BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION
AT HYDERABAD.
F.A. 1805/2005 against C.D. 531/2001, Dist. Forum-I, Hyderabad
Between:
The Divisional Manager
M/s. United India Insurance Co. Ltd.,
Divisional Office No. 7
Basheerbagh, Hyderabad. *** Appellant/
O.P. No. 1
And
1. Pamidigantam Murahari Rao
S/o. Late P. Ranga Rao
Age: 62 years,
H. No. 5-12/5,
New Maruthi Nagar
Kothapet, Hyderabad. *** Respondent/
Complainant
2. The in-charge
Claims Department
M/s. Mercury International Assistance &
Claims Ltd., P.O. Box. No. 673
HOVE SUSSEX, BN3 5JL
England, United Kingdom. *** Respondent/
O.P. No. 2.
Counsel for the Appellant: Mr. Naresh Byrapaneni
Counsel for the Resp: Mr. V. Gourisanakara Rao (R1)
QUORUM:
HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT
&
SMT. M. SHREESHA, MEMBER
MONDAY, THIS THE FIRST DAY OF SEPTEMBER TWO THOUSAND EIGHT
Oral Order: (Per Hon’ble Justice D. Appa Rao, President)
*****
This is an appeal preferred by the insurance company against the order of Dist. Forum-I, Hyderabad in directing it to pay US $ 5,877.66.
The case of the complainant in brief is that he took Videsh Yatra Mitra medi claim policy from the appellant on 7.5.1999 for a period of six months valid from 16.05.1999 to 11.11.1999. As per the terms of the policy, both the respondents are jointly and severally liable to pay the claim if any. During his visit to his son in Urbana of United States of America on 18.7.1999 he felt uncomfortable, unsteady in feet, fell down, and lost consciousness. He went to M/s. Carle hospital a division of Neuro-sciences of Urbana of USA. After conducting several tests they opined that it was not a seizure disorder nor of hypoglycaemic event. It was related to heart-rhythm disturbance. Accordingly, he submitted the claim for US $ 5877.66 spent by him to R2 directing it to pay the said amount. It repudiated the claim on the ground that pre-existing medical conditions were not declared while taking the policy. In fact he had informed that he was suffering from diabetes, and the treatment taken by him in the very policy. Since he has suffered illness during the period of insurance policy and the ailment suffered has nothing to do with any of the ailments suffered within 12 months prior to the inception of the policy he was entitled to the claim. Therefore, he claimed Rs. 2,85,212.82 with future interest @ 18% p.a., and Rs. 1,99,268.90 towards treatment and costs.
Respondent No. 1 filed counter denying the facts mentioned in the complaint, however, it admitted that it had issued Videsh Yatra Mitra medi-claim policy. The complainant had declared that he was afflicted with diabetes. He did not declare any pre-existing disease, especially pre-existing seizures. As per the terms and conditions of the policy he has to approach M/s. Mercury International Assistance & Claims Ltd., Sussex, England (R2) for any claims made under the policy as it has main office at Sussex in England and other places. R2 after considering all the aspects of the claim repudiated it stating that pre-existing seizures or medical conditions were not declared at the time of taking of the policy. Since the claim was made in United State of America the Dist. Forum has no jurisdiction. The appellant was only an agent of R2.
While denying the reasons for unconsciousness, heart rhythm disturbance, given by the complainant it alleged that it was more towards seizure disorder which was suppressed. The respondents are not liable to pay the amount spent towards medical expenses etc. since the complainant knowingly and fraudulently suppressed the pre-existing medical conditions especially the seizures at the time of taking of the policy. R2 was competent to consider the claim of the complainant. It has nothing to do with the claim made by the complainant, and therefore prayed for dismissal of the complaint with costs
R2 did not choose to contest the matter.
The complainant in proof of his case filed his affidavit and Exs. A1 to A20, while the appellant filed the affidavit of its officer and Ex. B1 policy. The Dist. Forum after considering the evidence placed on record opined that the complainant visited Urbana in USA where he fell sick and the doctors at Carle Clinic Association, Urbana diagnosed as ‘heart rhythm disturbance’ nothing to do with diabetes which he was suffering from and disclosed at the time when he took the insurance policy. The repudiation was unjust. By virtue of terms of the policy under Ex. B1 he was entitled to the claim. The appellant is liable to pay the same.
