Tamil Nadu

StateCommission

FA/75/2014

N.Ganesan - Complainant(s)

Versus

The Branch Manager, United India Insurance Co. Ltd., & another - Opp.Party(s)

A.Balasingh Ramanujan

02 Jul 2015

ORDER

 

BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION,CHENNAI

BEFORE :   THIRU.A.K.ANNAMALAI                           PRESIDING JUDICIAL MEMBER

                                                     TMT.P.BAKIYAVATHI                                MEMBER                                                                                  

F.A.NO.75/2014

(Against the order in CC.No.415/2008, dated 12.02.2013 on the file of DCDRF, Chennai (South)

DATED THIS THE 2^nd DAY OF JULY 2015

N.Ganesan,

S/o.RP.Namasivayam,

No.1, Guruvappa Chetty Street,                               M/s.A.Balasingh Ramanujam

Old Washermenpet,                                           Counsel for Appellant /Complainant

Chennai 600 021.

-vs-

 

1.The Branch Manager,

   United India Insurance Co Ltd,                             M/s.S.K.Krishnamorthy

   DO 010500,                                                    Counsel for 1^st Respondent/1^st OP

   No.64, Armenian Street,

   Chennai 600 001.

 

2. Manager,

    TTK Health and Care Services Pvt Ltd,

    “Anmol Palani”, No.88, G.N.Chetty Street,         2^nd Respondent /2^nd opposite party

    T.Nagar, Chennai 600 017.                                            Served absent

          The appellant is the complainant filed a complaint before the District Forum against the opposite parties praying certain relief.  The District Forum dismissed the complaint.  Against the said order, the appellant / complainant filed this appeal praying for to setaside the order of the District Forum in CC.No.415/2008, dated 12.02.2013.   

          This appeal coming before us for hearing finally on 09.06.2015, upon hearing the arguments on both sides, perusing the documents, lower court records, and the order passed by the District Forum, this commission made the following order.

A.K.ANNAMALAI,  PRESIDING JUDICIAL MEMBER

          The unsuccessful complainant is the appellant.

2.       The complainant had taken the mediclaim policy from the 1^st opposite party for the sum assured was Rs.1,50,000/- and the policy period was from 6.7.2007 to 5.7.2008 for himself and his wife and had paid Rs.2,708/- as premium.  The complainant on complaint of severe cough for three weeks continuously during middle of November 2007 consulted his family Doctor and on his advise he was admitted and treated at Nichanis Hospital.  He was hospitalized from 7.12.2007 to 25.12.2007.  On 5.1.2008 the complainant submitted a claim for Rs.70,145.40 with requisite documents to  the opposite parties.  The complainant submitted additional documents sought for by the opposite party and the opposite parties failed to settle the claim of the complainant till date.  The act of the opposite parties in not settling the claim of the complainant amounts to deficiency in service.  Hence a consumer complaint came to be filed claiming the reliefs.

3.       The 1^st opposite party denied the allegations and stated that the complainant failed to intimate the claim notified the pending of the claim with the 2^nd opposite party and the 2^nd opposite party not appeared before the District Forum and thereby it was set exarte.

4.       Based on the both sides materials and after an enquiry the District Forum dismissed the complaint observing that there was no deficiency in service on the part of the opposite parties since on the date of complaint notify pending for settlement by relying Ex.B1 and B2.

5.       The complainant as appellant contended in the grounds of appeal that the District Forum failed to consider as if the complainant having pre existing disease and it was not proved by the respondents with any documentary evidence.  The opposite parties never sent any letter about the repudiation till the date of complaint and no letter dated 12.01.2009 was received by the appellant at any point of time and after received the summon only the opposite parties informed that the letter was sent to the complainant on 12.1.2009 falsely under EX.B2 and filing the documents belatedly would itself proved the negligence and deficiency in service and the 1^st opposite party having no locus-standi to represent the 2^nd opposite party who was set exparte.  There is no explanation and information of repudiation of the appellant’s claim and what the disease contracted and what was the material facts suppressed and there is no material on record.  The alleged claim form said to have been filed with error was not happened wantonly and the District Forum pointed out the clerical error even though it was not raised by the respondents.

6.       Though the 1^st respondent appeared before this commission through the lawyer when the appeal is taken up for arguments, nobody have represented and the 2^nd respondent remained absent and after closing the 1^st respondent side arguments and after hearing the arguments of the appellant the order being passed on merits.

