DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD Dated this the 17th day of September 2010 .
Present : Smt. Seena.H, President : Smt. Preetha.G. Nair, Member : Smt. Bhanumathi.A.K, Member
C.C.No.89/2008 N.V. Kalyanaraman S/o. Late Dr.N.P. Venkiteshwara Iyer r/a “Geethanjali” Chinamaya Mission Road Palat Road Ottappalam Taluk Palakkad - Complainant (T.K. Sandeep) Vs 1. New India Assurance Co Ltd Divisional Office Kollannur Buildings Palace Road Thrissur. (Adv. K.V. Sujith) 2. Medi Assistant Pvt Ltd No.406, Chandralayam Ravipuram Kochi – 682 015. - Opposite parties (Adv. K.V. Sujith)
O R D E R By Smt. Seena.H, President Case of the Complaint in brief: The Complainant availed a C S B Health Care Support Insurance Policy issued by the 1st Opposite party vide policy No.760300 CSBHS0707855 for the period 01/08/07 to 31/07/08. An amount of Rs.3841 was paid as premium and the mediclaim sum assured was Rs.2,00,000/-. Complainant was admitted in Christian Medical College Hospital, Vellore as he was suffering from Low Blood Pressure . The Doctors at the Christian Medical College Hospital found that the complainant was suffering from Coronary Artery disease, Triple Vessel Disease and Systemic Hypertension. Hence on 25/10/2007, Coronary Angiogram was done and later on 01/11/2007, Recanalization of Coronary Artery disease with stenting + PTCA with stenting to PDA of RCA was also done. On 17/11/2007, complainant claimed an amount of Rs.2,98,233.95 and Rs.37,433.66, the expenses incurred for treatment with the 2nd opposite party, who is the authorized person to deal and settle the claims pertaining to the policies issued by the 1st Opposite party. As per the direction of the 2nd opposite party, additional documents pertaining to his treatment were also submitted by the complainant on 04/12/2007. On 22/02/2008, 1st Opposite party repudiated the claim stating that the claim made by the complainant is one directly related to the noted pre existing ailments and complication and its repudiated under clause 4.1 of the policy conditions. Complainant submits that he had never history of any of the diseased for which the present claim is made. According to him, opposite party has repudiated the genuine claim of the Complainant without any valid reasons. Hence the complaint. Complainant prays for payment of Rs.2,00,000/- being the sum assured along with Rs.50,000/- as compensation towards mental agony.
Opposite parties contested the complaint by filing written version. Opposite parties admits the policy issued by them, but contented that the complainant has incepted the policy from 01/08/2007 and soon after 2 months from the date of inception, he was admitted to Vellore Hospital for treatment of Coronary Artery Disease, tripple vessel disorder along with other complications. According to the opposite parties, the complainant was suffering from the said diseases for the last 2 years and as per the medical opinion of the panel Doctor the ailment in pre-existing and hence excluded as per exclusion clause No.4.1 in the conditions of the policy. Though not pleaded in the version, in the affidavit filed by the opposite parties it is contented that complainant has no previous policy coverage. Further in the additional version opposite party admits the previous policies issued by the opposite parties to the Complainant and has raised a contention that the complainant has availed the present CSB Health Insurance policy when a policy for Rs.50,000/- is in existence. Opposite parties submits that Complainant concealed the existence of another policy as well as fact of pre existing diseases while availing a new policy. Hence Opposite parties has rightly repudiated the claim.
- 3 - Complainant and opposite parties has filed their respective affidavits. Exhibit A1 to A5 marked on the side of the Complainant. Exhibit B1 to B3 marked on the side of opposite parties.
Now the following issues are raised for our consideration.
Whether there is any deficiency in service on the part of opposite parties? If so, what is the relief and cost complainant is entitled to?
Issues 1 & 2 Since Policy is admitted by the opposite parties, the short questions to be considered is Whether the non disclosure of the fact of the previous policy while availing a new one while the previous one is in existence amounts to a fit reason to avoid insurance payment. Whether the disease for which the present claim is made is a pre-existing one?
