KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL No. 160/2023
JUDGMENT DATED: 29.03.2023
(Against the Order in C.C. 123/2022 of CDRC, Malappuram)
PRESENT:
HON’BLE JUSTICE SRI. K. SURENDRA MOHAN : PRESIDENT
SRI. AJITH KUMAR D. : JUDICIAL MEMBER
SRI.RANJIT. R : MEMBER
SMT. BEENA KUMARY. A : MEMBER
SRI. RADHAKRISHNAN K.R. : MEMBER
APPELLANT:
Life Insurance Corporation of India, Branch Office, Trikkandiyur, Tirur, Royapettah, Chennai-600 014 (Appellant represented by the Authorized Officer, Manager (L & HPF) LIC of India, Divisional Office, Thiruvananthapuram.
(By Adv. Anitha Aji)
Vs.
RESPONDENT:
Pushpaletha E., W/o Balan P.V., PuthenVeettil, Kattilangadi P.O., Tirur, Malappuram-676 302.
JUDGMENT
SRI. AJITH KUMAR D.: JUDICIAL MEMBER
This is an appeal filed by the Manager of Life Insurance Corporation, Tirur, the opposite party challenging the order passed by the District Consumer Disputes Redressal Commission, Malappuram(District Commission for short) in C.C. No. 123/2022 dated 05.12.2022 wherein the District Commission directed the appellant to pay the complainant Rs. 57,778/- towards the expenses incurred for her treatment, compensation for Rs 50,000/- and costs Rs.10,000/- in respect of the insurance policy availed by her on 28.11.2018.
2. The case of the complainant is that on 28.11.2018 she had availed an insurance policy from the appellant by remitting Rs. 3446.42 as annual premium having coverage from 28.11.2018 to 28.11.2042. At the time of availing the policy the agent of the opposite party had assured that the policy covers the expenses that may be incurred by him for inpatient treatment, but the opposite party had arbitrarily cancelled the policy on 05.06.2020. The complainant was paralysed and taken to Medical College, Kozhikode where she had undergone treatment up to 11.06.2020 and later in Aster MIMS Hospital, Kottakkal and Sree Chitra Hospital where she incurred a total expense amounting to Rs.57,778/-. Thereupon she filed a complaint before the Insurance Ombudsman but her application was dismissed and the claim placed by her before the opposite party also was repudiated on 27.07.2021 on the ground of pre-existing illness at the time of taking the policy. The complainant contended that there was gross deficiency of service on the part of the opposite party and sought for a direction to the opposite party to pay Rs 1,00,000/- as compensation for the mental agony and hardships and Rs. 25,000/- as costs.
3. The opposite party filed a version objecting to the claim but it was not accepted by the District Commission on the ground that the same was filed after the expiry of the statutory period. The District Commission had passed an order against the opposite party without considering the merits of the claim put forth by the complainant. The failure of the opposite party to file a version is not a ground to grant a relief to the complainant if her case does not sustain on the basis of the policy produced. According to the opposite party the policy does not contemplate reimbursement of medical expenses as her claim comes under Jeevan Arogya Health Insurance Plan - 904 which provides for four major health benefits to the policy holders. According to the appellant the finding of the District Commission is unsustainable. Insurance policy is a contract between the insured and the insurer and both parties are bound by the conditions stipulated.
4. Heard the counsel for the appellant, perused the order passed by the District Commission. According to the appellant the policy does not contemplate reimbursement of medical expenses but provides for certain benefits. The order of the District Commission would show that the claim was allowed as the policy contemplates reimbursement of treatment expenses. The appellant contended that there was non-disclosure of pre-existing ailments of the complainant and that the policy does not contemplate reimbursement of treatment expenses which facts were not properly considered by the District Commission. Admittedly the complainant had subscribed a policy and treatment was availed by her during the subsistence of the policy. The ailments of the complainant alleged as pre-existing at the time of taking the policy were not specified in the appeal memorandum. It is averred that the District Commission did not evaluate the discrepant evidence adduced by the complainant. The appellant did not cause production of the policy before us in order to appreciate the contentions raised by the appellant. Admittedly the treatment was availed during the coverage of the policy. The claim relates to a lady who was paralysed and sought for the expenses incurred by her for the inpatient treatment in three hospitals. On going through the appeal memorandum, it could be seen that her ailments arose after elapsing more than one and a half years from the date of taking the policy and the opposite party has no case that there was any default on the part of the complainant in remitting the requisite premium. There is no valid circumstance to find that the complainant had any pre-existing illness at the time of taking the policy. On a perusal of the appeal memorandum, we could not find any ground to justify repudiation of the claim of the complainant. The appellant has no arguable case. No purpose will be served in admitting the appeal. So without issuing notice to the respondent and calling for the records of the District Commission the appeal is liable to be dismissed.
In the result, this appeal is dismissed.
Sd/-
JUSTICE K. SURENDRA MOHAN : PRESIDENT
Sd/-
AJITH KUMAR D. : JUDICIAL MEMBER
Sd/-
RANJIT. R : MEMBER
Sd/-
BEENA KUMARY. A : MEMBER
Sd/-
RADHAKRISHNAN K.R. : MEMBER
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