CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM

KATHRUKKADAVU, KALOOR, KOCHI - 17

consumer case(CC) No. CC/08/222

M.A.GEORGE
...........Appellant(s)
Vs.

UNITED INSURANCE COMPANY

TTK HEALTH CARE SERVICES PVT.LTD.

NATIONAL INSURANCE CO.LTD.
...........Respondent(s)

BEFORE:
1. A.RAJESH
2. C.K.LEKHAMMA
3. PROF:PAUL GOMEZ


Complainant(s)/Appellant(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):




ORDER

O R D E R

A. Rajesh, President.

1. Very briefly, the facts as brought out in the complaint are :-
The complainant is a mediclaim policy holder of the 3rd opposite party. In August 2007, he underwent treatment for rheumatic complaint in a local hospital. Thereafter on 20-08-07, he approached Government Ayurveda Hospital, Aluva for expert management. He got admitted in the hospital on 24-08-07 and discharged after treatment on 30-09-07. He incurred Rs. 5,373/- for his medical expenses. His claim for insurance claim was repudiated by the 3rd opposite party. Hence the complainant approaches this Forum for reimbursing the medical expenses from the opposite party with its interest.

2. The 3rd opposite party filed the following reply refuting the claim of the complainant:
i) The mediclaim insurance policy issued in favour of the complainant was active during the period of hospitalization of the complainant.
ii) The complainant was admitted in the hospital for the treatment of numbness of the left arm and shoulder pain, these ailments can be treated as an out patient. Since the complainant was suffering from pain and numbness on the left arm and shoulder the treatment could have been undergone as an out patient.
iii) It is clearly stated in the policy condition that treatments usually done in out patient department are not payable under the policy even if converted to day care procedure or as inpatient in hospital for more than 24 hours.
iv) The 3rd opposite party has no liability to admit the claim of the complainant and requests to dismiss with their cost.


3. The 1st opposite party was deleted from the party array as per the order in I.A. No. 198/08 dated 24-09-08. Despite service of notice from this Forum, the 2nd opposite party abstained from the proceedings. The complainant was examined as PW1 and Exts. A1 to A5 were marked from his side. No oral evidence was adduced by the 3rd opposite party, Ext. B1 was marked from their side. The complainant appeared in person and the learned counsel for 3rd opposite party was heard.


4. The only point that came up for our determination is whether the complainant is entitled for mediclaim insurance from the 3rd opposite party. It is not in dispute that the complainant had undergone treatment for shoulder pain at Government Ayurveda Hospital, Aluva as inpatient from 25-08-2007 to 30-09-2007. It is also not in dispute that the above period is within the validity of insurance policy. The reason for the repudiation of the claim as per Ext. A3 rejection letter is as follows:
“Since pain and numbness manifested on left arm shoulder only, the procedure could have been undergone as an out patient without the need for confinement in the hospital.”

The relevant clause which lead the 3rd opposite party to repudiate the claim of the complainant as per Ext. B1 policy (Clause 2.6) is as follows:
“Procedures/treatments usually done in Out patient/Department (OPD) are not payable under the policy even if converted to Day Care Surgery Procedure or as inpatient in hospital for more than 24 hours”


5. The complainant had underwent treatment in a Government Ayurveda Hospital at Aluva. As per Ext. A5, he has undergone the following treatment.
1. Thailabyangam
2. Elakizhi
3. Pizhichil
We think that the doctor, who treated the patient is to decide whether the treatment of the patient is to be continued as inpatient or outpatient. In the instant case, the doctor prescribed inpatient treatment for the complainant. Apart from the submission by the learned counsel, there is no other reason before us to disbelieve Ext. B5 the discharge summary issued by the attending doctor. The 3rd opposite party ought to have taken steps to adduce medical evidence to contradict the prescription of the doctor. Hence the 3rd opposite party is liable to indemnify the complainant and to pay the mediclaim insurance with its interest Ext. A4 series medical bills.


6. In the above circumstances, we allow the complaint and direct that the 3rd opposite party shall pay mediclaim insurance claim of Rs. 5,373/- to the complainant with interest at the rate of 12% p.a. from the date of complaint till realisation.

BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT MANGALORE

Dated this the 13th March 2009

COMPLAINT NO.183/2008

(Admitted on 07.07.2008)

PRESENT: 1. Smt. Asha Shetty, B.A. L.L.B., President
2.Smt. Sulochana V. Rao, Member
3.Sri. K. Ramachandra, Member
BETWEEN:
Sri.Ramayya Bangera,
S/o. Appanna Salian,
Aged about 61 years,
R/A. Laxmi Kripa,
Near Natraj Talkies,
Surathkal, Mangalore Taluk,
Dakshina Kannada District. …….. COMPLAINANT

(Advocate: Sri.M.Rajesh Kudva).

VERSUS

1. TTK Healthcare Services Pvt. Ltd.,
No.201, 202, 203, 2nd Floor,
CityPlaza, Shedigudda,
Mangalore – 575 003.

2. The New India Assurance Company Limited,
2nd Floor, Ram Bhavan Complex,
Kodialbail,
Mangalore. ……. OPPOSITE PARTIES

(Advocate for Opposite Party No.2: Sri.Anil Kumar K.)

ORDER DELIVERED BY SMT. ASHA SHETTY, PRESIDENT;

1. The facts of the complaint in brief are as follows:
This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Parties claiming certain reliefs.
The Complainant is a mediclaim Insurance policy holder bearing policy No.670802/34/70/14/0681 valid from 21.1.2008 to 19.1.2009 for a sum of Rs.50,000/-.
The Complainant submits that, he underwent a surgical process for right PCNL for impacted calculus at the PU junction causing infected hydronephrosis and taken treatment in KMC hospital, Mangalore from 1.4.2008 to 10.4.2008 and has spent Rs.65,181/- towards the treatment. Thereafter, the Complainant preferred a claim before the Opposite Party and the Opposite Party No.1 vide their letter dated 2.5.2008 instead of honouring the claim they have requested to receive a sum of Rs.13,500/- towards settlement. It is contended that the stand taken by the Opposite Party is not correct and the Complainant is entitled for the full amount and issued a legal notice dated 14.05.2008 by demanding the entire payment but the Opposite Party not complied the same and hence it is contended that the service rendered by the Opposite Party amounts to deficiency and filed the above complaint before this Hon'ble Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from the Forum to the Opposite Parties to pay Rs.65,181/- towards the hospitalization and other expenses along with interest at 18% p.a.

2. Version notice served to the Opposite Parties by RPAD. Opposite Party No.1 despite of serving notice, neither appeared nor contested the case till this date and proceeded exparte as against Opposite Party No.1 and the acknowledgement placed before the FORA marked as court document No.1.
Opposite Party No.2 appeared through their counsel and filed version. It is submitted that the Opposite Party No.2 issued Janatha Mediclaim Policy bearing No.670802/34/70/14/0681 commencing from 21.01.2008 to 19.1.2009 in favour of the Complainant. And submitted that Opposite Party No.2 reimbursed the charges inclusive at room rent/ICU charge/doctors fee/medicines/internal appliances and other charges incurred during the hospitalization period for the illness/operations as per the schedule of the policy and contended that there is no deficiency in service and prayed for dismissal of the complaint.

3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
(i)Whether the Complainant proves that the Opposite Parties have committed deficiency in service?

(ii)If so, whether the Complainant is entitled for the reliefs claimed?






(iii)What order?

4. In support of the complaint, Sri.Ramayya Bangera (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C3 were marked for the Complainant as listed in the annexure. One Sri.P.Narasimha Prabhu (RW1), Administrative Officer of the Opposite Party No.2 filed counter affidavit and answered the interrogatories served on him. Ex R1 and R2 were marked for the Opposite Party No.2 as listed in the annexure. The Complainant and Opposite Party No.2 produced notes of arguments.
We have considered the notes of arguments submitted by the learned counsels and we have also considered the materials that was placed before the Hon'ble Forum and answer the points are as follows: Point No.(i): Affirmative.
Point No.(ii) & (iii): As per the final order.
Reasons


