is very much essential for getting benefits under the Policy. The liability of the Opposite Party if any is strictly in accordance with the terms and conditions of the policy. The Opposite Party admitted that the Complainant had submitted a claim form to the Opposite Party alleging that the patient named Sumi Joshi was admitted and treated at Baby Memorial Hospital for the period from 15.02.2019 to 18.02.2019 for the treatment of ovarian dermoid cyst.  As per the documents submitted, the insured was admitted for treatment of ovarian dermoid cyst which falls under category of congenital defect/anomalies. Evaluation and treatment related to a condition which is present since birth has been excluded in the policy as per Clause 2(e) of the schedule of the policy. Therefore, the Opposite Party is not liable to pay any amount to the Complainant as per the terms of the Policy and hence the Opposite Party has repudiated the claim. The averment in the complaint that the Petitioner was treated for hemorrhagic cyst is false. The same has to be proved by the Complainant. The allegation in the complaint are made only for the purpose of the case.  The further allegation that there is deficiency of service on the part of the Opposite Party and that therefore the Complainant is entitled to get full benefits as per the Policy is devoid of any merit.  As per the terms of the Policy, the Complainant is not entitled to get Rs.1,04,963/- with interest and cost from the Opposite Party.  There is no deficiency of service or unfair trade practice on the part of the Opposite Party in processing the claim of the Complainant. The Opposite Party has rendered adequate and proper service to the  Complainant in the matter of settling the claim made by the Complainant. The allegation that there was negligence and deficiency of service on the part of the Opposite Parties in considering the claim application and that the Complainant has sustained loss and damage on account of the same etc are false. As per the terms of the policy the Complainant is not entitled to get any amount or compensation from the Opposite Party.  Hence prayed to dismiss the complaint.

