Complainant through Lrd. Adv. Rathod
Opponents through Lrd. Adv. Maheshwari
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Per : Mr. V. P. Utpat, President Place : PUNE
// J U D G M E N T //
(04/04/2014)
This complaint is filed by the insurer against the Insurance Company and Health Care Service Private Limited, for deficiency in service under section 12 of the Consumer Protection Act, 1986. The brief facts are as follows,
1] The complainant is a permanent resident of Khadki, Pune-3, the opponent no.1 is a insurance company and the opponent no. 2 is a health care service unit. The complainant has obtained health insurance policy from the opponent no. 1 for last 12 years without any break. The daughter of the complainant i.e. Miss. Aditi Mahendra Rathod was insured for Rs. 1, 00,000/- under the said policy. On 7/2/2010, she got married with Mr. Jayesh Jain. The complainant is paying premium for her without any lapses. The daughter of the complainant was admitted in Bhatiya Hospital, Mumbai for the treatment of Acute Calculus Cholecystitis operation for the period of 3/4/2011 to 5/4/2011. The complainant had submitted all the hospital papers, bills, receipts and marriage certificate to the opponent no. 1 on 11/4/2011 for the reimbursement of the bills. These papers were also submitted to the opponent no. 2. The claim amount was Rs. 67,444/-. The complainant was consulted to Dr. Kamlesh Khandelwal while submitting mediclaim. He has paid Rs.500/- as a consultancy charges to him. The complainant had received letter from the opponent no. 1 dated 20/4/2011 called upon clarification for not intimating hospitalization, within 24 hours of admission. He was asked to provide USG report and detailed break up of Rs. 1,561/- of BGH Pharmacy and Rs. 5,042/- of material charges. The complainant had supplied information as per requirements to the opponent. However, the opponent called upon him to comply with the letters dtd. 26/8/2011 and 3/11/2011. It is the case of the complainant that he had not received those letters. He had received letter dtd.3/5/2011 from the regional office of the opponent no. 1 and it was informed that, the additional documents request, which were made in the previous letters was not complied with. Thereafter he has informed that his claim was repudiated on the ground that the daughter of the complainant got married on 7/2/2010. This fact was not intimated to the opponent and after marriage she does not dependant on the complainant. It is the case of the complainant that, the opponents have wrongly repudiated the mediclaim and that amounts to deficiency in service. He has claimed hospitalization charges of Rs. 67,444/-, Rs.500/- as a follow up charges, Rs. 16,185/- interest @ 18% from 9/4/2011 till filing of the complaint. Rs. 25,000/- as a compensation for mental and physical harassment as well as costs of the proceeding. The total claim of the complainant is Rs. 1,09,129/-.
2] The opponents resisted the complaint by filing written version. It has denied the contents of the complaint in toto. It has flatly denied that the opponent has wrongly repudiated the mediclaim of the complainant and caused deficiency in service. It is the case of the opponent that even after receiving letters from the opponent, the complainant has failed to comply with those letters and supply the required documents. It is further contended that, the complainant has suppressed material fact that the daughter of the complainant was married on 7/2/2010. According to the opponent after marriage, she can not be dependent upon the complainant. Hence, the complainant is not entitled for the mediclaim as regards the treatment given to his married daughter, which is not covered by the policy, as she was not the family member at the time of her medical treatment. According to the opponent, it had rightly repudiated the mediclaim and the complaint deserves to be dismissed.
3] After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the counsels and considering pleadings, the following points arise for my determination. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether opponent has rightly repudiated the mediclaim of the complainant? | In the negative. |
2. | What order? | Complaint is partly allowed. |
REASONS :-
4] The undisputed facts in the present proceeding are that the complainant has obtained mediclaim policy from the opponent for himself and other three members of his family. It is also not in dispute that at the time of medical treatment of daughter of the complainant Aditi, the policy was in existence. It reveals from the record that the mediclaim is repudiated on the ground, firstly, that the complainant has not intimated about the illness of his daughter within 24 hours from the hospitalization. Secondly, the complainant has not supplied the required documents as demanded by the opponent. Thirdly, the daughter of the complainant got married on 7/2/2010; still the policy was renewed in her old name. As per the terms and the conditions of the policy, the proposer can cover the family members that who were residing with the proposer i.e. spouse, eligible dependent children and dependent parents. As the daughter Aditi is no more dependent on the complainant after marriage, she can not cover under the said policy. The learned Advocate for the opponent argued that the insurance company has rightly repudiated the claim of the complainant, as the complainant has not supplied the required information and the daughter of the complainant was not member of the family at the time of taking medical treatment.
5] The learned Advocate for the complainant drew attention to the documents of policy. The title of the document is “Individual Health Insurance Policy – 2009”. It is significant to note that this is not a family package policy; this is an individual health insurance policy. It further reveals from the policy that, the separate premium for each insured person has been recovered by the insurance corporation. The complainant has paid an amount of Rs. 2,624/- for himself and his wife and Rs. 1,048/- each, for his daughter and son. In these circumstances, the inference can be drawn that, it is an individual mediclaim policy and not family policy. Moreover, it reveals from the record that the daughter of the complainant has already submitted the documents, which were called from the opponent by letter dated.29/4/2011. It is very absurd to say that after marriage, the daughter has untied all her ties with her parents. Legally when she is entitled to claim right in the ancestral property, she is responsible to maintain her parents, in such circumstances, it can not be said that after marriage, the daughter can not be covered under the insurance policy, which is obtained by her father. It is the opinion of the Forum that the insurance company has wrongly repudiated the mediclaim, as it can not be expected from the insured person that she should intimate about hospitalization within 24 hours. Moreover, it reveals from the record that the complainant had submitted all the documents, which were called upon by the insurance company. In these circumstances, the only legitimate inference can be drawn that the opponent has wrongly repudiated mediclaim policy of the complainant.
6] There is no much dispute raised by the opponents as regards the hospitalization bills for Rs. 67,444/- and follow up charges of Rs.500/-. The complainant has claimed interest on the said amount @ 18% and compensation of Rs. 25,000/-. After considering nature of the dispute and delay caused by the opponents for settlement of the claim, this Forum is of the opinion that the complainant is entitled to receive Rs. 10,000/- by way of compensation on the ground of mental and physical sufferings as well as costs of the litigation, in addition to the hospitalization charges of Rs. 67,444/- and follow up charges of Rs.500/-. In the result the Forum answers the points accordingly and pass the following order.
** O R D E R **
1. The complaint is partly allowed.
2. It is hereby declared that the opponents
have caused deficiency in service by
wrongly repudiating the mediclaim of
the complainant.
3. The opponents are directed to pay
jointly and severally an amount of
Rs. 67,444/- (Rs. Sixty Seven Thousand
Four Hundred and Forty Four only),
Rs. 500/- (Rs. Five Hundred only) and
an amount of Rs. 10,000/- (Rs. Ten
Thousand only) i.e. total amount of
Rs. 77,944/- (Seventy Seven Thousand
Nine Hundred and Forty Four only)
to the complainant within six weeks
from the date of receipt of copy of
this order.
4. On failure to pay the abovementioned
amount within six weeks, it shall carry
interest @ of 9% p.a. from the date of
filing of the complaint till its realization.
6. Copies of this order be furnished to
the parties free of cost.
7. Parties are directed to collect the sets,
which were provided for Members within
one month from the date of order, otherwise
those will be destroyed.
Place – Pune
Date- 04/04/2014