5. Point No. (i) to (iii):
In the present case, it is undisputed fact that the Complainant obtained Janatha Mediclaim policy bearing No.670802/34/70/14/0681 commencing from 21.1.2008 to 19.1.2009 for a sum of Rs.50,000/-.
It is the case of the Complainant that during the coverage of the policy, he underwent surgical process for right PCNL for impacted calculus at the PU junction causing infected hydronephrosis and taken treatment in KMC hospital, Mangalore from 1.4.2008 to 10.4.2008 and spent Rs.65,181/- and thereafter preferred a claim before the Opposite Party. The Opposite Party No.1 vide their letter dated 2.5.2008 has requested the Complainant to receive a sum of Rs.13,500/- towards the full settlement and the Complainant contended that he is entitled for the entire amount and not a sum of Rs.13,500/- hence he came up with this complaint.
On the contrary, the Opposite Party contended that the Complainant obtained a Janatha Mediclaim policy for a sum of Rs.50,000/- and the Complainant admitted for right renal calculus which is nothing but kidney stone for which maximum charges allowed as per item No.15 in Janatha policy is Rs.13,000/- plus Rs.500/- is allowed as per the Central Government Health Scheme.
The documents i.e., certificate issued by the treated doctor, KMC Hospital dated 11.4.2008 reveals that ‘the Complainant has undergone right PCNL for impacted calculus at the PU junction causing infected hydronephrosis’. But there is no document to show that the right PCNL for impacted calculus at the PU junction causing infected hydronephrosis is nothing but kidney stone. The Opposite Party ought to have examined any of the experts i.e., a doctor to show that it is a case of kidney stone but no such evidence was produced before the FORA. In the absence of any material/cogent evidence, we are declined to consider the defence taken by the Opposite Party No.2 and hence the stand taken by the Opposite Party No.2 is not justifiable. Therefore, the Opposite Party No.2 is not correct in applying a schedule under the policy by taking into consideration that it is a case of kidney stone and offered Rs.13,500/-.
In view of the above discussion, we are of the considered opinion that the settlement arrived by the Opposite Party is not acceptable. That the illness suffered by the insured is not found in the schedule of payment. In the absence of the same, the Opposite Party No.2 namely, New India Assurance Company Limited is hereby directed to pay Rs.50,000/- to the Complainant under the Mediclaim policy along with interest at 8% p.a. from the date of claim application till the date of payment. And further Rs.1,000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
As far as Opposite Party No.1 is concerned, there is no contractual relationship between the Complainant and Opposite Party No.1 and hence complaint against Opposite Party No.1 is hereby dismissed.

6. In the result, we pass the following:
ORDER

The complaint is allowed. Opposite Party No.2 namely, New India Assurance Company Limited is hereby directed to pay Rs.50,000/- to the Complainant under the Mediclaim policy along with interest at 8% p.a. from the date of claim application till the date of payment. And further Rs.1,000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
The complaint against Opposite Party No.1 is hereby dismissed.

Copy of this order as per statutory requirements, be forward to the parties free of costs and file shall be consigned to record room.

(Dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 13th day of March 2009.)



PRESIDENT
(SMT. ASHA SHETTY)



MEMBER MEMBER

(SMT.SULOCHANA V.RAO) (SRI. K.RAMACHANDRA)


APPENDIX


Witnesses examined on behalf of the Complainant:

CW1 – Sri.Ramayya Bangera – Complainant.

Documents marked on behalf of the Complainant:
Ex C1 – : Xerox copies of the certificates, bills, vouchers.
Ex C2 – 14.05.2008: Legal notice along with acknowledgement.
Ex C3 – : Claim settlement advice by the 1st Opposite Party along with cheque for Rs.13,500/-.

Witnesses examined on behalf of the Opposite Parties:

RW1 – Sri.P.Narasimha Prabhu – Administrative Officer of the Opposite Party No.2.

Documents marked on behalf of the Opposite Parties:
Ex R1 – : Janata Mediclaim Policy with terms and conditions.
Ex R2 – 08.07.2008: Reply to the Complainant’s legal notice.


Dated:13.03.2009 PRESIDENT

COMPLAINT NO: 1313 OF 2008 Ajay Maiti S/o. Sri Mohini Mohan Maiti R/at No. 7/5, 2ndA Main Road A.K. Colony, Domlur Bangalore 560 017 Complainant


V/S

1. National Insurance Co. Ltd. Having its Divisional Office At No. 1, 3rd Floor, Unity Building Annexe, 72, P. Kalinga Rao (Mission) Road, Bangalore 560 027 2. T.T.K. Health Care Services P. Ltd. No. 4, Jeevanbhimanagar HAL 3rd Stage Bangalore 560 075 Opposite Parties



ORDER By the President Sri. S.S. Nagarale


This is a complaint filed by the complainant. The facts of the case are that he had purchased one mediclaim policy for himself and for his family members including his parents. Father of the complainant had some problem in his right eye and took the treatment in Susrut Eye Foundation and Research Centre, Kolkata. Complainant’s father was admitted at the hospital on 12.06.2006 and got operated of his right eye on the same day and discharged from hospital on 14.06.2006. Sum of Rs 94,000/- paid by the complainant towards charges of operation. Complainant submitted bills, vouchers etc., for reimbursement of Rs. 94,000/- to the opposite parties. Opposite party No. 2 has repudiated the claim with the observation that operation in question could have been done under OPD basis. It is submitted by the complainant that his father was admitted for 3 days in the hospital.

It is duty of the opposite party to pay the hospital bills. Complainant has paid the premium for the mediclaim policy and duly renewed the same. It is also submitted that without any bonafide reason the opposite parties rejected the claim. Complaint filed before the District Consumer Disputes Redressal Forum, Paschim, Medinipur in complaint No. 89/2006 came to be disposed off on 13.11.2007 stating that said forum has no jurisdiction to entertain the case.

Thus, the complainant has made the present complaint before the forum seeking relief that opposite parties be directed to pay Rs. 94,000/- towards mediclaim and Rs. 1,00,000/- as compensation.


2. Notice issued to opposite parties. Opposite parties No. 1 & 2 appeared through counsel and defence version filed stating that complaint is not maintainable. The other complaint filed before District Forum at Paschim, Medinipur came to dismiss. There is no deficiency of service. The opposite party submitted that complainant has obtained mediclaim policy for himself and for his parents. The patient has undergone Photo Dynamic Therapy which is an out patient procedure, which does not involve huge expense.
There is no need for admission of patient for the said treatment. Complainant has taken undue advantage of the mediclaim policy. The opposite party No. 2 have medical experts. As per the opinion of Dr. Vivek Kodambi treatment Photo Dynamic Therapy rendered to the patient is an out patient procedure and therefore, the claim is not payable under the policy. Hence, opposite party vide their letter dated 10.08.2006 informed the insured that the alleged claim is not payable. Therefore, the opposite parties prayed to dismiss the complaint. 3. Complainant has filed affidavit evidence.

On behalf of the opposite party No. 2 affidavit evidence of Dr. Neetha Sudharman has been filed. The opposite party No. 1 National Insurance Company has not filed any affidavit evidence in support of their defence. The learned advocate for the opposite party No. 1 has filed memo on 13.11.2008 stating that the case posted for settlement and therefore, respondent No. 1could not file affidavit in the case. Since the suggestions / proposal made was not acceptable the opposite party No. 1 could not finalize the settlement.



4. Arguments are heard. 5. The points for consideration are: “1. Whether repudiation of the mediclaim by opposite party No. 1 is justified? 2. Whether the complainant is entitled for the claim amount of Rs. 94,000/-?”


6. It is admitted case of the parties that the complainant had obtained group mediclaim policy from the opposite party No. 1 National Insurance Co. Ltd. Policy covers self, spouse, two kids and parents / in-laws of the complainant. The policy issued by opposite party No. 1 has been produced. The opposite party No. 1 has clearly admitted in the defence version that complainant has obtained mediclaim policy for himself and for his family members and his parents. Therefore, there is absolutely no dispute about the group mediclaim policy and its validity. The only point urged by the learned advocate for the opposite party is that the company repudiated the claim on the ground that father of the complainant had taken treatment of Photo Dynamic Therapy which is out patient procedure.

Therefore, claim is not payable under the policy. The complainant has produced admission approval of Susrut Eye Foundation & Research Centre, Kolkata. This document clearly establishes that father of the complainant undergone surgery on 12.06.2006. The complainant has produced receipt of the hospital which is for Rs. 94,000/-. Rs. 50,000/- was paid under receipt No. 60368 and another Rs. 44,000/- was paid under receipt No. 60888. Rs. 94,000/- was paid to the hospital towards operation charges for PDT (Photo Dynamic Therapy (RE)). Complainant has also produced certificate of discharge of Susrut Eye Foundation & Research Centre.

This discharge certificate clearly establishes that patient was admitted on 12.06.2006 and surgery was conducted on 12.06.2006 itself and patient discharged on 14.06.2006 with advice of discharge. The opposite parties have not produced any rules and regulation or conditions of policy to show that treatment taken on out patient basis, the mediclaim is not admissible. Secondly, it is the case of the opposite party that the treatment taken by the patient in this case is out patient procedure.
Again to show this fact there is absolutely no evidence or proof or expert opinion that this treatment is out patient procedure. In the defence version it has been stated that as per opinion of Dr. Vivek Kodambi the Photo Dynamic Therapy rendered to the patient is an out patient procedure but the opposite parties have not produced any opinion rendered by Dr. Vivek Kodambi and affidavit evidence of Dr. Vivek Kodambi has not been filed to establish this fact. The opposite party has produced affidavit of Dr. Neetha Sudharman. The affidavit produced by Dr. Neetha Sudharman is nothing to do with the present case because she has not given any opinion with regard to the patient. She has not at all concerned with the treatment undergone by the patient. In the defence version the opposite parties have not taken any defence that Dr. Neetha Sudharman had given opinion in this case. Therefore, the affidavit filed by Dr. Neetha Sudharman is absolutely irrelevant and same will not help in any way to the opposite parties. Admittedly, the patient was admitted in the Susrut Eye Foundation & Research Centre, Kolkata and operation was conducted to the right eye on 12.06.2006 and discharged on 14.06.2006 under certificate of discharge.

