Date of filing : 16-10-2012
Date of order : 31-12-2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.296/2011
Dated this, the 31st day of December 2012
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT. K.G.BEENA : MEMBER
Bhaskaran.N, } Complainant
S/o.Krishna Purusha,
Sai Saurabha, Kanakapady,
Badiadka, Po.Perdala, Kasaragod.Dt.
(Adv.K.Shrikantha Shetty, Kasaragod
1. National Insurance Co.Ltd, High Lane Plaza, } Opposite parties
M.G.Road, Kasaragod 671121
Rep. by it’s Manager.
(Adv.M.Balagopalan, Kasaragod)
2. Good Health Plan Ltd,
Plot No.49, Nagarjuna Hilla, Panjagutta,
Hyderabad.82.Rep. by it’s Manager.
(Adv.M.Balagopalan, Kasaragod)
O R D E R
SRI.K.T.SIDHIQ, PRESIDENT
In quintessence the case of the complainant is that his mediclaim is repudiated by opposite party alleging suppression of material facts noted in submitted information and pre-existing disease. According to complainant he admitted in KMC Hospital Mangalore on 14-06-2011 for the treatment of TANDY ULNAR NERVE PALSY (Lt) ELBOW and undergone anterior reposition of ulnar nerve. He spent 32558/- for treatment and when the claim is made opposite party rejected the claim stating the aforesaid reason.
2. According to opposite parties complainant and his family were insured with them as per Gramin Suswasthya Micro Insurance Plan for the period from 15-12-2010 to 14-12-2011. But it was not a continuation of several years previous policy. Claim of the complainant is repudiated on the ground of suppression of material facts noted in submitted information by the complainant. The complainant had pre-existing disease which are not covered under the policy. As per the discharge summary received from the hospital complainant had history of complaints regarding numbness and tingling in left forearm since 6 years and loss of sensation of left little finger since 4 years and wasting of his hand muscle since 8 months. As per the policy conditions and exclusion the said disease falls under the pre-existing disease. Hence the claim is repudiated.
3. Complainant filed affidavit in support of his claim. Exts A1 to A10 series marked on his side. Complainant subjected to cross-examination by the learned counsel for the opposite party. On the side of opposite party Exts B1 to B3 marked and the case sheet pertaining to the treatment of the complainant is summoned from KMC Hospital Mangalore that is marked as Ext.X-1 and X-1(a). Both sides heard and documents perused.
4. The points to be considered are:
1. Whether the complainant was suffering from any pre-existing disease at the
time of proposal of the policy?
2. Whether the complainant is entitled for the relief claimed?
5. For the sake of brevity both points are discussed together.
Complainant is relying on Ext.A2 discharge summary and Ext.A5 Doctors Certificate to establish that the Tardy Ulnar Nerve Palsy he suffered with was not a pre-existing disease.
6. In Ext.A2 discharge summary issued from KMC Hospital Manipal it is noted that patient developed numbness and tingling in his left forearm 4 days back, insidious in onset and gradually progressive. In Ext.A5 certificate issued by Dr.Surendra Kamath of KMC, Hospital, Manipal it is noted that this nerve palsy (Trady Ulnar nerve Palsy) was of recent onset within last 4 to 6 months and more symptoms recently and this type of nerve palsies can develop any time.
7. Contrary to this evidence the opposite party is relying on Ext.X-1 case sheet produced by KMC Hospital, Manipal. Ext.X1(a) is the case history and details of physical examination relating to the complainant. In Ext.X-1 (a) it is noted that the patient developed numbness and tingling in his left fore arm 6 years back. Relying only on this entry opposite party rejected the claim of the complainant alleging that complainant had suppressed material facts about his pre-existing disease.
8. But in order to prove Ext.X-1(a) no doctors or witness were examined by the opposite party. Even the nature, symptoms etc of the disease TARDY ULNAR NERVE PALSY is not explained.
9. On the other hand learned counsel for the complainant Shri.Srikanta Shetty relying on the judgments reported in 2012 (2) CPR 190 in the case of National Insurance Co.Ltd Rep by Managing Director & Anr V. E.j. Anto and in the case National Insurance Co. Ltd V. Muttil Valsala reported in 2012 (3) CPR 19 and the judgment of Hon’ble National Commission in the case LIC of INDIA & Ors V Dr. P.S. AGGARWAL reported in I (2005) CPJ41 (NC) has argued that the onus to prove the material concealment of disease which directly proved fatal is on the party who allege it.
10. In the case on hand the opposite party has not adduced any substantial evidence to prove their contention that the complainant had pre-existing disease at the time of proposing for the policy Ext.X1(a) cannot be considered as a substantive piece of evidence since it is unsupported by any cogent medical evidence. On perusing Ext. X1(a) it can’t even be deciphered who prepared it.
11. Therefore we are of the view that the repudiation of the claim in a slipshod manner without any ample cogent supporting evidence alleging suppression of material facts of pre-existing disease amounts to deficiency in service on the part of the opposite party. Hence they are liable to honour the claim of the complainant.
12. The claim of the complainant is that he spent is ` 32,558/- towards the treatment out of that `23,558/- is towards the hospital bills and `9000/- towards bystander expense. In addition to that he is claiming `40,000/- towards the compensation for mental and physical harassment. But according to opposite parties the complainant had spent only `21,692/- for the treatment and hospital bills and medical expenses. The complainant is not entitled for bystander expenses, extra nourishment etc which is outside the purview of the policy.
13. As per the policy condition complainant is entitled for the actual medical bill spent for treatment and medicines.
Therefore the complaint is allowed and opposite parties are directed to pay `21,700/- (rounded figure ) to the complainant within 30 days from the date of receipt of copy of this order. Failing which `21,700/- will carry interest @ 12% per annum from the date of complaint till payment. There is no order as to costs.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exts.
A1.Photocopy of Policy
A2.Dishcarge Summary
A3. 28-6-2011 Bill issued by KMC Hospital
A4.25-06-2011 Denial of cashless Access. (Good Health Plan Ltd)
A5. Certificate issued by KMC Manipal
A6.12-8-2011 copy of lawyer notice.
A7.Postal acknowledgement card
A8.Postal acknowledgement card.
A9.24-08-2011 reply notice.
A10.9& Nos) Bills.
B1.Applicaion Form.
B2. Gramin Suswasthya Micro Insurance Policy.
B3.Gramin Suswasthya Micro Insurance Policy.
X1-and X1(a) series Hospital Records (KMC Manipal)
PW1. Bhaskaran
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Pj/ Forwarded by Order
SENIOR SUPERINTENDENT
