IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA
Dated this the 06th day of June 2014
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member-I)
Smt. Sheela Jacob (Member-II)
C.C. No. 159/2013 (Filed on 10.12.2013)
Between:
1. C.M. Abraham,
Cherukara Thadathil House,
Plankamon, Velliyara P.O.,
Ayroor, Ranni,
Pathanamthitta District.
- Susan Abraham, of -do- -do- … Complainants.
(By Adv. Kuriakose Mathew)
And:
- M/s. Universal Sompo General Insurance
Co. Ltd., represented by its duly
Constituted Attorney Unit 401, 4th Floor,
Sangam Complex, 127 Andheri-Kurla-
Road, Andheri (East), Mumbai – 400 059.
(By Adv. Saji Isaac. K.J.)
- The Branch Manager,
Indian Overseas Bank, Plankamon Branch,
Velliyara P.O., Ranni, Pathanamthitta Dist.
Pin – 689 612.
(By Adv. Lalu John)
- M/s. TTK Health Care TPA Pvt. Ltd.,
H.B. Complex, 100 Ft BTM Ring Road,
BTM first Stage, BTM Lay out,
Bangalore – 560 068. … Opposite parties.
ORDER
Sri. Jacob Stephen (Member):
The complainants have filed this complaint against the opposite parties for getting a relief from the Forum.
2. The brief facts of this complaint is as follows: The first complainant is the husband of the second complainant. The first complainant, his wife and 2 children are IOB Health Care Plus policy holders of the first opposite party obtained through the second opposite party which is valid from 11.11.2011 to 10.11.2012. As per the terms and conditions of the policy, the policy holders are entitled to get a maximum sum of Rs. 1,00,000/- for their treatments in connection with the ailments and Rs. 1,00,000/- for personal accident. While so, the second complainant had undergone treatment for back ache degenerative listhesis and disk extrusion at Holy Family, Hospital, Thodupuzha during 2012 July and she had spent an amount of Rs. 1, 27,614/- for the said treatment. The said treatment was done during the policy is in force. So she is entitled to get the said amount as per the terms and conditions of the policy in question. On the strength of the said policy, the first complainant submitted his claim before the third opposite party as directed by the second opposite party with all relevant documents. But they have rejected the claim of the complainant on flimsy grounds. Thereafter, the complainant caused a legal notice to the opposite parties on 08.11.2013 demanding the claim. Though opposite parties received the notice, they have not given any reply or honoured the complainants’ claim. The above said acts of the opposite parties is a clear deficiency in service which caused financial loss and mental agony to the complainants and they are liable to the complainants for the same. Hence this complaint for the realization of the treatment expenses of Rs. 1,27,614/- and compensation of Rs. 50,000/- and cost of this proceedings.
3. Opposite parties 1 and 2 entered appearance and filed their versions separately. Third opposite party is exparte.
4. The main contentions in the version of the first opposite party is as follows: They admitted the validity of the policy and the treatment. According to them, the disease of the second complainant was lower back ache L5-S1 degenerative listhesis and L4, L5 disc extrusion. The second complainant was treated with disectomy, fixation, PLIF L5, S1 on 10.07.2012, i.e. within 8 months from taking of policy. According to the complainant, the patient had first consulted the doctor on 30.04.2012. As per the MRI report, the second complainant was having the disease since long time and the duration of the disease was more than 8 months and hence the second complainant was aware of the disease. The treatment in case of disc extrusion begins with a number of conservative (non surgical) treatments. Surgical option will be taken only after the non surgical treatment options are exhausted. So the opposite party has to ascertain whether the second complainant’s ailment was a pre-existing disease at the time of taking the policy. For ascertaining the same, opposite party had sent several letters to the complainant for producing clarification from the treated doctor about the exact duration of the illness and the first consultation reports, previous treatment details, clarification from the treated doctor about whether the patient had previous similar episodes, internal case papers etc. But the complainant has not submitted the required clarifications. The claim is allowable only if the patient’s treatment was within the terms and conditions of the policy, the claimants are liable to submit all details required which was not submitted by the complainant. So the opposite party could not consider the claim of the complainant. The other allegations such as mis-representation, inducement, unfair trade practice etc. are false and hence denied. Even if the claim is found allowable, the amount claimed by the complainant is more than the assured amount. There is no cause of action for the complainants and the first opposite party has not committed any deficiency in service, unfair trade practice etc. as alleged by the complainants. With the above contentions, first opposite party prays for the dismissal of the complaint with their cost.
