SMT. RAVI SUSHA: PRESIDENT
Complainant filed this complaint U/s 12 of Consumer Protection Act 1986 against OPs seeking to give direction to OPs 1 and 2 to allow the claim of the complainant and to grant the claimed amount Rs. 1,39,807/- together with Rs.50,000/- towards compensation for mental agony caused to him alleging deficiency in service on the part of OPs 1 and 2.
The averments in the complaint are that the complainant was working as a plant assistant in Hindusthan Newsprint Factory, Nagar, Kottayam. The company of the complainant introduced a Medi-claim policy to its employees including its pensioners made a tie up with the New India Insurance Company for giving Medical Insurance. As per the policy coverage was available to all the employees and retired employees of the company along with their family members. The Premium paid by the insured and the company was 70:30 ratios. The complainant has joined in the scheme and paid premium regularly without any break. The complainant retired in the year 2011. In the year 2015 the company directed the complainant to take account in Punjab National Bank, Kannur branch, the 3rd OP herein, and the complainant opened an account in the 3rd OP bank with account No. 425900010052. In the year 2016 the company and Punjab National Bank become tie up with oriental Insurance company and the insurance coverage was implemented through the oriented insurance company. The complainant has paid his share of premium and renewed the policy. As per the policy a total sum insured is Rs.2,00,000/- (Rupees Two Lakhs only). In the month of September 2018, the complainant had undergone Coronary Artery Bypass Graft Surgery from Meitra Hospital, Kozhikode. The complainant had paid total amount of Rs.1,39,807/- towards the expenses in the hospital. After discharge the complainant has claimed the total amount of Rs.73,409/- from the OP No.1. But OP No.1 has rejected the claim of the complainant with a letter signed by the 2nd OP, stating that the present condition is a pre-existing condition and under clause 4.1, the claim is not payable. It is submitted that complainant has paid the premium as per the terms and conditions of the OPs. He has not served with a copy of document containing covenants and conditions, regarding the admissibility of claim. The complainant has renewed the policy believing the representations made by the OP No.1. The complainant has claimed only the medical expenses he has incurred which are borne by the original bills. The acts of the OPs in rejecting the claim without any valid reason amounts to deficiency of service and unfair trade practice from the part of the OPs. Hence this complaint.
1st OP Insurance Company filed written version. It was not denied that the Insurance company issued PNB – ORIENTAL Royal Mediclaim policy to the complainant for himself and for his spouse for an amount of Rs.2,00,000/- which was valid for the period from 24/01/2018 to 23/01/2019. It was also not denied that complainant had undergone Coronary Artery Bypass Graft Surgery from meitra Hospital, Kozhikode and was under treatment as impatient from 27/09/2018 to 29/09/2018. It was also admitted that complainant has submitted claim form. It was admitted that the claim was repudiated for the reason that the present condition is a pre-existing condition and under clause 4.1. So the claim is not payable”. Therefore the repudiation was legal and valid and prayed for the dismissal of the complaint. OP No.1 further contended that the claim of the complainant is not supported by adequate and dependable medical bills. According to Insurance company as per policy condition CD 1.2 all the bill amount cannot be sanctioned. Further the treatment taken by complainant was pre-existing which is specifically excluded as per policy exclusion clauses. It is stated that there is no deficiency in service on the part of OP No.1. OP No.2 neither appeared nor filed version. Hence OP No.2 is set ex-parte.
