BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 7th April 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : HON’BLE MEMBER
ORDERS IN
C.C.No.367/2015
(Admitted on 17.10.2015)
Mr. K.N. Alva,
S/o Late. K.T. Alva,
Aged 74 years,
Residing at Srinidhi,
Door No.15.1.3, Bendoor,
Mangalore.
……… Complainant
(Advocate for Complainant by Sri. YBPR)
VERSUS
United India Insurance Company Ltd,
Divisional Office, Post Box No.705,
Krishnaprasad Building,
1st floor, Rama Bhavan Complex,
Kodialbail, Mangalore and
Represented by its Authorised Signatory.
…. Opposite Party
(Advocate for Opposite Party by. Sri. AKK)
ORDER DELIVERED BY HON’BLE MEMBER
SMT. LAVANYA M. RAI
- This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service against the opposite party claiming certain reliefs.
The brief facts of the case are as under:
The complainant had insured with the Opposite Party under the Individual Health Insurance Policy Scheme bearing policy No.070800/48/13/97/00002254 the period of insurance under the aforesaid policy was a period of 1 year commencing from 1.1.2014 and ending with 31.12.2014 and the sum insured was Rs.2,00,000/ The complainant had been continuously holding the health insurance of the Opposite Party for the last 14 consecutive years, since 31.12.2001 and he had not filed any claim petition before the Opposite Party each year, the agent of Opposite Party assured that the policy availed by the complainant was a cashless entry policy. On 24.11.2014 the complainant got admitted to ORTHO ONE orthopaedic Specialty Centre, 657, Trichy Road, Singanalur, Coimbatore 671005, T.N, India for the total Knee replacement surgery. The said hospital is in the list of companies recognized by the Opposite Party. At the time of admission of the complainant to the hospital, the complainant has intimated to the Opposite Party about hospitalization and has submitted the insurance policy to the hospital authorities they have accepted the insurance policy. After the surgery the complainant discharged from the hospital on 03.12.2014 and the complainant was informed by the hospital authorities that they have contacted Opposite Party on several occasions with regard to the settlement of the bill amount pertaining to the complainant and as the Opposite Party did not respond positively hence hospital authorities requested the complainant to clear the bill amount and advised the complainant to claim the insurance amount directly. Therefore the complainant was compelled to make the full payment of the bill amounting to Rs.5,43,503/ to the hospital authorities, by borrowing the same from third parties and thereafter got discharged from the hospital. Complainant forwarded the claim papers with all the supporting documents to the Opposite Party in the end of December. At the time of forwarding the claim papers the Opposite Party had assurd that the claim amount would be released within a week time from the date of receipt of the claim papers. This being so, after waiting for a week the complainants representative contacted the officials of the Opposite Party and on enquiry the Opposite Party was informed through his representative that the claim papers are being processed and the claim amount will be credited to the bank account of the complainant within a week. Finally on 6.4.2015 the complainant came to know through his bankers that the Opposite Party had credited only a sum of Rs.1,05,000/ to the complainants account through NEFT, even though the sum assured under the policy aforesaid insured by the complainant with the Opposite Party was for Rs.2,00,000/ and the hospital charges was Rs.5,43,503/ That no explanation or any intimation has been given to the complainant by the Opposite Party for the reduction of the claim amount to Rs.1,05,000/, when the sum assured under the policy was Rs.2,00,000/, which is illegal, unjust and unethical. Because of the delay in the payment and also reduction in the claim amount the complainant has been suffered mental agony, stress and humiliation from borrowers who made good the amount during the time of discharge of the complainant from hospital. Thereafter the complainant has got issued a legal notice dated 15.4.2015 to the Opposite Party calling upon the Opposite Party to settle the balance claim of the complainant. That the Opposite Party inspite of receiving the notice has not complied with the demand made in the notice. Hence the above complaint filed by the complainant before this forum under section 12 of the C.P.Act 1986(here in after referred to as the Act) seeking direction from this Fora to the Opposite Parties to pay Rs.95,000/ as the balance claim amount, to pay the interest at the rate of 18% p.a. on Rs.95,000/ from 6.4.2015 till payment, to pay Rs.1,00,000/ towards the loss, hardship and mental agony suffered and such other reliefs.
- Version Notice served to the opposite parties by RPAD, inspite of receiving notice the Opposite Party filed version stating that the Opposite Party admits issue to individual Health Insurance policy bearing No.070800/48/13/97/00002254 to the complainant which is valid from 1.1.2014 to 31.12.2014. However, the claim, if any, under the said policy is subject to the terms, conditions and exclusion clauses attached there in which are duly furnished to the complainant along with the policy which are part and parcel of the policy. The Opposite Party states that during the course of its regular business, they have received claim from the complainant stating that complainant has undergone total knee replacement at Coimbatore on 24.11.2014 and on receipt of the claim of the complainant, the Opposite Party has investigated the said claim and made scrutiny of the medical records of the complainant. As per the clause No.1.2.1 of the above referred policy, the expenses incurred in respect of major surgeries which includes cardiac surgery, will be restricted to 70% of the sum insured minus the policy excess, if any. Therefore, acting upon the Exclusion clauses of the above policy, this Opposite Party has paid Rs.1,05,000/ on 6.4.2015 directly crediting the said amount to the account of the complainant. The Opposite Party states that claim if any, under the above referred policy is being processed by the TPA of this Opposite Party namely VIDAL HEALTH TPA Private ltd, said TPA of this Opposite Party is necessary party to the above proceedings. Hence the above complaint is bad for non joinder of necessary parties. This Opposite Party would submit that the maximum liability of this Opposite Party shall be to the extent mentioned in clausen.1.2.1 of the above referred policy, which the Opposite Party has already re imbursed the complainant and as such the complainant is not maintainable and prays for dismissal.
III. In support of the above complaint the complainant Mr. K.N. Alva, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C7. On behalf of the opposite parties Mr. Pundalik M Nayak, (RW1), Divisional Manager, United India Insurance co. ltd, of opposite party also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked Ex.R1.
IV. In view of the above said facts, the points for arise for our consideration in the case are:
- Whether the Complainant proved that the Opposite Party committed deficiency in service?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
We have considered the arguments submitted by the complainant and Opposite Party and also considered the materials that was placed before the Fora and answered the points are as follows:
Point No. (i) : Affirmative
Point No. (ii) : Affirmative
Point No. (iii): As per the final order.
REASONS
V. POINTS No. (i) and (ii): In order to substantiate the case, complainant and Opposite Party filed evidence by affidavit and produced documents Ex.C1 to C7 and Ex.R1 as listed in the annexure. It is the case of the complainant that he had insured with Opposite Party for a sum of Rs.2,00,000/ as per Ex.C1 and on 24.11.2014 the complainant got admitted for the total knee replacement surgery. The admitted hospital is in the list of companies recognised by the Opposite Party when the complainant admitted in the hospital he informed about the policy and the said hospital accepted the insurance policy. At the time of discharge from the hospital the authority of the said hospital informed that the Opposite Party did not respond for settlement of bill hence the complainant compelled to make full payment of the bill amount of Rs.5,43,503/ as per Ex.C3 by borrowing third parties and discharged from the hospital. After discharge the complainant forwarded the claim paper to the Opposite Party but Opposite Party postponing the disbursement of the claim amount one or other pretext. Finally on 6.4.2015 the Opposite Party credited a sum of Rs.1,05,000/ to the complainant account even though the sum assured for Rs.2,00,000/ and liable to pay the balance amount of Rs.95,000/ along with interest. On the other hand the Opposite Party contended that the claim under the policy is subject to the terms, conditions and exclusion clauses the complainant has under gone total knee replacement. As per clause No. 1.2.1 of the policy the