Kerala

Idukki

CC/87/2019

sabu mathew - Complainant(s)

Versus

Unaited India Insurance co ltd . - Opp.Party(s)

27 Jun 2023

ORDER

DATE OF FILING : 30/04/2019

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  27^th day of June 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.87/2019

Between

Complainant                                :  Sabu Mathew,

                                                        Kollappallil House,

                                                        Muthalakkudam P.O., Thodupuzha.

                                                        (By Adv.K.M.Sanu)

                                                   And

Opposite Party :                      : The Manager,

                                                   United India Insurance Co.Ltd.,

                                                   Thodupuzha Branch,

                                                   Thodupuzha P.O.

                                                    (By Adv.Sony George)

 

O R D E R

SRI.AMPADY K.S., MEMBER

 

This complaint is filed U/s 12 of Consumer Protection Act 1986.  Complainant’s averments are briefly discussed hereunder:-

 

1 . Complainant is a policy holder of opposite party for more than 10 years and has been renewing the same without break.  He has renewed the policy for the period from 26/03/2018 to 25/03/2019 by paying premium of Rs.8225/-.  As per policy, complainant, his wife and 3 children were covered for Rs.75,000/- for any kind of treatment, accident etc., and cashless facility is offered.

 

(Cont....2)

-2-

2 . In 2016 while previous policy was live, his son Mathews Kollappally met with bike accident and sustained injuries.  For this, treatment was done at Lakeshore Hospital, Ernakulam and medical implant was done.  For this about Rs.1.5Lakhs had spend and opposite party had given cashless treatment facility for Rs.75,000/- at that time.  Doctor had advised to change the implant on completion of 3 years.

3 . As advised by doctor, his son was admitted in above hospital for changing the implant.  Hospital authorities had given claim request for cashless facility and it was informed that claim is approved.  For removal of implant surgery an amount of Rs.58,663/- was spent.  But opposite party had given Rs.24,723/- only. Opposite party is liable to pay the entire hospital expenses as insured amount is Rs.75,000/-.

4 .  As the policy offers cashless facility and during earlier occasion such facility was given, he had not secured sufficient amount at the time of admission in hospital.  It is informed from hospital that claim request was approved.  But he came to know that reduced amount only was sanctioned by opposite party while he obtained discharge bill.  He could collect balance amount only after efforts were made for several hours.  Hence, his son and family members had to spent all these hours in the veranda of hospital.

5 . As per policy terms, opposite party is liable to pay entire expenses.  His son had treated in tie up hospital of opposite party.  If any dispute exists about bill, it has to be resolved between them. 

6 . Non-payment of full amount is deficiency in service.  Complainant is entitled to get bill amount with 18% interest and also to get compensation for deficiency in service and other difficulties.

So, he prayed for the following reliefs.

(Cont....3)

-3-

1 . Recover and give balance bill amount of Rs.33,940/- from opposite party.

2 . Allow compensation of Rs.25,000/- towards deficiency in service and for difficulties caused to him.

3 . Litigation costs of Rs.5,000/- may be allowed.

Opposite party filed written version as follows.

1 . All the averments in the petition except those which are specifically admitted hereunder are denied as it is false and denied.

2 . The petition is not maintainable either in law or on facts.  Contentions in paragraph No.1 of the petition are almost admitted.

3 . The facts stated in paragraph No.2 of the petition is to be proved by the petitioner by producing original documents.

4 . The contentions in paragraph No.2 of the petition is not fully correct.  It is admitted that after the treatment of Mathews Kollappilly, who is the son of the petitioner, an amount of Rs.75,000/- has been paid by this opposite party.  The opposite party is not aware of the removal of implant after 3 years.

5 . The allegations in paragraph No.3 of the petition is not correct.  The maximum amount covered in the policy is Rs.75,000/- and that amount was already paid by the opposite party.  But the opposite party is not liable to pay non medical expenses and also not liable to pay the additional amount incurred from the same incident in which the entire claim amount already paid.  The implantation is the result of the accident happened earlier and the entire amount has been paid by the opposite party for the original accident and this opposite party has given an additional amount of Rs.24,723/- for the implantation.  This opposite party is not liable to pay any additional amount.

(Cont....4)

-4-

6 . There is no cause of action for the petitioner to file this petition.

7 . This opposite party may be permitted to file additional written statement if found necessary.

Hence opposite party prayed for dismissal of complaint with costs.

No oral evidence was adduced from both sides.  Copy of 3 documents produced by complainant were marked as Ext.P1 to Ext.P3 and copy of one document produced by opposite party was marked Ext.R1.  While case was posted for hearing on earlier occasion counsel for opposite party sought time. Though case was subsequently posted for hearing on 28/04/2023, neither opposite party nor counsel was present and no representation also.  Hence complainant’s side heard and taken for orders.

