Tamil Nadu

StateCommission

FA/10/2014

K G ANURADHA - Complainant(s)

Versus

UNITED INDIA INSURANCE CO LTD - Opp.Party(s)

T. RAVIKUMAR

10 Mar 2022

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present:   Hon’ble THIRU. JUSTICE. R. SUBBIAH                     :     PRESIDENT

                 Tmt. Dr. S.M. LATHA MAHESWARI                          :      MEMBER

 

F.A. No. 10 of 2014

(Against the order passed in C.C. No.371 of 2012 dated 19.02.2013 on the file of the D.C.D.R.F. Coimbatore.

 

Thursday, the 10^th day of March 2022

 

K.G. Anuradha

58, Kaliamman Koil Street

K.K.Pudur

Coimbatore- 641 038.                                                                                                                 .. Appellant/ Complainant

 

 

- Vs –

 

1.  M/s.United India Insurance Co.Ltd.

     768 (Old No.1028) First Floor

     Avinashi Road

     United India Building

     Coimbatore – 641 018.

 

2.  M/s. TTK Health Care TPA Pvt. Ltd.

     146 Sri Sai Baba Towers

     Raju Naidu Road, Tatabad

     Coimbatore - 641 012.

 

3.  M/s.United India Insurance Co.Ltd.

     Regional Office

     178 Dr.Nanjappa Road

     Coimbatore – 641 018.                                                                                                         .. Respondents/ Opposite Parties

 

    Counsel for Appellant /Complainant                                        : M/s. T. Ravikumar

    Counsel for the Respondents 1 & 3/    Opposite Parties 1 & 3: M/s.S.Arunkumar

 

    Counsel for the 2^nd Respondent/2^nd Opposite Party          :M/s.S.K.Krishnamoorthy

                                                                                                                            

This appeal is coming before us for final hearing on 24.02.2022 and on hearing the arguments of both parties and on perusing the material records, this Commission made the following :-

O R D E R

HON’BLE THIRU JUSTICE R.SUBBIAH, PRESIDENT

1.        This appeal has been filed by the Appellant/ Complainant under Section 15 of the Consumer Protection Act, 1986 as against the order dated 19.02.2013 passed in C.C. No.371 of 2012 by the District Consumers Disputes Redressal Forum, Coimbatore, dismissing the complaint filed by the appellant herein.

 

2.   The factual background culminating this appeal is as follows:

The case of the Appellant/ Complainant is that she had taken an Individual Health Insurance Policy bearing No.170400/48/09/97/00001973 for the period covering from 12.03.2010 to 11.03.2011, with the first opposite party.  The complainant has paid a sum of Rs.1062/- towards premium for medical insurance.  The first opposite party has a tie-up arrangement with M/s.TTK Healthcare TPA Pvt. Ltd., under whom the claim should be lodged within 7 days from the date of discharge from the hospital and the claim amount would be settled by the first opposite party to M/s.TTK Healthcare TPA Pvt. Ltd.  When the policy was in force, the complainant was admitted in Swathi Poly Clinic as in-patient on 10.11.2010 to undergo surgery for Hysterectomy, since the complainant was having bleeding continuously for six months, she was discharged from the hospital on 17.11.2010.  After admission to Swathi Poly Clinic, the complainant gave the details about the policy that she was holding with the first opposite party and the hospital authorities sent a message to the second opposite party for obtaining authorisation for the claim.  But, strangely, the second opposite party has rejected the authorisation on the ground that the ailment is not payable in the first two years of taking the policy.  This rejection is without any basis and application of mind and as such the same would amount to gross deficiency in service.  The complainant has been taking the policy continuously from the year 2002-2003 and had renewed the policy every year.  Whileso, on 12.11.2010, the second opposite party had issued the approval letter authorising a limit of Rs.10,000/- only.  The authorisation of Rs.10,000/- is also without any basis and application of mind.  On 11.11.2010, the complainant paid a sum of Rs.37,803/- to Swathi Poly Clinic, Rs.500/- towards advance, a sum of Rs.1900/- to J.K.P. Medical Centre.  That apart, the complainant has paid a sum of Rs.1000/- to Arunodhaya Medical Centre towards biopsy.  The complainant also paid a sum of Rs.308/- to Swathi Poly Clinic towards post hospitalization expenses.  Thus, she had totally spent a sum of Rs.41,511/- which includes room rent, cost of medicines, laboratory report charges, amount paid to the hospital etc.  Hence, she preferred a claim for a sum of Rs.41,511/- for treatment and the said claim was received and processed by the second opposite party, as a Third Party Administrator.   However, only a sum of Rs.10,000/- was paid to Swathi Poly Clinic, withholding a sum of Rs.31,511/- .  But, the complainant is eligible for the entire sum of Rs.41,511/-  as the claim is fully supported by relevant bills for payments made towards purchase of medicines, laboratory report, hospital charges etc.  But, the third opposite party, Insurance company by their letter dated 15.12.2010 stated that the policy taken by the complainant after 2007-2008 is an Individual Health Insurance Policy and the claim amount payable will be 20% of the sum insured, subject to a maximum of Rs.50,000/-.  Hence, the claim settled for a sum of Rs.10,000/- is in order and the 3^rd opposite party expressed their inability to consider the request of the complainant favourably.  However, the complainant again wrote to the third opposite party on 18.10.2011 for which the third opposite party sent a reply dated 25.10.2011 reiterating the contentions which have already been made by them in their letter dated 15.12.2010.  The complainant took up the matter to the Insurance Ombudsman on 24.02.2012 and the office of the Insurance Ombudsman also reiterated the same stand taken by the third opposite party and expressed their inability to entertain the complaint.  The stand taken by the opposite parties while rejecting the claim of the complainant is illegal, arbitrary and without any basis, which amounts to gross deficiency in service.  Hence, she has come forward with the present complaint, seeking the following reliefs:-

