Andhra Pradesh

Visakhapatnam-II

CC/288/2012

Verigiraju DB Varma - Complainant(s)

Versus

Reliance General Insurance Company Limited - Opp.Party(s)

B.D.V. Prasad

21 Jul 2015

ORDER

                                              Date of Registration of the Complaint:11-09.2012

                                                                                                Date of Order:21-07-2015

BEFORE THE DISTRICT CONSUMERS FORUM-II AT

                             VISAKHAPATNAM

 

P  r  e  s  e  n  t:

1.  Sri H. Ananda Rao, M.A., L.L.B.,

     President           

2. Smt K. Saroja, M.A. B.L.,

     Lady Member 

                                3. Sri C.V. Rao,  M.A., B.L.,

                                     Male Member

 

                                Tuesday, the 21^st day of July, 2015.

                                 CONSUMER CASE No.288/2012

Between:-

Mr. Verigiraju DB Varma, S/o V.V.S.N. Raju,

Hindu, aged 25 years, R/o Door No.24-71-10,

MIG-57, VUDA Colony, Pedagantyda,

Visakhapatnam.

….. Complainant

And:-

1.Reliance General Insurance Co., Ltd.,

   570, Naigum Cross Road, Next to Royal

   Industrial Estate, Wadala (W), MUMBAI-400031.

2.Reliance General Insurance Co., Ltd., 403

   Eswar Paradise, Dwaraka Nagar Main Road,

   Visakhapatnam-530016.

3.Reliance General Insurance Co., Ltd.,

   Reliance House, 6^th floor, No.6, Haddows Road,

   Nungambakkam , Chennai-600006.

                                                                                     …  Opposite Parties       

                     

          This case coming on 14.07.2015 for final hearing before us in the presence of Sri B.D.V. Prasad, Advocate for the Complainant and Sri Syed Moinuddin, Advocate for the Opposite Parties and having stood over till this date for consideration, this Forum made the following:

 

                                                ORDER

          (As per Sri. H. Ananda Rao, Honourable President, on behalf of the Bench)

 

1.       This consumer complaint is filed by the Complainant against the  Opposite Parties directing them to pay the policy claim amount of Rs.44,659/- (Rupees Forty four thousand, six hundred and fifty nine only) with interest @ 18% p.a.,  Rs.10,000/-towards compensation and Rs.5,000/- towards costs.

 

 

2.       The case of the Complainant in brief is that he had taken the Reliance Health wise policy for a period from 29.03.2011 to 28.03.2012 for an amount of Rs.2,840/- and during the period and he was underwent treatment as inpatient from 13.12.2011 to 27.02.2012, he spent nearly Rs.44,659/- and after discharge from the hospital, he applied for claim with medical record but unfortunately his claim was rejected, inspite of his approach to the office of the Opposite Parties, there is no response.   The acts of the Opposite Parties clearly shows that the deficiency in service on the part of the Opposite Parties.   Hence, this Complaint.

 

3.       The case of the Opposite Parties denying the material averments of the Complainant admitted issuance of the policy in favour of the Complainant and contended that themselves and the Complainant are governed by the terms and conditions of the policy and the Complainant has to give full details of the health conditions before applying for the medi-claim policy and the Complainant in the present case has not revealed the material facts of his health conditions and the Complainant was treated for acute and chronic pancreatitis and this disease will not be attract to the Complainant within 9 to 10 months and when the doctor has suggested  that it is a chronic pancreatitis one, it goes to prove that it is very old condition of health of the Complainant which he was well aware of and did not reveal and concealed at the time of taking the policy and suppression of material facts will amount to repudiation of the claim.    Thus, there is no deficiency of service on their part as such the Complaint is liable to be dismissed.

 

4.       To prove the case on behalf of the Complainant, he filed his evidence affidavit   and got marked as Exs.A1 to A9.   On the other hand, on behalf of the Opposite Parties, they filed their evidence affidavit and but no documents were marked for the Opposite Parties.

