IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM BELGAUM.<br /> <br /> Dated this 4th day of November 2010<br /> <br /> Complaint No. 487/2010<br /> <br /> Present: 1) Sri. T.H. Narayangowda, President.<br /> 2) Smt. Y.V. Uma Shenoi, Member.<br /> 3) Sri. Shivakumar .J, Member.<br /> <br /> Complainant: Pavan k Dagga, S/o Kanthilal.H., No.1103, Moksha Marga, Siddartha Nagar.<br /> <br /> (By Sri. Shashidhar, Advocate).<br /> <br /> V/S<br /> Opponents: 1. M/s Universal Sampo General Insurance Co. Ltd., No.201-208, Crystal Plaza, Opp. Infiniti Mill, Link Road, Andheri (West), Mumbai-400058.<br /> 2. The Authorised Officer, M/s TTK Health Care, TPA Pvt. Ltd., Anmol Palani, No.88, 1,2, C.N.Chetty Road, T.Nagar, Chennai-600017.<br /> 3. Manager, M/s Indian Overseas Bank, Ashoka Road, Mysore Main Branch, Mysore.<br /> <br /> (O.P.No.1 by Smt. N.Shobha, Advocate )<br /> (O.P.2 – EXPARTE)<br /> (O.P. No.3 by Sri. N.Parameswar, Advocate )<br /> <br /> (Order dictated by Sri. T.H.Narayana GowdaPresident)<br /> <br /> ORDER<br /> <br /> This is a complaint filed by the complainant u/s. 12 of the C.P. Act 1986against the opponents for directing them to pay the mediclaim insurance amount of Rs.1,46,226/- along with compensation towards mental agony and cost of the complaint etc., <br /> <br /> <br /> 2) The case of the complainant in brief as set out in the complaint is as follows:-<br /> That the complainant has taken the mediclaim policy bearing No.2817/50253667/00/000 from the opponent No.1 through the opponent No.3 bank. The said policy covered the risk of complainant and his family members for the period from 16.10.2009 to 15.10.2010. The second opposite party is the TPA for the said policy. The complainant’s father namely Sri Kanthilal.H. aged about 51 years was admitted to M/s BGS Apollo Hospital, Mysore during the first week of November 2009 for his ailment. As per rules, the complainant has claimed the medical expenses. But, as per letter dated 19.02.2010, the opponent No.2 has repudiated the claim on the ground that, the said claim is made by the complainant for the period of first 30 days of commencement of the policy. Infact, prior to the said policy, the complainant had taken the policy from M/s Future Henerali Insurance Company for which company also the opponent No.2 was the TPA and the particulars of this policy was furnished to the opponent No.2 for cross verification and thus, there is absolutely no suppression of any particulars. The present policy was taken for short broken period of the earlier mediclaim policy. Subsequently, the complainant’s father again fell ill and he was admitted to M/s Narayana Hrudayalaya, Bangalore on 14.11.2009 for treatment as inpatient and he was discharged on 30.12.2009. The complainant has incurred the medical expenses of Rs.1,46,226/- for the said period of treatment and lodged the claim with the opponent No.2 as per Rules. Thus, the claim of the complainant was genuine and in spite of the same, the opponents have again repudiated the claim on flimsy grounds and in violation of the terms and conditions of the policy issued by the opponent No.1. The said act of the opponents amounts to deficiency in service on their part. Hence, this complaint is filed against the opponents for directing them to pay the said amount along with compensation. Mainly on these averments, the complainant has filed this complaint against the opponents and urged for allowing the same with costs.<br /> <br /> 3) In pursuance of notice, the opponent Nos.1 and 3 appeared before this Forum through their advocates and resisted the complaint by filing the written version. But, the opponent No.2 remained absent in spite of service of notice. Hence, he has been placed exparte. In the version, the opponent No.1 has admitted the fact of taking the mediclaim policy by the complainant from its company and the coverage of his family members including the period of currency of the said policy alleged by the complainant as true. But, the opponent No.1 has denied the rest of the case of the complainant including the deficiency in service and the liability of paying the claim amount as false and further contended that the claim of the complainant for the treatment of his father for the coronary artery disease which is not payable for the period of first 30 days of commencement of policy as per the exclusion clause No.1 of the policy. The first claim was denied on the same ground and the second claim was denied on the ground that though the admission took place after 30 days from the date of commencement of the policy, the inception of the disease was within first 30 days of the commencement of the policy as the same is very clear from the reports of the diagnosis relied upon by the complainant. Thus, the opponent No.1 has contended that the complainant is not entitled for the second claim also and therefore, the denial of his claim is justified under the facts and circumstances of the case. Mainly on these grounds, the opponent No.1 has urged for the dismissal of the complaint with costs.<br /> <br /> 4) In the version, the opponent No.3 has also admitted the fact of taking the mediclaim policy by the complainant from the opponent No.1 through the Opponent No.3 bank, but denied the rest of the case of the complainant for want of knowledge and further contended that the opponent No.3 is only collecting agent of opponent No.1 and therefore, the opponent No.3 is not liable for any of the claims made by the complainant and the opponent No.1 alone is liable for the payments as per the terms and conditions of the policy. In spite of the same, this complaint is filed even against the opponent No.3 and the same is not maintainable either in law or on facts and the same is liable to be dismissed in limine. Mainly on these grounds, the opponent No.3 has urged for the dismissal of the complaint with costs.