BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI .A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No. 485/2002 Dated: 15..09..2009
Complainant:
Powlose Kesari, Panavila House, Venganji, Kollamcode (via) Panavila-P.O. Represented by R. Suma (The Power of Attorney Holder) (By Adv. C. Mohanan)
Opposite parties:
1.The New India Assurance Company Ltd., Represented by the Divisional Manager, Thiruvananthapuram. 2.The Branch Manager, The New India Assurance Company Ltd., Neyyattinkara Branch.
(By Adv. M. Nizamudeen) This complaint is disposed of after the period so specified under the Consumer Protection Act, 1986. Though the case was taken up for orders by the predecessors of this Forum on 22..11..2004, the order was not prepared accordingly. This Forum assumed office on 08..02..2008 and re-heard the complaint. This O.P having been heard on 30..07..2009, the Forum on 15..09..2009 delivered the following: ORDER
SHRI. G. SIVAPRASAD, PRESIDENT:
The facts leading to the filing of the complaint are that the complainant was a policy holder of the opposite parties, that the complainant entered into an insurance agreement with the opposite parties - Pravasi Suraksha Kudumba Arogya Scheme, that the premium amount was Rs. 3,490/-, that the effective date was from 27/3/2001 to 26/3/2006, that the policy certificate No.is 2001/47/76140/81660 (761401), that on 17/7/2002 complainant was admitted in P.R.S Hospital, Thiruvananthapuram, that pain and swelling Rt-ing-region of 6 months was detected and an operation was conducted on 18/7/2002, that the complainant was an impatient from 17/7/2002 to 21/7/2002 and that the complainant spent Rs.15,137.05 towards the said treatment. Complainant submitted the claim application with all the original records to opposite parties and the same was repudiated by the opposite parties and intimated vide letter dated 12/9/2002 stating that there was prior existing disease prior to the said policy. The opposite parties have committed deficiency in service by stating false reasons. Complainant sent an advocate notice which was accepted by the opposite parties. Hence this complaint claiming Rs.15,137/- towards medical and treatment expenses from the opposite parties.
2. Opposite parties entered appearance and filed version contending that the claim submitted by the complainant was repudiated by opposite parties. On perusal of records it was found that the disease was in existence prior to the issuance of the policy and that under exclusion vii.1 of the policy conditions issued to the complainant pre-existing disease and illness are excluded, that the claim submitted by the complainant was not payable under the conditions of the policy issued to the complainant. Opposite parties have not committed any deficiency in service and the claim has been repudiated for valid, legal and cogent reasons. Hence opposite parties prayed for dismissal of the complaint. 3. Points that arise for consideration are: Whether complainant had undergone RIH repair before taking policy? Whether the said disease and its treatment was in his knowledge? Whether complainant is entitled for claim amount from the opposite parties? Whether there has been deficiency in service on he part of opposite parties?
4. In support of the complaint, the power of attorney holder of the complainant has filed affidavit and Exts.P1 to P47 were marked. In rebuttal, opposite party has filed counter affidavit and Exts.D1 & D2 were marked. 5. Points (i) to (iv): Admittedly, complainant is a policy holder of the opposite parties and complainant is a beneficiary of the said policy called Pravasi Suraksha Kudumba Arogya Scheme. It has been the case of the complainant that he was admitted and treated in P.R.S Hospital, Thiruvananthapuram on 17/7/2002, pain and swelling Rt-ing-region of 6 months was detected and an operation was conducted on 18/7/2002 and complainant was an impatient from 17/7/2002 to 21/7/2002 and complainant had spent a sum of Rs.15,137/- for the said treatment. It has also been the case of the complainant that the claim application submitted to opposite parties has been repudiated and the same was intimated to him vide letter dated 12/9/2002, thereby opposite parties has committed deficiency in service. It is argued by opposite parties that the claim of