1. Directing the opposite parties to pay a sum of Rs.31,511/- being the balance claim amount;
2. Directing the opposite parties to pay a sum of Rs.50,000/- being the damages to the complainant for the mental agony, tension etc., due to their deficiency of service;
3. To award interest @ 18% per annum till date of payment; and
4. Award cost of this application.

  

 3.      The said complaint was resisted by the third opposite party, by filing a written version stating that the complainant had obtained an Individual Health Insurance Policy from the third opposite party for the period from 12.03.2010 to 11.03.2011.  This policy has been issued subject to the terms and conditions prescribed therein.  The second opposite party, who is the Third Party Administrator has been duly licensed by the Insurance Regulatory and Development Authority for servicing the health insurance policies issued by the Indian Insurance Companies.  In the said insurance policy itself it has been clearly stated that in the event of any claim becoming admissible the insurance company will pay through the TPA i.e., Third Party Administrator.  Since the complainant had accepted the terms and conditions of the policy, the contract becomes valid, which has equal binding on the insurer as well as the insured.  The complainant after undergoing treatment for hysterectomy in Swathi Poly Clinic, Coimbatore had submitted a claim for Rs.41,511/- to the second opposite party.  After processing her claim, the second opposite party had paid a sum of Rs.10,000/- to Swathi Poly Clinic, wherein she had taken treatment.  As per the policy conditions, the complainant is entitled only to 20% of the sum insured for availing the treatment for hysterectomy.  This fact has been clearly mentioned in the policy availed by her.  The third opposite party had also stated in its letter dated 15.12.2010 sent to the complainant that she was covered under Individual Mediclaim Policy till 2007-2008 and thereafter under Individual Health Insurance Policy, the claim amount payable for hysterectomy will be 20% of the sum insured subject to a maximum of Rs.50,000/- and  hence the amount of Rs.10,000/- settled by the second opposite party, is in order.  But, being not satisfied with the reply of the second opposite party, the complainant sent a letter dated 18.10.2011 to the third opposite party, for which the third opposite party sent a reply dated 25.10.2011.  Inspite of the said reply, the complainant approached the Insurance Ombudsman in Chennai in the form of a complaint.  However, the Insurance Ombudsman by letter dated 29.02.2012 reiterated the stand taken by the third opposite party.  Thus, it is the assertive submission of the third opposite party that the sum insured in the policy is only Rs.50,000/-.  Hence, the second opposite party had paid 20% of the sum insured i.e., Rs.10,000/- to Swathi Poly Clinic.  Therefore, there is absolutely no deficiency of service on the part of the opposite parties and sought for dismissal of the complaint.

 

4.    In order to prove the case, on the side of the appellant/ complainant along with proof affidavit 11 documents were filed, which were marked as Ex.A1 to A11.  On the side of the opposite parties, along with proof affidavit, the Individual Health Insurance Policy copy was filed and the same was marked as Ex.B1.  

 

5.  The District Forum, after analyzing the entire evidence and records, has come to the conclusion, that Clause 1.2 of the Health Insurance Policy-Gold restricts itself to 20% of the sum insured as payable subject to a maximum of Rs.50,000/-  When treatment is availed for hysterectomy, the complainant is entitled for only 20% of the sum insured, as per the terms of the policy.  Hence, 20% of the sum insured, namely, Rs.10,000/- has been paid for the complainant, by the opposite parties.  Therefore, there is no deficiency of service and thus dismissed the complaint.  Aggrieved over the same, the present appeal has been filed. 