We have examined the pleadings of both sides and evidence on record.  On a perusal of the same, following points arise for consideration.

1. . Whether there is any deficiency in service on the part of opposite party?
2. .  If so, for what reliefs complainant is entitled to?
3. .  Order to be passed?

 

Point Nos.1 and 2 considered together

On going through the averments in complaint, it is seen that allegation of the complainant is with regard to disallowance of partial amount of treatment though the policy is live and insured amount is Rs.75,000/-.  There is no dispute that cashless facility was not given.  Hospital authorities filed claim request and it is informed from hospital that cashless facility is allowed.  But at the time of discharge and final bill was raised, he came to know that only partial amount is sanctioned.  This fact is not denied by

(Cont....5)

-5-

opposite party.  Contention of opposite party is that on earlier occasion cashless facility for Rs.75,000/- was  given and insurance company was not aware of the changing of implant after 3 years.  This version of opposite party is not believable.  Earlier treatment details were available with opposite party as it had sanctioned the amount at that time based on the treatment details and discharge summary given by hospital. On both times treatment was done in same hospital with which it has tie-up.  Moreover, if any details were needed, it can obtain the same from hospital.  From this, it is clear that opposite party’s contention is not correct.  A patient cannot know his health condition especially in a case like this.  It is for the doctor who treated the patient to decide the future course of action.  A patient is acting according to the direction of concerned doctor.  Total bill amount as per Ext.P3 is Rs.58,663/-.  Complainant’s claim is that an amount of Rs.27,723/- was only sanctioned.  Balance Rs.33,940/- is claimed by complainant.  Opposite party has not rebutted this.

Insurance is a contract of speculation.  Though contract of insurance is voluntary act on the part of a consumer, obvious intendment is to cover any contingency that might happen in future.  Premium is paid obviously for that purpose, as there is legitimate expectation of reimbursement when ACT OF GOD happens.  Insurer is expected to keep that objective in mind and that too from point of view of consumer to cover risk as against plausible repudiation.  Opposite party has not raised any valid and legally sustainable reasons for disallowing an amount of Rs.33,940/.   On a perusal of Ext.R1 policy document, no condition is seen prescribed to the effect that for a subsequent treatment for the same disease /ailment, further claim is not payable.  Obviously, it cannot be prescribed so.   Each policy period is separate.  For renewal   of   policy   separate   premium   is   levied.    Hence   the

 

(Cont....6)

-6-

 

contention that for treatment done due to accident in earlier occasion, opposite party is not liable to honour the claim is unsustainable.  Besides, opposite party has paid partial amount also which seems to be contrary to their contention shown above.  On an analysis of the entire facts and circumstance of the case, we are of the firm view that there is gross deficiency in service on the part of opposite party in not honouring the claim.  Disallowance of genuine claim would definitely create mental agony and loss to the insured for which opposite party is liable to compensate him.  In the above circumstance, we are inclined to allow the balance claim of Rs.33,940/- raised by complainant together with compensation of Rs.5,000/- with simple interest @ 9 % per annum from the date of complaint ie, 30/04/2019 till realization.  Besides, he is entitled to recover litigation costs of Rs.3,000/- from opposite party.  Hence, point Nos.1 and 2 are answered as above.

Point No.3

In the light of foregoing discussions and our findings on point Nos.1 and 2, opposite party is ordered to pay balance treatment expenses claimed by complainant Rs.33,940/- (Rupees Thirty Three Thousand Nine Hundred and Forty only) and compensation of Rs.5,000/- (Rupees Five Thousand only) along with simple interest @ 9% per annum from the date of complaint 30/04/2019 till realization.  Besides, opposite party should pay Rs.3,000/- (Three Thousand only) to the complainant towards litigation expenses.  Above amounts should be paid by opposite party to complainant within 30 days of receipt of this order, failing which complainant is entitled to recover

 

 

(Cont....7)

-7-

the same as ordered above.  Interest ordered will follow as shown above till realization except on litigation costs.

In the result, complaint is allowed in part as shown above.

Parties shall take back extra copies without delay.

Pronounced by this Commission on this the  27^th  day of June 2023.

                                                                                                Sd/-

                                                                            SRI.AMPADY K.S., MEMBER

                                                                                            Sd/-

                                                                 SRI.C.SURESHKUMAR, PRESIDENT

                                                                                            Sd/-

                                                                        SMT.ASAMOL P., MEMBER

 

 

APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1 – Copy of Individual  Health Insurance Policy Schedule front page.

Ext.P2 – Copy of Discharge Summary, Department of Orthopedics, Lakeshore Hospital dated 25/03/2019

Ext.P3 – Copy of inpatient bill summary dated 25/03/2019

On the side of the Opposite Party :

Ext.R1 – Copy of Individual  Health Insurance Policy Schedule

 

 

                                                                                              Forwarded by Order  

 

 

                                                                                        ASSISTANT REGISTRAR