the complainant was repudiated since the complication of sickness arose from pre-existing disease. Ext.D1 is the copy of the discharge summary issued by P.R.S Hospital. As per Ext.D1 it is stated that complainant was admitted on 17/7/2002 and discharged on 21/7/2002. As per Ext.D1, Diagnosis is RIH RCC, C/o pain and swelling Rt-ing-region 6 months. Under relevant investigations it is seen recorded that “H/O undergrowing repair RIH 2 years back in Medical College Hospital. On 18/7/2002 under GH the RIH was repaired”. Ext.D2 is the conditions of the policy issued to the complainant. As per Ext.D2 under Exclusion VII (1) it is seen stated that “Such diseases which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition”. As per Ext.D2 exclusion VII it is clearly mentioned that companies shall not be liable to make payment under the Scheme in respect of expenses whatsoever incurred by or for any insured person in connection with or in respect of such diseases which have been in-existence at the time of proposing the insurance. It is pertinent to point out that complainant was admitted in P.R.S Hospital, Thiruvananthapuram on 17/7/2002 for treatment of pain and swelling Rt-ing-region. It is clear from Ext.D1 that the treatment allegedly undergone by the complainant at P.R.S Hospital is the continuation and due to the complication arising from the disease which was in existence years back prior to the commencement of the policy and the complainant had sufficient knowledge regarding the pre-existing condition at the time of taking the policy. Admittedly, the policy was issued in favour of the complainant for the period from 27/3/2001 to 26/3/2006. On going to the relevant investigation stated in Ext.D1 discharge summary, it is crystal clear that complainant was suffering from pre-existing disease from 17/7/2000 ie. one year prior to the commencement of the policy. It is stated in discharge summary that H/O undergrowing repair RIH 2 years back in MCH ie 17/7/2000. According to opposite parties the policy was taken by the complainant suppressing the material facts and misrepresentations and suppressing his pre-existence of disease, therefore, the policy is void and the complainant cannot get any benefit under the policy. The documents furnished by the complainant do not show that the said disease started after the commencement of the policy. We cannot disbelieve the discharge summary issued by the competent Doctor. Evidently by Ext.D1 complainant was suffering from disease years back prior to the commencement of the policy. In this context we need to say that insurance contracts are uberima fides and are founded upon good faith. If any party fails to observe utmost good faith the contract may be avoided by the other. This legal proposition has been re-iterated time and again by the Supreme Court as well as various High Courts. In this case, there is material to show that there was H/o undergrowing repair RIH 2 years back in Medical College Hospital which was not disclosed by the complainant. In view of the above discussion and in the light of evidence available on records we find opposite parties have proved beyond doubt that the insured had suppressed material facts while obtaining the policy and the treatment undergone at P.R.S Hospital from 17/1/2002 to 21/7/2002 is the continuation and due to the complication arising from the disease which was in existence years back prior to the commencement of the policy and complainant had sufficient knowledge regarding the said treatment. Deficiency in service not proved. Complaint has no merit which deserves to be dismissed.
In the result, complaint is dismissed. Parties are left to bear and suffer their own costs.
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 Forum, this the 15th day of September, 2009.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI. A : MEMBER
S.K. SREELA : MEMBER
ad.
