O R D E R
Per Sri A. Hazarath Rao, President:-
The complainant filed this complaint u/s 12 of the Consumer Protection Act seeking reimbursement of medical expenses of Rs.10,162.45 ps and interest of Rs.4830-55 ps on it @24% p.a., from 15-04-11; Rs.10,000/- as damages for pain and suffering; Rs.5,000/- towards deficiency of service and Rs.5,000/- towards expenses.
2. In brief averments of the complaint are hereunder:
The complainant on 24-12-90 took ‘Bhavishya-Arogya’ policy for Rs.50,000/- and paid premium amount to the opposite parties who in turn on 16-12-93 issued the policy bearing No.150801/91/0000/000001. The opposite party undertook to reimburse medical/surgical expenses upon the advice of a duly qualified physician/medical specialist as an in-patient or under domiciliary hospitalization benefits from the policy retirement age. The subject policy will come into force after the complainant completing 55 years. The complainant on 08-01-11 suffered with heart problem and consulted M/s Lakshmi Super Specialties hospital, Guntur. Dr. P.V. Manohar Rao of the said hospital referred the complainant to M/s Krishna Institute of Medical Sciences, Vijayawada for coronary angiogram. The complainant got himself admitted as inpatient on 16-01-11 in M/s Krishna Institute of Medical Sciences, Vijayawada and underwent coronary angiogram on 17-01-11. The complainant was discharged on 17-01-11. The complainant incurred Rs.10,162.45 ps towards treatment. The complainant on 19-01-11 addressed the 2nd opposite party for issue of claim form and requested for reimbursement. The complainant submitted claim forms to the opposite parties on 15-03-11 enclosing the bills and receipts who in turn registered it as claim No.15080148122490000125. Since then the opposite parties did not settle complainant’s claim inspite of repeated requests. Any claim has to be settled within thirty days from the date of submission of claim form as per notification dated 16-10-02 of Insurance Regulatory and Development Authority. The act of opposite parties in not settling the claim amounted to deficiency of service. The complaint therefore be allowed.
3. The contention of the opposite parties in brief is thus:
The complaint is barred by time as it was filed beyond two years. The opposite parties are not liable to pay any amount as claimed by the complainant towards mental agony, interest and legal expenses. The complaint therefore be dismissed.
4. Exs.A-1 to A-9 on behalf of complainant were marked. No documents were marked on behalf of opposite parties.
5. Now the points that arose for consideration in this case are these:
1. Whether the complaint is barred by time?
2. Whether the opposite parties committed deficiency of service?
3. Whether the complainant is entitled to compensation and if so to what amount?
4. To what relief?
6. POINT No.1:- Ex.A-4 is copy of letter dated 19-01-11 addressed by one K. Siva Prasad, insurance surveyor to the 2nd opposite party. Ex.A-5 is another letter dated 13-03-12 addressed by the said Siva Prasad to the 1st opposite party. It is not the case of the opposite parties that they did not receive claim form from the complainant. It can therefore be presumed that the claim is pending with the opposite parties.
7. Relying on the judgment of Supreme Court rendered in Kandimalla Raghavaiah and company vs. National Insurance Company Limited 2009 CTJ 950 (SC) the National Consumer Disputes Redressal Commission in Lakshmi Bhai and others vs. ICICI Lombard General Insurance Company Limited and others 2011 (4) CPR 64 (NC) held:
“The cases where such payment is not made, would fall in one of the following categories—
1) Where no claim is made either with nodal officer or the Insurance Company, within 2 years of date of death such claims shall be barred by limitation.
2) Cases where claim is made to nodal officer or nodal officer has forwarded the claim to Insurance Company or claim has been directly filed with Insurance Company within 2 years of the death and the claim has remained undecided. In such a case the cause of action will continue till the day the Respondent/insurance Company pays or rejects the claim.
3) In a case where the Respondent/insurance company rejects the claim, the cause of action arises again from the date of such rejection.
8. The contention of the complainant is that the complaint was in time as it is pending unsettled with the opposite parties and the said contention is amply supported by the above judgment. Hence we opine that the complaint is in time and answer this point in favour of the complainant.
