KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAD, THIRUVANANTHAPURAM

APPEAL 632/2010

JUDGMENT DATED: 11.10.2011

PRESENT

JUSTICE SRI.K.R.UDAYABHANU         : PRESIDENT

The Branch Manager,                               : APPELLANT

National Insurance Co.Ltd.,

Branch Office, P.B.No.32,

Perumal Building, Main Road,

Perumba, Payyanur.

(By Adv.S.Rajeev)

              Vs.

1. Smt.Muttil Valsala,                                             : RESPONDENTS

    W/o Late Sri.O.K.Devendran,

    Ward IV/42, Viliyaparamba Amsom,

    South Trikkaripur, Kadappuram,

    Hosdurg Taluk, Kasargod District.

2. Master Abhi(minor) rep. by its

    Mother Muttil Valsala.

3.  Master Arun(minor) rep.bt its

     Mother Muttil Valsala.

(By Adv.N.G.Mahesh, Amicus curiae)

JUDGMENT

JUSTICE SRI.K.R.UDAYABHANU         : PRESIDENT

          The appellants are the opposite parties/Insurance Company in CC 302/05 in the file of CDRF, Kannur.  The appellants are under orders to pay Rs.20000/- the sum insured under medi claim policy with interest at 5% from 7.5.03 till payment and cost of Rs.1000/-.

          2. The case of the complainant is that he is having coverage under medi claim policy  with the opposite party with the sum insured as Rs.20000/-.  The present policy is from 16.7.02 onwards.  On 26.9.02 he was admitted in the hospital for multiple sclerosis at BKM hospital, Payyannur and later he was referred to KMC hospital, Mangalore wherein  he was inpatient for 4 days and discharged  on 4.10.02.  According to him he spent Rs.25000/- for treatment.  The opposite party has not honoured the claim so far.  In the reply notice it is mentioned that probable  duration of illness is 6 years and hence they are not liable to honour the claim.  It is mentioned that the disease got  manifested only in 2002 when his limbs were paralysed.  He has claimed Rs.20000/- the sum insured and Rs.25000/- as compensation towards mental agony. 

          3. On the otherhand the opposite parties have filed version disputing the claim contending that the illness was pre-existing.  It is pointed out that the case history mentioned by the doctor at KMC hospital it is mentioned that the probable duration of the disease as 6 years. The complainant is having demyelinating disease caused due to sclerosis.   Demyelination is a disease process selectively damaging the myelin sheath in the central or  peripheral nervous  system and in turn affects the function of the nerve fiber which the myelin normally supports.  Multiple  selerosis is a chronic disease of the nervous system affecting young and middle aged adults.  The doctor has observed in the certificate that it is relapsing and remitting disease and that the complainant has currently reported improvement but sequel persists.  It is alleged that complainant had full knowledge of the existence of the  disease and hence opposite parties are not liable.

          4. The evidence adduced consisted of the testimony of PW1,DW1; Exts.A1 to A9 and Exts.B1 to B4.

          5. The Forum has allowed the claim on the ground that the opposite parties have not adduced expert evidence to establish  that the probable duration of the illness is 6 years.  It is pointed out  by counsel for the appellant that the complainant was admitted within 70 days of the inception of the policy ie, 16..07..02.  He was admitted on 26.9.02.  The above indicates that he was  already afflicted with the illness.  It was also pointed out that in Ext.B3 claim form submitted by the complainant himself  the Neuro Surgeon of the KMC hospital has noted that the probable duration of illness as 6 years. 

          6. In the instant case we find that the case records contained previous policies produced by the complainant also. The same would establish that he was having policy coverage from 13.7.99 onwards.  He was renewing the policy every year.  Only with respect to present policy ie Ext.A1 there was break of 4 days which is endorsed on the reverse of  Ext.A1 wherein it is mentioned that due to inadvertent understanding a break of 4 days occurred for renewal and hence the claim if any that arise  will be considered on merits.  As evident the complainant was having policies since 13.7.99 onwards.  There is no case that he had made any other claim earlier. Hence the contention that the complainant was admitted within 70 days of the commencement of the present policy and hence he was suffering from the  illness earlier also cannot be accepted as such.   He has not underwent hospitalization prior to the present hospitalization.  There is no positive evidence to show that the illness was present before 13.7.99..

          7. It is the contention that Ext.A1 policy should be treated as  a fresh policy  in view of the fact of break of 4 days from the date of the previous policy.  We find that the opposite party/concerned official has endorsed that the renewal was on account of inadvertent understanding.  In view of the fact that the complainant was having coverage since July 1999 onwards the contention that with the probable duration would have been beyond the above date cannot be treated as proved as noted above.  Although there is a break of 4 days in renewing the policy in the endorsement by the opposite party over Ext.A1 policy it is mentioned that the break up occurred due to inadvertent understanding and that the claim if any that arise will be dealt on merits.  The above would indicate that the opposite parties have treated the policy as a continuing one despite the break of 4 days. Hence we find that the opposite parties are liable to honour the policy claim.  The complainant vide Ext.B4 has produced 28 bills alongwith the claim before the opposite party with respect to  IP treatment undergone by him at BKM hospital, Payyannur and KMC hospital, Mangalore.  The complainant will be entitled for the amount incurred with respect to Ext.B4 series of bills.  The opposite parties are directed to make the payments as per Ext.B4 series of bills.  Opposite parties are directed to make the  payment at the earliest at any rate within 2 months from the date of receipt of this order failing which the complainant will be entitled for interest at 12% from 11.10.2011 the date of this order.  The direction with respect to the cost is sustained.

          In the result the appeal is allowed in part as above.  Office will forward the LCR to the Forum alongwith the copy of this order.

          JUSTICE K.R.UDAYABHANU       : PRESIDENT

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