            5.  Contents of version filed by Opposite Party No.4 (Adopted by Opposite Party No.3):-  The Opposite Party admitted that the Complainant’s husband Joshy Antony had taken a family Insurance Medi-claim Policy No: 0284956640 of the first Opposite Party through the 4^th  Opposite Party and had renewed the policy on 05.05.2019 after paying Rs.7,360/- as premium. It is also admitted that Joshy Antony, Sumi Joshy, Aldion Joshy and AIdan Joshy are the insured persons and the insured sum is Rs.2,00,000/-.  The Opposite Party No.4 denied the averments in complaint regarding the          illness of the Complainant; treatment taken from Baby Memorial Hospital Kozhikode; and the amount spent towards hospital expenses etc as the Opposite Party No.4 has no direct knowledge about those things. The allegation regarding violation of the policy, rejection of claim etc is also not within the knowledge of the Opposite Party No.4. The Opposite Party No.4 denied the entire allegations in the complaint. The allegations are false and made only for the purpose of the case. The Opposite Party No.4 denied the allegation in the complaint that the Opposite Party No.4 had promised at the time of taking the policy that the policy would cover all the diseases after 4 years from the commencement of the policy. The Opposite Party No.4 had not given such promises. The further allegation that the repudiation of claim on the ground that cyst was dermoid cyst was against the undertaking given by the Opposite Party No.4 is false.  The Opposite Party No.4 had not given such undertaking. The Opposite Party No.4 had explained all the terms and conditions of the policy to the Complainant’s husband and he took the policy after clearly understanding the same. It is also denied that the Complainant approached the Opposite Party No.4 for reimbursement of the claim amount and that the Opposite Party No.4 did not take any steps to reimburse the amount etc. The decision to approve or reject the claim is taken by the Opposite Party No.1 and the Opposite Party No.4 has no role to play in the same in addition to what is stated above.  The Opposite Party No.4 submitted the following:- At the time of taking the policy this Opposite Party had clearly communicated all the terms and conditions to the Complainant's husband and he had agreed to take the insurance only after fully understanding and accepting the same. Invariably all insurance policies would explicitly mention the exclusions and limitations to the policy. Even otherwise, when the terms of the policy are explicitly recorded in the policy document, there is no question of anyone misguiding the Complainant. Further it is known to everyone that before taking the policy, the insured is required to disclose few details to the insurance company, including the details of all pre-existing ailments and considering the same, the policy document would be drawn and issued. Hence in the instant case also the Complainant ought to have mentioned regarding her existing ailments, if any. If the Complainant had not done so, then she had acted in a malafide manner by suppressing her existing ailments. The Opposite Party No.1 might have issued the policy document relying on the declaration given by the Complainant. Even assuming without admitting that the terms and conditions were not communicated to the Complainant, the Complainant always had the opportunity to opt out of the policy within 15 days from the receipt of the policy document if he was not satisfied with the terms and conditions of the policy. However, he had not exercised the said option. It is submitted that once the claim form and related documents are submitted, it is up to the Opposite Parties No.1 and 2 to decide whether the claim can be settled or not. The Opposite Party No.4 does not have any role in processing the claim form. The Opposite Parties No.1 and 2 after processing the claim form decide whether the benefit under the policy could be extended or not in accordance with the terms and conditions. The limitations or conditions of the policy subject to exclusions would be checked by the Opposite Parties No.1 and 2 and then the decision to allow or disallow the claim is taken. It is solely determined by the Opposite Parties No.1 and 2 and the Opposite Party No.4 cannot interfere in the same as both are two different entities. As such there was no deficiency of service or unfair trade practice on the part of the Opposite Party No.4. Hence the Complainant is not entitled to get any of the reliefs claimed in the complaint from the Opposite Party No.4. If at all the Complainant is entitled to get any amount, the same has to be paid by the Opposite Party No.1.  The Opposite Party No.4 is not liable or responsible for any repudiation of claims by the Opposite Party No.1. It is clear that, all insurance policies, including the one under question, are issued with certain conditions and exclusions as specified in the policy documents itself and all decisions regarding whether a claim could be allowed or not is the absolute discretion of the Opposite Party No.1 at all times and this Opposite Party cannot interfere with or influence the decision of the Opposite Party No.1, the insurer. Since there was no deficiency of service and/or unfair trade practice on the part of the Opposite Party No.4, the Opposite Party No.4 is not liable to compensate the Complainant in any manner. Hence, prayed to dismiss the complaint.

            6.  Chief affidavit was filed by the Complainant, Ext.A1 to A9 were marked from her side and she was examined as PW1 and Dr. Usha Payyady, Gynaecologist was examined as PW2; Ext.A10 was marked by PW2.  Ext.B1 was marked from the side of Opposite Parties but Opposite Parties had no oral evidence to adduce.

            7.  From the complaint, version, documents marked, oral evidence adduced by PW1 and PW2 and the arguments of the Counsels in hearing, Commission raised the following Points for consideration:-

1. Whether there has been any deficiency in service/unfair trade practice from the part of the Opposite Parties?
2. If so, Relief and Cost?

