BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION : HYDERABAD
F.A.No.9/2013 against C.C.No.118/2012, Dist. Forum,Guntur.
Between:
Maddi Srinivasa Rao, S/o.Hanumantha Rao,
Aged 39 years, R/o.Door No.26-192,
Subbaiah Thota , Beside Old CTO Office,
Chilakaluripet Town, Guntur District. … Appellant/
Complainant
And
1.The Branch Manager,
Star Health & Allied Insurance Company Ltd.,
D.No.4-5-125, 4th Lane Ring Road,
Opp:SBI, Koritepadu, Guntur District-522 001.
2. Star Health & Allied Insurance Company Ltd.,
Rep. by its Authorized Signatory,
Zonal Office , Paradice Circle,
Secunderabad-500 003.
3. Star Health & Allied Insurance Company Ltd.,
Rep. by its Authorized Signatory,
KRM Centre, 6th Floor, No.2, Harrington Road,
Chetpet, Chennai-600 031, Tamilnadu. …. Respondents/
Opp.parties
Counsel for the Appellant : M/s. Sricharan Telaprolu
Counsel for the Respondents : Mr.G.S.G.Radhakrishna
QUORUM: SRI. T.ASHOK KUMAR, HON’BLE MEMBER
AND
SRI S.BHUJANGA RAO, HON’BLE MEMBER
MONDAY, THE THIRTIETH DAY OF JUNE
TWO THOUSAND FOURTEEN.
Oral Order: (Per Sri S.Bhujanga Rao, Hon’ble Member)
****
The unsuccessful complainant filed this appeal against the order dt.30.11.2012 of the District Consumer Forum, Guntur made in C.C.No.118/2012 filed by the appellant/complainant seeking direction to the opposite parties to pay to the complainant a sum of Rs.2,80,000/- incurred by the complainant towards hospitalisation and Rs.50,000/- towards mental agony besides costs.
The brief case of the appellant/complainant is that on 23.07.2009 he took Family Health Optima Insurance Policy from the opposite parties for Rs.1 lakh bearing policy no.P/131214/01/2010/000170 and the policy was valid from 25.07.2009 to 24.07.2010. The complainant renewed the policy from 25.07.2010 to 24.7.2011 increasing the policy amount from Rs.1 lakh to Rs.4 lakhs. The complainant fell sick due to heart valves problem and he took treatment as in patient in M/s.Apollo Hospitals from 13.09.2010. The specialist doctors of Apollo Hospital operated the complainant for cure of heart valves problem. The complainant incurred Rs.2,80,000/- towards treatment at M/s.Apollo Hospital. Before getting treatment in the said hospital, the complainant intimated the same to the opposite parties, who in turn issued claim intimation no.C.L.I./2011/131214/0046012. After discharge from the hospital, the complainant submitted treatment particulars and bills to the opposite parties. The complainant sent need value invoice and sticker documents, as sought by the opposite party no.2 on 29.11.2010 as per their requirement. On 09.02.2011, the opposite party no.2 required the complainant to send the medical report of Star Hospital in June,2010. Subsequently, on 27.02.2012, the opposite party no.2 repudiated the complainant’s claim on flimsy grounds, which amounts to deficiency in service on the part of the opp.parties. The complainant never suppressed any material facts regarding his health condition at the time of taking the policy. The health condition of the complainant was in perfect condition. A panel of doctors of opposite parties examined the complainant at the time of taking the policy and having satisfied with his condition only, opp.party no.2 issued the policy. Hence the complaint.
The opposite party no.1 filed written version and the same was adopted by the opposite parties 2 and 3. The contention of the opposite parties is that the complainant insured had undergone AORTIC VALVE REPLACEMENT on 17.03.2009 and concealing the same, the complainant had taken the policy with the opposite parties on 25.07.2009 without disclosing the same. In the present case onset symptom is prior to inception of the policy in March,2009 itself and therefore, the claim of the complainant is inadmissible The contract of insurance is liable to be declared as null and void. The opposite parties have rightly repudiated the claim and did not commit any deficiency in service.
During the course of enquiry, in order to prove his case, the complainant filed his evidence affidavit and got marked Exs.A1 to A24. On behalf of the opposite parties, the evidence affidavit of Sri Viswanatha Venkata Subrhamanyam, Branch Manager along with Exs.B1 to B3 was filed.
