CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present. Sri.Santhosh Kesavanath.P. President Smt.Bindhu M.Thomas Member Sri.K.N.Radhakrishnan Member. CC.No.98/09 Friday, the day of 30th, Octber, 2009.
Petitioner. K.J.Alaxander Kanithara Devalokam.P.O. Kottayam-686 038. Vs. Opposite parties. 1. The Branch Manager United India Insurance Co. Ltd. Parekulam Buildings Near Collectorate, Kottayam. 2. The Regional Manager United Indian Insurance Co.Ltd.(Grievance Cell) Regional Office Sharanya, Hospital Road Kochi-11. (Adv.Satheesh Mathew Zacharia.) 3. Manager T.T.K.Healthcare service (P) Ltd.1400 B, Mareena Building M.G.Road, Rvipuram, Kochi-682016 O R D E R Smt.Bindhu M.Thomas, Member.
The crux of the complainant’s case is as follows.
The complainant and his wife had taken United India Insurance Co. Ltd. Mediclaim policy. They have been holding the mediclaim policy continuously and without break for the past nine years. Before the -2- commencement of the complainant’s present policy vide No.100505/48/08/97/00000007, he held a previous policy No.100505/48/07/20/00000029 with a period of insurance from 26-4-07 to 25-4-08 for a cover of Rs.1,25,000/- including cumulative no claim bonus. During the period of the above mentioned previous policy he claimed Rs.1,00,000/- for an angioplasti done on 12-02-2008 and Rs.25,000/- for another bypass surgery, done on 14-4-2008 and these claims were honoured. After the bypass surgery conducted on 14-4-2008, the petitioner was again hospitalised for treatment of pleurisy on 25-4-2008 and was discharged on 29-4-08. The complainant submitted another claim for Rs.5320/- to TTK Health care services Ltd. On 13-5-2008 but it was repudiated stating that the sum insured in the previous policy stood fully exhausted on the date of admission ie. 25-4-2008. The complainant had renewed the abovementioned policy on 3-4-2008 and the present policy came to effect on 26-4-08, the very next day of admission in the hospital. So according to the complainant the policy was continuous and without any break with Rs.1,50,000/- as sum insured. The complainant remained in the hospital continuously from 25-4-08 to 29-4-08. Out of these 5 days, four days were having full cover of the present policy. As per the complainant he was holding a valid policy which was renewed without break on 25-4-08, the date of admission. The complainant alleged that it is a very serious case of deficiency of service and hence he filed this complaint claiming the following reliefs. (i) To allow the claim of Rs.5320/-. (ii) to allow Rs.10,000/- as compensation.
The opposite party entered appearance and filed version with the following main contentions.
-3- (i) The petition is not maintainable either in law or on facts of the case. (ii) The claim for Rs.5,320/- was rejected on the ground that the sum insured stood fully exhausted before the admission on 25-4-2008 which was date of expiry of the previous policy. (iii)If the admission was on or after 26-4-2008 the new policy will be deemed active. (iv)While the renewal policy is deem to cover all admissions occur on or after 26-4-2008 in so far as heart ailment and related complaints are concerned, the increase become ineffective as the diseases are pre existing.
(v)As per the terms and conditions of the policy the company’s liability in respect of all claims admitted during the period of insurance shall not exceed sum insured per person as mentioned in the schedule. (vi) The complainant has tried to cheat the opposite parties by renewing the policy well in advance of the expiry and that too increasing the sum insured while his claim was pending before TPA. so as to make claim
like this. (vii) There is no cause of action against the opposite parties as the repudiation was on very clear grounds as per condition 1. 1 &1 2d of the policy. (viii) As per medical report of Caritas Hospital the petitioner was having hyper tension and dyslipidaemia even 12 years back. -4- (ix) The petitioner is not entitled to get any relief as prayed.
Hence the opposite party prayed to dismiss the petition with costs to them. Points for consideration are. (i) Whether there is any deficiency in service or unfair trade practice on the part of the opposite party? (ii) Reliefs and costs?
