PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding dispute between the Complainant and the Opposite Party regarding the deficiency in service on the part of Opposite Party, as it partly rejected the mediclaim of the Complainant.
2) The facts of this case as stated by the Complainant are that the Complainant had obtained a mediclaim policy since 1991. The Opposite Party, after having verified all the details and documents, issued the 1st mediclaim insurance policy without any endorsement of exclusion. The Complainant has been renewing the said policy regularly. The Complainant renewed the said policy with enhanced sum of Rs.5 Lacs on 30/11/01 in the year. The policy No. is 020400/48/01/03778 valid from 30/11/01 to 29/11/02.
3) It is further submitted by the Complainant that she was admitted in Breach Candy Hospital for treatment of knee replacement on 02/05/02. The Complainant intimated the Opposite Party vide its letter dtd.20/05/02. The Complainant has stated that this letter is annexed to the complaint as Exh. ‘D’(but actually when we perused the papers this document is not there and it is missing).
4) The Complainant has submitted that she lodged her mediclaim with the Opposite Party. Claim form was duly filled in and submitted to the Opposite Party alongwith all the required documents such as, discharge card, bills, medical report. Thereafter all efforts were made so that the Opposite Party could settle the claim but the Opposite Party only sent a disbursement voucher of Rs.68,900/- against the Complainant’s claim of Rs.2,19,596/-. The Complainant then wrote a letter dtd.25/02/03 to Opposite Party protesting the said voucher and return the voucher vide letter dtd.15/10/03.
5) The claim was lodged by the Complainant with the Opposite Party on 20/05/02 but no decision was taken by the Opposite Party till 26/11/02. As per rules and regulations of the policy the Opposite Party ought to have taken decision within 3 months from the date of receipt of the claim. So in this respect also the Opposite Party is deficient in approving the mediclaim within the stipulated period of time as per rules and regulations of the policy. Moreover the Opposite Party have failed to give any reason for less amount of settlement.
6) Therefore, the Complainant has finally submitted that the Complainant is entitled for compensation of Rs.2,19,596/- alongwith interest @ 12 % p.a. from 02/05/02 and Rs.20,000/- for mental torture and harassment and legal charges, incidental expenses of Rs.20,000/- the total amount being Rs.3,47,396/-. The Complainant has attached the xerox copies of the following documents alongwith the complaint to support her allegations of deficiency against the Opposite Party.
a) Policy of 1991 alongwith terms and condition (No terms & conditions are attached as alleged by the Complainant).
b) Receipt No.1850025 dtd.26/11/2000 for Rs.7,597/- for policy No.3332 – page 13, policy document No.3332 sum
assured 5 Lacs and valid till 30/11/2000 to 29/11/2001.
c) Policy No.020400/48/01/03778 from 30/11/01 to 29/11/2002.
d) Receipt of premium issued by the Opposite Party.
e) Disbursement (claim) voucher dtd.26/11/02 issued by the Opposite Party to the Complainant.
f) Letter from the Complainant to Opposite Party, dtd.25/02/2003.
g) Letter dtd.15/10/03 from the Complainant to Opposite Party.
7) The complaint was admitted and notice was served on the Opposite Party. Opposite Party appeared through its Ld.Advocate and filed written statement wherein all the allegations are denied and specifically the Opposite Party has stated that the Complainant is not entitled to any more claim that what was offered by the Opposite Party earlier for the reason that “the enhanced sum insured shall not be available for any ailment/disease which has been contracted after inception of the policy but before increase in the sum insured and/or for which claim have already been reported/settled, whether with the present or previous insurer.”
8) In the instant case the enhancement of the policy was done in the year 2001(exactly on 30/11/01). Therefore, the Complainant is not entitled to any enhancement benefit. The Complainant’s symptoms of Osteoarthritis commenced from 1st Nov., 01 as per the certificate from attending Orthopaedic Surgeon. The papers and x-rays were scrutinized by Dr. Unadkat, Orthopaedic Surgeon, attached to Breach Candy Hospital. Though the symptoms started in November and the changes of Osteoarthritis and associated deformities of knee indicate a long chronic problem. Hence, the claim is payable as per limit prior to enhancement. Therefore, the Opposite Party has submitted that there is no deficiency in service on its part. Hence, the complaint be dismissed.
