BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 31st day of August, 2009

Present:

SRI.LAIJU RAMAKRISHNAN PRESIDENT

SMT.SHEELA JACOB MEMBER

SMT.BINDU SOMAN MEMBER

C.C No.22/2009

Between

Complainant : P.M.Ibrahim,

Perunilathu House,

Madathikkandam P.O,

Thodupuzha.

(By Adv: K.M.Sanu)

And

Opposite Party : The Branch Manager,

National Insurance Company Limited,

Pulimoottil Shopping Arcade,

P.B No.21, Thodupuzha P.O.

(By Adv: K.Pradeepkumar)

O R D E R

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

Complainant availed a medi-claim policy from the opposite party from 2002 onwards. The coverage included the complainant and his wife. But the claim of the complainant was rejected by the opposite party in 2004 and a case was filed by the complainant for the same. Afterwards the policy coverage of the complainant was not renewed. But the policy coverage of the wife was renewed. The medi-claim policy of the complainant's wife from the period 6.03.2008 to 5.03.2009 was renewed for Rs.50,000/- and a premium of Rs.1,837/- was paid. The complainant's wife was admitted in Holy Family Hospital, Muthalakkodam from 14.08.2008 to 18.08.2008 for the treatment of respiratory problem. Then the complainant filed a claim for getting the insurance amount after discharging from the hospital. But it was repudiated by the opposite party on 19.01.2009. So this petition is filed for getting the treatment expenses of the petitioner's wife which amounts to Rs.2,000/-.
 

2. The opposite party filed a written version and admitted that there was a mediclaim policy in the name of the complainant and for the coverage of his wife Smt.Pathumma Ebrahim for the period from 6.03.2003 to 5.03.2004. The policy was availed by suppressing the fact that both of them were suffering from various diseases. The wife of the complainant was suffering from airway obstructive disease from October 2000. Insured is bound to discharge the details of the disease he suffers. In this case policy was obtained by suppressing the material facts. The certificate issued from the hospital shows that the complainant's wife was in treatment for the disease in question from 9.10.2000 onwards. As per exclusion clause No.4.1 of the contract of insurance, all the pre-existing diseases at the time of the insurance is excluded from insurance cover. Hence the petition is liable to be dismissed.
 

3. The point for consideration is whether there was any deficiency in service on the part of the opposite party, and if so, for what relief the complainant is entitled to?
 

4. The evidence consists of the oral testimony of PW1 and Exts.P1 and P2 marked on the side of the complainant and the oral testimony of DW1 and Exts.R1 to R3 marked on the side of the opposite party.
 

5. The POINT :- Complaint is filed for getting the insurance amount for the treatment of his wife. Complainant is examined as PW1. PW1 deposed that there was insurance coverage for the complainant upto 2004. But when a claim was repudiated by the company, a case is filed by the complainant. So the coverage of the complainant was not renewed by the opposite party. The policy is marked as Ext.P1. But his wife is having policy coverage. She was treated from 14.08.2008 to 18.08.2008 in Holy Family Hospital, Muthalakkodam for respiratory problem. The expenses for the treatment was Rs.2,000/-. Only because the complainant filed case against the opposite party, they repudiated the claim of his wife. The repudiation letter is marked as Ext.P2. DW1 is the doctor from Holy Family Hospital, Muthalakkodam. DW1 deposed that DW1 perused the case sheet of Pathumma Ebrahim, wife of the complainant and a certificate issued. The certificate is marked as Ext.R1. The said Pathumma was under treatment for airway disease from 9.10.2000 onwards. She often comes to the hospital. The case sheet is marked as Ext.R2. The airway diseases are mainly due to allergy so it needed treatment very often. As per the opposite party, the claim was repudiated because of the suppression of the material facts. But the complainant has taken the policy from 2002 onwards and the policy was renewed yearly after that. But what prevented the opposite party to make medical check up before renewing the policy or at the time of issuing the policy. The complainant's claim was rejected in the year 2004 because of suppression of material facts, that he was a diabetic patient. Even after that the opposite party received the premium for renewal of the coverage of his wife. It is the duty of the opposite party, before issuing the policy to conduct a medical check up especially in the case of mediclaim policy. There is a panel of doctors for the opposite party. As per the complainant the opposite party received a premium of Rs.1,837/- and renewed the policy. But the treatment expenses for Rs.2,000/- was rejected. It is a gross deficiency in the part of the opposite party. The ordinary lay man is not liable for that. Hence we think that it is fit to direct the opposite party to pay the insurance amount to the complainant.
 

Hence the petition allowed. The opposite party is directed to pay the treatment expenses for the wife of the complainant which is Rs.2,000/- with 12% interest from the date of this petition within one month and Rs.500/- for the cost of this petition within one month of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default.
 

Pronounced in the Open Forum on this the 31^st day of August, 2009

Sd/-

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

Sd/-

SMT.SHEELA JACOB(MEMBER)

Sd/-

SMT.BINDU SOMAN(MEMBER)

APPENDIX

Depositions :

On the side of Complainant :

PW1 - P.M.Ibrahim

On the side of Opposite Party :

DW1 - Girija Thankappan

Exhibits

On the side of Complainant:

Ext.P1 - Photocopy of Policy Schedule

Ext.P2 - Repudiation letter dated 19.01.2009 issued by the opposite party

On the side of Opposite Party :

Ext.R1 - Certificate issued by Dr.Girija Thankappan, Holy Family Hospital, Muthalakkodam

Ext.R2 - O.P Record issued from Holy Family Hospital, Muthalakkodam

Ext.R3 - Policy Copy