Judicial Analysis Court Copy Headnote Facts Arguments Court observation

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, THIRUVANANTHAPURAM
K. Surendra Mohan, President, T.S.P. Moosath, Judicial Member, Ranjit R., Member, Beena Kumari A., Member and Radhakrishnan K.R., Member
United India Insurance Company Ltd. —Appellant
versus
Margaret A. Chirayath —Respondent
First Appeal No.781 of 2016
(Arisen out of Order Dated in Case No.CC/490/2012 of District Trissur)
Decided on 30.5.2022

Advocates:
Counsel for the Parties:
For the Appellant:T.J. Lakshmanan, Advocate
For the Respondent: Party in person

IMPORTANT POINT
Dismissal of Compliant before Insurance Ombudsman - Dismissal of the complaint by the Insurance Ombudsman does not prejudice in any way, the complainant’s right to seek legal remedy against the action of the insurers complained against, as per normal process of law.

Headnote:
Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Services – Insurance – Individual Health insurance – Disallowance of claim by Insurance Ombudsman – Will not disentitle, Right to seek remedy before Consumer forum - The complaint relates to a dispute regarding the amount paid in respect of a claim under an individual health insurance policy taken from the opposite party - Dismissal of the complaint by the Insurance Ombudsman does not prejudice in any way, the complainant’s right to seek legal remedy against the action of the insurers complained against, as per normal process of law - As per section 3 of the Consumer Protection Act, 1986 (corresponding section 100 of Consumer Protection Act, 2019), the reliefs available to the Consumer are in addition to and not in derogation of any other law for the time being in force - The complainant has exercised this right and Commission does not find any illegality in filing the complaint before the District Commission despite a dismissal order by the Insurance Ombudsman. Being a separate and independent proceeding, it was for the District Commission to decide whether to consider or accept any of the observations in the award - It is evident that even payment of the admitted claim was unnecessarily delayed. This is in violation of the provisions of the IRDAI (Protection of Policyholders’ interests) Regulations - The mere statement of the appellant that the disallowed amount of Rs. 43,490.17 relates to purchase of Gefonib tablets is not sufficient. It should be substantiated with supporting documents. All the vital information and records including original bills from the hospital are in the custody of the appellant / opposite party, which were not produced before the District Commission to prove their contention – Thus, without verifying the bills Commission cannot conclude whether the disallowed bills pertain to inadmissible items like purchase of tablets or otherwise. There is no evidence before us to prove that the bills for the disputed amount of Rs. 43,490.17 pertain to inadmissible treatment as per clause 2.3 of the policy – Appeal dismissed with cost, The sum of Rs. 25,000/- deposited by the appellant on filing the appeal shall be released to the respondents/ complainants on proper application before this Commission. [Paras 7 to 10]
Result: Appeal dismissed with costs.

JUDGMENT

Radhakrishnan K.R., Member.—The appeal has been filed by the opposite party u/s 15 and 17 of the Consumer Protection Act, 1986, against the order dated 21.05.2016 in C.C. No. 490/2012 on the file of the Consumer Disputes Redressal Forum, Thrissur (District Forum/Commission for short). The District Forum allowed the complaint and directed the opposite party to pay Rs. 62,673.17 with 9% interest from the date of the complaint till realization. No compensation and costs were awarded.

2. The case of the complainant is briefly as follows: The complaint relates to a dispute regarding the amount paid in respect of a claim under an individual health insurance policy taken from the opposite party. The first complainant has been taking health insurance policy from the opposite party from March 2001 onwards for covering herself and her mother (2nd complainant). The policy relevant to the claim was taken for a period from 23-03-2011 to 22-03-2012 by paying a premium of Rs. 13, 417/- for covering the first complainant for a sum insured of Rs. 100,000/- and the second complainant for Rs. 200,000/-. The second complainant was suffering from lung cancer and was treated in Amala Institute of Medical Sciences, Amala Nagar, Thrissur. The treatment records including the original bills for Rs. 62,673.17 for her treatment were submitted to the opposite party on 21-09-2011. After constant follow up the opposite party sent a letter dated 14-11-2011 partially admitting the claim for Rs. 19,183/- and stating that the balance amount is not payable as it pertains to expenses incurred for chemotherapy other than that of parenteral in nature which do not come under the scope of the policy coverage. Even the admitted amount was not paid. A complaint was filed before the Insurance Ombudsman on 01.03.2012. As decision was delayed, this complaint was filed on 29.10.2012, alleging deficiency in service on the part of the opposite party and claiming Rs. 85,401/- with interest @ 12% per annum towards treatment expenses, interest, compensation and costs.

3. Head office of the opposite party insurance company is impleaded as 1st opposite party and their Thrissur Divisional office is impleaded as 2nd opposite party. The 2nd opposite party entered appearance and filed version admitting the policy subject to terms and conditions. They stated that they had informed the complainant on 14.11.2011 about their readiness to pay an amount of Rs. 19,183/- towards their claim. Balance amount claimed was not admissible as per clause 2.3 of the policy as it pertains to purchase of Gefonib tablets for oral consumption at home, which will not come within the exceptions to the said clause. There was no deficiency in service or unfair trade practice on their part and hence they prayed for dismissal of the complaint.

4. The first complainant filed proof affidavit and the second opposite party also filed proof affidavit. Exbts. P1 to P11 were marked on the side of the complainant and Exbts. R1 to R4 were marked on the side of the opposite party. During the pendency of the case, the second complainant passed away and her legal heirs were impleaded as additional complainants 3 and 4. On the basis of the evidence adduced, the District Commission allowed the complaint as stated earlier. Aggrieved by the impugned order the opposite party has filed this appeal.

5. We heard the counsel for the appellant and the first respondent/ first complainant who appeared in person. The learned counsel for the appellant submitted that only an amount of Rs. 19,183/- is payable under the policy and the balance amount pertains to cost of tablets which is not admissible as per clause 2.3 of the policy. These expenses cannot be considered under parenteral chemotherapy which is an exception to this clause. The complaint submitted to the Insurance Ombudsman was dismissed and the District Commission failed to observe the findings of the Ombudsman as per his award (Exbt. R3) dated 05.06.2013. The finding

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Judicial Analysis

SupremeToday

IMPORTANT POINT Dismissal of Compliant before Insurance Ombudsman - Dismissal of the complaint by the Insurance Ombudsman does not prejudice in any way, the complainant’s right to seek legal remedy against the action of the insurers complained against, as per normal process of law.

Judicial Analysis

IMPORTANT POINT
Dismissal of Compliant before Insurance Ombudsman - Dismissal of the complaint by the Insurance Ombudsman does not prejudice in any way, the complainant’s right to seek legal remedy against the action of the insurers complained against, as per normal process of law.