THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present: Sri. Santhosh Kesavanath P., President Smt. Bindhu M. Thomas, Member Sri. K.N. Radhakrishnan, Member CC. No. 27/08
Friday, the 30th day of October, 2009. Petitioner : V.C Varghese, Vattamala, Manganam P.O Kottayam. (By Adv. Sabu K.)
Opposite parties : 1) The Divisional Manager, Oriental Insurance Co. Ltd. Divisional Office- 1, Kottayam Matteethara Building, P.B No. 166, IIIrd Floor, Baker Junction, M.C Road, Kottayam. (By Adv. John Joseph & Adv. Sajan A Varghese)
M/s. T.T.K. Health Care Service (P) Ltd.,
1400-B, Mareena Building Ist Floor, Kochi. Reptd. By its Manager.
O R D E R
Sri. Santhosh Kesavanath P., President.
Petitioner had taken a Medi claim Policy of the opposite party, with vide Policy No. 441300/2006/1325, Petitioner renewed policy on July 2006. Petitioner underwent medical treatment at Sukodaya Ayurvedic Hospital, Kanjikuzhy, for pain and stiffness at back of the neck and low back. The petitioner was treated as inpatient from 6..7..2006 to 26..7..2006 he incurred an expense of Rs. 31050/- for treatment. Petitioner submitted a -2- medi claim before the second opposite party on 16..8..2006 along with all relevant records of treatment and expenditure for re-imbursement of the treatment expenses. But the opposite party repudiated the claim of the petitioner as per letter Dtd: 5..9..2006 stating that Ayurvedic treatment is not covered by the above said policy. Petitioner sent a registered letter to the second opposite party stating that petitioner is the holder of the medi claim policy since 2003 and at the two earlier occasions the Ayurvedic nature of claims were allowed by the opposite parties. Opposite party replied by the letter Dtd: 2..12..2006 stating that since the Ayurvedic discipline is excluded from the scope of the policy. Petitioner’s claims is not allowable . According to the petitioner only at the time of delivery of policy certificate opposite party affixed rubber stamp on the policy. showing Ayurvedic treatment excluded from the purview of the policy. Petitioner paid the premium for the renewal without the knowledge of exclusion. So, the act of the opposite party according to the petitioner is a clear deficiency of service. So, he prays for a direction to the opposite party to allow the claim of the petitioner. Petitioner also prays for the direction to the opposite party to pay an amount of Rs. 25,000/- as compensation and Rs. 5,000/- as cost of the proceedings. First opposite party entered appearance and filed version contenting that petition is not maintainable. Second opposite party has not filed any version. Second opposite party was set ex-parte. According to the first opposite party the claim was repudiated on valid and legal grounds. The first opposite party specifically excluded in the scope of the policy. According to the opposite party if the terms and conditions of stipulations are not acceptable by the insured he can very well cancel the policy and receive back the -3- premium. According to the opposite party there is no deficiency in service on their part. So, they pray for dismissal of the petition with their costs. Points for determinations are: Whether there is deficiency in service on the part of the opposite party? Relief and costs?
Evidence in this case consists of affidavit filed by both parties and Ext. A1 to A13 documents on the side of the petitioner and Ext. B1 document on the side of the opposite party. Point No. 1 Petitioner produced a copy of the policy schedule along with the conditions of the policy, said policy is marked as Ext. A1. In Ext. A1 there is an affix by way of a seal stating that Ayurvedic treatment is excluded from the policy. According to opposite party since claim of the petitioner is for expenses for Ayurvedic treatment taken it is not allowable. Counsel for the petitioner argued that after giving the premium, while issuing the policy the affix is made by way of seal. So, the petitioner is not binding by the said condition. In our view by paying the premium and issuing the policy contract is completed. Any condition excluding Ayurvedic treatment should be mentioned to the petitioner before paying premium and that should be specifically made a condition in the policy conditions issued to the petitioner. Along with Ext. A1 printed conditions of the policy is produced by the petitioner. In the said condition there is no mentioning of exclusion of Ayurvedic treatment. So, we are of the view that the affixer of exclusion of Ayurvedic treatment by putting a seal is not a fair trade practice. Contract of insurance -4- is a uberimifidae contract that should be entered with utmost good faith. Insurer as well as the insured has a bounden duty to disclose every fact with regard to the contract. In our view the act of the opposite party in issuing the policy certificate by affixing exclusion in the form of a seal is an unfair trade practice and the act of the opposite party in repudiating the claim of the petition is a clear deficiency in service. So point No. 1 is found accordingly. Point No. 2 In view of finding in point No. 1. Petition is allowed and the petitioner is entitled for relief sought for. Opposite party is ordered to allow the claim of the petitioner and reimburse the amount claimed by the petitioner. Opposite party is also ordered to pay an amount of Rs. 1500/- as cost of the proceedings. The order shall be complied with within one month if the order is not complied within the stipulated time of one month. Petitioner is entitled for interest at the rate of 9% till realization. Since, there is no evidence with regard to loss and sufferings no compensation is ordered. Dictated by me transcribed by the Confidential Assistant corrected by me and pronounced in the Open Forum on this the 30th day of October, 2009. Sri. Santhosh Kesavanath P. President Sd/- Smt. Bindhu M. Thomas, Member Sd/- Sri. K.N. Radhakrishnan, Member Sd/- APPENDIX Documents for the Petitioner: Ext. A1: Policy schedule with conditions. -5-
Ext. A2: Copy of Medical certificate Ext. A3: Copy of letter issued of V.C Varghese dtd: 16..8..2006. Ext. A4: Letter issued by the TTK Health Care to the petitioner Dtd: 5..9..2006 Ext. A5: Copy of letter from V.C Varghese to TTK Health Care Dtd: 29/9 Ext. A6: Copy of letter from TTK Heath Care to V.C Varghese Dtd: 20..10..2006 Ext. A7: Copy of letter from V.C Varghese to TTK Health Care Dtd: 26..10..2006 Ext. A8: Copy of letter from TTK Health Care to V.C Varghese Dtd: 2..12..2006 Ext. A9: Copy of letter from V.C Varghese to TTK Health Care Dtd: 8..12..2006 Ext. A10: Repudiation letter Dtd: 19..12..2006 Ext. A11: Letter Dtd: 2..3..2007 issued by the first opposite party to the petitioner. Ext. A12: Repudiation letter Dtd: 9..5..2007 Ext. A13: Repudiation letter Dtd: 30..5..2007
Documents for the Opposite party Ext. B1: Individual Medi claim Policy vide No. 1325/2006.
By Order,
Senior Superintendent
amp/ 5 cs
......................Bindhu M Thomas
......................K.N Radhakrishnan
......................Santhosh Kesava Nath P | | 
