Kerala

Idukki

CC/100/2022

Mohanan R - Complainant(s)

Versus

United India Insurance Co ..Ltd - Opp.Party(s)

Adv.K M Sanu

07 Jan 2023

ORDER

DATE OF FILING : 14/06/2022

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  7^th day of January 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.100/2022

Between

Complainant                          : Mohanan R.,

                                                 Enchakkattu House,

                                                 Keerikkodu,

                                                 Thodupuzha East P.O., 685 585.   

                                                     (By Adv.K.M.Sanu)

                                                              And

Opposite Party                  :1 . The Manager, United India Insurance Co.Ltd.,  

                                                G.M.Arcode, Piravam P.O., Ernakulam      

                                                District, 686 664.

                                                (By Adv.Sony George)

                                           2 . The Manager, New India Assurance Co.Ltd.,

                                                 Divisional Office, Madhura Road,

                                                 Virutha Nagar P.O., Tamil Nadu 626 001.

                                           3 . The Manager, New India Assurance Co.Ltd.,

                                                 Thoduuzha Branch, Thodupuzha P.O.

                                            4 . The Manager, Medi Assist Insurance Co.,

                                                 TPA P Ltd., Rajaji Road, Chikkago Plaza,

                                                  Kochi- 682 035.

                                                (For 2^nd , 3^rd  and 4^th OP by Adv.R.Sajeev)

 

O R D E R

SMT.ASAMOL P., MEMBER

 

Complainant’s case is briefly discussed hereunder:-

 

1 . Complainant is a retired government employee.  He has been a member in Rubber Growers and Producers Association.  Hence, he was also a member

(Cont.....2)

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in the policy scheme provided by first opposite party for the association members since 2010.  As per this policy scheme, complainant, his wife and their 2 children were insured with coverage of 1 Lakh Rupees.  Complainant had renewed this policy without fail in proper time.  During the period from 20/12/2019 to 19/12/2020, complainant had renewed this policy with coverage of Rs.1,75,000/-.

2 . Thereafter, during the period from 20/12/2020 to 19/12/2021 complainant had applied to first opposite party for renewing this policy with premium of Rs.34,824/-.  But, policy was renewed by second opposite party.  First opposite party has done this change without either the consent obtained from complainant or any information given to complainant.  There was no disputes regarding the claim at the time of the policy had been in effect on this first opposite party.

3 . Complainant’s wife is an advocate who is practicing at Thodupuzha.  She is suffering cancer since 2012 and has been in treatment at Aster Medicity Hospital, Ernakulam.  At that time, treatment expenses was also costly and claim amount had given by first opposite party without any dispute.  As per this policy, there is double amount coverage for cancer type diseases without 24 hours admission in hospital.

4 . Thereafter, the disease was spreading to bones so, she had needed more treatment.  Thus, she had gone to hospital on 22/07/2021 and 19/08/2021 for more treatment.  Moreover, increasing the severity of the diseased and when the given medicine does not work, highly expensive medicines were prescribed.  Kemo treatment  was also continued.  For the treatment of these 2 days, there were 6 bills and total amount was Rs.1,77,319/-.  After coming from the hospital, complainant had applied for claim amount along with

 

(Cont.....3)

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needed documents.  But Rs.17,500/- was only allowed as per the claim number 26734991.  They had reduced the balance amount Rs.1,59,819/- without any reason.  When the amount credited in bank account, complainant was informed about less amount only allowed by opposite parties.

5 . As per the policy, it would be getting the amount of Rs.3,50,000/- in one year.  Out of this amount, Rs.1,46,198/- was only given by these opposite parties.  Complainant has given another complaint as CC No.166/2021 before this Commission for claim amount of Rs.1,25,870/-.

6 . Opposite parties have not allowed claim amount without proper reason.  This is deficiency in service on the part of them.  Complainant is entitled to get claim amount and compensation also.  Hence he has prayed the following reliefs.

1.   Opposite parties may be directed to pay the balance amount of Rs.1,59,819/- in the claim application.
2.    Opposite parties may be directed to pay Rs.50,000/- as compensation and Rs.10,000/- as legal expense.

