FILED ON:02.03.2010

DISPOSED ON:09.11.2011

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)

9^th DAY OF NOVEMBER – 2011

       PRESENT:- SRI. B.S.REDDY                 PRESIDENT                        

                         SMT. M. YASHODHAMMA        MEMBER    

                         SRI. A. MUNIYAPPA                 MEMBER

O R D E R S

SRI. B.S.REDDY, PRESIDENT

The complainant filed this complaint seeking direction against the Opposite Party (herein after called as O.P) to pay entire medical expenses of Rs.71,792/- with interest at 24% p.a. along with costs of litigation and compensation on the allegation of deficiency in service on the part of OP.

2. The case of the complainant to be stated in brief is that:

In July-2003 the complainant purchased the Health Insurance Policy No.071804/48/08/97/ 00001060, which covers is hospitalization expenses upto the Upper Limit of Rs.1,00,000/- in case he is hospitalized. Since then the complainant is regularly paying premiums and the policy was renewed every year. This policy is currently in force. It is stated that on 30.03.2009, the complainant had a cataract operation for which he had spent Rs.71,792.40/-. The bills were submitted to the OP and all procedural formalities were fulfilled. Instead of making the payments as agreed in its policy, the OP-company agreed to pay only Rs.20,000/- and refused to make payments as per the policy. To justify this breach of contract, the OP invoke Clause-1.2A, which favours the OP and puts an Upper cap on claims of cataract to just Rs.10,000/- per eye. The said clause is missing in the original policy sold to the complainant in the year 2003. The complainant is not aware as to when this clause was introduced, the OP-company never informed him about this clause. The complainant had complained to IRDA the same has not applied its mind, nor enquired into the matter. IRDA has failed to conduct any enquiry when the fraud is evident on the face of the record. Thus the complaint seeking relief as stated above.

3.On appearance, OP filed version admitting that the complainant had taken Medical Health Policy No.071804/48/08/97/00001060 for the period 19.07.2008 to 18.07.2009. The said policy is called the individual Health Insurance Policy and the same was issued in terms and conditions mentioned therein. The complainant is not entitled to any compensation much less compensation of Rs.71,792/- claimed. It is stated that the OP received a claim from the complainant regarding hospitalization of complainant on 30.03.2009 at Shekar Nethralaya for cataract operation of both the eyes for which he had spent Rs.71,792.40 paisa. As per the policy issued in favour of the complainant as per clause 1.2 of the policy in the event of any expenses with respect to cataract operation limit was restricted to 10% of the sum insured or maximum Rs.25,000/. In this case the sum insured was Rs.1,00,000/- and it was brought to the notice of the complainant that he would be entitled for 10% of the sum assured for both the eyes to the maximum of Rs.20,000/-. Discharge Voucher was remitted to the complainant for the said amount, but complainant never returned the same. The contention of the complainant that Clause-1.2 of the policy was not available in the policy given to the complainant is not at all true. There is no deficiency of service on the part of OP since they have acted as per the terms and conditions of the policy and the non-admission of the claim as per complainant’s demand will not amount to deficiency of service on the part of the OP. Hence, it is prayed to dismiss the complaint.

4. The complainant along with complaint produced documents, Annexure-A the Medi-claim Insurance Policy, Annexure-B reply letter of OP dt.16.06.2009, Annexure-C copy of Health Insurance Policy Page-3, Annexure-D letter issued by IRDA dt.09.12.2009. Along with additional affidavit evidence, the complainant produced Annexure-E copy of letter in the form of circular issued by the Head Office of OP.

5. The complainant in order to substantiate complaint averments filed affidavit evidence and additional affidavit evidence. The Senior Divisional Manager of OP filed affidavit evidence in support of the defence version and produced copy of the policy issued in favour of the complainant. Further additional affidavit was filed.

6. The complainant filed written arguments. Arguments on both sides heard.

7 Points for our consideration are:  

      Point No.1:- Whether the complainant proved the        

                        deficiency in service on the part of

                          the OP?

Point No.2:- Whether the complainant is entitled

                   for the reliefs claimed?

     Point No.3:- To what Order?

8.   We record our findings on the above points are:

Point No.1:- Affirmative.

Point No.2:- Affirmative in part.

Point No.3:- As per final Order.

R E A S O N S

In July-2003 the complainant purchased the Health Insurance Policy No.071804/48/08/97/00001060 covering hospitalization up to the upper limit of Rs.1,00,000/- of his hospitalization. Since then the complainant claims that the policy was renewed every year. On 30.03.2009 the complainant had a cataract operation for which an amount of Rs.71,792.40 was spent. As the policy was in force the complainant submitted the bills and lodged claim with the OP for reimbursement of the medical expenses. OP refused to make payments of the entire amount but restricted the payment to only Rs.20,000/- by invoking Clause-1.2 A which puts an upper cap on claims of cataract to Rs.10,000/- per eye. The complainant claims that he was not aware as to when the said clause was introduced, the OP Company never informed him about this clause. Thus Op was not justified in refusing to pay the entire claim of medical reimbursement; there is deficiency in service on the part of the OP in denying the admissible claim.