Having heard the counsel for both the parties and having considered the evidence on record, the District Forum came to the conclusion that the repudiation of the claim by the opposite parties on the ground of suppression of material fact, regarding ill health of the complainant is valid and thereby the opposite parties did not commit any deficiency in service, consequently, the District Forum dismissed the complaint without costs.
Aggrieved by the said order, the complainant preferred the above appeal urging that the District Forum ought to have seen that a perusal of Ex.A5 (Ex.B2) the Discharge Summary of the appellant/complainant clearly show that the appellant underwent Aortic Valve Replacement on 17.09.2010 at Apollo Hospitals, Hyderabad, but taking advantage of typographical mistake at the ‘Comments’ column mentioned in the Discharge Summary, regarding the date of Aortic Valve Replacement as 17.03.2009 instead of 17.09.2010, the respondents raised false defence that the appellant already underwent Aortic Valve Replacement on 17.03.2009. That the District Forum erroneously upheld the defence of the respondents and wrongly came to the conclusion that the appellant suppressed the material facts regarding ill health prior to the policy, solely relying on the typographical mistake crept in Ex.A5 (Ex.B2). The District forum ought not to have dismissed the complaint solely basing on typographical mistake. The appellant/complainant finally prayed to allow the appeal and set aside the impugned order, allowing the complaint.
After filing of the appeal, the appellant filed a petition in I.A.No.820/2013 praying to receive the Reply dt.02.01.2013 issued by the Apollo Hospitals, Hyderabad as additional evidence on their behalf, in this appeal. After hearing both sides, the petition was allowed and the document was marked as Ex.A25.
We heard the counsel for both the parties and perused the entire material placed on record.
Now the point for consideration is whether the impugned order of the District Forum is vitiated for misappreciation of fact or law?
The appellant/complainant had taken Family Health Optima Insurance Policy bearing policy no.P/131214/01/2010/000170 vide Ex.A1 for an amount of Rs.1 lakh valid from 25.07.2009 to 24.07.2010. Subsequently, the appellant/complainant renewed the policy from 25.07.2010 to 24.7.2011 increasing the policy amount from Rs.1 lakh to Rs.4 lakhs vide Ex.A2. The appellant/complainant again renewed the policy for second time for the same amount covering the period from 25.07.2011 to 24.07.2012 vide Ex.A14. The appellant/complainant took treatment as inpatient in M/s.Apollo Hospitals from 13.09.2010 to 23.09.2010 vide Ex.A5. The appellant/complainant has undergone operation and he incurred Rs.2,80,000/- towards treatment at M/s.Apollo Hospitals. After the discharge, the appellant/complainant submitted his claim along with material papers to the opposite parties. The appellant/complainant’s claim was repudiated by the respondent/opposite party no.2 on 27.2.2012 on the ground that the appellant/complainant suppressed the material facts, regarding his health condition, at the time of taking the policy. All the above said facts are not in dispute and they are also established by the documentary evidence adduced by the complainant.
Mere allegation of concealment of material facts is not acceptable, in the absence of any evidence in support there of, as held by the Hon’ble National Commission in M/s. Aviva Life Insurance Company India Pvt. Ltd. vs. T.Umavathi reported in 2007 (3) CPR 322 ( NC). The appellant/complainant contended that he did not suppress any material facts regarding his health and that a panel of doctors of Apollo Hospital after thoroughly examined the appellant and having satisfied with the health condition of the appellant, the policy was issued by opp.parties.
Any negative aspect cannot be proved by adducing positive evidence. Therefore, the burden is on the respondents/opposite parties to prove that the appellant/complainant suppressed the material facts regarding his health conditions. To prove the same, the respondents/opposite parties relied on Ex.A5, the copy of the Discharge Summary filed by the appellant/complainant, which was issued by M/s.Apollo Hospitals, Hyderabad. In Ex.A5 under Column ‘History’ it is mentioned “Evaluated in Star Hospital in June, 2010 revealed Bicuspid AV with severe Aortic Stenosis, moderate to severe AR. No.CHF. Under the head“Comments” it was mentioned that “Mr. Srinivas Rao Maddi, a 35 years old gentleman was admitted with diagnosis of Rheumatic Heart Disease. Severe AorticStenosis. The patient was evaluated and underwent Aortic Valve Replacement on 17.03.2009”. Basing on this date i.e. 17.03.2009 under “comments” column of Ex.A5, the District Forum came to the conclusion that the appellant/complainant was suffering from rheumatic heart disease and underwent rheumatic valve replacement on 17.03.2009 itself i.e. prior to the taking of the first policy itself on 25.07.2009.