expenses incurred in respect of major surgery will be restricted to 70% of the sum assured minus the policy excess if any. Therefore acting upon Opposite Party paid Rs.1,05,000/ and also stated that policy is being processed by the TPA of the Opposite Party and the TPA is necessary party to the proceedings hence complaint is bad for non-joinder of necessary party. Now the points for consideration is that the policy taken by the complainant from Opposite Party is not disputed as per Ex.C1. The policy clause 1.2.1 which clearly mentioned that “surgery include cardiac surgeries, brain tumour surgeries, pace maker implantation, for sinus syndromes, cancer surgeries hip, Knee joint replacement surgery, organ transplant. The above limits specified are applicable per hospitalisation/surgery the clause clearly reveals that 70% of the sum insured benefit available to the insurer. But case in our hand the complainant availed benefit of Rs.1,05,000/ as assured amount of Rs.2,00,000/ as per Ex.C1. even though the acting upon in exclusion clauses as 70% in sum assured from Rs.2,00,000/ it would be Rs.1,40,000/ and not for Rs.1,05,000/ hence liable to pay balance amount of Rs.35,000/ another aspect we noted that the complainant admitted to the hospital on 24.11.2014 for total knee replacement and discharged from the hospital on 3.12.2014. The Opposite Party credited the insured amount of Rs.1,05,000/ on 6.4.2015 there is a delay on part of Opposite Party to credit the amount to the policy holder. It is true that being a senior citizen waiting for claim amount since 4 months is not justified hence to meet ends of justice the Opposite Party is liable for pay towards the mental agony and the Opposite Party committed deficiency in service is proved. Apart from that the Opposite Party raised the objection that TPA of the Opposite Party is necessary party to the proceedings but here in, the complainant taken the policy from Opposite Party and paid premium to the Opposite Party hence making party to the proceeding does not arise, hence the objection raised by the Opposite Party not considered. In view of the above discussion we are of the opinion that the Opposite Party is directed to pay balance amount of Rs.35,000/ along with 9% interest from date of discharge i.e. 3.12.2014 till the date of payment, further pay Rs.25,000/ as compensation for mental agony caused to the senior citizen and Rs.5,000/ as cost of the litigation expenses is justified. Hence the point No. 1 and 2 in the affirmative
In the result, accordingly we pass the following Order.
ORDER
The complaint is allowed with cost. The Opposite Party is directed to pay Rs.35,000/ along with 9% interest from 3.12.2014 till the date of payment, further pay Rs.25,000/ as compensation and pay Rs.5,000/ as cost of the litigation expenses. Payment shall be made within 30 days from the date of receipt of copy of this order.
Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.
(Page No.1 to 9 dictated by Member to the Stenographer typed by him, revised and pronounced in the open court on this the 7th April 2017)
MEMBER PRESIDENT
(LAVANYA M RAI) (VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Mr. K.N. Alva,
Documents marked on behalf of the Complainant:
Ex.C1: Original of the individual health insurance policy No.070800/48/13/97/00002254 for the period of 1.1.2014 to 31.12.2014.
Ex.C2: original of the statement of account pertaining to the complainant.
Ex.C3: Xerox copy of the claim form forwarded by the complainant to the Opposite Party along with bills.
Ex.C4: office copy of the notice dated 15.4.2015 issued by the Advocate for the complainant to the Opposite Party.
Ex.C5: Acknowledgement of the Opposite Party for having received the notice at Doct. No.4 issued by counsel for the complainant.
Ex.C6: Office copy of the rejoinder dated 26.6.2015 issued by the Advocate for the complainant to the Opposite Party.
Ex.C7: Acknowledgement of the Opposite Party for having received the notice at Doct. No.6 issued by the counsel for the complainant.
Witnesses examined on behalf of the Opposite Party:
RW1: Mr. Pundalik M Nayak,
Documents marked on behalf of the Opposite Party:
Ex.R1: Individual Health Insurance policy bearing no. 070800/48/13/97/00002254 valid from 1.1.2014 to 31.12.2014.
Dated: 7.4.2017 MEMBER
