State Consumer Disputes Redressal Commission
S.G. Radhakrishnan S/O. Gurusamy ... vs T.T.K. Healthcare Services Pvt. Ltd., ... on 16 May, 2011
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE : Honble Thiru Justice M.THANIKACHALAM PRESIDENT Thiru J. JAYARAM, M.A.,M.L., MEMBER (JUDICIAL) F.A.NO.781/2008 (Against order in CC.NO.26/2006 on the file of the DCDRF, Srivilliputhur) DATED THIS THE 16th DAY OF MAY 2011 S.G. Radhakrishnan S/o. Gurusamy 123-A, Sri Rengapalayam Street Rahapalayam Appellant/ Complainant Vs. 1.
T.T.K. Healthcare Services Pvt. Ltd., Rep. through its Branch Manager No.146, Raju Naidu Road Sri Sai Baba Towers, Coimbatore-
641 01
2. M/s. National Insurance Company Ltd., Through its Divisional Manager No.706, 1st Floor, Thenkasi Road Rajapalayam, Virudhunagar District Respondents/ Opposite parties The Appellant as complainant filed a complaint before the District Forum against the opposite parties praying for the direction to the opposite parties to pay a sum of Rs.2,00,000/- alongwith interest. The District Forum dismissed the complaint. Against the said order, this appeal is preferred praying to set aside the order of the District Forum dt.30.01.2008 in CC.No.26/2008.
This petition coming before us for hearing finally on 03.05.2011. Upon hearing the arguments of the counsel on both sides, perusing the documents, lower court records, and the order passed by the District Forum, this commission made the following order:
Counsel for the Appellant/ Complainant: M/s. S.J. Jagadev Counsel for the 1st Respondent/1st Opposite party : M/s. S.V. Joga Rao Counsel for the 2nd Respondent/2nd Opposite party: M/s. N.B. Surekha M. THANIKACHALAM J, PRESIDENT
1. The complainant is the appellant.
2. The complainant/appellant, had taken hospitalization and domiciliary hospitalization benefit policy, from the 2nd opposite party, for the period covering 20.5.2005 to 19.5.2006, through the 1st opposite party, for the sum assured Rs.1,50,000/-. The complainant who was suffering from abdominal pain, admitted in Apollo Hospital, where he was treated for Acute Pancreatitis, for the period 2.7.2005 to 16.7.2005, for which he spent more than Rs. 2 lakhs. After discharge, the complainant based upon the policy, lodged a claim, which was negatived/repudiated, on the ground that the complainant had taken treatment for pre-existing disease, which is not covered under the policy, though fact being it is not a pre-existing disease.
The non-settlement of the insurance claim by the opposite party, would amount to deficiency in service. Despite number of request, they failed to pay the amount, which should be construed as negligent act, followed by deficiency, for which the complainant is entitled to compensation also, including the medical expenses incurred, totaling a sum of s.2 lakhs. Hence this complaint.
3. The opposite party, admitting the mediclaim policy, as well as the treatment taken by the complainant in Apollo Hospital, resisted the case, interalia contending, that even before the date of inception of the policy, the complainant had this kind of problem, for which he had taken treatment, and subsequently also he suffered by the same type of abdominal pain, for which he had taken treatment, which should come within the meaning of pre-existing disease, and therefore the repudiation of the claim is justifiable, not warranting to label it as negligent act, or deficiency in service, praying for the dismissal of the complaint.
4. The District Forum, by its order dt.30.1.2008, considering the treatment taken by the complainant, as well as medical history, in addition to the nature of disease, for which treatment was taken, has recorded a finding, that even at the inception of the policy, the complainant had this kind of problem, and suppressing the re-existing disease, since policy was taken, that was rightly repudiated, will not come under the category of deficiency in service. In this view, the complaint was dismissed, resulting this appeal.
5. The complainant, under Ex.A1, had taken a mediclaim policy, subject to certain conditions available therein, which is also admitted in the complaint, reiterated in the written version. It is not in dispute, that the terms and conditions available in the policy, are binding upon the parties, including the complainant. Under clause 4.1 all diseases/ injuries, which are pre-existing, when the cover incepts for the first time, the company shall not be liable to make any payment, under this policy. Therefore, if the complainant had taken treatment, for the pre-existing disease, when the cover incepts for the first time, then automatically, he goes outside the purview of the policy, and in that case, if amount claimed, for taking treatment for the pre-existing disease, then repudiated cannot be termed as negligent act, or deficiency of service. Therefore, now we have to see, what was the disease, for which the complainant had taken treatment, whether it could have been in existence, at the time of taking the policy, thereby bringing that disease within the meaning of pre-existing.
6. Ex.A2, is the discharge summary, for the treatment taken by the complainant, at Apollo Hospital. In this document, while giving the history of illness, ascertaining from the complainant, it is said patient known case of acute necrotizing pancreatitis, thereby meaning, an inflammation of the pancreas, which had developed the stage of inflammation/acute pancreatitis. This kind of disease, would not have occurred, within the short period, or all of a sudden. We are having intrinsic evidence in the discharge summary itself, indicating that the complainant should have had this disease, even at the time of taking the policy, which is described under the heading past history history of pain abdomen-4 months back, treatment taken for that 15 days back, he was treated conservatively for the same, this treatment was given to the complainant, admitting him as inpatient on 2.7.2005. If we calculate the period, on the basis of the past history, he had the same kind of problems, 4 months ago, thereby taking us to March 2005. It is not the case of unknown problem, whereas even as reported by the complainant, to the doctor concerned, it is a known problem for the complainant, for which he had taken treatment conservatively. The policy was taken w.e.f. 20.5.2005, thereby undoubtedly disclosing the fact that even before the inception of the policy, i.e in the month of May 2005, he had same kind of problem, later after taking the policy alone, he went to hospital for further treatment, thereby showing he had suppressed the pre-existing, and had taken the policy, thereby by his conduct, the insurance of conduct become void, on the basis of the conditions available under clause 4.1, and since the complainant had taken treatment for pre-existing disease, the company is not bound to pay the sum assured, or reimburse the medical expenses, which they did correctly appreciated by the District Forum also, in accordance with the conditions of the policy, in which findings we are unable to interfere for the reasons assigned above. Hence the appeal is devoid of merits.
7. In the result, the appeal is dismissed, confirming the order of the District Forum in COP.No.26/2006 dt.30.1.2008. There will be no order as to cost throughout.
J. JAYARAM M.THANIKACHALAM JUDICIALMEMBER PRESIDENT INDEX : YES / NO Rsh/d/mtj/Bench-1/Miscellaneous