Kerala

Idukki

CC/16/2019

Thankachen Pk - Complainant(s)

Versus

Indian Oversees bank - Opp.Party(s)

30 Aug 2019

ORDER

DATE OF FILING : 25.1.2019

IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 30^th day of August, 2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT. ASAMOL. P MEMBER

CC NO.16/2019

Between

Complainant : Thankachan P.K.,

Paimpillil House,

Karimkunnam P.O.,

Thodupuzha, Idukki.

(By Adv: K.M. Sanu)

And

Opposite Parties : 1. The Manager,

Indian Overseas Bank,

Thodupuzha Branch,

Thodupuzha P.O., Idukki.

(By Adv: Thomas Sebastian)

2. The Manager,

Universal Sompo General

Insurance Co. Ltd.,

Extension Counter,

Indian Overseas Bank,

Thodupuzha Branch,

Thodupuzha P.O., Idukki.

3. The Manager,

Universal Sompo General

Insurance Co. Ltd.,

Unit 401, 4^th Floor, Sangam Complex,

Andheri (east), Mumbai – 400 059.

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

 

Case of the complainant is that :

 

Complainant is the account holder of 1^st opposite party. On the request of the 1^st opposite party, complainant joined a Health Insurance Policy having the name 10B Health Care Plus Policy. At the time of joining in this policy, 1^st opposite party assured the cashless treatment through the policy. Due to the instigation of 1^st opposite party, complainant happened to join the policy, while

(cont....2)

- 2 -

this policy was live with United India Assurance Company. The coverage of this policy is 2 lakhs rupees and its validity is from 4.10.2018 to 3.10.2019 and this policy covers the complainant, his wife and 2 children. At the time of filling the proposal form, the complainant given the details of the previous policy to 1^st opposite party and its continuance and he requested to continue this policy without breaking the previous policy. The staff of the opposite party filled the proposal form.

 

While so, in the month of November 2018, complainant was admitted in MOSC Medical College hospital, Kolenchery for the ailment of joint pain. He was admitted there and treated as inpatient from 22.11.2018 to 23.11.2018. On examination, it is found that the kidney is infected. He was discharged with a direction to follow up treatment. An amount of Rs.24,667/- was spent for the treatment alone. Immediately after discharge from the hospital, complainant lodged a claim application before the opposite parties, but the opposite parties 2 and 3 repudiated the claim on some baseless reasons.

 

Complainant further stated that, he was joined the health insurance policy years back and continued without any break and as a continuation of previous policy, he took the present policy. The matter was properly intimated to the staff of the 1^st opposite party who filled the proposal form of the policy in question and the complainant only signed in it. Complainant further averred that, due to the persuasion of the opposite parties, complainant happened to avail this policy, eventhough his policy with the United India is on live. Denying the policy claim which is legally entitled on some baseless ground is a gross deficiency in service and unfair trade practice. Against this the complainant approached this Forum for getting releifs such as to direct the opposite parties to honour the claim along with cost and compensation.

 

Upon notice, opposite parties entered appearance and filed detailed reply version. In their version, 1^st opposite party contended that, they have not issued any medi-claim policy to the complainant and has no insurance contract with the complainant. Hence the 1^st opposite party is a misjoinder to the complaint. 1^st opposite party further contended that they have not collected any amount from the complainant towards premium of the said policy issued by the 3^rd opposite party. The complainant is only an account holder of 1^st opposite party. The 3^rd opposite party made an offer to the SB account holders of the 1^st opposite party, to provide medi-claim policy at low premium. The 1^st opposite party has only facilitated the complainant to 3^rd opposite party. Hence the 3^rd opposite party alone is liable to reimburse the medical expenses of the complainant. (cont....3)

- 3 -

 

In their version, 2^nd and 3^rd opposite parties contended that the medi-claim policy of the complainant with United India Assurance Company is not aware of them. These opposite parties denied the averement of the complainant that it was informed and the opposite parties agreed that the benefits of the policy without break should be given. The first policy was issued to the complainant for the period from 4.10.2017 to 3.10.2018 and it renewed till 3.10.2019.