9. POINT No.2:- Ex.A-4 and A-5 clearly revealed the attitude of the opposite parties. Not settling the claim for a period of about two years by the opposite parties itself amounted to deficiency of service. We therefore opine that the opposite parties committed deficiency of service.
10. In Smt Ganga Patil and others vs. the Executive Engineer (Electrical and others 2013 (1) CPR 255 (NC) it was held that the amount of compensation must commensurate with the quantum of loss. No doubt the complainant was subjected to mental agony as rightly contended by him and it cannot be estimated in monitory terms. Under those circumstances, awarding Rs.3000/- towards deficiency of service and compensation will meet ends of justice. We therefore answer this point accordingly.
11. POINT No.3:- The complainant filed Ex.A-2 showing the amount incurred by him at M/s Lakshmi Super Specialty Hospitals, Guntur and KIMS hospital, Vijayawada amounting to Rs.10,162.45 ps. The risk under Ex.A-1 policy commenced from 01-07-03. Clause (1.2) of Bhavishya Arogya policy reads as follows:
“Now this policy witnesses that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon the company undertakes that if during the balance period of life time of the insured commencing from the ‘Policy Retirement Age’ as herein defined and as stated in the schedule hereto, the insured shall whilst anywhere in India incur medical/surgical expenses upon the advice of a duly qualified physician/medical specialist duly qualified surgeon/medical practitioner (hereinafter called Medical practitioner) at (i) any nursing home/hospital herein defined (hereinafter called hospital) as an inpatient or (ii) under domiciliary hospitalization benefits as hereinafter defined in connection with illness/disease or bodily injury through accident the company will pay to the insured the amount of such expenses as are actually and necessarily incurred in respect thereof by or on behalf of such insured but not exceeding the amount for any one illness and the amount during the life time of the insured commencing from the ‘Policy Retirement Age’ as stated in the schedule” .
12. The complainant underwent treatment in Krishna Institute of Medical Sciences, Vijaywada on the advice of a cardiologist at Guntur as revealed from Ex.A-2. Therefore, we opine that the complainant satisfied the terms and conditions of Ex.A-1 policy and the opposite parties have to reimburse the medical expenses. We therefore answer this point also against the opposite parties.
13. POINT No.4:- In view of above findings, in the result the complaint is partly allowed as indicated below:
1. The opposite parties are directed to pay Rs.10,162.45 ps (Rupees ten thousand, one hundred and sixty two and paise forty five only) together with interest @9% p.a., from 15-04-11 till payment.
2. The opposite parties are directed to pay Rs.3,000/- (Rupees three thousand only) towards deficiency of service and compensation.
3. The opposite parties are directed to pay Rs.2,000/- (Rupees two thousand only) towards costs.
4. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of the order.
Typed to my dictation by Junior Steno, corrected by me and pronounced in the open Forum dated this the 30th day of July, 2013.
Sd/-XXX Sd/-XXX Sd/-XXX
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
DOCUMENTS MARKED
For Complainant:
Ex.Nos. |
DATE |
DESCRIPTION OF DOCUMENTS |
A1 |
24-12-90 |
Copy of Bhavishya-arogya policy bearing No.150801/91/0000/000001 issued by the OP |
A2 |
15-03-11 |
Copy of claim form submitted by the complainant along with bills and receipts for charges |
A3 |
17-01-11 |
Copy of discharge summary format of the complainant issued by KIMS, Vijayawada |
A4 |
19-01-11 |
Copy of letter of complainant addressed to the Divisional Manager, United India Insurance Company Limited, Guntur |
A5 |
13-03-12 |
Letter of complainant addressed to the Branch Manager, United India Insurance Company Limited, Guntur |
A6 |
|
Copy of online grievance of complaint |
A7 |
29-01-13 |
Copy of grievance acknowledgement letter |
A8 |
16-10-02 |
Copy of insurance regulatory and development authority notification |
A9 |
16-05-13 |
Copy of e-mail addressed by complainant to the Sr. Branch Manager, United India Insurance Company Limited, Guntur. |
For opposite parties:- NIL
Sd/-XXX
PRESIDENT
NB: The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.