Therefore, it cannot be said that the treatment taken by the father of the complainant is out patient procedure. Therefore, the rejection of the mediclaim by opposite party No. 1 is unjustified and unreasonable. The opposite party No. 1 could have settled the claim after getting the documents and claim from the complainant. But, it is unfortunate on the part of opposite party No. 1 to reject the claim without there being any legal and acceptable basis. The earlier complaint filed by the complainant before District Forum at Paschim Medinipur came to be dismissed on the point of territorial jurisdiction.

The Hon’ble Forum in there order has held that office of the opposite parties are in Bangalore and from the provisions of Consumer Protection Act 1986 the said forum has no jurisdiction to entertain the complaint and it is held that complaint is not maintainable in that forum and it has been clearly stated in the order that they are not considering the merits of the case. Therefore, dismissal of the complaint filed before Paschim Meinipur District Forum is no bar to file the present complaint before the competent jurisdictional forum. Therefore, there is absolutely no merit in the arguments advanced by the advocate for the opposite parties that complaint is not maintainable on the ground of dismissal of the earlier complaint.

Taking into consideration of all the facts and circumstances of the case this is a fit case to allow the complaint. The opposite parties have committed deficiency in rendering services. Consumer Protection Act is a social and benevolent legislation intended to protect better interests of the consumers.

The opposite parties have rejected the mediclaim without any justifiable grounds. Therefore, they must be ordered to pay the bill amount to the complainant. In the result I proceed to pass the following: ORDER 7. The Complaint is allowed. The opposite party No. 1 is directed to pay Rs. 94,000/- to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within 30 days the above amount carries interest at 12% p.a. from the date of filing complaint before this forum till payment / realization. 8. The opposite party No. 1 is also directed to pay Rs 2,000/- as costs of the present proceedings to the complainant.

ORDER

1(a). This Complaint has been filed on 11.12.2008 alleging deficiency of service by the Opposite Party-Service Provider to the Complainant and seeking certain reliefs which according to the Complainant, are appropriate.

(b) The facts leading to the Complainant in brief are as hereunder: The Complainant is a retired Officer of B.E.L. He retired in the year 1997. At that time, he was provided with an Identification Card. On the basis of his Identity Card NO.TTK ID/BLR-UI-B177-01-01-01985-A Insurance Coverage is provided by the Opposite Party. Accordingly, he approached Tirumalai Eye Clinic and got registered under No.16259 on 25.4.2008. On examination, it was noticed that he had cataract and accordingly, it was advised for the removal of the same. In the result, an operation was held in that Eye Clinic and he was discharged. Since there was an insurance coverage so provided by the Opposite Party touching that ID Card, he thought that the Opposite Party would reimburse the cost of that operation and treatment in a sum of Rs.20,000/- directly to that Eye-Clinic. However, it was not reimbursed and in the result, he had to pay the same to the said hospital directly as per their Bill. It is learnt that the said Hospital Authorities had sent a letter to the Opposite Party demanding reimbursement of that amount of Rs.20,000/-, but there was no response from the Opposite Party in that regard. In the circumstances, the Complainant sent a letter to the Opposite Party on 8.7.2008 seeking reimbursement. Even thereafter also, he wrote letters to the Opposite Party in that connection, but, there was no response. As per the insurance coverage under that ID Card, the Opposite Party was required to reimburse that amount and since there was no reimbursement, that conduct of the Opposite Party amounted to deficiency of service resulting in agony, sufferance and loss to the Complainant and ultimately, this Complaint is necessitated to direct the Opposite Party to reimburse that amount of Rs.20,000/- and to pay cost and compensation.

(c) Along with the Complaint, the Complainant has made available Xerox copies of some documents.


2. The Opposite Party entered appearance through Counsel and sought time to produce their Version of the case. Accordingly, time was being extended from time to time and ultimately on costs too. At that stage, it was submitted that settlement would be reported. However, neither settlement was reported, nor Version was produced.

3. Thereafter, the Complainant was called upon to substantiate the allegations made in the Complaint by way of evidence in the form of affidavits and documents. Accordingly, the Complainant had chosen to produce his affidavit on 23.3.2009. Thereafter, the matter stood posted for hearing on merits. At that stage, the learned Counsel representing the Opposite Party produced a cheque dt.3.4.2009 for a sum of Rs.20,000/- made payable to the Complainant and the Complainant had received the same on 25.4.2009 without prejudice to his contentions. The learned counsel representing the Opposite Party in the circumstances submitted that since the refund sought by the Complainant is made, the Forum may take a lenient view of the matter and dispose-off the Complaint. However, the Complainant on the other hand submitted that this refund could have been made by the Opposite Party earlier in which event, this very Complaint could have been avoided and now the Complainant since made to suffer, it would be just and proper to award a reasonable amount by way of cost and compensation for the sufferance and loss to which, he was put to on account of the commissions and omissions of the Opposite Party.


4. We have gone through the case papers. Having regard to the materials on record, it is but reasonable to hold that the Opposite Party ought not have driven the Complainant to this litigation that too in the evening of his life. The very fact that the Opposite Party had refunded the amount sought to be refunded would go to show that the Opposite Party had an obligation to make that refund as per the Terms and Conditions touching the insurance coverage under that ID Card. Moreover, it is not as if the Complainant had rushed to this Forum in hot-haste with this Complaint. On the other hand, as revealed in the correspondence letters, the Complainant was persistently insisting the Opposite Party to reimburse the said amount and that the Opposite Party had willfully dodged the same. What we feel is, a stitch in time could have saved nine and the Opposite Party ought to have avoided this litigation having due regard to their role as Insurer. When that is the position, there is every justification in the submission of the Complainant that a reasonable amount may be provided to him by way of cost and compensation to secure the ends of justice. Therefore, having regard to the totality of the facts and circumstances of the case, we deem it just and proper to quantify that amount in a sum of Rs.2,000/-.

Accordingly, we proceed to pass the following: O R D E R The Opposite Party since found deficient in rendering services to the Complainant, shall pay a sum of Rs.2,000/- (Rupees two thousand) to the Complainant by way of cost and compensation for the mental agony, physical discomfort and financial loss to which he was put to on account of the above deficiency of service on their part. The Opposite Party is granted 30 days time from this date to comply this Order.

Asif Iqbal U.S.,

Aged about 30 years,

S/o. Ahmed Bava U.S.,

Behar Complex,

Near U.S.A. Enterprises,

Bunder, Mangalore,

Dakshina Kannada. …….. COMPLAINANT



(Advocate: Sri.G.K. Parameshwara Jois).



VERSUS



1. TTK Health Care TPA Private Limited,

2nd Floor, Anmol Palani,

G.N. Chetty Road,

T. Nagar, Chennai – 600 017.



(Advocate: Dr.S.V. Joga Rao).



2. United India Insurance Co. Ltd.,

Divisional Office,

Sudharshan Building,

Old No.14, Whites Road,

Chennai – 600 014. ……. OPPOSITE PARTIES

The Complainant is a mediclaim policy holder called as “Indian Overseas Bank Health Care Plus” policy issued by 2nd Opposite Party through Opposite Party No.1. The policy commenced from 17.11.2007 valid upto 16.11.2008.

It is submitted that Complainant developed health problems in the 1st week of October 2008 and he got admitted to Mangala Hospital and Mangala Kidney Foundation for treatment on 8.10.2008 and it was diagnosed that the Complainant was suffering from left Distal Ureteric Calculus as well as lower Calyx Left Renal Calculus. The Complainant was advised to undergo surgery, accordingly underwent surgery and treatment discharged from the hospital on 11.10.2008.


It is submitted that before treatment request for authorization was submitted, after the treatment the 1st Opposite Party ought to have paid the medical bills amounting to Rs.24,658.51 but inspite of authorization 1st Opposite Party did not settle bills and claim was rejected stating that ‘this ailment is not payable in the 1st year of taking policy’. It is submitted that the rejection was against the terms of the policy which amounts to deficiency in service and hence the above complaint is filed by the Complainant before this Hon'ble Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Hon'ble Forum to the Opposite Parties to pay Rs.38,358/- towards the medical bills, damages, interest and cost of the litigation expenses.