 

5.       Ex.A1 is the original Reliance Health wise Policy Schedule issued by the 2nd Opposite Party in favour of the Complainant dated 29.03.2011.   Ex.A2 is the original letter issued by the 2^nd Opposite Party in favour of the Complainant dated 29.03.2012.   Ex.A3 is the photo copy of letter addressed by Dr. K. Rama Krishna of Lata Hospitals (P) Ltd., dated 31.10.2011.   Ex.A4 is the photo copy of Complete Abdomen Scan Report issued by the Lata Hospital (P) Ltd., dated 16.12.2011.   Ex.A5 is the photo copy of Inpatient Case Record of the Complainant issued by the Vizag Heart Centre dated 13.12.2011/27.12.2011.   Ex.A6 is the photo copy of bunch of medical bills (10) issued by Lata Hospital Pvt. Ltd.   Ex.A7 is the office copy of Registered Lawyer’s Notice issued by the Complainant’s counsel to the Opposite Parties dated 31.05.2012.    Ex.A8 is the original acknowledgement card from the 3^rd Opposite Party.  Ex.A9 is the original acknowledgement card from the 2^nd Opposite Party.  Ex.A10 is the certified photo copy issued by the Lata Hospital (P) Ltd., in favour of the Complainant dated 27.04.2012.

 

6.       Both sides filed their respective written arguments.

7.       Heard oral arguments from both sides.

8.       Now the point that arises for determination is:-

Whether there is any deficiency in service on the part of the Opposite   Parties and the Complainant is entitled for the reliefs asked for?

 

9.       As seen from record, it is not in dispute that the Complainant had taken Reliance Health wise policy by paying Rs.2,840/- and the period of the said policy is from 29.03.2011 to 28.03.2012.   According to the Complainant on 13.12.2011 he got admitted in LATA HOSPITAL (P) LTD.,  underwent treatment for Chronic Pancreatitis and he was given inpatient treatment from 13.12.2011 to 27.02.2011 and he spent Rs.44,659/- towards medical expenses, and after discharge he has applied for claim to compensate the amount spent by him along with medical record and after due negotiations the 2^nd Opposite Party sent a letter dated 29.03.2012 stating that their inability to admit liability due to clause No.18 i.e., Ethnolic abuse treatments not payable”.  According to the Opposite Parties, the Complainant obtained policy by suppressing of the material facts and since knowingly furnished in correct information, he is not entitled to the benefits of Section-45 of Insurance Act.

 

10.     Ex.A1 Reliance Health wise Insurance Policy.   Ex.A3 is the letter Certifying that the Complainant suffering from Chronic Pancreatitis .  Ex.A4 is the Case Sheet of Lata Hospital (P) Ltd., and Vizag Heart Center.   Ex.A6  is the Medical Bills.   Ex.A10 is the Certificate issued by Lata Hospital (P) Ltd., by Dr. K. Rama Krishna Certifying that the Complainant is suffering from Chronic Pancreatitis and he is not an alcoholic patient and the cause of Pancreatitis is not know and this was issued on 27.04.2012.   Thus, it is clear as seen from medical record, the Complainant was not an alcoholic patient and after full treatment the doctor advised him to avoid alcoholic.   It does not mean that he was under state of alcohol.   Ex.A7 shows that the Hospital Authorities issued for clarifications of its treatment and it clearly showing that the Complainant is not alcoholic patient.   The Opposite Parties did not file any record evidencing contra to the certificate issued by the hospital authorities vide Ex.A7.   Mearly because the Complainant was treated for Chronic Pancreatitis, it cannot be said that it is very old one which he was very well aware of it and did not reveal and concealed the same, at the time of taking the policy.     On a careful perusal of the Exs.A1 to A7, we are of the considered view, that the acts of the Opposite Parties repudiating the claim of the Complainant on the ground of suppression of the material facts without any positive proof himself clear deficiency in service on the part of the Opposite Parties.   Therefore, the Complainant is entitled for the amount which was spent under insurance policy i.e., an amount of Rs.44,659/- towards medical expenses.     There is no evidence whatsoever, let in by the Opposite Parties that the insured was suffering with age old ailments and knowing the same he obtained medical insurance policy from them.    If really the Complainant is having any ailment as argued by the Opposite Parties the Complainant would have joined or treated for the said ailment and the said record also be available at the relevant authorities, but the Opposite Parties did not choose to collect and any take steps to get the record marked on their behalf.   In the absence for filing of the same, it can be held for the best reasons known to the Opposite Parties, they took such a plea as an afterthought. 

