Kerala

Thiruvananthapuram

CC/14/162

Gulam Muhammed .M - Complainant(s)

Versus

Branch Manager,National Insurences - Opp.Party(s)

29 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION THIRUVANANTHAPURAM

PRESENT

                                   SRI.P.V.JAYARAJAN       : PRESIDENT

                                  SRI.VIJU.V.R.                   : MEMBER

CC.NO.162/14 (Filed on : 28/04/2014)

ORDER DATED : 29/05/2023

COMPLAINANT

Gulam Mohammed.M

S/o.Mohammed Kasim,

Residing at TC.701/1394,

Raheena Manzil, Bemapalli,

Trivandrum - 695026

(By Adv.K.S.Gopinathan Nair & Adv.K.G.Ragesh)

 

VS

OPPOSITE PARTY

The Branch Manager,

National Insurance Co.Ltd,

Branch 2, KK Building, Aristo Junction,

Thampanoor,

Thiruvananthapuram

(By Adv.S.Rajeev)                                                                         

ORDER

SRI.VIJU.V.R        :MEMBER

1.  
2. The opposite party has averred that the complaint is not maintainable either in law or on facts. The opposite party had issued policy No.570203/48/12/850000/2367 subject to the policy condition. Since the claim of the complainant is not maintainable under Clause 4:1 of the policy the file was closed by the opposite party as “no claim” and communicated the same to the complainant vide letter dated 13/06/2013. On perusal of the medical records submitted by the complainant it is revealed that the main cause for stroke was “hyper tension” which did pre existing for the last eight years. The habits like chronic alchaholic and smoking increased the risk as per the medical records. Since the ailment is a pre existing one as per the Clause 4:1 of the policy the opposite party cannot legally entertain the claim of the complainant. The opposite party can act only as per the terms and conditions stipulated in the policy. The complainant is not entitled to get any relief as prayed in the complaint, hence the complaint may be dismissed with compensatory cost to the opposite party.  

3. Issues to be ascertained:

(i). Whether there is deficiency in service from the side of opposite    

      Party?

(ii). Whether the complainant is entitled to get the reliefs?

 

4. Issues (i) & (ii):- Both these issues are considered together for the sake of convenience.  The complainant has filed affidavit in-lieu of chief examination and has produced 8 documents which were marked as Exts. P1 to P8.  Complainant was examined as PW1 & was cross-examined by opposite party. The Opposite party has filed affidavit in-lieu of chief examination. In 2019 one official of the opposite party was examined as DW1 and after that as DW1 retired from the service another official was examined as DW2. Two documents were marked from the side of OP as Exts. D1 & D2. Both DW1 & DW2 were cross examined by complainant. The complainant and opposite party filed argument notes.  The policy issued to the complainant was admitted by the opposite party. The opposite party has rejected the claim raising the contention that the complainant was having hypertension for the last 8 years & the illness was due to this hypertension. So the ailment was considered as a pre-existing disease.  It is admitted by the opposite party that they have rejected the claim as the medical records submitted by the complainant to them shows the ailment of the complainant was due to hypertension, which was pre existing for last 8 years. Even though opposite party has took the contention of pre existing disease they have not produced any tangible evidence to prove that the deceased was having pre-existing disease.  So it is not proved that the complainant was having any past history of hypertension.

5. It is also relevant to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community.  The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease.  It is mere an excuse to escape liability and is not bona fide intention of the insurance company.  Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.

 6. Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.

 7. If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months.

 8. Disease that can be easily detected by subjecting the insured to basic tests like blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person.

9. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that insurance Companies don’t discharge this obligation as half of the population is suffering from such malaises and they would be left with no or very little business. Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, nor is exclusion clause invokable.

10. Hence we find that the claim was wrongly and illegally repudiated by the opposite party and there is deficiency in service from the side of opposite party. The opposite party is liable to compensate the complainant.

                   In the result, the complaint is allowed. The  Opposite party is directed to pay Rs 91,402/-  (Rupees ninety one thousand four hundred and two only) with 6% interest from 29/11/2012 to the complainant along with     Rs.15,000/-(Rupees Fifteen thousand Only) as compensation to the complainant for the mental agony suffered by the complainant and Rs 2,500/- (Rupees two thousand five hundred only) to the complainant towards the cost of the proceedings within one month from the date of receipt of this order failing which the entire amount except cost carries interest @ 9% per annum from the date of order till realization.

                   A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

                  Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Commission, this the 29^th day of May 2023.

 

                                                                                  Sd/-

P.V.JAYARAJAN   : PRESIDENT

 

                                                                                             

 

                                                                                                  Sd/-

VIJU.V.R     : MEMBER

 

 

 

Be/

 

 

 

APPENDIX

CC.NO.162/2014

List of witness for the complainant

PW1            - Gulam Mohammed.M

List of Exhibits for the complainant

Ext.P1         - Copy of National Insurance Company

Ext.P2         - Copy of Health card

Ext.P3         - Copy of IP Advance from Sree Chithra Thirunal Hospital

Ext.P4         - Copy of advocate notice

Ext.P5         - Copy of national insurance company dated 13/06/2013
Ext.P6         - Copy of Discharge summary

Ext.P7         - Copy of statement of account

Ext.P8         - Copy of medical bill particulars

List of witness for the opposite parties

DW1            - Mallika

DW2            - Jidhya.C

List of Exhibits for the opposite parties

Ext.D1        - Copy of Insurance Company dated 13/06/2013

Ext.D2        - Copy of National Insurance Company Ltd

Court Exhibits      - NIL

 

                                                                                               Sd/-

                                                                                       PRESIDENT