O.P.No.485/2002 APPENDIX I. Complainant's witness: NIL II. Complainant's documents: P1 : Receipt No.39055 dated 21/7/2002 issued by PRS Hospital, Tvpm. P2 : " No.34151 dated 17/7/2002 " P3 : Bill No. 146663 dated 18/7/2002 P4 : Bill No.146663 dated 18/7/02 for Rs.910.80 P5 : Bill No.146713 dated 19/7/02 for Rs.29.80/- P6 : Bill No.7419 dated 19/7/2002 for Rs.24.70/- P7 : Bill No.146637 dated 18/7/2002 for Rs.1135.40/- P8 : Bill No.14680/- dated 20/7/2002 for Rs.9/- P9 : Bill No.146947 dated 21/7/2002 for Rs.1.50/- P10 : " 146638 dated 18/7/2002 for Rs.40/-. P11 : Electro Cardiogram dated 9/7/2002 reported by PRS Hospital. P12 : Laboratory Report of Blood dated 9/7/2002 with Sl.No.295997. P13 : " Urine dated 9/7/2002 P14 : Prescription issued from PRS Hospital, Tvpm dated 26/7/02. P15 : " dated 21/7/2002 P16 : " dated 19/7/2002 P17 : " dated 19/7/2002 with Reg.No.225053 P18 : " dated 20/6/2002 with IP No.225053 P19 : Medicine requisition issued from PRS Hospital dated 19/7/2002. P20 : " dated 17/7/2002. P21 : Prescription issued from PRS Hospital dated 21/7/2002 P22 : " dated 15/7/2002. P23 : Report of ECG issued by Dr. Parthiban dated 16/7/2002. P24 : Bill No.656516 dated 26/7/2002. P25 : Cash bill No.2971 dated 26/7/2002. P26 : " No.836 dated 21/7/2002. P27 : " No.CA/7848 dated 22/7/2002. P28 : Cash Bill No.2495 dated 20/7/2002. P29 : Bill No.654647 dated 21/7/2002 for Rs.384/-. P30 : Bill No.654285 dated 20/7/2002 for Rs.689.50/-. P31 : Bill No.653855 dated 19/7/2002. P32 : Bill No.653671 dated 19/7/2002 for Rs.768/-. P33 : " 653183 dated 17/7/2002. P34 : " 86567 dated 16/7/2002 for Rs.900/-. P35 : " 1371 dated 9/7/2002 for Rs.60/-. P36 : " 2224 dated 15/7/2002 for Rs.100/-. P37 : " 295997 dated 09/7/2002 for Rs.188/-. P38 : Photocopy of flight coupon of Oman Air bearing No.9103678698 283. P39 : Bill No.2448 dated 16/7/2002 for Rs.40/-. P40 : Photocopy of passport No.V-318423 of Pawlos Kesari P41 : Bill details for 52412 IP 225 053. P42 : Credit bill No.52412 dated 21/7/2002. P43 : Biochemical Analysis issued by K.H.Lab, Tvpm dated 9/7/02. P44 : Copy of reply nltice dated 29/10/2002. P45 : Postal receipt dated 29/10/2002. P46 : Postal acknowledgment card dated 30/10/2002. P47 : Certificate of Insurance issued by New India Assurance Co.Ltd No.2001/47/761401/31660 dated 27/3/2001.
III. Opposite parties' witness: NIL IV. Opposite parties' documents: D1 : Photocopy of discharge summary dated 17/7/2002. D2 : Specimen copy of Pravasi Kudumba Arogya Scheme.
PRESIDENT ad.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI .A : MEMBER SMT. S.K. SREELA : MEMBER O.P. No. 485/2002 Dated: 15..09..2009
Complainant:
Powlose Kesari, Panavila House, Venganji, Kollamcode (via) Panavila-P.O. Represented by R. Suma (The Power of Attorney Holder) (By Adv. C. Mohanan)
Opposite parties:
1.The New India Assurance Company Ltd., Represented by the Divisional Manager, Thiruvananthapuram. 2.The Branch Manager, The New India Assurance Company Ltd., Neyyattinkara Branch.
(By Adv. M. Nizamudeen) This complaint is disposed of after the period so specified under the Consumer Protection Act, 1986. Though the case was taken up for orders by the predecessors of this Forum on 22..11..2004, the order was not prepared accordingly. This Forum assumed office on 08..02..2008 and re-heard the complaint. This O.P having been heard on 30..07..2009, the Forum on 15..09..2009 delivered the following: ORDER
SHRI. G. SIVAPRASAD, PRESIDENT:
The facts leading to the filing of the complaint are that the complainant was a policy holder of the opposite parties, that the complainant entered into an insurance agreement with the opposite parties - Pravasi Suraksha Kudumba Arogya Scheme, that the premium amount was Rs. 3,490/-, that the effective date was from 27/3/2001 to 26/3/2006, that the policy certificate No.is 2001/47/76140/81660 (761401), that on 17/7/2002 complainant was admitted in P.R.S Hospital, Thiruvananthapuram, that pain and swelling Rt-ing-region of 6 months was detected and an operation was conducted on 18/7/2002, that the complainant was an impatient from 17/7/2002 to 21/7/2002 and that the complainant spent Rs.15,137.05 towards the said treatment. Complainant submitted the claim application with all the original records to opposite parties and the same was repudiated by the opposite parties and intimated vide letter dated 12/9/2002 stating that there was prior existing disease prior to the said policy. The opposite parties have committed deficiency in service by stating false reasons. Complainant sent an advocate notice which was accepted by the opposite parties. Hence this complaint claiming Rs.15,137/- towards medical and treatment expenses from the opposite parties.