Aggrieved by the said decision, R1 insurance company preferred this appeal contending that the Dist. Forum did not appreciate the facts in correct perspective. The repudiation by R2 was not considered. There was suppression of material regarding the health of the claimant. It is R2 that is liable to pay the amount. Therefore prayed for dismissal of the complaint against it.
It is an undisputed fact that the appellant has issued Ex. B1 Videsh Yatra Mitra medi-claim policy to the complainant on 7.5.1999 for a period of 180 days valid from 16.5.1999 to 11.11.1999. In Ex. A1 policy the complainant has mentioned that he was suffering from diabetes for the last 8 years and was taking treatment from Dr. K. D. Modi, C.C. Shroff Hospital, Hyderabad. He was aged 78 years. He made a mention that he was insulin dependent.
It is also not in dispute that after he went to Urbana of USA on 18.9.1999 while he was visiting a mall he felt uncomfortable, unsteady of his feet, fell down and lost consciousness. Immediately, he was admitted in Carle Clinic Association, Urbana . After several investigations they assessed that it was related to ‘heart rhythm disturbance’. They categorically mentioned that
“ One can certainly not be absolutely confident that this is a seizure disorder, but the story fits that diagnosis reasonably well. In addition, I don’t think it fits the diagnosis of hypoglycaemic event very well at all, and with this normal cardiological evaluation, I doubt that this is related to a heart rhythm disturbance.
He spent US $ 4,267 by way of treatment and US $ 1610.66 by way of medical expenses, in all US $ 5,877.66 evidenced by receipts Exs. A13 to A18. The complainant has taken the claim form and submitted the same to R2 as required under terms of the policy. He also answered to the queries made by it under Ex. A3 by submitting the treatment certificate issued by Dr. Modi from whom he took treatment for diabetes. Despite the medical opinion that the complainant had suffered from heart rhythm disturbance, R2 by way of reply under Ex. A5 opined that the complainant had suffered from pre-existing seizures and that was not informed to the insurance company. The policy excludes any known or treated condition in the 12 months prior to the inception of the policy, and therefore they declined the claim.
It is not known as to how they could come to a conclusion that the complainant had suffered from seizures and it was pre-existing and the same was suppressed. The complainant had issued Exs. A7 & A8 legal notices claiming the amount. Finally the complainant issued Ex. A10 legal notice to both the respondents directing them to settle the claim. After protracted correspondence and having denied the claim, the complainant filed the case.
At the out set, it can be said that no evidence whatsoever was filed by the appellant to prove that the complainant had suffered from pre-existing seizures. He had faithfully disclosed the ailment from which he was suffering in the very policy. The appellant had accepted his health condition and issued Ex. A1 policy under which the appellant was liable to pay the amount spent towards any ailment suffered in the foreign country. At the cost of repetition it may be stated that on 18.7.1999 when he fell down and lost consciousness, he was admitted in Carle Clinic Association, Urbana where it was diagnosed that he was suffering from ‘heart rhythm disturbance’ . They have completely excluded from seizures or complications of diabetes. In the teeth of medical opinion, the repudiation of claim was unjust.
It is not in dispute that the complainant had spent US $ 5,877.66 towards treatment and medical expenses etc. evidenced by various receipts Exs. A13 to A18. Since the appellant has issued the policy undertaking to cover the risk, the question of collecting it from R2 will not arise. That was a pact between the appellant and R2. The complainant can undoubtedly claim the amount under the terms of the policy by filing a complaint before the Dist. Forum. Non-payment of amount covered under the policy undoubtedly constitutes deficiency in service. When the complainant has proved that he has spent the amount towards medical treatment the appellant is bound to reimburse the same. Having issued the policy agreeing to pay the amount as per the terms of the agreement, it cannot shirk its responsibility and direct the
complainant to recover the amount from R2. More so, the appellant itself admitted that it was an agent of R2, may be such sort of plea was raised to get over the liability. Even assuming that it was an agent, it was liable to pay the same. Having issued the policy it cannot repudiate the claim on any ground whatsoever. He is entitled to the said amount in Indian currency computed at the rate prevailing. The Dist. Forum has considered the entire evidence in correct perspective and rightly allowed the complaint. We do not see any merits in the appeal.
In the result the appeal is dismissed with costs computed at Rs. 2,000/-.
PRESIDENT LADY MEMBER
Dt. 1. 9. 2008
*pnr
CORRECTED – O.K.