 

11.     Now the question that comes up for consideration, at this stages of our discussion what is the rate of interest for which the Complainant is entitled.   The rate of interest claimed by the Complainant is 18% p.a.  This rate of interest claimed by the Complainant appears to be excessive, of course, it is a fact that the transaction covered by Ex.A1 is in commercial in nature, but that does not and cannot mean to say that the Complainant is a licenced to claim interest @ 18% p.a. on Ex.A1.    But at the same time, it is an imperative on our part to award a reasonable interest.   Having regard to all these facts and circumstances, we sincerely feel having considered the case on hand awarding of interest @ 9% p.a. on Ex.A1 would better serve the ends of justice.    Consequently, we proposed to fix at rate in question @ 9% p.a. on Ex.A1 in question.   Accordingly interest is ordered.

 

12.     Whether the Complainant is entitled for compensation of Rs.10,000/- is to be considered.   It appears as seen from the evidence of PW-1 that the Complainant was compelled to approach the Opposite Parties and therefore experienced a lot of physical strain besides mental agony and financial loss. It is un-dispute fact that the Opposite Parties did not refund the amount subscribed by the Complainant.   Naturally that made have put the Complainant to suffer some mental agony besides physical stress and strain.   In this view of the matter, we sincerely feel that it is a fit case to award compensation.   But that does not and cannot mean to say that the Complainant claim for compensation is acceptable.    Having regard to all these facts and circumstances, we are of the considered opinion, award of compensation of 5,000/- would serve the ends of justice.   We therefore, proposed to award compensation of Rs.5,000 /-,  in the circumstances of the case on hand. Accordingly this point is answered. 

 

13.     Before parting our discussion, it is incumbent and imperative on our part to consider the costs of litigation.    The Complainant ought not have to approach this Forum had his claim for refund of the sum of Rs.44,659/- or reliefs sought for have been honored by the Opposite Parties within a reasonable time and in view of the matter, the Complainant’s claim for claims for costs deserves to be allowed.   In our considered and unanimous opinion awarding a sum of Rs. 2,500/- as costs would appropriate and reasonable.   Accordingly costs are awarded.

 

14.     In the result, this Complaint is allowed in part directing the Opposite Parties to pay an amount of Rs.44,659/- (Rupees Forty four thousand, Six hundred and fifty nine only) with interest @ 9% p.a. from the date of registration of the complaint till the date of realization, Rs.5,000/- (Rupees Five thousand only) towards compensation and costs of Rs.2,500/- (Rupees Two thousand and five hundred only) to the Complainant.  Time for compliance, one month.

 

     Dictated to the Steno, transcribed by him, corrected and pronounced by us in the Open Forum, this the 21^st day of July, 2015.

 

Sd/-                                     Sd/-                                               Sd/-

Male Member                      Lady Member                                 President

 

                                       APPENDIX OF EVIDENCE

For the Complainant:-

NO.	DATE	DESCRIPTIONOFTHEDOCUMENTS	REMARKS
Ex.A01	29.03.2011	Reliance Health wise Policy Schedule issued by the 2nd OP in favour of the Complainant	Original
Ex.A02	29.03.2012	Letter issued by the 2nd OP in favour of the Complainant	Original
Ex.A03	31.10.2011	Letter addressed by Dr. K. Rama Krishna of Lata Hospitals (P) Ltd.,	Photo copy
Ex.A04	16.12.2011	Complete Abdomen Scan Report issued by the Lata Hospital (P) Ltd.,	Photo copy
Ex.A05	13.12.2011/27.12.2011	Inpatient Case Record of the Complainant issued by the Vizag Heart Centre	Photo copy
Ex.A06		Bunch of Medical Bills (10) issued by Lata Hospital Pvt. Ltd.,	Original
Ex.A07	31.05.2012	Registered Lawyer’s Notice issued by the Complainant’s counsel to the Ops	Office copy
Ex.A08		Acknowledgement Card from the 3rd OP	Original
Ex.A09		Acknowledgement Card from the  2nd OP	Original
Ex.A10	27.04.2012	Certified copy issued by the Lata Hospital (P) Ltd., in fvour of the Complainant	Photo copy

For the Opposite Parties:-     

                                      -Nil-

 

Sd/-                                      Sd/-                                                 Sd/-   

Male Member                       Lady Member                                   President