Tamil Nadu

StateCommission

FA/223/2013

NATIONAL INSURANCE COMPANY LIMITED, BRANCH MANAGER - Complainant(s)

Versus

C.T. NAGARAJ - Opp.Party(s)

N. VIJAYA RAGHAVAN

11 Mar 2022

ORDER

 

 

IN THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present: Hon’ble Thiru Justice R.SUBBIAH       ... PRESIDENT

            Tmt. Dr. S.M.LATHA MAHESWARI  ... MEMBER

 

F.A. No.223 of 2013

 

(Against the Order, dated 20.03.2013, in C.C.No.201/11,

on the file of the DCDRF, Chennai-South)

                                            

    

                                  Orders pronounced on:  11.03.2022

            

1. The Branch Manager,

National Insurance Company Limited,

116, D  South, Tidel Park,

4, Canal Road,

 Taramani,

Chennai 600 113.

 

2. The Chairman & Managing Director,

National Insurance Company Ltd.,

Registered Office at No.3,

Middleton Street,

Post Box No.9229,

Kolkatta-700 071.                        … Appellants / OPs 1 & 2

 

vs.

 

 C.T.Nagaraj,

 S/o.H.Thammiah,

No.121, 1^st Floor, 4^th Street,

 Secretariat Colony,

 Kilpauk, Chennai 600 010.            … R1/Complainant

 

 

2. The Manager,

TTK Health Care TPA Pvt Ltd.,

2.  

GN Chetty Road,

T. Nagar, Chennai 600 017. … R2/3rd OP.

 

             Counsel for Appellants    : Mr.S.Vadivel

             Counsel for R1         : Mr.S.Veerasami

             R2, called absent.

          This First Appeal came up for final hearing on 25.02.2022 and, after hearing the arguments of both sides and perusing the materials on record and having stood over consideration till this day, this Commission passes the following:-

 

O R D E R

R.Subbiah, J - President.

             Aggrieved by the Order, dated 20.03.2013, passed by the DCDRF, Chennai-South,  in C.C. No.201 of 2011,  the Insurance Company has come up with the present First Appeal before this Commission.  

 

             2. The appellants  and the 2^nd respondent herein are OP Nos.1 to 3 and the 1^st respondent is the complainant before the District Forum.  For the sake of convenience, in the course of this Order, the parties shall be referred to as per their rankings before the District Forum.

 

             3. The case of the complainant, as projected in the complaint before the District Forum, in brief, runs thus:-

             The complainant has been holding a Mediclaim Insurance Policy, covering his life and that of his father-H.Thammiah, aged about 85, and mother Savithramma, aged about 75, and it was renewed from time to time.   While the Policy was in force, the complainant’s mother, who  had fallen sick on 21.07.2009, was admitted in Vikram Hospital Pvt. Ltd., Mysore, which is covered under the network of Hospitals identified by OP Nos.1 and 2.  After undergoing Angiogram, she was discharged on 25.07.2009.  Thereafter, by enclosing all medical records and documents, on 20.08.2009, the complainant submitted a Claim Form to the 3^rd OP, claiming a sum of for Rs.53,522/- from the 1^st Opposite Party. Once again, the mother of the complainant was admitted on 24.09.2009 in Sri Jayadeva Institute of  Cardiovascular Sciences and Research, Bangalore, which is also covered under the network of Hospitals identified by Opposite Parties 1 and 2.  After discharge, for the expenses incurred in treating his mother from 24.09.2009 to 29.09.2009, the complaint claimed a sum of Rs.12,390/- from the 1^st Opposite Party by submitting the Claim Form, dated 09.10.2009, along with all relevant medical records. The complainant had also submitted further records as sought for by the Insurance Company in respect of the 2^nd claim which was only a continuation of the first claim.  While so, by reply, dated 28.01.2010, by referring to Clause-4.1 of the Policy, the 1^st Opposite Party repudiated the claims on the ground of pre-existing disease. Even after issuance of legal notices calling upon them to settle the claims, the Opposite Parties did not come forward to honour the claims.   The said act of the Opposite Parties in not settling the claims of the complainant would amount to deficiency in service, hence, he filed the complaint seeking the District Forum to direct the Opposite Parties-1 and 2 to pay a sum of Rs.1,67,612/- towards the claims, losses, pains, sufferings and mental agony and to pay costs of Rs.10,000/-.

 

             4. OP Nos.1 and 2 filed a written statement, wherein, among other things, it is stated thus:-

             It is true that the complainant is the holder of the Policy in question since 2005 and has been renewing the same from time to time. Having accepted the said policy subject to the terms and conditions contained therein, the complainant is bound by the exclusions contained therein.  In respect of the claim for Rs.53,522/-, on perusing the documents, it was found that the complainant’s mother, for whose treatment the claim was lodged, has been suffering from the said disease even prior to the inception of the policy ie., before March, 2005.  Therefore, the claim was repudiated on the ground that the treatment was in respect of pre-existing disease.  In respect of the claim for Rs.12,390/-, after scrutiny of the documents, it was found that the disease was pre-existing and its complications are not payable by insurance.  Accordingly, in terms of clause 4.1 of the policy terms, which says that the company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of all diseases/injuries which are pre-existing when the cover incepts for the first time, by letter dated 28.01.2010, the Insurance Company rightly repudiated the claim.  Insurance is based on utmost good faith and both parties are bound by the agreed terms and conditions of the contract of insurance.  Since the relevant clause in the Policy excludes the claim in respect of treatment for pre-existing diseases, the repudiation cannot be termed as deficiency in service and accordingly, they sought for dismissal of the complaint.

