Andhra Pradesh

Visakhapatnam-II

CC/470/2011

Pujari Jagannadha Rao - Complainant(s)

Versus

Bajaj Alianz Life Insurance Company Limited - Opp.Party(s)

Chikkala Nageswara Rao

13 Apr 2015

ORDER

                                              Date of Registration of the Complaint:12-12-2011 

                                                                                                Date of Order:13-04-2015

BEFORE THE DISTRICT CONSUMERS FORUM-II AT

                             VISAKHAPATNAM

 

P  r  e  s  e  n  t:

1.  Sri H. Ananda Rao, M.A., L.L.B.,

     President           

2. Smt K. Saroja, M.A. B.L.,

     Lady Member 

                                3. Sri C.V. Rao, M.A., B.L.,

                                     Male Member

 

                          Monday, the 13^th day of April, 2015.

                             CONSUMER CASE No.470/2011

Between:-

Pujari Jagannadha Rao, S/o Sannibabu,

Hindu, aged 58 years, residing at Door

No.7-102/3, Dronam Raju Nagar, Pendurthi,

Chinamushdiwada, Visakhapatnam District.

                                                                                                     ….. Complainant

And:-

Bajaj Alianz Life Insurance Co., Ltd., Rep. by its

Assistant Manager (Operation) Dwaraka Nagar,

Visakhapatnam.

                                                                                             …  Opposite Party

                     

This case coming on 07.04.2015 for final hearing before us in the presence of Sri Chikkala Nageswara Rao, Advocate for the Complainant and Sri Syed Moinuddin, Advocate for the Opposite Party and having stood over till this date for consideration, this Forum made the following:

 

                                                ORDER

        (As per Smt. K. Saroja Honourable Lady Member on behalf of the Bench)

 

1.       The case of the Complainant in brief is that the Complainant obtained Mediclaim Policy from the Opposite Party on 27.01.2009 bearing Policy No.0117395784 and paid premium on 05.01.2009 as a first installment on 05.01.2010, the 2^nd and the 3^rd Installments paid on 31.01.2011.   The policy was in force from 27.01.2009 to 26.01.2012.   The Complainant was admitted in Surya Hospital, Visakhapatnam on 16.05.2011 due to “IMPLINGAMENT SYNDROME”, and after treatment the Complainant was discharged on 25.05.2011.   The Complainant intimated the same to the Opposite Party and claimed individual Mediclaim Policy amount.   But the Opposite Party refused for the same and sent a repudiation letter on 02.06.2011.   Then the Complainant issued a legal notice to the Opposite Party, received the same by the Opposite Party and replied for the same.    Hence, this Complaint.   

2.       a) For an amount of Rs.41,375/- and subsequent interest @ 25% p.a. from 27.01.2009 to till the date of realization;

          b) For damages is Rs.90,000/-;

          c) For costs of litigation is Rs.10,000/-;

          d) For such other relief as this Forum may deems fit and proper in the circumstances of the case.

 

3.       The Opposite Party strongly resisted the claim of the Complainant by contending, as can be seen from its counter.   The Opposite Party stated that the Complainant admitted in Manipal Hospital on 20.08.2010 for diabetic nephropathy with HTN, thus the claim of the Complainant was repudiated as he suppressed material fact and obtained the insurance policy.    So, they have no liability to pay any reliefs asked by the Complainant.

 

4.       At the time of enquiry, the Opposite Party filed affidavit as well as written arguments to support his contention.   The Complainant did not file written arguments.   Exs.A1 to A7 are marked for the Complainant.    Exs.B1 to B7 are marked for the Opposite Party.  Heard the both sides.

 

5.       Ex.A1 is the Bajaj Alianz Insurance Company Mediclaim Policy Document No.0117395784 issued by the Opposite Party in favour of the Complainant dated 28.01.2009.    Ex.A2 is the 3 Policy Deposit Renewal Premium Receipts issued by the Opposite Party in favour of the Complainant.  Ex.A3 is the Repudiation letter issued by the Opposite Party to the Complainant dated 02.06.2011.   Ex.A4 is the Office copy of Registered Lawyer’s Notice sent by the Complainant’s counsel to the Opposite Party dated 02.08.2011.   Ex.A5 is the Postal Acknowledgment due from the Opposite Party.   Ex.A6 is the Office copy of Registered Reply Notice sent by T.H. Ramanath, Advocate counsel for the Opposite Party to the Complainant dated 17.08.2011.   Ex.A7 is the photo copy of Medical Bills along with Health Insurance Claim Form issued by Surya Hospital to the Complainant.

