Andhra Pradesh

Nellore

CC/06/2014

Aduru Rama Krishna Son of Venkata Seshaiah - Complainant(s)

Versus

1.TTK Health care TPA Private Ltd. Rep by its Managing Director - Opp.Party(s)

SK.Abdulsamath

17 Dec 2015

ORDER

Date of Filing     :22-01-2014

                                                                                                Date of Disposal:17-12-2015

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE

Thursday, this the  17^th day of December, 2015

 

PRESENT: Sri M. Subbarayudu Naidu, B.Com.,B.L.,LL.M.,President(FAC) & Member                             

                   Sri N.S. Kumara Swamy, B.Sc.,LL.B., Member.

 

C.C.No.6/2014

 

Aduru Rama Krishna, S/o.Venkata Seshaiah,

Income Tax Practitioner,

Hindu, Aged about 58 years,

Resident of 27-1-1582, Lakshmi Nagar,

Balaji  Nagar, Nellore-524 002.                                                           ..… Complainant           

 

                                                                           Vs.

 

1.	TTK Health Care TPA Private Limited, Represented by it’s Managing Director, Anmol Palani, # 88 L2, GN Chetty6 Road, T.Nagar, Chennai-600 017.
2.	Universal Sopmpo General Insurance Company Limited, Represented by it’s Managing Director, Unit No.401, 4th floor,  Sangam complex, Andheri East, Mubai-400059.
3.	Indian Overseas Bank (00064), Represented by it’s Manager, R.R.Street, Opposite to  Narthaki Theatre, Trunk Road, Nellore.                                                                  ..…Opposite parties

                                                              .  

            This complaint coming on 10-12-2015 before us for hearing in the presence of                Sri Sk. Abdul Samath, advocate for the complainant and                                                          Sri P.V. Mallikarjuna Reddy, advocate for the opposite party No.1, Sri E.V.Rami Reddy, advocate for the opposite party No.2 and Sri P. Gangadhara Reddy, advocate for the opposite party No.3  and having stood over for consideration till this day and this Forum made the following:

 

ORDER

(ORDER BY  Sri.N.S. KUMARA SWAMY, MEMBER)

 

 This complaint filed under Section-12 of Consumer Protection  Act, 1986 prays to  pay insurance amount of Rs.5,00,000/- under policy bearing No.2817/52044226/00/000 with interest at 12% p.a. from the date of death i.e., 30-10-2012 till the date of realisation, Rs.50,000/- towards damages for negligence  and deficiency in service, costs  and such other further reliefs.

 

2.         The brief averments of the  complaint are that  complainant is a  customer of  Indian Overseas Bank, Nellore (opposite party No.3)  since longtime  and opposite party No.3 stated that they newly introduced Health Insurance Policy schemes and assured  that they will immediately   pay the medical insurance claim if any arises immediately after submitting  the claim and believing the statement of  opposite party No.3, the complainant obtained IOB  Health Care Plus Policy bearing No.2817/52044226/00/000 for himself and for his wife A. Radha Kumari, which were commenced from 17-02-2012 to 15-02-2013.  The opposite parties  have collected Rs.11,743/- towards  the medical insurance policy of the complainant which was debited from the complainant S.B.Account at opposite party No.3.  The above said   policy issued as per the terms  of policy was floater sum of Rs.5,00,000/- and personal  accident floater sum of Rs.5,00,000/-.  The opposite parties issued U.I.D. Health Card bearing No.CHE-US-IBOI-000-0055089-A relating to the complainant and No.CHE-US-IBOI-000-0055089-B relating to the complainant’s spouse A. Radhakumari. The complainant further averred in the complaint that they are having continuously  taking policies since 08-06-2009 i.e., AB Arogyadhan policy and has not claimed anything since 08-06-2009.  The complainant and his wife were existing policy holders in other  company at the time of taking the policy and they are  hale and healthy  and have no ailments previously.  The complainant further  averred in the complaint that his wife Smt.A. Radha Kumari approached  Dr.P. Raja Sekhar, M.D., Nellore  on 28-03-2012 for taking treatment for fever and it was  cured after medication.   Again in the month of June, 2012, she suffered  with urinary infection  problem and approached Vijaya Hospital, Chennai and consulted urology doctor and also Gynaecologist wherein the sister who examined and stated that she was  having HTN  and advises to consult  Cordiologist.  The complainant further stated that  she is suffering from illness since  4 months  and hence admitted in Vijaya Hospital, Chennai for treatment on 05-07-2012 and discharged on 12-07-2012 by spending amount of Rs.50,000/-. After that she again  admitted in Narayana Medical Hospital, Nellore for fever and  admitted there for five days  i.e., from 15-10-2012 to      20-10-2012 by spending amount of Rs.30,000/-  towards  medical expenses.  For better treatment again she was  shifted  to Apollo Hospital on 20-10-2012 and admitted as inpatient and his wife expired on 30-10-2012 and the petitioner spent Rs.4,55,000/-. Totally the complainant spent more than Rs.5,00,000/-.When the complainant  submitted claim application, the  opposite party No.1 repudiated the claim on 26-07-2012 stating that  she was  pre-existing ailment  such as “HTN” present since 4 years which has no basis.  The complainant got issued legal notice on 25-11-2013 and having received the same,  they did not reply and due to non-payment of claim, the complainant sustained lot of financial loss but also suffered mental agony.  Hence, the claim for deficiency in service on the part of opposite parties   jointly and severally liable.