2. Version notice served to the Opposite Parties by RPAD. Opposite Parties appeared through their counsel.

Opposite Party No.1 not filed any version but filed a memo stating that the mediclaim policy is valid in this case. But it is submitted that the Complainant not submitted his claim papers along with the medical records for scrutiny by the Opposite Party No.1 Company for settling the claim. It is prayed for direction from this Hon'ble Forum to the Complainant to withdraw the complaint and submit his claim immediately for consideration and settlement.


Opposite Party No.2 filed version denied that the Complainant is a consumer and submitted that this Forum has no jurisdiction to entertain the complaint. In this case the 1st Opposite Party will not be able to come to a conclusion that the particular disease is admissible in the policy and hence cashless settlement is denied and also submitted that the patient can send a claim for consideration of reimbursement which will have to be submitted within 15 days from the date of discharge of the patient.

In the present case, the hospital has not furnished the brief note about the disease nor has the Complainant submitted the earlier policy if any held by him. Since the hospital has not furnished the brief note about the disease nor has the Complainant submitted the earlier policy if any held by him the claim of the Complainant was rejected and he is not entitled to receive reimbursement under the present policy as it is not a renewed policy and the ailment of the Complainant is not covered in the 1st year of issuance of policy and prayed for dismissal of the complaint.


3. In view of the above said facts, the points now that arise for our consideration in this case are as under

(i) Whether the Complainant proves that the Opposite Parties have committed deficiency in service?

(ii) If so, whether the Complainant is entitled for the reliefs claimed?

(iii) What order?

4. In support of the complaint Sri.Asif Iqbal U.S. (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C5 were marked for the Complainant as listed in the annexure. One Dr.TS Seshadri (RW1), working for Opposite Party No.2 filed counter affidavit and one Sri.D.Subramoney answered the interrogatories served by the Complainant. One document produced by the Opposite Parties as listed in the annexure. The Complainant as well as Opposite Party No.1 filed written notes of arguments.

We have considered the notes/oral arguments submitted by the learned counsels and we have also considered the materials that was placed before the Hon'ble Forum and answer the points are as follows: Point No.(i): Affirmative.

Point No.(ii) and (iii): As per the final order.
Reasons

Point No. (i) to (iii):

It is admitted that the Complainant is a mediclaim policy holder and had been covered under mediclaim policy through M/s. Indian overseas bank issued by the United India Insurance Company covering the period commenced from 17.11.2007 to 16.11.2008 vide policy No.011100/ 2007/484100900/10 (as per Ex C5). And it is also admitted that 1st week of October 2008 the Complainant developed pain and got admitted to Mangala Hospital and Mangala Kidney Foundation there it was diagnosed as 6 mm left distal ureteric calculus with mild hydronephrosis. 5 mm left lower calyx and advised to undergo surgery and the Complainant underwent surgery and treatment and admitted to the hospital on 8.10.2008 and discharged on 11.10.2008 as per Ex C4 i.e., discharge summary issued by Mangala Kidney Foundation, Mangalore.

However, we have perused the rejection letter dated 13.12.2006 issued by the TTK Health Care i.e., Opposite Party No.1 reveals that the hospital authority submitted pre-authorization letter as per reference No.CHE-1008 PA 0000781. Only thereafter the Opposite Party No.1 sent a rejection letter through fax to the hospital. The above document is not disputed by the Opposite Party No.1 and 2. In the rejection letter it is very clear that the hospital authority has sent the request for authorization before the treatment and now the Opposite Parties cannot take a contention that the Complainant has failed to submit the claim form along with all medical records pertaining to the said treatment during the said period to the Opposite Parties. Once the authorization is sent by the concerned hospital it is the duty of the Opposite Party No.1 to look into the matter and receive the relevant papers from the concerned hospital and should see that the claim should be properly processed.

But in the present case, the memo filed by the Opposite Party No.1 dated 9th March 2009 before this FORA in prayer column the Opposite Party No.1 prayed before this FORA to issue direction to the Complainant to withdraw the complaint and to submit the claim form immediately to consider and settle the claim. What we consider in this case is that this Opposite Party ought to have processed the claim at the earliest by taking relevant papers from the hospital without causing delay to the beneficiaries herein the Complainant. Opposite Party No.1 instead of taking relevant documents from the concerned hospital simply sent a rejection letter stating that this claim is not payable in the 1st year of taking the policy but there is no such condition nor any material/cogent evidence in order to show that the Complainant is excluded to claim the benefit for the 1st year of taking the policy.


The Opposite Parties are miserably failed to establish their case before this FORA. In the present case, the documents as well as the oral evidence submitted before the FORA it is proved that immediately on admission of the Complainant sent his request for cashless facility through the hospital M/s. Mangala Hospital and Kidney Foundation Hospital, Mangalore to the Opposite Party No.1 i.e., M/s. TTK Health Care TPA Private Limited i.e., 3rd party administrator to process the claim. But it is proved that the TTK Health Care TPA Private Limited i.e., Opposite Party No.1 not taken any steps. Instead of collecting the relevant documents from the concerned hospital denied the cashless facilities available to the Complainant and the same was rejected by stating that it is not covered under the policy which amounts to deficiency in service.


The Opposite Party No.1 ought to have processed the claim by obtaining the relevant documents and made available cashless facility to the Complainant when he was admitted to the hospital. Since the Opposite Party No.1 is the 3rd party administrator, the Opposite Party No.2 is the insurer liable to reimburse the entire medical amount. However, the documents i.e., Ex C1 to C6, wherein the Ex C1 showing the expenditure incurred for the treatment by the Complainant a sum of Rs.22,658.51. In view of the above discussion, we hereby direct the Opposite Party No.2 i.e., United India Insurance Co. Ltd. is liable to pay Rs.22,658.51 along with interest at 10% p.a. from the date of admission to the hospital i.e., 8.10.2008 till the date of payment. However, the interest as well as compensation both cannot be allowed. Interest is always inclusive of compensation. And further Rs.1,000/- awarded as cost of the litigation expenses to the Complainant. Payment shall be made within 30 days from the date of this order.

6. In the result, we pass the following:

ORDER

The complaint is allowed. Opposite Party No.2 i.e., United India Insurance Co. Ltd. is liable to reimburse the entire medical expenses incurred by the Complainant i.e., Rs.22,658.51 along with interest at the rate of 10% p.a. from the date of admission to the hospital i.e., 8.10.2008 till the date of payment and further Rs.1,000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

Divakaran Nair
...........Appellant(s)

Vs.

M/s.T.T.K.Health care services Pvt

The Divisional Manager
...........Respondent(s)





ORDER



The grievances of the complainant are the following: The complainant had taken a mediclaim policy from the 2nd opposite party which was effective from 13.10.2003 to 12.10.2004 and the policy covered hospitalisation and domiciliary hospitalisation benefit during the policy period and the 1st opposite party had issued a health card also. Unfortunately on 04.04.2004 the complainant was admitted to Amrita Institute of Medical Sciences and Technology, Ernakulam, consequent to severe chest pain and allied discomforts and the complainant had to undergo an angiogram test on 05.04.2004 wherein it was found that he has Triple Vessel Artery disease.


The complainant was discharged on 06.04.2004 and was advised to undergo immediate surgery to save his life. As advised the surgery was done on 21.04.2004 and the complainant was discharged on 28.04.2004 with advice to continuous follow-up check ups. The opposite parties were informed of the sickness of the complainant vide letter dated 22.04.2004. As the complainant had the Medicare policy, the hospital bills, medical certificate, discharge summary, X-ray report, Angiogram report, medical bills and other connected clinical reports were submitted to the 1st opposite party on 17.05.2004 along with the claim form for Rs. 95,764.13. Even though all the required documents were submitted before the 1st opposite party the opposite party was bent upon finding one defect or other on many occasions.


All the documents sought for by the 1st opposite party were given and despite the furnishing of all the documents and details, the 1st opposite party has chosen to decline the claim of the complainant. The 1st opposite party had informed the complainant vide letter dated 13.09.2004 that the disease for which the complainant had undergone treatment was pre-existing and the non-disclosure of the same had prompted the opposite party to decline their liability under the policy. Complainant had never concealed any facts either before or after the taking of the policy. The story of TMT and the existence of the heart disease were cooked up by the 1st opposite party to decline the genuine claim of the complainant. The said acts constitute deficiency in service and unfair trade practice on the part of the opposite parties. Hence this complaint for redressal of his grievances along with compensation and costs.



The 1st opposite party remains exparte. The 2nd opposite party has filed their version contending as follows: The complaint is not maintainable. The policy is admitted. For availing the insurance coverage vide medi-claim (individual) policy from this opposite party it mandates for the due performance of the contract that the person who availed the said policy should disclose all the pre-existing disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company. But in the present case in dispute the complainant at the time of making the proposal before the opposite party has not made mention of any disease or any symptoms or complaints even though the complainant has got sufficient knowledge regarding the pre-existing disease suffered by him as he had undergone treatments even prior to the availing of medi-claim policy from this opposite party.