 

The opposite parties further contended that the complainant was having a history of diabetes mellitus since 10 years and hypertension since 20 years. The complainant has not disclosed these facts at the time of signing the proposal form contrary averements are false and hence denied. Suppressing of pre-existing disease at the time of submitting the proposal was a material fact. Therefore the company was duly repudiated the claim on 22.12.2018, as the claim was in violation of terms and conditions of the policy.

 

Opposite party further contended that the state of health of the insured in the proposal form and the personal statement were the basis of the contract and the complainant had obtained this policy by falsifying and suppressing material facts. Hence the complainant is not entitled to any of the reliefs claimed in the complaint and the complainant is liable to be dismissed with compensatory cost.

 

Evidence adduced by the complainant by way of proof affidavit and documents. Complainant was examined as PW1 and Exts.P1 to P5 marked. Ext.P1 is the copy of policy schedule. Ext.P2 is the copy of insurance card. Ext.P3 is the copy of discharge summary. Ext.P4 is the copy of medical bills. Ext.P5 is the claim repudiation letter.

 

From the defence side, 2^nd and 3^rd opposite parties produced 2 documents such as copy of proposal form and policy document and are marked as Exts.R1 and R2 respectively. At the time of adducing evidence, complainant stated that he is not seeking any reliefs against the 1^st opposite party. Hence 1^st opposite party deleted from the party array.

 

Heard both sides.

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?

(cont....4)

- 4 -

The POINT :- We have heard the counsels for both the sides and had gone through the evidence on record. It is an admitted fact that the complainant joined in the health insurance policy of the 2^nd and 3^rd opposite parties from 2017 onwards. In the month of November 2018, he was admitted in the MOSC, Kolencherry and treated there as inpatient for 2 days. Ext.P3 discharge summary says that he was treated at there with the complaint of joint pain on evaluation. He was found to have early NDPR and ANA positive with proteinuria. He was admitted for renal biopsy. Here in this document, it specifically stated that the patient is having early diabetes mellitus and hypertension. At the same time, the complainant vehemently argued that he disclosed this ailment to the person who filled the proposal form. On perusing the Ext.R1 proposal form, Forum found that it is filled by someone and the complainant was only signed there. There is a vast difference in the handwriting of the filled up part of the form by comparing the signature of the complainant. It is a usual practice that the proposal form is filling up by the agent of the company, or the person who approaching and canvassing the customers. On perusing the document, it is very clear that the person who filled the form is signed in the bottom left side of the form.

 

Eventhough the learned counsel for the opposite party vehemently argued by pointing out various decisions of the Apex Court and the Hon'ble National Consumer Disputes Redressal Commission, they have not taken any steps to cross examine the complainant, when he was examined as PW1. Except by filing 2 documents such as copy of proposal form and policy documents, no endeavour has been taken by the opposite party to adduce any evidence on their part to strengthen their plea. It is the bounden duty of the opposite party to counter the allegation levelled against them with clear and cogent evidence. Since absence of specific evidence in order to establish the contention in the reply version of opposite parties 2 and 3, the Forum is of a considered view that, no need to go deep into the defence version.

 

On the basis of above discussion and the circumstances in this case, the Forum found that the denial of legally entitled claim to the complainant on some baseless and flimsy ground is a gross deficiency in service and unfair trade practice on the part of opposite parties 2 and 3.

 

Hence the complaint allowed. Opposite parties 2 and 3 are directed to pay the claim amount as per Ext.P4 medical bills along with Rs.2000/- as cost to the complainant within 30 days from the date of receipt of a copy of this

 

(cont....5)

- 5 -

 

order, failing which the bill amount shall carry 12% interest per annum from the date of default, till its realisation.

 

Pronounced in the Open Forum on this the 30^th day of August, 2019

 

Sd/-

SRI. S. GOPAKUMAR, PRESIDENT

Sd/-

SMT. ASAMOL. P, MEMBER

 

APPENDIX

 

Depositions :

On the side of the Complainant :

PW1 - Thankachan P.K.

On the side of the Opposite Party :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1 - copy of policy schedule.

Ext.P2 - copy of insurance card.

Ext.P3 - copy of discharge summary.

Ext.P4 - copy of medical bills.

Ext.P5 - claim repudiation letter.

On the side of the Opposite Party :

Ext.R1 - proposal form

Ext.R2 - policy document

 

 

Forwarded by Order,

 

 

 

SENIOR SUPERINTENDENT