KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL NO.562/12

JUDGMENT DATED:31.08.2013

                         (Against the order in CC.375/11 on the file of CDRF, Ernakulam, dtd:29.02.12)

PRESENT : 

JUSTICE SHRI. P.Q. BARKATHALI                        :  PRESIDENT

SHRI.V.V. JOSE                                                                   : MEMBER

M/s Oriental Insurance Company Ltd.,

Regional Office, Paramara Road,

Ernakulam North, Cochin-16. R/by its                                      : APPELLANT

Senior Divisional Manager,

Divisional Office-II, Thiruvananthapuram.

(By Adv: Sri.Varkala B Ravikumar)

            Vs.

1. P.N.Prakasan,

S/o Narayanan,

Panakkattampilly thundy House,

Kuthappady, Thammanam.P.O,

Ernakulam, Cochin-16.                                                     : RESPONDENTS

2. TTK Health Care Service Pvt. Ltd.,

39-4130, 1^st floor, Mareena Buildings,

M.G.Road, Ernakulam, Cochin-681 016.

(r1 BY Adv: Sri.Mohan Chacko)

JUDGMENT

JUSTICE SHRI.P.Q. BARKATH ALI : PRESIDENT

This is an appeal filed by the 1^st opposite party/Oriental Insurance Company in CC.375/11 in the file of CDRF, Ernakulam under section 15 of the Consumer Protection Act challenging the order of the Forum dated, February 29, 2012.

2.      The case of the complainant as testified by him as PW1 before the Forum and as detailed in the complaint in brief is this:

The complainant was employed in M/s Kalyan Silks, Thrissur.  The employer insured their employees under a group insurance policy of 1^st opposite party for an amount of Rs.15,000/- each.  On July 07, 2009 the complainant was admitted in Amrita Institute of Medical Science and Research Centre, Kochi for treatment of carcinoma alveolus recurrence and he had undergone radio therapy treatment. He was treated in the hospital from 8.7.2009 to 13.7.2009.  The claim application filed by the complainant before the 1^st opposite party was rejected.  Therefore complainant filed the complaint.

3.      First opposite party is Oriental Insurance Company, Kochi who filed a version contending that the claim of the complainant was rejected as even prior to the issuance of policy he was suffering from the said disease which is not covered as per clause.4(i) of this policy.  The 2^nd opposite party, TTK Health Care Services Private Limited was absent before the Forum.

4.      Complainant was examined as PW1 and Exts.A1 to A5 were marked on his side.  On the side of the 1^st opposite party DW1 was examined.  On an appreciation of evidence the Forum found that there is no evidence to show that the disease of the complainant was pre-existing at the time of the issuance of the policy and allowed the complaint and directed the 1^st opposite party to pay the claim amount to the complainant.  The 1^st opposite party has challenged the said order in this appeal.

5.      The only point which arises for consideration is, whether the impugned order of the Forum can be sustained?

6.      It is the admitted case that complainant was employed in M/s Kalyan Silks, Thrissur and that he joined in group insurance mediclaim scheme.  The sum assured was Rs.15,000/-.  Ext.B2 is the copy of the said policy which was valid from June 06, 2009 to June 05, 2010.  It is also proved by Ext.A2 discharge summary issued from Amrita Institute of Medical Science, Kochi that PW1 underwent treatment during the period July 08, 2009 to July 13, 2009 for cancer of the right lower jaw, ie carcinoma alveolus recurrence.  The appellant repudiated the claim on the ground that disease of the opposite party was a pre-existing one based on clause.4(1) of Ext.B2 policy.

7.      The appellant relied on Ext.B1 medical certificate which shows that complainant was under treatment one year back for callous cell carcinoma.  But no evidence was adduced by the appellant in support of Ext.B1.  Further merely on the basis of Ext.B1 it cannot be said that disease of PW1 was a pre-existing one.  Therefore in our view the Forum is perfectly justified in allowing the complaint.

8.      The Forum has ordered the complainant to produce all documents relating to his claim before the first opposite party and claim the amount.  Before this Commission the complainant produced bills regarding his treatment worth Rs.22,761/- but the policy amount is only Rs.15,000/-.  Therefore the complainant is entitled to that amount with interest at 12% per annum from the date of complaint till realization.

In the result we find no merit in this appeal and the same is hereby dismissed.  No costs.

JUSTICE P.Q. BARKATHALI:  PRESIDENT

V.V. JOSE : MEMBER

VL.