ADV. RAVI SUSHA, MEMBER.

            The complainant had a Medi-claim Insurance Policy from 18..12..2009 to 17..12..2004 with the Oriental Insurance Company, Deserting the said policy the complainant under the instigation of the Indian Bank Branch Chengamanade, Kottarakkara [here in the third opp.party] became a holder of the scheme namely Indian Bank IB Arogyaraksha plus policy piloted by the United India Insurance Company.   As per the first opp.party the U.I.I. Co. M/s. TTK Health Care Service Private Ltd, Chennai is for servicing the Policy in respect of any claim arising under the policy.  Any way only the first opp.party is the ultimate responsible party in this Medi-claim Policy.  The complainant became a holder of the Medi-claim policy of the UIIC for Rs.1,00,000/- maximum from 4..3..2005 after duly giving the filled up proposal form, with the due remittance of the premium and also with strict yearly renewal,   The present and third renewal was from 1..9..2007 to 31..8..2008.   Everything, including the previous treatments, if any, was disclosed truthfully by the complainant [policyholder] in the proposal form – appropriate columns.   Duplicate proposal from kept up by the complainant/policy holder on 4..3..2005 while joining in it is seen.  Nothing was suppressed by the complainant/policyholder, that in the year 2003, the complainant, then policy holder, was operated for Billnguinal Hernia and Prostrate Hypertrophy in the Upasana Hospital, Kollam  while joining the UIIC on 4..3..2005.  From 2003-2008 the complainant and his family had no disease and treatment at all.  But the complainant felt some abdominal disorders which were diagnosed as Left Recurrent Inguinal Hernia in the Holy Cross Hospital, Kottiyam, Kollam.   They  recommended an early keyhole surgery which was performed on 14..2..2008.  The complainant duly submitted the claim for Rs.36,208/-  duly with necessary records to the appropriate agency, the 2^nd opp.party for the 1^st opp.party.  Instead of the treatment expenses, an empty reply came from the 1^st opp.party that the Doctor of TTK [ 2^nd opp.party] opined that the disease is existing [pre-existing] from 1..9..2005 and claim for the existing disease at the time of the 1^st inception is not admissible.  Hence the repudiation of the claim.  Hence filed this complaint for getting relief.

The first opp.party filed version contending that, the complainant has approached this Forum with unclean hands by suppressing the material facts regarding the case. The 2^nd opp.party on verification of the medical certificate issued by the treated doctor and the discharge summery issued from the treated hospital, come to a conclusion that the complainant was suffering from the ailment related to inguinal hernia from the year 2003 itself, for which he had undergone inpatient treatment at Upasana Hospital, Kollam from 15..7..2003 to 23..7..2003.   The complainant has produced the discharge summary before this 2^nd opp.party, for the treatment taken by him from 15..7..2003 to 23..7..2003 as per the request made by the 2^nd opp.party for the very same disease against which the present claim was made by him.  As per the exclusion clause 4.1 of the policy the medical expenses incurred for any existing ailment is not payable by the insurance company and hence the claim was not payable as per the exclusion clause in the policy.  It is submitted that a claim relating a pre-existing disease is not payable even after any  number of renewal of the insurance policy due to the exclusion of above risk under the policy issued by this opp.party.   The treated doctor in the medical certificate issued by him has very clearly stated that the patient was suffering from recurrent left inguinal hernia, for which he had already undergone mesh repair previously.  As per the certificate of the above doctor, the present treatment taken by the complainant at Holy Cross Hospital, Kottiyam is a complication of his pre-existing disease.  By considering the above aspect the 2^nd opp.party has repudiated the claim of the complainant vide its repudiation letter dated 10..2..2009 stating specific reason for the same.  Hence  the 1^st opp.party prays to dismiss the complaint.