7.       The complainant having availed mediclaim policy through the 2^nd opposite party from the 1^st opposite party for himself and also for his wife having undergone  treatment   for “squmous metaplasia  right  lower  lung zone” with persistent cough admitted at Nichanis Hospital on 7.12.2007 and discharged on 25.12.2007 and had a visit on 2.1.2008 and thereby a claim on 5.1.2008 for Rs.70,145.40 was made through the 2^nd opposite party having correspondences by letter dated 8.1.2008, 30.1.2008 and on 5.5.2008, but it was not settled till the complaint was filed.  Whereas the 1^st opposite party contended that the complainant failed to notify the claim made to the 2^nd opposite party and thereby they were not aware of the claim came to know only after the summon received from the District Forum and also relied upon the documents under Ex.B1 and B2 and under Ex.B1 the 2^nd opposite party said to have sent the communication dated 8.1.2009 to the 1^st opposite party stating that the disease for which treatment taken was in existence from April 2007 and the policy was effected from 6.7.2007 and thereby the claim falls under the Exclusion clause 4.1 the policy and the claim stands repudiated.  On the basis of the same under Ex.B2 the 1^st opposite party said to have sent the letter to the complainant dated 12.1.2009 reiterating the contentions of the 2^nd opposite party repudiation under clause 4.1 of the policy.  By accepting the same the District Forum dismissed the complaint.  The complainant / appellant alleged that the repudiation / communication under Ex.B1 and B2 were not at all received by him till the complaint was filed before the District Forum on 15.10.2008.  There is no proof filed by the opposite parties to show that those letters were served or sent to the complainant / policy holder informing the repudiation of the claim.  As Ex.B1 and B2 dated 8.1.2009 and 12.1.2009 would go to show that they were said to have been sent after filing of the complaint in November 2008 and after receipt of the summon from the District Forum.  In those circumstances to evade their responsibilities, it seems that those letters were subsequently prepared for the purpose of the case and as far as the genuineness of the repudiation is concerned it is stated that the complainant was having pre existence disease of “squmous metaplasia” right lower lung from April 2007 and the policy was obtained in the month of July 2007.  For these, there is no proof or materials filed to show how they came to know that the complainant was having pre existence of disease prior to the policy dated 6.7.2007 and also it is not proved that the complainant was aware that he was having such a “squmous metaplasia” right lower lung disease even before the proposal for the policy given and no investigation report or other opinion of the panel doctor were filed.  On perusal of the discharge summary of the complainant under Ex.A3 it was noted that he was admitted on 7.12.2007 and surgery was conducted on 16.12.2007 and was discharged on 25.12.2007 for the complaint of  “ Patient admitted with the H/o cough since 3 weeks.  Blood stained sputum once 2 days back and diagnosis persistent consolidation with Squmous metaplasia Right lung lower zone” and no way in the discharge summary also it is pointed out that he was having such symptoms from April 2007 then how they the opposite parties have come to the conclusion that he was having such symptoms prior to the policy.  Under Ex.A4 the 2^nd opposite party admitting the receipt of the claim form asking for certain documents from the complainant and reminder was sent on 6.2.2008.  For that the complainant had sent a reply under Ex.A5 mentioning that he enclosed all the necessary details obtained from the hospital and also sent another letter dated 9.2.2008 and reminder letter dated 5.5.2008 was received by them as per acknowledgements and the claim form was also marked as under Ex.A6.  For all those materials the 2^nd opposite party who is an authorized person to claim the insurance from the 1^st opposite party have not responded and the 1^st opposite party in their written version no way stated under what basis the claim was repudiated under clause 4.1 of the policy Exclusion clause.  In those circumstance the claim was repudiated and the repudiation was made belatedly after filing the complaint even though the complainant’s claim was genuine supported with materials which was repudiated without any supporting materials by the opposite parties and thereby the District Forum erroneously dismissed the complaint by accepting the documents under Ex.B1 and B2 as observing the claim was already settled which is liable to be set aside accordingly,

          In the result, the appeal is allowed and the order passed by the District Forum in CC.No.415/2008 dated 12.2.2013 is set aside by allowing the complaint

1. the opposite parties 1 and 2 jointly and severally are directed to pay the medical claim of Rs.70,145/- to the complainant towards expenses for the hospitalization, surgery, other charges and other connected expenses towards Indian Bank IB Arogya Plus Policy under Ex.A1 plan issued by the 1^st opposite party and 

2. directed the opposite parties 1 and 2 to pay a sum of Rs.5000/- as compensation for mental agony due to deficiency of service and also

3.  to pay sum of Rs.3000/- as costs.

 4. The directions shall be complied within a period of 6 weeks from the date of this order.

 

P.BAKIYAVATHI                                                              A.K.ANNAMALAI

   MEMBER                                                            PRESIDING JUDICIAL MEMBER

 

INDEX; YES/ NO

VL/D;/PJM/INSURANCE