State Consumer Disputes Redressal Commission
The New India Assurance Co. Ltd., vs Syed Ahmed Mohiuddin Afzal on 13 December, 2023
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION:HYDERABAD
(ADDITIONAL BENCH)
FA. No. 427/2021
AGAINST ORDERS
IN
CC. No. 106/2015
ON THE FILE OF DISTRICT CONSUMER COMMISSION-III,
HYDERABAD
Between :
The New India Insurance Co. Ltd.,
Rep. by its Manager, C/o. TTK Health Care,
TPA Pvt. Ltd., Office at: 2, HB Complex,
100 Feet Ring Road, BTM First Stage,
BTM Layout, Bangalore, Karnataka.
.....Appellant/Opp. Party No.4
AND:
1. Mr. Syed Ahmed Mohiuddin,
S/o. Syed Mohiuddin Afzal,
Aged about: 40 years, Occ: Advocate.
2. Mr. Syed Mohiuddin Afzal,
S/o. Late. Syed Mohd. Abdur Rahman,
Aged about: 70 years, Occ: Retd. Service.
R1 & R2 are R/o. 13-6-822/1/11,
Mehdi Colony, Plot No.35,
Langarhouse, Hyderabad.
(R2 died on 07.04.2021 and memo filed by R1,
that he is the sole legal heir of R2).
.....Respondents/Complainants
3. Synergy Aditya Insurance Brokers,
Rep. by its Mangar, Corp. Office at Plot No.401,
Siri Estates, Ellareddyguda, Ameerpet, Hyderabad-500016.
4. Synergy Aditya Insurance Brokers,
Rep. by its Mangar, Corp. Office at Plot No.301,
Govinda Mansions, Plot No.18, CMB Compound,
Visakhapatnam-3, Andhra Pradesh.
2
5. TTK Healthcare Pvt. Ltd.,
Rep. by its Manager at 47-14-30,
04th Floor, Vidisha Towers,
Dwarakanagar Main Road,
Visakhapatnam - 530016,
Andhra Pradesh.
.....Respondents/Opp.Parties No.1 to 3 (Not
necessary Parties)
Counsel for the Appellants/Opp. party No.4 : M/s. S.N. Padmini
Counsel for the Respondent No. 1& 2/ Complainants : Mr. Shashank
Goel
QUORUM: Hon'ble Sri V.V.Seshubabu, Member (M-J),
&
Hon'ble Smt.R.S.Rajeshree, Member (N-J)
WEDNESDAY, THE THIRTEENTH DAY OF DECEMBER,
TWO THOUSAND TWENTY THREE
*****
ORDER :(HON'BLE SRI V.V.SESHUBABU, MEMBER JUDICIAL)
1. The appeal is filed on U/s.15 of C.P. Act, 1986, aggrieved by the order of the District Consumer Disputes Redressal Commission-III Hyderabad, dt.21.02.2018, in CC. No. 106/2015, directing the Opposite Party No.1 to 5 to pay Rs.65,000/- with joint and several liability besides compensation of Rs.50,000/- and the costs of Rs.10,000/- payable within 30 days, else the complainants are entitled interest on the amounts @7% p.a., till realization.
2. The brief averments of the complaint are that complainant No.1 is an Advocate and son of complainant No.2 and they have obtained medi-claim policy from the opposite parties and issued with separate health care cards which are valid from 13.10.2011 to 12.10.2012; that on 27.08.2012 the complainant No.2 was admitted in safe health heart centre, Erramanzil Colony, Hyderabad with a complaint of chest pain and discharged on 28.08.2012 after treatment; 3 that the Complainants have incurred Rs.65,000/- towards cost of the treatment and the claim was submitted with the opposite parties; that on 05.09.2012 complainant NO.1 personally approached the opposite party No.1 with a request to settle the claim; that subsequently also complainant approached the opposite parties, but there was no response; that a legal notice dt.03.04.2013 was issued to the opposite parties demanding to settle the claim for which opposite party No.4 given a reply dt.25.04.2013 stating that the treatment undergone by the complainant NO.2 is excluded from the scope of policy; that it was repudiated after 8 months of the treatment which caused lot of mental agony; hence, the complaint.
