Tamil Nadu

North Chennai

CC/300/2018

C.M.Rathanasababathy - Complainant(s)

Versus

M/s.TTK Health Care Service s Pvt Ltd. - Opp.Party(s)

K.Kumaran

27 Mar 2023

ORDER

Complaint presented on  :25.03.2011    Date of disposal               :27.03.2023

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (NORTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 600 003.

 

PRESENT: THIRU. G.VINOBHA, M.A., B.L.                            : PRESIDENT

                   TMT. KAVITHA KANNAN,M.E.,                           : MEMBER-1

                                 THIRU V. RAMAMURTHY, B.A.B.L., PGDLA    : MEMBER II

 

C.C. No.300/2018

 

DATED THIS MONDAY THE 27^th DAY OF MARCH 2023

 

C.M.Rathnasababathy,

No.22, Dr.Guruswamy Road,

Chetpet,

Chennai-600 031.

                                                                                                 .. Complainant.                                                                 ..Vs..

 

1.M/s. UNITED INDIA INSURANCE COMPANY LTD.,

Rep. by its Chairman & Managing Director,

Having its Regd & Head office at No.24,

Whites Road,

Chennai-600 014.

 

2. M/s. UNITED INDIA INSURANCE COMPANY LTD.,

Rep. by its Branch Manager,

New No.75, Old No.9, Shanmugam Road,

Tambaram West,

Chennai-600 045.

 

3. M/s. TTK HEALTH CARE SERVICES PRIVATE LIMITED,

Rep. by its Manager,

No.88, G.N.Chetty Road,

T.nagar, Chennai-600 017.

                                                                       ..  Opposite parties.

 

Counsel for the complainant                      : M/s.K.Kumaran and 2 others

Counsel for   opposite parties 1 & 2                  : M/s.S.K.Krishnamurthy

Counsel for   opposite party 3                  : Exparte.

 

ORDER

THIRU V. RAMAMURTHY, B.A.B.L., PGDLA    : MEMBER II

          This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 prays to directing the Opposite parties to refund the balance amount of Rs.245044.25 paid by the complainant to the Apollo Hospital for his treatment together with interest at 12% p.a. from 28.03.2008 till the date of payment to the complainant and to pay a sum of  Rs.100000/- as compensation to the complainant for the deficiency in service and unfair trade practice on the part of the opposite parties and costs.

This complaint was originally filed before the District Commission, Chennai (South) and taken on file in C.C. No. 190/2011.  Thereafter, the said complaint has been transferred to this Commission as per the proceedings of the Hon’ble S.C.D.R.C. and taken on file as C.C. No.300/2018.

1.THE COMPLAINT IN BRIEF:

The complainant submits that in the year 1997 the complainant had taken a health insurance policy from the 1^st opposite party through the 2^nd opposite party covering medical risk for himself, wife and son and periodically renewing the policy.  Since no claim was made against the policy, the complainant was given 5% no claim bonus for every no claim free year from 1997.  For the year 2008-2009 the opposite party issued a renewal notice and accordingly the premium of Rs.25,454/- was paid for the period 07.06.2008 to 06.6.2009 and renewed policy No. 011305/48/1997/00000120 covering the medical risk of Rs.6.5 Lakhs for complainant, Rs.6.5 Lakhs for his wife and Rs.2.75 Lakhs for his son.  Suddenly,the complainant had a chest pain and taken to Apollo Hospitals at Greams Road on 23.03.2009 and preliminarily he was diagnosed Acute Coronary Syndrome (Antero Septial MI) and admitted for further treatment.  On further study the complainant was diagnosed to have “Diabetus Mellitus, Systemic Hypertension, Myasthenia Gravis, Acute Anteo-Septal Myocardial Infarction single vessal disease-Thrombotic Prox Lad Occulusion, RT trans-Radial primary PCI with stent to Lad, Mild LV Dysfunction” and the same was informed to 1^st, 2^nd and their Third Party Administrator being the third opposite party herein. The complainant was advised to undergo Angioplasty and the same was done on 23.03.2009 and discharged on 28.03.2009 and was demanded to pay Rs.4,45,044.25 by the hospital. Whereas the 3^rd opposite party who is the TPA of 1^st opposite party issued a authorisation letter to Apollo Hospital only for a sum of Rs.2 Lakhs and asked the hospital to collect the balance from the complainant and hence the hospital demanded the balance amount of Rs.2,45,044.25 from complainant.  On enquiry with the 3^rd opposite party it was informed that as per the renewed policy No. 011305/48/1997/00000120 from 07.06.2008 to 06.06.2009 the maximum amount payable for Angioplast is only Rs.2 Lakhs and not Rs.4,45,044.25 from and out of the insured amount of Rs.6.5 Lakhs based on the stipulation inserted in the above renewed policy.  The complainant submits that there was no such condition of maximum of Rs.2 Lakhs for Angioplast in the original policy issued to complainants by 1^st and 2^nd opposite parties.  The opposite parties had renewed the policy by inserting new condition which was not in the original policyand it is without the concurrence and knowledge of complainant and hence the same is not valid and binding on the complainant.  The complainants further submits that the opposite parties failed to heed the demands of the complainant to pay the entire hospital expenses and to avoid further stay in the hospital, the complainant was forced to pay the balance amount of Rs.2,45,044.25 and got discharged.  The complainant again approached the opposite party to refund the balance amount paid but the opposite parties failed to do so and thus the actions of opposite parties caused mental agony and hardship which the complainant estimates for Rs.1,00,000/- and the same is liable to be paid by the opposite parties besides refund of balance hospital expenses and cost of this complaint.  Hence this complaint.