 

3.         The 1^st opposite party did not file any counter eventhough several opportunities given:

 

4.         The 2^nd opposite party filed written version denying all the  allegations made in the complaint  except admitting that complaint  and his wife obtained  IOB  Health Care Plus Policy by paying premium amount of Rs.11,743/- which was commenced from 17-02-2012 to 15-02-2013.  The complainant was  wantonly suppressed the preexisting ailment  of his wife  A. Radha Kumari at the  time of taking the policy.  The pre-existing   disease of HTN  was  suffered by his wife since 4 years i.e., much prior to obtaining the policy i.e., before 17-02-2012.  The said  fact came to know only through TTK Pre-Authorisation and as such the complainant and his wife violated  the terms  and conditions of clause-I and  therefore  there is no deficiency of service on their part and hence the claim may be dismissed with exemplary costs.

 

5.         The 3^rd opposite party filed counter / written version  denying all the  averments made in the complaint except that off certain facts.

 

6.         The 3^rd opposite party  further contended that the 1^st opposite party and 2^nd opposite party are doing the insurance business; and having a business tie-up with  the third opposite party.  Further they are collecting insurance premium through the 3^rd opposite party from the intending insurers/policy holders, and the 2^nd opposite party alone issues policy bond and other related documents to the policy holders and the 3^rd opposite party has no any way concerned or connected with the insurance business.  The 3^rd opposite party is only a collecting agent of premium / counter desk on behalf of 1^st opposite party and 2^nd opposite party for collecting the  amount as directed by                            1^st opposite party and 2^nd opposite party.  The 3^rd opposite party further stated  that collecting  of premium by debiting from the SB account   of the  complainant is the usual practice of business of the opposite party No.3 and it carried out by the specific direction / taking signatures of the complainant at his own interest but not on any inducement; and making of claim by the complainant was  directly  connected / concerned  to the Ist  and 2^nd  opposite parties and it is purely a business transaction between  the complainant and Ist and 2^nd opposite parties and this opposite party No.3 has no any intervention in this regard and  repudiating a policy is the firmly a concurrent decision of opposite party No.2 and it is no way concerned with the 3^rd  opposite party.  The other  contra averments made in the complaint no way connected and concerned to the 3^rd  opposite party  and the same can be ignored.  There is no privity of contract between the complainant and 3^rd opposite party.

 

7.         The 3^rd opposite party further stated  that  repudiation or settling a claim is purely the decision of opposite party No.2 and this opposite party has no  any liability to pay the amount to the complainant as required by him in his complaint and gross negligence and deficiency  of service on the part of this opposite party cannot be considered.

 

8.         The 3^rd opposite party acted in accordance  with the  norms   prescribed by the bank authorities and as such this complaint is baseless;  a false, vague and fancy litigation to harass the 3^rd  opposite party to get wrongful gain.

 

9.         Hence,  in the afore said circumstances, the 3^rd opposite party prays the Forum to dismiss the complaint  against  the 3^rd opposite party / bank with exemplary costs as there is no role between the complainant and the 3^rd opposite party .

 

             10.      The points for determination would be :

 

1. Whether there is deficiency in service on the part of  opposite parties 1 and 2 in

repudiating  the claim?  If so, whether the complainant is entitled  for the relief as prayed for?

2.  Whether the 3^rd  opposite party is also liable  for payment of insured amount as well  as  compensation and costs? If so, whether the complainant is also entitled for the same  from the  3^rd opposite party?
3. To what relief?

