FA 1359/2005    against CD No. 300/1999    on the file of the

 District Consumer Forum, Karimngar.

Between:

D. Bapu Reddy @ Bapi Reddy

S/o Raji Reddy,

Sambaiahpally (v), Gollapally post,

Sulthanabad Mandal,

Karimnagar District.                                   … Appellant/complainant

And

M/s. United India Insurance Company Ltd,

H.No.3-5-150/17, Gandhi road,

Karimnagar.                                                … Respondent/opposite party.

Counsel for the Appellant               :        M/s. A. Sudarshan Reddy.

Counsel for the   Respondent          :           M/s. Naresh Byrapaneni.

CORAM    :  HON’BLE SRI JUSTICE D. APPA RAO   … PRESIDENT

SMT. M. SHREESHA                                  … LADY MEMBER

                                                            AND

                        SRI G. BHUPATHI REDDY                       … MALE MEMBER

Wednesday, the Thirteenth  Day of August, Two Thousand Eight

Oral order :   ( as per Sri G. Bhupathi Reddy, Hon’ble Member )

*           *           *

This is an appeal filed by the appellant/complainant  U/s.15 of the Consumer Protection  Act to set aside  the dismissal  order passed by the District Forum, Karimnagar  in CD No 300/99  dated 13.05.2005.

The case of the complainant in brief is that he obtained a mediclaim hospitalization and ( domiciliary hospitalization benefit) policy bearing  No. 058001/48/37/48119/97 from the opposite party and paid Rs.2009 on 8.8.1997.  The complainant had undergone Aortic valve replacement a major surgery on 4.3.98 by incurring Rs.1,70,000/-. The opposite party refused  to make payment under the said policy with malafide intention. Hence the complaint.

The opposite party in its counter submitted that one Sri D. Rajireddy took policy for himself and for his second son D. Bapu Reddy for Rs.1,50,000/- on 8.8.97 with malafide intention to lodge a claim in future  though he is  suffering from chronic heart disease which is pre-existing one and suppressed the material facts. It is further alleged that the complainant took treatment as per  IP No. 924 Discharge summary issued by Durgabhai Deshmukh Hospital and Research Centre, A. P. Mahila Sabha, Hyderabad dated 13.3.1998 and in the final diagnosis it  is stated that the complainant was having chronic rheumatic heart disease mithral stenosis and regurgitation with PAH Acute rheumatic plus cardiatis.  Hence the opposite party repudiated the claim of the complainant  under insurance policy inclusions (2)  and 2.1.2004. The opposite party by its needs letter date 19.10.1998 informed the complainant with particulars.

The complainant  filed Ex. A1 to A3 also evidence affidavit in support of his  case and the opposite party also  filed  Ex B1 to B4 along with evidence affidavit on their behalf. Based on the evidence adduced on record , the District Forum dismissed the complaint. Aggrieved by the said order, the present appeal has been filed.

The point that arises for determination in this appeal is, whether  the appellant was suffering from pre-existing disease at the time of taking the policy and  whether the order passed by the District Forum is sustainable.

The appellant submits that he was not suffering  from           pre-exiting disease  and the insurance policy was valid when he undergone treatment  in hospital.  The Insurance Company  has given 10% discount while renewing the policy on 8.8.97.  The policy was subsistent even prior to 8.8.97.  There is deficiency in service  on the part of the respondent.  The District Forum has not properly appreciated  the evidence on record and prayed for setting aside the  order of the District Forum.

The appellant submits that  he has not suppressed any material  or  the pre-existing disease at the time of  taking the Insurance policy or even when the respondent has renewed the policy and repudiation of the claim by the respondent  is not sustainable. The respondent submits that the repudiation order was confirmed by the District Forum. There is no deficiency in service on the part of the respondent and hence prayed for confirmation of the order of the District Forum.

The appellant has obtained hospitalization benefits policy.  Before issuing the policy, medical tests were conducted  by the respondent. The appellant has undergone surgery and spent Rs.1,70,000/-  is an admitted fact. Issuance of the policy is not in dispute and during the validity  of the policy, the appellant has undergone heart surgery.  The father of the complainant has obtained medi-claim policy for Rs. 50,000/-  and the other in the name of his son for Rs.1,50,000/-. The complainant gave  his proposal on 8.8.97 vide Ex B1.  In the said proposal form, the complainant gave answers regarding his health in the negative for all questions  to show that the complainant was not suffering from any disease nor he was hospitalized.   Ex A2 discloses that  the complainant has approached Dr. B. Jagannadha Reddy, Physician  and Cardialogist on 24.1.1998 and he was referred to the Hyderabad Hospitals. In the said prescription chit, the doctor mentioned the ailment as MSMR  and he referred to a cardiologist.  Apart from this, the complainant has also  taken treatment in Durgabhai Deshmukch  Hospital on 26.1.98 and there also the Doctors advised  to conduct Open Heart surgery. The burden lies on the respondent  to prove that the complainant  was suffering from Heart ailment prior to taking of the policy.  To substantiate their claim, the respondent  has filed Ex B5, discharge summary of the Durgabhai Deshmukh Hospital  dated  28.1.98 and it shows  that  the complainant was admitted into the hospital on 23.2.1998,  on 4.3.98 surgery was conducted  and on 13.3.98 he was discharged. In the Discharge Summary, the final diagnosis, i.e.,  Chronic Rheumatic Heart Disease Mithral Stenosis and Regurtation PAH  and the clinical findings was also mentioned. Ex B6 is the report of the Cardiologist of Durgabhai Deshmukh Hospital  dated 28.1.1998 discloses that he was suffering from Heart ailment and Ex B7 is the receipt issued by the Durgabhai Deshmukh Hospital  discloses that the complainant has paid Rs.76,827/-towards consumables like oxygenalor set, catheters, and disposables etc., and Mitral Valve Charges, Valve sut.res,  and Professional charges like surgeon, Asst.surgeon, Anaesthetist and cardiologist for Coronary Artery Bypass Graft surgery done on 04.03.1998. Ex 8 is the  certificate issued by the Chief Cardiologist, Dr. V. Dayasagar Rao of  Durgabhai Deshmukh Hospital, itself, discloses  that D. Bapi Reddy  has undergone Aortic Valve Replacement and  he has to be on Life Long Oral Anti Coagulants  ( Tablet Acitrom)  which requires also constant Monitoring.  The District Forum has elaborately discussed all the documentary evidence and given finding that the respondent has suppressed about his previous ailment and obtained policy.  Apart from this, the third party affidavit  of a doctor also filed who conducted operation.  The complainant has made proposal on 8.8.97 and within short time of  about five months the complainant has approached Dr. B. Jagannadha Reddy, physician and Cardiologist.  The complainant has suppressed  his pre-existing heart disease and obtained the insurance policy.  The District Forum has elaborately discussed and given finding that the appellant is suffering from heart ailment.  There was no reasonable ground to interfere with the order passed by the District Forum and the order of the District Forum is confirmed.  The appeal is dismissed. In the circumstances of the case, but, without costs.

President                   Lady                    Male

                                                                                    Member              Member

                                                                           Dated : 13.08.2008

3. P. Suresh