BEFORE THE DISTRICT CONSUMER FORUM AT NALGONDA
PRESENT: SRI MAMIDI CHRISTOPHER,
PRESIDENT.
SMT.S.SANDHYA RANI,
FEMALE MEMBER.
SRI K.VENKATESHWARLU,
MALE MEMBER.
. . .
TUESDAY, THE EIGHTEENTH DAY OF FEBRUARY, 2020
CONSUMER COMPLAINT No. 43 OF 2011
Between:
Gattu Venkanna S/o Yadagiri, Age: 42 years, Occ: Business,
R/o C/o Venkata Ramana Motors, Ramagiri, Nalgonda Town and
District.
…Complainant.
AND
- TTK Healthcare TPA Private Limited, 2nd Floor, Anmol Palani,
G.N.Chetty Road, T.Nagar, Chennai-600 017.
- United India Insurance Company Limited, Divisional Office,
2nd Floor, Sudharshan Building, Old No.14, Whites Road,
Chennai-600 014.
- Branch Manager, Indian Overseas Bank, Nalgonda Branch,
Nalgonda Town and District.
…Opposite Parties.
This complaint coming on before us for final hearing, in the presence of Sri V.Surendar Reddy, Advocate for the Complainant, and Sri A.Srinivas, Advocate for the Opposite Party No.2, and Sri K.Muralidhar Rao, Advocate for the Opposite Party No.3, and the Opposite Party No.1 having been set exparte, and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
ORDER OF THE FORUM DELIVERED
BY SRI MAMIDI CHRISTOPHER, PRESIDENT
- This is a complaint filed by the Complainant Under Section 12 of
Consumer Protection Act, 1986 alleging deficiency in services on the part of the Opposite Parties No.1 to 3 and sought direction to the Opposite Parties to pay a sum of Rs.55,335/- towards operation expenses and a sum of Rs.1,00,000/- towards damages on account of mental agony.
Contd…2
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2. Originally, the complaint was filed against the Opposite Parties No.1 and 2, which was disposed off on merits by this Forum on 23/01/2012, by allowing the complaint with a direction to the Opposite Party No.2 to pay a sum of Rs.58,334.91 Ps. [which includes Rs.3,000/- towards deficiency of services] with interest @ 9% p.a. from the date of complaint till realization and a sum of Rs.2,000/- towards costs of the complaint, within one month from the date of order and there was no order against the Opposite Party No.1.
3. Feeling aggrieved the order, the Opposite Party No.2 namely; United India Insurance Company Limited [D.O., Chennai], had preferred an appeal vide F.A.No.673/2012 before the Hon’ble A.P.State Consumer Disputes Redressal Commission at Hyderabad. The Hon’ble State Commission had disposed the appeal by allowing the same setting aside the order of the District Forum. The Hon’ble State Commission also given liberty to both parties to adduce evidence, for which the matter is remitted back to this Forum with a direction to the parties to appear before the District Forum to adduce evidence. On such directions, the matter is remitted back to the District Forum again. Hence, the matter is reverted back and accordingly on 12/07/2013, this Forum again reopened the matter and directed the parties to appear on 22/07/2013, from there onwards the case is proceeded and ultimately posted for orders. Meantime, on such consequences, the Opposite Party No.2 placed documentary evidence and submitted the documents marked as Exs.B-2 to B-4.
4. The Opposite Party No.1 remained exparte from the beginning till now.
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5. The brief facts of the complaint are that the Complainant obtained IOB Health Care Plus Policy through IOB, Nalgonda in the year 2007 and it was valid till 15-08-2008 and during the coverage period he was renewed the next policy vide Policy No.01111000/2008/484100660/127 for his entire family, i.e. himself, wife, son and daughter. On 04-09-2008 Keerthi Manu, the son of the Complainant got sinusitis and approached Medi Centre Hospital, Hyderabad with the above policy. The Opposite Party No.1 was entrusted the matter by the hospital authorities, who instructed the Complainant to join his son in the hospital and accordingly he got admitted his son in the hospital on 06-09-2008. Mr.Keerthi Manu underwent operation by the doctors. Since the Opposite Party No.2 could not be contacted in time under unavoidable circumstances, the Complainant paid the hospital bills worth of Rs.55,334-91 Ps. Apart from it, he also incurred a sum of Rs.10,000/-. When the claim was preferred the Opposite Party No.1 asked the Complainant to submit the split bills and accordingly the Complainant submitted the required bills for a sum of Rs.49,000/- towards surgery and bilateral fees for the remaining amount. Again, the same Opposite Party No.1 asked the Complainant to submit the same, for which the Complainant had again complied. However, the claim remained unsettled and thereby the Complainant had issued notice. It is, thus, the complaint is necessitated.