2.WRITTEN VERSION OF 1^ST AND 2^NDOPPOSITE PARTIES IN BRIEF:

The opposite parties preliminary objection is that the complaint is not maintainable as there was no deficiency in service in repudiating the claim.  This opposite party is a nationalized company under the control of Ministry of Finance, Government of India was made to incur cost in contesting this vexatious petition with no fault on them.  The opposite parties submits that the legal aspects of settlement of claims involves examination of claim in  relation to coverage under policy and compliance with policy conditions, warranties and exclusion.  As per the terms and conditions, the maximum payable for the ailment treatment for the complainant is Rs.2 Lakhs as such in terms of the policy conditions a sum of Rs.2 Lakhs was settled.  The opposite parties submits that the averment of the complainant that insertion of a new clause fixing maximum limitation for ailment is not valid and binding on him is totally unwarranted and unlawful and the complainant being a party to the contract of insurance cannot plead that he was unaware/not informed/not revealed the policy terms, conditions and exclusions. Further the contract of insurance is not extended during its lapse, but freshly renewal policy for a period of 12 months alongwith policy terms, conditions and exclusions is issued and as such the complaint is unsustainable and liable to be dismissed.  Hence it is prayed that the complaint may please be dismissed with cost and damages.

In spite of notice, the 3^rdopposite party had not appeared before this Commission and hence, 3^rd opposite party was set ex-parte.

3. POINTS FOR CONSIDERATION:

1. Whether there is any deficiency in service on the part of the opposite parties as alleged in the complaint?

2. Whether the complainant is entitled to the reliefs prayed in the complaint. If, so to what extent?

The complainant had filed proof affidavit, written arguments and documents Ex.A1 to Ex.A11 were marked on his side.The 1^st and 2^nd opposite parties have filed written version, proof affidavit, written arguments and no documents were marked on their side.

4.Point No.1:-

The undisputed facts of the complaint are that complainant had taken health insurance policy in the year 1997 from the opposite parties for his family and subsequently it was renewed every year.   The documents marked as Ex. A1 to Ex. A6 are the proof of policy and payment of premium from the year 2005-06 to 2007-08.  The opposite parties had given no claim bonus of 5% for each claim free year during renewal which is noticed from Ex. A2, A5 and A6.  The health insurance policy was renewed for the period of 07.06.2008 to 06.06.2009 on payment of premium of Rs.25,454/- and the renewed policy no. 011305/48/08/1997/00000120 was issued to complainant covering medical risk of Rs.6.5 Lakhs for complainant, Rs.6.5 Lakhs for his wife, Rs.2.75 Lakhs for his son as evidenced from Ex. A7.  The complainant had chest pain and got admitted in Apollo Hospital, Greams Road on 23.03.2009 and undergone Angioplasty and got discharged on 28.03.2009 as per Ex.A9.  The same was informed to opposite parties and 3^rd opposite party sanctioned a sum of Rs.2 Lakhs for Angioplasty and advised the hospital to collect the balance amount from complainant as per Ex.A10.

5. The complainant alleged that under the renewed policy he was covered for a sum of Rs.6.5 Lakhs and the total amount of treatment was Rs.4,45,044.25 but the opposite party sanctioned only Rs.2 Lakhs citing the newly inserted condition of the policy that for Angioplasty the maximum permissible amount is Rs.2 Lakhs only.   The complainant alleged that insertion of new condition was done without his knowledge and concurrence, and it is not binding on him because no such condition was prevailed at the time of original policy and hence the opposite parties are liable to pay the balance amount of Rs.2,45,044.25 to complainant.

