BEFORE THE DISTRICT FORUM:KURNOOL
Present: Sri. K.V.H.Prasad B.A.LL.B., President
And
Smt. C.Preethi, M.A.LL.B., Lady Member
Friday the 14th dayof September, 2007
C.C.No. 33/07
1. Sri. B. Ramanath,
2. Smt. B. Lakshmi Kanthamma,
Both are residing at Door No. 13/122, Sandthapeta, Adoni, Kurnool District. Complainant
Versus
1. New India Assurance Company Limited, By its Divisional Manager,
Ananthapur.
2. New India Assurance Company Limited, Represented by its Branch Manager,
Adoni Branch, Kurnool District.
3. Good Health Plan Limited, By its Managing Director,
Hyderabad. … Opposite Parties
This complaint coming on this day for orders in the presence of Sri.N.Nanda Kishore, Advocate, Kurnool, for complainant, and Sri.P.Ramanjaneyulu, Advocate, Kurnool opposite parties 1 and 2 and opposite party No.3 called absent and set exparte and upon pursuing the material papers on record, the Forum made the following:-
ORDER
C.C.No. 33/07
(As per Smt. C.Preethi, Member)
1. This consumer complaint of the Complainant is filed U/S 11 and 12 of C.P.Act, 1986 seeking a direction on opposite parties to pay insured amount under medi claim policy of Rs.1 lakh, Rs.1 lakh as compensation with 12% interest per annum, cost of the complaint and any other relief or reliefs which the complainant is entitled in the circumstances of the case.
2. The gist of the Complaint of the Complainants is that they covered under the medi claim policy No.610702/48/05/75006 covering from 5.8.2005 to 4.8.2006. The above policy is renewed policy and the Complainants continuously from 1988 was covered under the medi claim policies issued by opposite parties. The last policy had a brake of 35 days for renewal as there was communication gap between the Complainants and opposite parties. The said policy was issued after covering the delay of 35 days by loading premium at 300% to 200% pertaining to the Complainants. The said policy was issued without exclusion of any decease specically mentioned as none in the exclusion
column of the policy, basing on the same terms and conditions which exist in the previous policies. Nothing was suppressed from the opposite parties about the history of surgeries under gone, medicines being administered etc., and taking into account all these factors the Opposite Parties issued the said policy loading the premium excessively. The Complainants basing on the above medi claim policy , put a claim for reimbursement of expenses incurred for angio-plastic with stent on 23.3.2006 for Rs.2,96,176/- which was rejected by 3rd party admistrator (M/S. Good Health Plan) vide letter dated 18.5.2006 . The contract is between the Complainants and Opposite Party 1& 2 and 3rd party has no jurisdiction to repudiate the claim of the complainants. Hence, there is no valid repudiation by the Opposite Parties. Therefore, the rejection of claim of the Complainants by the so called 3rd party is not valid and non acting on the claim of the Complainants by the Opposite Party 1 and 2 is amounting to deficiency of service to the Complainant’s, therefore the Complainant resorted to the forum for reliefs.
3. The Complainant’s in support of their case relied on the following documents viz., (1) policy issued to the Complainant’s bearing No. 610702/48/05/ 75006 (2) repudiation letter dated 18.5.2006 by Opposite Party No.3 (3) paper advertisement dated 20.1.2004 of Eendau paper (4) claim form dated 6.4.2006 (5) letter dated 15.6.2004 of Opposite Party No.2 to the Complainant (6) reply letter dated 19.6.2004 of Opposite Party No.2 and (7) reply letter dated Nil of Opposite Party No.2, besides to the sworn affidavit of the Complainants in reiteration of his Complainant avernments and the above documents are marked as Ex.A1 to A7 for its appreciation in this case. The Complainants caused interrogatories to Opposite Party No.2 and replied to the interrogatories caused by opposite parties.
4. In pursuance to the notice of this forum as to this case of the Complainants the opposite party No.3 remained absent throughout the case proceedings. The opposite parties 1 and 2 appeared through their standing counsel and opposite party No.2 filed written version, the Opposite Party No.1 adopted the written version of Opposite Party No.2.