OP No.3 filed version and additional version stated that it is submitted that the complainant had opened an account with Panjab National Bank having Account No.4259000100527238. He had also availed the benefit of PNB-ORIENTAL ROYAL MEDICLAIM POLICY from OP No.1 bearing No.44020248/2018/9281 covering the period from 24/01/2018 to 23/01/2019. It is also submitted that this OP has nothing to do with the alleged claim and its rejection/settlement also. It is further submitted that as per the terms of master agreement Viz. “AGREEMENT FOR PNB ORIENTAL ROYAL MEDICLAIM POLICY” dated 19/06/2015 entered between the Oriental Insurance Company Limited (insurer) and Panjab National Bank (banker), this OP will not be responsible for settlement of claim, and for that only the insurer is liable to be insured. The Clause No.11 of the said Agreement, which relates to the ‘Liability clause of the Banker’ reads as follows :- “Except, as otherwise provided for in the Agreement, on remitting the premium, as stated in clause 3(a), the Bank’s responsibility under the Agreement shall be over and Bank will not be responsible for insurance of the Policy, TPA Cards, Settlement of the claims or any other liability relating to the policy. For all other liabilities, insurer is liable for the Insured’. The clause No.3 (a) refers the payment of premium collected in respect of the policy. Thus this OP is not liable for the claim made by the complainant. In this specific case there is no issue regarding payment of the premium. It is thus clear that this OP Bank is not responsible for payment of the premium.
Complainant filed his affidavit and additional affidavit. Complainant also produced documents Ext.A1 to A4. On the other hand deputy Manager of OP No.1 filed affidavit and produced documents B1 to B4. From the side of OP No.3 the agreement for PNB oriental Royal mediclaim policy was marked as Ext. B5.
After that the learned counsel for complainant and learned counsels for OPs 1and OP3 made oral argument.
The submission of the learned counsel for the OP No.1 is that complainant had undergone Coronary Artery Bypass Graft Surgery which was excluded as per clause 4.1 because the disease happened to complainant was a pre-existing disease. Therefore, the complainant is to entitled to any insurance claim.
We have perused the records available and considered the submissions.
The admitted facts are that OP No.1 had issued the medi claim policy in the name of complainant for an amount of Rs.2,00,000/- lakhs and the said policy was valid for the period from 24/01/2018 to 23/01/2019. The insurance policy has been produced from the side of both parties, complainant as well as OP No.1 (Ext.A1 and Ext.B2). It is also admitted between parties that complainant was admitted in Meitra Hospital Kozhikode on 27/09/2018. He was conducted Coronary Artery Bypass Graft Surgery and was discharged on 29/09/2018. Discharge summary was produced from the side of OP No.1 and was marked through complainant (Pw1) as Ext.B1. It was pleaded by the complainant that an amount of Rs.1,39,807/- was spent on the hospital towards treatment expense. OP No.1 had denied the said pleading. OP No.1 stated that the claim of the complainant is not supported by medical bills. Further as per policy section (i)1.2 all the bill amount cannot be sanctioned.
Ext.B4 series is the Inpatient Bill (Detail). Complainant also produced photocopy of Ext.B4 series. On perusal of clause 1.2 of the policy, it is stated that coverage under the policy: Reasonable and necessary expenses are payable under the policy. The Inpatient bills shows for the surgery amount mentioned as 1,05,000/- and pharmacy total for Rs.33,660/-. Therefore, the complainant is entitled to get Rs.1,05,000/-.
Next so far as exclusion clause is concerned, it is undisputed fact that complainant was undergone Coronary Artery Bypass Graft Surgery on 27/09/2018. The learned counsel for the OP No.1 contended that the disease for which the complainant availed treatment is hit under exclusions 4.1 of the policy. On perusal of clause 4 and 4.1 of policy conditions in Ext.B2, it is stated that 4 exclusion. The complainant shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of 4.1 pre-existing health condition or disease. Any disease which are pre-existing, in case of any of the insured person of family, when the cover incepts for the first time, are excluded for such insured person up to 3 years of this policy being in force continuously.