Upon notice from this Commission, all opposite parties have appeared and  have filed detailed written version.  Contentions of first opposite party are briefly discussed hereunder:-

1 . The petition is not maintainable either in law or on facts.

2 . The petitioner has not remitted an amount of Rs.34824/- to this opposite party for renewing his policy.  This opposite  party is not aware whether the policy of petitioner is still in existence from 20/12/2020 to 19/12/2021.

3 . The petitioner has not filed any claim application before this opposite party.  The petitioner had taken policy from the second opposite party covering a period from 20/12/2020 to 19/12/2021 and therefore the petitioner

(Cont.....4)

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had to file claim application before the second opposite party.  More over this opposite party is not liable to pay any claim amount to the petitioner since he has not taken any policy from the 1^st opposite party during the relevant period.  There is no unfare trade practice from the part of 1^st opposite party.

4 . The petitioner has no right to get any claim amount from this opposite party since there is privity of contract between the petitioner and this opposite party.  There is no cause of action for the petitioner to file this petition against this 1^st opposite party . The petitioner unnecessarily dragged this opposite party to this petition.  Hence petition is to be dismissed with cost of this opposite party.

Contentions of 2^nd and 3^rd opposite parties are discussed hereunder:-

1 . All averments in the petition except those which are specifically admitted hereunder are false and hence denied by this respondent.

2 . The petition is not maintainable either under law or on facts against this respondent.  The petitioner has no cause of action against this respondent.

3 . It is admitted that the petitioner and his wife were insured with this respondent  insurance company vide a master policy No.73040034200400000040 for a period of one year from 20/12/2020 to 19/12/2021, issued  to Rubber Growers and Processors Association, Cochin – 15, with a sum insured of Rs.1,75,000/- under “critical illness care”.  Claims to the extent of Rs.1,46,198/- are paid to the insured for the treatment of his wife for Metastatic Carcinoma of the Breast, who underwent chemo/radiotherapy treatments, and a sum of Rs.28,802/- is the only balance amount available for future claims in the policy period, under “critical illness care”.

 

(Cont.....5)

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4 . It is admitted that another claim was reported in the policy on 19/08/2021 for reimbursement of Rs.1,77,319/- for secondary Malignant Neoplasm of the breast and was discharged on the same day.  On scrutiny of the claim documents by our panel doctors, an amount of Rs.17,500/- was approved and paid on 06/12/2021.  The reasons for the difference of Rs.1,59,819/- is as under.

Rs.1,58,039/- towards pharmacy and medicine charges being the excess of sub limit for oral chemotherapy over 10% of sum insured and 25% for Monoclonal Antibody, which is paid on previous claims.  Rs.1400/- towards consultation charges, Rs.200/- towards miscellaneous charges and Rs.180/- towards hospital charges come under the excess of 10% of the sum insured sub limit, included in the above.

5 . The claim is rightly settled as per Policy Terms and Conditions No.19.44, which reads as : “Oral Chemotharapy”.  It is hereby declared and agreed that at the request of the insured that cost of oral chemotherapy will be payable under the policy.  The limits will be as mentioned in the schedule”.

6 . It is submitted that this respondent had promptly attended the claim of the complainant and settled it as per policy conditions.  Hence there is no deficiency of service or unfair trade practice from the side of this respondent, as alleged by the petitioner.

7 . It is submitted that a case no.166/2021 is pending before this Hon’ble Commission filed  by the same complainant, during the same policy period, regarding the repudiation of certain claims by this respondent.  The overall liability, if any, is subject to the sum insured as per the policy.

8 . It is submitted that this respondent has a co-insurance agreement with the 1^st respondent insurance company as to share the compensation amount in the ratio of 51:49, in the event of a claim, which is specifically mentioned on the

(Cont.....6)

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face of the policy.  Hence even if this respondent is found liable under the policy, the liability is limited to 51% and the balance 49% vests with the 1^st respondent.

9 . It is submitted that, even if the petitioner is entitled for any compensation, the interest if any payable on the same shall not exceed the prevailing bank rate and also this respondent shall not be liable to pay any interest for the period prior to the date of the award.

10 . The petitioner has to prove that he has not preferred any other claim petition before any other Court of Law in respect of the accident alleged in this case.  

