O R D E R
(By Sri A. Radha Krishna, President on behalf of the Bench)
1 The complainant seeks amount of Rs.78,327/- towards medical expenses incurred by her and also for damages and costs of the complaint.
2. This version of the complainant is that she obtained policy from the opposite party which is Gold policy, paid an amount of Rs. 5,370/- towards premium and she was also issued a policy for the same. The period is for one year. As per the policy she is entitled for medical expenses for health problems.
3. She developed some pain in uterus in the month of January, 2013. Immediately she approached Surya Global Hospital, Kakinada while she underwent medical checkups and it was found she was suffering from Fibroid uterus and they advised to undergo operation. Accordingly she got admitted in hospital on 19.02.2013 and underwent operation on the next day and later she was discharged on 23.02.2013. Her husband informed the health problem to the opposite parties who advised them to undergo operation and also informed she was entitled for getting claim under the policy taken by her husband. Accordingly she submitted claim forms through 2nd and 3rd opposite parties who received the same and promised to scrutinize and send the same to 1st opposite party for payment. Though she waited for long time there was no response and as such he issued a lawyer’s notice to the opposite parties. Having received the same, a reply was given repudiating the claim under cover of exclusion clause. According to her when policy was obtained at the time of taking policy the opposite parties informed them that they are entitled to any claim. They never informed it is only for limited health problems. Thus she is entitled for the amounts claimed in the complaint.
4 The 2nd and 3rd opposite party remained exparty where as the 1st opposite party filed written version interalia contending that the TTK Health care TPA administrators received the claim form and unable to entertain the same and suggested for repudiation of the claim as the ailment fibroid uterus with which complication the complainant was admitted in the hospital falls under exclusion clause 4.3 i.e. pre existing ailment at the time of proposal by the husband of the complainant. The insured had knowledge about pre existing disease and had taken treatment on her own and thereby she is not entitled to claim reimbursement. Thus they sought dismissal of the complaint.
5 Now the points for determination are:
1. Whether there is deficiency of service on the part of the opposite parties in repudiating the claim of the complainant on the ground of exclusion clause in the policy?
2. If so, whether the complainant is entitled for the amounts sought in the complaint?
6 Point No.1: It is an admitted fact the husband of the complainant obtained health insurance policy from the opposite parties. It is also not disputed the complainant undergoing operation for removal of fibroid uterus at Surya Global Hospital, Kakinada. The ground of repudiation by the opposite parties is that as per exclusion clause 4.3 of the policy the pre existing ailment is not covered and the complainant had knowledge about the disease at the time of taking policy and as such she is not entitled for the amounts claimed in the complaint.
7 To buttress her contention the complainant filed her chief affidavit and exhibited 9 documents which are individual health insurance policy Ex.A1, individual health card Ex.A2, claim form along with courier receipt Ex.A3, delivery run sheet Ex.A4, letter addressed by the complainant to TTK Health Care Pvt. Ltd., Visakhapatnam Ex.A5, acknowledgment Ex.A6, lawyer’s notice issued by the complainant to opposite parties Ex.A7, reply issued by the opposite party to the counsel for complainant Ex.A8, letter addressed by the 3rd opposite party to the counsel for complainant Ex.A9. As against this evidence the opposite parties marked Ex.B1 the policy and no other evidence is produced.
8 As seen from the terms and conditions of the policy as per clause 4.3 this particular disease of the complainant is excluded for a period of first two years of operation of the policy.
9 It may be mentioned here according to complainant at the time of obtaining policy by her husband the opposite parties informed that she was entitled for claim form any ailment under the insurance coverage. They never informed that it is only for limited health problems. If at all they were appraised of thing her husband could have thought of taking policy or not. When it is specifically averred in the complaint there is no specific denial by the opposite parties with regard to the same and on other hand the opposite parties also did not chose to file chief affidavit contradicting or disputing the version of the complainant in this regard. Even it is not their case that the husband of the complainant was posted with the terms and conditions of the policy at the time of obtaining the same. Hence under these circumstances the said exclusion clause does not come to the rescue of the opposite party for repudiating the claim of the complainant. Thus in these circumstances there is deficiency of service on the part of the opposite parties in repudiating the claim of the complainant on the ground of exclusion clause. Hence this point is answered in favour of the complainant.
10. Point No.2: As there is deficiency of service on the part of opposite parties the complainant is entitled for the expenses incurred by her which is mentioned as Rs. 57,327/-. Thus this point is answered accordingly.
11 In the result, the opposite parties are directed to pay sum of Rs. 57,327/- [Rupees fifty seven thousand three hundred and twenty seven only] being the medical expenses incurred by the complainant and sum of Rs. 2,000/- [rupees two thousand only] towards mental agony and suffering and sum of Rs. 1,000/- [rupees one thousand only] costs of the complaint to the complainant. The opposite parties are directed to pay the above said amounts within one month from the date of this order, otherwise the said amounts shall carry interest @9% from the date of this order till realization.
Dictation by the Steno, transcribed by her, corrected and pronounced by us, in open Forum, this the 29th day of January, 2015
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MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For complainant :
Smt. Ganesana Satyavathi [Complainant
For opposite parties : None
DOCUMENTS MARKED
For complainant:-
Ex.A1 Individual health insurance policy
Ex.A2 Individual health card
Ex.A3 Claim form along with courier receipt
Ex.A4 Delivery run sheet
Ex.A5 22.04.2013 Letter addressed by the complainant to TTK Health Care Pvt. Ltd., Visakhapatnam Ex.A6 Acknowledgment
Ex.A701.07.2013 Lawyer’s notice issued by the complainant to opposite parties
Ex.A8 Reply issued by the opposite party to the counsel for complainant
Ex.A9 08.07.2013 Letter addressed by the 3rd opposite party to the counsel for complainant
For opposite parties:
Ex.B1 Policy terms and conditions
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MEMBER PRESIDENT
