SRI. JIMMY KORAH (PRESIDENT)
Filed on 9.9.2009
Complainants are insurance holders with the opposite parties. The said policy is under 'Hospitalization and Domiciliary Hospitalization Benefit Scheme' from the year 2005. Initially the sum insured was Rs.50000/-. In the year 2007, the policy was renewed and the amount insured was enhanced to Rs.1,00,000/-. The number of the said policy was 571400/48/06/8500000485. The benefit of the enhanced sum assured was extended to the complainant as well as the whole family members. On 26th June 2007, consequent to an ailment, the 2nd complainant was taken to Str.Gregorious Hospital, Parumala, Mannar and therein he was treated as inpatient till 2nd July 2007. His ailment was diagnosed as 'Coronary Artery disease', and an amount of Rs.21000/-(Rupees twenty one thousand only) had to be expended there. As part of further treatment, the said complainant was admitted to MIOT Hospital, Chennai. On 6th August 2007, he underwent a bypass surgery there and got discharged on 27th of the same month in 2007. In the said hospital, an amount ofRs.153000/- was spent for his treatment.
2. There after the 1st complainant submitted a claim for the sum assured with the 1st opposite party. All the medical records concerned were also produced. With the result, the 2nd opposite party settled the claim vide settlement advise dated 18th October 2007 only for an amount of Rs.50000/- (fifty thousand only).The reason stated therein was that the claim was restricted to the previous sum insured and enhanced sum insured was not available for ailment. Discontented with this, the complainant demanded the outstanding fifty thousand rupees and the cumulative bonus of Rs.25000/-(twenty five thousand only) from the opposite parties. The 2nd opposite party required the complainant to produce some more documents, and despite the same being compiled, the opposite party gave out only Rs.l0,000/- on unlawful reason. The 1st complainant sent as many letters to the opposite parties, complained to the concerned 'Grievance cell'. Still the opposite parties are disinclined to disburse the balance outstanding sum insured or the said bonus. The opposite parties are virtually disentitled to withhold the same. There is deficiency of service on the part of the opposite parties. Got aggrieved by the afore said acts of the opposite parties the present complaint has been filed seeking direction from this Forum to be given to the opposite parties to afford the balance amount of Rs.40000/(forty thousand only) along with cumulative bonus of Rs.25000/- (Rupees twenty five thousand only) to the complainant and other incidental relief.
3. Notice issued. The opposite parties appeared and filed version. The policy and the enhancement of sum assured are not disputed. The opposite parties contended that since prior to the time of the proposal of the policy itself, the complainant was suffering from multiple diseases. The complainants purposefully suppressed this to the opposite party. With the result, the exclusion clause under clause 4.1 of the condition comes into play and is applicable to the present policy. Thus the policy is voidable and subsequent enhancement of the insured amount is of no use to the complainant. In full and final settlement, the opposite party paid Rs.60,000/-. Executing a voucher, the complainant has accepted the same. As such the complainants are disentitled to make any further claim of the policy amount or cumulative bonus. There is no any deficiency of service on their part, the opposite party asserts. The complaint is only to be dismissed with cost and compensatory cost to the opposite parties.
4. On the side of the complainant, the 1st complainant was examined as PWl and the documents Exts. Al to A5 were marked. Al and A2 are the settlement advices, Ext. A3 is the policy certificate issued by the opposite party on 31st March 2007, A4 is the copy of the 'discharge summary' from Parurmala St.Gregorious Hospital 'discharge summary' from Parurmala St.Gregorious Hospital and Ext. A5 is the copy of the letter complaint sent to the opposite party. The Asst. Manager of the 1st opposite party was filed proof affidavit and the documents Exts. B1 to B3 were marked. Ext. B1 is the discharge summary from MIOT Hospital, B2 and B3 are settlement advices. Both the parties filed argument notes and also were heard in detail.
5. Now the questions arise for consideration are:-
(a) Whether the complainant is entitled to the outstanding sum insured?
(b) Whether he was suffering from pre-existing ailment if any, is he disentitled to any further claim?
(c) Is their deficiency of service on the part of the opposite parties?
6. Complainants were holding medical claim policy. In the year 2007, the policy was renewed and the sum insured was enhanced from 50,000/- to 1,00,000/-. All the said issues are not in dispute. The crux of the contentions of the opposite party is that the complainant has been suffering from multiple diseases even prior to the proposal of the present policy. They suppressed this aspect conveniently at the time of the policy to wangle unfair gain. Resultantly they are disentitled to the balance amount of Rs.40,000/- and the cumulative bonus as claimed by them. From the material on record, we are unable to draw any reasonable inference that the complainant had pre-existing ailment and even if any, we do not think that the complainant had the knowledge of the same or they willfully suppressed the said aspect. No evidence worth the name is forthcoming on the part of the opposite parties to establish its contentions. Acceptance of such allegation without something more substantial will lead to miscarriage of justice. A bald allegation by itself will not take the place of proof. The plea of the opposite party that the complainant took the said policy suppressing serious ailment will not at any rate hold water. More over, the opposite parties have no logical reasoning on what basis the complainant was allowed the partial insured amount. In this back drop, we out rightly reject this ground in support of the prayer of the opposite party for the dismissal of the complaint. Needless to say the complainant is entitled to the outstanding assured sum of Rs.40,000/-. As far as the cumulative bonus is concerned no any useful evidence has been adduced by the complainants. Hence no order as to this.
Considering the question of deficiency of service, it appears that the opposite parties were groping for reasons to repudiate the claim of the complainants on one pretext or other. Exts. Al & A2 demonstrate that the opposite parties have no consistent reasoning to dishonour the claim of the complainants. For no valid reasoning, the complainants were made to run from pillar to post to procure their insured amount. There is deficiency of service on the part of the opposite parties. The complainants obviously deserve compensation towards this point. As such, we direct the opposite parties to pay to the complainants the outstanding assured sum of Rs.40,000/-(Rupees forty thousand only) and compensation to the tune of Rs.10,000/-(Rupees ten thousand only).
For the forgoing discussion the complaint is allowed accordingly. No order as to costs.
Pronounced in open Forum on this the 31st day of July, 2010.
Sd/- Sri. Jimmy Korah:
Sd/- Sri.K. Anirudhan:
Sd/- Smt.N.Shajitha Beevi:
Appendix:-
Evidence of the complainant:-
PW1 - M.S.Manoj (Witness)
Ext.A1 - Settlement advice dated 22.11.07 (Photo copy)
Ext.A2 - Settlement advice dated 18.10.07 (Photo copy)
Ext.A3 - Policy Schedule
Ext.A4 - Discharge Summary (Photo copy)
Ext.A5 - Letter dated 1.12.2007
Evidence of the opposite parties:-
Ext.B1 - Discharge Summary (Photo copy)
Ext.B2 - Settlement advice dated 18.10.07 (Photo copy)
Ext.B3 - Settlement advice dated 22.11.07 (Photo copy)
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:-pr/-
Compared by:-
