D.O.F:09/09/2020
D.O.O:25/04/2022
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.No.112/2020
Dated this, the 25th day of April 2022
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SRI.RADHAKRISHNAN NAIR.M: MEMBER
SMT.BEENA.K.G : MEMBER
Noorudheen.T aged 40 years
S/o Ibrahim
P.V.K. House, P.O Chithari
Hosdurg Taluk, Kasaragod District : Complainant
(Adv: P. Latheesh)
And
1. The Branch Manager
Oriental Insurance Co. Ltd : Opposite Parties
Rahmath Complex, Kottachery
P.O. Kanhangad, Kasaragod District- 671315
2. The Divisional Manager
Oriental Insurance Company Ltd.
Divisional Office , Unity Complex
S.N Park Road, Kannur
(Adv: A.K.V. Balakrishnan)
ORDER
SRI.RADHAKRISHNAN NAIR.M: MEMBER
The complaint is filed under section 12 of the Consumer Protection Act, 1986 ( as amended ).
The facts of the case in brief is that the complainant took the insurance policy, namely , Nagriksuraksha Individual Policy schedule of the Opposite Party and was remitting the premium amount promptly. The period of in insurance coverage was from 27.02.2019 to 26.02.2019. The complainant was insured under the policy scheme for total sum of Rs.5,00,000/-, where in the insurance coverage for personal accident was for Rs 4,00,000/- and the insurance coverage for hospitalization was for Rs 1,00,000/-,with 80 % and 20% respectively.
The complainant was injured at his knee while playing football on 04.05.2019 and hospitalised at Thejaswini Hospital, Manglore as there was pain at right knee and treated there till 31.05.2019. The complainant spent a total amount of Rs.1,07,676/- Viz. Rs. 87,676/-for medical expenses and Rs. 20,000/-for other expenses . The complainant forwarded claim intimation form to Opposite Party No. 2 through Opposite Party No.1 with all relevant documents, but the Opposite Parties did not sanction any amount, inspite of several requests and Lawyer's registered notice.
The denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony.
Hence this complaint is filed seeking direction to the OP to pay Rs.1,06,000/- the expense incurred for treatment together with a Compensation of Rs. 50,000/- as compensation for mental agony and cost.
The opposite party entered appearance and filed written Version.
As per the written version of the Opposite Party No.1 and 2, the complaint is unbelievable, false and not maintainable either in law or on facts, made without any basis.
It is admitted that they have issued an insurance policy to the complainant for the period from 27.02.2019 to 26.02 .2020. Previous policy issued to the complaint expired on 25.04.2018 and the present policy issued on 27.02.2019. So there is no continuity of the policy.
As per the complaint, the complainant was injured on 04.05.2019 and treatment was on 26.05.2019. There is no document to prove this date of injury and the treatment given. There is a delay in intimating the claim to the Opposite Parties. After receiving the claim intimation, the Opposite Parties requested the complainant to produce the records such as previous MRI records, X- Ray in relation to the treatment, which were not produced by the complainant. Also no prescription or discharge summery is produced.
There is no service deficiency on the part of the Opposite Parties since the claim is not repudiated. The complainant failed to produce the documents as requested by Opposite parties and hence the delay in settlement. The complaint is liable to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and documents
Ext. A 1 to Ext. A 9 are marked .The Ext - A1 is the Nagarik Suraksha individual Policy schedule scheme, Ext. A 2 is the Medical certificate issued from Thejaswini Hospital Mangalore, Ext. A3 Series are the Discharge Summary dated 31-05-2019 from Thejaswini Hospital Mangalore and medical bills (12 in number) , Ext - A 4 is the claim intimation dated 03-06-2019, Ext A5 is the copy of Regd.Lawyer's Notice. dated 01 -02-2020 to Opposite Party No .2, Ext. A 6 is is the copy of Regd.Lawyer's Notice dated 03 -02-2020 to Opposite Party No .1, Ext A 7 and 8 are the Postal Acknowledgement cards, Ext. A9 is the Reply Notice dated 11.02.2020 issued by Opposite parties.
The opposite party's did not adduce any oral evidence but produced certain documents and marked as Ext. B1 to Ext. B7. The document Ext B1 is the the Nagarik Suraksha individual Policy schedule scheme, Ext.B2 is the Medical certificate issued from Thejaswini Hospital Manglore , Ext. B3 is the claim intimation dated 03-06-2019, Ext. B4 the claim intimation dated 05-06-2019, Ext B5 is the copy of the letter issued to the complainant to produce documents, Ext. B6 is copy of Reply Notice dated 11.02.2020 issued by Opposite parties, Ext. B7 is the Postal Acknowledgement card. dated 25.07.2020.
