BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION:
HYDERABAD.
FA.NO.77 OF 2005 AGAINST C.D.NO.699 OF 2003 District Forum-I, HYDERABAD.
Between:
1. The Divisional Manager,
The New India Assurance Co. Ltd.,
Divisional Office, Anasuya Complex,
2nd floor, Opp:TTD Kalyanamandapam
Himayathnagar, Hyderabad-29.
2. The Managing Director,
The New India Assurance Co. Ltd.,
Reg. Office New India Assurance Building,
87 MG Road Fort, Mumbai-001. ...Appellants/
Opp.parties
And
Prof. K.Nagi Reddy, S/o.Narapa Reddy,
Aged 69 years, Continental designers,
R/o.No.4, Silpa Apartments,
Erramanzil Colony, Hyderabad-82. ..Respondent/
Complainant
Counsel for the Appellants : Smt.M.Seetha Devi
Counsel for the Respondent:- served.
QUORUM:THE HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT.
AND
SMT.M.SHREESHA, LADY MEMBER.
THURSDAY, THE TWENTY EIGHTH DAY OF FEBRUARY
TWO THOUSAND EIGHT.
Oral Order : (Per Smt.M.Shreesha, Hon’ble Lady Member)
***
Aggrieved by the order in C.D.No.699/2003 on the file of District Forum-I, Hyderabad, opposite parties preferred this appeal.
The brief facts as set out in the complaint are that complainant is a mediclaim policy holder of opposite parties having Policy bearing No.610100/48/00/002698 dated 15-2-2001. The premium paid was Rs.3,393/- plus service tax No.Rs.170/- and is a continous policy taken for the complainant and his wife. The complainant submitted that in case of any hospitalization, the insurer has to reimburse the medical expenses relating to hospitalization along with incidental hospital expenses. The complainant submitted that he was hospitalized in the month of January, 2002 and as there was significant blockage in one of his coronary arteries, he was subsequently treated for blockage by C balloon and stent placement on 7-2-2002. After discharge from the hospital, the complainant sought for reimbursement through a letter dated 13-2-2003 but the claim was repudiated by the opposite parties vide letter dated 13-2-2003. Hence the complaint for a direction to the opposite parties to pay Rs.2,50,000/- towards reimbursement of hospital expenses etc. along with Rs.50,000/- towards mental agony and Rs.50,000/- for deficiency in service together with interest at 18% p.a. from 17-2-2002 till the date of payment and for costs.
Opposite parties filed counter stating that they are not proper parties and submitted that New India Assurance Company Ltd. is a proper party. They contended that there is no ‘consumer dispute and that there is no deficiency of service on their part. They submitted that they were right in repudiating the claim as the complainant has taken treatment for hypertension, which is a pre-existing disease since 1995 and hence he is not entitled to reimbursement as it attracts exclusion clause No.4.1 of the medi-claim policy. They admitted the medi-claim policy of the complainant and its continuation and submitted that the policy is valid only for one year from the date of acceptance of the proposal. They further submitted that after going though the medical record placed by the complainant and after going through the opinion of the panel doctor of opposite parties, the claim of the complainant was rightly repudiated as the complainant was suffering since 1995 and the said hypertension was the cause for the disease CAD and therefore the disease for which the complainant underwent treatment is a pre-existing disease, which was suppressed by the complainant in his proposal form.
Based on the evidence adduced i.e. Exs.A1 to A12 and B1 to B4 and the pleadings put forward, the District Forum allowed the complaint in part by directing the opposite parties to pay Rs.1,00,000/- to the complainant together with costs of Rs.2,000/-.
Aggrieved by the said order, opposite parties preferred this appeal.