We have gone thorough the rival submissions of both parties and has perused relevant documents on record.
Regarding point No.1, opposite parties has stated in the affidavit that the complainant has no previous policy coverage. The complainant has filed an application for production of the policies issued by the opposite parties to the complainant and the same was produced. It is seen that complainant is an insured of the opposite party from 2002 onwards to 2010. Further there is no bar in availing any number of policies during a particular period. Regarding the fact that whether the complainant has suppressed the said fact while availing the new policy, it is seen in Exhibit B3 which is application to join CSB Health Insurance Policy that the column for entering the details of previous medi claim policy is left blank. But we are of view that, the said fact alone will not be a genuine reason for avoiding payment. It is to be noted that all the policies are issued by the same opposite parties and opposite parties has no case that the complainant has claimed amount in both these policies. - 4 - Regarding the next point complainant has stated that the disease for which claim is preferred is not existing at the time of availing policy. Exhibit A4 series, which is the discharge summary of the complainant shows that the Doctor has diagonosed the disease of the complainant as Coronary Artery Disease and Tripple Vessel Disease. Coronary Angiogram was also seen to be done. No where in the column of history recorded, it can be seen that either the complainant has the knowledge of the said disease earlier or he has ever been treated for the said diseases. Complainant has past history of Diabetics/hypertension is seen recorded in the history, but the period during which he was suffering from the said ailment or whether the complainant has knowledge of the said ailment is not born out from records. Opposite parties mainly rely in Exhibit B2 which is the medical opinion of the Doctor in the panel of the Insurance Company that the diseases are pre existing one. Much reliance cannot be placed on Exhibit B2 in the absence of supporting documents because it is the opinion of the interested person of the Opposite party company. Further opposite party has not proved the said document by examining the signatory of the of the document.
In view of the above discussions, we hold the view that opposite parties failed to prove with cogent and convincing evidence that the disease for which the claim is preferred is a pre existing one and the fact of non disclosure of the existence of the previous policy alone will not be a fit reason to evade payment since the opposite parties has no case that complainant has preferred claim in both the polices. Complainant has produced Exhibit A3 series which is the receipts for the payments made at the hospital, which is seen to be above the insured amount.
In view of the above stated circumstances of the case, we allow the complaint. Both opposite parties are jointly and severally directed to pay complainant an amount of Rs.2,00,000/- (Rupees Two Lakhs only) being the insured amount together with interest at the rate of 12% per annum from the date of repudiation till realization. Opposite parties shall pay complainant an amount of Rs.1,000/- as cost of the proceedings. Order to be complied within one month from the date of order.
- 5 - Pronounced in the open court on this the 17th day of September, 2010 PRESIDENT (SD) MEMBER (SD) MEMBER (SD)
APPENDIX Date of filing : 08/08/2008 Witness examined on the side of Complainant Nil Witness examined on the side of Opposite party Nil Exhibits marked on the side of the complainant Ext. A1 – Copy of CSB Health care Support Group Insurance Certificate
2. Ext. A2 - Copy of letter from Medi Assist dated 17/01/2008 3. Ext. A3 series – Copy of Consolidated Receipt dated 06/11/2007 4. Ext. A4 series – Copy of Discharge summary of Christian Medical College, Vellore. 5. Ext. A5 series – Copy of Details of Insured of Mediclaim Insurance policy of The New India Assurance Company Ltd.
Exhibits marked on the side of the Opposite Party Ext – B1 – Copy of CSB Health Care Support Group Insurance Certificate Ext – B1 A – Copy of Clauses of CSB Health Care Mediclaim Insurance Policy Ext- B2 – Copy of Medical Opinion dated 17/01/2008
4. Ext – B3 – Copy of Application to join CSB Health Care Report Scheme
Forums Exhibits Nil Cost (allowed) Rs.1,000/- (Rupees One thousand only) allowed as cost of proceedings
| | [HONORABLE Smt.Bhanumathi.A.K] Member[HONORABLE Smt.Seena.H] PRESIDENT[HONORABLE Smt.Preetha.G.Nair] Member | | 
