DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD<br /> <br /> Dated this the 24th day of November 2008.<br /> <br /> Present : Smt. H. Seena, President<br /> : Smt. Preetha.G. Nair (Member)<br /> : Smt.A.K. Bhanumathi (Member) <br /> C.C.No.152/2006<br /> <br /> T A Abdul Salam<br /> Thattathazhath House<br /> P.O Mezhathur<br /> (Via) Thrithala<br /> Palakkad – 679 534. - Complainant<br /> (Advocate P.K. Mohanan)<br /> V/s<br /> 1. M/s. Family Health Plan Ltd<br /> No.39/4967 G<br /> Uznag Towers <br /> 5th Floor<br /> Medical Trust Junction<br /> Pallimukku<br /> M G Road<br /> Ernakulam – 682 016.<br /> <br /> 2. The Manager<br /> Oriental Insurance Co. Ltd<br /> Pranavam<br /> P.O. Mele Pattambi<br /> Via Pattambi<br /> Palakkad – 679 306. - Opposite parties<br /> (Advocate P. Ramachandran)<br /> O R D E R<br /> By Smt. Seena.H. President.<br /> <br /> Complainant had availed an individual medi claim policy through the second opposite party. He joined the scheme on 29/07/2004 and the same was in force till 28/07/05 and thereafter also the same was renewed yearly by paying the necessary premium amount. On 29/07/04 while taking the policy, a complete medical checkup was done and the medical certificate was handed over to the 2nd opposite party. At that time the complainant had no medical complainants. After taking the policy on 29/07/2004, complainant went to Kuwait. In 2004 December, he had undergone a coronary angiogram in Kuwait Chest Hospital. Again while the policy was in force, he had undergone treatment for <br /> - 2 -<br /> heart ailments in Moulana Hospital, Perinthalmanna and coronary Angiogram was performed through the right femoral artery. Complainant claimed the medical expenses from the Opposite party. It was repudiated by the Opposite party stating the disease was pre existing at the inception of the policy. According to the complainant, on September 2006, when he met the Doctor at Moulana Hospital, Perinthalmanna, the complainant had informed the treatment undergone by him in December 2004 from Kuwait. The doctor in his report has mistakenly stated that the complainant has been suffering from this ailment for the last 2 ½ years. Subsequently, the doctor understood his mistake and entered the correction as 1 year and 10 months and the corrected records were furnished and renewed by the 1st Opposite party. When the claim of the complainant was not considered by the opposite parties, the complainant sent a lawyer notice dated 23/10.2006 to the Opposite parties for which the 1st Opposite party has sent a reply repudiating the claim, stating as per initial intimation the complainant had been suffering from ailments for the last 2 ½ years. According to the complainant, the act of opposite party in rejecting the claim on the basis of an error, which is later accepted and corrected by the doctor himself is not correct. Such repudiation is deficiency in service and unfair trade practice committed by the opposite parties. Hence the complaint.<br /> <br /> Notice was served on both the opposite parties. First opposite party did not appear before the forum and hence was set exparte. The contention of the second opposite party is as follows.<br /> <br /> That the disease for which the complainant had undergone angiogram test is pre exiting to the inception of the policy issued by the opposite party. In the medical certificate produced by the complainant along with his claim form, it is written that the complainant has been suffering from the disease for 2 ½ years. If that be so, the complainant was suffering from the ailment long before the conception of the medi claim policy. After repudiction of the claim the complainant produced the medical certificate after making correction. According to the opposite party, the subsequent correction of medical certificate raises series doubt about the genuinenesses of the claim preferred. The opposite party denies the claim of the complainant that he had taken mediclaim policy <br /> - 3 -<br /> after medical checkup. According to the opposite party, in the light of the deleberate suppression of material facts, the complainant is not entitled to get the relief claimed.<br /> <br /> The evidence adduced consists of the proof affidavit and Ext A1 to A10 marked on the side of the complainant and proof affidavit alone on the side of the 2nd opposite party.<br /> <br /> The issues for consideration are:<br /> <br /> 1.Whether the disease was pre- existing at the time of taking policy.<br /> 2.Whether there is any deficiency of service on the part of the Opposite parties?<br /> 3.If so, what is the reliefs and cost?<br /> <br /> Points 1 & 2<br /> <br /> We have carefully gone through the evidence on record. In this case the only question in dispute is whether the disease for which insurance amount is claimed is pre existing or not?<br /> <br /> The claim was repudiated by the 2nd Opposite stating it was pre existing at the time of availing policy. Reference was given to the report of the consultant doctor, where in it was stated that the complainant was suffering from the disease for 2 ½ years. This was admitted by complainant also. According to the complainant, it was an error committed by the Doctor. In September 2006, when the complainant met the doctor at Moulana Hospital, Perinthalmanna, he had informed the doctor about the treatment undergone by the complainant in December 2004 from Kuwait. Doctor mistakenly stated in his report that the complainant has been suffering from this ailment for the last 2 ½ years . Subsequently when he understood the mistake, it was corrected as 1 year and 10 months. The revised report is marked as Ext A10. The corrected records were again furnished to the Opposite parties. But they were not ready to settle the claim stating as per the initial records, the complainant is suffering from ailments for the last 2 ½ years. 2nd Opposite party has not sent any reply to the notice. The question is whether the complainant should made to suffer due to an error committed by a Doctor?<br /> - 4 - <br /> In National Insurance Company Vs Radhey Shyam Gopal, III (2008), CPJ 498, the Honourable State Commission has observed that when the fact of pre existing disease which was found in the policy of another Insurance Company and the same was deleted later, on ground of wrong mentioning. The Insurance company could not take the benefit of that ground. In view of the above discussion, we hold the view that on repudiation of claim of the complainant amounts to deficiency of service on the part of the opposite parties.<br /> <br /> Point 3<br /> Since deficiency of service is established opposite parties jointly and severally, are liable to compensate the complainant.<br /> <br /> In the result complainant is allowed. Opposite parties are directed to pay an amount of Rs.10,000/- being the claim amount and Rs.2,000/- as compensation and Rs.1,000/- as cost of the proceedings within one month from the date of communication of the order failing which the whole amount shall carry interest at the rate of 9% per annum from the date of order till realization. <br /> <br /> Pronounced in the open court on this the 24th day of November 2008.<br /> President (SD)<br /> Member (SD)<br /> Member (SD)<br /> Exhibits marked on the side Complainant<br /> A1 - Copy of the policy receipt dated 29/07/2004<br /> A2 - Copy of the policy receipt dated 18/07/2005.<br /> A3 - Copy of the policy receipt dated 18/09/2006<br /> A4 - Copy of the coronary angiogram report from Moulana Hospital.<br /> A5 - Copy of OP card and Bill<br /> A6 - Copy of discharge summary<br /> A7 - Copy of Lawyer notice along with Postal receipt and acknowledgement.<br /> - 5 -<br /> <br /> A8 - Reply notice<br /> A9 – Repudiation letter<br /> A10 – Reviewed report by Dr. Rajeev.<br /> <br /> Exhibits marked on the side Opposite parties<br /> Nil<br /> costs<br /> Allowed<br /> Forwarded/By order<br /> <br /> Senior Superintendent<br />