O R D E R

ADV. RAVISUSHA, MEMBER.

            The complainant is a mediclaim policy holder having policy No.441404/48/2007/2145 which is having coverage for his wife and daughter for the year 2007 to 2008,.  He was enlisted and included the said policy on 13.11.2006 by accepting Rs.2,117/- by way of premium amount from the complainant on 12.10.2007 .  After accepting the said consideration from the complainant, a policy holding certificate was issued to the complainant.   The complainant and his family was included in the said mediclaim after having made a thorough medical check up by the expert doctors as directed by the opp.parties.   The opp.parties offered the coverage period from 13.11.2006 to 12.11..2007 to the complainant.   At the time of issuyance of the said policy to the complainant, he was made believe by the opp.parties that he along with his family would come under the coverage period and the sum insured for each of them for the particular period was for Rs.50,000/- [as  maximum] and if any of them would become a victim of any kind of diseases and thereby if they were hospitalized, they would get the hospital expenses by limiting up to the coverage amount on presentation of claim form with relevant records, if any  the complainant was forced to enter the scheme on believing the words and deeds of the opp.parties.   On 7.5.2007, the complainant’s wife was hospitalized due to illness at Bishop Benziger, Hospital, Kollam and she was treated there for Multi Nodular Goitre upto 14.8.2007.  After his wife’s discharge from the hospital, the complainant was forced to approach the opp.parties with claim form and original certificate and medical bills for getting the benefits covered under the scheme on 31.5.07.  Then he was intimated through a letter dated 29.11.1987 by the opp.parties that he should forward a duly filled TTK along with Doctor certificate and he produced the same  on due time itself.   After accepting all the valid  and relevant documents from the complainant, opp.parties has not taken any steps for granting the benefits covered under the insurance policy.  Hence he was forced to send a legal notice dated 1.3.2008 to the 2^nd opp.parties demanding his due benefits covered under the policy.  But the opp.parties has not responded to the notice till date and hence the complainant was forced to approach this Hon’ble Forum for redressal of his grievances.   Hence the complaint

          Opp.parties filed version contenting that, the complaint is not maintainable either in law or on facts.  It is admitted that this opp.party had issued an individual medicalim policy to the complainant and two of his family members for a sum insured of Rs.50,000/- each for a period commencing from 13.11..2006 to 12.11.2007.   The policy issued by this opp.party is subject to the terms, conditions clauses and exclusions contained in the contract of insurance, which is a deciding factor in determining the rights and liabilities of the contracting parties M/s. TTK Health Care Services Pvt Ltd. was designated as the 3^rd party administrator in deciding the claims arising under the above mediclaim policy as per the endorsement made in the policy itself.   The complainant reported a claim of his wife Smt. Sudha with M/s TTK Health Care Services Pvt. Ltd., for the treatment taken by her at Hishop Benziger Hospital for a period from 7.5.2007 to 14.5.2007 for her disease of Multinodular Goitre.   The complainant had submitted the necessary claim form, the medical certificate of the treated doctor in the prescribed form, the discharge certificate and medical bills etc. before M/s. TTK  Health Care Services Pvt. Ltd. Ravipuram, Ernakulam in the connection with the claim reported by him.   The claim of the complainant was considered and a decision regarding the same has been  taken by M/s. TTK Health Care Services Pvt. Ltd. on the basis of records available with them and in terms of the policy conditions.   The claim of the complainant’s wife was repudiated by M/s. TTK Health Care Services Pvt. Ltd. vide their letter dated 14.12.2007.  So TTK Health Care Services Pvt Ltd. is a necessary party in deciding the present complaint filed by the complainant before this Hon’ble Forum.   The complainant has not impleaded the above necessary party in to the array of the opp.parties in this case and as such the complaint is bad for non-joinder of necessary party..  The disease for which Smt. Sudha was treated for the goiter of multinodular nature having swelling in the front of the neck with a duration of more than 3 months on the date of her admission in the hospital.   Since the nature of goiter is multinodular [containing nodules of increased number of follicles] the same is having a duration of more than 6 months  to reach the present stage.   So the disease of Smt. Sudha was a pre-existing one which is not covered as per the exclusion clause given in the policy.  M/s TTK Health Care Services Pvt Ltd. on the basis of the medical opinion received by them, came to a conclusion that the disease of Smt. Sudha was a pre-existing one which was not admissible as per the exclusion clause in the policy and accordingly they have repudiated the claim vide there letter dated 14.12.2007.  The claim advanced by the complainant for a sum of Rs.16,792.50m was not payable as per the terms and conditions of the policy and the claim of the complainant was repudiated by M/s. TTK  Health Care Services Pvt. Ltd. on sound legal basis.   The complaint has no manner of right to prosecute the present  complaint against the opp.parties   This opp.party has not committed any deficiency in service as alleged by the complainant in his complaint.  Hence prays for dismissal of the complaint

For the complainant PW.1 was examined and Exts P1 to P6 are marked

For opp.parties  Exts D1 and D2 were marked

Points that would arise for consideration are:

1.     Whether there is deficiency in service on the part of the opp.parties

2.     Reliefs and cost

THE POINTS:

          It is not disputed that the complainant has taken Ext.P1  policy and that the policy was subsisting when the complainant’s wife  had undergone treatment from 7.5.2007 to 14.5.2007 at Bishop Benzigar Hospital, Kollam.   The complainant submitted Ext. P3 claim form which was repudiated by the opp.party on the ground  that the illness for which the complainant had undergone treatment is a pre-existing one which comes within the exclusion clause 4 [1] of Ext.D2 policy condition.