 

6.       Ex.B1 is the Proposal Form for Health Plan, letter of the Complainant along with Scrutiny Checklist Form dated 05.01.2009.   Ex.B2 is the Moral Hazard Report of the Complainant dated 05.01.2009.   Ex.B3 is the attested copy of Client Identification Slip of the Complainant (proof).  Ex.B4 is the attested copy of Ration Card with details of family members.   Ex.B5 is the photo copy of Repudiation letter sent by the Opposite Party to the Complainant dated 02.06.2011.   Ex.B6 is the Office copy of Registered Reply Notice issued by the Opposite Party’s counsel to the Complainant dated 17.08.2011.   Ex.B7 is the photo copies of Receipts and Medical Reports issued by the Surya Hospital in favour of the Complainant.

 

7.       The fact shown from Ex.B2 reveals that the Complainant was hale and healthy, at the time of obtaining the policy.   The panel doctor of the Opposite Party noted that the Complainant’s blood pressure was normal i.e., 120/80 before issuing the policy.   It shows that the Complainant was hale and healthy at the time of taking the policy, and he did not suppressed any pre-existing disease while obtaining insurance policy.   

 

8.       The point that would arise for determination in the case is:-

Whether there is any deficiency in service on the part of the Opposite Party.   Whether the Complainant is entitled to any reliefs asked for?

 

9.         After careful perusal of the case record, this Forum finds that the Complainant obtained Medicalim policy from the Opposite Party and paid 3 premiums.   The Complainant was hospitalized on 16.05.2011 and treatment was taken for “IMPLINGAMENT SYNDROME” in Surya Hospital, Visakhapatnam and he was discharged from the hospital on 25.05.2011.   He underwent treatment while the policy was in force.   The policy was in force from 27.01.2009 to 26.01.2012, surgery was done on 17.05.2011.   As per Ex.A7 the Complainant was diagnosed by Dr. T. Ramana Murthy and he noted that the Complainant was admitted with complaint of pain in the right shoulder.   Moreover, the panel doctor of the Opposite Party noted that the Blood Pressure of the Complainant is normal at the time of obtaining the policy.   It reveals that the Complainant has not suffered from hyper tension as alleged by the Opposite Party.    The Opposite Party stated in their counter that the Complainant was admitted in Manipal Hospital on 20.08.2010 for diabetic nephropathy with HTN.   But the Opposite Party failed to produce any piece of material regarding the treatment for diabetic nephropathy of the Complainant.   It amounts to deficiency in service on the part of the Opposite Party as they failed to settle the right claim of the Complainant.   Hence, the Complainant is entitled to Rs.41,375/- with interest, some compensation and costs too.

 

10.     In the result, this Complaint is allowed directing the Opposite Party: a) to pay an amount of Rs.41,375/- (Rupees Forty one thousand three hundred and seventy five only) with interest @ 9% p.a. from 02.06.2011 till the date of actual realization, b) a compensation of Rs.10,000/- (Rupees Ten thousand only) and c) Costs of Rs.2,500/- (Rupees Two thousand and five hundred only) to the Complainant.   Time for compliance, one month from the date of this order.  

Dictated to the Steno, transcribed by him, corrected and pronounced by us in the Open Forum, this 13^th day of April, 2015.

 

 Sd/-                                     Sd/-                                       Sd/-

President                              Male Member                      Lady Member

                                     

APPENDIX OF EVIDENCE

For the Complainant:-

NO.	DATE	DESCRIPTIONOFTHEDOCUMENTS	REMARKS
Ex.A01	28.01.2009	Bajaj Alianz Insurance Company Mediclaim Policy Document No.117395784 issued by the OP in favour of the Complainant	Original
Ex.A02		3 Policy Deposit Renewal Premium Receipts issued by the Opposite Party in favour of the Complainant.	Original
Ex.A03	02.06.2011	Repudiation letter issued by the OP to the Complainant	Original
Ex.A04	02.08.2011	Registered Lawyer’s Notice sent by the Complainant’s counsel to the OP	Office copy
Ex.A05		Postal Acknowledgment due from the OP	Original
Ex.A06	17.08.2011	Registered Reply Notice sent by T.H. Ramanath, Advocate counsel for the OP to the Complainant	Office copy
Ex.A07		Medical Bills along with Health Insurance Claim Form issued by Surya Hospital to the Complainant	Photo copy

 

For the Opposite Party:-               

                  

NO.	DATE	DESCRIPTIONOFTHEDOCUMENTS	REMARKS
Ex.B01	05.01.2009	Proposal Form For Health Plan, letter of the Complainant along with Scrutiny Checklist Form	Original
Ex.B02	05.01.2009	Moral Hazard Report of the Complainant	Original
Ex.B03		Client Identification slip of the Complainant (proof)	Attested copy
Ex.B04		Ration Card with details of family members	Attested copy
Ex.B05	02.06.2011	Repudiation letter sent by the OP to the Complainant	Photo copy
Ex.B06	17.08.2011	Registered Reply Notice issued by the OP’s counsel to the Complainant	Office copy
Ex.B07		Receipts and Medical Reports issued by the Surya Hospital in favour of the Complainant	Photo copy

 

Sd/-                                   Sd/-                                             Sd/-               

President                          Male Member                                Lady Member