IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Friday the 29th day of July, 2011
Filed on 16.11.10
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. Shajitha Beevi (Member)
in
C.C.No.303/10
between
Complainant:- Opposite Parties:-
Sri.Ismail Kutty, 1. National Insurance Co Ltd.,
Pattani Parambil House, Rep by its Managing Director,
Near M.S.M. College, National Insurance Co Ltd., Middleton Street,
Kayamkulam, Kolkata, Pin-700 071, West bengal.
Alappuzha.
(By Adv.A.K.Prasanth) 2. The Divisional Manager,
National Insurance Co. Ltd.,
Divisional Office, Kayamkulam, PB No.60,
Nelson Complex, Puthiyidam,
Kayamkulam, Pin-690 502.
(By Adv.C.Muraleedharan)
O R D E R
SRI.JIMMY KORAH (PRESIDENT)
The case of the complainant in a nutshell is as follows: - The complainant is a Medi Claim Policy holder of the opposite party. The complainant had to undergo Ayurvedic treatment for the disease 'Lumber pain spondilitic' for a period from 21st August 2008 to 3rd September 2008, and for 'Rheomatoid Arthritis' during 30th July 2009 to 12th August 2009. The said factum of treatment had been duly intimated to the opposite parties. Notwithstanding all these, the opposite party repudiated the complainant's claim for policy benefits on unfounded grounds. The repudiation of the policy by the opposite parties is illegal. The opposite parties' service is deficient. Got aggrieved on this the complainant approached this Forum for compensation and relief.
1. On notices being sent the opposite parties turned up and filed joint version. The core of the contentions of the opposite parties is that the policy availed originally by the complainant had expired on 30th March 2006. Thereafter, there occasioned a 10 days delay for the renewal of the policy. Resultantly, a fresh policy was issued to the complainant on 9th April 2006. As such whatever conditions applicable to a fresh policy are applicable to the policy claimed to have held by the complainant at the material time, the opposite parties allege. According to the opposite parties, the complainant had been suffering from the very same chronic disease since 1996. On that score, the complainant's claim is hit by Exclusion clause 4.1, and as such the same is liable to be repudiated. The complaint carries no merit. The same is only to be dismissed with cost, the opposite parties fervently argue.
2. The complainant’s evidence consists of the testimony of the complainant himself as PW1 and the documents were marked as Exbts. A1 to A11. The evidence of the opposite parties consists of documents Exbts. B1 to B5.
3. Taking into consideration the contentions of both the parties, the questions that come before us for consideration are:-
a) Whether the complainant policy claim is hit by Exclusion clause 4.1?
b) Whether the complainant had been suffering from pre-existing disease?
c) If the complainant is entitled to any relief?
4. Concededly, the complainant was the holder of the Medi Claim policy issued by the opposite parties. It is also not denied or disputed that the complainant was struck with diseases 'Lumber pain spondilitic' and 'Rheomatoid Arthritis'. The vigorous contention of the opposite parties is that while the complainant was holding the policy, there was a break of the policy for a period of 10 days from 30th March 2006. According to the opposite parties, on the policy being expired on 30th March 2006, the opposite parties issued a fresh policy to the complainant on 9th April 2006. The complainant had been suffering from the material disease since 1996. The opposite parties argue that the Exclusion Clause 4.1 comes into play as the complainant was already afflicted with the ‘pre-existing disease'. Bearing these contentions in mind, we anxiously perused the pleadings, documents and depositions brought on record by the parties. As we have already observed, the definite contention of the opposite party is that the complainant had been carrying the disease in question since 1996 viz. prior to the availing of the policy from the opposite parties. It is worthwhile to notice that admittedly, the opposite parties issued policy benefits thrice to the complainant on the basis of treatment for the very same disease viz. on 21st November 2006, 5th March 2007 and 24th July 2007. In this backdrop, we are of the strong view that the said contention of the opposite parties is of no avail to them. It appears that the other contention fervently advanced by the opposite party is that on 30th March 2006, there occasioned a break of complainant's policy, and the opposite party had to subsequently issued a fresh policy to the complainant. The complainant case is that there was mere a delay of 10 days for the renewal of the policy. To put it differently, the contention of the complainant is that it was the renewal of policy already existed, and not the issuance of a 'fresh policy' as claimed by the opposite parties. Interestingly, except making a mere statement as to this, the opposite parties did not produce a scrap of evidence to prove this point. Even if it is assumed that the policy so issued by the opposite parties was the fresh policy and all the conditions applicable to a fresh policy are applicable to the policy held by the complainant, the same is inconsequential so far as the opposite parties are concerned. As have been observed earlier, the opposite party issued policy benefits thrice to the on the basis of treatment for the very same disease viz. on 21st November 2006, 5th March 2007 and 24th July 2007. In this context, the contentions of the opposite parties do not inspire confidence in the mind of this Forum. On the other hand the complainant case stands well substantiated on the strength of the documents and other evidence put on record. It goes without saying that the complainant is entitled to relief.
In the light of the facts and circumstance discussed herein above the opposite parties are directed to pay to the complainant an amount of Rs.17,240/-(Rupees seventeen thousand two hundred and forty only) for the treatment of the disease 'Lumber pain spondilitic' for a period from 21st August 2008 to 3rd September 2008, and Rs.l6,825/- (Rupees sixteen thousand eight hundred and twenty five only) for the treatment of disease 'Rheomatoid Arthritis' during 30th July 2009 to 12th August 2009 with 9% interest from the date of her application for claim till the recovery of the said amount. The said opposite party shall comply with the order within 30 days of receipt of this order.
In the result the complaint is allowed accordingly. No order as to cost and compensation.
Pronounced in open Forum on this the 29th day of July, 2011.
Sd/-Sri. Jimmy Korah
Sd/-Sri. K. Anirudhan
Sd/-Smt. N. Shajitha Beevi
Appendix:-
Evidence of the complainant:-
PW1 - Ismail Kutty (Witness)
Ext. A1 - Copy of the Regd Notice with A/D (3 Sheets)
Ext. A2 - Copy of the Regd Letter dated, 07.01.10
Ext. A3 - Copy of the Letter dated, 19.11.09
Ext. A4 - Copy of the Cash Bill dated, 03.09.08
Ext. A5 - Copy of the Medical Certificate dated, 03.09.08
Ext. A6 - Copy of the Claim Form
Ext. A7 - Copy of the Discharge Summary dated, 03.09.08
Ext. A8 - Copy of the Hospital Details dated, 13.08.09
Ext. A9 - Copy of the ID card, MA-ID 5000064772 valid up to 10.04.08
Ext. A10 - Copy of the ID card, MA-ID 5000064772 valid up to 10.04.09
Ext. A11 - Copy of the Medical Details (8 sheets)
Evidence of the opposite parties:-
Ext. B1 - Claim Form
Ext. B2 - Medical Certificate dated, 14.08.09
Ext. B3 - Regd Letter Dated, 07.01.10
Ext. B4 - Copy of the Hospitalization Benefit Policy – Individual Mediclaim
Ext. B5 - Mediclaim Insurance Policy (Individual)
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite Parties/S.F.
Typed by:- P.R/-
Compared by:-