 

            11.       In order to substantiate  the complainant averments, complainant filed evidence on affidavit  as P.W.1 and marked Exs.A1 to A18.  On the other hand,   the opposite parties filed chief affidavit as R.W.1 and R.W.2 and no documents were marked on their behalf. The complainant as well as opposite parties 2 and 3 filed their written arguments. Heard on complainant side as well as opposite parties 2 and 3 Perused the entire material records for consideration.  

            12.       POINT No.1:  It is an admitted fact that  complainant obtained IOB Health Care  plus policy bearing No.2817/52044226/00/000 for himself and his wife               Smt A. Radha Kumari,  which was commenced from 17-02-2012 to 15-02-2013.    It is also admitted fact that opposite parties collected Rs.11,743/-  towards  the said  medical insurance policy premium  from the complainant, which was debited from the  complainants S.B.Account at opposite party No.3 bank.  It is also admitted that as per the  terms of the said policy floater sum assured for health is Rs.5,00,000/- and  personal accident floater sum assured is  Rs.5,00,000/-  and the opposite parties  issued UID Health Card bearing No.CHE-US-IBOI-000-0055089-A relating to the  complainant and No.CHE-US-IBOI-000-0055089-B  relating to the complainant’s spouse A. Radha Kumari. 

 

            13.       Soonafter the  death of complainant’s wife  namely A. Radha Kumari, the complainant, who was also jointly obtained IOB  Health Care Plus policy from the opposite party No.2,  preferred a claim before the 1^st and 2^nd opposite parties for policy amount and the said claim was  repudiated on the ground of  concealment of pre-existing disease  of  HTN present since 4 years.  Further from the date of inception of policy i.e., on 17-02-2012 HTN falls under PED (CVA is the complication of HTN so, the current ailment is pre-existing) and hence the repudiation is justified as per clause-I of policy condition.

 

            14.       According to the complainant, his wife was  keeping good health at the time of taking the policy from the opposite parties.  Subsequently i.e., after the date of obtaining the policy she suffered some ill-ness and took treatment from the hospitals concerned for which he spent more than Rs.5,00,000/- for her medical expenses  and  thus he prays for   payment of claiming amount of Rs.5,00,000/- with costs thereon. 

 

            15.       On the other hand, the 1^st and 2^nd opposite parties   contended that repudiation of claim made on the ground that insured had suppressed  the material facts regarding her health by not stating in the details of history when the policy was issued.  These facts came to light  based on the  scrutinizing  of the claim documents submitted by the complainant and also as per pre-authorisation request form HTN  present since        4 years.  Hence, the claim stands medically repudiated under clause-I of policy condition.  Thus, the contract between the parties becomes null and void and there is no liable on them to pay the claim amount  as the  material facts suppressed on the date of  obtaining the  policy. Hence burden lies on them to establish their case. 

 

            16.       In fact the wife of the complainant lastly  admitted in Apollo Hospital, Chennai on 20-10-2012 and date of  death on 30-10-2012 i.e., much after obtaining the policy.  In death summary issued by Apollo Hospital, which is Ex.A10 reveals that   the cause of death  i.e., Lymphoma, Septicemia, Multiorgan failure, Chronic liver disease.  Further, the  doctor  disclosed that in the death summary, she was admitted in Apollo Hospital with complaints of fever since March, 2012 (evening raise of temperature), dysuria, loss of appetite, loss of loose tools since one week.

 

            17.       Though, the opposite parties 1 and 2 concluded their opinion  as repudiation of claim based on the documents furnished by the complainant and also on the TTK preauthorization report, which is marked as Ex.A16, they did not take any evincing interest to examine any doctor, who treated her during the time of illness i.e., occurred after obtaining the policy.  Further, no affidavit of doctors concerned filed to establish their case.  The report of TTK  preauthorization i.e., Ex.A16, which is a crucial document also not filed.  Further, the complainant addressed a letter dated 04-07-2012 marked as Ex.A15 to the 1^st opposite party stating that  his wife was suddenly admitted in  Vijaya Hospital for urinary infection problem and spent about  Rs.40,000 to Rs.50,000/- for her medical expenses and requested to settle the claim of expenditure but that was rejected by the opposite parties  1 and 2  as HTN was already present i.e., prior to obtaining the policy.  Even  after acknowledged the same by the opposite parties 1 and 2, they did not investigate the  real fact of illness through their investigators.  In this context, this Forum feels that  mere mentioning the decision of repudiation after scrutinizing the documents furnished by the complainant and also the report of TTK authorization said to have been seen will not sufficient to establish their case.  Further the personal statement of the insured and also  proposal form or some other evidence viz., affidavits of doctors concerned, who treated her during  her illness did not place to know the exact state of health.  Except, self serving statement of opposite parties  1 and 2 through their evidence on affidavit, there is no iota of evidence placed.  Even otherwise with fast growing business  competition among the insurance companies unhealthy practices develop to get  maximum benefits and profits . It is the case of complainant put his hard earn money from their savings in such a scheme  with a fond hope and aspiration that  in case of accident or death he or his wife shall get immediate  financial assistance but in this case he is  left cheated and claim is rejected with a stroke of pen that he concealed some material facts at the time of  signing the proposal form or  claim was not properly submitted before insurance company.

