Andhra Pradesh

Chittoor-II at triputi

CC/54/2013

Agili Ananda Kumar, S/o. Late A.Krishnama Raju - Complainant(s)

Versus

M/s. Royal Sundaram Alliance Insurance Co. Ltd., Chennai, rep by its Managing Director - Opp.Party(s)

D.Jaya Chandra

18 Apr 2015

ORDER

Filing Date:13.09.2013

Order Date: 18.04.2015

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

CHITTOOR AT TIRUPATI

 

      PRESENT: Sri.M.Ramakrishnaiah, President ,

        Smt. T.Anitha, Member

 

SATURDAY THE EIGHTEENTH DAY OF APRIL, TWO THOUSAND AND FIFTEEN

 

C.C.No.54/2013

 

Between

 

Agili Anand Kumar,

S/o. late. A.Krishnama Raju,

H.No.11-69, Poolavani Gunta,

Opposite to Cotton Mill,

Renigunta Road,

Tirupati,

Chittoor District,

Andhra Pradesh.                                                                               … Complainant

 

 

And

 

M/s. Royal Sundaram Alliance Insurance Co. Ltd.,

Sundaram Towers,

45-46, Whites Road,

Chennai – 600 014.                                                                          …  Opposite party.

 

 

            This complaint coming on before us for final hearing on 13.04.15 and upon perusing the complaint, written version and other relevant material papers on record and on hearing Sri.D.Jayachandra, counsel for the complainant, and Sri.Prem Kumar Karanam, counsel for the opposite party, and  having stood over till this day for consideration, this Forum makes the following:-

 

ORDER

DELIVERYED BY SRI. M.RAMAKRISHNAIAH, PRESIDENT

ON BEHALF OF THE BENCH

 

            This complaint is filed under Section-12 of C.P.Act 1986, by the complainant against the opposite party for the following reliefs 1) to direct the opposite party to pay Rs.47,562/- with interest at 12% p.a. from the date of repudiation till realization 2) to direct the opposite party to pay Rs.20,000/- towards damages and compensation for mental agony and torture and costs of litigation.

            2.  The brief averments of the complaint are:- That the complainant purchased two medi-claim health insurance policies, one for him and another for his wife (his wife policy is not in dispute), covering the risk of both himself and his wife respectively on 30.03.2012, through online by transferring an amount of Rs.12,862/- through ATM card facility from his S.B.Account No.31281650741, S.B.I., Tilak Road Branch, Tirupati, towards premium for the said policies and the policies were commenced from 30.03.2012, it is an yearly premium. On 31.03.2012, while the complainant is coming to office on his motorcycle on Renigunta -  Tirupati road at about 9.15 a.m., a pig which was chased by a group of dogs, came across the road all of a sudden, due to which the complainant fell down and sustained fracture to his left forearm just above the wrist. He was admitted in M/s. Sai Sudha Multi Specialty Hospital, Tirupati, where surgery was conducted and charged Rs.47,562/-. On 23.04.2012 complainant submitted his claim form claiming the medical expenses of Rs.47,562/-. On 24.07.2012 the opposite party sent a letter repudiating his claim on the ground that the complainant was suffering from hypertension even prior to taking policy. Therefore, his claim cannot be accepted. Hence the complaint.

            3.  The opposite party filed his written version on 11.03.2014 admitting that the complainant has taken Family Good Health Policy No.GL00003498000100 from the opposite party for the period from 30.03.2012 to 29.03.2013 covering the risk of complainant on specific terms and conditions stipulated in the policy Ex.B1. However, admitted that the complainant made a claim on the ground that he met with accident on 31.03.2012 and he has been admitted in M/s. Sai Sudha Multi Specialty Hospital from 31.03.2012 to 03.04.2012. That on discreet investigation made by the opposite party, it is found that the complainant was suffering from pre-existing hyper tension since one year, through the indoor case sheet of M/s. Sai Sudha Multi Specialty Hospital, wherein the complainant had taken treatment. Had the complainant discloses his pre-existing disease of hypertension, opposite party ought not have given the policy in favour of the complainant. Since the complainant has suppressed the material facts that he is suffering from hypertension even prior to the date of policy, he is not entitled to the reliefs sought for and prays the Forum to dismiss the complaint with costs.