On the other hand, the submission of the learned counsel appearing for the complainant was that the terms and conditions of the insurance policy were not communicated to the complainant Mr. Raveendran K nor these were explained to him. In the complaint itself complainant pleaded that he has not served with a copy of document containing covenants and conditions regarding the admissibility of claim and he has renewed the policy believing the representations made by the OP No.1. Complainant also submitted that he has paid the premium regularly without dues. Further stated that when he was in service, the company of him introduced a medi-claim policy to its employees including its pensioners made a tie up with the New India Insurance company for giving Medical Insurance and thus the complainant has joined in the scheme and paid premium regularly without any break. After retirement in the year 2011, as per the direction of the company he has opened an account in the 3rd OP in the year 2016 January he has joined in the scheme and taken policy from OP No.1. OP No.1 has no case that after 2016 complainant has committed default in paying the premium. OP No.3 also admitted that complainant had opened an account with the Panjab National Bank having account number 4259000527238. In addition to these facts, complainant has categorically deposed while he was in box to the question put forward by the learned counsel of OP No1 in page 3 of Pw1 OP No.1 പറയുന്ന പോളിസി കണ്ടിഷനിലെ 4.1 പ്രകാരം നിങ്ങൾക്ക് യാതൊരു നിവൃത്തിയും കിട്ടാൻ അർഹതയില്ല എന്ന് പറയുന്നു? എനിക്കറിയില്ല
Here complainant has produced Ext.A1 PNB Oriental Royal Medi-calim policy Schedule. It is nowhere mentioned in this policy that the terms and conditions of the policy were also communicated to neither the insured nor the OP No.1, Insurance company has submitted any document before us to show that these policy terms and conditions were also signed by the insured. There is also no evidence on the insurance policy ( Ext.B2) that the terms and conditions of the insurance policy were duly communicated and the explained to the insured. More over we can see that the terms and conditions are printed on separate paper and attached with policy schedule. In the written version of OP No.1, it was not pleaded that the terms and conditions of the Insurance policy were communicated or explained to the insured. Therefore, there is no evidence that the terms and conditions of the insurance policy were duly communicated or explained or sent to the insured.
It is settled position of law that the Insurance company has to prove that the Insurance policy conditions with exclusionary close was duly communicated to the insured.
Further from Ext.B1 the discharge summary it is seen that coronary artery bypass grafting was done on the complainant in the years 2001.
During the examination Pw1 stated that within the period between 2001 and 2018, he had not undergone any treatment for heart disease. OP No.1 also not produced any document in contrary to the said statement.
Hence in view of the facts and circumstances of this case, the complaint is allowed. Since complainant has not alleged any deficiency in service on the part of OP No.3 bank and not sought any relief from the bank, OP No.3 is exempted from the liability. Moreover as per clause No.11 of the agreement between bank and company and as per clause 3 (a) the bank has no responsibility in settling the claim and there is no issue regarding payment of premium to company.
The claim application of the complainant submitted to OP No.1 Insurance company (Ext.B3) shows that he has claimed Rs.1,39,807 as hospitalization expenses. In condition No.1.1 of the condition states that “The company undertakes that if during the policy period any insured person shall suffer from any of the disease, and if such person shall require up on the advise of a duly qualified surgeon to incur hospitalization expenses for surgical treatment at any hospital in India, as an impatient, if the insured person opts for re-imbursement of the claim, the amount of such expenses as are reasonably and necessary incurred in respect thereby such insured shall pay. In Ext.B4 series out of total amount, Rs. 1,05,000/- was spent by the insured for as treatment expense for coronary Angioplasty. So as per condition No.1.1, OP 1 and 2 shall reimburse the said treatment expense to the complainant.
In the result, complaint is allowed in part. OP No.1 and 2 are directed to pay Rs.1,05,000/- to the complainant. Opposite parties 1 and 2 are also directed to pay Rs.25,000/- towards compensation for the mental agony caused to the complainant (senior citizen aged 67 years) due to the deficiency in service on the part of OPs 1 and 2. OPs 1 and 2 shall comply the order within one month from the date of receipt of this order, failing which the awarded amount carries interest @ 9% per annum from the date of complaint till realization. Complainant is at liberty to file execution application against opposite parties 1 and 2 for realization of the ordered amount as per provisions of Consumer Protection
Act 2019.
Exts.
A1 - Mediclaim policy Schedulr dated 15/01/2018
A2 - Photostat copy of Claim form
A3(series) - Inpatient bill (2 in numbers)
A4 - Repudiation letter dated 13/11/2018
B1 - Discharge Summary of Meitra Hospital, Kozhikode
B2 - Insurance policy
B3 - The claim application of the complainant submitted to OP No.1 Insurance company for hospitalization expenses.
B4(series)- Inpatient Bill (Detail)
Pw1 - Complainant
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