It is wrong to say that the complainant had submitted all the details of his treatment before the 1st opposite party on 17.05.2004. The officials attached to the 1st opposite party made enquiries with the hospital wherein the complainant had undergone treatment. The said enquiry revealed that the complainant had consulted with the doctors for Ostial Stenosis, a case of Tripple Vessel Coronary Artery Disease as early as 20.09.2003.


As the complainant has suppressed the material facts regarding the pre-existence of illness at the time of proposal for availing the policy and its inception on 13.10.2003, he cannot compel this opposite party to indemnify or to fasten up with any liability to indemnify and therefore the complaint is to be dismissed. Exclusion clause 4.1 of the policy conditions attached to the policy certificate clearly states that the insurer shall not be liable to indemnify the insured, if the insured suppressed the fact that the disease for which he underwent treatment was pre-existing. Therefore this opposite party has been justified by truth by repudiating the claim. The complainant is not entitled to any of the reliefs claimed in the complaint.


Complainant, PW1, has filed affidavit and marked Exts. P1 to P9. PW1 has not been cross examined and hence his affidavit stands unchallenged. No evidence has been adduced on behalf of the opposite parties.



The issues that would arise for consideration are:-

1. Whether the act of the opposite party in repudiating the claim is justifiable?

2. Whether the complainant is entitled for any of the reliefs claimed?


Points (i) & (ii):- Admittedly, as per Ext. P1, the hospitalisation and domiciliary hospitalisation benefit policy of the complainant is for a period from 13.10.2003 to 12.10.2004. The complainant alleges that he was admitted in AIMS Ernakulam, on 09.04.2004 consequent to severe chest pain and allied discomforts and had undergone Angiogram test on 05.04.2004 where it was found that the complainant had Triple Vessel Artery. Complainant further submits that as advised by the Cardiologist of the AIMS, he was again admitted on 19.04.2004, the surgery was done on 21.04.2004 and he was discharged on 28.04.2004 with advice to continuous follow up check up. According to the complainant, he had submitted all the required documents to the 1st opposite party along with the claim form for Rs. 95,764.13 ps., but the same has been repudiated by the 1st opposite party stating that the disease for which the complainant had undergone treatment was pre-existing.


The 2nd opposite party in their version has contended that as per the said policy it is mandatory that the person who had availed the said policy should disclose all the pre-existing disease or symptoms, but the treatment details collected by the officials of the 1st opposite party reveal that the complainant had suffered illness even prior to the date of availing the policy, i.e, 13.10.2003, and this has not been disclosed by the complainant at the time of proposal and accordingly the 2nd opposite party permitted the 1st opposite party to repudiate the claim on their request.



We have carefully gone through the records on file. Though the opposite parties contend that the disease of the complainant is a pre-existing one, there is nothing on record to support the same. The 2nd opposite party contends that, in the medical certificate produced by the complainant, the column No. 7 & 8 which relates to the past history of the patient with the duration of illness and whether the present ailment is a complication of pre-existing disease seems corrected in such a way to tune the false claim. But the 2nd opposite party has not produced the said document. When the insurance company alleges a contention with regard to pre-existing disease, the onus is on them to prove the same with corroborative evidence. But in the present case, no such records have been produced in support of the contentions in the version.


The burden of proving that insured had made false representation and suppressed material facts was undoubtedly on the opposite parties. Having gone through the entire records and evidence, we find that the opposite parties have failed to discharge the burden of proving the defence story about the pre-existing disease of the insured at the time of taking out the insurance policy and knowingly suppressing the material information. No record of treatment prior to proposal form has been produced by the opposite parties. Since there is no proof, the contention of the 2nd opposite party cannot be accepted. The suspicious approach of the opposite parties without proof cannot be justified.


For the foregoing discussions, we are of the view that, the act of the opposite parties in repudiating the claim of the complainant without any base is unjustifiable amounting to deficiency in service on their part for which the complainant has to be compensated.



The complainant claims for Rs. 95764.13 from the opposite parties. As per the records produced by the complainant, though there is no specific document for the same, the said amount has been mentioned and also made known to the opposite parties. In the above circumstance, since the opposite parties have failed to establish their contention in the version and since they have failed to disprove the case of the complainant, we allow the said amount along with 12% interest from 17.05.2004 till realisation along with a cost of Rs. 2000/-. Since interest has been awarded there is no separate order as to compensation.

K.Govinda,

Aged about 68 years,

S/o Jogappa Hegde,

Residing in Jaddu House,

PO Kukkehalli, Udupi Taluk.



………….. Complainant

Versus



1. TTK Healthcare Services Pvt. Ltd.,

No.4, Crimson Court II,

Jeevan Bhima Nagar, Main Road,

HAL III Stage, Bangalore – 560 075.



2. United India Insurance Co. Ltd.,

Krishna Complex, G.B.Panth Road,

Udupi – 576 101.



……… Opposite Parties





1. Complainant has filed this complaint against the Opposite Party alleging deficiency in service in repudiating the claim the Complainant and prayed for a direction to the Opposite Party to pay to the Complainant a sum of Rs.56,877/- being the medical expenses with interest at 15% per annum from 27.01.2008 till 05.01.2008 Rs.,8019/-, Rs.1,00,000/- towards the compensation and for misecellaneous expenses and cost of the legal notice, cost of the proceedings, Rs.11,500/- in all a sum of Rs.1,76,396/-.



2. The case of the Complainant is that he had medi claim insurance policy from Opposite Party No.2 under policy No.240500/48/06/20/00001451 to cover the risk of the period 29.3.2007 to 28.3.2008 midnight. The Complainant has

Contd…….2

been issued with TTK Health Card bearing No.BLR-UI-0000-H0-10497-A by the Opposite Party No.1. The Complainant was admitted into the KMC Hospital Manipal on 27.11.2007 as an inpatient and was operated for right femur and discharged on 27.01.2008. Immediately on his admission as an inpatient the hospital authorities commences the Opposite Parties regarding Complainant’s admission, treatment details past history and clinical notes alongwith estimate of hospitalization expenses to Opposite Party No.1 since the Complainant was eligible for cashless facilities for treatment. However the Opposite Parties have illegally refused the cashless excess to the Complainant.



3. Since the Complainant required operation on emergency basis he was operated by the KMC hospital, Manipal to the pre operational authorization the Opposite Parties went on requisition more information as per their letters dated 2.12.2007. Both the Complainant and the hospital authorities submitted all the information required by the Opposite Party for grant of cashless access. The Opposite Parties without properly scrutinizing the documents and other information provided to them illegally and baselessly without applying their mind refused cashless access as per their letter dated 14.12.2007



4. The Complainant spent Rs.56,877/- for the operation who paid the same for getting discharge from the hospital. Thereafter the Opposite Parties went on putting queries after queries requesting the Complainant to produce documents which requirements of the Opposite Parties have been complied by the Complainant in time, inspite of the same Opposite Parties refused cashless access as per letter dated 14.12.2007.



5. The Complainant submits that he is a consumer of medical cum insurance service and the Opposite Parties are service provider as per the contract. Opposite Parties are disowning their liability and reasonability under the concluded bilateral contact which amounts to deficiency in service ultimately amounting to repudiation of the claim. Complainant got issued a legal notice dated 5.12.2008 to the Opposite Parties calling upon the Opposite Parties to pay the above claimed amounts. But the Opposite Parties accepted the said notice without demur. Hence, this complaint.

Contd…….3

6. After service of notice the Opposite Party No.1 appeared through the counsel and filed the version. Admitting that the Complainant is a medi claim policy holder vide policy No. 240500/48/06/20/00001451 for a period from 29.03.2007 to 28.03.2008 issued by M/s United India Insurance Co. The Opposite Party No.2. M/s TTK Healthcare service Ltd. is a Third Party Administrator duly licenced by IRDA New Delhi and appointed by various insurance companies for the purpose of handling claim process. M/s TTK Health Care service renders service on behalf of the insurance company to the Network hospital and the patient who are policy holders of the concerned insurance companies. Accordingly the Complainant being a mediclaim policy holder was attached to M/s TTK Healthcare Service Pvt. Ltd., vide TTK Number for the purpose of claiming medical expenses.



7. As per records, the Complainant had been admitted between 27.11.2007 and 27.01.2008 for complaints of Right Femur, at KMC, Manipal wherein he was advised to undergo surgery for the above said ailment during the above said period. On admission the hospital had sent a request for cashless facility which was received by the Respondent No.1 on 01.12.2007. On scrutiny of the request, a query was raised on 2.12.2007 for previous discharge summary. As the request had mentioned mainly about evaluation and management of Diabetic control and previous discharge summary faxed by the Hospital also mentioned treatment of DM, a query was again raised for duration of DM and all policy copies. The diagnosis was “OPERATED SEGMENTAL FRACTURE FEMUR, AND DM FOR INVESTIATION ANDDIABETIC CONTROL AND FURTHER MGMT, NO OTHER PAST HISTORY”.