<br /> <br /> 5) After filing the version by both the contesting opponent Nos.1 and 3, the case was posted for evidence. Thereupon in order to prove his case, the complainant has filed his affidavit in lieu of evidence and relied upon several documents and closed his side. Thereafter, the opponent No.3 has filed the affidavit in lieu of the evidence and relied upon several documents. But, the opponent No.1 has not filed any affidavit in spite of giving sufficient opportunity. Hence, the prayer of his counsel for adjournment was rejected and then posted the case for hearing arguments. Subsequently, the complainant and the opponent No.3 have filed their written arguments and also heard their oral arguments and then posted the case for orders. <br /> <br /> 6) In view of the aforesaid contentions taken by both the parties and the arguments submitted by their advocates, the points that would arise for our consideration are as follows:-<br /> <br /> 1) Whether the complainant is entitled for the reliefs sought for in the complaint?<br /> <br /> 2) What Order?<br /> <br /> <br /> 7) Our findings on the aforesaid points are as follows:-<br /> <br /> Point No.1:- Partly in the affirmative.<br /> <br /> Point No.2:- As per final order for the following, <br /> <br /> REASONS<br /> <br /> 8) Point No.1:- In order to establish his case, as already stated above, the complainant has filed his affidavit in lieu of evidence and relied upon several documents. In his affidavit, the complainant has duly sworn on oath in respect of all the averments of his case made out in the complaint. The said evidence of the complainant is neither challenged nor rebutted by the main opponent Nos.1 and 2. Even the other opponent No.3 has also not disputed the case of the complainant. On the other hand, the main defence of the opponent No.3 is that it is only the collecting agent of opponent No.1 company and therefore, the opponent No.3 is not liable for any claims but the opponent No.1 alone is liable for the claims arising out of the policy issued in favour of the complainant. Thus, the defence of the opponent No.3 is only the denial of its liability of paying any amount claimed in the complaint. But, the opponent No.3 has not denied the liability of the opponent No.1. On the other hand, as already stated above, opponent No.3 has taken the contention that the opponent No.1 alone is liable for the claim of the complainant. Thus, the evidence of the complainant remained unchallenged and therefore, we have no other alternative except to believe the said evidence of the complainant and his case made out in the complaint.<br /> 9) Of course, in the objections, the opponent No.1 has taken the contention that the expenses claimed by the complainant are incurred by him for the disease which was incepted during the first 30 days of commencement of the policy in question and the same falls within the purview of exclusion clause No.I and therefore, the claim of the complainant is not admissible. Accordingly, the claim of the complainant was repudiated and the same is justified under the facts and circumstances of the case. In support of the said defence, the opponent No.1 has not adduced any evidence on his side except producing copies of documents of treatment and policy terms etc., Of course, as per the exclusion clause No.1 of policy, the insured not entitled for the expenses incurred for the disease which was incepted during the first 30 days of commencement of the policy. But, naturally even after curing of the disease, there is every possibility of recurring of the same disease again within a short period. Such being the position of disease of human beings, if any disease incepted in the first 30 days of commencement of the policy, after curing same disease recurred again during the subsequent period of the policy as in the case on hand, on the basis of the said exclusion clause, the insurance company can easily escape from the liability of paying the claim on the ground that the said disease was incepted during the first 30 days of commencement of the policy and the insurance company can also continue to the same stand till the expiry of the entire period of the policy. In such case, taking of the mediclaim policy will not serve any useful purpose. Thus, the exclusion clause No.1 of the policy is in the nature of unfair trade practice and the same cannot be encouraged. The opponent No.1 has not disputed the quantum of amount claimed by the complainant. The said claim is also supported by the documentary evidence placed on record by the complainant. Hence, we have no other alternative except to believe the said claim made by the complainant and to award the same along with reasonable rate of interest.<br /> 10) In view of all the aforesaid reasons and the material on record discussed above, we hold that the opponent No.1 insurance company is liable to pay the mediclaim amount of Rs.1,46,226/- to the complainant. Opponent Nos.2 and 3 are only a formal parties and as per the terms of the policy, they are not liable for the payment of the claim amount. Therefore, the complainant is entitled to recover the claim amount only from the opponent No.1 and the complaint against opponent Nos.2 and 3 is liable to be dismissed. Having regard to the facts and circumstances of the case and the material on record, we feel it just and reasonable to award the interest at the rate of 6% p.a. on the claim amount from the date of complaint till the date of payment and cost of Rs.1,000/-. Accordingly, we answer point No.1 partly in the affirmative.<br /> <br /> 11) Point No.2: In view of the reasons and finding recorded on the point No.1, we hold that the complaint deserves to be allowed in part with costs in the ends of justice. Hence in the final result, we proceed to pass the following, <br /> :: O R D E R ::<br /> <br /> The complaint is allowed in part and the opponent No.1 is directed to pay the mediclaim amount of Rs.1,46,226/- to the complainant along with interest at the rate of 6% p.a. from the date of complaint till the date of payment.<br /> The opponent No.1 is also directed to pay the cost of Rs.1,000/- to the complainant.<br /> All the aforesaid amounts shall be paid to the complainant within 30 days from the date of receipt of copy of this order.<br /> The complaint against the opponent Nos.2 and 3 is dismissed. <br /> <br /> (Order dictated, corrected and then pronounced in the open Forum on this 4th November 2010)<br /> <br /> <br /> Member. Member. President.<br /> <br /> <br /> <br /> S.R.L<br /> <br /> <br /> <br />