Kerala

Alappuzha

CC/249/2004

George Thomas - Complainant(s)

Versus

Branch Manager, U.I.I. - Opp.Party(s)

03 Nov 2008

ORDER


Alappuzha
CONSUMER DISPUTES REDRESSAL FORUM ,BAZAR P.O
consumer case(CC) No. CC/249/2004

George Thomas
...........Appellant(s)

Vs.

Branch Manager, U.I.I.
Greivance Cell
...........Respondent(s)


BEFORE:
1. JIMMY KORAH 2. K.Anirudhan 3. Smt;Shajitha Beevi

Complainant(s)/Appellant(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):




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ORDER

SRI. K.ANIRUDHAN (MEMBER) Sri. George Thomas Advocate, Mavelikara has filed this complaint before the Forum alleging deficiency in service on the part of the opposite parties. The brief facts of the case of the complainant are as follows: - He has taken a joint Medi claim policy from the Kayamkulam Branch of the first opposite party on 10-06-2002. The first opposite party issued the insurance policy certificate vide policy No. 101501/48/02/00238 dated 10-06-2002. It was a joint medi claim policy to the complainant and his wife Smt. Alice George, for the period from 11-06-2002 to 10-06-2003. It is contended that the wife of the complainant was undergone a thyroid operation (Thyroidoectomy) on 02-08-2002. After that the complainant submitted a claim form before the 1st opposite party on 09-10-2002 for the claim amount. But the 1st opposite party, after four months intimated the complainant that they have rejected the claim. The complainant filed an appeal before the Insurance Ombudsman. That was rejected on the ground that the complainant has to seek remedy through the grievance cell. So he has filed appeal before the grievance cell. Since there were no positive steps on the part of the grievance cell and the Ombudsman, he had withdrawn the petition from the ombudsman. Hence this complaint, seeking relief. 2. Notices were issued to the opposite parties. First and second opposite parties entered appearance and filed version. In the version, they have stated that there is no deficiency in service on their part. It is admitted that the first opposite party issued a Mediclaim Policy to the complainant for the period from 11-06-2002 to 10-06-2003 covering the complainant and his wife for Rs. 25,000/- each. It is stated that the certificate of the doctor in the prescribed form submitted along with the claim is not a complete one and that some of the relevant questions are not answered. The Surveyor, appointed by the company, investigated the matter with relatives and neighbours and submitted his report. The report of the surveyor reveals that the patient had the very same disease for the last 3 years and was undergoing treatment for the same when the disease aggravated opted by operation. The wife of the complainant had pre existing disease even prior to the commencement of the policy. The complainant was well aware of the existence of the disease at the time of the submission of the proposal and obtained the policy by misrepresentation and that the complainant is not entitled to get any amount. 3. Considering the rival contentions of the parties, this Forum has raised the following issues:- 1) Whether there is any deficiency in service on the part of the opposite parties? 2) Compensation and costs. 4. Issues 1 and 2: - On the side of the complainant, he has produced documents in evidence – Exts. A1 to A5 – marked, and he was examined as PW1. Ext. A1 document is the policy certificate dated 10-06-2002. It shows that the period of policy was from 11-06-2002 to 10-06-2003. Ext. A2 is the claim form dated 09-10-2002. It shows the name of the insured, nature of disease, name of the attending medical practitioner, name of the hospital etc. Ext. A3 is the Medical Certificate in the form supplied by the 1st opposite party. It shows the name of the patient – Smt. Alice George, date of first reported at the Hospital and nature of disease, nature of illness (Thyrotoxicosin) date of admission, date of discharge, and IP No., name of the doctor attended, and name of Hospital etc. Ext. A4 is the letter dated 22-09-2003 addressed to the grievance cell of the 1st opposite party requesting for a direction to the 1st opposite party to release the amount. Ext. A5 is the letter dated 04-08-2004 addressed to the complainant, informing the permission to withdraw the complaint. 