It is submitted that the response for the final query was received from the hospital on 14.12.2007 stating that the patient was not diabetic and also inability to send policy copies. Since the diagnosis made as stated above conveys that the claimant requires to undergo tests pertaining to Diabetes and for further management, it was opined that admission is not required for the above said tests and it is only investigation that he requires to undergo and also, there was no mention of any detailed treatment plans the request for cashless benefit was denied on the grounds “ADMISSION PURELY FOR INVESTIGATIVE PURPOSES NOT PAYABLE BY INSURANCE. HENCE, CASHLESS ACCESS DENIED. IF ANY ACTIVE LINE OF TREATMENT IS DONE, PLS

Contd…….4

REVERT BACK WITH DETAILS”. It may please be noted that the Opposite Party No.1 has not rejected the claim in total. The above statement is self-explanatory that the claimant can revert back to them with required details. Hence, the decision taken by the Opposite Party No.1 is according to the terms and conditions of the policy.



8. On discharge, the Complainant submitted his claim form alongwith the documents to the Opposite Party No.1 for reimbursement. However, once again there was no proper information and required documents for considering the claim of the Complainant. It is submitted that letters were sent to the Complainant calling for the required documents like Original Discharge Summary, inpatient main Bill and Pre-operative X-ray Report without which, the claim could into be settled immediately. This aspect was informed to the Complainant. Since there was neither a response to the said letter nor the required documents were received from the Complainant the claim file had to be closed on 17.8.2008 on the ground “Short Fall Documents Not Received”. However, instead of complying with the request of the Opposite Party No.1, the Complainant directly has approached this Forum alleging deficiency in services by the Opposite Party No.1.



9. Opposite Party No.1 further informs this Forum that even now, if the Complainant submits the requested documents the claim will be scrutinized and considered, if eligible as per the terms and conditions of the policy and prays to dismiss the complaint with costs.



10. Opposite Party No.2 appeared through its counsel and filed the version contending that the above complaint is false, frivolous vexatious and not maintainable either in law or on merits. It is further submitted that the Complainant suppressed certain relevant material before this Forum with an intention to get wrongful gain and the same abuse of process of this Forum. Opposite Party admits that the Complainant had taken medi claim insurance policy from the Opposite Party No.2 and the policy No. 240500/48/06/20/00001451 to cover the risk for the period 29.3.2007 to 28.3.2008 midnight. But t he Opposite Party denies that Complainant was

Contd……..5

admitted into KMC hospital Manipal on 27.11.2007 as inpatient and was protected from right femur and discharged on 27.01.2007 and further denies that immediately on his admission as inpatient hospital authorities communicated Opposite Parties regarding the Complainant’s admission.



11. Opposite Party denies that all the information required by the Opposite Party submitted by the hospital authorities and Complainants. It s false to state that without properly scrutinizing the documents and other information provided to them illegally, baselessly and without applying his mind refused cashless access as per the letter dated 14.12.2007. It is submitted that by applying his mind in terms of the policy the aforesaid letter was addressed to the Complainant but the Complainant failed to comply with mandatory requirements to disburse the claim. Opposite Party denies that Complainant has spent Rs.56,877/- for the operation. Paid the same to hospital on getting discharge. It further denies that Opposite Parties refused to cashless access as per the letter dated 1r.12.2007. The Opposite Party denies the allegation made by the Complainant in para No.6 of the complaint against the Opposite Party.



12. It is further denied that the Complainant is a ‘consumer’ of medical cum insurance service and Opposite Parties are service provider as per contract. The dispute between the Opposite Parties and the Complainant regards the terms of the contract, therefore it comes under the Civil Dispute between them. The dispute involved serious question of law and facts. In view of the same this Forum has no jurisdiction to try such dispute by time bound proceedings.



13. The Opposite Party further submitted that it denies the contention of the notice issued by the Complainant. Therefore, he has constrained to issue reply to the said notice by explaining the reasons why claimed amount is not possible to pay to the Complainant. Further it is denied the validity truth and genuineness of the documents produced by the Complainant alognwith the complaint The Complainant is not a consumer as defined under C.P. Act. Hence he is not entitled for any reliefs under law before this Forum. The Opposite Party reserves it right to file additional version if afresh facts are gathered at a future date.

Contd……6

14. Opposite Party No.2 filed additional version contending that the Opposite Parties have given several letters and remainders to the Complainant by demanding to produced original discharge summary, original inpatient bill and pre-operative X-Ray report to confirming the diagnosis of the insured as the said documents are just and necessary to process the claim. it is pertinent to note that as per conditional clause No.5.4 of the Policy.

“All supporting documents relating to the claim must be filed with TPA within 7 days from the date of discharge from the Hospital. In case of Post Hospitalization, treatment (limited 60 days) all claim submitted within 7 days after completion of such treatment”.



Condition Clause No.5.5 of the Policy reads as follows:

“The insured person SHALL obtain and furnish the TPA with all ORIGINAL bills, receipts and other documents upon which a claim is based and shall give the TPA/Company such additional information and assistance as the TPA/Company may require in dealing with the claim”.





15. This is clear terms of the concluded contract under the Policy which is binding to both parties to the contract under Policy. In the instance, even though letter dated 13.03.2008 got issued by the Opposite Party by requesting the insured/Complainant to send the said original discharge summary, original inpatient bills, X-ray report to the Company or TPA to process the claim of the Complainant, but Complainant with an ulterior motive not produced such relevant and material documents to substantiate his contentions. Such attempt made by the Complainant is amounts to violation of terms of the Policy under the Contract in insurance. In view of this fact, the Complainant has no locus standi to allege that the Opposite Party has committed deficiency in rendering their service as he himself committed wrong by withholding such material documents which bound to have produce the same to the Opposite Parties in terms of the contract. Therefore, this complaint is liable dismissed withholding such documents to the Company.



16. The Opposite Party further submits before this Forum that the Complainant has opted policy for sum insured of Rs.52,000/- for the year of 29.03.2007 to midnight 28.03.2008 under the policy No.240500/48/06/20/00001415. It clear that the total sum insured of

Contd…….7

Rs.52,000/- for his life during the period from 29.03.2007 to midnight 28.07.2008. The Complainant prior to this treatment in question, he took the medical treatment at KMC Hospital, Manipal and produced the original bills worth of Rs.15,727/- to the Opposite Parties. Accordingly the Opposite Party has paid of Rs.15,727/- as per discharge summary certificate dated 24.05.2007. In view of this fact, the remaining balance sum insured is Rs.36,273/- only stands in the aforesaid policy under Contract at the time of submitting entitled compensation more than amount i.e. Rs.36,273/- stands in the policy as he already received of Rs.15,727/- under this policy in earlier. The aforesaid payment received by the Complainant for the treatment during the period of this policy intentionally suppressed by the Complainant with an ulterior motive.



17. It is further submit before this Forum that the Complainant has filed a petition in MVC No.157/2007 before the Civil Judge (Sr.Div) and MACT, Udupi . The aforesaid medical bill produced before the said court to reimbursement of medical bill amount. The Court also granted the said medical amount by perusing the said bills under the Head of Medical expenses. This fact is suppressed by the Complainant with the dishonest intention to get wrongful gain. In view of this fact, the Complaint is himself committed fraud to this Forum by not disclosing the said fact to the court and which is nothing but abuses of the court.


The Complainant cannot take the double benefit under the Policy in different mode. Since entire bill amount reimbursed to him in the aforesaid MVC case filed by the petitioner, then he cannot entitled said bill amount once against from the Opposite Party trough this Forum as such attitude of the Complainant against the public policy. Hence, this complainant liable is to be dismissed.



18. The dispute regards the payment of insured amount without producing the original medical bills, discharge summary and reimbursement of the said amount through MVC case is purely question of law and facts which is involved this case where such disputes involved this Forum cannot be adjudicated or decided by time bounding proceedings. Such disputes purely civil nature which is enquired to be decided by the Civil Court in its detail trial. Therefore, it is submits that this Court has no jurisdiction to decide this case. Hence liable to be dismissed.

Contd…….8

19. The Complainant has produced 08 documents which are marked as Ex.C-1 to Ex.C-11. Opposite Party has produced 5 documents which are marked as Ex.R-1 to Ex.R-5. Both the parties filed affidavits, interrogatories and reply affidavits. We heard both the parties.



20. Now the points that arise for our consideration are:

1) Whether the Opposite Parties are justified in repudiating the claim of the Complainant?



2) Whether the Opposite Parties have committed deficiency in service?



3) Whether the Complainant is entitled for the relief claimed in the

complaint?

4) What Order?