        The defence of the OP is as per Clause-1.2 of the policy issued in favour of the complainant for the period 19.07.2008 to 18.07.2009 in the event of any expenses with respect to cataract operation limit is restricted to 10% of the sum insured or maximums of Rs.25,000/-. In this case the sum insured was Rs.1,00,000/- and it was brought to the notice of the complainant that he would be entitled for 10% of the sum assured, for both the eyes to the maximums of Rs.20,000/-. Discharge voucher was remitted to the complainant for the said amount but the complainant never returned the same. There is no deficiency of service on the part of the OP, the non admission of the claim as per complainants demand will not amount to deficiency of service on the part of the OP.

It may be noted that as per Annexure-A. Copy of medi-claim insurance policy produced by complainant, there is no any upper limit restriction with regard to the medical expenses to be reimbursed for cataract operation. Annexure-B is the letter dt.1506.2009 issued to the complainant by OP stating that as per the policy condition Clause-1.2 A restrict the amount payable for cataract to 10% of the sum insured under the policy i.e., 10% of Rs.1,00,000/- amounts to Rs.10,000/- per eye. Hence, the claim has been approved for Rs.10,000/- only. Annexure-C is the copy of the Health Insurance Policy-gold in that Clause-1.2 it is shown that expenses in respect of the specified illness will be restricted as detailed below.

Hospitalization Benefits                         Limits Restricted to

    a) Cataract                                   a) 10% of SI or

                                                            Max.Rs.25,000/-.

b) ………….

c)…………..

d)…………..

e)…………..

        OP has produced the certified copy of Insurance policy issued to the complainant for the period from 19.07.2008 to 18.07.2009. Clause-1.2(a) restricts the expenses to be reimbursed to 10% of the S.I subject to a maximum of Rs.25,000/-. OP has not produced any material to show that the policy containing terms and conditions restricting the limits as per Clause-1.2(a) was sent to the complainant and complainant was aware of the said Clause. In this copy of the policy it is stated as “terms, conditions and clauses attached as per the respective individual schemes, date of proposal and declaration 15.07.2005. Further it is shown that “in witness where of the undersigned being duly authorized has hereunto set his/here hand at K.G.Road on this 8^th day of June-2010”. From this becomes clear that the policy has been issued with duly signed on 08.06.2010 but the policy period is from 19.07.2008 to 18.07.2009. Thus it becomes clear that subsequent to this dispute this policy has been prepared inserting clause 1.2(a) restricting the limits of medical reimbursement. Op has not produced any material to show that the complainant has been duly informed about the upper limit on cataract to an extent of only Rs.10,000/- per eye. In view of the same, OP cannot take the benefit of the circular stated to have been issued on 09.07.2007 as per Annexure-E introducing caps on certain decease. Mere issuing circular is not sufficient the person likely to be effected by introduction of such caps has to be duly informed the policy issued has to contain the terms and conditions restricting the upper limit.

        In 2011 (1) CCC 350(NS) Mahesh Chand Ghiya V/s New India Assurance Co.Ltd., The Hon’ble National Commission observed that Insurance too is in the nature of contract between the parties and no unilateral act on part of any party to the contract could be binding on the other.  As in this case OP has not produced any material to show that fresh proposal was taken from the complainant to issue the policy for the period 19.07.2008 to 18.07.2009 so as to justify that every year fresh policy is issued containing the terms and conditions for that particular year. The complainant has produced the insurance premium paid receipts for the period 2006 to 2010(5 receipts) with Memo on 13.09.2011. Every year complainant has renewed the policy by paying the required premium amount and no fresh policies are issued. The renewal of the policy by accepting yearly premium goes to show that the same terms and conditions of the first policy issued in the year-2003 governs the claims regarding reimbursement of medical expenses. OP has not produced any material to show that the complainant has consented for restricting limit of medical expenses for certain deceases as shown in Clause-1.2 of the policy issued for the period 19.07.2008 to 18.07.2009. The unilateral act of OP restricting the medical expenses reimbursement to a maximum of Rs.20,000/- for cataract is not binding on the complainant.

9.The learned counsel for the complainant contended that the policy issued for the period from 19.07.2008 to 18.07.2009 is a fresh policy, the terms and conditions incorporated in the said policy are binding on the complainant, the maximums medical expenses for cataract is 10% of sum insured hence the complainant is entitled for Rs.20,000/- only. In our view, without there being any material to show that the complainant was informed about the limits restricted and the policy with terms and conditions is received by the complainant, it cannot be said that the complainant has accepted the terms and conditions of the policy. Under these circumstances, we are of the view that OP was not justified in restricting the medical reimbursement of cataract for Rs.20,000/-, as against the medical expenses incurred for the same was Rs.71,792/- as per the bills submitted by the complainant. The act of OP in not admitting the entire claim of medical reimbursement amounts to deficiency in service. The complainant is entitled for reimbursement of entire medical expenses of Rs.71,792/-. Accordingly, we proceed to pass the following:               

                                O R D E R

The complaint filed by the complainant is allowed in part.

OP is directed to pay an amount of Rs.71,792/- towards reimbursement of medical expenses with interest at 9% p.a. from the date of complaint till the date of realization with litigation costs of Rs.3,000/- to the complainant within 4 weeks from the date of this Order.

Send copy of this order to both the parties free of costs.

 (Dictated to the Stenographer and typed in the computer and transcribed by her, verified and corrected, and then pronounced in the Open Court by us on this the 9^th day of November– 2011.)

MEMBER                   MEMBER                PRESIDENT

Cs.