 

            18.       A common man is not supposed to know all the niceties and technicalities  of law.  Once accepting the premium and having entered into agreement without verifying the facts, the insurance authorities cannot wriggle out of liability merely by saying that contract was made by mis-representation and concealment.  The insurance policy should not be issued and repudiated in such a casual mechanical manner.  The policy entitles liability on both sides. 

 

19.       In the  case on hand except depending on documents placed by the  complainant, the original record of case sheet maintained by the doctor pertaining to the alleged disease of HTN  is not produced.  Without the said record, it cannot be established the suppression of facts satisfactorily. Onus is on the insurance authority and should be discharged by leading cogent evidence rather than making allegations in that behalf. 

 

20.       Admittedly, during the period of illness which was suffered by the insured and even though the alleged fact of illness  came to light to the opposite parties, they did not take  any steps  to get the  health  condition of the proper to be verified.  Even in the discharge summary also the alleged  disease has not been specifically shown in the column of cause of death.

 

21.       The complainant placed reliances viz 1999(2) ALD (Cons.) 1993,                      dated 03-09-1999 in F.A.No.66/1997 and 2000 (1) ALD  (Cons.) 34 in  C.D.No.110/1992 in support of his evidence.  The above reliances  placed by the complainant is  squarely applicable in the instant case.

 

22.       It is suffice to say that the opposite parties 1 and 2 except assertion  through their self serving statement by way of evidence on affidavit, they did not place any positive proof  with regard to  concealment of  alleged  ill-health of the diseased. Question of disentitlement under insurance policy on the ground of  concealment, suppression of information would have arisen  only if there was  evidence to show that  insured had  undergone hospitalization for a longer period  for the particular alleged disease in near proximity of time when policy was obtained and had chosen not to disclose it.  Insurance authorities cannot take disadvantage of its own acts of commission or omission.  They simply relying on some surmises and conjectures and unilaterorily repudiate the claim which is against the  principles of natural justice.  In view of the above circumstances made supra, the deficiency of service on the part of  opposite parties 1 and 2 are proved,  accordingly point No.1 is answered.

 

            23.       POINT No.2:  Further with regard to the  claim against 3^rd opposite party, there is no liability on its side as 3^rd opposite party is only acting agent in collecting the premiums from the policy holders, who are having accounts in their bank and  remit the same to the insurance authorities, who are having tie up with them. No privity of contract lies between the 3^rd opposite party and the insured.  The settling of claim is only by the 2^nd opposite party and the 3^rd  opposite party has no role to decide the claim.  Hence, no deficiency of service can be attributed to the 3^rd opposite party. As such the case against  3^rd opposite party is liable to be dismissed.  Accordingly, point No.2 is answered.

 

             24.      POINT No.3:  In the result, complaint is allowed directing the opposite parties 1 and 2 jointly and severally to pay the insured amount of Rs.5,00,000/- (Rupees   five lakh only)  with subsequent interest at 9% p.a. from the date of complaint i.e.,                     22-01-2014 till the date of realisation.  The opposite parties 1 and 2  are also further directed to pay to the complainant a sum of Rs.5,000/-  (Rupees five thousand only) towards compensation  and also costs of Rs.3,000/- (Rupees three thousand only).  The complaint against opposite party No.3 is dismissed as the 3^rd opposite party has no role and privity of contract between the complainant and the 3^rd opposite party.

Typed to the dictation to the Stenographer, corrected and pronounced by us in the open  Forum, this the 17^th day of  December, 2015.

 

                 Sd/-                                                                                                  Sd/-

           MEMBER                                                                               PRESIDENT(F.A.C.)

 

           

APPENDIX OF EVIDENCE

Witnesses Examined for the complainant

 

P.W.1  -

14-11-2014

Sri Aduru Rama Krishna, S/o.Venkata Seshaiah, Income Tax Practitioner,  Nellore ( Chief Examination filed).