5. The written version of opposite parties 1 and 2 admits that it has issued a medi claim policy No.610702/ 48/05/020/ 70050006 commencing from 5.8.2005 to 4.8.2006 for a period of one year. But it is not a renewal of any previous policies as the complainant himself admitted that there was a brake of 35 days, hence the said policy is a fresh policy and as such all the exclusion including pre-existing deceases as applicable to fresh policies are equally applicable to this policy and there is no relevancy of the earlier policies to this policy and the Complainant intentionally concealed the information about the various claim payments he received from Opposite Party No.1 and 2. The gap in renewal of insurance policy in solely on account of gross negligence of the Complainants and the delay of 35 days in renewing said policy was not covered by the opposite party and the loading of premium was charged on account of very high claims and as per the direction of ombudsman orders dated 8.6.2004 and not to cover the delayed period. The medi claim clause attached to the policy clearly describes the coverage extended under the policy besides various exclusions and conditions. As such “None” mentioned in the exclusion column of the policy schedule means that the policy is only subject to exclusions as mentioned in the medi-claim clause and that no additional exclusions are imposed. The complainant’s in the proposal form furnished the details of pre-existing decease and as per Clause No.4.1 pre-existing decease are excluded, as such all the pre-existing deceases as declared by the Complainants in the proposal form are excluded from the scope of the policy. The complainants further submitted that the rejection of claim by the opposite party No.3 is on baseless grounds, but it is the Complainant who approached Opposite Party No.3 i.e., Good Health Plan Limited, Hyderabad as per policy terms and conditions and after due enquiry Opposite Party No.3 repudiated the claim of the Complainant on 18.5.2006, so when there is clear repudiation by the Opposite Party No.3 and this Opposite Party need not repudiate the claim once again. The Complainants approach to Insurance ombudsman and the order of the ombudsman dated 23.11.2006 is binding on both parties. Hence, there is no cause of action for the Complainants as alleged in the complaint and there is no deficiency of service on the part of opposite parties and lastly seeks for the dismissal of complaint with exemplary cost of Rs.1,00,000/-.
6. In substantiation of their case the opposite parties relied on the following documents viz., (1) policy bearing No.610702/48/ 05/ 20/ 70050002 (2) policy No.610702/48/05/20/70050006 (3) printed broucher of medi claim Insurance policy (4) Award No. I.O (Hyderabad) G- 175 / 2004-2004 and (5) proposal form, dated 5.8.2005, besides to the sworn affidavit of opposite party No.1 and the above documents are marked as Ex.B1 to B5 for its appreciation in this case. The opposite party No.1 caused interrogartories to the complainant and replied to the interrogatories of complainant.
7. Hence, the point for consideration is to what relief the Complainant is entitled alleging deficiency of service on part of opposite parties ?
.
8. It is the case of the Complainants that they are covered under the medi claim policy bearing No.610702/ 48/05/ 75006 vide Ex.A1, issued by Opposite Party No.1 and 2 and the said policy commenced from 5.8.2005 to 4.8.2006 . On 6.4.2006 the complainants put forth a claim vide Ex.A4 for reimbursement of medical expenses incurred for Angio-plastic with stent on 20.3.2006 for Rs.2,96,176/- . To the dismay of the complainants the Opposite Party No.3 repudiated the claim of the Complainants vide Ex.A2, dated 18.5.2006 as per policy exclusion 4.1 pre existing decease not covered under the Insurance policy.
9. Hence, the opposite parties repudiated the claim of the complainants vide Ex.A2 on five reasons viz., firstly as per fresh proposal form dated 5.8.2005 vide Ex.B5 the insured Mrs. Laksmikanthamma is having coronary artery disease since, 1999. The opposite parties accepting the coronary artery disease since 1999 issued previous policies to the Complainants and the present disputed policy in Ex.A1/B2, reveals that it was issued based on the proposal form and declaration dated 1.7.2004 and the repudiation says they have acted upon the fresh proposal dated 5.8.2005, which has no relevancy to the disputed policy and more so no policy was issued on the so called fresh proposal dated 5.8.2005. Hence, the first ground of Ex.A2 is baseless.
10. Secondly , as per policy condition 2.17 the policy has to be renewed without any break, but the opposite parties in support of the above did not place any supporting material to substantiate the said plea. Hence, the second ground is also baseless.
