BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD.
F.A. 4/2007 against C.C. 958/2005, Dist. Forum-III, Hyderabad
Between:
United India Insurance Company Ltd.
Rep. by its Divisional Manager
Divisional Office No. 4
Posnett Bhavan, 2nd Floor
Tilak Road, Ramkote
Hyderabad-500 001. *** Appellant/
Opposite Party
And
Smt. Ch. Rani, W/o. Ch. Swamy
Age: 45 years, House Wife
R/o. 16-1-427/30, Ekalavyanagar
Saidabad, Hyderabad. *** Respondent/
Complainant
Counsel for the Petitioner: Mr. R. Brizmohan Singh
Counsel for the Respondent: Admission Stage.
CORAM:
HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT
SRI SYED ABDULLAH, MEMBER
&
SRI R. L. NARASIMHA RAO, MEMBER
MONDAY, THIS THE SECOND DAY OF NOVEMBER TWO THOUSAND NINE
ORAL ORDER: (Per Hon’ble Sri Justice D. Appa Rao, President)
***
1) This is an appeal preferred by the insurance company against the order of the Dist. Forum directing it to pay Rs. 36,393/- with interest @ 10% together with compensation and costs.
2) The case of the complainant in brief is that her husband was an account holder in Andhra Bank who was covered by medi-claim policy known as “Arogya Daan Policy” for a sum of Rs. 50,000/-, and the period of coverage was from 23.7.2004 to 8.6.2005. When she developed stomach pain on 25.2.2005 she was admitted in Sai Nursing Home, Saidabad, Hyderabad where it was diagnosed as ‘ cheolecystitis with gall stone’ and advised to undergo surgery for removal of gall bladder stones. On 1.3.2005 when she had again pain, she was taken to Dr. Vijayanand, who referred her to Aditya Hospital where it was suggested that she had stones in gall bladder. Accordingly operation was conducted. She spent Rs. 36,793/- towards hospitalization and other charges. When she made the claim it was repudiated on the ground that the ailment was pre-existing. Therefore she filed the complaint claiming the said amount together with interest, compensation and costs.
3) The appellant insurance company resisted the case. It alleged that the patient was suffering from the said ailment prior to the date of taking policy. Initially the ailment was diagnosed as ‘Cholelithiasis’ and later as ‘Empyema of Gall Bladder’. She developed distal CBD structure. It takes more than eight months to form. She had history of hysterectomy during the year 2002. Ultrasound Scan report shows that she had multiple hyper echoic faci with past acoustic shadowing in the lumen of GB measuring 9 mm size of Calculi. Gall bladder shows wall thickening 7.8 mm with Oedema. Since she had suppressed the ailment, she was not entitled to the amount.
4) The complainant in proof of her case filed her affidavit evidence and got Exs. A1 to Ex. A19 marked, while the appellant filed Exs. B1 to B11.
5) The Dist. Forum after considering the evidence placed on record opined that there was no proof that the complainant was suffering from the said ailment at the time when she had taken the policy, and the repudiation was unjust, directed the insurance company to pay Rs. 36,393/- with interest @ 10% p.a., together with compensation of Rs. 5,000/- and costs of Rs. 1,000/-.
6) Aggrieved by the said decision, the insurance company preferred the appeal contending that the Dist. Forum did not appreciate the facts in correct perspective. It ought to have seen that the complainant had pre-existing ailment which she had concealed, and therefore was not entitled to the amount by virtue of condition Nos. 4.0 and 4.1. The complainant could not prove by examining any doctor to state that the ailment was not pre-existing. Therefore, it prayed that the complaint be dismissed.
7) At the outset, we may state that it is not in dispute that ‘Arogya Daan’ medical insurance policy was issued by the appellant for Rs. 50,000/-. It is also not in dispute that she underwent surgery and was discharged on 18.3.2005 when the doctors opined that she had Cholelithiasis and later as Empyema of Gall Bladder. No doubt by virtue of Clause 4.0 and 4.1 if there was pre-existing disease the complainant shall not be entitled to the amount covered under the policy. Coming to the facts Dr. Vijayanad gave Ex. A19 letter mentioning that ‘she had no past history of Gall Bladder disease’. The opinion adverted to by the insurance company was that of Dr. Bhagavath Reddy marked as Exs. B3 & B4. What all he stated was that “the Gall stones are long standing in the Gall Bladder, probably more than a year, but is difficult to say at what stage the symptoms have developed.”
When he himself was not sure as to when these stones were developed, she should not be accused of suppression of ailment. For the policy taken on 23.7.2004 she got operated on 16.3.2005, after 8 months. Therefore it cannot be said that she was aware that she had pre-existing disease of Gall Bladder. The insurance company did not adduce any evidence to state that she was suffering from said ailment and that she had surpassed the same. In the light of Ex. A9 opinion of Dr. Vijayanand, previous ailment can be ruled out. The Dist. Forum after appreciating the evidence in correct perspective awarded an amount of Rs. 36,393/- with interest at !0% p.a., which we do not think is on higher side and it is moderate and just. There are no merits in the appeal.
8) In the result the appeal is dismissed, however without costs. Time for compliance four weeks.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
3) ________________________________
MEMBER
Dt. 02. .11. 2009.
*pnr
