Advocate Dhumal for the Complainants
Advocate Sanjay Gaikwad for the Opponents
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Per Hon’ble Shri. V. P. Utpat, President
:- JUDGMENT :-
Date -31st August 2013
This complaint is filed by consumers against the Insurance Company for deficiency in service u/s 12 of the Consumer Protection Act, 1986. Brief facts are as follows-
[1] Complainant No.1 is son of the complainant No.2. They are doing the retailer business of Supari in Campt at Pune. They have obtained insurance policy bearing No. 150400/48/02/02544 for the period from 13/10/2002 to 12/10/2003. The total sum assured for the same was Rs.3,60,000/- and the net premium was Rs.5005/-. The said policy was family package of the complainant and their family members. On 27/01/2003 complainant No.1 came to the shop in order to give breakfast to the complainant No.2. At that time the complainant No.1 was feeling giddy hence complainant No.2 took him to KEM hospital and the treatment was given to him. Doctor has diagnosed that the complainant No.1 is suffering from Dyspnoea with severe anemia, worm infestation. He was treated as indoor patient in the said hospital for 11 days and was discharged on 6/2/2003. Amount of Rs.25,989.90 was spent for his medical treatment. Complainants have asked reimbursement of that amount from the Opponents but they were informed that the claim is inadmissible as per the terms and conditions of the policy. According to the complainant the act of the Opponents is deficiency in service. They have claimed compensation of Rs.25,989.90 alongwith interest @ 24% p.a. and cost of Rs.10,000/-.
[2] The claim is resisted by the OpponentNo.1 by filing written statement. It has denied the contents of the complaint in toto. It is specifically denied that they have caused deficiency in service. According to them eventhough the complainants have obtained mediclaim policy they are not entitled for reimbursement as the disease which is diagnosed for the Complainant No.1 is excluded from the terms and conditions of the policy. It has prayed for dismissal of the complaint.
[3] After scrutinizing the documentary evidence, affidavits of both parties and considering the written argument as well as hearing the argument of both counsel following points arise for my determination. The points, findings and reasons thereon are as follows-
S.No. | POINTS | FINDINGS |
1 | Whether complainants have proved that Opponents have wrongly repudiated the mediclaim ? | In the affirmative |
2 | What order ? | Complaint is partly allowed. |
Reasons-
As to the Point Nos. 1 to 3 –
It is not in much dispute that the complainants have purchased mediclaim policy from the Opponent No.1 and it was a family package. The facts as regards the premium as well as total coverage are not in much dispute. The Opponents have produced the policy. This indicates that the complainants were covered by the insurance policy. The facts as regards the illness of the complainant No.1 as well as medical treatment taken by him in the hospital are also not seriously challenged. The complainants have produced voluminous documentary evidence in order to substantiate the contents regarding the medical treatment including the discharge card. The main grievance of the Opponents is that the disease which is diagnosed by the doctor is not covered by the insurance policy. On the contrary it is specifically excluded by the terms and conditions of the policy. The Opponents have mostly relied upon the clause No. 4.8 of the policy which is laid down as follows-
“4.8 Convalescence, general debility, “Run-down” condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alchohol.”
According to the complainants complainant No.1 was suffering from Dyspnoea with severe anemia, worm infestation. It is significant to note that the Opponents have not taken medical examination of the complainants and their family members who had been covered under the policy. In such circumstances it is very difficult to accept the contention of the Opponents that the complainant was suffering from the disease which is diagnosed by the doctor on the date of issuance of the policy. More over the disease referred in the exclusion clause 4.8 and the disease which is diagnosed by the doctor of the complainant are not similar. Hence I held that the Opponents have wrongly repudiated the mediclaim and that amounts to deficiency in service. The complainants have claimed the reimbursement of the medical expenses as well as interest on the said amount by way of damages. But there is no clause about the payment of interest hence the complainants are entitled for appropriate compensation instead of interest. The complainants are also entitled for the cost of litigation. I answer the points accordingly and pass the following order-
:- ORDER :-
1. Complaint is partly allowed.
2. It is hereby declared that the Opponents have caused deficiency in service by repudiating the claim of the complainants.
3. The Opponents are jointly and severally directed to pay Rs.25,989.90 to the complainants within six weeks from the date of receipt of copy of order.
4. The Opponents are jointly and severally directed to pay compensation of Rs.10,000/- by way of deficiency in service and Rs.5,000/- for compensation on the ground of physical and mental sufferings and Rs.2,000/- as cost of litigation to the complainants within six weeks from the date of receipt of copy of order.
5. Both Parties are directed to collect the sets which are provided for the Hon’ble Members within one month from the date of order. Else those will be destroyed.
Copy of order be supplied to both the parties free of cost.
Place- Pune
Date – 11/10/2013