Point No.1:

21. It is an admitted fact that the Complainant is a medi claim policy holder vide policy No.240500/48/06/20/00001451 for a period from 29.03.2007 to 28.03.2008 issued by United India Insurance company, the Opposite Party No.2 and the Opposite Party No.1 M/s TTK Health Care Service Limited is a Third party administrator duly licensed by IRDA New Delhi and appointed by various insurance companies for the purpose of handling claim process. Opposite Party No.1 renders service on behalf of the insurance company to the network hospital and the patient who was policy holders of the concerned insurance company. Accordingly the Complainant being the claim policy holder has attached to M/s TTK Healthcare Service Pvt. Ltd.



22. There is no dispute that the Complainant admitted between 27.11.2007 and 27.01.2008 for the complaint of Right Femur at KMC, Manipal wherein he was advised to undergo surgery for the above said ailment during the above said period. On admission the hospital has sent a request for cashless facility which was received by the Opposite Party No.1 on 1.12.2007. On scrutiny of the same a query was raised on 2.12.2007 for previous discharge summary as request had mentioned mainly about evaluation and management of diabetes control and previous discharge summary faxed by the hospital mentioned for treatment of DM a query was again aside for duration of DM and all policy copies.



23. The Complainant was operated on emergency basis at KMC hospital Manipal. Complainant submits that to the pre operational authorization

Contd……9

Opposite Parties went on requisition of more information as per their letter dated 2.12.2007. According to the hospital authorities, they have submitted all the information required by the Opposite Party for grant of cashless access. It is alleged that the Opposite Party without properly scrutinizing the document and other information provided to them illegally and baselessly and without applying their mind refused for cashless access as per their letter dated 14.12.2007.



24. The defence of the Opposite Parties is that the insurance policy is a concluded contract between the insured and insurer which is binding on both the parties to the contract under the policy. As per the condition clasue No.5.4 of the policy

“All supporting documents relating to the claim must be filed with TPA within 7 days from the date of discharge from the Hospital. In case of Post Hospitalization, treatment (limited 60 days) all claim submitted within 7 days after completion of such treatment”.



Condition Clause No.5.5 of the Policy reads as follows:

“The insured person SHALL obtain and furnish the TPA with all ORIGINAL bills, receipts and other documents upon which a claim is based and shall give the TPA/Company such additional information and assistance as the TPA/Company may require in dealing with the claim”.



25. In the present case, the Opposite Party through a letter dated 13.3.2008 informed the Complainant requesting him to send the original discharge summary, original inpatient bill, X-ray of the Complainant either to the company or to TPA (Opposite Party No.1) to process the claim of the Complainant. The Opposite Party argued that since the Complainant has failed to produce the required document in originals which is mandatory as per the policy conditions, the Opposite Party No.1 could not process the same.



26. The Opposite Party argued that the Complainant has opted policy for a sum of Rs.52,000/- for the period from 29.03.2007 to mid night 28.03.2008 as per the policy. It is clear that the total sum assured is Rs.52,000/- for his life during the aforesaid period. The Complainant prior to this treatment in question, has took the medical treatment at KMC, Manipal and produced the originals bills worth of Rs.15,727/- to the Opposite Party. Accordingly the Opposite Party has

Contd………10

paid Rs.15,727/- as per discharge summary certificate dated 24.05.2007, in view of the said fact the remaining balance of the sum insured is Rs.36,273/- only stands in the aforesaid policy under contract at the time of submitting for compensation.



27. Opposite Party submitted that the aforesaid payment received by the Complainant for the treatment during the period of this policy intentionally suppressed by the Complainant with an ulterior motive. Further the Opposite Party submitted that the Complainant has filed a petition in MVC No.157/2007 before the Civil Judge (Sr.Dvn.) and MACT, Udupi. The Complainant cannot take double benefit under the policy in different mode. Since the entire bill amount reimbursed in the aforesaid MVC case filed by Complainant, this complaint is not maintainable.



28. Counsel for the Complainant filed a citation reported in 2008(4) KCCR 2005, wherein the Hon’ble High Court of Karnataka has held as under:

“MOTOR VEHICLES ACT, 1988- Section 166 – Amount received by the claimants from Mediclaim Policy – Whether Insurance Company can claim deduction of that amount from the total compensation payable under the MV Act for accidental injury - Held No.”



It is further held in the judgment :

“The amount receivable as compensation under Motor Vehicles Act is on account of accidental injury or accidental death, without making any contribution towards it. If it is so, the fruits, of the amount received through contribution of the insured cannot be deducted out of the amount receivable under Motors Vehicles Act. It is to be noted that the compensation payable under Motor Vehicles Act is statutory, while the amount receivable under the Life Insurance Policy or Mediclaim is contractual.”



29. In view of the above citation, we are of the opinion that the objections raised by the Opposite Parties that the Complainant cannot claim double benefit amount for the same policy cannot be sustained.



30. The Opposite Party No.1 submitted in his argument that even now, if the Complainant submits the requested documents the claim will be scrutinized and considered if eligible as per the terms and conditions of the policy. Opposite

Contd…….11

Party further submitted that Complainant has opted policy for a sum insured of Rs.52,000/- for the year 29.03.2007 to mid night 28.03.2008 under the policy No. 240500/48/06/20/00001451. It is clear that the total sum insured of Rs.52,000/- for his life during the said period. The Complainant prior to this treatment in question, took the medical treatment at KMC, hospital, Manipal and produced the original bills worth of Rs.15,727/- to the Opposite Parties.


Accordingly the Opposite Party has paid Rs.15,727/- as per discharge summary certificate dated 24.5.2007. In view of the said facts the remaining balance sum insured is only Rs.36,273/- stands in the aforesaid policy under the contact at the time of submitting the claim form. The Opposite Party has taken the aforesaid contention in the additional version and this contention of the Opposite Party is not denied by the Complainant in his evidence affidavit. The Complainant has suppressed the aforesaid fact.



31. In view of the above discussion and in view of the fact that the complainant failed to comply with the mandatory condition as per 5.5 clause of the policy. We are of the opinion that the Opposite Parties are justified in closing the claim of the Complainant. Hence, we answer the point No.1 in the Affirmative.



Point No.2:

32. The Opposite Parties have argued that there is no deficiency on their part in closing the file of the Complainant. Since the Complainant has not fulfilled the mandatory requirements of the terms and conditions of the policy, the claim was closed by them. Opposite Parties have got issued the letters dated 14.12.2007, 22.02.2008, 13.03.2008 and 14.4.2008. Inspite of service of the said letters the Complainant failed to produce the documents sought by the Opposite Parties.



33. Opposite Party No.2 has produced a citation reported in 2004 SAR(CIVIL) 907 (Supreme Court) and the gist as under. While dealing with above case, the Supreme Court was pleased to observed in Para No.12 and 13 that by nothing the decision reported in 1999(6) SCC 451.

“The Insurance Policy between the Insurer and the Insured represents a contract between the parties. Since the Insurer undertakes to compensate the loss suffered by the INSURED on account of risk covered by the Insurance Policy, the terms of the Agreement have to strictly construed to determine the extent of liability of the insurer”.

Contd……12

Para NO.13 by noting the decision reported in 1966(3) SCR 500- the Constitution Bench has observed that the POLICY DOCUMENT BEING CONTRACT AND IT HAS TO BE READ STRICTLY. It was observed that

“In interpreting documents relating to a Contract of insurance, the duty of the Court is to interpret the words in which the contract is expressed by the parties because it was not for the court to make a New Contract, however reasonable, if the parties have not made it themselves.”



34. Admittedly the Complainant has not produced the Original discharge summary, Original Inpatient Bill and pre-operative X-Ray report to the Opposite Parties. It is admitted that the said original documents have been submitted before the Motor Accident Tribunal in MVC No.157/2007 by the Complainant. Said proceedings has come to an end on 20th March 2008 by passing an award. There is no impediment to the Complainant to get back the original documents from the Claims Tribunal and submit the same to the Opposite Party for reconsideration. In view of the above fact, we are of the opinion that there is no deficiency on the part of Opposite Parties. Hence point No.2 is answered in the Negative.



Point No.3:

35. Admittedly the Complainant is the medi claim insurance policy holder. The complainant has undergone emergency operation for right femur in the KMC hospital, Manipal and the hospital issued bill for Rs.56,877/-. The insured amount under the policy is Rs.52,000/- for the validity period. The complainant has claimed prior to this treatment in question has taken the medical treatment at KMC hospital, Manipal and claimed the amount of medical bill for Rs.15,727/-, same was paid by the Opposite Party.


The remaining balance sum insured is Rs.36,273/- for which the Complainant is entitle for the present claim. Hence, the Opposite Parties are liable to pay to the Complainant a sum of Rs.36,273/- subject to the production of Original discharge summary, Original Inpatient Bill and pre-operative X-Ray report as required under law. Hence, we are of the opinion that the Complainant is entitle for the reliefs as per order below. Hence the point No.3 is answered in the Affirmative. .

