BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION - AT HYDERABAD.
FA.No.540/2008 against CC.No.1059/2005 District Consumer Disputes Redressal Forum-I, Hyderabad.
Between-
The National Insurance Company Ltd.
Kachiguda, DAB, Javeri Mansion, Bank Street,
Hyderabad.
…Appellant/O.P.No.1.
And
1.Smt.T.Sujatha, W/o.late T Bairaiah,
C/oT.Veeresham, Occ- Housewife,
H.No.3-14-21/A1, Srinivasapuram,
Hyderabad.
…R.1/Complainant.
2.Heritage Health Services (P) Ltd.
10078, Babukhan Estate,
Basheerbagh, Hyderabad – 500 029.
…R.2/O.P.No.2.
Counsel for the Appellant - Mr.Naresh Byrapaneni.
Counsel for the Respondents - Ms.P.Jayalakshmi.
QUORUM- THE HON’BLE MR.JUSTICE D.APPA RAO, PRESIDENT,
SMT.M.SHREESHA,HON’BLE LADY MEMBER,
AND
SRI G.BHOOPATHI REDDY, HON’BLE MALE MEMBER.
TUESDAY, THE TWENTY SECOND DAY OF APRIL,
TWO THOUSAND EIGHT.
Oral Order (Per Hon’ble Mr.Justice D.Appa Rao, President)
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Heard both sides.
1. This is an appeal preferred by the 1st opposite party against the order of the District Consumer Disputes Redressal Forum-I, Hyderabad, dated 24.09.2007 allowing the complaint.
2. The case of the complainant in brief is that she had taken a Mediclaim Insurance Policy for herself and also for her son, Master T.Sai Lalitha Prasad with the appellant. The policy was valid upto 17.05.2005. While so, her son Sai Lalitha Prasad fell sick and was admitted in Apollo Hospital, Jubilee Hills, Hyderabad on 17.01.2005. On investigation, it was found that he was suffering from acute cardiac problem and the doctors advised that her son had to be operated on emergency basis. Since she was a widow and had no money, she requested the Insurance Company to give pre-authorization letter. The request was not acceded. However, she got her son operated and spent an amount of Rs.1,20,000/-. Thereafter, she submitted the claim form along with the relevant documents. The Insurance Company repudiated the liability on the ground that the boy was having pre existing disease. Therefore, she filed the complaint seeking direction to the 1st opposite party to pay the policy amount of Rs.1,00,000/- together with interest at 9 percent per annum from 19.01.2005 till the date of payment along with costs of Rs.2,000/-.
3. The Insurance Company resisted the case. It alleged that a Mediclaim policy to the complainant and her son was issued covering a period from 18.04.2004 to 17.05.2005 covering the risk of payment of medical expenses upto a sum of Rs.1,00,000/-. On 18.01.2005, it has received a fax letter from the Apolo Hospital with regard to admission and treatment in their hospital to Master Sai Lalith Prasad for heart problem. On that, O.P.No.2 Health Services, reviewed with its medical officer, who opined that the claim is non-admissible as the ailment was pre-existing, and therefore, pre - authorization letter cannot be given. When the complainant had filed the claim form, it was repudiated on the ground that the said ailment was existing, right from his birth. In the discharge summary issued by the Apollo Hospitals, it was mentioned that there was a history of recurrent chest infection associated with failure to thrive known to have CHD i.e. Congenital Heart Disease. This indicates that the disease was present since the time of his birth. Since the boy was having history of cardiac problem, they need not pay any amount and therefore, prayed for dismissal of the complaint. In fact there was no deficiency of service on their part. Therefore, it prayed for dismissal of the complaint.
4. The complainant filed Exs.A.1 to A.6, original policy, receipt issued by the opposite party, correspondence, while the opposite parties filed Exs.B.1 to B.14, claim form submitted by the complainant along with a letter Ex. B.13 issued by Dr.S.Haider Khan mentioning that the ‘boy would have had coronary heart disease’.
