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TTK Health Care Services Pvt. Ltd. BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD.
F.A. No. 198/2006 against C.C. No. 264/2005, Dist. Forum, Ongole.
Between:
National Insurance Company Ltd.
DAB-II, No. 9, Lingaraj Complex
Gandhi Bazar, Main Road
Basavangudi, Bangalore-560 004. *** Appellant/
O.P. No. 1.
And
1. Panguluri Rama Rao
S/o. Malakondaiah
D.No. 37-1-407/B/1
1st Line, Bhagyanagar
Ongole- 523 002. *** Respondent/
Complainant
2. TTK Health Care Services Pvt. Ltd.
No. 4, Crimson Court
80 Feet Road, HAL-III Stage
Bangalore-560 075. *** Respondent/
O.P. No. 2.
Counsel for the Appellant: M/s. Katta Laxmi Prasad
Counsel for the Respondent: M/s. C. Niranjan Rao (R1)
CORAM:
HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT.
&
SRI SYED ABDULLAH, MEMBER.
WEDNESDAY, THIS THE FIRST DAY OF APRIL TWO THOUSAND NINE
ORAL ORDER: (Per Hon’ble Sri Justice D.Appa Rao, President.)
***
This is an appeal preferred by opposite party insurance company against the order of the Dist. Forum directing it to pay Rs. 25,802/- under mediclaim policy together with interest and costs.
2) The case of the complainant in brief is that he was a Vijaya Bank Credit Card holder taken medical claim insurance policy under Vijaya Bank Credit Card holders Group Insurance Coverage. He sustained pain on the lower back bone. An operation was performed on 1.3.2005 wherein he spent about Rs. 50,000/- towards medical expenses, however, bills to a tune of Rs. 25,802/- were only issued. When he sent the claim form along with certificate on 18.3.2005 the appellant did not choose to settle the claim on the other hand repudiated the claim on the ground that he incurred the expenses within 30 days of taking the policy. Therefore he claimed the said amount with interest @ 24% p.a., and compensation of Rs. 1 lakh together with costs of Rs. 2,000/-.
3) The appellant insurance company resisted the case. While admitting issuance of policy it alleged that the claim was repudiated by letter Dt. 1.6.2005 by virtue of exclusion clause 4.2 ‘the expenses incurred within 30 days of the policy were not covered’. When the complainant had been diagnosed for acute IVDP with sciatica @ LL on 21.1.2005 itself, and took treatment at Sanjivini Orthopedic & Physiotherapy Centre, Guntur between 28.2.2005 and 12.3.2005 and the policy being effective from 1.1.2005 he having been contracted with the said disease within 30 days he was not entitled to any amount. Therefore it prayed for dismissal of the complaint with exemplary costs.
4) R2 third party administrator filed a memo adopting the counter of R1.
5) The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A5 marked. Refuting his evidence the appellant filed the affidavit evidence of its Divisional Manager and got Exs. B1 to B5 marked.
6) The Dist. Forum after considering the evidence placed on record opined that exclusion clause 4.2 would not bar the complainant from recovery of amount spent towards operation charges, and therefore directed the appellant to pay Rs. 25,802/- with interest @ 9% p.a., together with compensation of Rs. 2,000/- and costs of Rs. 1,000/-.
7) Aggrieved by the said decision, the insurance company preferred this appeal contending that the Dist. Forum erred in stating that the case does not cover under Clause 4.2. Since the complainant contracted the ailment within 30 days clause 4.2 would apply, and consequently not entitled to any amount.
8) It is an undisputed fact that the complainant had taken Vijaya Bank Credit Card holders Group Insurance Coverage policy bearing No. 602101/46/04/8500000154 from the appellant effective from 1.1.2005 to 31.12.2005 vide Ex. B6. While so on 28.2.2005 he had developed back ache. He went to a doctor wherein he was diagnosed for acute IVDP with sciatica @ LL on 21.1.2005 at Ongole. On that he was admitted in Sanjivini Orthopedic & Physiotherapy Centre, Guntur wherein an operation was performed on 1.3.2005 and was discharged on 12.3.2005. He spent an amount of Rs. 25,802/- evidenced under receipts. When he claimed the said amount the same was repudiated on the ground that the ailment was contracted within 30 days of commencement of policy, and excluded under clause 4.2 of the policy. Clause 4.2 reads as follows :
Exclusions : 4.2: “Any expenses on hospitalization incurred during first 30 days of the commencement date of insurance cover except in the case of injury arising out of an accident.“
9) Unfortunately the insurance company added words to this condition in order to read ‘any disease’ in the place of ‘any expenses on hospitalization’ . It has filed the terms and conditions marked as Ex. B6. It is not the case where the complainant claimed any expenses incurred within 30 days from the date of commencement of the policy. The policy was commenced on 1.1.2005. The operation was performed on 1.3.2005 and was discharged on 12.3.2005, and those expenses were incurred subsequent to 30 days period prescribed under clause 4.2. The insurance company has unjustly added words which were not there while repudiating the liability of the insurance company. Since the repudiation was unjust and not within the terms and conditions of the policy, we do not see any mis-appreciation of fact by the Dist. Forum in this regard. We do not see any merits in the appeal.
10) In the result the appeal is dismissed with costs computed at Rs. 1,000/-. Time for compliance four weeks.
PRESIDENT MALE MEMBER
Dt. 01. 04. 2009.
Submit Complaint..