6. The opposite parties defended that the claim was processed in relation to coverage under policy and compliance of policy conditions, warranties and exclusions and as per the policy terms and conditions the maximum payable amount for the ailment treatment of complainant was Rs. 2 Lakhs only and the same was settled.  The opposite parties contended that insertion of new clause fixing maximum limitation for ailment is not valid and binding on him is unwarranted and unlawful and the complainant being the party to the contract of insurance cannot plead that he was unaware/not informed/not revealed the policy terms, conditions and exclusions.  Further the contract of insurance is not extended during its lapse, but freshly renewal policy for a period of 12 months alongwith policy terms, conditions and exclusions.

7. After careful examination of averments of both sides, documents filed by complainant side and also the oral arguments of learned counsel for complainant, it is observed that the complainant had taken health insurance policy for his family from the year 1997 and subsequently it was renewed every year.  It is observed from the averments of the complainant that his family have not availed any claim against the policy till 2008.  It is observed from Ex. A6, till the policy year 2007-08 there was no change in the conditions of the policy and only during the renewal of insurance for the year 2008-09, new clause was inserted.  The policy document for the year 2007-08 marked as Ex.A6, clause 1 states :

1. In the event of any claim/s becoming admissible under this scheme, the company will pay through TPA to the Hospital/Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in aggregate mentioned in the schedule herein.

1. Room, Boarding Expenses as provided by the Hospital / nursing home.
2. Nursing Expenses.
3. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees
4. Anaesthesia, Blood, Oxygen, Operation Theatre charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray.
5. Dialysis, Chemotherapy, Cost of Pacemaker, Artificial Limbs & Cost of organs and similar expenses.

(N.B.: Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per person as mentioned in the schedule).

The policy document for the year 2008-09 marked as Ex.A7, Clause I states :

1. In the event of any claims becoming admissible under this scheme, the company will pay through TPA to the Hospital/Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in aggregate mentioned in the schedule herein.

6. Room, Boarding Expenses as provided by the Hospital / nursing home.
7. Nursing Expenses.
8. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees
9. Anaesthetist, Blood, Oxygen, Operation Theatre charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of organs and similar expenses.

Expenses in respect of the following specified illnesses will be restricted as detailed below :

Hospitalisation Benefits	LIMITS RESTRICTED TO
Cataract	10% of SI or Max.Rs.25,000/-
Hernia	15% of the SI or Max. Rs.30,000/-
Hysterectomy	20% of the SI or Max.Rs.50,000/-
Major surgery-Angioplasty	70% of the SI or Max.Rs.2 lacs.
Pre & Post Hospitalisation	Maximum 10% of the sum assured

 

(N.B.: Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per person as mentioned in the schedule).

8. It is found from the Ex.A7 that the complainant herein is entitled to Rs.6.5 lakhs as sum insured and hence any restriction on the sum payable by the opposite party in respect of treatment for angioplasty and fixing a maximum limit of Rs.2 lakhs that too without the consent and knowledge of the complainant will amount to deficiency in service on the part of the opposite party. It is observed that opposite parties have made major changes in the entitlement.  The complainant alleged that the insertions of new clause was not intimated and without his knowledge and concurrence the opposite parties have inserted new conditions thus depriving his entitlement to get entire expenses incurred in respect of treatment.  The complainant alleged that insertion of new clause/condition is unilateral and arbitrary action of opposite parties which was not prevailed during the enrolment of policy first time and hence claimed that new inserted condition is not binding on him and he is entitled for full reimbursement subject to the maximum of sum insured.  The complainant further claimed that the policy was renewed in good faith based on the same terms and conditions and if the insertion of new clauses/conditions are informed well in advance, he would have had the option of renewing the existing policy or shifting to some other policy which is advantage to him.  The complainant further claims that it is a well settled law that “A renewal of an insurance policy means repetition of the original policy.  When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force.  In common parlance, by renewal, the old policy is revived and it is a sort of a substation of obligations under the old policy unless such policy provides otherwise.  It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as that of the original policy”. 

9. According to Ex. A7, Clause 5 Conditions, subclause 5.1 that the “premium payable under the policy shall be paid in advance”.  Clause 5.9, the Renewal clause states that the “policy may be renewed by mutual consent and in such event the renewal of premium shall be paid to the Company on or before the date of expiry of policy or of the subsequent renewal thereof.  In any case not later than 15 days from the date of expiry of the current policy”

10. According to the above clauses, the premium for the renewal of policy is payable in advance and the policy may be renewed by mutual consent.  From the averments of the opposite party it appears that no such consent was obtained from the complainant before renewal of policy and no documents were filed by the opposite party to prove that the complainant consent was obtained for inserting a new clause in the policy.  From the Ex.A6, it is noted that the Mediclaim policy renewed by the opposite party for 2007-08 was an ordinary Mediclaim policy and from the Ex.A7, the Mediclaim policy for 2008-09 renewed by the opposite party was Platinum policy for complainant’s son and Gold Policy for Complainant and his wife.  When the opposite party asks for advance payment for renewal of policy and in such case how the customer come to know the change in conditions or change of type of policy as happened in this case.  The opposite parties are providing policy document along with terms and conditions only after receipt of premium.  Hence no opportunity was given to insured for going through the terms and conditions or brought to the knowledge of insured.  The opposite party has not filed any documents to prove that the insertion of new condition in the policy during renewal was brought to the notice of the complainant or his consent obtained.

