Per :- Mr. J. L. Deshpande, President Place : Bandra -*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-* ::::: JUDGMENT ::::: Facts giving rise to this complaint may be stated, in brief, as follows :- The Opposite party is an Insurance Company and the Complainant had purchased a Mediclaim Insurance Policy bearing no.120900/48/07/97/00003468 and the sum insured was Rs.2,00,000/-. The Policy was valid during the period of 21st August, 2007 to 20th August, 2008. 2 The Complainant underwent Bypass Surgery at Hospital “Asian Heart Institute” at Bandra Kurla Complex, Bandra – East, Mumbai – 51 and incurred expenses in sum of Rs.3,03,000/-. 3 The Complainant submitted insurance claim to the Opposite party and it was repudiated, on the ground that the sum insured in this policy was exhausted and no claim could be admitted. The Complainant made an appeal to Grievance Committee but there was no favourable reply. 4 The Complainant received Rs.1,40,000/- and for the balance of Rs.60,000/-, the Complainant moved the Opposite party by claim application followed by reminders and for above stated reasons claim for balance came before repudiated.Ultimately, the Complainant filed present complaint for recovery of sum of Rs.60,000/- and compensation. 5 The Opposite party – Insurance Company contested the claim by filing written statement and justified its action in repudiating the claim. According to the Opposite party, sum of Rs.1,40,000/- has been paid to the Complainant and the claim for balance amount was not maintainable. 6 The Complainant filed rejoinder to the written statement and reiterated the same facts. 7 Both the sides filed their affidavits of evidence and documents. The Opposite party filed written statement and written argument. We have gone through the pleadings, documents and written arguments. 8 Following points are arising for our considerations and our findings thereon are as follows :- Nos. | Points | Findings | 1 | Whether the Complainant has proved that the Opposite party is guilty of deficiency in service ? | Yes | 2 | Whether the Complainant is entitled to recover sum of Rs.60,000/- with interest thereon ? | Yes | 3 | What order ? | Complaint is partly allowed. |
REASONS FOR FINDINGS :- 9 There is no dispute about the fact that the Complainant had purchased Insurance Policy from the Opposite party and sum insured was Rs.2,00,000/-. The policy was valid during the period of 21st August, 2007 to 20th August, 2008. There is no dispute also about the fact that the Complainant received sum of Rs.1,40,000/- from the Opposite party against his claim. Dispute only pertains to balance amount of sum of Rs.60,000/-. 10 At annexure -2, the Complainant has produced copy of the authorization letter issued by the Opposite party no.2, who is agent of the Opposite party no.1. While issuing that letter, the Opposite party no.2 informed the Complainant that if costs of treatment exceed Rs.1,40,000/-, he will require, further authorization. That note in the letter has been relied upon by the Opposite party to substantiate their stand that out of sum assured in sum of Rs.2,00,000/-. The Complainant was entitled to receive sum of Rs.1,40,000/- only and balance amount was not payable. 11 Copy of the Insurance Policy for the year 2007-2008 has been produced by the Complainant at Annexure-A and in the said certificate / policy, there is no mention of any restriction as regards payment of sum assured. It is only mention there that pre-existing, illness are excluded but there is no mention that out of Rs.2,00,000/- sum insured, only Rs.1,40,000/- will be paid. 12 The Complainant has produced copy of the letter, dated, 17th December, 2007 and copy of Annexure-VII received from the Opposite party and copy of the policy. This letter, dated, 17th December, 2007 was issued by the Opposite party on the basis of the Insurance policy. Letter dated, 17th December, 2007 as well as the policy was issued subsequent to the surgery under taken by the Complainant as well as subsequent to claim being submitted by the Complainant. On the first page of the policy, there is mention that the policy was received on 21st January, 2008. Thus both these documents were not brought to the notice of the Complainant before he underwent the surgery. There is no material on the record that the Complainant was informed at the commence not of the policy for the year 2007-2008 that though the sum assured was Rs.2,00,000/-, the Opposite party would pay only 70% of the sum assured and not the entire sum. It is only after the Complainant under went the bypass surgery and submitted the claim with the Opposite party pointed out this clause in the policy to substantiate the stand that only 70% was sum was payable. According to the Complainant, such clause did not appear in the earlier policies and this was sort of revised policy. It is seen from the record that the date of inception of policy 21st August, 1998, thus the policy was purchased long back and it was renewed from time to time. The Opposite party has not produced any material on record to show that even in the earlier policies such restriction clause had appeared. Absence of such material, substantiate grievance of the Complainant that the policy was revised and subsequent to the claim, condition was incorporated to restrict payment of sum assured to 70%. 13 Added to this, the Opposite party repudiated the claim vide letter, dated, 31st December, 2007, copy at annexure-V. While repudiating the claim, the Opposite party took stand that the sum assured in this policy was Rs.2,00,000/- and after reimbursement of earlier policy claim, the sum insured stands exhausted. Now, the Opposite party did not repudiate the claim on the ground that only 70% was sum assured was payable. It repudiated on the ground that certain other claims were reimbursed and on deduction of the same, there was no balance amount. 14 As pointed out to the above, policy in the year-2007-2008, commenced on 21st August, 2007 and the Complainant under went heart surgery on 28th September, 2007. Thus, about one month after commencement of the policy. As per the copy of the policy at annexure-1 and sum insured in the Complainant was Rs.2,00,000/-. The Opposite party has not produced any material on the record that during the period of one month, any other claim of the Complainant was paid and on payment of Rs.1,40,000/- under this claim, total amount of sum of Rs.2,00,000/- got exhausted. Thus, there is no material on the record to justify or substantiate the ground of repudiation mentioned in the repudiation letter. 15 The fact that the Complainant was paid and he accepted sum of Rs.1,40,000/- as part payment would not debar or estop him from claiming balance amount from sum assured. 16 For the following reasons, we hold that the Complainant has proved that the Opposite party wrongly repudiated the claim of the Complainant. Thus the Opposite party is guilty of deficiency in service. With this, we proceed to pass the following order. ::::: ORDER ::::: (1) The complaint is partly allowed. (2) The Opposite party is directed to pay sum of Rs.60,000/- to the Complainant with @ 9% interest thereon from the date of the repudiation i.e. from 31st December, 2007 till realization of the amount. (3) The Opposite party shall also pay costs in sum of Rs.5,000/- to the Complainant. (4) Certified copies of this order to be furnished to both the parties, free of costs, as per rule.
| | [HONABLE MRS. Mrs.DEEPA BIDNURKAR] Member[HONABLE MR. Mr. J. L. Deshpande] PRESIDENT[HONABLE MR. MR.V.G.JOSHI] Member | |
