IN THE DISTRICT CONSUMERS’ DISPUTES REDRESSAL FORUM AT MYSORE<br /> <br /> PRESENT: 1. Shri.D.Krishnappa<br /> B.A., L.L.B - President<br /> <br /> <br /> 2. G.V.Balasubramanya<br /> B.E., LL.M - Member<br /> <br /> CC 304/06 DATED 13-12-2006<br /> <br /> Complainant Padmaja B.S. W/o Sri.A.R.Rangaswamy, R/at # 22, IV Cross, Ist Stage, Brindavan Extension, Mysore – 570 057.Mysore District.<br /> (By Sri.B.S.P., Advocate)<br /> Vs. <br /> Opposite Party M/s TTK Health Care Services Private Limited being the third party claims Administrator of M/s The Oriental Insurance Company Ltd., Represented by its C.E.O. Mr.Girish Rao, No.45, Ground Floor, No.7, Crimson Court, Jeevan Bhimanagar Main Road, 80 Feet Road, H.A.L. III Stage, Indiranagar, Bangalore – 560 075.<br /> (Exparte)<br /> <br /> Nature of complaint : Deficiency in service<br /> Date of filing of complaint : 07.11.2006<br /> Date of appearance of O.P. : Exparte <br /> Date of order : 13-12-2006<br /> Duration of Proceeding : --<br /> <br /> <br /> <br /> PRESIDENT <br /> <br /> MEMBER<br /> Sri.D.Krishnappa,<br /> President<br /> <br /> 1. The Complainant Smt.Padmaja B.S. has filed this Complaint under section 12 of the Consumer Protection Act, 1986 against M/s TTK Health Care Services Pvt. Ltd., being the 3rd party claims Administrator of M/s The Oriental Insurance Company Ltd., alleging that herself and her husband had taken Individual Medi-claim Insurance Policy of Rs.50,000/- and Rs.1,00,000/- respectively issued by the Oriental Insurance Company. The polices are valid from 28.04.2006 to 27.04.2007 with a condition that the claim of the policy holders to be preferred with M/s TTK Health Care Services Pvt. Ltd., which is the opponent. That she underwent Dental surgery and made a claim with the opponent on 04.08.2006 which involved hospitalization and claimed for reimbursement of Rs.7,430/- and other medical and incidental expenditure incurred to the tune of Rs.10,000/-. But the opponent with whom the claim was made has repudiated the claim by invoking condition No.4.7 of the medi-claim policy stating that “Dental Treatment or Surgery of any kind arising due to an accident and requiring hospitalization” is not admissible. It is further contended that her claim came to be rejected by the opponent and thereby claimed for reimbursement of Rs.7,430/- towards the medical expenditure, Rs.20,000/- towards wrongful repudiation, with interest and other incidental charges, total amounting of Rs.36,830/-.<br /> 2. The opponent who has been served with the notice of this Complaint through registered post has remained absent, as such is placed exparte. Thereafter, the Complainant has filed her affidavit evidence in support of her claim besides producing the Medi-claim Insurance Policy the bills furnished to the opponent and reply sent by the opponent. We have heard the counsel for the Complainant and perused the records. <br /> 3. On the above contentions, following points for our determination arise.<br /> 1. Whether the Complainant proved that the repudiation of the contract by the opponent is improper and it amounts to deficiency in their service?<br /> 2. What order?<br /> 4. Our findings are as under:-<br /> Point no.1 : In the affirmative.<br /> Point no.2 : See the final order.<br /> <br /> REASONS<br /> <br /> 5. Point no.1:- The complainant in her affidavit evidence reasserting the complaint allegations has sworn to the fact that she had taken Medi-claim Insurance Policy bearing No.1293/06 for Rs.50,000/-. It has been further deposed by her that she on the advise of Dr.Shetty underwent surgery and treatment with Dr.Anantharamaiah and she was an inpatient from 28.07.2006 to 30.07.2006 and incurred medical expenditure of Rs.7,430/- besides other incidental charges and further stated that she made a claim for reimbursement of those expenditure with the opponent. But, the opponent repudiated the contract and declined to reimburse her claim and therefore has come up with this complaint for the relief sought for.