COMPLAINT FILED: 30.05.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 18th JULY 2008<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SRI. SYED USMAN RAZVI MEMBER <br /> SMT. M. YASHODHAMMA MEMBER <br /> <br /> <br /> COMPLAINT NO. 1222/2008<br /> <br /> <br /> COMPLAINANT Ramesh Kodi,<br /> Aged about 58 years,<br /> S/o. K. Krishna Murthy,<br /> R/o. House No. 33, ‘Sumukha’<br /> Karthik Nagar,<br /> LRDE Layout,<br /> Outer Ring Road,<br /> Marathahalli,<br /> Bangalore – 560 037.<br /> <br /> <br /> Advocate (Ganesh Bhat. Y.H.)<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTIES 1. The Tata AIG General Insurance Company Ltd., <br /> Ahura Centre, 4th Floor,<br /> 82, Mahakali Caves Road,<br /> Andheri (E), <br /> Mumbai – 400 093.<br /> Represented by its <br /> Managing Director.<br /> <br /> <br /> 2. Tata AIG General Insurance,<br /> 3rd Floor, JP & DJ Archade,<br /> #69, Miller Road,<br /> Bangalore – 560 052.<br /> Represented by its <br /> Branch Manager.<br /> <br /> <br /> Advocate (Ravi S Samprathi)<br /> <br /> <br /> O R D E R<br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant to direct the Opposite Party (herein after called as O.P) to settle the claim for Rs.1,00,000/- with respect to the expenses incurred by complainant’s wife in taking treatment along with interest and for such other reliefs on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> Complainant took a policy known as “TATA AIG MAHARAKSHA” by paying a premium of Rs.8,990/- to OP which came to be effective from 09.03.2006 to 08.03.2007. Under the said policy the wife of the complainant Smt. K. Jaya Ramesh is a beneficiary. Complainant’s wife was undergoing treatment for Osteoarthritis. When complainant was thinking of taking her for medical treatment the Agents of the OP contacted him and assured him that any treatment taken by his wife for Osteoarthritis will be compensated by their Company. Believing the words of the OP officials complainant renewed the said policy. Then took his wife for treatment between 06.03.2007 to 26.03.2007 incurred a total expenditure of Rs.1,00,000/-. After the discharge he made claim to OP to settle the said medical bill. Unfortunately OP repudiated the said claim on flimsy reasons and grounds. The said repudiation is unjust, improper and without due application of the mind. When the repeated requests and demands made by the complainant, went in futile he even got issued the legal notice. Again there was no response from the OP. Complainant for no fault of his, he is made to suffer both mental agony and financial loss. The hostile attitude of the OP amounts to deficiency in service. Under the circumstances he is advised to file this complaint and sought for the relief accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP under the impugned policy OP covered the risk with respect to accidental death, fractures and dislocations, burns during the course of accident. The policy does not cover sickness related to non-accidental medical expenses. Complainant’s wife has taken treatment for the pre-existing disease like Osteoarthritis which is not covered under the policy. The said ailment occurred due to age and not due to any accident. Under the circumstances OP after due application of mind and on the perusal of the medical records rightly repudiated the claim. There is no deficiency in service of any kind on the part of the OP. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced the documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has proved <br /> the deficiency in service on the part of the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the reliefs now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainant has taken “TATA AIG MAHARAKSHA” policy by paying the necessary premium to the OP and under the said policy his wife Smt. K. Jaya Ramesh is a beneficiary. Of course the said policy was effective from 09.03.2006 to 08.03.2007. In the meantime the wife of the complainant started feeling pain due to Osteoarthritis. During that juncture he was in a double mind whether to renew the said policy or not. When he was under confusion OP Executives contacted him on conversation and deliberation they prevailed upon him saying that treatment for Osteoarthritis is covered under the policy and expenses incurred towards the treatment will be reimbursed. Complainant believed and trusted the said words of the OP officials.<br /> <br /> 7. It is further contended by the complainant that he took his wife for the treatment between 06.03.2007 to 26.03.2007 thereby incurred expenses of Rs.1,00,000/-. A document to that effect is produced. Now it is the grievance of the complainant that after the discharge when he made claim to OP to reimburse the expenses they repudiated it on the ground that the policy does not provide for sickness related or non-accidental medical expenses. Complainant felt the deficiency in service on the part of the OP because there is a breach of promise committed by the OP officials by taking the different stand and opinion while reimbursing the medical expenses. As could be seen from the documents produced by the complainant, wherein he made several correspondence to the OP, complainant in a highly educated ex-central government servant who took VRS. <br /> <br /> 8. His own letters speaks to the fact that he had a doubt about covering of the risk under the said policy other than non-accidental treatment, that is why he was thinking twice whether to renew his policy or not. At that time OP executives contacted him and promised that the expenses incurred by him towards the treatment for Osteoarthritis is reimbursable. There is nothing to discard the contention of the complainant in that regard. Insurance is mainly based on the good faith and confidence between the two. Unfortunately to promote their business OP officials gave promises to the complainant to renew the policy. But when the question of settling of the claim comes they take shelter under certain clause of the policy that it does not provide for sickness related or non-accidental medical expenses. The approach of the OP in that regard is not fair and honest.<br /> <br /> 9. When we go through the so called policy terms, it refers to some special conditions relating to Osteoporosis or pathological fracture. This Osteoporosis is a condition that causes thinning and weakening of normal bones. It is a decrease of density of bone mass. When this occurs, a patient with Osteoporosis will have weaker bone and have a higher risk of bone fracture. That means to say actually there is no fracture under Osteoporosis. When we consider Osteoarthritis it is a clinical syndrome in which low-grade inflammation result in pain in the joints, caused by abnormal wearing of the cartilage that covers and acts as a cushion inside joints.<br /> <br /> 10. So both the ailments refers to the bone and the joints. There is a thin line of difference. Osteoarthritis symptom cannot be defined as a disease but it is a pathological problem and as noted in Osteoporosis may amounts to pathological fracture, though not the actual fracture. Unfortunately OP restricted its defence contending that person who takes the policy, that too under the head of “MAHARAKSHA” is entitled for settlement of the claim only in case of accidental death, fractures, dislocations and burns. Of course we have borne in our mind that the present policy is not a medi claim policy, but when once the terms of the policy discloses that they can very well cover Osteoporosis, then why not Osteoarthritis, both ailments sailing in the same boat.<br /> <br /> 11. Having noted down the above said facts and circumstances, the repudiation appears to be unjust and improper. The reasons assigned for repudiation are not sound. The replies given by the OP denying the claim of the complainant are not based in a good faith and actual facts of the case. Complainant’s wife has not taken treatment for any pre-existing disease. To our understanding Osteoarthritis is interrelated with Osteoporosis. Under such circumstances we are of the view that the complainant deserves the relief as claimed. There is a proof of deficiency in service on the part of the OP. For no fault of the complainants, they are made to suffer both mental agony and financial loss. With these reasons we answer point nos.1 and 2 accordingly and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP is directed to settle the claim for Rs.1,00,000/- and reimburse the said amount to the complainant within 4 weeks from the date of communication of this order. In view of the nature of dispute no order as to costs.<br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 18th day of July 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br />