DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 13th day of January, 2023
Present : Sri.Vinay Menon V., President
: Smt.Vidya A., Member
: Sri.Krishnankutty N.K., Member
Date of Filing: 12/11/2019
CC/262/2019
Ambika
W/o A.Vijayan, Kalamputta House
Uppumpadam, Kinassery
Palakkad - Complainant
(By Adv. P.Sreeprakash)
V/s
United India Insurance Company Ltd.
Soorya Complex, Mission School Junction
T.B.Road, Palakkad - Opposite party
(By Adv. Ajitha.A)
O R D E R
By Smt. Vidya.A, Member
1. Pleadings of the complainant in brief
Complainant’s son had availed an individual Health Insurance policy from the opposite party with No: 1012012819P100405303. The validity of the policy was from 08/04/2019 to 07/04/2020. As per the terms and conditions, the policy covers mother and sister of the policy holder.
On 26/05/2019, the complainant was admitted in Kuppuswamy Naidu Memorial Hospital, Coimbatore and was treated as an inpatient upto 30/05/2019. On 27/05/2019 the complainant underwent ASD device closure through right femoral catch site. On 28/10/2019, complainant’s son submitted claim before the opposite party and it was acknowledged and numbered by them. Thereafter the claim was accepted in part and a sum of Rs. 70,000/- only was disbursed. The actual expenditure for treatment was Rs. 2,03,934/-. Without any basis and proper explanation the complainant’s son’s entire assured claim amount of Rs. 1,50,000/- was rejected and it is against the terms and conditions of the policy. The act of the opposite party in rejecting the entire assured claim amount is clear deficiency in service. The complainant is entitled to get the balance of Rs. 80,000/- with 12% interest per annum and a compensation of Rs. 25,000/-
A registered lawyer notice was also issued by the complainant demanding the balance amount. Due to the non-reimbursement of the treatment expenses paid by the complainant’s son, he is in financial crisis.
So this complaint is filed to direct the opposite party to pay Rs. 80,000/- with interest @ 12% till realisation, Rs. 25,000/- as compensation, cost of the petition and such other reliefs prayed by the complainant from time to time.
2. After admitting complaint, notice was issued to the opposite party. The opposite party entered appearance and filed their version.
3. The main contentions raise by the opposite party in their version is as follows:
They admit that Arun, the son of the complainant has taken an individual health insurance policy from the opposite party covering a period from 08/04/2019 to 07/04/2020. As per the policy certificate, Arun, his mother Ambika (the complainant) and his sister are covered.
They also admit that the complainant was admitted in Kuppuswamy Naidu Memorial Hospital on 26/05/2019 and was discharged on 30/05/2019. After the treatment the complainant’s son submitted a claim for Rs. 2,03,934/- and the opposite party had disbursed Rs. 70,000/- for settling the claim. They denied all other allegations in the complaint.
The insured is covered under United India Health Insurance Gold Policy and expenses for pre-existing ailments are covered only after 4 claim free policy years and the claim was processed by restricting the sum insured to Rs. 1,00,000/-; since the sum insured was enhanced to Rs. 1,50,000/- on 08/04/2016/-. As per policy conditions, expenses for major surgeries are limited to 70% of sum insured and the claim was processed and settled for 70% of admissible sum insured of Rs. 1,00,000/- and Rs. 70,000/- was paid accordingly.
The insured has taken policy with sum insured of Rs. 1,00,000/- for the period from 08/04/2015 to 07/04/2016. Complainant underwent ASD (Atrial Septal Defect) closure in the hospital. ASD constitute a major class of heart formation abnormalities present at birth. So it is clear that the complainant was having this problem at the time of taking the policy. So far as the internal pre-existing ailments are concerned, the policy condition is that only after completion of 4 claim free years, the insured will be entitled for coverage. Accordingly, after completion of 4 years in 2019, the complainant is entitled for a coverage of Rs. 1,00,000/- only because after enhancement of the sum insured 4 years have not been completed.
As per the terms and conditions of the policy, each of the beneficiary is entitled for a coverage for a sum upto Rs. 1,50,000/-. For a pre-existing ailment, the lock period for availing the benefits under the sum insured of Rs. 1,50,000/- is 4 years. Since the period has not been completed, she is entitled only for the benefits under the previous sum insured of Rs. 1,00,000/- only. For major surgeries the coverage is for actual expense incurred or 70% of the sum insured, whichever is less. So the complainant is entitled for Rs. 70,000/- which is already paid by the opposite party. There is no deficiency in service on their part. The complainant is not entitled to the reliefs claimed and the complaint has to be dismissed with the cost of the opposite party.
4. From the pleadings of both parties the following points arise for consideration:
- Whether the complainant is entitled to get the entire claim amount as per the terms and conditions of the insurance policy?
- Whether there is any deficiency in service on the part of the opposite party in making only the part-payment?
- Whether the complainant is entitled to the reliefs claimed?
- Reliefs as cost and compensation.
5. Complainant filed proof affidavit in evidence and Exhibits A1 to A4 marked in evidence (A1 and A3 in series). Marking of Ext.A3 is objected on the ground that it is a photocopy. Since this commission is not bound by the tenets of the Evidence Act, in the absence of any contention that the said document is forged one Ext. A3 is taken on file. Opposite party did not file proof affidavit even after availing more than one year. So their evidence was closed. Later on they filed IAs 494/22 and 495/22 to re-open evidence and production of documents. Both IAs were dismissed as they had slept on the order dated 09/02/2021 till 10/08/2022 when evidence was closed. Complainant and opposite party filed notes of argument.