2. Opposite parties entered appearance and filed version contending that the claim submitted by the complainant was repudiated by opposite parties. On perusal of records it was found that the disease was in existence prior to the issuance of the policy and that under exclusion vii.1 of the policy conditions issued to the complainant pre-existing disease and illness are excluded, that the claim submitted by the complainant was not payable under the conditions of the policy issued to the complainant. Opposite parties have not committed any deficiency in service and the claim has been repudiated for valid, legal and cogent reasons. Hence opposite parties prayed for dismissal of the complaint. 3. Points that arise for consideration are: Whether complainant had undergone RIH repair before taking policy? Whether the said disease and its treatment was in his knowledge? Whether complainant is entitled for claim amount from the opposite parties? Whether there has been deficiency in service on he part of opposite parties?
4. In support of the complaint, the power of attorney holder of the complainant has filed affidavit and Exts.P1 to P47 were marked. In rebuttal, opposite party has filed counter affidavit and Exts.D1 & D2 were marked. 5. Points (i) to (iv): Admittedly, complainant is a policy holder of the opposite parties and complainant is a beneficiary of the said policy called Pravasi Suraksha Kudumba Arogya Scheme. It has been the case of the complainant that he was admitted and treated in P.R.S Hospital, Thiruvananthapuram on 17/7/2002, pain and swelling Rt-ing-region of 6 months was detected and an operation was conducted on 18/7/2002 and complainant was an impatient from 17/7/2002 to 21/7/2002 and complainant had spent a sum of Rs.15,137/- for the said treatment. It has also been the case of the complainant that the claim application submitted to opposite parties has been repudiated and the same was intimated to him vide letter dated 12/9/2002, thereby opposite parties has committed deficiency in service. It is argued by opposite parties that the claim of the complainant was repudiated since the complication of sickness arose from pre-existing disease. Ext.D1 is the copy of the discharge summary issued by P.R.S Hospital. As per Ext.D1 it is stated that complainant was admitted on 17/7/2002 and discharged on 21/7/2002. As per Ext.D1, Diagnosis is RIH RCC, C/o pain and swelling Rt-ing-region 6 months. Under relevant investigations it is seen recorded that “H/O undergrowing repair RIH 2 years back in Medical College Hospital. On 18/7/2002 under GH the RIH was repaired”. Ext.D2 is the conditions of the policy issued to the complainant. As per Ext.D2 under Exclusion VII (1) it is seen stated that “Such diseases which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition”. As per Ext.D2 exclusion VII it is clearly mentioned that companies shall not be liable to make payment under the Scheme in respect of expenses whatsoever incurred by or for any insured person in connection with or in respect of such diseases which have been in-existence at the time of proposing the insurance. It is pertinent to point out that complainant was admitted in P.R.S Hospital, Thiruvananthapuram on 17/7/2002 for treatment of pain and swelling Rt-ing-region. It is clear from Ext.D1 that the treatment allegedly undergone by the complainant at P.R.S Hospital is the continuation and due to the complication arising from the disease which was in existence years back prior to the commencement of the policy and the complainant had sufficient knowledge regarding the pre-existing condition at the time of taking the policy. Admittedly, the policy was issued in favour of the complainant for the period from 27/3/2001 to 26/3/2006. On going to the relevant investigation stated in Ext.D1 discharge summary, it is crystal clear that complainant was suffering from pre-existing disease from 17/7/2000 ie. one year prior to the commencement of the policy. It is stated in discharge summary that H/O undergrowing repair RIH 2 years back in MCH ie 17/7/2000. According to opposite parties the policy was taken by the complainant suppressing the material facts and misrepresentations and suppressing his pre-existence of disease, therefore, the policy is void and the complainant cannot get any benefit under the policy. The documents furnished by the complainant do not show that the said disease started after the commencement of the policy. We cannot disbelieve the discharge summary issued by the competent Doctor. Evidently by Ext.D1 complainant was suffering from disease years back prior to the commencement of the policy. In this context we need to say that insurance contracts are uberima fides and are founded upon good faith. If any party fails to observe utmost good faith the contract may be avoided by the other. This legal proposition has been re-iterated time and again by the Supreme Court as well as various High Courts. In this case, there is material to show that there was H/o undergrowing repair RIH 2 years back in Medical College Hospital which was not disclosed by the complainant. In view of the above discussion and in the light of evidence available on records we find opposite parties have proved beyond doubt that the insured had suppressed material facts while obtaining the policy and the treatment undergone at P.R.S Hospital from 17/1/2002 to 21/7/2002 is the continuation and due to the complication arising from the disease which was in existence years back prior to the commencement of the policy and complainant had sufficient knowledge regarding the said treatment. Deficiency in service not proved. Complaint has no merit which deserves to be dismissed.
