COMPLAINT NO. 268/2007




COMPLAINANT:                                SMT. PISTABAI



1.      M/S The New India Assurance Co. Pvt. Ltd.,

2.      M/s Medi Assist India Pvt. Ltd.,



This is a complaint filed by the Complainant against the Opposite Parties for the payment of Rs.75,000/- with interest and Rs.10,000/- for mental harassment, costs and for such other reliefs.

The brief facts of the case are that the Complainant is covered under Mediclaim Policy No.670500/48/04/75228 for the period 10.12.2004 to 09.12.2005 issued by The New India Assurance Company Private Limited. That the policy covers hospitalization etc. for a sum of Rs.75,000/-. The Complainant was admitted to Narayana Hrudayalaya on 02.06.2005 and got discharged on 17.06.2005, and underwent aortic valve replacement surgery, i.e., open-heart surgery. Immediately Complainant by letter dated 07.06.2005 intimated the OP about the hospitalization and requested for cashless hospitalization. That in response to the request, instead of extending cashless hospitalization OP instructed the hospital to collect the money from Complainant on the assurance that after discharge of the complainant, they shall reimburse the expenses incurred. After the surgery, etc. Complainant had totally incurred expenses of Rs.2,25,305/-. Further, by letter dated 09.06.2005, the OP’s had assured that on receipt of the discharge summary they shall process and pay off the claim. Accordingly, after discharge on 21.06.2005 Complainant’s husband submitted the discharge summary and bills of Narayana Hrudayalaya Hospital to the OP to process her claim. But, surprisingly by letter dated 23.06.2005, OP’s demanded the history of past medical illness etc. Accordingly, complainant who was admitted to Cambridge Hospital previously for delivery submitted the past discharge summary of Cambridge Hospital also to the OP on 27.07.2005.

After receiving Complainant’s previous hospitalization at Cambridge Hospital, OP’s falsely rejected Complainant’s claim with respect to the hospitalization at Narayana Hrudayalaya, by letter dated 08.07.2005. This clearly shows that OP’s have dishonestly circumvented and twisted the facts of the claim. That the Complainant’s claim was with respect to the hospitalization at Narayana Hrudayalaya but OP’s have rejected the claim stating that Complainants demand is for Cambridge Hospital. That when Complainant requested OP to reconsider the claim with respect to Narayana Hrudayalaya, they have sent another reply on 15.08.2005 stating that the bills of Narayana Hrudayalaya were not submitted towards the expenses incurred. The OP’s have deliberately harassed and have wrongfully repudiated the Complainant’s genuine claim. Consequently, on 27.01.2006, Complainant once again submitted all the bills of Narayana Hrudayalaya to the OP but even after receiving the same, they have failed to reply to the same. That the OP’s are guilty of deficiency of service for wrongfully repudiating claim under the said policy. Hence, the Complainant approached this forum.

OPs appeared through their counsel filed their version and gave their presence of OP2 by way of affidavit with the evidence of Dr. K.V. Shenoy and the learned counsel submitted that OP1 adopts the evidence of OP2. Complainant gave her evidence by way of affidavit. The learned counsel for OP have submitted written arguments. As the learned counsel for complainant was not present he was permitted to submit his written arguments within three days and posted the case for orders.

The main contention of the Ops is that as the claim is connected to maternity and caesarian the same was repudiated as per clause 4.12 of the policy. When we peruse the claim from it is not the claim of the maternity of caesarian expenses it is clearly mentioned in the claim form about the name of the hospital as Narayana Hrudayalaya. It is an admitted fact that the policy was in force, when the Complainant was admitted to Narayana Hrudayalaya on 04.06.2005 and got discharged on 17-6-2005 and underwent aortic valve replacement surgery incurred an expense of Rs.2,25,305/-. When we peruse the pleadings of the OP, it is not the first policy and it is the renewal policy and the first policy took on 10.12.2003 and renewed in the subsequent years by enhancing the assured amount.

The another contention of the learned counsel for OP is that they have not all produced the discharge summary issued by Narayana Hrudayalaya and they have not produced the bills for consideration. But according to the correspondence made by the Complainant he has already submitted the bills along with discharge summary issued by Narayana Hrudayalaya. When we peruse the letter of the OP2 dated 11.08.2005 they have clearly admitted about the submission of discharge summary issued by Narayana Hrudayalaya. The Complainant obtained the duplicate bills copies from Narayana Hrudayalaya and submitted the same for consideration. The learned counsel for OPs submitted the evidence of Dr. K.V. Shenoy who is one of the panel of doctors of OP2. The said doctor stated as “I submit that on the basis on the records relating to the Complainant, I have given my opinion and also a finding that the liability of the Insurance Company does not arise to reimburse the amount spent by the Complainant”. The said doctor has produced report along with evidence. Except these sentences, the OP has produced the documents of Manipal Hospital and Lakeside Hospital along with the evidence of the doctor who treated the Complainant. In the absence of specific documents and evidence only on the opinion of doctor who verified the documents cannot be relied upon. The OP has not proved that the heart ailment is directly connected to the maternity treatment taken by the Complainant prior to the present ailment.

As per the documents and the bills produced by the Complainant she has incurred nearly Rs.2,25,305/- for heart ailment. But the claim is restricted to Rs.75,000/- to the sum assured under the policy. When the OPs have failed to establish their cases of heart ailment directly connecting to the maternity treatment taken by the Complainant it is their bounden duty to pay the amount under the policy.

The first policy was taken in the year 2003 and after renewal, the present policy renewed from 10.12.2004 to 09.12.2005. Even if we consider the date of admission of the Complainant at Cambridge Hospital on 01.05.2005 it was after the renewal of the policy on 10.12.2004, much prior to the admission to Cambridge Hospital the Complainant has obtained the policy by renewing the earlier policy from 2003. Even at this stage, the OPs have failed to establish that on the date of renewal of the policy on 10.12.2004, the Complainant was suffering with heart ailment. Under such circumstances the submission of OPs are total baseless and their submission is hereby rejected.

In view of the discussions made above, we are of the opinion that the Complainant has proved the deficiency in service on the part of the OPs. Accordingly we passed the following order:-


Complaint is allowed. Opposite Parties 1 and 2 are jointly and severally liable. Opposite Parties 1 and 2 are directed to pay an amount of Rs.75,000/- (Rs.Seventy five thousand only) to the Complainant within six weeks from the date of this order with interest at the rate of 9% per annum from 17.06.2005 till the date of realization including the cost of Rs.5,000/- (Rs. Five Thousand Only).

Dictated to the Stenographer, got it transcribed and corrected pronounced in the open forum on this the 19th June 2007.