6. The version of the Opposite Party No.2 that the very issuance of the policy is not correct and also the second policy for renewal. In turn, the Opposite Party No.2 stated that it had issued only the first policy and pleaded the sinusitis for which the son of the Complainant
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was operated, is excluded during the subsistence of first policy. At first instance, the Opposite Party No.2 had filed written arguments and it has stated therein that the policy purchased by the Complainant in the year 2007 had expired on 15/08/2008 and after a gap of 15 days, the Complainant had renewed the policy. The Opposite Party No.2 denied the expenditure incurred by the Complainant. It is also stated that the Complainant having account with Indian Overseas Bank and purchased Health Care Policy, for the period commencing from 04/09/2008 and it is the first policy. During the first year, the Rihnal Sinusitis disease with which the son of the Complainant was suffering, was excluded according to Condition 8.3. Such disease is covered only during the subsistence of the extended policy. The son of the Complainant was having pre-existing disease of sinusitis and he did not disclose the same and it amounts to suppression of the disease and as such the Opposite Party No.2 had rightly not settled the claim and sought for dismissal of the complaint.
7. Before going to discuss the case in detail, it is pertinent to mention that there was development in the case by adding the Opposite Party No.3, i.e. Branch Manager, Indian Overseas Bank, Nalgonda Branch, to the proceedings and the Opposite Party No.3 submitted Ex.B-1, i.e. the Statement of Account of the Complainant namely; Gattu Venkanna for the period from 01/04/2008 to 31/10/2008. It is, thus, the Exs.B-1 toB-4 were marked on behalf of the Opposite Party No.3 and Opposite Party No.2 respectively. The Complainant not submitted any additional documents except Exs.A-1 to A-7 which were already marked and referred in the earlier order passed by this Forum on 23/01/2012.
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8. The Opposite Party No.3 filed its written version admitting that the Complainant has a bank account with it, he pleaded ignorance about the Complainant having a policy, which was sought to be enforced. There was no contract or agreement between the Complainant and the bank to remit the premium, that in fact, the Complainant did not give any instructions regarding payment of premium to renew the policy, that as per the Statement of Account, the Complainant had no balance to meet the premium amount as on 13/08/2008.
9. On the basis of the pleadings of parties, they gave rise the following points for consideration and determination:
1) Whether the subsequent policy issued by Opposite Party No.2
is in force as on the date of treatment of the son of the
Complainant?
2) Whether the disease caused to the son of the Complainant
covers under the Policy?
3) Whether any deficiency of services on the part of the
Opposite Party No.2?
4) Whether Opposite Party No.3 was under obligation to
pay the premium from out of the Complainant’s S.B.Account
to continue for renewal of the Policy?
5) Whether the Complainant is entitled to get relief as prayed?
6) If so, to what extent?
10. POINTS No.1 & 2:
On scrutiny of the documents filed by the Complainant, i.e. Proposal Form [Ex.A-1], it appears that the period of insurance opted
from 14/08/2018 to 13/08/2009 for the persons, i.e. the Complainant and his family members including Mr.Keerthi Manu and it also contains the acknowledgement by Indian Overseas Bank, Nalgonda Branch in
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respect of payment of total package premium debited Rs.1,848/-. It is also seen under the portion of acknowledgement that the authorized signatory of IOB while acknowledged the premium amount also the proposal and premium under the proposal are have been acknowledged on 04/09/2008. It is, thus, evident that Ex.A-1 is only the proposal for renewal of policy, to be obtained from 14/08/2008 to 13/08/2009.