After pronouncement of the order by the District Forum in C.C.No.118/2012, the petitioner came to know that the appellant/complainant underwent Aortic valve replacement on 17.09.2010 at Apollo Hospitals, Hyderabad, but by mistake at the Comments column, in the Discharge Summary regarding the date of Aortic Valve Replacement it was mentioned as 17.03.2009 instead of 17.09.2010 and issued legal notice on 17.12.2012 to the Apollo Hospitals to rectify their mistake and for issuance of necessary reply in that regard. Pursuant to the said legal notice, the Apollo Hospitals, Hyderabad, issued reply dt. 02.01.2013 to the complainant, subsequent to the filing of the above appeal. The appellant/complainant filed the said reply as additional evidence in this appeal and the same is marked as Ex.A25. In Ex.A25 it is categorically stated that Mr.Maddi Srinivas Rao, S/o.Hanumantha Rao was admitted in Apollo Hospital, Jubilee Hills Hyderabad on 13.09.2010 and he underwent Aortic Valve Replacement on 17.09.2010 and not on 17.03.2009 as stated in the Discharge Summary dt.23.09.2010 and that the statement in the Discharge Summary that the said Srinivas Rao underwent Aortic Valve Replacement on 17.03.2009 is a typographical error for 17.9.2010.
In view of Ex.A25, we are not inclined to accept the contention of the respondents /opposite parties that the complainant /insured had undergone Aortic Valve Replacement on 17.03.2009 and he had taken the policy with the opposite party on 25.07.2009 without disclosing the same. Therefore, the impugned order of the District Forum, based on the typographical mistake at the ‘comments’ column mentioned in Ex.A5 Discharge Summary regarding the date of Aortic Valve Replacement as 17.03.2009 instead of 17.09.2010 is not sustainable under law and is liable to be set aside. The defence raised by the respondents/opposite parties, basing on the typographical mistake as to the date of the operation in Ex.A5 that the appellant/complainant already underwent Aortic Valve Replacement on 17.03.2009 is without any basis. Inspite of verifying with the Apollo Hospital with regard to the date of the operation, the respondents/opposite parties repudiated the claim of the appellant/complainant basing on the typographical mistake crept in Ex.A5 Discharge Summary of the appellant/complainant. Thus there is negligence and deficiency in service on the part of the respondents/opp.parties.
For all the aforesaid facts and circumstances, in our considered view, the impugned order of the District Forum is not sustainable under law and is liable to be set aside.
The affidavit evidence of the complainant coupled with the medical record and Ex.A7 medical bill and receipt filed by the complainant proved that the appellant/complainant took treatment as inpatient in M/s. Apollo Hospitals, Hyderabad from 13.9.2010 and underwent operation for cure of heart valves problem and that the complainant incurred Rs.2,80,000/- towards treatment at M/s.Apollo Hospitals. Infact , the opp.parties have not disputed the above facts. Therefore, the appellant/complainant is entitled to the said amount and the opp.parties are liable to pay the same to the complainant. There can be no dispute that the appellant/complainant subjected to mental agony etc. due to the conduct of the opp.parties in repudiating his claim. As such, the complainant is entitled to compensation. However, as we are granting interest on the claimed sum, we are not awarding any compensation in favour of the complainant.
In the result, the impugned order of the District Forum is set aside. The complaint filed by the appellant/complainant is partly allowed directing the respondents/opposite parties to pay a sum of Rs.2,80,000/- towards medical expenses incurred by the appellant/complainant along with interest at 12% p.a. from the date of the repudiation i.e. 27.02.2012 till the date of realisation, to the complainant. The respondents/opp.parties are also directed to pay a sum of Rs.10,000/- to the appellant/complainant through out towards the costs. The remaining claim of the appellant/complainant is dismissed.
MEMBER
MEMBER
Pm* Dt.30.06.2014