          Opp.party 2 called absent and set exparte

          The 3^rd opp.party filed a separate version contending that the complainant in this case is not comes under the definition of Consumer as per the Consumer Protection Act and there is lno Consumer relatuionship is existing between the complainant and the 3^rd opp.party.  The 3^rd opp.party had never compelled or instigated the complainant to choose the Insurance Scheme of the 1^st opp.party.   The averment about reimbursement of hospitalization expenses for illness for the insured and his dependents are not correct.   The said policy is issued with detailed terms and conditions and it having an exclusion clause and it is reproduced here for the information

Any disease contracted by the insured person during the first 30 days from the commencement of the 1^st policy shall not be covered.   Cost of spectacles, contact lenses, hearing aids are excluded.  Dental treatment or surgery of any kind is excluded.  All pre-existing diseases/injuries will get cover only after three continuous claim free policy years i.e. from 4^th year onwards.   The above quoted exclusion clause of the policy is given the clear provision of eligibility to get reimbursement of hospitalization of the covered persons/insured.   These exclusion clauses of the policy is very well known to the complainant.  But he purposefully suppressed the details of Exclusion clause of the policy from the Hon’ble Forum.  The said policy is issued without any medical check up at the time of application, and it is issued on the basis of declaration of good health by the covered persons.  Hence exclusion clause is strictly applicable to the covered persons/insured.

Points that would arise for consideration are:

1.     Whether the repudiation of the claim is made as per the policy terms

and conditions?

2.     Whether there is  any deficiency in service on the part of the opp.parties?

1.     Reliefs and costs?

For the complainant PW.1 was examined and mared Exts. P1 to p3

Opp.party 1 produced Ext. D1

POINTS:

In this case there is no dispute that at the time of claiming the policy amount the complainant had a valid insurance policy with 1^st opp.party.   The grievance of the complainant is that though he submitted claim with supporting documents, the opp.parties did not allow his claim.

According to the 1^st and 3^rd opp.parties as per clause mentioned in 4.3 of Ext.P3 proposal form ‘during the first year of the operation of the policy, the expenses on treatment of disease such as hernia etc are not payable. If the above disease is pre-existing at the time of proposal,  the same  will not be covered even during subsequent period of renewal” and also as per exclusion  clause 4.1 in  Ext.P3 proposal form “ All diseases which are pre-existing when the cover incepts for the first time.   For the purpose of applying this condition, the date of inception of the initial medical policy taken from any Indian Insurance Co. shall be taken provided the renewals have been continuous and without any break.  However this exclusion will be deleted after three consecutive claim free policy years”.

          Complainant’s case is that there is no pre-existing disease” at the time of joining Ext.P3 .  But Ext.P3 and Ext.P2 shows that the complainant has the complaint of Hernia at the time of joining the policy.  More over Ext.P1 the discharge summary from Holy Cross Hospital shows that  in operation notes that “The mesh from the previous anterior hernia plasty seen”.   The main contention  of opp.party 1 is that as per exclusion clause 4 [1] in Ext.P3 the complainant joined in the insurance policy with the opp.party on 4..3..2005.   Then the three consecutive claim free years will be attained only on 3..3..2008.  But the complainant got admitted in the hospital in the subject matter of the claim on 13..2..2008 ie. 15 days before 3..3..2008.  During cross-examination of PW.1 he deposed that 4..3..2005 Â XpS-§nb t]mfnkn  3 hÀjvjT XnI-bp-¶-Xn\p c­m-gvNbv¡p a#p³]mbn  Xs¶ surgery bv¡p hnt[-b-ambn Ext. P1 also corroborate this point.   So the claim preferred by the complainant is not payable as per the exclusion clause 4.1 of the proposal form.  According to the opp.party the liability of the opp.party in admitting a claim is strictly on the basis of the terms and conditions of the policy alone.    More over according to them the opp.party has got every right to invoke the terms and conditions incorporated in the policy in deciding a claim arising under the policy.

The learned counsel for the 1^st opp.party at the time of argument produced a decision of the Hon’ble Supreme Court in United India Insurance Co. Ltd. V/s. Harchand Rai Chand an Lal in which it is held that the policy is a contract between parties and both parties bound by terms of contract..  Hence  from the available materials we are of the view that there is no ground to interfere with the rejection of the claim by the opp.parties and that there is no deficiency in service on their part. Point found accordingly.

In the result the complaint fails and the same is hereby dismissed.  No cost

Dated  this the23rd day of April, 2012.

         I N D E X

List of witnesses for the complainant

PW.1. – K. Narayanan

List of documents for the complainant

P1. – Discharge summary

P2. – Discharge card

P3. – Proposal form

List of witnesses for the opp.parties : NIL

List of documents for the opp.parties

D1. – Repudiation letter17..4..2008

D2. – Repudiation letter dated 27..2..2009