BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 14/02/2012

Date of Order : 31/10/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 90/2012

Between

And

O R D E R

A. Rajesh, President.

1. The case of the complainant is as follows :-

On 26-07-2010, the complainant availed an insurance policy from the opposite party. The same has been renewed subsequently. During the currency of the policy, the complainant underwent treatment and submitted a claim application before the opposite party claiming Rs. 13,955/- towards treatment expenses. On 20-12-2011, the opposite party sent a letter informing the complainant regarding repudiation of the insurance claim. But the repudiation of the insurance claim is unsustainable in law. The complainant is entitled to get the insurance claim together with Rs. 1,670/- towards interest and Rs. 10,000/- towards compensation. This complaint hence.

2. The version of the opposite party is as follows :-

The opposite party repudiated the insurance claim in accordance with law relying on the terms and conditions of the policy. As per the treatment records, the complainant was treated for Cervical radiculopathy. She was suffering from the said illness even prior to the commencement of the insurance policy. The pre-existing diseases are not covered under the terms and conditions of the policy. There is no deficiency in service on the part of the opposite party.

3. No oral evidence was adduced by the complainant. Exts. A1 to A10 were marked. Neither oral nor documentary evidence was adduced by the opposite party. Ext. X1 also was marked. Heard the authorised representative of the complainant and the learned counsel for the opposite party.

4. The only point that comes up for consideration is whether the complainant is entitled to get a total sum of Rs. 25,625/- from the opposite parties?

5. Admittedly, the complainant was holding an insurance policy of the opposite party from 26-07-2010 to 25-07-2012 evident from Exts. A1 and A2. During the currency of the policy, the complainant had undergone treatment at Amritha Institute of Medical Sciences from 27-08-2011 to 30-08-2011. Her illness was diagnosed as Cervical radiculopathy evidenced by Ext. A5. The insurance claim of the complainant was repudiated by the opposite party by Ext. A10 letter dated 14-12-2011. The letter reads as follows :-

“Please note that your file stands closed, on account of Sr. No. 1 and 3 below :

1. In spite of letters/reminders sent to you, you have not complied with the required papers/documents.

    

2. As you have withdrawn your claim by giving your consent through your letter dated.............. we are closing your claim file as NO CLAIM.

    

3. Wee are closing your claim file on account of the following reasons :

CERVICALRADICULOPATHY/EXISTING DISEASE.

We absolve ourselves from any further liabilities, arising out of this claim which please note.”

6. At the instance of the opposite party, the case sheet of the complainant maintained by Amritha Institute of Medical Sciences was summoned to this Forum and marked as Ext. X1. Ext. X1 goes to show that the complainant was taken to the hospital only on 27-08-2011 and discharged on 30-08-2011. The disease was diagnosed as Cervical Spondylosis with Cervical Canal Stenosis. We could not find any material in Ext. X1 to show that the complainant had been suffering from a pre-existing illness other than the claim of the opposite party without material evidence prior to the inception of the policy. In the absence of such evidence, we are only to hold tat the repudiation of the insurance claim of the complainant amounts to deficiency in service on the part of the opposite party. Resultantly, the complainant is entitled to get the insurance claim from the opposite party with interest at the rate of 12% p.a. from the date of repudiation of the insurance claim till payment. The complainant had to knock at the doors of this Forum due to the rejection of the insurance claim on irregularised grounds. Costs of the proceedings is called for. We fix it at Rs. 1,000/- .

7. In the result, we partly allow the complaint and direct as follows :-

1. The opposite party shall pay the insurance claim of the complainant with 12% interest p.a. from the date of repudiation till realisation.

2. The opposite party shall also pay to the complainant Rs. 1,000/- towards costs of the proceedings.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in the open Forum on this the 31^st day of October 2012

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By order,

Senior Superintendent. A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :: Nil

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