DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD Dated this the 20th Day of December 2011 Present : Smt.Seena H, President : Smt. Preetha.G. Nair, Member : Smt. Bhanumathi.A.K, Member Date of filing: 24/05/2011 (C.C.No.74/2011) 1. Sankar.G, S/o.P.S.Ganesan, 2. P.S.Ganesan S/o.Sankara Iyer, Both residing at Sankar Nivas, Kalchetty Street, Old Kalpathy, Palakkad. (Adv.M.P.Ravi) - Complainants V/s 1.Chief Executive, M/s.TTK Health Care TPA P.Ltd., Chennai – 600 006 2. Manager, The New India Assurance Co.Ltd. Divisional Office, 712500, New No.260, Anna Salai, Chennai. Pin – 600 006. (By Adv.T.Giri) 3. Manager, The New India Assurance Co.Ltd. PB No.43, N.S.Towers, Near Stadium, Bus Stand, Coimbatore Road, Palakkad – 678 001. - Opposite parties (By Adv.T.Giri) O R D E R By Smt.PREETHA G NAIR, MEMBER Complaint in brief:- The complainants had taken a medi claim policy from the 2nd opposite party from 1/11/2009 to 31/10/2010. As per the policy the father of the complainant also an insured person. The complainant had paid a sum of Rs.4920/- being the premium amount. On 7/4/2010, the 2nd complainant had undergone a surgery for ulcer on the left side of the tongue at G.K.N.M. Hospital, Coimbatore. He was admitted on 6/4/2010 and discharged on 17/4/2010. Since this hospital was not in the list of the network hospitals for cashless hospitalization, the complainant had paid the amount for the surgery and hospital expenses. Subsequently he had preferred a claim for Rs.55,802/- with the 1st opposite party who is an agent of 2nd opposite party for settling the claims. So far they have not settled the claim or repudiated. On 3/11/2011 the complainant had sent a letter requesting to disclose the status of the medi claim reimbursement. The opposite parties have not replied. The act of opposite parties amounts to clear deficiency in service and unfair trade practice. Hence the complainants pray an order directing the opposite parties to - Pay an amount of Rs.55,802/- along with 12% interest from 20/4/10 till date of realization and
- Pay Rs.10,000/- as compensation for the mental agony and
- Cost of the proceedings.
After receiving the notice, 1st opposite party was absent before the Forum. Hence 1st opposite party set exparte. 2nd and 3rd opposite parties filed version stating the following contentions. The complainants had taken policy at Chennai and he has hospitalized and undergone surgery at Kuppuswamy Hospital, Coimbatore. So the cause of action arises for filing the complaint arises not within the jurisdiction of the Hon’ble Forum. The 2nd opposite party admitted that the complainant had taken Citi Bank Credit Card Holders Good Health Medi claim Policy at Chennai, valid from 1/11/09 to 31/10/09. As per the policy the 2nd complainant is also covered for medical treatment. The 2nd opposite party admitted that the complainant has preferred a medi claim for Rs.55,802/- through 1st opposite party. As per the terms of the policy the complainant has submitted claim form and medical certificate duly filled up by Dr.Mohanraj who was treated the complainant. In the medical certificate, in column 5, date of first consultation for the disease was on 26/7/2007. The treating doctor’s certificate clearly shows that the disease of the complainant was preexisting one and first consultation was on 26/9/07 itself. As per the terms and conditions of Good Health Policy clause 4.1 and 4.4.12 says that preexisting diseases are not covered. Clause 4.4.12 specifically mentioned in the terms and conditions of the good Health Policy that the preexisting carcinoma (cancer) of all types are come under permanent excluded diseases and not covered under the Good Health Policy conditions. Then the diseases affected to the claimant comes under the permanent exclusion under the policy. So the claim of the complainant against 2nd opposite party cannot be granted as per the terms and conditions of the policy. Moreover the 1st opposite party has already repudiated the claim of the complainant and intimated him as per the letter dated 6/10/10. The allegation in the complaint that the opposite parties have not settled the claim so far was not correct. The 2nd and 3rd opposite parties were not received any letter as alleged in the complaint. Hence the 2nd and 3rd opposite parties prayed that dismiss the complaint with cost. Complainants and 2nd and 3rd opposite parties filed affidavit. Ext.A1 and A2 marked on the side of the complainants. Ext.B1 to B5 marked on the side of the opposite parties 2 and 3. 2nd complainant was examined as PW1. The doctor was examined as DW1. Matter was heard. Issues to be considered are - Whether the complaint is maintainable ?