 

6.   Counsel for the appellant/ complainant submitted that the complainant had taken Individual Health Insurance Policy from the first opposite party.  The policy covers the period from 12.03.2010 to 11.03.2011.  The second opposite party is the Third Party Administrator.  The insured value of the policy is Rs.50,000/-.  Whileso, the appellant underwent surgery for Hysterectomy in Swathi Poly Clinic and was discharged on 17.11.2010.  Since she had spent a sum of Rs.41,511/- for her treatment, she made a claim for the said amount.  But, the claim was rejected in toto.  After continuous efforts by the father of the appellant, the claim was settled only for a sum of Rs.10,000/-.  Actually, the complainant has been the subscriber of the Health Insurance Policy from the year 2002-2003 onwards.  The policy could only be a renewal and there cannot be any change in terms and conditions of the policy, for periodical renewal.  Any change in terms and conditions of the policy, cannot be hidden so as to frustrate the policy itself.  The clause that the policy holder will be entitled for 20% of the sum insured, subject to the maximum of Rs.50,000/- was introduced only in the year 2010-2011.  In the original policy which was taken by the complainant in the year 2002-2003, the said clause was not there.  When it is the renewal of the policy, the condition imposed in the year 2010-2011 cannot be made applicable to the complainant.  Moreover, the said clause is introduced without any notice to the insured, who had taken the policy in the year 2002-2003.  Therefore, rejection of the claim by the opposite party is not legally sustainable.  There is deficiency of service on the part of the second opposite party.  But, without considering all these aspects, the District Forum had dismissed the complaint.  Counsel for the appellant has also relied upon the judgment of the Hon’ble Supreme Court in Civil Appeal No.6778 of 2013, in the case of JACOB PUNNEN & ANR. VS. UNITED INDIA INSURANCE CO. LTD. Dated 09.12.2021.

 

7.  Countering the submission, counsel for the Respondents 1 & 3 submitted that it is true that the appellant had obtained a Medi Claim Policy from the first opposite party for the period from 12.03.2010 to 11.03.2011.   She lodged a claim for a sum of Rs.41,511/- in respect of medical expenses incurred for undergoing hysterectomy surgery as inpatient, inclusive of post hospital treatment and medical investigation.  After scrutinizing the claim as per the terms of contract of insurance, the appellant was found eligible for reimbursement of Rs.10,000/-.   The counsel for the opposite parties further submitted that as per Clause-C of Para 1.2 of the policy, in the event of hysterectomy the amount payable is “20% of the sum insured subject to a maximum of Rs.50,000/-”.  But the appellant without understanding the concept of upper ceiling limit of Rs.50,000/-, has claimed for reimbursement of Rs.41,511/-. Counsel for the respondents 1 & 3/ opposite parties 1 & 3 relied on the judgment reported in 2009 (7) SCC 777 in the case of Sikka Papers Limited vs. National Insurance Company Limited and Ors., wherein he refers to paragraph 13, stating that the endeavor of the court must always be to interpret the words in which the contract is expressed by the parties.  The Court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties.  Therefore, as per Clause 1.2(c) of Ex.A1 Insurance Policy, 20% of the sum insured subject to a maximum of Rs.50,000/- cannot be given a different interpretation. Thus, he sought for dismissal of the appeal.

 

8.  Heard the submissions made by the counsel for the appellant and the respondents 1 & 3. No representation for the 2^nd respondent.  We have carefully gone through the entire material available on records.

 

9.  Though very many contentions have been raised by the counsel for the complainant, the core contention of the counsel for the appellant is that the appellant has taken the Health Insurance Policy right from the year 2002-2003 and periodically she was renewing the Health Insurance Policy.  According to her, only in the year 2010-2011, clause 1.2 was introduced and as per the said Clause 1.2 (c), for the treatment of hysterectomy the amount payable is 20% of the sum insured subject to a maximum of Rs.50,000/-.  But, this clause is not applicable to the insured/ complainant since she was only renewing the policy right from the year 2002-2003 and that this clause was not there in the original policy. Moreover, the insurer has the duty to inform the insured regarding the change in the liability, once being introduced.  But in the instant case, no such information was given. Therefore, there is deficiency of service.  In support of his contention, he relied on the judgment of the Hon’ble Supreme Court in Civil Appeal No.6778 of 2013, in the case of JACOB PUNNEN & ANR. VS. UNITED INDIA INSURANCE CO. LTD. (cited supra).  But, counsel for the complainant has not filed the original policy to find out as to whether the clause introduced in the year 2010-2011 was in the original policy or not.  Therefore, the submission made by the counsel for the complainant in this regard cannot be accepted.  It is a well settled legal principle that the insured cannot claim what is not covered in the insurance policy.  Therefore, the complainant cannot claim the entire amount spent by her for treatment, when the clause specifically says for the treatment of hysterectomy the amount payable is 20% of the sum insured subject to a maximum of Rs.50,000/-.  In the instant case, the sum of Rs.10,000/-, being 20% of the sum insured, paid by the insurance company is perfectly correct.   Therefore, we do not find any infirmity in the order passed by the District Forum. 

 

10.   In the result, the Appeal is dismissed confirming the order of the District Consumers Disputes Redressal Forum, Coimbatore made in C.C. No.371 of 2012 dated 19.02.2013.  There shall be no order as to costs in this appeal. 

 

 

S.M. LATHA MAHESWARI                                                                                                                                R.SUBBIAH

               MEMBER                                                                                                                                                PRESIDENT

 

 

Index :  Yes/ No

AVR/SCDRC/Chennai/Orders/March/2022