          Clause 4 of the condition deals with exclusion and 4 [1] deals with pre-existing diseases.  Now the question is whether the illness for which the complainant had undergone treatment  is a pre-existing one or not.   According to the opp.party the illness for which the complainant had undergone treatment  is a pre-existing one.  Opp.parties 1 and 2 contended that as per the policy issued to the complainant, M/s TTK Health Care Service is designated as the 3^rd opp.party administrator, who is authorized to take a decision about the admissibility of the claim and the claim of the complainant is repudiated by M/sTTK Health Care Service Pvt. Ltd.

          According to the complainant, the complainant’s wife went Bishop Benziger Hospital, Kollam for the first time only on 17.4.2007 and after clinical test she was admitted there on 7.5.2007 and was discharged on 14..5..2007.  In Ext. P2 also shows that the date of first consultation was on 17.4.2007.  Opp.party 1 and 2 contented that according to the finding of M/s TTK Health Care Service Pvt. Ltd., it is evident from the medical records that the complainant’s wife is suffering from multinodular goiter as per the discharge summary of the complainant’s wife and on the basis of the medical records, the duration of the disease shall be a minimum of more than 6 months for reaching the present stage.  But Ext.P2 Medical certificate filled by the treating doctor shows that the patient was suffering from the said complaints since last three months

          In this case the main case of the opp.party is that before issuance of the policy in question, the complainant’s wife was  suffering from the disease of Multinodular goiter and since it is a pre-existing disease, the opp.party rightly repudiated the claim.   There is no dispute on the point that on 17.4.2007 the complainant’s wife was examined by Dr. Prakash and after clinical test she was admitted at Benzigar Hospital, Kollam on 7.5.2007 and  discharged on 14.5.2007 for the treatment of multinodular goiter.   The  question  for consideration is whether the  disease for which the complainant’s wife had taken treatment is a pre-existing one or not.   There is nothing on record to show that the complainant’s wife had ever taken any treatment for the disputed disease.   Even the Medical certificate filled by the treated doctor [Ext.P2] does not revel that the patient had ever taken any treatment for multinodular goiter or it has minimum of more than 6 months duration.  Since, there is a disputes in both of these, there was definitely a requirement to take evidence of the treating doctor to get the correct picture.  However, the same has not been done by the opp.parties on whom the onus lay to prove pre-existing  disease.  In this case our view is that the opp.parties have clearly failed to prove that the complainant was suffering from a pre-existing disease by giving any cogent Medical evidence.

          Ext. D1  policy shows that TPA for the mediclaim policy taken by the complainant is M/s. TTK Health Care Services Pvt. Ltd..   Ext P2 shows that the complainant preferred the claim before M/s TTK Health Care Services.   The evidence shows that M/s TTK Health Care Services Pvt. Ltd. Is the authority to decide the claim of the complainant.  They were impleaded as additional 3^rd opp.party.  But they did not appear before the forum and hence set exparte.   The claim preferred by the complainant is repudiated by additional 3^rd opp.party.   Since the opp.parties 1 and 2 issued Mediclaim Policy to the complainant they are also having duty to verify,  the repudiation of the claim done by the 3^rd additional opp.party is correct or not.  Hence from the entire fact and evidence we are of the view that there is deficiency in service on the part of all opp.parties.

          In the result, complaint is allowed.   Additional 3^rd opp.party is directed to pay the complainant an amount of Rs.16792.50 along with interest at the rate of 12% per annum from the date of this complaint [11..6..2008] till actual payment.  Opp.parties 1 to 3 are  directed to pay Rs.2000/- as costs of litigation.  It is further directed that the order be complied with within 30days from the date of receipt of this order.

            Dated this the  26^th       day  of November, 2012.

                                                                        I N D E X

List of witnesses for the complainant

PW.1. – Sudha.B

List of documents for the complainant

P1. – Policy Certificate

P2. – Medical bill

P3. – Claim Form

P4. – Letter dated 29..11..2007

P5. – Legal notice

P6. – Postal receipt

List of witnesses for the opp.party: NIL

List of documents for the opp.party

D1. – Mediclaim policy schedule

D2. – Mediclaim Insurance policy