 

             5. To substantiate the claim and counter-claim, both the complainant and the OPs-1 and 2 filed their respective proof affidavits before the District Forum and, on the side of the complainants, 23 documents were marked as Exs.A1 to A23, while the OPs-1 and 2 marked 5 documents as Exs.B1 to B5.  The District Forum, after consideration, found that the complainant is entitled to the claim in terms of clause 4.3 of the Policy  and ultimately, allowed the complaint, by directing the OPs to settle a sum of Rs.65,912/- as claimed by the complainant, along with costs of Rs.5,000/-.  Aggrieved thereby, the Insurance Company/OPs-1 and 2 have come up with the present First Appeal.

 

                6.  It is mainly contended by the learned counsel for the appellants/Insurance Company that 1^st respondent had already made a claim in June, 2005 itslef; as such, similar claims made in 2009 are not covered by the Policy in view of pre-existing disease.  According to him, the fourth policy of the 1^st respondent would be completed on 30.03.2010,  but, the claims were made on 20.08.2009 and 09.10.2009, hence, it is apparent that the claims were made much before the completion of four continuous claim-free policy years.  Apparently, when the claims were made with the appellant much before completion of the four continuous claim-free policy years, the District Forum instead of dismissing the complaint at the threshold, erroneously applied Clause No.4.3 to allow the complaint, hence, the impugned order deserves interference by this Commission.

 

        7. Per contra, learned counsel for the 1^st respondent, by relying upon clause-4.3 of the Policy would submit that R1 has been a policy holder of the appellants for a period of more than 4 years immediately preceding the date of claim, therefore, he is definitely eligible for the claim under Clause 4.3.  It is pointed out that R1 is a policy holder for a period of 13 years between 03.04.1998 and 30.03.2011 and that he did not lodge any claim whatsoever for the period immediately preceding 4 years from the date of claim.  The said aspect has been rightly appreciated by the District Forum to hold against the Insurance Company in terms of clause 4.3 of the Policy and hence, there is no scope for interfering with the impugned order. Accordingly, he sought for dismissal of the appeal.

 

          8. We have carefully considered the rival submissions advanced on either side and meticulously gone through the materials made available before us.

       

          9. While it is the assertive submission of the learned counsel for the appellants, by referring to clause 4.1 of the Policy which runs to the following effect,

  “The company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of all diseases/injuries which are pre-existing when the cover incepts for the first time. …. ”,

that, in terms of such clause, the 1^st respondent is not eligible to make the claim for the reason that he had already lodged a claim for his mother in June, 2005, thereby, subsequent similar claims made in 2009 would amount to pre-existing disease and thus, not covered under the Policy,  according to the learned counsel for the 1^st respondent, inasmuch as the 1^st respondent has been a policy holder with the Insurance Company for a period of more than 4 years immediately preceding the date of claim, he is eligible for the claim under clause-4.3 which says that if the diseases are pre-existing at the time of proposal, will be covered only after 4 continuous claim-free policy years; as such, the 1^st respondent is eligible to raise and receive the claim.

            

     10. In that regard, on perusing the materials, we could see that the repudiation by the appellants/Insurance Company is grounded on the claim made by the 1^st respondent in June, 2005 in respect of the his mother for a sum of Rs.31,705/-.  In other words, according to the appellants, since a claim had already been made in the year 2005, the 1^strespondent cannot raise a similar claim with the appellants in 2009, as it would amount to pre-existing disease not covered under the policy.  The said version of the appellants, on the face of it, is unsustainable for the reason that the claim made in June 2005 is prior to the four year coverage between “31.03.2006-30.03.2007” and “31.03.2009 and 30.03.2010”.  The appellants also take a parallel stand that the present claims made on 20.08.2009 and 09.10.2009 could not be accepted since the fourth policy would get completed only on 30.03.2010, which calculation, in our view, cannot be correct, once again for the same reason that the Insurance Company synchronized the claim made in June, 2005, that was prior to the 4 year coverage, with the present claims.  Apart from that, the repudiation letter seems to be so cryptic that, except referring to Clause 4.1 of the Policy and to the claim made in June, 2005, no particulars are given therein as to how logically they reached the conclusion that it was a pre-existing disease.  Further, the said letter also lacks break-up details to precisely calculate and apply the claim-free policy years. Although the written version filed before the District Forum proceeds as if that the repudiation letter covered both the present claims, a perusal of the said letter refers only to the claim relating to the 2^nd round of treatment.  Since the case of the appellant suffers from lack of material particulars thereby it is rendered vague and unclear, we have no other option in a case of this peculiar nature, except to extend the benefit thereof to the insured and accordingly, we see no error on the part of District Forum in applying Clause 4.3 of the Policy for ultimately issuing the direction against the Insurance Company/appellants herein.

 

             11. In the result, the first appeal is dismissed, confirming the order, dated 20.03.2013, passed by the DCDRF, Chennai-South, in C.C. No.201 of 2011.

 

 

S.M.LATHA MAHESWARIR.SUBBIAH, J.

MEMBER                                                      PRESIDENT.

 

Index    :  Yes  / No.

 

ISM/SCDRC/Chennai/Orders/March/2022.