CONSUMER DISPUTES REDRESSALFORUM, KOTTAYAM Present Sri.Snthoshkesavanath.P. President Smt.Bindhu M.Thomas Member Sri.K.N.Radhakrishnan Member.
CC.No.42/09 Wednesday, the day of 31st, December, 2009.
Petitioner. Divya.V. Leelavilas Near Union Club Kottayam-1. Vs. Opposite parties: 1. United India Insurance Co.Ltd. Branch Manager Parekulam Buildings Collectorate.P.O. Kottayam. (Adv.Stheesh Mathew Zacharia) 2. Sheela Kinnagiri ouse, Arthooty Kottayam-1. 3. T.T.K.Health Care Service Pvt.Ltd. 7, Jeevan Bhima Nagar Main Road AL 3rd Stage, Bangalore-560 075.
O R D E R Smt.Bindhu M.Thomas, Member.
The case of the complainant is as follows: Complainant is a Bsc Nursing student who availed an Individual Health Insurance Policy from the first opposite party. Second opposite party is an authorized agent of the first opposite party and third opposite party is the claim settlement authority of the first opposite party. The second opposite party collected yearly premium of Rs.608/- from the complainant and the first opposite party issued a policy vide policy No. 100505/48/08/97/00000199 to the complainant after the full medical examination which was valid from 12-5-2008 to 11-52009. On 14-5-2008, complainant fell down in the bath room and caused severe pain to her back. Immeditely she was taken to hospital and -2- treatment including surgery and physiotherappy was done. She was discharged from the hospital on 2-6-2008. Subsequently the complainant claimed an amount of Rs.57,961/- to the third opposite party and gave all original medical records including medical bills. On 26-8-2008, third opposite party rejected the claim on the medical certificate sentence ''basic cause of disc degeneration would have started few months back. ''The complaint contented that the reason for the claim repudiation is not sustainable as the said treatment started only after the complainant fell down in the bathroom. The complainant further contented that he had no prior knowledge of disc degeneration and had never consulted a doctor before 14-5-2008 for any disc problem. According to the complainant the said disc degeneration was detected after she fell down in the bathroom. The complainant alleged ''deficiency in service'' and unfair trade practice'' on the part of opposite parties and filed this complaint claiming Rs.57,961/- with18% interest, Rs10,000/- as compensation for mental agony and cost. Notice was served to all the opposite parties. Third opposite party called absent hence set expartee. First and second opposite parties entered appearance and filed version seperately. The first opposite party filed version with the following main points. The complainant was having disc prolapse even much before and hence she took individual health policy and admitted in the hospital for the treatment of the same. The claimant was insured for a sum of Rs.50,000/- only by her individal policy but she claimed an exhorbitant amount of Rs.57,961/-. The claim was repudiated on the ground that the disease was a pre-existing one. The policy explicitly excludes any disease contracted within 30 days from the inception and pre-existing diseases are not covered. In this case there is suppression of material facts from the side of the -3- complainant and hence the contract of insurance is void abinitio. As the claim was repudiated on valid and reasonable grounds, there shall be no mental agony or money loss happened to the complainant. Hence the first opposite party prayed to dismiss the complaint with costs to them. The second opposite party filed version with the following main contentions.
According to the information received by this opposite party, the cause of the fall is due to disk degeneration which was existing prior to the inception of the policy. As there is suppression of material facts by the complainant the rejection of the claim is on valid grounds. There is no deficiency in service or unfair trade practice on the part of opposite parties.
Hence the second opposite party prayed to exonerate her with regard to this petition allowing the cost. Point No.1. Heard boh sides and perused the entire documents on record. The first and second opposite parties counsel argued that the policy excludes any disease contracted within 30 days from the inception. The Individual Health Insurance Policy originl and true copy are produced by the complainant and opposite parties and they are marked as exhibit A4 and exhibit B1 respectively. On perusal of exhibit A4 & B1 no such exclusion clause is seen. So the opposite parties' abovesaid contention will not stand. It is not in dispute that the cmplainant was admitted to Caritas Hospital on 14-5-09 and was treated there till 2-6-2009. The petitioner submitted that the aforesaid
-4- treatment was taken due to fall in bathroom. The opposite parties produced the medical report from Caritas Hospital and it is marked as exhibit B3. The opposite party's counsel further submitted that as per the 'history of illness' in the medical report, the basic cause of disc degeneration would have started a few months back. The learned counsel for opposite parties argued that the complainant had not revealed the ailment in the proposal form and therefore the claim is inadmissible. The repudiation letter is produced and marked as exhibit A7. As per exhibit A7the claim was repudiated on grounds that the disease was pre-existing and that the treatment was wthin 2 days of inception of cover. In this case the policy was taken by the complainant on 12/5/08 and prior to that no proof had been given by the opposite parties to show that the complainant was ever admitted in the hospital for the treatment of the alleged disease. There is nothing on record to prove that the complainant was a patient of ''disc degeneration'' before filling in up the declaration form. Furthermore there is no record to prove that the complainant was in knowledge of the said disease prior to the date of admission in the hospital. So in our opinion the non-mentioning of such type of disease in the declaration form by the complainant does not amount to suppression or concealment of material fact or mis-statement. In our view the repudiation of the claim on flimsy grounds is not justified and we hold the opposite parties dificient in service. Point No.1 is found accordingly. Point No.2. The learned counsel for first and second opposite parties submitted that the complainant had insured herself for an amount of Rs.50,000/- only as sum insured. On perusal of ext.A4, policy it is seen that the sum insured is only Rs.50,000/-. The complainant submitted tht she made a claim of Rs.57,961/- based on the actual expenses incurred by her in the hospital. The opposite parties one and two has no case that the claim of Rs.57,961/- is untrue or incorrect. So we feel that the insured sum of Rs.50,000/- is to be given to the complainant.
-5- In the result the petition is allowed and the petition is ordered as follows. The first opposite party will pay the insured amount of Rs.50,000/- with interest @ 9% p.a. from the date of repudiation till realisation to the complainant. The first opposite party will also pay Rs.1000/- as litigation cost to the complainant. As interest is allowed no compensation is ordered. Smt.Bindhu Mthomas Member Sd/- Sri.Santhosh Kesavanath.P. President Sd/- Sri.K.N.Radhakrishnan Member. Sd/- APPENDIX Documents of the petitioner. Ext.A1 Insurance policy receipt Ext.A2 Health Insurance guide book. Ext.A3 Health card Ext.A4 Individual Halth Insurance policy xt.A5 Photostat of Medical report Ext.A6 Opposite pary's letter dtd. 11/8/08 Ext.A7 Letter dtd.26/8/08 Documents of the opposite parties. Ext.B1 Copy of policy Ext.B2 discharge summary Ext.B3 Medical report. Ext.B4 Opposite party's letter dtd. 26/8/08. By Orders,
Senior Superintendent. Kgr/5 copies.
......................Bindhu M Thomas
......................Santhosh Kesava Nath P | | 