11. It is seen from the letters Ex.A-2, dated 31/12/2008 and Ex.A-3, dated 23/01/2009, addressed by the Opposite Party No.1 to the Complainant that it sought for the required documents, i.e. break up for bilateral fees and other break up bills for surgery etc. to proceed to process the claim of the Complainant. By analysis of the above said documents, it is clear that the policy was in force from 14/08/2008 to 13/08/2009, and the son of the Complainant was admitted in the hospital and operated by the doctors on 06/09/2008. The premium was paid on 04/09/2008. Ex.B-2 and Ex.A-1 are one and the same. Ex.B-3 is the Certificate for IOB Health Care Plus Policy, issued by United India Insurance Company Limited, i.e. Opposite Party No.2, vide Policy No.2008/484100660/127, dated 24/09/2008, which evidencing that an amount of Rs.1,848/- was the total premium amount. It is also discloses that the Certificate of Medical Insurance Premium paid for the said policy for Rs.1,603/- on 04/09/2008 and certified by Opposite Party No.2 that Mr.Gattu Venkanna, i.e. Complainant herein having Account No.22328 at Indian Overseas Bank, Nalgonda Branch and he has paid the above said amount on 04/09/2008 towards medical insurance premium under IOB Health Care Plus Policy. It is clear that the said Policy Certificate was issued
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on 24/09/2008 for a period from 04/09/2008 to 03/09/2009 for sum assured of Rs.1,00,000/- in favour of the Complainant and his family members including Keerthi Manu, for whom the medical bills submitted to Opposite Party No.2 for medical claim. As the son of the Complainant was undergone treatment on 06/09/2008, the claim of the Complainant is in force as per the Policy, i.e. Ex.B-3. Though the Certificate was issued on 24/09/2008, the premium received prior to issuance of the Certificate, i.e. 04/09/2008.
12. In view of the above discussion, it is clear that the policy is in force and the Complainant can claim the insurance for his son as his name is also included in the policy. Accordingly, the Points No.1 and 2 decided in favour of the Complainant.
13. POINT No.3:
In view of the aforesaid discussion in respect of Point Nos.1 and 2, the Opposite Party No.2 is responsible to pay the claim amount, because the policy, i.e. Ex.B-3 issued by itself which shows the period from 04/09/2008 to 03/09/2009. Even after receipt of the premium amount, the Certificate was not issued and it is delayed by Opposite Party No.2. Even issuance of the Certificate of Policy which shows negligence on the part of the Opposite Party No.2 for issuance of Policy Certificate. Though it is the contention of Opposite Party No.2 that the Complainant while obtaining the policy had suppressed the disease with which his son was suffering, it had not proved the same. Under Section 45 of the Insurance Act, it is the burden of the insurer to specifically plead and prove the suppression of any material fact. In
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this case except pleading there is no proof of suppression of material
fact and as such the Opposite Party No.2 had failed to establish that the Complainant had suppressed the factum of his son allegedly suffering from the disease of sinusitis. The another contention of the Opposite Party No.2 that it has not issued the very first and second policies and it had alternatively stated that it had issued only the first policy and pleaded that sinusitis with which the son of the Complainant was suffering is excluded during the subsistence of first policy. The Opposite Party No.2 further stated that the policy purchased by the Complainant in the year 2007 had expired on 15/08/2008 and after gap of 15 days, the Complainant had renewed the policy. It is not shown that the Complainant claimed amounts during the subsistence of first policy. The only objection was that the policy was renewed after 15 days. In spite of gap of 15 days being there between two policies, the second one can be treated as an extended policy. The Complainant had taken both the policies with Opposite Party No.2 and the delay of 15 days in getting the policy is extended, is not fatal to the claim. Even by virtue of the subsequent policy, the claim is enforceable as the premium was paid on 04/09/2008. In these circumstances, the second policy can be treated as valid and also as a continued policy. Therefore, the claim for sinusitis disease during the subsistence of second policy is valid.
14. In view of the aforesaid discussion, it is clear that the Opposite Party No.2 had failed to render its services to the insured person, i.e. the Complainant, in discharging/settling the claim and also caused delay in respect of issuance of the so-called second policy, in spite of receipt of premium amount in time. All these things, establish that
Contd…9
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there is negligence and deficiency in service on the part of Opposite Party No.2. Accordingly, the Point No.3 is decided against the Opposite Party No.2 and in favour of the Complainant.