            4.  Both the parties have filed their respective evidence affidavits and written arguments and got marked Exs.A1 to A6 for the complainant and Exs.B1 to B5 for the opposite party.

            5.  Now the points for consideration are:-

            (i).  Whether the repudiation is justified?

            (ii).  Whether the non-disclosure of pre-existing hypertension by the

                    complainant vitiate his claim?

            (iii).  Whether the complainant is entitled to the reliefs sought for?

            (iv).  To what relief?

            6. Point No.(i):-  Admittedly, the policy that was given in favour of the complainant is under Ex.A1. Exs.B1 and A3 are Family Good Health Insurance Policy and brochure. The diseases that covered by the policy are specified in the first page of Ex.A1 policy schedule, in which the abbreviations and its expansions were given, as Ex.B1 first page also contains the same. In Ex.A1 admittedly among the diseases covered by the policy, the disease of hypertension was not found place in the policy to show that such type of disease shall not covered by the policy. The specific case of complainant is that as a pig, which was chased by a group of dogs came across the road all of a sudden and he fell down from the two wheeler and sustained fracture. Even according to the discharge summary under Ex.A6, the cause of injury is also only due to fall from his two wheeler but not otherwise. Even assuming for a moment that the complainant is suffering from hypertension even prior to the date of taking policy, the accident was not because of hypertension, there is no evidence or proof on behalf of the opposite party that the complainant fell down from his two wheeler due to his pre-existing disease of hypertension, as such they are repudiating the claim. Similarly no document is filed in proof of such contention raised by the opposite party. As such though hypertension is a disease, which may leads to so many complications in health, when the incident / accident was not because of such hypertension, the opposite party cannot repudiate the claim of the complainant, in view of the nature of the policy itself. Ex.A5 is the letter given by the opposite party dt:24.07.2012 shows “that patient is a known case of hypertension since the last one year, which is before policy inception and hence this is pre-existing and the same was not disclosed to us at the time of proposing for insurance. Though the present admission is not for the same, the contract of insurance is based on the doctrine of utmost good faith. The policy becomes null and void due to the suppression of material facts”.  The words though the present admission is not for the same itself discloses that he present admission of the complainant in hospital is not for the disease of hypertension or not because of that disease. When it is admitted that the injury sustained by the complainant is not because of the hypertension, the opposite party cannot repudiate the claim of the complainant. As there is no nexus between the accident and the alleged hypertension for the benefit of complainant, the family good health insurance policy was taken and it was issued by the opposite party in favour of the complainant, when the accident was taken place on the next day of the inception of the policy, that too because of the consequences narrated, which were not in the hands of the complainant or not because of his ill-health of any sort, therefore, we are unable to convince with the case of opposite party in repudiating the claim of the complainant and hence we are of the opinion that the repudiation is not justified. Accordingly, this point is answered.

            7.  Point No.(ii):-  disclosure or non-disclosure of pre-existing disease of hypertension suffered by the complainant is not root cause of the accident and there is no nexus between the accident and the alleged hypertension said to have been suffered by the complainant since one year i.e. much prior to the date of taking policy. If the accident is occurred because of his hypertension, then the complainant cannot made such claim against the opposite party. It is not the case of either complainant or the opposite party that while the complainant is proceeding on his two wheeler, he suffered from hypertension and fell down from the vehicle, consequently he suffered fracture to his left forearm. Therefore, the non-disclosure of pre-existing hypertension of the complainant is, in our opinion is not a fatal or does not vitiate the claim of the complainant. In Ex.B1 at Page.5 under the head of  D-Exclusions, it is specified some sort of diseases under which the company shall not be liable for any claim. Those type of diseases are given in First Year Exclusions, Two Year Exclusions etc., the disease known as hypertension is not covered, which clearly shows that the company is liable even for the disease of hypertension. However, in the case on hand, the accident was not due to hypertension of the complainant. Therefore, non-disclosure of the pre-existing disease of hypertension does not vitiate the claim of the complainant. Accordingly this point is answered.