9) The Opposite Party has attached the xerox copy of letter dtd.24/09/03 addressed to the Opposite Party by Dr. Sunawala and another letter dtd.23/08/03 of Dr. Chetan Unadkat. The written statement is supported by the affidavit of the Divisional Manager of the Opposite Party.
10) Thereafter the Complainant submitted her affidavit of evidence and written argument wherein the facts mentioned in the complaint are reiterated. The Opposite Party also filed written argument wherein the facts and points raised in the written statement are reiterated by the Opposite Party.
11) During the course of proceedings the Complainant died on 19/11/08. Mr. Manilal Damji Dharod, the son of the Complainant who was on record as a representative of the Complainant applied before this Forum to delete the name of the Complainant and further prayed that the legal heirs be brought on record. The said application was allowed after taking into consideration the no objection of the Opposite Party. Legal heirs as mentioned in the title were added to this complaint.
12) We heard the Ld.Advocates of both the parties and perused all the papers submitted by both the parties. Our findings are as follows –
The Complainant has obtained mediclaim policy from the Opposite Party since 1991. The 1st mediclaim policy was obtained since 29/10/1991 and was continued till October, 2002. Meanwhile in the year 2000, the sum insured was increased upto 5 Lacs. This relevant policy was valid from 30/11/2000 to 29/11/2001 and the sum assured was of Rs.5 Lacs. Thus, the sum insured was increased since 30/11/2000.
13) Though the Complainant has averred in her complaint in para 7 that she has attached letter dtd.20/05/02 intimating the claim, we do not find this letter alongwith the complaint. But as the Opposite Party has admitted in the written argument that the Complainant was admitted on 02/05/02 in Breach Candy Hospital for knee replacement surgery and it had sanctioned the claim of Rs.68,900/-. It can be concluded that the Complainant was suffering from knee problem. She was admitted in Breach Candy Hospital on 02/05/02 and submitted her mediclaim. The Opposite Party approved the claim of Rs.68,900/- only on 26/11/02. It is the contention of the Complainant that her mediclaim was of Rs.2,19,596/-.
14) In written statement of the Opposite Party, it is the contention of the Opposite Party that the Complainant is entitled for only 68,900/-. The reason given by the Opposite Party is that –
“The enhanced sum insured shall not be available for any ailment/disease which has been contracted after inception of the policy but before increase in the sum insured and/or for which claim have already been reported/settled, whether with the present or any previous insurer.”
15) In the instant case, in the first instance there is no previous settlement of the claim with present or previous insurer for the disease knee replacement surgery. The sum is increased on 30/11/2000. The surgery was performed on or about 02/05/2002 i.e. one year and 6 months after the increase in the sum insured. In this respect the Opposite Party has produced the xerox copy of a letter dtd.24/09/03 i.e. after the offer of Rs.68,900/- given to the Complainant i.e. after the decision was taken to approve the claim of Rs.68,900/- instead of the claim Rs.2,19,596/-. In this letter Dr. Sunawala has wrongly stated that sum insured has been enhanced in November, 2001. Actually the papers clearly show that the sum was increased exactly from 30/11/2000.
16) Similarly Dr. Sunawala also made a wrong statement in his letter that the Complainant preferred a claim for hospitalization expenses in May, 2001. Actually she has preferred this mediclaim in May, 2002.
17) Dr. Sunawala has made a statement that her symptoms of Osteoarthritis commenced from November, 2001. She has further stated that they (including Dr. Unadkat) are of the opinion that though the symptoms started in 2001, and changes of Osteoarthritis as seen in the x-ray and the associated various deformities, of the knee indicate a long standing chronic problem. The term long standing chronic problem is a vague term. As per her own observation, the symptoms of Osteoarthritis appear on 1st November,01. An ordinary prudent person thinks that a disease is contracted when the symptoms appear. In this case the disease is Osteoarthritis. Dr. Sunawala does not opine exactly as to when this disease was contracted but only commented that it is a long standing chronic problem. She is not clear unambiguous in her opinion.