8.  Point No.1:-  The case of the Complainant is that being a member of the family insurance Medi-claim policy, though claim application was submitted before the Opposite Parties for getting claim amount in respect of a surgery conducted for removing a cyst from her right ovary, the Opposite Parties repudiated her claim on untenable ground which is deficiency in service from the part of the Opposite Parties.  On the other hand, the contentions of the Opposite Parties, admitting the policy and claim application, are that (1) Hospitalisation due to illness/accident is required for getting benefits under the policy. (2)  The Complainant had submitted claim application alleging that the patient named Sumi Joshi was admitted and treated at Baby Memorial Hospital for the period from 15.02.2018 to 18.02.2019 for the treatment of ovarian dermoid cyst which falls under the category of congenital defect/anomalies which is excluded in the policy as per clause 2(e) of the schedule of policy.  (3) The averment in the complaint that the Complainant was treated for haemorrhagic cyst is false etc.  All other allegations in the complaint are denied by the Opposite Parties.  According to the Complainant, the cyst was haemorrhagic.  But in the claim form it was mistakenly written as dermoid cyst, which was occurred at the time of filling the claim form.  After knowing the mistake, the doctor who treated the Complainant had issued a Certificate stating that the cyst was haemorrhagic.  The same Certificate was issued on the basis of the lab report.  Then corrected claim form was submitted before the Opposite Parties, along with the Certificate issued by the treated doctor.  But it was not considered by the Opposite Parties.  It is also seen submitted by the Complainant that even though she had undergone treatment for two pregnancies at Assumption Hospital, Sulthan Bathery and had taken scan, no cyst was found and if the cyst was dermoid, definitely it could have been detected in the scan.  At the time of taking the first policy, Opposite Party No.4 had promised that after 4 years from the commencement of the policy, the policy would cover all the decease.  From Exts.A3, A4, A6, A7 documents, it is evident and convinced by the Commission that the cyst for which the Complainant had undergone surgery and treatment was haemorrhagic but not dermoid.  Moreover, PW2, the treated doctor who is the Senior Consultant of Baby Memorial Hospital, having more than 25 years of experience has deposed in her detailed oral evidence that “in the present case it is a corpus mutium.  Cu case    congenital AÔ.  So Ext.A3, A4, A6, A7 and the deposition of the PW2 clearly substantiate the contentions of the Complainant, disproving the contentions of the Opposite Parties.  Therefore, the repudiation of the claim of the Complainant can no way be admitted as it is not in good faith but only to cheat the Complainant by non-payment of her valid claim, which is deficiency in service from the part of the Opposite Parties.  In the present case, complaint against Opposite Party No.2 was dismissed. Opposite Party No.3 and Opposite Party No.4 are related to insurance broking agencies of Opposite Party No.1.  The claim of the Complainant is repudiated by Opposite Party No.1.  Hence there is no proved deficiency in service on the part of Opposite Party No.2 and 3.  Being the Insurance Company, Opposite Party No.1 had issued the policy and repudiated the claim.  So deficiency in service that is Point No.1 is proved against Opposite Party No.1.

9.  Point No.2:-  As point No.1 is seen answered against the  Opposite Party No.1, they are liable to  compensate the Complainant.

In the result, the complaint is allowed and Opposite Party No.1 is directed to

1. Pay the claim amount of Rs.1,04,963/- (Rupees One Lakh Four Thousand Nine Hundred and Sixty Three Only)
2. Pay compensation of Rs.50,000/- (Rupees Fifty Thousand Only)
3. Pay cost of Rs.10,000/- (Rupees Ten Thousand Only).

The above amounts shall be paid by Opposite Party No.1 to the Complainant within one month from the date of receipt of this Order, failing which the amounts will carry interest @ 9% per annum from the date of this Order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 23^rd day of November 2023.

Date of Filing:-08.03.2021.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Sumy Mathew.                               Nil.

PW2.              Dr. Usha Payyadi.                          Gynecologist.                                             

Witness for the Opposite Parties:-

                        Nil.     

Exhibits for the Complainant:-

A1.                  Receipt.                                                                     Dt:25.05.2017.

A2.                  Copy of Claim Form.                                             Dt:23.02.2019.

A3.                  Certificate issued from Assumption Hospital , Sulthan Bathery.

                        Dt:01.06.2019.

A4.                  Certificate issued by Dr. Usha Payyadi, Baby Memorial Hospital,

                        Kozhikode. Dt:28.03.2019.

A5.                  Copy of Certificate of Insurance-Renewal.

A6.                  Lab Investigations of Sumy Joshi.

A7.                  Copy of Histopathology Report.

A8.                  IP Receipt Voucher.                                               Dt:23.02.2019.

A9.                  Printout of Email sent by Opposite Party No.4 to Opposite Party

No.1 and 2.

A10.               Copy of Discharge Summary of Sumy Joshi from Baby Memorial

Hospital, Kozhikode.

Exhibits for the Opposite Parties:-

B1.                  Copy of Renewal Notice/Group Medi-prime.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

                                                                                                              Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-