BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION
AT HYDERABAD.
F.A. 1706/2007 against C.C. 827/2006, Dist. Forum-I, Hyderabad.
Between:
The United India Insurance Company Ltd.
Regd. Office : 24, Whites Road
Chennai-600 014. *** Appellant/
O.P. No. 1.
And
1. Peddi Reddy Rama Mohan Rao
S/o. Late P. Raju
Flat No. 601, Keshava Towers
New Mettuguda, Hyderabad *** Respondent/
Complainant
2. The Chief Executive Officer
Family Health Plan Ltd.
Aditya JR Towers, III Floor
Road No. 2, Banjara Hills
Hyderabad-500 034. *** Respondent/
O.P. No. 2
3) Andhra Bank
Rep. by its Manager
Vidyanagar Branch,
Hyderabad. *** Respondents/
O.P. No. 3.
Counsel for the Appellants: Smt. S. A.V. Ratnam
Counsel for the Respondent: Mr. N. Ch. Prasad (R1)
Mr. V. Ravindra Reddy (R3)
R2 served.
CORAM:
HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT
SRI SYED ABDULLAH, MEMBER
&
SRI R. L. NARASIMHA RAO, MEMBER.
WEDNESDAY, THIS THE TWENTY FIRST DAY OF APRIL TWO THOUSAND TEN
Oral Order: (Per Hon’ble Justice D. Appa Rao, President)
*****
1) This is an appeal preferred by the insurance company opposite party No. 1 against the order of the Dist. Forum directing it to pay Rs. 1 lakh covered under the policy with compensation and costs.
2) The case of the complainant in brief is that he was a member of Arogya Daan medi-claim policy sponsored by opposite party No. 3 Andhra Bank for Rs. 1 lakh covering the risk of himself and his dependents. The policy was covered for the period between 11.4.2005 and 8.6.2005 and again renewed covering the period from 18.6.2005 to 17.6.2006 and there after from 9.8.2006 to 8.8.2007. However, the appellant had issued a fresh policy on 24.8.2006 covering the period from 29.7.2006 to 28.7.2007 though he was continuously under cover of the above said policy. On 11.8.2006 he felt heaviness in his chest and approached Dr. M.R.M. Babu of Kamineni Wockhardt Hospital for consultation. He underwent angiogram which revealed that he had developed blockages in his blood vessels. They have advised to undergo an early Coronary Artery Bypass Grafting (CABG) and was discharged on 15.8.2006. He paid Rs. 28.039/- in all. On that he admitted in Global Hospitals, Hyderabad on 3.9.2006 and he was operated for CABG and was discharged on 11.9.2006. He paid Rs. 1, 18,348/- towards treatment. When he sought for reimbursement of the amount it was repudiated on the ground that he was having pre-existing disease, and a known diabetic, and the same suppressed. Thereupon he filed the complaint claiming the amount covered under the policy with interest @ 36% p.a. together with damages and costs.
3) The appellant resisted the case. While admitting issuance of policy to the complainant under Aarogya Daan scheme, it alleged that it was meant for reimbursement of necessary hospitalization for diseases contracted after taking the policy with exclusions given under clause 4 of the terms and conditions of the policy. The inception of policy is from 29.7.2006. His date of admission in the hospital was on 11.8.2006 i.e., within 30 days of the policy. Any admission within 30 days of the policy inception is excluded from the cover of the policy as per Clause 4.1 of the terms and conditions of the policy. A panel of doctors considered the claim along with documents and opined that it was pre-existing and therefore the claim was repudiated. He was not entitled to any claim and it prayed for dismissal of the complaint with costs.
4) Opposite Party No. 3 bank equally resisted the case stating that it was only a facilitator. It had nothing to do with the settlement of the claim. It was the responsibility of the appellant to settle the matter. There was no deficiency in service on its part and therefore prayed for dismissal of the complaint with costs.
5) The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A19 marked, while the appellant filed the affidavit evidence of its Asst. Divisional Manager, whereas the bank filed the affidavit evidence of its Branch Manager. The opposite parties did not file any documents.
6) The Dist. Forum after considering the evidence placed on record opined that he had suffered from Coronary artery disease, two vessels disease and diabetes Mellitus (Denovo). This expression denotes that it was diabetes afflicted recently and his discharge sheet shows that he was non-hypertensive and non-diabetic, and was for the first time admitted with a complaint of heaviness in the chest. There was no pre-existing disease. At any rate, he was having policy since 11.4.20005. Though the said policy was given afresh however considering the basis on which earlier policies are being extended from time to time it should be construed as renewal and therefore clause 4.1 does not exclude the claim made by the complainant. Therefore it directed the insurance company to pay Rs. 1 lakh besides compensation of Rs. 25,000/- together with costs of Rs. 2,000/-.
7) Aggrieved by the said decision, the insurance company preferred the appeal contending that the Dist. Forum did not appreciate the facts in correct perspective. It ought to have seen that the policy was issued on 29.7.2006, and the complainant complained heaviness in his chest on 11.8.2006 within 30 days of the policy inception attracting clause 4.1 of the terms and conditions of the policy, consequently not entitled to the amount.
8) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
9) It is an undisputed fact that the complainant was given a medi-claim policy commencing from 11.4.2005 to 8.6.2005 and later renewed from 18.6.2005 to 17.6.2006 and there after from 9.8.2006 to 8.8.2007. We may mention herein that even earlier the renewal was from 18.6.2006 but not from 8.6.2006. The insurance company was undoubtedly renewing the policy not from the last date of expiry of the policy. There were gaps in the policy while renewing the same. Equally the policy was renewed on 29.7.2006 to cover the risk from 9.8.2006 to 8.8.2007. All this shows that policies are renewed erratically. Now the appellant contends that it was not renewal of policy but a fresh policy. The insurance company cannot blow hot and cold at the same time. When it had renewed earlier, it was from 18.6.2005 to 17.6.20006. It is not its case that it is a new policy. However, when it comes to renewing the policy from 17.6.2006 it had renewed on 29.7.2006. Covering the risk from 9.8.2006 to 8.8.2007. They alleged that this policy was issued afresh. Even it confirmed in their written arguments stating “The complainant was renewing the policy year by year. Initially the coverage of policy was from 11.4.2005 to 8.6.2005. Again the policy was renewed w.e.f. 18.6.2005 to 17.6.2006. Thereafter the policy was renewed on 29.7.2006 to cover the risk from 9.8.2006 to 7.7.2007. But the policy was issued from 29.7.2006 to 28.7.2007. Thus the complainant was under the coverage of medi-claim policy.” This contention of the appellant makes it clear that the policy was commenced from 11.4.2005. It was valid till 28.7.2007. It is not in dispute that on 11.8.2006 the complainant felt heaviness in his chest. He got angiogram tested and on finding that there was blockage in his blood vessels he underwent CABG on 15.8.2006. He incurred Rs. 1,18,348/- for surgery etc. The claim was repudiated on two grounds i) he was a diabetic which he suppressed ii) the disease was contracted within 30 days from the
commencement of the policy and therefore clause 4.1 of the terms and conditions of the policy comes into play. The discharge summary Dt. 15.8.2006 issued by Kamineni Worckhardt Hospital shows that “he was non-hypertensive, non-diabetic. He was admitted with history of heaviness in chest. “Therefore the allegation that he was diabetic is false. Even otherwise the discharge summary Ex. A5 maintained by Global Hospitals, Hyderabad emphatically stated that “Coronary Artery Disease, Two vessel disease. Diabetes Mellitus (Denovo).” The Dist. Forum after considering the meaning of Denovo opined that it was fresh or new and therefore it cannot be said that it was pre-existing by the date of taking policy. Equally so with CABG. Had he been suffering from said ailment, he could have taken treatment earlier, as admittedly he was covered by a medi-claim policy when he felt heaviness in his chest on 11.8.2006 for the first time, he was not having any idea that he had Coronary Artery Disease. It was confirmed only after conducting angiogram. Therefore the contention that he suffered from pre-existing disease has no basis.
10) Though the appellant alleged in its written version that they got it reviewed through a panel of doctors and on the basis of their opinion the claim was repudiated, for the reasons best known the insurance company did not file the said report. Therefore, there is no evidence to show that the disease was pre-existing.
11) The learned counsel for the appellant contended that since the disease was contracted during the first 30 days from the commencement of the policy he was not entitled to the amount by virtue of clause 4.1 of the exclusions. The exclusion clause 4.1 reads as follows:
“Diseases contracted during the first 30 days from the commencement date of the policy. The clause is applicable if the insured has taken this policy for the first time. If it is a renewal policy, this clause is not applicable provided if the previous policy is issued for a minimum of 30 days.”
Unfortunately, the insurance company intended to reckon the date from 29.7.2006 forgetting the fact that they have been renewing the policy right from 2005 onwards. By no stretch imagination it could be construed that the disease was contracted within 30 days from the commencement of the policy. This was contrary to their own submission made in the written arguments which we have already extracted. The policy was renewed covering the risk from 9.8.2006 to 7.7.2007. In view of the above, it cannot be said that it should be considered as commencement of policy from 29.7.2006 and therefore the exclusion clause 4.1 would apply and therefore the insurance company was not liable.
12) The Dist. Forum has rightly awarded the amount covered under the policy. There is neither suppression of pre-existing disease nor violation of terms and conditions of the policy. Learned counsel for the appellant contended that awarding compensation of Rs. 25,000/- for the policy amount of Rs. 1 lakh is very high and disproportionate. No doubt the complainant could not let in any evidence to establish that he was entitled to Rs. 25,000/- towards compensation. In the complaint he did not mention any amount as such. In the light of the fact that repudiation was unjust, necessarily the complainant must have felt mental agony. He is already a heart patient. The insurance company ought not to have repudiated the claim on illogical grounds. We are of the opinion that an amount of Rs. 10,000/- towards compensation could be reasonable and modest in the circumstances. For the reasons best known the Dist. Forum did not award interest. Undoubtedly the complainant is entitled to interest @ 9% p.a., from the date of complaint till the date of realization on the assured sum.
13) In the result the appeal is allowed in part, modifying the order of the Dist. Forum. The appellant insurance company is directed to pay Rs. 1 lakh with interest @ 9% p.a., from the date of complaint viz., from 24.10.2006 till the date of realization together with compensation of Rs. 10,000/-. The costs of Rs. 2,000/- awarded by the Dist. Forum is confirmed. The complainant is also entitled to costs of Rs. 2,000/- in the appeal. Time for compliance four weeks.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
3) ________________________________
MEMBER
Dt. 21. 04. 2010.
*pnr
“UP LOAD – O.K.”