5. The main contentions in the version of the second opposite party is as follows: Second opposite party admitted that the policy in question was issued through them as the part of a contractual obligation between the first and second opposite parties. The first and third opposite parties are responsible to entertain the claim as per the policy conditions and the second opposite party has no role in honouring the claim of the complainant. It is the responsibility and liability of the first and third opposite party to honour the claim by verifying the documents submitted by the complainant as per the terms and conditions of the policy. Thus, second opposite party has not committed any deficiency in service in connection with the complainant’s claim and hence the complainant is not entitled to get any relief against the second opposite party. With the above contentions, second opposite party prays for exonerating them from the claim of the complainants.
6. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
7. The evidence of this complaint consists of the oral deposition of PW1 and Exts. A1 to A6 and B1 to B3. After closure of evidence, both sides were heard.
8. The Point: The complainants’ case is that the first complainant, his wife, the second complainant and their 2 children are IOB Health Care Plus policy holders of the first opposite party which was first taken with effect from 11.11.2011 and renewed the same with effect from 11.11.2012 and is valid upto 10.11.2013. The said policy was taken through the second opposite party. As per the terms and conditions of the policy, the policy holders are entitled to get a maximum amount of Rs. 1,00,000/- for their hospital treatments for any ailment during the policy period. While so, the second complainant had undergone various treatments in connection with her lower back ache at Holy Family Hospital, Muthalakodam, Thodupuzha from 10.07.2012 to 23.07.2012. In connection with the said treatment, the complainant had spent an amount of Rs.1,27,614/-. As per the terms and conditions of the policy, the complainants are entitled to get the said amount. For getting the said amount, the complainants filed their claim along with all relevant documents. But opposite parties repudiated the claim on flimsy grounds. Thereafter, the complainant sent a legal notice to the opposite parties. Even after the legal notice also, opposite parties did not allowed the complainant’s claim. According to the complainants, the above said act of the opposite parties is a deficiency in service and the complainants are entitled to get the claim and opposite parties liable for the same.
9. In order to prove the case of the complainants, the first complainant filed a proof affidavit in lieu of his chief examination along with 6 documents. On the basis of the proof affidavit, first complainant was examined as PW1 and the documents produced are marked as Exts. A1 to A6. Exts. A1 and A1(a) are the IOB Health Care Plus policy certificates issued by the first opposite party in the name of the complainant valid from 11.11.2011 to 10.11.2013. Ext. A2 is the discharge summary issued from Holy Family Hospital, Muthalakkodam, Thodupuzha in respect of the second complainant’s treatment from 10.07.2012 to 23.07.2012. Ext. A3 series (4 bills) for Rs. 1,28,764/- in respect of the second complainant’s treatment. Ext. A4 is the medical certificate issued by the treated doctor in connection with the second complainant’s treatment in the prescribed format of the third opposite party. Ext. A5 is the copy of the legal notice dated 08.11.2013 issued by the complainant to the opposite parties. Exts. A5(a) and A5(b) are the postal acknowledgment card and postal receipt in respect of Ext. A5 legal notice. Ext. A6 is the certificate dated 17.09.2012 issued from Holy Family Hospital, Muthalakodam, Thodupuzha showing the diagnose of the second complainant’s ailments as L5-S1 degenerative listhesis and L4, L5 disc extrusion.