15. POINT No.4:
The plea of the Complainant is that of so, i.e. Opposite Party No.3 did not remit the premium amount in time, the contention of Opposite Party No.3 is that it has no such agreement and that there was no funds to meet the premium amount. Whether there are sufficient funds in the account of the Complainant as on 13/08/2008 to meet the premium, is a question to be examined, for which Opposite Party No.3 has submitted Ex.B-1, which is Statement of Account of the Complainant, vide Account No.041001000022328, for the period from 01/04/2008 to 31/10/2008. The entries of the said statement of account reflects in respect of balance amount. As on 31/08/2008, the balance was Rs.263.08 Ps. It is found credit amount of Rs.2,000/- on 01/09/2008 and the balance shows as Rs.2,263.08 Ps. It is also seen, a sum of Rs.1,903/- was debited on 04/09/2008 to Health Care TFR. By which, it is evidencing that as on 31/08/2008 there was no sufficient balance to pay the premium and there upon by crediting of Rs.2,000/- was made on 01/09/2008 by way of cash remittance and thereafter Rs.1,903/- was debited on 04/09/2008 towards Health Care. The other contentions of the Opposite Party No.3 are that there was no obligation to pay premium amount on behalf of the Complainant and not aware of the agreement between the Complainant and the Opposite Parties No.1 and 2. Even in the absence of any contract in between the Complainant and the Opposite
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Parties and the bank, it is the duty of the Opposite Party No.3 bank to follow the instructions of the customer, i.e. the Complainant, but as there was no sufficient funds in the account of the Complainant as on 31/08/2008, it could not be fulfilled. Only after credit of Rs.2,000/- made by the Complainant on 01/09/2008, an amount of Rs.1,903/- was debited towards Health Care by the Opposite Party No.3 and to that extent the Opposite Party No.2 also acknowledged the receipt of the premium amount. As such, the allegation of the Complainant that the Opposite Party No.3 committed deficiency, cannot be considerate. Accordingly, the Point No.4 decided against the Complainant. The case against Opposite Party No.3 is dismissed.
16. POINT Nos.5 & 6:
There is no dispute in respect of medical expenditure incurred by the Complainant as the bills attached to the Policy Ex.A-1 proves that the Complainant had incurred a sum of Rs.55,334.91 Ps., for which the Complainant is entitled the same. The Opposite Party No.2 did not settle the claim in spite of the Complainant submitting all the required documents from time to time and not rendered proper services, which amounts to deficiency in services under Consumer Law. It is, therefore, the Complainant is entitled further Rs.3,000/- towards deficiency of services. On the whole, we conclude that the Order passed by this Forum earlier on 23/01/2012 to be confirmed and can be considered on merits.
In the result, the complaint is allowed in part and the Opposite Party No.2 is directed to pay a sum of Rs.55,334-91Ps. round about Rs.55,335/- (Rupees Fifty Five Thousand Three Hundred and Thirty
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Five only) with interest @ 9% p.a. from the date of the complaint till realization, a sum of Rs.3,000/- (Rupees Three Thousand only) towards deficiency of services and a sum of Rs.2,000/- (Rupees Two thousand only) towards costs of the complaint, within one month from the date of receipt of this Order. No amount is awarded against the Opposite Party No.1 and Opposite Party No.3. The complaint is dismissed against Opposite Party No.3 and Opposite Party No.1.
Dictated to Steno-Typist, transcribed by him, corrected and pronounced by us in the open Forum on this 18th day of February, 2020.
FEMALE MEMBER MALE MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For Complainant: For Opposite Parties:
Affidavit of Complainant. Affidavit of Opposite Party No.2.
Affidavit of Opposite Party No.3.
EXHIBITS MARKED
For Complainant:
Ex.A-1 Dt.04-09-2008 Xerox copy of IOB Health Care Plus Policy
Proposal Form.
Ex.A-2 Dt.31-12-2008 Letter addressed by Opposite Party No.1 to
the Complainant.
Ex.A-3 Dt.23-01-2009 Letter addressed by Opposite Party No.1 to
the Complainant.
Ex.A-4 Dt.31-03-2009 Complaint-Settled Reply Letter addressed by
the Superintendent of Post Offices, Nalgonda
to the Complainant.
Ex.A-5 Dt.24-12-2010 Office copy of legal notice issued by the
counsel for the Complainant to the
Opposite Parties.
Ex.A-6 Dt. Postal Receipts.
Ex.A-7 Dt. Postal Acknowledgement.
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For Opposite Party No.1:
Nil.
For Opposite Party No.3:
Ex.B-1 Dt.31/10/2008 Statement of Account of the Complainant,
Vide Account No.041001000022328.
For Opposite Party No.2:
Ex.B-2 Dt.04/09/2008 Attested copy of Proposal Form.
Ex.B-3 Dt.24/09/2008 Attested copy of Certificate for Indian
Overseas Bank Health Care Plus Policy.
Ex.B-4 Terms and conditions of the IOB Health Care
Plus Policy.
PRESIDENT
DISTRICT CONSUMER FORUM
NALGONDA