18) There is a certificate of one Dr. Chetan Unadkut, produced by the Opposite Party. He also states in this certificate that the x-ray of the Complainant show tricometmental Osteoarthritis changes in knee which to me has been a long standing problem. This certificate is also dtd.03/08/03 i.e. after the decision was taken about the sanction of the mediclaim submitted by the Complainant. In this certificate also, the Dr. has used the same vague language as Dr. Sunawala i.e. the disease “has been a long standing problem”. (Long standing means exactly since what time ?). Thus, nobody has exactly confirmed that the disease was contracted before 30/11/2000. Thus, the term/condition/ground cited by the Opposite Party for rejecting the claim does not hold water and cannot be considered as an authentic ground for repudiation of the mediclaim of Rs,2,19,596/-.
19) The Opposite Party has relied on the rules/regulations mentioned in para 14 above on which the Opposite Party has rejected the claim of Rs.2,19,596/- but the Opposite Party has failed to attach this regulations/rules/conditions of the policy. Therefore, only averment in written statement without any supporting document to this effect cannot be relied upon.
20) On the other hand, the Complainant has averred in para 11 of the complaint that the Opposite Party agreed to settle the claim for Rs.68,900/- as against Complainant’s claim for Rs.2,19,596/- and Opposite Party has admitted the whole para No.11 vide its para no.11 of written statement. It is also submitted by the Complainant that she had already submitted all the relevant documents to the Opposite Party.
21) Therefore, it appears that the Complainant had submitted the mediclaim of Rs.2,19,596/- to Opposite Party in the month of May, 2002. Therefore, it would be the obligation of the Opposite Party to pay the expenses incurred by the Complainant at the time of hospitalization.
22) The papers filed by both the parties also revealed that the Complainant was hospitalized on 02/05/02 and the claim was submitted in the month of May, 2002 only but the decision on this claim was taken on 26/11/02 i.e. after 6 months after the receipt of the claim documents. This also amounts to the deficiency in service on the part of Opposite Party.
23) The Complainant did not accept the disbursement voucher of Rs.68,900/- and requested the Opposite Party to reconsider her claim of Rs.2,19,596/- vide her letter dtd.25/02/03 and returned the voucher of Rs.68,900/- to the Opposite Party on 15/10/03 but the Opposite Party has not shown any response to her letters. It failed to give any reason as to why the claim of Rs.2,19,596/- was not approved and why only a claim of Rs.68,900/- only was approved. When the Complainant pays a premium to the Opposite Party, the insured is certainly a valuable consumer of the Opposite Party and it is the legal obligation of the Insurance Company to explain the reason for the decision taken by it on the approval or repudiation of the claim. In the instant case Opposite Party has not given any heed to the request made by the consumer nor any reason was given for not sanctioning the complete claim of the Complainant. Therefore, the Opposite Party is certainly negligent in performing its legal obligation and thus, there is a deficiency in service on the part of the Opposite Party. Therefore, we pass the following order -
O R D E R
i. Complaint No.231/2005 is partly allowed.
ii. Opposite Party is directed to reimburse Rs.2,19,596/- (Rs. Two Lacs Nineteen Thousand Five Hundred Ninety
Six Only) to the Complainants against their mediclaim alongwith interest @ 9 % p.a. from 20/08/2002 till the
entire payment.
iii.Opposite Party is directed to pay Rs.10,000/- (Rs. Ten Thousand Only) to the Complaints as compensation for
committing deficiency in service as discussed in the above order and causing mental agony and physical
harassment to the Complainants.
iv.Opposite Party is directed to pay Rs.5,000/- (Rs. Five Thousand Only) to the Complainants as a cost of this
complaint.
v. Opposite Party is directed to comply with the above said order within 30 days from the receipt of this order.
vi.Certified copies of this order be furnished to the parties.
