Date of Filing:16.03.2009<br /> Date of Order:18.08.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> <br /> Dated: 18TH DAY OF AUGUST 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> COMPLAINT NO: 604 OF 2009<br /> <br /> S.V. Sreedhar,<br /> S/o A.S. Vishwanath,<br /> New No.19, Old No. 124/43,<br /> 11th Cross, 20th Main,<br /> Padmanabhanagar,<br /> Bangalore-560 070. Complainant<br /> <br /> V/S<br /> <br /> The New India Assurance Company Limited,<br /> Represented by its Manager,<br /> 10/1, “Kukreja House”, <br /> I Floor, Kumara Krupa Road,<br /> Bangalore 560 001. Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed u/Sec. 12 of the Consumer Protection Act, 1986.<br /> The facts of the case are that, the complainant is a policy holder with the opposite party under the Hospitalization and Domiciliary Hospitalization Benefit Policy and the father of complainant was also insured for a sum of Rs.50,000/- for a period from 01/08/2007 to 31/07/2008. The premium amount for the period from 01/-8/2007 to 31/07/2008 was Rs.4,075/-. Subsequently the complainant increased his policy from 01/08/2008 to 31/07/2009 and was paying a premium of Rs. 9,194/- and his father’s coverage was enhanced from Rs.50,000/- to Rs.1,00,000/- and the policy was renewed. The complainant’s father was suddenly admitted to Sri Jayadeva Institute of Cardiology, Bangalore on 26/08/2008 i.e., after 26 days from the renewal of the policy. He was advice for a pace maker and accordingly the father of the complainant got implanted the pace maker. The cost of the Hospitalization was Rs.1,87,535/- and the respondent had to pay Rs. 1,00,000/- at that critical juncture but, paid only Rs.36,250/-. The health policy is taken to avoid making payments at the time of Hospitalization and the respondent is bound to make the hospitalization a cashless transaction. The complainant handed over the discharge summary, hospital bills and medical bills to the opposite party and sought for refund of the insured sum of Rs.1,00,000/- and the complainant in all incurred Rs.1,50,000/- expenses to his father’s hospitalisation. It is submitted by the complainant that his father had no preexisting illness and the pace maker has nothing to do with the preexisting illness. The policy was renewed for several years. The opposite party has not settled claim for one or the other pretext. The complainant is entitled for a sum of Rs.50,000/- towards damages for mental agony and also entitled for refund of Rs.63,750/- with interest. <br /> 2. Notice was issued to opposite party. Opposite party appeared through Advocate and defence version filed admitting that, Hospitalisation benefit policy / Mediclaim policy has been taken by the complainant and policy was valid from 01/08/2008 to 31/07/2009. The opposite party submitted that there is no deficiency in service or negligence. Complainant should have approach the proper “JUDICIAL FORUM” and not before this Consumer Forum. The opposite party allowed the claim to the extent of Rs.36.250/- as the complainant was entitled to sum assured of Rs.25,000/-, plus bonus of Rs.11,250/-. As per clause 6.0-C, complainant is not entitled for additional claim of Rs.75,000/-. Additional premium paid by the complainant shall be treated as fresh policy. The complainant is claiming an amount within the statutory period of 30 days from the date of renewal of policy. Therefore, it is the case of bonafide reputation. Hence, opposite party requested to dismiss the complaint. <br /> 3. Affidavit evidence of respective parties filed and the documents are also produced. Arguments are heard. <br /> 4. In the light of the arguments advanced before us, following points arise for consideration:<br /> 1. Whether there was deficiency in service on the part of opposite party?<br /> <br /> 2. Whether the repudiation of part of the claim is justified and lawful?<br /> <br /> 3. Whether the complainant is entitled for the claim amount (insured amount)?<br /> REASONS<br /> 5. Almost all the facts are admitted in this case. The complainant has taken Hospitalisation and Domiciliary Hospitalisation benefit policy from the opposite party company for himself and his family members. The first policy was taken for the period from 01/08/2008 to 31/07/2009. The sum assured in case of father of complainant Sri. A.S. Vishwanath was Rs.25,000/-. This fact has been admitted by the opposite party. There is no dispute on this aspect. The complainant has obtained hospitalisation benefit policy/mediclaim policy and the previous mediclaim policy was renewed. The policy period was from 01/08/2008 to 31/07/2009. In this renewal policy the sum assured for his father A.S. Vishwanath was enhanced to Rs. 75,000/- and in addition to Rs.25,000/- which was sum insured in the earlier policy. In this way the total sum assured comes to Rs. 1,00,000/- in respect of A.S. Vishwanath. All these facts are admitted and there is absolutely no dispute. Unfortunately, the father of complainant A.S. Vishwanath was not well and he was admitted to Jayadeva Institute of Cardiology. Discharge summary has been produced. Date of admission was