IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 30thday of March, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 44/2020(Filed on 27.02.2020)
Complainant : M.K.Sherly, Onattu House
Thazhathangadi P.O
Kottayam
(ByAdv.Roy George)
Vs
Opposite parties : 1. Vidal Health TPA (Pvt) Ltd
AnmolPalani
No.88, 6 N Chetty Road, L2
T.Nagar , Madras.
2. United India Insurance Co.Ltd
Div.Office-010500
Catholic Centre 64,
ArmerianStreet , Chennai
(Policy No.0105002019484100000974695)
(By Adv.P.G.Girija)
3. Indian Bank, Baker Junction, Kottayam
(By Adv.C.L.Joseph)
O R D E R
Sri.Manulal.V.S, President
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties.
The complainant is a medi claim policy holder of the second opposite party by name ArogyaRaksha vide policy number 01050020948400000974695.Complainant availed said policy through the third opposite party. The features of the said policy cover extends to the policy holder, spouse, and other family members of the complainant.
On 29-09-2019, complainant’s husband Jacob Simon was got admitted atNangelilhospital,Nallikkuzha,Kothamangalam which is anAyurvedic hospital due to severe back pain. The said Jacob Simon was treated there as an inpatient from 30-09-2019 to 08-10-2019 and on 30-09-2019 itself the same was informed to the first opposite party who is acting as a subordinate unit of the second opposite party. The treatment expenses of the surgery was Rs.17,928/. The complainant submitted a claim form along with discharge summary, medical certificate, cashreceipts, dischargebill etc to the first opposite party on 17-10-2019 through professional Courier service. But on 04-11-2019 the first opposite party sent a message to the complainant requestingthe documents which were already sent to them by the complainant. Though the complainant sent several communications to the first opposite party stating the facts that the complainant had already sent all documents tothem, the first opposite party purposefully evading from honoring the claim falsely stating that they did not receive the documents relating to the treatment of the Jacob Simon. The act of the opposite parties is violation of the policy conditions and amounts to deficiency in service on the part of the opposite parties. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to reimburse Rs.1,79,28,000/- along with a compensation of Rs.5,000/-.
Upon notice second and third opposite parties appeared before the commission and filed separate version. Despite the receipt of notice from this commission the first opposite party neither care to appear before the commission nor to file version. Hence first opposite partyis set ex-party.
Version of the second opposite party is as follows:
The second opposite party had issued ArogyaRaksha vide policy number 01050020948400000974695 to the complainant. The complainant’s claim could not be processed because the treating doctor’s clarification regarding the cause and duration of the ailment was not submitted to the first opposite party. Even though the complainant was required to submit the same, she did not submit it. As per policy conditions, it is necessary to know the cause and duration of the ailment. Hence the claim could not be processed by the first opposite party. There is no deficiency in service on the part of the second opposite party.
Version of the third opposite party is as follows:
The third opposite party arranged the policy to be taken by the complainant from the second opposite party. Apart from that the third opposite party is in no way bound to honour the claim of the complainant. The third opposite party is not serviceprovider. The third opposite party acted only as an agent, introducing the parties to the contract of insurance. There are no reliefs claimed against the third opposite party.
Complainant filed proof affidavit in lieu of chief examination and markedExhibit A1 to A8 from the side of the complainant. VigneshAnand who is the Assistant Manager of the second opposite party filed proof affidavit in lieu of chief examination and marked Exhibit B1 and B2 from the side of the second opposite party. No oral or documentary evidence on the part of the third opposite party.
On the basis of the contention of the rival parties we framed the following issues for consideration.
- Whether the opposite parties committed any deficiency in service asalleged?
- Regarding the relief and costs?
Point number 1 and 2.
There is no dispute on the fact that the complainant had availed anArogyaRaksha policy vide number 01050020948400000974695 from the second opposite party.On perusal of Exhibit A1 policy we can see that the complainant, her husband Jacob Simon were the insured persons and the sum insured was Rs.1,00,000/- and the period of cover was 01-10-2019 to 30-09-2020. It is proved by Exhibit A6 that Jacob Simon was treated at Nangelil hospital, the diagnosis was Sandhigatha Vatham from 30-09-2019 to 08-10-2019. It is further proved that the system of treatment was Ayurveda.
The specific case of the complainant is that though she had submitted the claim form along with relevant documents to the first opposite party on 17-10-2019 through professional Courier service, the first opposite party purposefully evading from honoring the claim falsely stating that they did not receive the documents relating to the treatment of the Jacob Simon.In Exhibit A8(i) which is a mail sent by the first opposite party to the complainant it is stated that the first opposite party acknowledged the receipt of claim documents regarding the treatment of Jacob Simon at Nangelil hospital and they further requested to produce the treating doctor’s clarification about the cause for the ailment with its duration and reason for late submission and the originals of payment receipt. In reply to the said mail communication the complainant vide Exhibit A8 (e) which is mail communication dated 19-12-2019 sent all the required documents which were sought by the first opposite party vide Exhibit A8 (i) mail communication. Moreover on 24-12-2019 the first opposite party sent an mail communication to the complainant to sent the couriers details and copy of the Exhibit A7 POD to them. On a scrutinyof these documentary evidences we cannot accept the contention of the second opposite party that complainant’s claim could not be processed because the treating doctor's clarification regarding the cause and duration of the ailment was not submitted to the first opposite party.
The case on hand shows clear malafides on the part of first and second opposite parties in the manner they dealt with the insurance policy, after learning of the treatment of Jacob Simon on intimation from the affected persons. The way the issue was addressed by the first and second opposite parties following the information conveyed does fail, in our opinion, the test of Reasonable Conduct. On top of that, to cover up their late reaction, most tellingly, under the garb of an unfounded reason was raised. These in our opinion, amount to a clear case of deficiency of service and a non-bonafide conduct by the first and second opposite parties.
We are, therefore, persuaded to conclude that the complaint stand allowed in part. The first and second opposite parties are accordingly directed to process the complainant’s insurance claim and remit the payable sum within 30 days from the date of receipt of this order. The first and second opposite parties are directed to pay Rs.5,000/- as compensation to the complainant for the deficiency in service on their part.
Order shall be complied within 30 days from the date of receipt of the copy of this order, failing which the compensation amount will carry 9% interest till the date of realization.
Pronounced in the Open Commission on this the 30th day of March, 2023.
Sri. Manulal.V.S, President sd/-
Smt.Bindhu.R, Member sd/-
Sri. K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant.
A1- Copy of the policy cum certificate for ArogyaRaksha issued by United India Insurance Company Limited.
A2- Copy of ArogyaRaksha - due date notice dated 05.09.2019
A3- Copy of e-mail intimation of admission in hospital
A4- Copy of letter to the Manager, Vidal Health TPA Pvt Ltd, T Nagar, Chennai.
A5- Copy of claim form
A6- Copy of discharge summary dated 08.10.2019 issued from Nangelill Hospital, Nellikuzhy P.O
A7- Copy of receipt of Professional Couriers, Kottayam
A8- Copy of intimation of admission in hospital
Exhibits marked from the side of opposite party.
B1- Certified copy of Arogya Raksha(Group Health Insurance Scheme) Policy (No.0105002818P107977691) of United India Insurance company Ltd.
B2- Certified copy of Arogya Raksha (Group Health Insurance Scheme) Policy (No.0105002819P108379392) of United India Insurance company Ltd.
By order
sd/-
Assistant Registrar