State Consumer Disputes Redressal Commission
United India Insurance Co.Ltd vs P.Gireesh, on 31 January, 2014
Daily Order
Kerala State Consumer Disputes Redressal Commission Vazhuthacaud,Thiruvananthapuram First Appeal No. A/13/288 (Arisen out of Order Dated 15/06/2012 in Case No. 307/2011 of District Thiruvananthapuram) 1. UNITED INDIA INSURANCE CO LTD DIVISIONALOFFICE, LMS COMPOUND, TVM ...........Appellant(s) Versus 1. P GIREESH PADMAVILASOM, MANKUZHY, PANGAPPARA, TVPM ...........Respondent(s) BEFORE: HON'ABLE MR. JUSTICE SRI P.Q.BARKATH ALI PRESIDENT SRI. V. V. JOSE MEMBER PRESENT: ORDER
KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION SISUVIHARLANE VAZHUTHACADU THIRUVANANTHAPURAM
APPEAL No.288/2013
JUDGMENT DTD : 31.01.2014
( Appeal filed against the order in CC.No.307/2011 on the file of CDRF, Thiruvananthapuram dated : 15.06.2012)
PRESENT
SRI.K.CHANDRADAS NADAR : JUDICIAL MEMBER
United India Insurance Co.Ltd,
Divisional Office 1, L.M.S.Compound,
Thiruvananthapuram
Rep.by its Assistant Manager, APPELLANT
T.Rasmi
(By Adv.R.Jagadishkumar, TVPM)
Vs.
P.Gireesh,
Padmavilasam, Mankuzhy, RESONDENT
Pangappara.P.O
Thiruvananthapuram
JUDGMENT
SRI.K.CHANDRADAS NADAR : JUDICIAL MEMBER Appellant was the opposite party in CC.No.307/2011 in the CFRF, Thiruvananthapuram. The complainant / respondent in this appeal was a member of Unihealth Insurance Scheme of the United India Insurance Company (opposite party) from March 2000. He joined the scheme through the SBT Engineering College Branch, Thiruvananthapuram. The insured amount was Rs.1 lakh. The complainant alleged that he was admitted at the Ananthapuri Hospital, Thiruvananthapuram on 12.07.2013 for surgery and was discharged from the hospital on 15.07.2013. Ananthapuri Hospital is a hospital approved under the scheme. The opposite party at the time of discharge of the complainant from the hospital had denied his claim and he was forced to remit the bill amount of Rs.32,780/-. The complainant took up the matter with the insurance company. He was told to submit fresh claim and accordingly he submitted a revised claim on 20.07.2011. On 20.08.2011 he received cheque for Rs.15,000/- from M/s. T.T.K.Health Care and the balance amount of the bill was disallowed. The insurance company disallowed his claim for expenses in connection with the surgery for the reason that the amount exceeded the authorized limit. At the time of joining the scheme policy document did not specify any upper limit for claims, but specified only the maximum amount of claim per annum as Rs.1 lakh. The complainant further took up with the matter with the insurance company and M/s.TTK Health Care. But there was no response. Hence the complaint.
2. The opposite party contended before the District Forum that the parties are strictly bound by the terms and conditions mentioned in the policy. The claim of the complainant was in relation to hernia surgery done at the hospital. As per the recitals in the policy in the case of hernia surgery he opposite party is liable to pay only 15% of the sum insured (Rs. 1 lakh in this case). The opposite party has already paid Rs.15,000/- to the complainant which alone is due to him as per the policy . This being the true state of affairs the claim is not sustainable.
3. Before the District Forum none of the parties tendered oral evidence. Exts.P1 to P10 were marked on the side of the complainant and Exts.D1 and D2 were marked on the side of the opposite party. The District Forum reasoned that documents like Ext.P8 could be considered only as a " document to deceive people with transparent deceptions" and the failure of the opposite party in not providing cashless facility to the complainant and not entertaining his claim amounted to deficiency in service. Accordingly the District Forum allowed the complaint. The opposite party, United India Insurance Company is challenging the order of the District Forum.
