BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 27th day of October 2011
Filed on : 23/07/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No.401/2010
Between
Venugopal Menon, : Complainant
S/o. Shivarama Menon, (By Adv. V.V. Sidharthan,
Pazhangad Vidya Nivas, Valanjambalam, Chittoor road,
Ezhipuram, Marampilly, Kochi-682 016)
Aluva-683 101.
And
1. M/s. TTK Healthcare : Opposite parties
Services Pvt. Ltd., (O.P 1 Exparte)
TPA (P) Ltd., 39-4130,
Mareena Building, 1st floor,
M.G. Road, Ravipuram,
Kochi-682 016.
2. M/s. National Insurance (O.Ps. 2&3 by Adv. C.M. Rasheed
Co. Ltd., Aluva Divisional Office, Rex Buildidng, Railway Station Road,
Urumbath Building Pump Alwaye)
Junction, Aluva-683 101.
3.The Senior Divisional Manager,
Aluva Divisional Office,
National Insurance Co. Ltd.,
Urumbath Building,
Pump Junction, aluva-683 101.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant availed himself of a family health insurance policy from the 2nd opposite party for the period from 09-06-2009 to 08-06-2010. The sum insured was Rs. 1,50,000/-. During the currency of the policy on 19-01-2010 the complainant was admitted in Sanjoe Hospital, Perumbavoor as he suffered from a sudden chest discomfort and pain. His disease was diagnosed as A/C ST Elevated Myocardial Infarction. On 20-01-2010 he was referred to AIMS, Kochi for better treatment and discharged on 23-01-2010. He had to incur a total sum of Rs. 1,38,133 for his treatment expenses. The complainant duly submitted a claim application before the opposite party. The opposite parties repudiated the claim stating that the disease of the complainant was pre-existing. The disease of the complainant was not at all a pre-existing one as alleged by the opposite party. Thus the complainant is before us seeking direction against the opposite parties to pay insurance claim to the complainant with interest together with costs of this proceedings.
2. Version of the opposite parties 2 and 3.
The complainant was having hyper tension as on the date of submitting the proposal form to the 3rd opposite party and that the above material fact was purposefully concealed by him in the proposal form. The liability of the 2nd and 3rd opposite parties is clearly excluded as per clause 4.1 of the terms and conditions of the policy. There is no deficiency in service on the part of the 2nd and 3rd opposite parties in rejecting the claim of the complainant.
3. Despite service of notice from this forum the 1st opposite party did not respond to for their own reasons. The complainant was examined as PW1 and Exts. A1 to A13 were marked on the side of the complainant. The witness for opposite parties 2 & 3 was examined as DW1 Exts. B1 was marked in their side. Heard the counsel for the parties.
4. The points that came up for consideration are
i. Whether the opposite parties are liable to pay the insurance claim to the complainant. ?
ii. Costs of the proceedings if any
5. Point No. i. According to the opposite party they are not liable to pay the insurance claim since the complainant’s ailment was pre-existing prior to inception of the policy. Ext. A4 is the treatment certificate issued from AIMS, Kochi. The doctor who treated the complainant at AIMS, Kochi was examined as DW1. DW1 deposed that a patient who has hyper tension is prone to suffer from heart ailment at any time. Further he deposed that though the history of the complainant as stated in Ext. A4 that he is hypertensive for 20 years has not been recorded by him. Apart from the entry in Ext. A4 no medical evidence is before us to show that the complainant had been undergoing a treatment for hyper tension or he had been suffering from the same. The hypothesis of the opposite party is unsustainable in law and before this Forum for lack of medical evidence whatsoever. In the absence of inconclusive proof we are only to allow this complaint.
6. The Hon’ble National Consumer Disputes Redressal Commission in LIC of India Vs. Shri. Anil Kumar Rastogi 2009 (4) CPR 130 (NC) held in para 13 as follows:
“Except a mere noting that has been made in the discharge summary regarding respondent’s history and the diagnosis nothing is on record has been shown as to what medication the respondent was taking for any of the ailments for which he took treatment in year 2002”.
The principle laid down by the Hon’ble National Commission squarely applicable in the instant case as well
7. In the result, we allow the complaint and direct that the opposite parties 2 and 3 shall pay the insurance claim of the
Complainant together with 12% interest p.a. from the date of this complaint till realization along with an exemplary costs of Rs. 1,000/- especially since the costs have not been quantified. The good will of the complainant in not having claiming compensation is only to be unplanned in finalization of this case.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order
Pronounced in the open Forum on this the 27th day of October 2011
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’sExhibits :
Ext. A1 : Copy of family health insurance policy
A2 : Copy of discharge summary dt. 20-01-2010
A3 : Copy of angioplasty report dt. 21-01-2010
A4 : Copy of appointment for patient dt.17-09-2010
A5 : Copy of statement
A6 : Copies of building
A7 series : copies of claim forms
A8 : copy of acknowledgement dt. 18-02-2010
A9 : Copy of letter dt. 22-03-2010
A10 : Copy of lawyer notice dt. 21-05-2010
A11series : Copies of postal receipt
A12 : Copy of letter
A13 : Copy of A.D. card
Opposite party’s exhibits :
Ext. B1 : Copy of proposal form cum Schedule
Depositions:
PW1 : Venugopal Menon
DW1 : Dr. Praveen G. Pai