The learned counsel for the appellants submitted that the District Forum failed to observe that there was no continuation policy and that there was a gap between the first policy and subsequent policy. He also submitted that the District Forum failed to appreciate the oral and documentary evidence placed by the appellant, wherein the doctor, who treated the complainant has prescribed medicines for hypertension in the year 1995, which clearly establishes the pre-existing disease. The learned counsel further submitted that the Medi claim policy does not cover pre-existing disease and that it is only for a period of one year and has to be renewed without any gap and if there is any gap, the policy will be treated as a fresh policy. He also submitted that there is no deficiency of service on their part as after careful scrutiny in terms and conditions, it was rightly repudiated under clause 4.1 of the policy.
We have perused the material on record. It is not in dispute that the respondent is a policy holder of medi-claim policy and the period of coverage being 25-1-2000 to 24-1-2001, the premium paid is Rs.3,393 in addition to service tax of Rs.170/-. It is the case of the appellants that C.A.D disease for which the respondent had taken treatment is due to hypertension and was pre-existing disease since 1995 and that Medi Claim policy is not a continuing policy and is valid for one year from the date of acceptance of proposal and issuing policy to the assured. Whereas it is the respondent’s case that it is a continuing policy which was taken for himself and his wife and in case of any hospitalization, the policy holder has to be reimbursed the medical expenses relating to hospitalization. Ex.A2 is the Medi claim policy for the period from 15-2-2001 to 14-2-2002 and Ex.A5 is the Medi Claim policy for the period from 15-2-2002 to 14-2-2003. The respondent/complainant submits that he did not make any claim during the year 2000 and subsequently in 2002, he was hospitalized and tests revealed that there was a blockage in one of his arteries and he was treated with balloon and stent replacement on 7-2-2002. Thereafter he made a claim through letter dated 13-2-2003 which was repudiated on the ground that it is not a continuing policy and the disease is a pre-existing one.
Firstly, we address ourselves to the point, whether the claim made by the respondent is covered by the Medi Claim policy issued by the opposite party. The date of hospitalization is 4-2-2002 and the date of discharge is 7-2-2002, whereas Ex.A2 Medi Claim policy is for the period from 15-2-2001 to 14-2-2002, therefore, we are of the considered view that hospitalization period was very much within the period of policy coverage.
Secondly, we address ourselves to whether the respondent had suppressed any pre-existing disease prior to the taking of the policy. Ex.A9 is the discharge summary which states in patient’s history that, he is a 68 years old male patient and admitted for CAG, which was done on 4-2-2002 and no where in the report, it states that he had history of hypertension, prior to the date of issuance of the policy. A perusal of Ex.A11, which is a report issued by Dr.R.L.Kumar, a Cardiologist of Yashoda Hospital states that 15 years ago when the patient had some slight abnormality, an angiogram was taken which showed that his coronary arteries were completely normal without any evidence of disease. The appellants contend that as per their investigation report, Ex.B2, dated 5-12-2002, the respondent regularly visited Dr.Vasanth Kumar, Physician for Asthama and Diabetes and also for Hypertension. We have also gone through Exs.B3 and B4 which are just prescriptions and do not clearly specify that the patient is hypertensive. Merely because B.P. reading is 120/90 on 11-10-1994 and 140/90 on 01-11-1995, it cannot conclusively establish that the patient had hypertension. The appellants neither filed the affidavit of the doctor, who treated the respondent nor did they choose to lead any evidence in support of their contention. We rely on the judgement of the Apex court in LIC OF INDIA v. SMT. ASHA GOEL, I (2001) SLT 89= (2001) 2 SCC 160, wherein it was that
‘Section 45 of the Insurance Act is restrictive in nature and depends upon the conditions. It lays down that the suppressed material must be of such material which ought to have been disclosed and that the insured might have played fraud’.
The burden of proving false representation and suppression of material facts lies on the insurance company. . It is also pertinent to note that the District Forum did not grant any interest on the awarded amount but only awarded the insured amount with nominal costs. Therefore in the absence of any documentary evidence to prove that the respondent suppressed any pre-existing disease, we see no reason to interfere with the well considered order of the District Forum.
In the result the appeal fails and is accordingly dismissed. Time for compliance six weeks.
PRESIDENT. LADY MEMBER.
JM Dated 28-2-2008
