Tamil Nadu

StateCommission

A/500/2022

Star health and Allied Insurance Co., Ltd., Nungambakkam Chennai - 34 - Complainant(s)

Versus

K.Palanisamy Naicken Pettai Post Salem 9 - Opp.Party(s)

M.B.Gopalan Associates

28 Mar 2023

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present:   Hon’ble THIRU JUSTICE R. SUBBIAH  : PRESIDENT

                 THIRU R  VENKATESAPERUMAL           :    MEMBER

 

F.A. No. 500 of 2022

(Against the order passed in C.C. No.39 of 2019 dated 23.08.2022 on the file of the D.C.D.R.C., Salem.

 

Tuesday, the 28^th day of March 2023

 

1.  Star Health and Allied

         Insurance Co. Ltd.,

     Regd. & Corporate Office

     1, New Tank Street

     ValluvarKottam High Road

     Nungambakkam

     Chennai – 600 034.

 

2.  Star Health and Allied

         Insurance Co. Ltd.,

     4/452, 2^nd Floor,

     ARRS Multiplex Road

    Near New Bus stand

    Salem – 636 009.                         .. Appellants/Opposite Parties

 

 

- Vs –

 

K. Palanisamy

S/o.Karumalai Gounder

D.No.2/61, Nallampatti

Naickenpatti Post

Salem – 636 307.                                .. Respondent/ Complainant

   

  Counsel for Appellants /

Opposite parties   :  M/s.M.B. Gopalan Associates

  Counsel for the Respondent/Complainant   :   M/s.B.Vijay Kumar                                                                        

 

                The Respondent as complainant had filed a complaint before the District Commission against the opposite parties praying for certain directions. The District Commission had allowed the complaint. Against the said exparte order, this appeal is preferred by the opposite parties praying to set aside the order of the District Commission dt. 23.08.2022 in CC. No.39/2019.

 

        This petition came before us for hearing finally, today.  Upon hearing the arguments of the counsel appearing on both sides, perusing the documents, lower court records and the order passed by the District Commission, this Commission made the following order in the open court.

 

JUSTICE R. SUBBIAH ,  PRESIDENT  (Open court)

 

        1.  The opposite parties 1 & 2 before the District Commission are the appellants herein.

 

        2. The case of the complainant before the District Commission is that he and his wife N.Padma applied for Insurance Policy under ‘Family Health Optima Insurance’ in the year 2015 as per the strong advice of the recognized agent of the opposite parties.  The respondent/ complainant has been paying the premium amount regularly for 3 years.  Whileso, the complainant’s wife got sudden illness and she took treatment in SIMS Hospital, Vadapalani, where a surgery was performed to her on 02.11.2017 and she was discharged from the hospital on 07.11.2017.  The hospital authorities have raised a bill for a sum of Rs.4,50,000/- from the complainant.  Since there was a policy coverage for the medical treatment, the complainant made a claim to the opposite parties.  But, to the shock and surprise of the complainant, the medi-claim was rejected.  The complainant did not suppress any pre-existing disease as alleged by the opposite parties, in their correspondences.   After exchange of correspondences, he had filed a complaint claiming a sum of Rs.4,50,000/- towards medical bill, Rs.10 lakhs towards compensation for the unbearable and intolerable mental agony, Rs.3000/- towards the cost of legal notice and Rs.10,000/- towards the cost of litigation.

 

        3.     Though notice was served, the Appellants/ opposite parties, did not appear before the District Commission, on the date of hearing, namely, 04.11.2019.  Hence, the 2^nd opposite party was called absent and set ex-parte on 04.11.2019 and the 1^st opposite party was set ex-parte on 16.12.2019.   Consequently, an ex-parte order was passed in favour of the respondent/ complainant by holding that there is deficiency of service on the part of the opposite parties and thus directed the opposite parties jointly and severally, to pay a sum of Rs.3,00,000/- towards medical bills, to pay the complainant a sum of Rs.2,00,000/- towards compensation for deficiency of service and for mental agony and pay a sum of Rs.2000/- towards cost of the proceedings.  Aggrieved over the said order, this appeal is preferred by the opposite parties, praying for setting aside the order and for a chance to contest the case on merit. 

 

        4. Before this commission the opposite parties would contend that the complainant’s wife is a known case of Central Retinal Artery Occlusion suffering from left eye vision loss for almost 10 years.  The said material fact was not disclosed in response to the specific questions in the proposal form.  Therefore, there is clear suppression of pre-existing disease.  They have a fair chance of succeeding the complaint. The non-appearance before the District Commission is neither willful nor wanton.  Thus, prayed for an opportunity to contest the case on merit.

 

        5. When the case had come up before this Commission on 10.03.2023, after hearing the submission of both sides, this Commission had felt that there is some force in the arguments of the counsel for the appellants/opposite parties and therefore in order to give a chance to the opposite parties to agitate their right on merits, was inclined to allow this appeal by remanding the matter to the District Commission, to dispose of the case on merit.   However, considering the lethargic attitude of the opposite parties, in not appearing before the District Commission, we imposed a cost of Rs.3000/- to be paid to the Legal Aid Account of the State Commission on or before 27.03.2023. Today, when the matter appeared in the list it was reported that the condition imposed by this Commission has been complied with.    Hence, this appeal is allowed today by remanding back the complaint to the District Commission for fresh disposal according to law. 

 

        6. In the result, the appeal is allowed by setting aside the order of the District Commission, Salem, in C.C.No.39/2019 dt.23.08.2022, and the matter is remanded back to the District Commission, Salem, for fresh disposal according to law and on merits.

        Parties are directed to appear before the District Commission, Salem on 28.04.2023, for taking further instructions. On which date itself, the opposite parties shall file their vakalat, written version, proof affidavit and documents if any. The District Commission is directed to dispose of the complaint, within three months from the date of appearance, according to law and on merits.  

        The amount deposited by the appellants, shall remain in the custody of this commission, till the disposal of the original complaint.

 

 

 

   R  VENKATESAPERUMAL                                                                                                            R. SUBBIAH

                 MEMBER                                                                                                                             PRESIDENT

 

 

 

Index :  Yes/ No

 

AVR/SCDRC/Chennai/Orders/March/2023