5. The District Forum after considering the evidence placed on record opined that the opposite parties did not produce any record to show that the boy had coronary heart disease. Ex.B.7 letter issued by Dr.S.Haider Khan is not enough to dispel that the boy had coronary heart disease since his birth. The complainant had spent Rs.1,20,000/- towards surgery and other expenses. Since the policy covers an amount of Rs.1,00,000/-, the District Forum awarded an amount of Rs.1,00,000/- with interest at 9 percent per annum from 19.01.2005 till the date of payment along with costs of Rs.2,000/-.
6. Aggrieved by the said order, the National Insurance Company Limited, 1st opposite party preferred this appeal contending that the District Forum did not appreciate the facts in correct perspective. It ought to have seen that the child was suffering from pre existing heart ailment, evidenced under Ex.B.7, the certificate issued by Dr.Haider Khan. Therefore, it prayed that the order of the District Forum be set aside and the appeal be allowed.
7. The point that arises for consideration is whether there was any deficiency in service on the part of Insurance Company?
8. It is not in dispute that the complainant had taken Ex.A.1 Mediclaim Policy under hospitalization and domicilliary benefit policy No.550105/48/04//8500113 dt.18.5.2004 valid from 18.5.2004 to 17.5.2005 It is also not in dispute that when the boy fell sick, he was admitted in Apollo Hospital on 17.1.2005. The doctors considering the gravity of the disease had conducted an operation on 19.1.2005. The complainant spent an amount of Rs.1,20,000/- for operation and other charges. It is also not in dispute that when the complainant claimed the said amount, the Insurance Company repudiated the liability on the ground that the complainant had suppressed the fact of boy’s pre-existing ailment. Had they known the said disease, it could not have given the policy.
9. The moot question that arises is whether there was suppression of material facts while taking the policy? A perusal of the record shows that when the policy was issued on 18.5.2004, the complainant was not aware that the boy had any heart ailment. Only when the boy was taken to Apollo Hospital on 17.1.2005, 7 months after it was found that the boy was suffering from heart ailment. Accordingly, an operation was conducted and the complainant had spent Rs.1,20,000/- towards operational charges. When the complainant made her claim, the appellant Insurance Company disallowed the claim on the ground that the pre existing ailment was not informed to them. It may be stated that the complainant asserts that she was not aware, that the boy was having pre-existing heart ailment. Obviously, the appellant had issued Mediclaim policy only after satisfying that there was no ailment or pre existing disease. Only after 8 months, it was revealed that the boy had heart problem. The appellant mainly relies on Ex.B.7 letter issued by Dr.Haider Khan for repudiation of claim which reads as follows-
“The child was having ailment since the time of birth.”
10. The appellant did not file the affidavit of the doctor nor produced any record to show that the boy had coronary heart disease. It is not known the basis for giving Ex.A.7, letter. It would in no way prove that the boy had heart ailment since his birth. When there is no evidence, whatsoever, from any of the medical experts, it can be held that the boy was not having any coronary heart disease. In such circumstances, the doctor ought to have been examined. The Insurance Company must have procured Ex.A.7 for repudiating liability. Ex.A.7 cannot be basis for repudiating liability. The appellant Insurance Company having satisfied about the health condition of the complainant’s son must have issued the policy. As per the terms and conditions of the policy, the appellant Insurance Company is liable to pay Rs.1,00,000/-. Therefore, the District Forum has rightly granted an amount of Rs.1,00,000/- towards the policy amount with interest at 9 percent per annum from 19.1.2005 till the date of payment. We do not see any error either in appreciation of fact or law. We do not see any merits in this appeal.
11. In the result, the appeal is dismissed. However, no costs. The execution proceedings pending before the District Forum shall stand suspended till four weeks for payment of the amount.
PRESIDENT LADY MEMBER MALE MEMBER
Dt-22.04.2008
Vvr.