 

 

Witnesses Examined for the opposite parties

 

R.W.1  -	01-10-2014	Sri N. Ramesh, S/o.N. Balarama Murthy (Late), Chief Manager, Indian Overseas Bank, Nellore (Affidavit of 3rd opposite party filed).
R.W.2  -	06-05-2015	Sri Piyush Shankar, S/o.R.K.Sharma, Working in Universal Sopmpo General Insurance Company Limited (2nd opposite party), Mumbai-400059 (Affidavit filed).

 

                             EXHIBITS MARKED FOR THE COMPLAINANT

 

Ex.A1  -	-	Photocopy of  IOB-Health Care Plus Policy Schedule  in favour of complainant issued by  opposite party No.2
Ex.A2  -	-	Photocopy of  UHID No.FHAU.0000977831 in favour of complainant issued by  Andhra Bank in policy No.050400/48/08/41/00000084
Ex.A3  -	-	Photocopy of  UHID No.FHAU.0000977832 in favour of complainant issued by  Andhra Bank in policy No.050400/48/08/41/00000084
Ex.A4  -	-	Photocopy of HDFC ERGO General Insurance  brochure  showing the details of  complainant, policy start date as            08-01-2010 in UHID No.HDFC 0000160323 in Ref.No.HN07012010000699 issued by Family Health Plan (TPA) Limited.
Ex.A5  -	-	Photocopy of HDFC ERGO General Insurance  brochure  showing the details of  complainant, policy start date as            08-01-2010 in UHID No.HDFC 0000160324 in Ref.No.HN07012010000699 issued by Family Health Plan (TPA) Limited.
Ex.A6  -	-	Photocopy of HDFC ERGO General Insurance  brochure  showing the details of  complainant, policy start date as            17-02-2011 in Ref.No.HN07012010000699 issued by Family Health Plan (TPA) Limited.
Ex.A7  -	-	Photocopy of HDFC ERGO General Insurance  brochure  showing the details of  complainant, policy start date as            17-02-2011 in Ref.No.HN07012010000699 issued by Family Health Plan (TPA) Limited.
Ex.A8  -	-	Photocopy of Discharge Summary  dated 12-07-2012 in favour of A. Radhakumari issued by Vijaya Medical and Educational Trust, Chennai and Discharge Summary              dated 19-10-2012 in favour of  A. Radhakumari issued by Narayana Medical College Hospital, Nellore.
Ex.A9  -	19-10-2012	Discharge Summary in favour of  A. Radhakumari issued by Narayana Medical College Hospital, Nellore.
Ex.A10 -	01-11-2012	Photocopy of Death summary in favour of Aduru Radhakumari  issued by Apollo Hospitals.
Ex.A11 -	-	Photocopies of two final bills issued by Vijaya Hospital, Chennai, Two bills and Three Inpatient Bills issued by Apollo Hospitals, Chennai   and Two  Deposit Intimations, all are issued in the name of  Aduru Radha Kumari.
Ex.A12 -	-	Photocopies of Three prescriptions issued in the name of  Aduru Radha Kumari issued by Dr.P. Rajasekhar,  Nellore-1.
Ex.A13 -	25-11-2013	Legal notice from complainant’s advocate to the opposite parties.
Ex.A14 -	-	Three postal acknowledgements and three registered post receipts  sent by the complainant’s advocate to the opposite parties.
Ex.A15 -	04-07-2012	Photocopy of  letter from complainant to the opposite party No.1.
Ex.A16 -	26-07-2012	Photocopy of letter from  opposite party No.1 to the complainant.
Ex.A17 -	17-02-2012	Photocopy of  Health Card issued by opposite party No.2 in favour of complainant and  A. Radha Kumari.
Ex.A18 -	08-11-2012	Photocopy of letter from complainant to the opposite party No.2.

 

                         EXHIBITS MARKED FOR THE OPPOSITE PARTIES

-Nil-

 

                                                                                                                            Id/-

                                                                                                         PRESIDENT(F.A.C.)

 

Copies to:

 

1.	Sri Sk. Abdul Samath, Advocate, Office Room No.11, First Floor,                            S.V.S. Complex, Near Madras Bus-Stand, Nellore.
2.	Sri P.V. Mallikarjuna Reddy, Advocate, 24/2/1456, Military  Colony, 1st line, Dargamitta, Nellore-524 004 (A.P.)
3.	Sri E.V. Rami Reddy, Advocate, 1st floor, Raju Bhavan, Beside District Court, Nellore-524 001.
4.	Sri P. Gangadhara Reddy, Advocate, 23/826/1, Ramesh Reddy Nagar,                   Nellore-524 003.

 

Date when free copy was issued: