BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 18/12/2009
Date of Order : 27/07/2011
Present :-
Shri. A. Rajesh, President.
Smt. C.K. Lekhamma, Member.
C.C. No. 658/2009
Between
V.T. George, | :: | Complainant |
Vadedath House, C/o. Rosily Xavier, Kothad House, Ellichuvadu Junction, Mundamveli, Kochi – 7. |
| (By Adv. T.A. Antony, Roll No. K/24/1981, Kochi - 5) |
And
1. Untied India Insurance Co. Ltd., | :: | Opposite parties |
Regd. & Head Office : 24, Whites Road, Chennai – 600 014. 2. Untied India Insurance Co. Ltd., Handicrafts Building, Indira Gandhi Road, W/Island, Kochi – 682 003. |
| (Op.pts. 1 & 2 by Adv. T.J. Lakshmanan, Penta Queen, Padivattom, Kochi - 25) |
O R D E R
A. Rajesh, President.
1. The facts leading to this complaint are as follows :
The complainant availed himself of a Jana Arogya Bima Policy for himself and his family for the period from 19-11-2008 to 18-11-2009. During the currency of the policy, the complainant underwent surgery on 28-09-2009 at Lourdes Hospital, Ernakulam for Inguinal Hernia. He incurred a sum of Rs. 27,000/- towards treatment expenses. The complainant duly submitted application for insurance claim. But they did not pay the insurance claim for reasons best known to them alone. The complainant is entitled to get the insurance claim together with compensation and costs of the proceedings. Hence this complaint.
2. Version of the opposite parties :
The 2nd opposite party issued the insurance policy to the complainant and his family. The 2nd opposite party processed the claim application of the complainant. The claim of the complainant was not payable under exclusion clause 4.3 of the policy. The illness of the complainant was excluded during the 1st year of the policy. The 2nd opposite party directly intimated and convinced the complainant about the non-admissibility of the claim. The opposite parties are not at all liable to pay any amount to the complainant.
3. The complainant was examined as PW1. Exts. A1 to A9 were marked on his side. No oral evidence was adduced by the opposite parties. Ext. B1 was marked on the side of the opposite parties. Exts. X1 and X2 also were marked. Heard the counsel for the opposite parties.
4. The points that arose for consideration are :-
Whether the complainant is entitled to get insurance claim from the opposite parties?
Compensation and costs of the proceedings?
5. Point No. i. :- Admittedly, the complainant availed himself of Ext. A1 Jana Arogya Bima Policy from the 2nd opposite party for the period from 19-11-2008 to 18-11-2009. During the currency of Ext. A1 policy, the complainant underwent treatment at Lourdes Hospital, Ernakulam for the period from 22-09-2009 to 28-09-2009. As per Ext. A8 discharge summary, his disease was diagnosed as left inguinal exploration extended minilaparatomy adhenolysis hernia repair.
6. According to the opposite parties, the claim of the complainant is not payable in view of Clause 4.3 in Ext. X2 policy terms and conditions. Clause 4.3 reads are follows :
“During the first year of the operation or insurance cover, the expenses on treatment of disease such as Cataract. Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia of Fibromyoma, Hernia, Hydrocele, Congenital Internal disease. Fistula, in anus, Piles, Sinusitis and related disorders are not payable.”
7. During evidence, the complainant deposed that he has been holding insurance policy since 2002. At the instance of the complainant, the opposite party has produced Ext. X1 series insurance policies of the complainant. The details of X1 series are stated as follows :
Sl. No. | Exhibits | Period of average | Sum insured | Remark |
| X1 | 08-11-2002 to 07-11-2003 | Rs. 5,000 | - |
| “ | 09-11-2003 to 18-11-2004 | “ | - |
| “ | 10-12-2004 to 09-12-2005 | “ | 22 days delay in receipting the policy. |
| “ | 27-12-2005 to 26-12-2006 | “ | 18 days delay in receipting the policy. |
| “ | 02-03-2007 to 01-03-2008 | “ | 6 days delay in receipting the policy. |
| “ | 19-11-2008 to 18-11-2009 | “ | 8 months delay (impugned policy) |
It is pertinent to note that the opposite party has issued above policies on the basis of the proposal and declaration on 23-10-2002. the impugned policy is only a continuation of the policy contracted by the complainant in 2002. So Clause 4.3 as mentioned above is not applicable in this case. Though the complainant claimed an insurance claim of Rs. 27,000/- from the 2nd opposite party, the sum insured in the insurance policy is only Rs. 5,000/-. The complainant is not entitled to get any more than the insured amount.
8. Point No. ii. :- The legitimate claim of the complainant has been met no compensation is called for, however costs have been incurred and that is allowed at Rs. 1,000/-.
9. In the result, we allow the complaint to the extend of what is allowable as per the insurance policy that is a sum of Rs. 5,000/- alone together with interest @ 12% p.a. from the date of the claim till realisation. The opposite parties shall also pay Rs. 1,000/- towards costs of the proceedings.
The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.
Pronounced in open Forum on this the 28th day of July 2011.