Hence, the petition may be dismissed and exonerating these opposite parties from all liabilities and costs.

Contentions of 4^th opposite party are discussed as follows:-

1 . This respondent is 3^rd party administrator appointed by 2^nd respondent to service the insured in case of a claim is reported on the specific medical insurance policies issued by the 2^nd respondent.  This respondent is authorized by the 2^nd respondent to service the insureds, as per the policy conditions and exclusions attached to the policy.

2 .It is admitted that the petitioner and his wife was insured with 2^nd and 3^rd respondent Insurance Company vide a master policy No.73040034200400000040 for a period of one year from 20/12/2020 to 19/12/2021, issued to Rubber Growers and Processors Association, Cochin – 15, with a sum insured of Rs.1,75,000/- under “Critical Illness Care”.  Claims to the extent of Rs.1,46,198/- are paid to the insured for the treatment of Metastatic Carcinoma of the Breast, who underwent chemo/radiotherapy treatment, and an amount of Rs.28,802/- is the only balance amount available

(Cont.....7)

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for future claims in the policy period, under “Critical Illness Care”.

3 . It is admitted that another claim was reported in the policy on 19/08/2021 for reimbursement of Rs.1,77,319/- for Secondary Malignant Neoplasm of the breast and was discharged on the same day.  On scrutiny of the claim documents by our panel doctors, an amount of Rs.17,500/- was approved and paid on 06/12/2021.  The reasons for the difference of Rs.1,59,819/- is as under.

Rs.1,58,039/- towards pharmacy and medicine charges being the excess of sublimit for oral chemotherapy over 10% os sum insured and over 25% for Monoclonal Antibody, which is paid in previous claims.  Rs.1400/- towards consultation charges, Rs.200/- towards miscellaneous charges and Rs.180/- towards hospital charges come under the excess of 10% of the sum insured sub limit, included in the above.

4 . The claim is rightly settled as per Policy Terms and Conditions No.19.44 which reads as “Oral Chemotherapy” it is hereby declared and agreed that at the request of the insured that cost of oral chemotherapy will be payable under the policy.  The limits will be as mentioned in the schedule.

5 . It is submitted that this respondent had promptly attended the claim of the complainant and settled it as per policy terms and conditions.  Hence there is no deficiency of service or unfair trade practice from the side of this respondent, as alleged by the complainant.

Hence, the petition may be dismissed and exonerating these opposite parties from all liabilities and costs.

Complainant has produced 5 documents.  These were marked as Exts.P1 to P5.  No oral evidence adduced.  Opposite parties also have not adduced oral evidence.  They have produced 2 documents.  These were marked as R1

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and R2.  After hearing, the case was taken for orders.  No notes filed by both parties.  Now, the points which arise for consideration are:-

1. Whether there is any deficiency in service on the part of opposite parties?
2. If so, what are the reliefs entitled to complainant?

The Points are considered together

We have heard the counsels for both parties.  On the perusal of documents, we have found that complainant was insured person under group family healthcare and personal accident insurance policy.  Thus, his wife and children were also insured under this policy.  This policy was issued by 1^st opposite party during the period from 20/12/2019 to 19/12/2020.  Thereafter, this policy was renewed under Ext.R1 by New India Assurance Co.Ltd., during the period from 20/12/2020 to 19/12/2021.  According to complainant his wife as a cancer patient was consulted for review of her treatment in Aster Medicity, Kochi on 22/07/2021 and 19/08/2021 and there were 6 bills of Rs.1,77,319/- of the treatment and medicines also.  But, opposite parties has reimbursed Rs.17,500/- only.  These bills were produced and marked as Ext.P4.  As per this Ext.P4 documents, it is seen that there were bills of Rs.1,77,319/-.  On the perusal of Ext.R2, we have found that New India Assurance Co.Ltd., has settled for Rs.17,500/- against the amount claimed for Rs.1,77,319/-. Petitioner and his wife was insured with 2^nd and 3^rd opposite parties for a period from 20/12/2020 to 19/12/2021 with sum insured of Rs.1,75,000/- under critical illness and extension of Rs.1,75,000/-. Complainant has given evidence that he was paid Rs.1,46,198/- from basic care, which according to him is an extension of sum assured under critical illness care.  There is no contrary evidence from the side of opposite parties in this regard.  Total premium paid by complainant was for Rs.1,75,000/- has