11. The learned counsel for complainant relied upon the following judgement of Hon’ble National Consumer Disputes Redressal Commission and Hon’ble Supreme Court of India:

1. Hon. Supreme Court of India, I(2000) CPJ 1 (SC), Modern Insulators Ltd., vs Oriental Insurance Co. Ltd.,
2. Hon. Supreme Court of India, Appeal (Civil) 2296 of 2000, Biman Krishna Bose vs United India Insurance Co. Ltd. &Anr.
3. Hon. NDCRC, I(2011) CPJ 25 (NC), Mahesh Chand Ghiya vs New India Assurance Co. Ltd.,
4. Hon. Supreme Court of India, Civil Appeal No.6778 of 2013, Jacob Punnel&Anr vs United India Insurance Co. Ltd.,

12. Though the facts of the above cases are similar in nature, but the judgement of Hon. Supreme Court of India in Civil Appeal No.6778 of 2013 aptly suits to this case because the opposite party is same party and the period of policy and issues in question are similar to this case and the extract of the findings are given below:

“The insurer was clearly under a duty to inform the appellant policy holders about limitations which it was imposing in the policy renewed for 2008-2009.  Its failure to inform the policy holders resulted in deficiency in service”.

13. Based on the above observations, we are of the considered view that opposite parties failed to inform the insertions of new clauses/conditions in the Mediclaim policy amounts to deficiency in service and therefore the opposite parties are liable to refund the balance amount of treatment to complainant besides compensation and cost of complaint as claimed in the complaint.  Point No.1 is answered accordingly.

14. Point No.2.

            Based on findings given to the Point.No.1 since there is deficiency in service on the part of Opposite parties, the complainant is entitled for relief.  Point no.2 answered accordingly.

          In the result, the complaint is partly allowed.  The 1^st, 2^nd and 3^rd opposite parties are directed pay jointly and severally to complainant a sum of Rs.2,45,044.25 towards balance treatment charges with 9% interest from the 28.03.2009 till date of payment and to pay Rs.50,000/- towards compensation for mental agony and hardship and Rs.5,000/- towards cost of this complaint. The above amount shall be paid to the Complainant within two months from the date of receipt of the copy of this order, failing which the above said amount shall carry 9% interest from the date of order to till the date of payment. 

          Dictated  by Member II to the Steno-Typist taken down, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 27^th day of March 2023.

 

MEMBER I                                  MEMBER  II                             PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1	18.06.2004	Letter issued by the insurance company.
Ex.A2		Policy certificate with terms of policy for the period from 07.06.2005 to 06.06.2006.
Ex.A3	06.06.2005	Receipt issued by the United Insurance Company Ltd.,
Ex.A4	05.06.2006	Receipt issued by the United Insurance Company Ltd.,
Ex.A5		Policy certificate with terms of policy for the period from 07.06.2006 to 06.06.2007.
Ex.A6		Policy certificate with terms of policy for the period from 07.06.2007 to 06.06.2008.
Ex.A7		Policy certificate with terms of policy for the period from 07.06.2008 to 06.06.2009.
Ex.A8	28.03.2009	Bills issued by Apollo Hospitals to the complainant.
Ex.A9	28.03.2009	Discharge summary issued by Apollo Hospitals to the complainant.
Ex.A10	28.03.2009	Authorisation letter issued by the 3rd opposite party to the complainant.
Ex.A11	30.03.2009	Letter sent by the complainant to the 3rd opposite party.

LIST OF DOCUMENTS FILED BY THE  OPPOSITE PARTIES 1 AND 2:

                                                NIL

MEMER  I                    MEMBER  II                         PRESIDENT

 

 

 

 

 

 

 

C.C.No.300/2018, Dated:27.03.2023

Order Pronounced,

        In the result, the complaint is partly allowed.  The 1^st, 2^nd and 3^rd opposite parties are directed pay jointly and severally to complainant a sum of Rs.2,45,044.25 towards balance treatment charges with 9% interest from the 28.03.2009 till date of payment and to pay Rs. 50,000/- towards compensation for mental agony and hardship and Rs.5,000/- towards cost of this complaint. The above amount shall be paid to the Complainant within two months from the date of receipt of the copy of this order, failing which the above said amount shall carry 9% interest from the date of order to till the date of payment.