6. Point No: 1
Complainant’s grievance is that the complainant’s son took an individual health insurance policy form the opposite party covering a period from 08/04/2019 to 07/04/2020. As per the policy, it covers the policy holder, mother (complainant) and his sister. Complainant underwent ASD device closure through right femoral cath site on 27/05/2019. For that she was admitted in Kuppuswamy Naidu Hospital on 26/05/2019 and treated upto 30/05/2019. The complainant’s son submitted claim form with necessary documents before the opposite party. Actual expenses incurred was Rs.2,03,934/- The opposite parties accepted the claim in part and paid Rs. 70,000/- According to the complainant, they are entitled to entire assured claim amount of Rs. 1,50,000/- and the opposite party without any reason paid only part claim.
7. Opposite party’s contention in this regard is that the insured is covered under United India Health Insurance Gold Policy and expenses for pre-existing ailments are covered only after 4 claim free policy years and he claim was processed by restricting the sum insured to Rs. 1 lakh since the sum insured was enhanced to Rs. 1,50,000/- on 08/04/2016. As per policy condition 1.2, expenses for major surgeries are limited to 70% of the sum insured and the claim was processed and settled for 70% of the admissible sum insured of Rs. 1 lakh and Rs. 70,000/- was paid accordingly.
8. As per the policy produced by the complainant and marked as Ext.A4, the period of insurance is from 08/04/2019 to 07/04/2020. Individual Health Insurance Policy schedule shows that the sum insured for the complainant is Rs. 1,50,000/- As per the policy clause 1.2. (b) For major surgeries - limits per surgery restricted to – Actual expenses incurred or 70% of the sum insured whichever is less and the next point is major surgeries include cardiac surgeries, brain tumar, etc.
9. The opposite party accepted the claim and made part payment. The only question to be considered is what is the sum insured as per the policy and whether the complainant is entitled to the balance amount as per the policy. The opposite party had stated in their version that in the reply sent to the Lawyer Notice issued by the complainant, they have explained how they arrived at the amount of Rs. 70,000/- but they have not stated this in the version.
10. The opposite party failed to file proof affidavit or mark any documents from their side. Later on they filed IA 494/22 to re-open the evidence and it was dismissed stating that the order directing the opposite party to file proof affidavit was passed on 09/02/2021 and till 10/08/2022, the opposite party did not file proof affidavit or take any step to adduce evidence and this IA was filed after passing of over 2 months.
11. Further in their version, the opposite party contended that the insured has taken the policy with sum insured of Rs. 1,00,000/- for the period covering from 08/04/2015 to 07/04/2016. The complainant was having ASD i.e., is a hole in the septor. ASD constitute a major class of heart formation abnormalities, present at birth. So the complainant was having this problem at the time of taking the policy and as far as the internal pre-existing ailments are concerned, the policy condition is that only after completion of 4 years the insured will be entitled for coverage. In this case, the complainant was having a pre-existing ailment at the time of issuing the policy in 2015 and she is entitled to a coverage of Rs. 1,00,000/- only because after enhancement of the sum insured to Rs. 1,50,000/- 4 years have not been completed.
12. The opposite party did not produce any document showing the existence of policy during the period 08/04/2015 to 07/04/2016. The complainant produced only the policy for the period 08/04/2019 to 07/04/2020 which is marked as Ext. A4. As per that policy condition, in the case of major heart surgery like that of the complainant, the insured is entitled to actual expenses incurred or 70% of the sum insured or whichever is less. So the complainant is entitled to 70% of Rs. 1,50,000/- which amount to Rs.1,05,000/- The opposite party had already paid Rs. 70,000/- and they have to pay balance amount of Rs. 35,000/- to the complainant. Point No: 1 is decided accordingly.
13. Points 2 to 4
There is deficiency in service on the part of the opposite party in not making the payment as per the terms & conditions of the policy. The complainant would have undergone mental agony and financial loss on account of that.
In the result the complaint is allowed in part
We direct the opposite party to pay
- Rs. 35,000/- together with interest @ 9% per annum from the date of payment of the claim amount till realization.
- The opposite party is further directed to pay Rs. 15,000/-for their deficiency in service, Rs. 10,000/- as compensation for the mental agony and financial loss suffered by the complainant and Rs. 10,000/- as cost of the litigation.
The opposite parties shall comply with the directions in this order within 45 days of receipt of this order, failing which opposite party shall pay to the complainant Rs. 250/- per month or part thereof until the date of payment in full and final settlement of this order.
Pronounced in the open court on this the 13th day of January, 2023.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Documents marked from the side of the complainant
Ext. A1 – Lawyer notice dated 05/08/2019.
Ext. A2 – Reply Notice dated 06/09/2019.
Ext. A3 – Copies of the medical bills.
Ext. A4 – Original of the Insurance Policy dated 08/04/2019.
Documents marked from the side of opposite parties- Nil
Witness examined from the side of the complainant- Nil
Witness examined from the side of the opposite party- Nil
Cost- Rs. 10,000/-
NB: Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