10. On the other hand, the contention of the first opposite party is that on processing the claim of the complainants, they suspected the second complainant’s ailment is a pre-existing disease. So they requested the complainants to furnish necessary documents for ascertaining whether the second complainant’s ailment is a pre-existing disease or not? But the complainant has not furnished the same in spite of the numerous written communications from the side of the first opposite party in this regard. Because of the non-production of the clarifications required and requested by the opposite parties, they could not allow the complainant’s claim as per the terms and conditions of the policy. So they argued that they have not committed any deficiency in service as alleged by the complainant and the only reason for not allowing the complainant’s claim is due to the fault of the complainant.
11. In order to prove the case of the first opposite party, first opposite party has not adduced any oral evidence. But they have produced 3 documents which are marked as Exts. B1 to B3. Out of the said 3 documents, Exts. B1 and B2 are marked through PW1 and Ext. B3 marked as per the consent of the parties. Ext. B1 series are the 10 letters sent by the third opposite party to the first complainant from 23.08.2012 to 03.01.2013 requesting the complainant to produce certain documents required for processing the complainant’s claim. Ext.B2 is the copy of scanning report dated 04.05.2012 issued from Life Scan, Thodupuzha in respect of the scanning done to the second complainant in connection with her ailments. Ext. B3 is the copy of the IOB Health Care Plus policy schedule and its terms and conditions in respect of the policy in question.
12. The contention of the second opposite party is that they have not committed any deficiency in service as alleged by the complainants as the responsibility for allowing or disallowing the claim in question is with the first opposite party and they are only an intermediary for the issuance of the policy alone.
13. In order to prove their contentions, the second opposite party has not adduced any oral or documentary evidence. But they have cross examined PW1.
14. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record and found that the parties have no dispute with regard to the validity of the policy and the treatment of the second complainant. The only dispute to be resolved by this Forum is whether the ailment of the second complainant is a pre-existing disease as per the terms and conditions of the policy. According to the complainants, the ailments of the second complainant is not a pre-existing disease whereas the contention of the first opposite party is that the ailment of the second complainant is a pre-existing disease on the basis of the available treatment records of the alleged ailment. According to the first opposite party, the second complainant’s ailment was lower back ache L5-S1 degenerative listhesis and L4, L5 disc extrusion and such a disease could not cause in a person immediately. So the patient was having the disease since long time and hence the patient was aware of the disease at the time of taking the policy. So according to the first opposite party, the patient was aware about her diseases at the time of taking the policy and she obtained policy by suppressing this fact willfully. So the ailment of the second complainant was a pre-existing disease which is not covered under the policy in question. In order to substantiate the above said contention, they are relying on Ext. B2 scanning report dated 04.05.2012. It is true that the complainant had subjected for scanning on the basis of the consultation with Dr. O.T. George. At the same time, it is a fact that no person will be aware of his ailments before a consultation and before getting scientific test report. In this case also the complainants came to know about their ailments only after the consultation and getting the test results which too is after 5 months from the date of taking the policy in question. Further, opposite parties has not adduced any cogent evidence to show that the complainants are aware of their ailments on the date of taking the policy in question. Moreover, the definition of pre-existing disease is as follows as per Ext. B3 policy conditions. “Pre-existing diseases means any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed, and/or received medical advice/treatment within 48 months prior to the first policy issued by the insurer” (first item in page No.6 of IOB Health Care Policy Conditions). So it cannot be said that an ailment diagnosed after 5 months from the date of commencement of the policy is a pre-existing disease. Apart from the above, Ext. A4 the prescribed format of the third opposite party, medical certificate to be filled in by the treated doctor, also clearly shows that the complainant’s ailment was not a pre-existing disease as the answers in col. Nos. 6(b) to 9 are in favour of the complainant. Therefore, under no circumstances, the argument, pre-existing disease, raised by the opposite parties will not stand.