3. The opposite parties No.1 to 4 were called absent and set-exparte.
4. Before the forum below complainant filed evidence affidavit as PW1 and got marked Ex.A1 to A16. The complainant filed written arguments and made oral submissions.
5. The forum below settled the following points for discussion, viz.,
(i) Whether there is deficiency of service on the part of the opposite parties?
(ii) Whether the complainants are entitled for the policy claim of Rs.65,000/-?
(iii) Whether the complainants are entitled for compensation and costs as prayed for?
(iv) To what relief?
6. Having heard the complainant counsel, the forum below passed the order as stated supra. Aggrieved by the same the Opposite party filed the present appeal with the following grounds:- 4
(i) The order under appeal is unsustainable and liable to be set aside.
(ii) The forum below failed to observe that the Complainants are not entitled for the claim amount as the treatment provided to the complainant No.2 i.e., the artery clearance therapy (ACT) or chelation therapy does not come under the purview of new India Flexi Floater Group medi-claim policy as per exclusion clause 4.4.19.
(iii) The forum below without any basis awarded compensation and costs. With these grounds and others that will be urged at the time of arguments requested to allow the appeal.
7. Now the points for determination in the appeal are:-
(i) Whether there is any deficiency of service by the opposite party In view of the exclusion clause made in the policy for the treatment given to the Complainant No.2?
(ii) Whether the impugned order of the forum below is sustainable under law?
(iii) Relief?
8. Points Nos. 1 to 3 :- Admittedly, complainants No.1 & 2 obtained tailor made floater Group Mediclaim Policy (hospitalization benefit policy) and it is valid from 15.10.2011 to 14.10.2012 midnight. The entire policy with all terms, conditions and exclusions is filed in the appeal. It consists pages 1 to 27. The clause 4 in page No.9 relates to exclusions. Clause 4.4.13 UNPROVEN TREATMENTS (CODE-EXCL16) at page No.12 shows "expense's related to any unproven treatment, services and supplies for or in connection any treatment. Unproven treatment or treatments, procedures or supplies that lack significant medical documentation to support their effectiveness". A reply notice dt.25.04.2013 given by the legal department of the opposite party to the Advocate of Complainant Mr. Shashank Goel goes to show that the claim was repudiated as the Complainant No. 2 had undertaken "Chelation Therapy" to improve the myocardial blood flow and enclosed 5 two sheets showing the exclusion for the said therapy. As per clause 4.4.19 experimental and unproven, (not recognized by India Medical Counsel) which includes Artery Clearance Therapy (ACT) or Chelation Therapy is excluded from the scope of policy. This clause 4.4.19 is not part of the policy that was filed consisting of pages No.1 to 27 of the policy.
9. No petition is filed to receive any documents. There is no clarity to the effect that, clause 4.4.19 as said to have furnished to the counsel of complainant vide reply notice dt.25.04.2013 is part of the policy. As per clause 4.4.19 of the policy mentioned in page No.13 of the policy document relates to vaccination and inoculation. No medical literature is filed to establish that the Indian Medical Counsel, not recognized ACT or Chelation Therapy. Therefore, we are of the view that, the Appellant failed to establish that the treatment that was taken by the second Complainant has been excluded from the policy. The forum below awarded compensation of Rs.50,000/-, when the claim amount was @Rs.65,000/-. We are of the view that it is high side, when compared with the claim amount. Therefore, we want to modify the amount from Rs.50,000/- to Rs.25,000/- and rest of the appeal is liable for dismissal.
10. In the result, the appeal is modified without costs by reducing the compensation from Rs.50,000/- to Rs.25,000/- and by confirming the rest of the order of the District Consumer Forum-III Hyderabad, dt.21.02.2018 in CC. No.106/2015. The Respondent/Complainant is at liberty to withdraw the amounts 6 deposited by the Appellant/Opposite Party while preferring the appeal after the expiry of appeal time, towards part satisfaction of the order. Typed to the dictation to the steno on system, corrected and pronounced by us in the open bench on 13.12.2023.
SD/- SD/-
----------------------------------------------
MEMBER(J) MEMBER(NJ)
Dated : 13.12.2023.
BSR