BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 13/09/2010

Date of Order : 30/06/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 491/2010

Between

And

O R D E R

A. Rajesh, President.

1. The case of the complainant is as follows :

The complainant availed a mediclaim policy from the opposite parties, which was in continuation of the mediclaim policy, he had with the United India Insurance Company. The opposite party issued the policy with effect from 17-11-2007 and he used to renew the policy till date with sum assured of Rs. 1 lakh. The complainant was hospitalised for accident injury from 25-03-2010 to 22-04-2010. He incurred a sum of Rs. 62,000/- for treatment expenses. The complainant duly submitted a claim application before the opposite parties. The opposite parties rejected the claim of the complainant for the reason “Diabetes Mellitus” vide letter dated 25-05-2010. So, the complainant is before us seeking direction against the opposite parties to pay the insurance claim with interest and to refund the excess amount of insurance premium. This complaint hence.

2. The opposite parties filed version contending as follows :

The complainant was not hospitalised for accidental injury. He was hospitalised for abscess left foot. The complainant was suffering from diabetes mellitus for 6 years and this was suppressed at the time of taking the policy. As per the terms and conditions of the policy, the disease was pre-existing at the time of taking the policy are excluded. The abscess of the complainant cannot be cured only, because he was suffering from diabetes mellitus. The disease of the complainant was a complication of diabetes mellitus, which the complainant was suffering from for the last 6 years. There is no deficiency in service on the part of the opposite parties. The complainant is not entitled to get any of the reliefs as claimed in the complaint.

3. The complainant was examined as PW1 and Exts. A1 to A6 were marked on his side. Neither oral nor documentary evidence was adduced by the opposite parties. Heard the counsel for the parties.

4. The points that came up for consideration are as follows :-

1. Whether the complainant is entitled to get the insurance claim amount from the opposite parties?

2. Whether the opposite parties are liable to pay costs of the proceedings?

5. Point Nos. i. and ii. :- Admittedly, the complainant availed himself of Ext. A1 to A3 policies from the opposite parties. The details of the policy reads as follows :

Sl. No.	Exhibits	Period of insurance coverage.
	A1	17-11-2009 to 16-11-2010
	A2	17-11-2008 to 16-11-2009
	A3	17-11-2007 to 16-11-2008

6. According to the complainant, he met with an accident and he had to undergo treatment for the period from 25-03-2010 to 22-04-2010 and incurred a sum of Rs. 62,000/- towards treatment expenses. The insurance claim of the complainant was repudiated by the opposite parties, vide Ext. A4 letter dated nil which reads as follows :

“On perusal of claim documents submitted found to be claimant on third year of policy, hospitalised for treating Abscess (L) Foot (heel), Diabetes mellitus. Delay in healing of abscess is due to Diabetes which the patient suffering since 6 years (as per PA no 5865458). But the fact is not disclosed in the proposal form while taking policy in 2007. Hence the claim stands declined under Terms and Condition no 2 (Duty of disclosure) of mediclaim health wise policy.

Hence, we regret our inability to admit this liability under the present policy condition. We wish to point out, that you still have the right of appeal to the Insurer.”

7. It is pertinent to note that the opposite party has failed to substantiate their contention that the ailment of the complainant was pre-existing prior to the inception of the policy. The complainant had been holding insurance policy from 17-11-2007 and continued upto November 2010 which would show that the complainant had undergone treatment within the currency of the policy. The learned counsel for the complainant submitted that as per Ext. A6 terms and conditions of the policy, pre-existing diseases prior to 2 years only to the inception of the policy is payable. So the contention of the opposite parties to the contrary is rejected. It is settled law, that the onus is on the opposite party to disprove the contentions of the complainant in which they have failed in both the issues raised by them. According to the Hon'ble National Consumer Disputes Redressal Commission the onus to prove exclusion clause in order to repudiate the insurance claim is on Insurance Company (M/s. Ace Glan Containers Ltd. Vs. The United India Insurance Co. Ltd. 2011 (1) CPR 321 (NC). In view of the above, the complainant is entitled to get the insurance claim from the opposite parties with interest. However, the complainant has not produced the document to show that he had incurred a sum of Rs. 62,000/- towards treatment expenses.

7. In the above circumstances, we are only to hold that the opposite parties are legally and contractually liable to pay the insurance claim of the complainant together with interest at the rate of 12% p.a. from the date of complaint till realisation, provided the complainant produces the relevant documents to prove the expenses incurred by him towards his treatment. Ordered accordingly.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 30^th day of June 2012.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :: Nil

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