(Cont.....9)

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sum assured for basic health care and ‘additional critical care’ for even amount, apart from a cover of Rs.2 Lakhs for personal accident.    Accordingly, complainant is entitled to claim up to Rs.3,50,000/- in  an year as per this policy.  Thus complainant has received Rs.1,46,198/- as claim amount from 2^nd opposite party during this policy period.  Therefore, complainant is entitled to get the balance claim amount of Rs.2,03821/- as per this policy period.  Since the claim amount was repudiated, complainant filed a complaint as CC No.166/2021 before this commission for claim of Rs.1,25,870/-.  It was finally decided and disposed. During the pendency of the above number case, complainant has filed this complaint for claim amount of Rs.1,59,819/-.  Complainant has submitted in this complaint that he has to get the claim amount of Rs.2,03,802/- as per both the complaint.  He has prayed the relief to get the claim amount of Rs.1,25,870/- in CC No.166/2021.  After receiving the claim amount Rs.1,46,198/-, complainant has right to get the balance claim amount Rs.2,03,802/- during this policy period.  If so, complainant will be entitled only for receiving the reimbursement amount of Rs.77,932/- as per this complaint.  After receiving Rs.1,46,198/- from 2^nd opposite party, he has claimed Rs.1,25,870/- under CC No.166/2021 case.  Thus, totally Rs. 1,46,198/-+1,25,870/-, ie, Rs.2,72,068/- was claimed out of Rs.3,50,000/- which was the insurance coverage under this policy.  Therefore complainant will be entitled for the balance amount out of which he already claimed.  This policy was issued by 2^nd and 3^rd opposite parties.  Therefore, they are liable to reimburse the claim amount in the policy period from 20/12/2020 to 19/12/2021.  But, these opposite parties didn’t reimburse the claim amount as per the policy to complainant.  This is deficiency in service on the part of them.   Hence complainant is entitled for compensation also. 1^st opposite party has not issued the insurance policy in

 

(Cont.....10)

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which the period from 20/12/2020 to 19/12/2021 to complainant and 4^th opposite party was authorized by 2^nd opposite party for service the insureds, as per the policy conditions and exclusions attached to the policy.  Hence, we are of the view that they are not liable. 

In the result, complaint is partly allowed against 2^nd and 3^rd opposite parties with cost as hereunder:-

1  . 2^nd and 3^rd opposite parties are directed to pay Rs.77,932/- to complainant along with 12% interest per annum from 15/11/2021 ie, date of claim until     payment or realization.

2 . Also, 2^nd and 3^rd opposite parties are directed to pay Rs.30,000/- as compensation and Rs.5000/- as litigation cost to complainant, failing which the amounts except cost of litigation shall carry 12% interest within 45 days from the date of receipt of copy of this order till its realization.

Extra copies to be taken back by parties without delay.

 

 Pronounced by this Commission on this the   7^th  day of January, 2023.

 

                                                                                          Sd/-                                                                                  

                                                                               SMT.ASAMOL P., MEMBER

                                                                                         Sd/-

                                                                        SRI.C.SURESHKUMAR, PRESIDENT

                                                                                                  Sd/-

                                                                               SRI.AMPADY K.S., MEMBER

 

 

 

 

 

 

 

 

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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 certificate of insurance dated 20/12/2019

Ext.P2 – Copy of Reimbursement Claim form dated 20/12/2010

Ext.P3 – Copy of Discharge summary of Aster Medcity

Ext.P4 – Copy of Cash bill Op of Aster medcity

Ext.P5 – Details of the payment  of  Medi Assist dated 08/12/2021

On the side of the Opposite Party :

Ext.R1 -  New India Assurance Co.Ltd., Policy Schedule

Ext.R2 - Details of the payment  of  Medi Assist dated 08/12/2021

 

                                                                                               Forwarded by Order 

 

 

                                                                                          ASSISTANT REGISTRAR