            8.  Point No.(iii):- In view of our holding on points 1 and 2, the complainant is entitled to the claim of Rs.47,562/-, which actually he met towards medical expenses altogether and paid to M/s. Sai Sudha Multi Specialty Hospital, Tirupati, and also entitled for compensation. Accordingly, this point is answered.

            9.   Point No.(iv):-  In view of our holding on points 1 to 3, we are of the opinion that the complainant is entitled to the reliefs sought for and complaint is to be allowed accordingly.

            In the result, the complaint is allowed in part. The opposite party is directed to pay Rs.47,562/- (Rupees forty seven thousand five hundred and sixty two only) towards cost of the surgery and treatment and also directed to pay Rs.5,000/- (Rupees five thousand only) towards compensation and also to pay Rs.1,000/- (Rupees one thousand only) towards costs of the litigation to the complainant. The opposite party is directed to comply with the orders within six (6) weeks from the date of receipt of copy of this order, failing which the total sum of Rs.53,562/- shall carry interest at 9% p.a. from the date of complaint, till realization.               

Typed to dictation by the stenographer, corrected by me and pronounced in the Open Forum this the 18^th day of April, 2015.   

 

       Sd/-                                                                                                                      Sd/-                                                                 

Lady Member                                                                                                      President

 

 

APPENDIX OF EVIDENCE

WITNESS EXAMINED ON BOTH SIDES

 

 

 

Witnesses Examined on behalf of Complainant.

 

PW-1: Agili Ananda Kumar (Evidence Affidavit filed).

 

RW-1: G.Vinay Prakash (Chief Affidavit filed).

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT

 

Exhibits	Description of Documents
Ex.A1.	A Photo copy of policy schedule in favour of the complainant issued by the opposite party. Dates between 30.03.2012 to 29.03.2013.
2.	A Photo copy of Policy schedule in favour of the wife of complainant issued by the opposite party. Dates between 30.03.2012 to 29.03.2013.
3.	A Photo copy of Broacher of the opposite party company.
4.	A Office copy of claim form submitted by the complainant to the opposite party.
5.	Original repudiation letter issued by the opposite party.
6.	Photo copies of Discharge Summary, Medical particulars and Bills. Dt: 03.04.2012 (D.O.D)

 

 

       EXHIBITS MARKED ON BEHALF OF THE OPPOSITE PARTY/S

           

Exhibits	Description of Documents
Ex.B1.	A true copy of Family good health insurance policy schedule filed on behalf of the Opposite Party.
2.	A photo copy of Health insurance claim form filed on behalf of the Opposite Party. Date of issue: 24.04.2012.
3.	A photo copy of Initial patient assessment record issued by the Sri Sai Sudha Hospitals filed on behalf of the Opposite Party. Dt: 31.03.2012(Date of Admission).
4.	A photo copy of Discharge Summary issued by the Sri Sai Sudha Hospitals filed on behalf of the Opposite Party. Dt: 03.04.2012.
5.	Office copy of the letter addressed to the complainant issued by the Opposite Party filed on behalf of the Opposite Party. Dt: 24.07.2012.

 

 

                                                                                                                                   Sd/-            

                                                                                                                President

// TRUE COPY //

// BY ORDER //

 

 

Head Clerk/Sheristadar,

           Dist. Consumer Forum-II, Tirupati.

 

 

 

Copies to:-     1. The Complainant.

                        2. The opposite party.