Contd.. 13

36. In the result, we pass the following:

ORDER

The complaint is partly allowed. Opposite Parties are directed to pay to the Complainant a sum of Rs.36,273/- subject to the production of Original discharge summary, Original Inpatient Bill and pre-operative X-Ray report. The Opposite Parties shall comply with this order within one month from the date of receipt of the aforesaid original documents from the Complainant. Under the circumstances of the case, the parties are directed to bear their own costs.

V. Murali Swarnamani,

S/o. Swarnamani

No.397, Sabari Illam

Alagesan Road,Saibaba Colony,

Coimbatore 641 0011. --- Complainant

Vs.

1. TTK Health Care Service P.Ltd.,

146, Raju Naidu Road,

Sivananda Colony,

Tatabad, Coimbatore – 641 012.

2. TTK Health care Service P.Ltd.,

7,Jeevan Bhima Nagar Main Road,

Hal II State, Bangalore – 560 075.

3. ICICI Lumpard General Insurance

Co. Ltd., ICICI Bank Towers,

Bandra Kurla Complex,

Mumbai – 400 051. --- Opposite Parties

This case coming on for final hearing before us on 17.07.09 in the presence of Mr.R. Selvaraj, Advocate for complainant and the 1st and 2nd opposite parties are remained absent and set exparte and Mr.S. Balasubramanian, Advocate for the 3rd opposite party and upon perusing the case records and hearing the arguments and the case having stood over to this day for consideration, this Forum passed the following:

ORDER

Complaint under Section 12 of the Consumer Protection Act, 1986 seeking direction against the opposite parties to pay a sum of Rs.23,578/- (1) Actual medical expenses incurred (2) interest from 24.09.07 to 24.07.08 at 24% per annum Rs.4,650/- (3) to pay Rs.75,000/- as compensation for mental agony , deficiency in service, unfair trade practice and to pay cost of the proceedings.

The averments in the complaint are as follows:

1. The Complainant has taken ICICI Lumbard Health Care Insurance Policy vide Policy Certificate No. 4034/TAG/01861849/00/000 covering the period of Insurance from 7.2.07 to 6.2.08 by paying a premium of Rs.8,438/- from the 3rd opposite party at Coimbatore. The 3rd opposite party is having branch at Coimbatore also. As per terms of the said policy the complainant and his spouse have been insured for a total sum of Rs.3,50,000 The 2nd opposite party is the 3rd opposite party administrator (TPA) and the 1st opposite party is branch office of the 2nd opposite party at Coimbatore. The 1st and 2nd opposite party receive the claim and process the same for settlement.

2. As per the terms of the policy, the opposite parties will have to reimburse to the insured for the various medical expenses like including room, boarding expenses as provided by the Hospital, Nursing expenses, surgeon, therapist, medical practitioner consultants, specialist fees, blood oxygen, operation theater charges, surgical appliances, medicine and drugs, diagnostic materials and X-ray, dialysis, chemo therapy, Radio Therapy, cost of Phase Maker, Artificial limbs and organs and similar Pre and Post Hospitalisation expenses, while so, the complaint experienced sudden vision loss for about 10 days during the month of August 2007. The complaint initially consulted the Eye foundation Post Graduate Institute of ortholmology at Coimbatore on 28.8.07 and latter got admitted in Sri Ramakrishna Hospital, Coimbatore for further treatment.

3. The complainant had taken treatment in the said hospital as in patient from 7.9.07 to 11.9.07. The complainant incurred a sum of Rs. 23,578/- towards , medical expenses in the said hospital. The entire expenses incurred by the complainant is reimbursable by the opposite parties as per the terms of the Insurance Policy. The complainant submitted his claim for Rs.23,578/- in claim form No. 9 with the 1st opposite party at Coimbatore on 24.9.07 with necessary documents. The 1st opposite party acknowledged the same. There was no response from the opposite parties. The complainant sent a registered notice dated 15.04.08 to the 2nd and 3rd opposite parties requesting settlement of claim. None of the opposite parties have cared to reply for the notice aforesaid till date. No reason was assigned by the opposite parties for non settlement of the lawful claims of the claimant. The inaction on the part of all the three opposite parties are unfair trade practice, deficiency in service and clear violation of policy terms. Hence the complaint.

The averments in the counter of the 3rd opposite party are as follows:

4. The complainant has not stated any where in the claim form as to for what disease he had undergone hospitalized treatment as inpatient. Further, although he has stated in the claim form that the alleged disease was first detected by Eye Foundation, R.S. Puram, Coimbatore, he has not produced any document in proof of the same. As per the complaint document No. viz., the discharge summary of Sri Ramakrishna Hospital, Coimbatore what has been diagnosed is primarily Diabetes mellitus and the complications arising out of Diabetes Mellitus. The medical tests for detection of Diabetes Mellitus or the treatment for controlling Diabetes Mellitus do not require hosipitalization. The complainant has got admitted as inpatient only for the purpose of getting reimbursement of his diagnostic expenses since outpatient treatment is beyond the scope of the Policy. Even otherwise, as stated herein above, Diabetes Mellitus being not a disease it is outside the scope of the Health Insurance Policy. Hence the complainant is not entitled for any relief.

5. The complainant and opposite parties have filed Proof Affidavits along with Ex.A1 to A9 was marked on the side of the complainant and the 1st and 2nd opposite parties remained absent and set exparte and Ex.B1 to EX.B5 was marked on the side of 3rd opposite party.







The point for consideration is

Whether the opposite parties have committed deficiency in service? If so to what relief the complainant is entitled to?

ISSUE 1

6. The case of the complainant is that he has taken ICICI Lombard Health Care Insurance Policy from the 2nd opposite party, as per the terms of the said policy the complainant and his wife have been insured for a total sum of Rs.3,50,000, after consulting the Eye Foundation Post Graduate Institute of Orthomology on 28.8.07 he got admitted in Sri Ramakrishna Hospital for further treatment, and submitted his claim form for Rs.23,578 but the opposite party has not come forward to reimburse Rs.23,578 till date. Hence this complaint.

7. The case of the opposite parties is that the claim being outside the scope of the policy the complainant is not entitled for any relief as prayed for.

8. The contract of insurance is a personal contract and is subject to the terms, conditions, exclusions and definitions incorporated therein. Ex.A1 and B1 are the certificate copy of policy. The policy of insurance explicitly states, inter alia, the definitions for hospitalization and illness as under:

“Hospitalisation shall mean admission in any hospital in India upon the written advice of medical practitioner and

Illness means sickness, disease first diagnose during the period of insurance for which immediate treatment by a medical practitioner is necessary”.

9. The complainant has not filed any document of Eye Foundation, Coimbatore and no written advice of any medical practitioner for admission in a hospital has been produced.

10. The complainant has not stated anywhere in the complaint as to for what disease he had undergone hospitalized treatment as inpatient. Not only that he has stated anywhere in the claim form as to for what disease he had undergone hospitalized treatment as inpatient. The copy of claim form dated 11.9.07 is marked as Ex.A2 and B2. In the claim form also in the col. Ailment/Disease/Injury = Disease is mentioned. Inspite of specific statement made in para 2 of written version the complainant has not come forward to produce any document for the alleged disease detected by the Eye Foundation, coimbatore.

11. The discharge summary of Sri Ramakrishna hospital is marked as Ex.A3. It has been diagnosed as primarily diabetes mellitus and the complications arising out of diabetes mellitus. Diabetes mellitus is not a disease but it is a complication arising out of the deficiency in the hormone viz. insulin.

12. The medical tests for detection of Diabetes Mellitus or the treatment for controlling Diabetes Mellitus do not require hosipitalization. Moreover as per Ex.A3 discharge summary the date of admission is on 7.9.07 and the date of discharge is on 11.9.07. Ex.A4 is a lab report series dated 13.9.07 in the name of Murali Swarnamani. This 13 lab test reports contains reports dt.13.9.07 for blood sugar and urine sugar only. These 13 reports dt.13.9.07 were obtained only after discharge. Thus it is clear the complainant has got admitted as inpatient only for the purpose of getting reimburse of his diagnostic expenses since outpatient treatment is beyond the scope of the policy. More over diabetes mellitus is not a disease and it is outside the scope of health insurance policy.

13. In the absence of any documents from Eye Foundation, Coimbatore and in the absence of written advice of any medical practitioner for admission in a hospital and finally diabetes mellitus being not a disease require any hospitalization treatment the closing of the claim made by the opposite party cannot be construed as deficiency in service. Hence the complainant is not entitled to get any relief.

14.In the result, this complaint is dismissed. No costs.

i was anodemain pain last september 2008 tll now not clear my claim. i sent all document which ttk needed but not clear claim till. so pls help me. my card number is= CHE-NI-GH07-05-00873A

to,
ttk sir i suresh gadade my card is not given monh
pls give me urjant my card



suresh
policy no112800/34/09/11/00005782 pls reply