Date of Filing : 15.12.2010
Date of Order : 24.06.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 24th JUNE 2011
PRESENT
Sri. S.S. NAGARALE, B.A., LL.B. (SPL) …. President
Smt. D. LEELAVATHI, M.A., LL.B. …. Member
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 2940 / 2010
1. Smt. T.S. Lakshmi,
W/o. Narayan, Aged: Major,
No. 60, Avani, Sir MV Layout,
7th Block, Next to Bharatinagar,
Bangalore – 560 091.
2. Kum. Sindhu,
D/o. Smt. T.S. Lakshmi, Aged Major,
No. 60, Avani, Sir MV Layout,
7th Block, Next to Bharatinagar,
Bangalore – 560 091. ……. Complainants
V/s.
1. Reliance General Insurance Co. Ltd.,
Having Branch Office at S.M. Towers,
2nd Floor, 11th Main, III Block, Jayanagar,
Bangalore – 560 004.
2. M/s. Medi Assist India Pvt. Ltd.,
No. 49, Shilpa Vidya Road, 1st Main,
J.P. Nagar, 3rd Phase,
Bangalore – 560 078. …… Opposite Parties
* * * *
ORDER
(By the President Sri. S.S. Nagarale)
This Complaint is filed by the Complainant u/s. 12 of the Consumer Protection Act, 1986.
2. The brief facts of the Complainants’ case are that the Complainants have taken Mediclaim Policy from the OP right from 1980. The renewed policy covered the period from 2009-10. Complainant No. 2 was diagnosed for large ovarian cystectomy and advised for surgery and she underwent surgery laparoscopic ovarian cystectomy done on 18.11.2009. Complainant No. 2 was hospitalized in Basavanagudi Medical Centre on 17.11.2009 and discharged on 22.11.2009. She has incurred medical & hospital charges in a sum of Rs.63,463/-. When the Complainants submitted claim form, to the utter shock of the Complainants, claim was rejected on the ground that the disease was preexisting and not covered as per the exclusion clause of the Policy. Rejection of the claim is totally false and illegal. Disease was not pre-existing as claimed by the OP. She came to know the problem only during operation of the policy period. OPs are intentionally denying the claim. Legal Notice was issued to the OPs and the same was not complied. Hence, the Complaint.
3. OP1 filed version sating that Policy was issued for a period from 02.08.2009 to 01.08.2010. Complainant No. 2 was suffering from the ailment since 1 ½ years. As per the exclusion clause of the Policy, pre-existing diseases are not covered. There is no cause of action to file the Complaint. There is no deficiency of service on the part of OP. Therefore, OP prayed for dismissal of the Complaint.
4. Respective parties have filed their affidavit evidence and produced the documents.
5. I have gone through the pleadings, documents and affidavit evidence carefully.
6. Points for consideration are as follows:
(i) Whether the OP has committed deficiency in service ?
(ii) Whether the Complainant is entitled for the claim as sought for?
REASONS
7. Complainant has produced Reliance Healthwise Policy Schedule which is valid from 02.08.2009 to 01.08.2010. As regards taking of the Policy, there is no dispute. Policy was in force is also not in dispute. During the Policy period the Complainant No. 2 was admitted to Hospital for treatment. She was admitted to Basavanagudi Medical Centre on 17.11.2009 and discharged on 22.11.2009. Complainants have produced Discharge Summary of the said Hospital. In the Discharge Summary, it is clearly mentioned that the Complainant No. 2 was suffering from abdominal distention since 1 ½ months. The Policy was taken in the month of August 2009 and the Complainant No. 2 was admitted to the Hospital in the month of November 2009. Therefore, Complainant No. 2 complained of disease after taking the Policy only. The defence taken by the OP is that the disease was pre-existing and all diseases / illness which are pre-existing when the cover incepts for the first time are excluded. Relying on the Policy condition, OP has repudiated the claim of the Complainant. The repudiation of the OP in this case is wholly unjustified and without any basis. OP has not produced any documents or medical evidence to show that the Complainant No. 2 was having pre-existing disease and she had taken treatment for that disease before taking the Policy. The defence taken by the OP to repudiate the claim is without any basis & foundation and such kind of repudiation is not proper on the part of OP. When the Discharge Summary of the Hospital clearly shows that the Complainant was suffering from the disease since 1 ½ months, the question of Complainant suffering from the disease before inception of the Policy does not arise. OP has not produced any evidence or documents or medical records to show that the disease was pre-existing.
8. Hon’ble National Commission in a case between National Insurance Co. Ltd. v/s. Sardar Kulbir Singh reported in 2010 CTJ 1032 (CP) observed in Para-17 as follows:
It is not the case of the Petitioner that the respondent was guilty of suppression of facts. The case put forth is that there was pre-existing disease. That the case of the respondent falls under the Exclusion Clause-4 as the respondent was suffering from a pre-existing disease. As mentioned above, the petitioner has failed to produce any evidence, whatsoever, except what has been stated in the discharge summary, to show that the respondent was suffering from chronic stable angina”
9. In this case also, OP Insurance Company has not produced any proof or evidence to show that the disease was pre-existing. Therefore, rejection of the claim is wholly unjustified. The OP should have accepted the claim and paid the amount of medical expenses.
10. OP relied upon the decision of Hon’ble Supreme Court in Civil Appeal No. 2776/2002. I have gone through the said judgement. It was the case wherein the insured at the time of giving the proposal form given false and untrue statement and there was clear suppression of facts with regard to health condition and claim found to be fraudulent and under those circumstances the Hon’ble Supreme Court has held that claimant is not entitled for the benefit of mediclaim policy. The above ruling with great respect cannot be made applicable to the facts of the present case. The facts of the present case are entirely different. This is not a case of any fraud or suppression of material facts. The only defence taken by OP is that the disease was pre-existing. But, as per the Discharge Summary of the Basavanagudi Medical Centre, the Complainant No. 2 was suffering from the disease since 1 ½ months only. So, under these circumstances, the question of pre-existing disease does not arise. Taking any view of the matter, the present case is fit case to allow the claim of the Complainant. Complainants have claimed a sum of Rs.63,463/-. Complainants have produced Cash receipt of the Basavanagudi Medical Centre for Rs.51,000/- and also produced the Bill to that effect. Except these 2 documents, Complainants have not produced any other Receipts or documents to show that they have spent more than Rs.51,000/-. Therefore, Complainants are entitled for Rs.51,000/- from the OP No. 1 towards mediclaim policy. With the above observations, I proceed to pass the following:
ORDER
Complaint is allowed. OP No. 1 is directed to pay a sum of Rs.51,000/- to the Complainants towards medical expenses incurred by the Complainants as per the mediclaim policy within 30 days from the date of this order.
In the event of non compliance of order within 30 days, the above amount carries interest @ 9% P.A. from the date of Complaint till the date of payment / realization.
Complainant is also entitled for Rs.2,000/- as costs of the present litigation from the OP No. 1.
OP1 is further directed to send the above awarded amount directly to the Complainant by way of DD / Cheque with an intimation to this Forum.
Send the copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 24th June 2011.
Order accordingly
PRESIDENT
We concur the above findings
MEMBER MEMBER
SSS