<br /> 6. On perusal of the letter of the opponent, it is seen that the opponent has admitted the Medi-claim Insurance Policy that the complainant had taken and presentation of the claim with them. For which the opponent by referring to condition no.4.7 of the policy has repudiated the claim and declined to reimburse the expenditure. Therefore, it is evident from these undisputed facts that the complainant had Medi-claim Insurance Policy of Oriental Insurance Company, wherein the opponent had undertaken to reimburse the Medi-claim on behalf of Oriental Insurance Company. With these undisputed facts, we shall now examine whether the repudiation of the claim by the opponent under condition no.4.7 of the policy is valid or not. Condition no.4.7 of the policy reads as - “Dental Treatment or Surgery of any kind unless requiring hospitalization”. “This condition fall under the exclusion clause of the policy”. Therefore, what it excluded is Dental treatment or surgery of any kind requiring no hospitalization. On the other hand, dental treatment or surgery of any kind required hospitalization is reimbursable, that means to show if a policy holder obtains a policy suffers any dental injury requiring surgery and he is hospitalized, such parties would become entitle for reimbursement. This is the condition and meaning of clause 4.7 of the policy. Whereas the opponent in the reply sent to the complainant has misquoted condition no. 4.7 which reads as - “Dental treatment or surgery of any kind unless arising due to an accident and requiring hospitalization”.<br /> <br /> 7. The opponent has on his own added the word “Unless arising due to an accident” to the condition no.4.7 which is not in the policy. With this, the opponent tried to repudiate the claim of the complainant on the pretext that Medi-claim made by the complainant is not admissible, as it has not happened due to an accident. The opponent cannot introduce it’s own conditions, which are not found in the policy conditions. The condition no.4.7 of the policy do not contemplate the cause for the injury it admits all the dental treatment, which require hospitalization. It do not further contemplate that injury must have happened due to an accident, but the opponent has by reading the word of his own to the said clause has repudiated the claim, which is not proper and permissible. Therefore, the repudiation of the contract in our view is unsustainable, and therefore we reject it. <br /> <br /> 8. The complainant except producing a bill of the Doctor amounting to Rs.7,430/- has not produced any other bills or documents to show the other expenditure, she has incurred. The complainant has claimed as if she travelled to the office of the opponent several times and incurred expenditure of conveyance. But, we are not finding any supporting evidence or documents in proof of it, as such we cannot accept such a claim. However, having regard to the unilateral and improper repudiation of the claim of the complainant by the opponent, we find it just to direct the opponent to reimburse the claim of the claimant to an extent of Rs.7,430/-, a sum of Rs.5,000/- for wrongful repudiation of the claim and Rs.1,000/- towards mental agony. With this, we observe that the companies like the opponents who enter in to the contracts receive premiums from the bonafide people to reimburse the medical claim by inducing them to take the policies take up some defence to repudiate the claim, which tendency in our view is to be depreciated. With this, we answer the above point no.1 in the affirmative and pass the following order:- <br /> ORDER<br /> <br /> 1. The Complaint is allowed. <br /> 2. The opponent is directed to reimburse the claimant to an extent of Rs.7,430/-, also to pay Rs.5,000/- towards wrongful repudiation of the claim and Rs.1,000/- towards mental agony within three months from the date of this order, failing which, the total amount shall carry interest at 12% p.a. from the date of this order till the date of payment.<br /> 3. The opponent shall also pay the cost of the complaint Rs.500/- to the Complainant. <br /> 4. Give a copy of this order to each party according to Rules.<br /> (Dictated to the Stenographer, transcribed by him, transcript revised by us and then pronounced in the open Forum on this the day 13th December 2006)<br /> <br /> <br /> <br /> (D.Krishnappa) <br /> President <br /> (G.V.Balasubramanya)<br /> Member<br /> <br />