DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD<br /> <br /> Dated this the 31st day of August, 2007.<br /> <br /> Present : Prof.O.Unnikrishnan, President (I/C)<br /> Smt.K.P.Suma, Member<br /> C.C.No.79/2006<br /> Aboobacker<br /> 54 years<br /> S/o. Hassan Musaliyar<br /> Anthrathodiyil House<br /> P.O. Vattamannapuram<br /> Alanallur<br /> Mannarkkad Taluk<br /> Palakkad - Complainant<br /> <br /> V/s<br /> <br /> 1.National Insurance Co Ltd<br /> P B No.89, City Branch<br /> Ambika Arcade<br /> M G Road<br /> Thrissur – 680 001. <br /> <br /> 2. National Insurance Co. Ltd<br /> 3rd Floor<br /> East Fort Complex<br /> Fort Maidan<br /> Palakkad - Opposite party <br /> O R D E R<br /> <br /> By Prof.O.Unnikrishnan, President (I/C)<br /> <br /> The complainant in this complaint submits that he is an Assistant Educational Officer, Mannarkkad. He took a Group Medi claim Insurance Policy for Rs.25,000/-with the opposite party M/s. National Insurance Company Ltd, vide Policy No.570704/2002/8201513. The validity of the said policy was from<br /> <br /> - 2 -<br /> 06.09.2002 to 05.09.2005. The complainant submits that as per the terms and conditions of the policy, there was insurance coverage for all accidents, diseases and untoward incidents happening during the period of 06.09.2002 to 05.09.2005.<br /> <br /> The complainant further submits that during July 2004, the complainant had some sight problem and he consulted Dr. Sunil Kumar of Ramadas Clinic and Nursing home, Perinthalmanna and started treatment. When the sight problem aggravated, the complainant again consulted Dr. Sunil Kumar and he opined that a surgery is necessary. Hence the complainant was admitted in Ramadas Clinic and Nursing Home, Perinthalmanna on 11.05.2005 and underwent an eye surgery on the same day. The complainant was discharged from the hospital on 13.05.2005<br /> <br /> The complainant further submits that the above mentioned disease was started and its treatment was done within the period of validity of the Insurance Policy, so the complainant is eligible to get the benefits of insurance coverage and the opposite party is bound to give the amount covered by the Policy to him.<br /> <br /> The complainant in his allegation states that he submitted an application with the opposite party on 16.05.2005 in prescribed format stating all details <br /> of the disease and its treatment and claiming the insurance amount. But on 27.10.2005 the complainant received a communication from one Varghese.P.J, who is said to be an Insurance Investigator attached to National Insurance Company, asking the complainant to submit the details regarding the treatment. The complainant replied the informations vide fax dated 02.11.2005. Again on 06.11.2005 the above said P.J. Vaghese sent another <br /> - 3 -<br /> letter which contained his observations and in that some of the portions were marked in yellow colour and the complainant was asked to give the explanations to those questions if any, within 7 days. The complainant submits that he gave the explanations to the said observations vide letter dated 14.11.2005. But on 07.12.2005 the complainant received a notice from National Insurance Company Ltd stating that the complainant's claim was turned down since the claim in related to pre-existing disease.<br /> <br /> The complainant in his allegation further submits that on 21.10.2005 the insurance investigator P.J. Varghese visited his house and informed the complainant's wife that the claim was allowed and all expenses incurred by the complainant for treatment will be given by the Insurance Company. The Insurance Investigator asked the complainant's wife to sign in blank paper as evidence for giving us the information regarding the grant of policy claim to be submitted to the insurance company. The complainant submits that his wife sent a letter to Branch Manager, National Insurance Company informing the above aspect.<br /> <br /> Hence the complainant prays before this forum to pass an order for an amount of Rs.22,621 incurred for the treatment and Rs.10,000/- towards the mental agony due to the act of opposite party.<br /> <br /> After admitting the complaint Notice was served to the opposite party. Opposite party appeared and filed version.<br /> <br /> The opposite party in his version submits that the insurance coverage available for all accidents, deceases and untoward incidents happening during the period of validity. During the month of July, 2004 the complainant had <br /> - 4 -<br /> some eye problems and consulted Dr. Sunil Kumar at Ramadas Clinic and Nursing Home, Perinthalmanna, and as per his advice the complainant underwent a surgery on 11.05.05 and was discharged from hospital on 13.05.05 <br /> <br /> The opposite party denies allegation of the complainant. The claim for Rs.22,621/- from the complainant was received and immediately on receipt of the claim form , the opposite party deputed an investigator to find out the genuineness of the claim. As per investigator's report, the complainant had pre - existing illness and was consuming medicines since 1995, thereby the policy conditions violated by the complainant The repudiation of the claim was after application of mind and therefore there was no deficiency of service. The opposite party submits that the complainant has suppressed the material fact to obtain the policy.<br /> <br /> The opposite party further submits that the complainant is not entitled to get any relief for claim amount and mental agony etc for their own acts as there was no deficiency of service since there was no repudiation of claim.<br /> <br /> Hence the opposite party prays before this forum to dismiss the complaint with costs.<br /> <br /> Both the complaint and opposite party filed proof affidavit. Exts A1 to A4 were marked on the side of the complainant and Exts B1 to B4 on the part of opposite party<br /> <br /> Heard both the parties. We have perused the documents on records.<br /> <br /> <br /> 5 -<br /> It is true that the complainant has obtained a medi claim policy with effect from 06.09.2002 to 05.09.2005. It is evident from Exhibit B3 that on 16.05.2005 the complainant has submitted his claim form for Rs.22,631/- to the opposite party in the prescribed form. The only objection raised by the opposite party is that the disease of catrat existed prior to the policy period and hence the complainant is not entitled to the benefit since pre existing illness are excluded as per clause 4.1 of the policy which was marked as Exhibit B1.<br /> <br /> The report of the investigator was produced and marked as Exhibit B2. It is to be noted that the said document was not objected by the complainant at the time of marking. As per the report of the investigator the complainant and his wife deposed that the complainant was under treatment and consuming medicines since 1995. In the above context, we cannot attribute deficiency of service on the part of the opposite party and the repudiation of the claim cannot be termed as illegal. In the above circumstances, the complaint is dismissed with no order as to costs.<br /> <br /> Pronounced in the open court on this the 31st day of August, 2007.<br /> <br /> President in charge (Sd) <br /> Member (Sd)<br /> APPENDIX<br /> Exhibits marked on the side of the complainant<br /> <br /> Ext.A1 – Copy of the letter send by complainant's letter to opposite party dated<br /> 23.10.2005.<br /> <br /> Ext.A2 - Intimation send by Branch Manager, National Insurance Co Ltd dated<br /> 07.12.2005<br /> - 6 -<br /> <br /> Ext. A3 - Insurance certificate<br /> <br /> Ext. A4 - Advt notice of the Insurance Policy (subject to proof)<br /> <br /> <br /> Exhibits marked on the side of the opposite party <br /> <br /> Ext.B1 – Copy of terms and conditions<br /> <br /> Ext. B2 – Investigation report.<br /> <br /> Ext. B3 – Claim form submitted by complainant<br /> <br /> Ext. B4 – Copy of the repudiation letter.<br /> <br /> <br /> Forwarded/by Order,<br /> <br /> Sd/-<br /> <br /> Senior Superintendent<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />