BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 25/04/2011

Date of Order : 31/12/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 205/2011

Between

And

O R D E R

C.K. Lekhamma, Member.

1. The brief facts of the complainant's case are as follows :

The complainant had taken a mediclaim policy from the 1^st opposite party. His wife, Bindu Tibu, is the second insured person. The 2^nd opposite party is the service provider (Agent) of the 1^st opposite party. The complainant was a policy holder, since 2002 and the present policy from 17-07-2010 to 17-06-2011 is an extension of the previous policies. The complainant's wife was admitted to the Paul's Hospital, Kaloor as inpatient on 08-09-2010 and discharged on 09-10-2010. Operation was on 08-09-2010. The diagnosis is left ovarian dermoid cyst. This was done under G.A. A total sum of Rs. 75,000/- was spent for the entire treatment. The sum insured is Rs. 50,000/-. Hence only this amount was claimed. The mediclaim was submitted before the 2^nd opposite party. Evenafter seven long months, the opposite parties have not cared to give a reply either accepting or rejecting the claim. All the original documents are submitted before the 2^nd opposite party. Several enquiries were made, but no response from the opposite parties. Failure to give a reply is an unfair trade practice. This also amounts to gross deficiency in service. Hence the complainant approaches this Forum on the following reliefs against the opposite parties :

1. To direct the opposite party to pay a sum of Rs. 50,000/- by way of reimbursement for treatment expenses of his wife.

2. To direct the opposite parties to pay a compensation for Rs. 5,000/- for mental agony and harassment.

3. Rs. 2,000/- as cost of litigation.

2. The version of the 1^st opposite party is as follows :

The opposite party had granted an Individual Mediclaim Policy to the complainant and to his wife for the period from 17-07-2010 to 16-07-2011. The policy was issued subject to the terms and conditions. The insurance policies are issued with terms and conditions and also with exclusions. There is no specific pleading to deficiency in service against the 1^st opposite party. The 1^st opposite party was already paid Rs. 12,500/- to the complainant towards the full and final settlement of his claim and the said settlement amount was arrived after considering all the relevant facts and also relying on the policy conditions. As per the discharge summary of the insured Mrs. Bindu Tibu, the illness was diagnosed as Left Ovarian Dermoid Cyst and the procedure adopted by the doctor was Laparoscopic Hysterectomy. As per Clause 1.2 of the policy condition, expenses incurred for Hysterectomy is payable upto 25% of the sum insured or actual expenses incurred whichever is less, and here in this case 25% of the sum insured is on the lower side and accordingly the claim of the complainant was settled for Rs. 12,500/- being the 25% of the sum insured of Rs. 50,000/-. The process of the claim was duly intimated to the complainant and suppressing all those facts, the complainant had made a false allegations in his complaint. There is no deficiency in service on the part of the opposite parties.

3. The complainant appeared in person. The 1^st opposite party appeared through counsel. The 2^nd opposite party remained absent. The complainant was examined as PW1. Exts. A1 to A4 were marked on his side. The 1^st opposite party adduced only documentary evidence. Exts. B1 to B4 were marked on their side. Heard the complainant and the counsel for the 1^st opposite party.

4. The points that arose for consideration are as follows :

1. Whether the complainant is entitled to get the mediclaim amount of his wife from the 1^st opposite party?

2. Compensation and costs, if any?

5. Point Nos. i. and ii. :- There is no dispute with regard to the issuance of the policy. The case of the complainant is that eventhough he submitted mediclaim of his wife before the 2^nd opposite party, they have not processed the claim application. The repeated enquiries made by the complainant were discarded by the opposite parties.

6. The 1^st opposite party contended that they have paid Rs. 12,500/- to the complainant towards full and final settlement of the claim. Since as per clause 1.2 of the policy conditions expenses incurred for hysterectomy is payable upto 25% of the sum insured or actual expenses incurred whichever is less. Hence 25% of the sum insured was given to the complainant, since sum insured is in the lower side.

7. Ext. A1 is the receipt issued by the 2^nd opposite party to the complainant. Ext. A2 is the discharge report of the complainant's wife, and Ext. A3 is the treatment report of the complainant's wife and Ext. A4 is the intimation dated 10-05-2011 from the 2^nd opposite party to the complainant. Ext. B1 is the complainant's policy (duplicate) and terms and conditions. On a perusal of Clause 1.2 of the terms and conditions, it is mentioned that expenses in respect of some specified illness will be restricted. In which 'Hysterectomy' is included. Limits per surgery restricted upto “actual expenses incurred or 25% of the sum insured whichever is less.”Exts. A2 and B3 are one and the same document. In which it is specifically stated that the procedure adopted for surgery was “Total laparoscopic hysterectomy with bilateral salpingectomy.” In accordance of the terms and conditions, the complainant is entitled to get 25% of the sum insured from the opposite parties. It is well settled law that the parties to the contract are bound by the terms and conditions of the agreement .

8. During the proceedings in this Forum, the 1^st opposite party paid Rs. 12,500/- to the complainant. It seems that Ext. A4 intimation letter was issued on 10-05-2011 with regard to the settlement of insurance claim that is after this complaint. As per Ext. A1, the complainant submitted claim documents before the 2^nd opposite party on 17-09-2010. Ext. B4 is the scan report and Ext. B2 is the medical bills. The opposite party has no case that the complainant was not provided any documents in time for processing the claim application. No evidence is before us, to show the reason for the inordinate delay in processing insurance claim. This negligent act of the opposite parties amounts to deficiency in service,for which the complainant has to be compensated. We fix the compensation at Rs. 5,000/-. It appears that the opposite parties dragged the complainant for unnecessary litigation. Hence the complainant is entitled to get litigation costs from the 1^st opposite party.

9. In the result, we partly allow the complaint and direct that, the 1^st opposite party shall pay Rs. 5,000/- and Rs. 1,000/- to the complainant as compensation and litigation costs respectively.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order, failing which the above amounts shall carry interest @ 12% p.a. from the day fixed for compliance of this order till realisation.

Pronounced in open Forum on this the 31^st day of December 2011

Forwarded/By Order, Sd/- C.K. Lekhamma, Member.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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