4. The only question that arises for consideration is whether the order of the District Forum can be sustained.
5. Admittedly, the complainant was a member of Group Medi Claim Policy issued by the appellant . He joined the scheme in March 2009 through the Engineering College Branch of SBT, Thiruvananthapuram. The relevant documents show that the insured amount was Rs. 1 lakh. The grievance of the complainant is that he was admitted at Ananthapuri Hospital , Thiruvananthapuram for surgery on 12.07.0211 and was discharged from hospital after surgery on 15.07.2011. At the time of discharge the appellant refused to provide cashless facility to the complainant. There is no dispute that Ananthapuri Hospital where the complainant under went surgery is one of the network hospitals covered under the scheme providing cashless facility. The reason for refusal of cashless facility to the complainant was that he underwent hernia surgery and as per the conditions in the policy only 15% of the insured amount was covered with regard to hernia surgery. The District Forum noticed that the "information given in Ext.P8 was only indicative and for the full terms and conditions the insured should refer to the original policy insured". The complainant has not produced the original policy conditions. The stand of the complainant appears to be that the policy conditions were not furnished to him. The opposite parties produced Ext.D2 as specimen conditions accompanying medi claim policies as per SBI Unihealth Insurance Plan A, B & C. It is clearly mentioned in Ext.D2 as condition 1.3 that in the case of hernia hospitalization benefits limits is restricted to 15% of the SI or maximum Rs.30,000/-. The refusal to extend cashless facility to the complainant was obviously based on the above condition coupled with the fact that the insured amount as per Ext.P1. (Same as Ext.D1) was Rs. 1 lakh. For ignoring Ext.D2 condition the Forum adopted the reasoning that " the act of the opposite party in issuing policy terms and conditions like that of Ext.P8 could be considered only as a document to deceive people with transparent deceptions ". The District Forum also held that when the terms and conditions like Ext.P8 are given to a policy holder which the insurance company claims to be only indicative the company has to make its terms and conditions as transparent as possible. Therefore the failure to provide cashless facility to the complainant was deficiency in service.
6. In arriving at the above conclusion, the District Forum ignored two important aspects. Firstly, Ext.P8 is apparently a document given by the State Bank of Travancore which floated the scheme in association with the opposite party. So the conditions in Ext.P8 are not the binding conditions with the opposite party and in the ordinary course the opposite party would have annexed their conditions of policy along with the certificate of insurance and therefore the conditions in Ext.D2 are the binding conditions. Secondly, the evidence indicates that the complainant was aware of the said policy condition. It is significant that when the complainant submitted Ext.P4 claim form he left the column to show nature of disease or illness blank. Even in the complaint there is no allegation as to what precise surgery he underwent in the hospital. Only in Ext.P6 medical certificate submitted to the Insurance Company the diagnosis of the illness is mentioned as left direct inguinal hernia and that inguinal hernioplasty was done. So the conduct of the complainant indicates that he was aware that if it was disclosed that hernioplasty was done his claim would be limited . This indicates that he was aware of the policy condition in Ext.D2.
7. The learned counsel for the appellant urged relying on the decision of the Hon'ble Supreme Court in Vikram Greentech (I) Ltd and Anohter V. New India Insurance Co. Ltd 2009 KHC 4613, that in order to determine the extent of liability of insurance , terms of insurance contract have to be strictly construed without venturing into extra liberalism that might result in rewriting of the contract or substituting the terms which were not intended by the parties. I have referred to the observations of the District Forum, which are mere assumptions. In a contract of insurance as in any other contract the terms agreed to between the parties can not be brushed aside on mere assumptions. Admittedly the appellant had disbursed 15% of the insured amount to the complainant to which alone the complainant was entitled to as per the terms of the policy. This being the situation the District Forum erred in allowing the complaint. Hence the appeal is liable to be allowed.
In the result, the appeal is allowed. In reversal of the order of the District Forum in CC.No.307/2011 dated 15.06.2012, the complaint is dismissed. Considering the facts and circumstances of the case the parties are directed to bear their respective costs in this appeal.
K.CHANDRADAS NADAR : JUDICIAL MEMBER Be/ [HON'ABLE MR. JUSTICE SRI P.Q.BARKATH ALI] PRESIDENT [ SRI. V. V. JOSE] MEMBER