Aduru Rama Krishna Son of Venkata Seshaiah filed a consumer case on 17 Dec 2015 against 1.TTK Health care TPA Private Ltd. Rep by its Managing Director in the Nellore Consumer Court. The case no is CC/06/2014 and the judgment uploaded on 12 Jan 2016.
Date of Filing :22-01-2014
Date of Disposal:17-12-2015
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE
Thursday, this the 17th 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.
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 1st opposite party did not file any counter eventhough several opportunities given:
4. The 2nd 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 3rd opposite party filed counter / written version denying all the averments made in the complaint except that off certain facts.
6. The 3rd opposite party further contended that the 1st opposite party and 2nd 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 3rd opposite party from the intending insurers/policy holders, and the 2nd opposite party alone issues policy bond and other related documents to the policy holders and the 3rd opposite party has no any way concerned or connected with the insurance business. The 3rd opposite party is only a collecting agent of premium / counter desk on behalf of 1st opposite party and 2nd opposite party for collecting the amount as directed by 1st opposite party and 2nd opposite party. The 3rd 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 2nd opposite parties and it is purely a business transaction between the complainant and Ist and 2nd 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 3rd opposite party. The other contra averments made in the complaint no way connected and concerned to the 3rd opposite party and the same can be ignored. There is no privity of contract between the complainant and 3rd opposite party.
7. The 3rd 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 3rd 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 3rd opposite party to get wrongful gain.
9. Hence, in the afore said circumstances, the 3rd opposite party prays the Forum to dismiss the complaint against the 3rd opposite party / bank with exemplary costs as there is no role between the complainant and the 3rd opposite party .
10. The points for determination would be :
repudiating the claim? If so, whether the complainant is entitled for the relief as prayed for?
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 1st and 2nd 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 1st and 2nd 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 1st 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 3rd opposite party, there is no liability on its side as 3rd 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 3rd opposite party and the insured. The settling of claim is only by the 2nd opposite party and the 3rd opposite party has no role to decide the claim. Hence, no deficiency of service can be attributed to the 3rd opposite party. As such the case against 3rd 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 3rd opposite party has no role and privity of contract between the complainant and the 3rd opposite party.
Typed to the dictation to the Stenographer, corrected and pronounced by us in the open Forum, this the 17th 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:
Consumer Court | Cheque Bounce | Civil Cases | Criminal Cases | Matrimonial Disputes
Dedicated team of best lawyers for all your legal queries. Our lawyers can help you for you Consumer Court related cases at very affordable fee.