Kerala

Idukki

CC/20/2018

Yeldho Abraham - Complainant(s)

Versus

The Oriental Insurance Company Ltd - Opp.Party(s)

Pradeep kumar

31 Oct 2019

ORDER

DATE OF FILING : 1.2.2018

IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 31^st day of October, 2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT. ASAMOL. P MEMBER

CC NO.20/2018

Between

Complainant : Padayattee Yeldo, S/o. Abraham,

Padayattil House,

Adimali P.O.,

Mannamkandom, Devikulam, Idukki.

And

Opposite Parties : 1. The Manager,

Oriental Insurance Company,

Valiyaparambil Shopping Complex,

First Floor, Pvt. Bus Stand Road,

Adimali – 685 561.

(By Adv: K. Pradeepkumar)

2. Medi Assist Insurance

TPA Pvt. Ltd. No.4/1,

IBC Knowledge Park,

Tower “D”4^th Floor,

Bannerghatta Road,

Bangalore – 560 029.

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

 

Case of the complainant is that :

 

Complainant is a policy holder of 1^st opposite party under Happy Family Floater 2015 policy. When the complainant approached 1^st opposite party for taking a health family coverage policy, the 1^st opposite party explained that the above said policy “Oriental happy Cash-Nishchint Rahein Policy is the best scheme availed to meet cash benefits at the rate of Rs.3000/- per every day of admission in the hospital to meet bystanders expenses. This policy also envisages convalescence benefit at the rate of Rs.3000/- per every day after discharge from the hospital till the insured regain health for return to duty to a maximum amount of the policy amount covering by the Happy Family Policy. Total coverage is floating

(cont....2)

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to all policy holders and the sum assured is Rs.2 lakhs. The complainant had taken this policy having No.441792/48/2017/548 on 23.2.2017 and valid upto 22.2.2018. This policy cover the complainant, his wife and their tow children.

 

The complainant further averred that on 11.10.2017, the complainant's car met with an accident near Kalady and the complainant and his wife sustained serious injuries. Immediately they were taken to Little Flower Hospital, Angamaly and underwent treatment in the emergency department.

 

After first aid, they were taken of Rajagiri Hospital, Aluva for better treatment on the same day.

 

Complainant's wife Minimol was admitted and treated there as Inpatient from 11.10.2017 to 25.10.2017. So she is entitled to get bystanders expenses at the rate of Rs.3000/- per day for 14 days and is estimated to the sum of Rs.42000/- as per the policy. Due to the seriousness of the injuries, the doctor advised the complainant's wife complete bed rest for regaining health to return to normal duty from 26.10.2017 to 20.12.2017 and entitled to get convalescence allowance as promised for 55 days of Rs.1,65,000/-. At the same time, complainant was admitted the same hospital as IP from 20.10.2017 to 24.10.2017 and hence is also entitled to get bystander expense at the rate of Rs.3000/- for 4 days and it comes Rs.12,000/-. But the opposite party refused to entertain the claim and the act of the opposite party amounts to gross deficiency in service and the complainant claims to Rs.50000/- as damages in addition to the claim amount.

 

Hence the complainant filed this petition against the opposite parties seeking relief such as to direct the opposite parties to allow Daily Cash Benefit of Rs.54000/- and convalescence allowance of Rs.2 lakhs. Further direct the opposite parties to pay compensation and cost.

 

Upon notice, opposite parties entered appearance and 1^st opposite party filed detailed reply version by admitting the issuance of the policy and its validity. 1^st opposite party further contended that as per the

(cont....3)

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condition No.2(b) and schedule in page No.13 of the policy, complainant is entitled to get Rs.20,000/- only. Considering the injuries sustained to the complainant, inpatient treatment is not required. As he wanted to take care of his wife, he also got admitted in the hospital. Hence the complainant is not entitled to get the benefit of Rs.3000/- per day.

 

Opposite party further contended that the complainant's wife is entitled to get Rs.42,000/- as per condition No.2(a) and Rs.20,000/- only as lump sum as per condition No.2(b) of the above said policy schedule. Contrary averment are due to misunderstanding of the terms and conditions of the contract of insurance.

Evidence adduced by the complainant by way of proof affidavit and documents. Complainant was examined as PW1 and Exts.P1 to P7 marked. Exts.P1 and P2 are the policy schedule. Ext.P3 is the discharge summary of the complainant issued from Little Flower hospital, Angamaly. Ext.P4 is the inpatient bill (summary) of Minimol, complainant's wife, issued from Rajagiri hospital, Aluva. Ext.P5 is the inpatient bill (summary) of the complainant issued from the above hospital. Ext.P6 is the copy of legal notice and Ext.P7 is the copy of AD Card.

 

From the defence side, Jimmy Mathew, manager of opposite party was examined as DW1 and Ext.R1 policy schedule cum document is marked.

 

Heard both sides.

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?

 

The POINT :- We have heard the counsel of both parties and had gone through the documents. It is an admitted fact that the complainant availed a family health policy from 1^st opposite party, having a special scheme, “Oriental Happy Family Floater Policy.” As per the scheme of this policy, the insured get a daily cash benefit at the rate of Rs.3000/- per

(cont....4)

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day of admission in the hospital to meet bystanders expense. In addition to this the policy envisages convalescence benefit of Rs.3000/- per every day after discharge from the hospital till the insured regain health for return to duty.

 

The learned counsel for the complainant argued that as per the policy scheme, the insured entitled to get convalescence benefit to a maximum amount of the policy amount covered by the Happy Family Policy. In the policy in question, the total coverage is floating to all policy holders and the sum assured is Rs.2 lakhs.

 

The learned counsel further submitted that due to the Road Traffic Accident and resultant injury, complainant and his wife admitted in Rajagiri Hospital, Aluva. Complainant's wife was treated there as IP from 11.10.2017 to 25.10.2017. AT the time of discharge, the doctor who attended her advised that to take complete bed rest. Hence the wife of the complainant was took 55 days to regain her health and to return her normal duty. Hence the complainant's wife is entitled to get 55 days convalescence benefit at the rate of Rs.3000/- per day and it come Rs.165000/- in total. In addition to it, she is also entitled to get bystanders expense for 14 days, from the date of admission to the date of discharge, that is, from 11.10.2017 to 25.10.2017, for 14 days at the rate of Rs.3000/- each and it come to Rs.42,000/- in total. The learned counsel further submitted that since the complainant was admitted in the same hospital as IP from 20.10.2017 to 24.10.2017 due to the infection to her wound, he entitled to get 4 days bystanders expense at the rate of Rs.3000/- per day and it come Rs.12,000/- as per the scheme of this policy. But the 1^st opposite party rejected his claim on the reason that the maximum amount they are entitled to grant is Rs.20000/- and this amounts to gross deficiency in service and unfair trade practice.

 

On the other hand, the learned counsel for the opposite party vehemently argued that as per policy terms and conditions 2(a), the complainant's wife is entitled to get Rs.42,000/- as bystanders expense as she is entitled to get Rs.20000/- to the maximum as convalescence benefit as per condition 2(b). The complainant is not entitled to get any benefit as he pleaded, because he was admitted in the hospital only to take care of his wife. (cont....5)

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For establishing their version, 1^st opposite party produced policy schedule along with policy document and it is marked as Ext.R1.

 

On perusing the document produced by the complainant, it is seen that as per Ext.P4, Minimol, complainant's wife admitted and treated in the Rajagiri hospital, from 11.10.2017 to 25.10.2017. As per the policy scheme, she is entitled to get 14 days bystanders benefit. From Ext.P5, it is very clear that complainant is admitted and treated in the same hospital for 4 days as inpatient and hence he is also entitled to get 4 days bystanders expenses. The counter version that the complainant is admitted for taking care of his wife is not sustainable, because separate inpatient treatment records are opened for the complainant and it is very clear that complainant availed treatment from the same hospital for his injuries and he paid Rs.9356/- as treatment expenses. As per records, both these patients were charges separate room rent also.

 

For answer the pertinent question, whether the complainant's wife entitled to get 55 days convalescence expenses as he averred in the complaint, no clear or specific records are produced by the complainant to convince the Forum that, whether the doctor who treated the complainant's wife advised 55 days bed rest. Moreover, except Ext.P4 inpatient bill, no other treatment records are produced by the complainant to convince that what line of treatment was given by the hospital to his wife. From this exhibit, it is seen that complainant's wife had undergone a surgery and the hospital authorities charged a huge amount by way of surgical charges and surgical equipments. Except this entry in Ext.P4, no other evidence such as treatment records etc. are produced by the complainant to convince the Forum that the complainant's wife took 55 days for recoup her health.

 

On perusing this records, Forum is of a considered view that eventhough the complainant failed to produce any evidence to show that his wife took rest for 55 days, we can assume that she took minimum 15 days bed rest, since she had underwent a surgery. Hence the convalescence benefit can be amounted as Rs.45000/-.

 

The objection raised by the 1^st opposite party in claiming convalescence amount cannot be sustainable because opposite party is

(cont....6)

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stressing the condition 2(b) of the policy documents. The Ext.R1 policy document is having 14 pages and this condition is stated in the page No.13. It is very common and a usual practice of every insurance company is that, they will not provide the policy documents along with policy certificate to the policy holders. Hence normally, the policy holders are totally ignorant about the policy conditions. The insurance companies produces the policy documents only at the time of an issue regarding the policy arises. Such a practice cannot be allowable and the defence by sticking on a policy condition cannot be considered, since the 1^st opposite party has not a case that they issued the policy document along with the policy schedule to the complainant at the time of taking the policy in question.

 

On the basis of above discussion, Forum is of a considered view that 1^st opposite party is liable to pay 14 days bystanders benefit and 15 days convalescence benefit to the wife of the complainant along with 4 days bystanders benefit to the complainant as per the peculiarity of this type of policy which is discussed above.

 

Hence the complaint allowed. The Forum direct the opposite party, to pay Rs.99000/- (14+15+4 = 33 days) to the complainant as the total bystanders benefit and convalescence charges of the complainant and his wife along with Rs.3000/- as litigation cost, within 30 days of receipt of a copy of this order, failing which the amount of Rs.99000/- will carry 12% interest per annum from the date of default, till its realisation.

 

Pronounced in the Open Forum on this the 31^st day of October, 2019

 

 

Sd/-

SRI. S. GOPAKUMAR, PRESIDENT

 

 

Sd/-

SMT. ASAMOL. P., MEMBER

 

 

 

(cont....7)

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APPENDIX

 

Depositions :

On the side of the Complainant :

PW1 - Padayattee Yeldo.

On the side of the Opposite Party :

DW1 - Jimmy Mathew.

Exhibits :

On the side of the Complainant :

Exts.P1 & P2 - policy schedule.

Ext.P3 - discharge summary of the complainant issued from

- Little Flower hospital, Angamaly.

Ext.P4 - inpatient bill (summary) of Minimol, complainant's wife,

issued from Rajagiri hospital, Aluva.

Ext.P5 - inpatient bill (summary) of the complainant issued

from the above hospital.

Ext.P6 - copy of legal notice.

Ext.P7 - copy of AD Card.

On the side of the Opposite Party :

Ext.R1 - policy schedule cum document.

 

 

Forwarded by Order,

 

 

 

SENIOR SUPERINTENDENT