Based on the pleadings and evidence of the rival parties in this case, the following
issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of any of the opposite party?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainants is that he had valid insurance policy for the period from 27.02.2019 to 26.02.2019 and was injured at his knee while playing football on 04.05.2019 and hospitalized at Thejaswini Hospital, Mangalore as there was pain at right knee and treated there till 31.05.2019 but the Opposite Parties denied insurance benefit for no valid reason.
The complainant states that he had spent a total amount of Rs.1,07,676/- Viz . Rs. 87,676/-for medical expenses and Rs. 20,000/-for other expenses and forwarded claim intimation form to Opposite Party No. 2 through Opposite Party No.1 with all relevant documents, but the Opposite Parties did not sanctioned any amount, inspite of Lawyer's registered notice.
The denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties due to which the complainant suffered mental agony.
Here the document Ext - A1 is the Nagriksuraksha individual Policy schedule scheme shows that the complainant is validly insured for the period from 00:00 on 27.02.2019 to the mid night of 26.02 .2020.
It is also stated that the complainant was insured under the policy scheme for total sum of Rs.5,00,000/- where in the insurance coverage for personal accident was for Rs 4,00,000/- and the insurance coverage for hospitalization was for Rs 1,00,000/-.with 80 % and 20% respectively.
The Opposite Parties admitted that they have issued an insurance policy to the complainant for the period from 27.02.2019 to 26.02 .2020. Previous policy issued of the complaint expired on 25.04.2018 and the present policy issued on 27.02.2019. So there is no continuity of the policy. As per their version, there is no document to prove the date of injury and the treatment given.
Regarding the evidence, the document Ext. A3 Series , the Discharge Summary dated 31-05-2019 from Thejaswini Hospital Manglore show that the complainant was admitted on 26.05.2019 with complaint of Left knee pain and history of twisting injury to right knee 1 month back while playing foot ball C/o pain on and off over right knee since then. He was undergone various tests and diagnosed as Left knee complete ACL TEAR . There after he undergone operative (surgical )procedures namely, Arthroscopic Left knee ACL Reconstruction with I /L ST Graft Augmented with Tight Rope and Bio composite Interference screw Arthrex on 27-05-2019 under SA . The Ext. A3 series would further show that the complainant had incurred an amount of Rs.91,616/- towards medical expense.
Here the opposite parties raise a very strange argument that even though there is valid insurance for the relevant period, he is not entitled for any insurance benefit, as there is no continuity of the policy.
The Opposite Party argues that the previous insurance policy issued to the complainant expired on 25.04.2018 and the present policy issued on 27.02.2019. This kind of argument is not at all acceptable. There is no such condition. It is well settled that insurance policy is issued for a particular period and the insurer is responsible to pay insurance benefit for medical expenses incurred during the validity period of policy.. The Ext. B1 would show that the policy shall pay for hospitaisation expenses for medical /surgical treatment at any nursing Home / Hospital in lndia as inpatient.
Therefore considering the facts and circumstance of the case, the complaint is entitled for the medical expenses incurred for his treatment. So this commission is of view that the complainant is entitled for Rs .91,616/- towards insurance benefit .
Denial of the insurance benefit for no valid reason is service deficiency on the part of opposite parties, due to which the complainant suffered mental agony. Therefore the Opposite Party is liable to pay compensation for that. This commission hold that Rs.20,000/- will be a reasonable amount of compensation.
ln the result , the complaint is allowed in part and the Opposite Parties are directed to pay a total amount of Rs. Rs.91,616/- with 8% interest per annum from 09.09.2019, the date of complaint till payment, to the complainant . The Opposite Parties are also directed to pay Rs. 20,000/- (Rupees Twenty thousand only) towards Compensation and Rs. 5,000/-(Rupees Five thousand only) towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Nagriksuraksha Individual Policy Schedule Scheme
A2- Medical certificate issued from Thejaswini Hospital
A3- Discharge summary and medical bills
A4- Claim intimation
A5- The copy of Registered Lawyer’s notice
A6- The copy of registered lawyer’s notice
A7 &8 – Postal acknowledgment cards.
A9- Reply notice Dt:11/02/2020
B1- Nagriksuraksha Individual policy schedule
B2- Medical certificate
B3- Claim intimation
B4- Claim form
B5- copy of letter issued to the complainant
B6- copy of reply notice Dt: 11/02/2020
B7- Postal acknowledgment
Witness Examined
Pw1-Noorudheen.T
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