11. Thirdly, since there is a gap of 35 days between the expiry of the previous policy and commencement of new policy the new policy is considered as fresh policy. Even though the Ex.B2/A1 shows the policy period from 18.00 hours of 5.8.2005 to mid night of 4.8.2006 from the contents of it as “proposal form and declaration dated 1.7.2004, the said policy remains to be a renewal policy to Ex.B1. Further the premium was loaded, even though the opposite parties submit that the said loading of premium was done to fresh policy in Ex.B2 in view of the earlier bad claims. But neither any such condition or term is placed for appreciation by the opposite parties side. In said circumstances the loading of premium is to be taken for issual of renewal policy in Ex.B2 in the circumstances exhibit there in. Hence, there appears any substance in the ground taken for repudiation.
12. Fourthly, as per policy exclusions 4.1` pre-existing disease are not covered under Insurance norms. The policy issued to the Complainants vide Ex.A1,/B2 and B1 does not reveal any where that the conditions mentioned there in are in addition to any of their other policy conditions issued by Insurance Company. Hence, there is no binding force of clause 4.1, on the complainants, as the said clause is not mentioned in the policy issued to the complainants. Hence, the fourth ground for repudiating the complainants claim is also improper.
13. And fifthly, and lastly, considering all the above facts we are repudiating the claim on the basis of pre-existing disease. Hence, the grounds taken in Ex.A2 are not having any merit and force to justify the repudiation of the complainants claim. Especially, when the said repudiation was not done by the insurer opposite party No.2 but by the third party administrator (opposite party No.3) who is entitled only to process the claim and submit his recommendations to the insurer for further necessary disposal.
14. Even if the Ex.B2 is taken for a movement as fresh policy as it also says as “none” excluded as Ex.B1 earlier policy. The Ex.B2 policy also covers the risk of medical reimbursement to the coronary artery disease existing to the claimant since 1999.
15. As the opposite parties are not disputing the correctness of the claim but only to the entitleness of it to the claimant. In the circumstances of holding the repudiation as not justifiable, the insurer/opposite parties 1 & 2are at liability to reimburse the incurred medical expenditure to the extent permissible under the policy.
16. As the opposite parties by their indifferent conduct and attitude driven Complainant to the forum for redressal. The Opposite Parties are liable not only to the costs of their litigation but also for mental agony suffered by the Complainant, at repudiation of the claim.
17. In the circumstances discussed above, the role of the Opposite Party No.3 is limited only to the purpose of processing the claim and submit its recommendation for further necessary disposal and their being no privity of it to the Complainants. The case against Opposite Party No.3 is dismissed.
18. Therefore, the complaint is allowed against the insurers opposite parties 1 and 2 with their joint and several liability to pay to the Complainant Rs.1,00,000/- as the maximum amount payable under the policy towards medical expenditure incurred by the complainants and also an amount of Rs.5,000/- as compensation for mental agony and Rs.1,000/- as costs within a month of receipt of this order. In default the supra stated award amount shall be paid by the opposite parties 1 and 2 in joint and severally liability with an interest of 9% per annum from the date of said default till realization.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 14th day of September, 2007.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witness Examined
For the Complainant: Nil For the Opposite Party : Nil
List of Exhibits marked for the complainant:-
Ex.A1 New India Assurance Policy No. 610702/48/05/75006.
Ex.A2 Repudiation letter, dated 18.5.2006 Of opposite party No.3.
Ex.A3 Paper advertisement, dated 20.1.2004 of Eenadu paper.
Ex.A4 Claim form, dated 6.4.2006 .
Ex.A5 Letter, dated 15.6.2004 of opposite party No.2 to complainant.
Ex.A6 Reply letter, dated 19.6.2004.
Ex.A7 Reply to letter Ex.A6, dated nil of opposite party No.2.
List of Exhibits marked for the opposite parties:-
Ex.B1 Policy No.610702/48/05/20/70050002Covering period 1.7.2004 to
30.6.2005.
Ex.B2. Policy No.610702/48/05/20/70050006 Covering period from
5.8.2005 to 4.8.2006.
Ex.B3. Printed Broucher of Mediclaim Insurance Policy.
Ex.B4. Award No. I.o. (Hyderabad) G- 175/ 2003-2004.
Ex.B5. Proposal Form, dated 5.8.205.
MEMBER PRESIDENT
Copy to:
1. Sri. N. Nanda Kishore, Advocate, Kurnool.
2. Sri. P. Ramanjaneyulu, Advocate, Kurnool.
Copy was made ready on:
Copy was dispatched on:
Copy was delivered to parties:
