3.
IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday, the 31st day of March, 2009
Filed on 26/08/2004
Present
1. Sri. Jimmy Korah (President)
2. Sri. K.Anirudhan (Member)
3. Smt. N. Shajitha Beevi (Member)
in
CC/No. 182/2004
between
Complainant:- Opposite parties:-
Sri.Peethambaran Raju 1. The Branch Manager, United
Kaniyudepadeettathil House India Insurance Co. Ltd.
Naduvile Muri, Padanilam P.O. Kayamkulam Branch
Nooranad, Alappuzha – 690 529 T.M. Buildings, Bank Road
(By Adv. B. Pradeep) Kayamkulam P.O., Pin – 690 502
2. The Divisional Manager
United India Insurance Co. Ltd.
Divisional Office, Sarada Shopping
Complex, Mullackal, Alappuzha
Pin – 688 010
3. The United India Insurance Co. Ltd.
Registered and Head Office – 24
Whites Road, Chennai, Tamil Nadu
Pin – 600 014
(By Adv. C.K. Thampiyappan –
for the opposite parties)
O R D E R
SRI. JIMMY KORAH (PRESIDENT)
The case of the complainant is that the complainant, in the year 2000 had availed a policy (SBT-NRI Family welfare Scheme) from the opposite parties for an amount Rs.10,00,000/- (Rupees ten lakhs only) for personal accident, and for an amount of Rs.2,00,000/- (Rupees two lakhs only) for hospitalization insurance. Subsequently, the complainant has undergone treatment for ailment with regard to his kidney, and later on, the same was transplanted. When the aforesaid treatment was effected, the policy was in force. On being discharged after recuperation, the complainant lodged a claim with the opposite parties for the sum assured. The 1st and the 2nd opposite parties repudiated the complainant's claim vide letters dated 21st November 2003 and 19th January 2004 respectively. The reason cited therein for refusal thereof was 'pre-existing disease'. The complainant, thereafter, caused to sent lawyer notice dated 16th April 2004 to the opposite parties. The complainant is entitled to the insured amount of Rs.2,00,000/- (Rupees two lakhs only) for hospitalization insurance. In any event, the repudiation of the claim of the complainant is unlawful. The opposite parties inflicted enormous mental agony and tribulation to the complainant. Got aggrieved on this the complainant approached this Forum for compensation and other relief.
2. On notice being sent the opposite party turned up and filed version. The contention of the opposite party is that the complainant was suffering from pre-proposal illness. The complainant was having nephrological complaint even when he was in Muscat. The deceased willfully suppressed the same in the proposal form. The insured did not answer the proposal form properly. The repudiation of the claim was the inevitable consequence of the prompt and proper enquiry by the opposite party. The medical records including discharge summary clearly unfold the fact that the complainant was suffering from serious ailment since long, the opposite parties allege. The ailment as to hypertension and renal failure was diagnosed in the complainant two years prior to his admission in the hospital on 20th July 2002. The conclusion arrived by the opposite party is not behind the complainant's back. There is absolutely no deficiency of service. As such the complainant hasn't sustained any mental agony. The complainant is not entitled to any relief sought for. The complainant is only to be dismissed with cost to the opposite party, the opposite party vociferously argues.
3. The complainant's evidence consists of the testimony of the complainant himself as PW1 and the documents Exts. Al to All were marked. On the side of the opposite parties, RW1 to RW3 were examined, and the documents B1 to B6 were marked. Court Exhibit was marked as Ext. Cl.
4. Taking into account the contentions raised by both the parties the issues arise for consideration are:-
(1) Whether the complainant suppressed any material facts the disclosure of which would have disqualified him from availing the policy?
(2) Whether the complainant is entitled to the policy amount and other relief?
5. The complainant was holding insurance at the time of treatment in various hospitals from the opposite parties. At the time of transplanting the kidney also, the policy was in force. All these aspects have not been disputed or denied by the opposite parties. The key contention of the opposite party is that the complainant, at the time of availing the policy suppressed material facts and tendered false information as to his health. On the other hand, the complainant affirms that he had never suppressed any material facts as to his health from the opposite parties. We thoroughly analyzed the facts and circumstances of the case. We perused the materials put on record by the parties with mathematical exactitude. At the out set, we are of the impression that the opposite parties have not adopted any positive steps to disprove the case of the complainant. That apart, even on a closer scrutiny of the version and the affidavit placed on record by the opposite parties, it does not come out categorically in evidence that the complainant was suffering from fatal illness prior to the proposal of the policy in question. We regret, we cannot accept the opposite party's contention that the insured was suffering from pre-policy diseases and he conveniently suppressed the same. It is worthier to note that the opposite party has not made it a point to prove the ailments were existing. As we have already several times observed, mere making statements alone is not sufficient to prove one's case. There must be materials to substantiate the contentions put forth by the parties. In the instant case, it appears that, there is no evidence worth the name to rebut the case advanced by the complainant. Thus, when the complainant case has not been rebutted by the opposite parties, this Forum has no other course open but to accept the version put forth by the complainant. The terms and conditions of the policy is marked as Ext.A1. Here for determining exclusion clause pre-existing disease, condition No.3 in the policy is relevant. We hold that the opposite parties repudiated the complainants claim on invalid grounds. Its service is deficient. Needless to say the complainant sustained indescribable mental woes.
7. In the light of the facts and circumstance discussed herein above the opposite parties are directed to pay to the complainant the assured sum of Rs.2,00,000/-( Rupees two lakhs only) with 9% interest from the date of his application for claim till the recovery of the said amount. The opposite party is further directed to pay a compensation of Rs.5,000/- (Rupees five thousand only) to the complainant and a cost of Rs.2,000/- (Rupees two thousand only) which will serve the purpose. The opposite parties shall comply with the order within 45 days of receipt of this order.
In the result, the complaint is allowed accordingly.
Pronounced in open Forum on this the 31st day of March, 2009.
Sd/- Sri. Jimmy Korah:
Sd/- Sri. K. Anirudhan:
Sd/- Smt.N. Shajitha Beevi:
Appendix:-
Evidence of the complainant:-
PW1 - Peethambaran Raju (Witness)
Ext.A1 - Copy of the certificate of insurance of United India Insurance
Co. Ltd.
Ext.A2 - Copy of the letter dated 21.11.2003
Ext.A3 - Copy of the legal notice dated 16.4.2004
Ext.A4 - Copy of the medical certificate
Ext.A5 - Copy of the discharge summary
Ext.A6 - Minutes of the authorities dated 19.11.2002
Ext.A7 - Sonogram report of whole abdomen
Ext.A8 - Copy of the bill cum receipt for Rs.1,35,000/-
Ext.A9 - Copy of the bill cum receipt for Rs.23,930/-
Ext.A10 - Copy of the cash bill for Rs.7385.08/-
Ext.A11 - Copy of the cash bill for Rs.7955/-
Evidence of the opposite parties:-
RW1 - Peethambaran (Witness)
RW2 - Mr.Biju.S. (Witness)
RW3 - Bindu.B. (Witness)
Ext.B1 - Letter dated 1.3.2003
Ext.B2 - Proposal Form
Ext.B3 - Copy of the OP record dated 10.7.2002
Ext.B4 - Copy of the diagnosis report
Ext.B5 - Copy of the Kenal Transplant recipient work-up
Ext.B6 - Copy of the OP record
Ext.C1 - Copy of the summons dtd.7.6.2006
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:-pr/-
Compared by:-
