KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.

APPEAL No. 282/2008

JUDGMENT DATED:  04-01-2010

PRESENT:

JUSTICE SHRI. K.R. UDAYABHANU              :  PRESIDENT

APPELLANTS

1.      The New India Assurance Co. Ltd.,

          Kottarathil Buildings, Palayam, Thiruvananthapuram

          Represented by its Divisional Manager.

2.      The Branch Manager,

          New India Assurance Co. Ltd., Thiruvananthapuram.

            (Rep. by Adv. Sri. Sreevaraham G. Satheesh)

                                    Vs

RESPONDENT

J. Gopinatha Pillai,

Vilayil Veedu, Cherunniyoor P.O., Varkala,

Thiruvananthapuram.

(Rep. by Adv. Sri. Cherunniyoor P. Sasidharan Nair)

JUDGMENT

JUSTICE SHRI. K.R. UDAYABHANU:   PRESIDENT

                        The appellant is the opposite party in OP No. 299/04 in the file of CDRF, Thiruvananthapuram.  The appellant is under orders to pay sum of Rs. 40,344/- with compensation of Rs. 3,000/- and costs of Rs. 1,000/- to the complainant.

          2.      It is the case of the complainant that he had availed a medical policy under Pravasi Suraksha Kudumba Arogya Scheme of the appellant starting from 02-08-2001.  On 11-11-2002 he was hospitalized for renal failure and his right kidney was removed.  He was inpatient up to 24-11-2002.  Thereafter also he was under treatment and incurred altogether a sum of Rs. 70,000/-.  The symptoms of the disease were noticed only on 28-09-2002.  The claim submitted was repudiated on the ground that the disease was pre-existing.  He has challenged the same.

          3.      The opposite parties/appellants have admitted the policy coverage.  It is contended that the disease was pre-existing and the above contention is supported by the opinion of the expert doctor to whom the records were given for opinion.  It is also pointed out that as per the claim submitted the amount claimed is only Rs. 40,344/-.  The alleged deficiency in service is denied.

          4.      The evidence adduced consisted of the testimony of PW1, PW2, DW1, DW2, Exts. P1 to P6 and D1 to D16.

          5.      On a perusal of the evidence adduced, we find that no interference as such is called for with respect to the finding of the Forum that it has not been established that there is suppression of pre-existing disease in the proposal.  PW2 the doctor who treated the complainant has testified that the complainant came to him with the complaint of abdominal pain, the duration of which was only for one month.  Evidence of PW2 could not be discredited in the cross examination.  The evidence of DW1 the doctor to whom the records were forwarded by the opposite party that illness that affected the kidney of the complainant would have taken at least 2 to 3 years time to reach the particular stage can only be treated as a probable inference.  The evidence of PW2 the doctor who treated the complainant has to be assigned more evidentiary value.

          6.      The other contention of the appellant is that as per the conditions of the policy, the pre hospital expenses beyond one month and post hospital expenses after two months are not liable to be paid.  The relevant clause in the policy, ie, Clause V Sub Clause 6 and 7 support the above contention.  Hence we find that the amounts claimed for the period beyond one month of pre hospitalization and after two months of discharge has to be deducted.  If the above amounts are deducted the balance would be Rs. 36,635/-.  Hence the order of the Forum is modified as follows; that the appellant would be liable to pay a sum of Rs. 36,635/- and compensation of Rs. 3,000/- and costs of Rs. 1,000/-.  The complainant also would be entitled for interest at 12% on Rs. 36,635/-. 

          In the result, the appeal is allowed in part as above.

                                          JUSTICE K.R. UDAYABHANU:   PRESIDENT

Sr.