- Whether there is any deficiency in service and unfair trade practice on the part of opposite parties ?
- If so, what is the relief and cost ?
Issue No.1 The 2nd and 3rd opposite parties stated that the complainant has taken the policy at Chennai and he has hospitalized and undergone surgery at Kuppuswamy Hospital, Coimbatore. So the complaint is not maintainable. The 3rd opposite party is the branch office of 2nd opposite party. Moreover the complainants residing in Palakkad. Section 11 (2) (a) A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction :- “the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or carries on business, or has a branch office or personally works for gain” At the time of cross examination of 2nd complainant deposed that he enquired about the claim amount to 3rd opposite party. No contradictory evidence was produced by 2nd and 3rd opposite parties. So the complaint is maintainable. Hence the 1st issue answered in favour of the complainants. Issue No.2 & 3 The specific case of the complainant is that the opposite parties failed to release the genuine claim of the complainants. Opposite party on the other hand contented that claim was repudiated on the ground of preexisting disease under clause 4.1 and 4.4.12 of the policy. Policy is admitted by 2nd and 3rd opposite parties. As per Ext.B1 period of coverage of the policy is 1/11/09 to 31/10/10. According to the complainant, the insured was hospitalized on 6/4/10 and discharged on 17/4/10 for surgery for ulcer on the left side of the tongue. According to the opposite parties surgery was for carcinoma (cancer) and the disease was a preexisting one as per Ext.B5. It is true that in Ext.B5 the treated doctor in column No.5 has stated the date of 1st consultation as 26/9/2007. But the said doctor while examining has deposed that the consultation on 26/9/2007 is in the cardiac department. DW1 (oncologist) has first consulted the patient on 1/4/2010. Further states that at that time history of the disease was 4 months as per the complainant as well as clinical co-relation. It is also stated that question No.5 was filled referring hospital records. Further as per the deposition of DW1, he was working in the said hospital from April 2009 onwards only. So the consultation by DW1 on 26/9/07 for carcinoma turn out to be false. No iota evidence is place before us to show that the insured has preexisting carcinoma. There is no dispute as to the amount claimed by the complainant. The act of opposite parties repudiating the claim is illegal. We find that there is gross deficiency in service on the part of opposite parties. It is a settled position that onus of proof of preexisting disease heavily lies upon the insurer. In Ext.B4 letter dated 6/10/10 by the 2nd and 3rd opposite parties shows that the claim repudiated. No evidence was produced by the opposite parties to show that Ext.B4 was sent to the complainants. In view of the above discussions we are of the view that there is deficiency in service on the part of opposite parties. In the result complaint allowed. We direct the opposite parties jointly and severally to pay complainant an amount of Rs.55,802/- (Rupees Fifty five thousand and eight hundred and two only) being the claim amount and pay Rs.10,000/- (Rupees Ten thousand only) as compensation for mental agony and pay Rs.2,000/- (Rupees Two thousand only) as cost of the proceedings. Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest for the whole amount from the date of order till realization. Pronounced in the open court on this the 20th day of December 2011 Sd/- Seena.H President Sd/- Preetha G Nair Member Sd/- Bhanumathi.A.K. Member APPENDIX Exhibits marked on the side of the complainant Ext.A1 – Photocopy of the policy issued by the 2nd opposite party dtd.1/11/09 Ext.A2 – Photocopy of letter issued by the complainant to the opposite parties dtd.3/1/11 Exhibits marked on the side of the Opposite parties Ext.B1 – True copy of Good Health Policy Certificate issued by 2nd opposite party to Ganesan and Others Ext.B2 – True copy of the terms and conditions of the Good Health Policy Ext.B3 –Claim Form Ext.B4 – Copy of letter dtd.6/10/10 issued by 1st opposite party to the complainant regarding repudiation of claim. Ext.B5 – Medical certificate to be filed in by the doctor treating the patient Complainant cross examined PW1 – P.S.Ganesan Witness examined DW1 – Dr.R.Mohanraj Cost Allowed Rs.2,000/- allowed as cost of the proceedings. | 
