BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 20/05/2009

Date of Order : 31/05/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 269/2009

Between

 

And

O R D E R

C.K. Lekhamma, Member.

1. Brief facts of the complainant's case are as follows :

The complainant availed an individual mediclaim policy for himself and his wife Juliet Antony with the 1^st opposite party during the year 2005 and later the said policy was renewed by him every year without any default. On 23-09-2008, the complainant undergone a LT ING VINAL HERNIA surgery at the Sunrise Hospital, Seaport-Airport, Kakkanad, Kochi under the treatment of Dr. P. Padmakumar. The said hospital is a network hospitals of the 1^st opposite party which is providing cashless access to the patients. The complainant incurred a total medical expense of Rs. 46,757/-. But the opposite parties allowed only 15% of the sum insured. Even if the 15% of the sum insured as sanctioned by the opposite parties would come 15,000/- instead of that opposite party paid only Rs. 7,500/- to the complainant. Thereafter, the complainant submitted a claim for full reimbursement of the hospital bill before the opposite parties and the 2^nd opposite party rejected the claim by stating that the complainant is entitled to a claim of 15% of the SI under the revised UIIC policy vide the authorization letter. The rejection of the claim by the 2^nd opposite party is not legally sustainable and the reasons stated is also absolutely false and in correct. It is to be noted that Hernia is not coming under the exception clause and at any point of time, the complainant was not informed that Hernia decease will entitled to get only 15% of the sum insured. It is also to be noted that the complainant has not taken directly the UIIC policy as stated by the opposite parties but on the other hand, the present policy of the complainant is the renewal of the individual mediclaim policy taken by the complainant in the year 2005. The complainant issued a legal notice to the opposite parties dated 21-03-2009 claiming the balance amount of Rs 39,257/- was received by the 1^st opposite party on 23-03-2009. Till this date, the opposite parties have not even paid the amount or issued any reply. Hence this complaint. The complainant seeks the following reliefs against the opposite parties :

1. To direct the opposite parties to pay the balance claim amount of Rs. 39,257/- as per the bill amount dated 23-09-2008 with 18% interest.

2. To direct the opposite parties to pay Rs. 7,500/- as compensation and along with costs of the proceedings.

2. Version of the 1^st opposite party in short is as follows :

The complainant had taken a mediclaim policy for the year 2008 for himself and his wife. From the year 2005, the policy is being renewed by the complainant. The policy issued during the year 2008-2009 has a slight variation from the prior policy. This policy copy has been issued to the complainant and he is clearly aware of the condition in the policy. As per the terms and conditions attached to the policy 2008-2009, the policy holder is entitled to get only 15% of the sum insured for the particular type of surgery he has undergone. It is mentioned in clause 1.2 of the policy. The surgery for Hernia will come under this clause. The complainant has raised the claim during the period 2008-2009. So the policy conditions in the year 2008-2009 will be applicable. The complainant was suffering from Hernia the cashless facility could not be opted and then Rs. 7,500/- was sent to the Sunrise Hospital, Kakkanad. Later, when the complainant submitted the bill for reimbursement a cheque in favour of the complainant was sanctioned. Thus, the opposite party has acted as per the terms of the policy and has not violated the terms of the policy. The complainant has not mentioned about the future payment of Rs. 7,500/- made to him in this complaint. So, he has approached the Forum with unclean hands and with an intention to make undue profit from the opposite parties.

3. The complainant and the 1^st opposite party represented through the counsel. The 2^nd opposite party remained absent. The complainant was examined as PW1. Exts. A1 to A8 were marked on his side. The 1^st opposite party adduced only documentary evidence as Ext B1. Both parties filed argument notes. Thereafter, we have heard both sides.

4. The points that arose for our consideration are as follows :

1. Whether the complainant is entitled to get the full insurance claim amount from the 1^st opposite party?

2. Compensation and costs, if any?

5. Point Nos. i. and ii. :- There is no dispute with regard to the issuance of the policy. The reason for repudiation is that the complainant is entitled to get only the 15% of the sum insured under revised UIIC policy. On a perusal of the Clause 1.2 of Ext. B1 policy for Hernia operation, the company will be liable for the 15% of sum insured or maximum of Rs. 30,000/- whichever is less. The sum insured of the complainant is Rs. 1,00,000/-. Hence he is entitled to get Rs. 15,000/-. Out which the 1^st opposite party had paid Rs. 7,500/- to the complainant.

6. According to the complainant, he has taken the policy in the year 2005 and he renewed it without any break upto 2008. And he contended that Hernia is not coming under the exception clause of Ext. A1 series of policy and he was not informed by the opposite parties that for Hernia the insured is only entitled to get 15% of the sum insured. The counsel for the complainant relied a decision of the Hon'ble Supreme Court in Biman Krisha Bose Vs. United India Insurance Co. Ltd. and Another (2001) 6 SCC 477). In which the Hon'ble Supreme Court held that a renewal of an insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewal policy in identical terms from a different date of its expiration comes into force. The opposite party did not have a case that they have informed the complainant in respect of clause 1.2 of the terms and conditions at the very inception of the policy. The subsequent incorporation of the clause 1.2 is not sustainable in law. Therefore, we are not relying in that clause.

7. In view of the above, we are of the opinion that the complainant is entitled to get the insurance claim. As per Ext. A2 bills, the complainant incurred Rs. 46,757/- towards the hospital expenses. It is just and fair that the 1^st opposite party shall deduct Rs. 7,500/-, which is the amount that had already been paid by the 1^st opposite party to the complainant. In that case, the complainant is entitled to receive Rs. 39,257/- only. Of course, the complainant is also entitled for interest. In the facts and circumstances of the case, we are not ordering any compensation and litigation costs.

8. Therefore, we allow the complaint and direct that the 1^st opposite party shall pay Rs. 39,257/- (Rupees Thirty nine thousand two hundred and fifty seven only) along with 6% interest p.a. from the date of receipt of this order till realisation to the complainant.

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 31^st day of May 2011.