Evidence consists of affidavits filed by both parties and exhibits A1 to A8 and B1 to B5. Point No.1. It is not in dispute that the sum insured in the policy vide No.100505/48/07/10000029 from 26/4/07 to 25/4/08 exhausted before 25/4/08, the date of admission of the complainant in the hospital and 25/4/08 was the expiry date of the said policy. It is also not in dispute that the abovementioned policy was renewed by paying the premium Rs.8863/- well in advance on 3/4/08 and the policy vide No.100505/48/08/97/00000007 from 26/4/08 to 25/4/09 came into effect at 00.00hours on 26/4/08. The copies of the abovesaid policies are marked as exhibits A2 and A1 respectively. From exhibit A1 it is clear that the said renewal was done before the alleged date of admission in the hospital 25-4-08 and therefore it is not an after thought. The opposite party’s counsel argued that as the date of admission in the hospital, 25/4/08 was the expiry of Ext.A2 and as the sum insured expired before 25/4/08, the claim of the complainant cannot be admitted as per clause i.i. The complainant objected the said argument and submitted that
-5- the claim of a policy holder cannot be rejected on the ground that there is no sum insured for the date of admission only, if he has a valid and continuous policy throughout the entire period of hospitalisation. The complainant submitted the claim form claiming the cover of the revised present policy marked as exhibit A1 not previous policy exhibit A2. On persuing the exhibit A1, no clause or condition is seen supporting the opposite party’s contention that in the case of a continuing policy, if the date of admission in the hospital happens to be on the date of expiry of the previous policy, the claim cannot be honoured. Furthermore the clause 1.1 of exhibit A1 reads that ’’if during the period stated in the schedule or during the continuance of this policy by renewal, any insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident.................................................... the amount of such expenses as are reasonably and necessairly insured in respect there of by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule. From clause 1.1 of ext.A1, it is clear that the continuation of insurance cover will be available if the renewal premium is paid in time. On timely remittance of premium and continuation of insurance cover, the insured becomes eligible for the benefits of the renewed policy. The treatment certificate issued from Carithas Hospital is produced and marked as exhibit B4. The opposite party’s counsel submitted that as per ext.B4 the complainant suffered hypertension and dyslipi daemia for the past 12 years. Whereas the complainant averred that he has been suffering from these ailments only since 2002. The complainant further averred that the -6- abovementioned erroneous statement might have crept into the medical report due to the answering of his wife or children to the doctor’s questions from guess work when he was under sedation. The copy of the repudiation letter is produced and marked as exhibit B5. The claim was not repudiated on the ground that hypertension, dyslipidaemia and pleurisy are pre-existing diseases. The alleged claim was repudiated stating reason that the sum insured of Ext.A2 vide No.100505/48/07/20/00000029 was fully exhausted. In this instant case during ext.A2, the previous policy period he had a claim for an angioplasty and another claim for CABG. The disputed claim is for pleurisy which is a CABG sequel. In our view the opposite party’s argument regarding pre-existing disease will stand only if there is a break in the existing policy and if a fresh policy is taken. In case of renewal without a break in the period, the policy will be renewed including the disease contracted during the expiring policy period. Here the claim is for a condition that happened as a result of the CABG done during the expiry policy period. Considering the facts and circumstances of the case we are of the considered view that as the renewal premimum is paid in time, the continuation of insurance cover will be available to the complainant and the opposite party will be liable to pay the claim amount. The act of opposite party in repudiating claim stating flimsy reasons is a clear case of deficiency in service. Point No.1 is found accordingly. Point No.1. In view of the findings in point No.1, the petition is allowed. The opposite party is ordered to pay the claim of Rs.5320/- with interest @ 9% p.a. from the date of repudiation till realisation to the -7- complainant. The opposite party is also ordered to pay Rs.2000/- as litigation cost to the complainant. As interest is allowed, no compensation is ordered. This order will be complied with within one month of receipt of its copy.
Smt.Bindhu M.Thomas Member Sd/- Sri.Santhosh Kesavanath.P. President Sd/- Sri.K.N.Radhakrishnan Member. Sd/-
APPENDIX Documents of the complainant. Ext.A1 Present policy vide No.100505/48/08/97/00000007 for 2008-2009. Ext.A2 Previous policy vide No. 100505/48/07/20/00000029 for 2007-2008. Ext.A3 Photocopy of claim form. Ext.A4 Copy of letter from TTK dated 20/5/08. Ext.A5 Copy of representation made by the petitioner to TTK. Ext.A6 Letter from TTK. Ext.A7 Representation dated 30/10/08 made by the petitioner to the grievance cell. Ext.A8 Reminder dated 12-12-08 by the petitioner to the grievance cell.
-8- Documents of the opposite party. Ext.B1 Copy of previous policy Ext.B2 Copy of new policy Ext.B3 Not mentioned Ext.B4 Copy of discharge summary Ext.B5 Copy of repudition.
By Orders,
Senior Superintendent. Kgr/6 copies.
......................Bindhu M Thomas
......................Santhosh Kesava Nath P | | 