on 26/08/2008 and date of discharge was on 01/09/2008. As per the discharge summary of the hospital Temporary Pacemaker Implantation was done on 26/08/2008 and Permanent Pacemaker Implantation + Coronary Angiogram done on 27/08/2008. The hospital records also shows permanent pace maker implantation. In the indication column it is mentioned as Complete Heart Block. In the procedure details it has been mentioned as “LHC done by the right femoral artery approach by Seldinger’s Technique”. Coronary Angiogram done by using Right and Left Judkins Catheter. The only defence taken by the opposite party in not allowing the entire claim is that, policy was renewed on 01/08/2008 and the sum assured was enhanced to Rs.75,000/-, the patient was admitted to hospital on 26/08/2008 i.e., within 30 days from the date of issuance of policy. The learned Advocate for the opposite party referred to us the mediclaim policy rules and conditions. Rule 4.2 states any diseases other than those stated in clause 4.3 below contracted by the insured person during the 30 days from the commencement date of policy is excluded. This exclusion clause will not apply if the policy is renewed with our Company without any break. Relying on this clause the company has paid Rs.25,000/- plus bonus as per the earlier policy to the complainant. The company refused to pay Rs.75,000/-, the sum enhanced under the renewal of policy on the ground that, if the policy is to be renewed for enhanced sum then the restriction as applicable to the fresh policy will apply to additional sum insured as if a separate policy has been issued for a difference. The company has not properly interpreted clause 4.2 of the conditions. Any diseases other than those stated in clause 4.3 contracted by the insured person during first 30 days from the commencement of policy is excluded. Clause 4.3 has given list of diseases/ailments/surgery not covered. In this clause totally 22 diseases have been specified. These 22 ailments/diseases are not covered if the insured person takes treatment during first 30 days from the commencement of the policy. By going through clause 4.3 we do not find the heart disease or ailment or any disease connected with heart. Therefore, there is no question of exclusion clause being applied to the present case. Admittedly, in this case the father of complainant was admitted to Jayadeva Institute of Cardiology for heart related ailments. As per the discharge summary of the hospital, Pacemaker Implantation was done since there was complete heart block and Coronary Angiogram was done. Therefore, the treatment taken by the complainant in the Jayadeva Institute of Cardiology was in respect of heart ailment/diseases and these disease or ailment does not find place in list of 22 diseases/ailments mentioned in clause 4.3 of the terms and conditions of policy. The learned Advocate for the opposite party submitted that hypertension is mentioned in the list of diseases. I am of the opinion that the father of complainant had not taken treatment for hypertension in Jayadeva Institute of Cardiology and on the other hand he has taken treatment for his heart ailment. Therefore, there is absolutely no justifiable reason to repudiate the claim put up by the complainant. The repudiation of the claim by the opposite party company for the enhanced sum is wholly unjustified and not proper. On careful reading of terms and conditions of mediclaim policy, it is very clear that, opposite party company should have accepted the claim and paid the additional sum insured i.e., Rs.75,000/- to the complainant in addition to the earlier sum insured. The complainant has spent more than Rs.1,87,000/- for his treatment and hospitalisation. He has produced hospital bills and receipts. However, the complainant is entitled only the enhanced sum insured of Rs.75,000/- from the opposite party company. Taking into consideration of all the facts and circumstances of the case, documents and by looking into the terms and conditions of mediclaim policy, I am of the opinion that it is a fit case to direct the opposite party company to pay Rs.75,000/- to the complainant. The complainant has claimed Rs.50,000/- towards damages for mental agony and deficiency in service etc.,. On the facts of the case, I am of the opinion that the ends of justice will be met in directing the opposite party company to pay the sum insured i.e., Rs.75,000/-. This is not a case to award damages. In the result I proceed to pass the following:<br /> <br /> ORDER<br /> 6. The complaint is allowed. The opposite party is directed to pay Rs.75,000/- to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within 30 days, the above sum carries interest at 10 per cent p.a., from the date of this order till payment / realisation. <br /> 7. The complainant is entitled for cost of Rs.1,000/- as costs of the present proceedings from the opposite party. <br /> 8. Send the copy of this Order to both the parties free of costs immediately. <br /> 9. Pronounced in the Open Forum on this 18TH DAY OF AUGUST 2009. <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> MEMBER MEMBER<br /> rhr.,