IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 27th day of January, 2009
Filed on 28.03.07
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. Shajitha Beevi (Member) in
C.C.No.63/07
between
Complainant:- Opposite Party:-
Sri.Sunny George, The New India Assurance Co.Ltd.,
S/o K.George, Rep. by its Branch Manager,
Perumpallil Kuttiyil, Kayamkulam.
Kurathiyadu.P.O., Mavelikkara. (By Adv.C.Muraleedharan)
(By Adv.C.P.Syjesh)
O R D E R
SRI.JIMMY KORAH (PRESIDENT)
The case of the complainant is that he was the holder of Universal Health insurance Policy from the opposite party for the period 4.7.2006 to 3.7.2007. During this period he was admitted in hospital and thereafter he claimed the medical expenses. But the insurance company repudiated the claim on the reason that the treatment taken for a pre existing disease at the time of taking policy. Against this decision complainant filed this complaint alleging deficiency of service.
1. Opposite party filed version stating that he was treated for a disease which he had at the time of taking policy. As per the terms and conditions of the policy repudiation of the claim is valid and proper. Hence complaint may be dismissed.
2. Considering the rival contention of both parties this forum raised following issues.
Is there any deficiency of service on the part of the opposite party?
3. Complainant filed 9 documents which are marked as Ext. Al to A9. Complainant examined as PW1. The opposite party filed 9 documents which are marked as Ext. B1 to B9. Manager of the opposite party examined as RWl.
4. The case of the opposite party is that the complainant was claimed the expenses for the treatment for "injury caused due to fall". But as per their investigation it was revealed that he was treated for his illness due to a problem from his child hood. Hence this disease may be considered as pre existing disease. Here for determining exclusion clause pre existing disease, Condition No.3 in the policy is relevant. Terms and conditions of tile policy marked as Ext. B1. As per condition No.3 “………………………………… Occurrence of same illness after a lapse of 60 days as stated above will be considered as fresh illness for the purpose of policy". This condition is very clear and unambiguous. The opposite party has no case that the alleged disease was caused within 60 days. There is no evidence for the same. Hence the said disease can be considered only as a fresh illness and not a pre existing disease. Hence this Forum found that repudiation of the claim is illegal and there is a deficiency of service on the part of the opposite party. The opposite party has no dispute with regard to the medical bills. Complainant claimed Rs.14,520/- (Rupees fourteen thousand five hundred and twenty only) as treatment expenses and same is to be allowed. Complainant is entitled to get Rs.l4,520/- (Rupees fourteen thousand five hundred and twenty only) with interest at the rate of 9% from the date of filing of this petition (28.3.2007) till date of realization. There is no order on cost.
Complaint allowed.
Pronounced in open Forum on this the 27th day of January, 2009.
Sd/-Sri. Jimmy Korah
Sd/-Sri. K. Anirudhan
Sd/-Smt. N. Shajitha Beevi
Appendix:-
Evidence of the complainant:-
PW1 - Sunny George (Witness)
Ext. A1 - The Insurance Policy – The New India Assurance Co.Ltd.,
Ext. A2 - The conditions of Universal Health Insurance Policy - The New India
Assurance Co.Ltd.,
Ext. A3 - The receipt of The New India Assurance Co.Ltd., dated, 04.07.2006
Ext. A4 - The Letter issued by The New India Assurance Co.Ltd., Kayamkulam
dated, 08.02.2007
Ext. A5 - The copy of the Medical Certificate dated, 13.09.2006
Ext. A6 - The Medical Certificate issued by Dr.J.Deyal Kumar dated, 21.02.2007
Ext. A7 - The Cash Bill dated, 05.09.2006 for an amount of Rs.14,520/-
Ext. A8 - The copy of the Treatment details dated, 22.08.2006 to 05.09.2006
Ext. A9 - The copy of the Claim Form of The New India Assurance Co.Ltd.,
Evidence of the opposite party:-
RW1 - Preetha.S (Witness)
Ext. B1 - The Policy and Conditions of The New India Assurance Co.Ltd.,
Ext. B2 - The Claim Form submitted by the Complainant
Ext. B3 - The Medical Certificate dated, 13.09.2006
Ext. B4 - The Discharge Card dated, 22.08.2006 to 05.09.2006
Ext. B5 - The copy of the Treatment details dated, 22.08.2006 to 05.09.2006
Ext. B6 - The Letter of the Complainant dated, 25.08.2006
Ext. B7 - The copy of the Letter issued to the Complainant dated, 08.02.2007
Ext. B8 - The Investigation Report
Ext. B9 - The Statement issued to the Opposite party
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite Parties/S.F.
Typed by:- k.x/-