5. On the side of the 1st and second opposite parties, they have produced 7 documents in evidence and marked the same as Exts. B1 to B7 and examined the Divisional Manager as RW1 and Surveyor as CW1 on their side. Ext. B1 is the Proposal form for Medi Claim Insurance Policy. It shows that Smt. Alice George is the proposer. Rs. 25,000/- was the insured amount. In clause 17 of the above said document, she has stated ‘NA’ regarding the positive existence or presence of any ailment sickness or injury. Ext. B2 is the policy certificate of the Medi claim insurance policy. Ext. B3 is the medi claim policy conditions. Ext. B4 is the claim form for the insured amount. Ext. B5 is the doctor’s certificate in the form of the 1st opposite party. Ext. B6 is the letter dated 03-12-2002 of the 1st opposite party addressed to the complainant intimating him the repudiation of the claim due to the pre existence of disease. Ext. B7 is the report of the Surveyor dated 28-11-2002. On going through the exhibits, it can be seen that the opposite parties had repudiated the claim of the complainant on that ground of ‘pre existing disease’ (Ext. B6). The complainant had taken the medi claim insurance policy on 10-06-2002 after remitting the premium amount and the period of insurance was from 11-06-2002 to 10-06-2003, covering the complainant and his wife Smt. Alice George. In the B1 document, (Proposal form for medi claim insurance policy) no pre existence of any disease was noted therein. But after taking the said policy, she has undergone an operation for thyrodicatomy on 02-08-2002 at Pushpagiri Hospital, Thiruvalla and the complainant produced medical Certificate showing the said operation, from the concerned doctor. But the opposite parties repudiated the claim mainly based on the surveyor’s report dated 28-11-2002 (Ext. B7). On a careful reading of the said report, we are of the strong view that it cannot be noted as a valid document to repudiate the claim. The surveyor was an incompetent party to make such an investigation of this Medical Claim. While in box, he has stated that he is a Diploma holder in Mechanical Engineer. He has prepared the report without collecting the genuine matter from the concerned authorities. So the opposite parties actions of repudiation of the claim are without any basis and the contentions raised by the opposite parties by denial of this medi claim cannot be accepted, and it is without any bonafides. The opposite parties cannot repudiate the medi claim of the complainant on the ground of Pre existence of disease. The opposite parties are bound to release the medi claim to the complainant. The denial of release of the insured sum to the complainant by the opposite parties will amount to “deficiency in service” and for this; the opposite parties are answerable to the complainant, by way of compensation. There is gross negligence on the part of the opposite parties in releasing the insured amount to the complainant in time. The action on the part of the opposite parties are highly illegal arbitrary and unauthorized. The issues are found in favour of the complainant. Hence after a careful reading of the evidence in record, depositions of both parties and a detailed hearing, we are of the strong view that the complaint is to be allowed. 6. In the result, we hereby direct the opposite parties to release the full insured amount to the complainant vide the Medi claim policy certificate No. 101501/48/02/00238 dated 10-06-2002 with 12% interest from 09-11-2002 till the date of payment together with a compensation of Rs. 5,000/- (Rupees Five Thousand only) for the mental agony, physical strain and loss of the complainant and a cost of Rs. 1,500/- (Rupees One Thousand and Five Hundred only) for this proceedings. We further direct the opposite parties to pay the said amount to the complainant within one month from the date of receipt of this order. Complaint allowed. Pronounced in Open Forum on this the 29th day of August, 2008 Sd/- Sri. K.Anirudhan Sd/- Sri. Jimmy Korah Sd/- Smt. N.Shajitha Beevi APPENDIX Evidence of the Complainant:- PW1 - George Thomas Ext. A1 10-06-2002 Copy of Policy Certificate Ext. A2 09-10-2002 Copy of Claim Form Ext. A3 - Copy of Medical Certificate Ext. A4 22-09-2003 Copy of letter from the complainant to the Grievance Cell Ext. A5 04-08-2004 Copy of letter to the complainant from the Insurance Ombudsman Evidence of the Opposite parties: - RW1 - Radhakrishnan Nair CW1 - N. Manu (Surveyor) Ext. B1 - Proposal form for Mediclaim Insurance Policy Ext. B2 10-06-2002 Policy Certificate Ext. B3 - Policy Conditions Ext. B4 09-10-2002 Mediclaim insurance policy claim form Ext. B5 - Medical Certificate Ext. B6 03-12-2002 Letter of the 1st opposite party to the Complainant Ext. B7 28-11-2202 Report of the Surveyor // True Copy // By Order Senior Superintendent To Complainant/Opposite parties/SF Typed by: Sh/- Compd by:




......................JIMMY KORAH
......................K.Anirudhan
......................Smt;Shajitha Beevi