15. In view of the above findings and on the basis of Ext.A2 discharge summary and Ext. A4 medical certificate, Ext. B1 series letters sent by the opposite parties asking clarifications for ascertaining whether the second complainant’s ailment is a pre-existing disease or not is found irrelevant and immaterial. Therefore, we find that the repudiation of the complainants’ claim by the first and third opposite parties is a clear deficiency in service and hence this complaint is allowable against them.
16. At the same time, there is no incriminating evidence against second opposite party and in view of the deposition of PW1 that the second opposite party has not committed any deficiency in service to the complainant, we find no deficiency against second opposite party.
17. However, the complainants are claiming an amount of Rs. 1,27,416/-. But the sum assured in the policy is only Rs. 1,00,000/- for the medical expenses. So the complainants are not entitled to get the entire claim for treatment expenses as prayed for.
18. In the result, this complaint is allowed, thereby the first opposite party being the insurer is directed to pay Rs. 1,00,000/- (Rupees One Lakh only) the sum assured with 7% interest from the date of filing of this complaint along with compensation of Rs. 5,000/- (Rupees Five thousand only) and cost of Rs. 1,000/- (Rupees One thousand only) to the complainant within 20 days from the date of receipt of this order, failing which the complainants are allowed to realize the whole amount ordered herein above with 10% interest per annum from today till the realization of the whole amount.
Dictated to the Confidential Assistant, transcribed and typed by him, corrected by me and pronounced in the Open Forum on this the 06th day of June, 2014.
(Sd/-)
Jacob Stephen,
(President)
Smt. K.P. Padmasree (Member-I) : (Sd/-)
Smt. Sheela Jacob (Member-II) : (Sd/-)
Appendix:
Witness examined on the side of the complainants:
PW1 : C.M. Abraham.
Exhibits marked on the side of the complainants:
A1 and A1(a) : IOB Health Care Plus policy certificates issued by the first
opposite party in the name of the complainant valid from
11.11.2011 to 10.11.2013.
A2 : Discharge summary issued from Holy Family Hospital,
Muthalakkodam, Thodupuzha in respect of the second
complainant’s treatment from 10.07.2012 to 23.07.2012.
A3 series: Bills (4 in number) for Rs. 1,28,764/- in respect of the second
complainant’s treatment.
A4 : Medical certificate issued by Dr. O.T. Geroge, Orthopaedic
Surgeon, Holy Family Hospital, Muthalakodam, Thodupuzha in
connection with the second complainant’s treatment in the
prescribed format of the third opposite party.
A5 : Copy of the legal notice dated 08.11.2013 issued by the
complainant to the opposite parties.
A5(a) & A5(b) : Postal acknowledgment card and postal receipt in respect of
Ext. A5 legal notice.
A6 : Certificate dated 17.09.2012 issued from Holy Family Hospital,
Muthalakodam, Thodupuzha.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties:
B1 series : 10 letters sent by the third opposite party to the first complainant
from 23.08.2012 to 03.01.2013.
B2 : Copy of MRI scan report dated 04.05.2012 issued from Life Scan,
Thodupuzha.
B3 : Copy of the IOB Health Care Plus policy schedule and its terms
and conditions.
(By Order)
(Sd/-)
Senior Superintendent
Copyto: (1) C.M. Abraham, Cherukara Thadathil House, Plankamon,
Velliyara P.O., Ayroor, Ranni, Pathanamthitta District.
- Susan Abraham, of do- -do-
- M/s. Universal Sompo General Insurance Co. Ltd., represented by its duly Constituted Attorney Unit 401, 4th Floor,
Sangam Complex, 127 Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059.
- The Branch Manager, Indian Overseas Bank, Plankamon Branch,
Velliyara P.O., Ranni, Pathanamthitta Dist., Pin – 689 612.
- M/s. TTK Health Care TPA Pvt. Ltd., H.B. Complex, 100 Ft BTM Ring Road, BTM first Stage, BTM Lay out, Bangalore – 560 068.
- Stock file.
