BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of January 2012 Filed on : 03/11/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 613/11
Between
M.R. Vijaya Raghavan Nair, : Complainant
Vysakh, Kizhakepram, (party-in-person)
N. Parur.
And
National Insurance Company, : Opposite party
1st Floor, Municipal Complex, (Absent)
N. Paravur, Pin-683513.
O R D E R
A Rajesh, President.
The undisputed facts of the complainant’s case are as follows:
On 17-10-2010 the complainant was admitted in Lourde’s Hospital with chest pain. On examination two blocks were found and angioplasty was done. In the meanwhile since the complainant holding an insurance policy with sum insured of Rs. 1,00,000/-, he duly submitted an insurance claim application before the opposite party, but it was rejected by them stating that the disease was pre-existing. Thus the complainant is before us seeking direction against the opposite party to pay the insurance claim of Rs. 1,00,000/- together with compensation of Rs. 10,000/-.
2. Despite service of notice from this Forum the opposite party has opted not to contest the matter for their own reasons. No oral evidence was adduced by the complainant. Exts. A1 to A27 were marked on his side. Heard the complainant who appeared in person.
3. The points that came up for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim from the
opposite party?
ii. Whether the opposite party is liable to pay compensation to the
complainant?
4. Point No. i. Ext. A27 is the insurance policy of the complainant for the period from 05-01-2009 to 04-01-2010 and Ext. A26 is the policy for the period from 05-01-2010 to 04-01-2011. The sum assured as per the policy is Rs.1,00,000/-. Admittedly within the currency of Ext. A26 policy the complainant underwent treatment at Lourde’s Hospital, Ernakulam for the period from 17-10-2010 to 23-10-2010 evident from Ext. A20 discharge summary. As per Ext. A20 the disease of the complainant was diagnosed as follows
“CORONARY ARTERY DISEASE – UNSTABLE ANGINA
SINGLE VESSEL CORONARY ARTERY DISEASE-LCX-80% STEOSIS
PCI TO LCX DONE ON 19/10/10
DIABETES MELLITUS TYPE II
DYSLIPIDEMIA.”
5. Thereafter the complainant submitted Ext. A9 application form dated 06-11-2010 claiming insurance from the opposite party. On receipt of Ext. A9 claim form the opposite party caused Ext. A1 letter to the complainant demanding the following.
“Kindly forward us a certificate from the treating doctor stating.
Whether there is any past history of Angina, if yes since when”
6. In response to Ext. A1 letter the complainant forwarded Ext. A2 certificate to the opposite party which reads as follows:
“This is to certify that Mr. Vijaya Raghavan H No. 840375 admitted on 17-10-2010 with the case of angina since 3 days duration. No past history of angina as per our record”.
However the opposite party vide Ext. A5 letter dated 15-03-2011 repudiated the claim of the complainant stating that ailment is considered as pre-existing and hence not payable.
7. Neither independent medical evidence nor anything is on record to show that the complainant had been undergoing treatment prior to inception of the insurance policy. The reason for repudiation of the claim of the complainant is unsustainable in law especially so the treating doctor in Ext. A2 stated in contra. In the above circumstances the complainant is entitled to get insurance claim from the opposite party. Ext. A18 series medical bills goes to show that he had to incur a total sum of Rs. 1,19,544.52 towards hospital expenses. Since the sum insured as per Ext. A26 policy is Rs. 1,00,000/- the opposite party is legally liable to pay that amount with its interest.
8. Point No. ii. Since the primary grievance of the complainant having been fully met no compensation is called for legally.
9. In the result, we partly allow the complaint and direct that the opposite party shall pay Rs. 1,00,000/- to the complainant together with interest @ 12% p.a. from the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 31st day of January 2012.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s Exhibits:
Ext. A1 : Copy of letter dt. 26-11-2010
A2 : Copy of certificate
A3 : Copy of letter dt. 11-02-2011
A4 : Copy of letter dt. 10-02-2011
A5 : Copy of letter dt. 15-03-2011
A6 : Copy of letter dt. 23-03-2011
A7 : Copy of letter dt. 08-04-2011
A8 : copy of rejection letter
A9 : Copy of claim former
A10 : Copy of medical certificate to be
filled in by the doctor treating the
patient
A11 : Copy of certificate
A12 : Copy of discharge bill
A13 : Copy of certificate
A14 : Copy of report dt. 19-10-2010
A15 : Copy of report dt. 18-10-2010
A16 : Copy of statement
A17 : Copy of policy
A18 a to h : Copies of series of bills
Series
A19 : Copy of clinical pathology report
A20 : Copy of discharge summary
A21 : Copy of report dt. 10-10-2010
A22 : Scan report
A23 : copy of report dt. 19-10-2010
A24 : Copy of pre-authorization
request form
A25 : copy of heart beating chart
A26 : Copy of policy
A27 : Copy of policy.
Opposite party’s exhibits: : Nil