In the result, complaint is dismissed. Parties are left to bear and suffer their own costs.
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 Forum, this the 15th day of September, 2009.
G. SIVAPRASAD, PRESIDENT.
BEENA KUMARI. A : MEMBER
S.K. SREELA : MEMBER
ad.
O.P.No.485/2002 APPENDIX I. Complainant's witness: NIL II. Complainant's documents: P1 : Receipt No.39055 dated 21/7/2002 issued by PRS Hospital, Tvpm. P2 : " No.34151 dated 17/7/2002 " P3 : Bill No. 146663 dated 18/7/2002 P4 : Bill No.146663 dated 18/7/02 for Rs.910.80 P5 : Bill No.146713 dated 19/7/02 for Rs.29.80/- P6 : Bill No.7419 dated 19/7/2002 for Rs.24.70/- P7 : Bill No.146637 dated 18/7/2002 for Rs.1135.40/- P8 : Bill No.14680/- dated 20/7/2002 for Rs.9/- P9 : Bill No.146947 dated 21/7/2002 for Rs.1.50/- P10 : " 146638 dated 18/7/2002 for Rs.40/-. P11 : Electro Cardiogram dated 9/7/2002 reported by PRS Hospital. P12 : Laboratory Report of Blood dated 9/7/2002 with Sl.No.295997. P13 : " Urine dated 9/7/2002 P14 : Prescription issued from PRS Hospital, Tvpm dated 26/7/02. P15 : " dated 21/7/2002 P16 : " dated 19/7/2002 P17 : " dated 19/7/2002 with Reg.No.225053 P18 : " dated 20/6/2002 with IP No.225053 P19 : Medicine requisition issued from PRS Hospital dated 19/7/2002. P20 : " dated 17/7/2002. P21 : Prescription issued from PRS Hospital dated 21/7/2002 P22 : " dated 15/7/2002. P23 : Report of ECG issued by Dr. Parthiban dated 16/7/2002. P24 : Bill No.656516 dated 26/7/2002. P25 : Cash bill No.2971 dated 26/7/2002. P26 : " No.836 dated 21/7/2002. P27 : " No.CA/7848 dated 22/7/2002. P28 : Cash Bill No.2495 dated 20/7/2002. P29 : Bill No.654647 dated 21/7/2002 for Rs.384/-. P30 : Bill No.654285 dated 20/7/2002 for Rs.689.50/-. P31 : Bill No.653855 dated 19/7/2002. P32 : Bill No.653671 dated 19/7/2002 for Rs.768/-. P33 : " 653183 dated 17/7/2002. P34 : " 86567 dated 16/7/2002 for Rs.900/-. P35 : " 1371 dated 9/7/2002 for Rs.60/-. P36 : " 2224 dated 15/7/2002 for Rs.100/-. P37 : " 295997 dated 09/7/2002 for Rs.188/-. P38 : Photocopy of flight coupon of Oman Air bearing No.9103678698 283. P39 : Bill No.2448 dated 16/7/2002 for Rs.40/-. P40 : Photocopy of passport No.V-318423 of Pawlos Kesari P41 : Bill details for 52412 IP 225 053. P42 : Credit bill No.52412 dated 21/7/2002. P43 : Biochemical Analysis issued by K.H.Lab, Tvpm dated 9/7/02. P44 : Copy of reply nltice dated 29/10/2002. P45 : Postal receipt dated 29/10/2002. P46 : Postal acknowledgment card dated 30/10/2002. P47 : Certificate of Insurance issued by New India Assurance Co.Ltd No.2001/47/761401/31660 dated 27/3/2001.
III. Opposite parties' witness: NIL IV. Opposite parties' documents: D1 : Photocopy of discharge summary dated 17/7/2002. D2 : Specimen copy of Pravasi Kudumba Arogya Scheme.
PRESIDENT
......................Smt. Beena Kumari. A
......................Smt. S.K.Sreela
......................Sri G. Sivaprasad | | 
