F.A.No802/2008 against C.C.No.350/2006, District Forum-I, HYDERABAD

Between:

1. The National Insurance Co. Ltd.,

    Rep. by its Managing Director, 101/102,

    First floor, Parekh market Phase-II,

    Opp:Bharti Jewellers, M.G.Road,

    Ghatkopar, East Mumbai-400 007.

2. M/s.National Insurance Co. Ltd,

    Rep. by its Manager, Office at III floor,

    Moghul Court, Basheerbagh,

    Hyderabad.                                                                                                               Appellants/

                                                                                                                                       Opp. Parties 1 & 3

And

1. Sri Chimanlal K.Shah S/o.Sri Kunverji

    Aged 70 years, Occ:Business, R/o.1-8-516,

    Chikkadpally, Hyderabad.                                                                                      Respondent/

                                                                                                                                      Complainant

2. M/s.Heritage Health Services Pvt Ltd.,

    Rep. by its Managing Director, Unit No.28,

    Ground floor, T.V.Industrial Estate, Hind

    Cycle Road, Worli, Mumbai-400 025.                                                                     Respondent/

                                                                                                                                      Opp.party No.2.

Counsel for the Appellants: Mr.Kota Subba Rao

Counsel for the Respondents: Mr.Shyam S.Agarwal

QUORUM:   THE HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT

AND

SMT.M.SHREESHA,  MEMBER

.

THURSDAY, THE TWENTY EIGHTH DAY OF OCTOBER,

TWO THOUSAND TEN

Oral order:(Per Hon’ble Justice Sri D.Appa Rao, President)
***

        This is an appeal preferred by the insurance company against the order of the District Forum directing it to pay Rs.1,75,009/- together with interest at 12% p.a. and costs of Rs.5,000/-.

        The case of the complainant in brief is that he obtained medi-claim policy for Rs.3,00,000/- under family reference No.1573 of Dakshin Bharat Kutchi Oswal Jain Ekkam for his family consisting of himself and his wife Smt.Gunvati C.Shah.  While so, the complainant’s wife had health problem and she was admitted in hospital and taken treatment by spending Rs.1,75,009/-.  He claimed the said amount by filing claim forms and also got issued a legal notice to the insurance company but it did not settle the claim.  It is his case that his wife expired on 12-11-2003 due to insufficient funds and hence he claimed Rs.1,75,009/- along with interest at 24% p.a. from the respective dates of claim till the date of payment together with damages of Rs.1,00,000/- and costs of Rs.10,000/-.

        The appellants for reasons best known did not choose to contest the matter and therefore, they were set exparte.

        The complainant in proof of his case filed his affidavit evidence and got marked Exs.A1 to A8.

        The District Forum after considering the evidence placed on record and as the same was uncontroverted allowed the complaint in part  directing the insurance company to pay Rs.1,75,009/- with interest at 12%p.a. from the respective dates of claim till the date of payment together with costs of Rs.5,000/-.

        Aggrieved by the said order, the insurance company preferred this appeal contending that the District Forum did not appreciate the facts in correct perspective and that an amount of Rs.50,000/- was paid towards full and final satisfaction by letter dated 15-11-2006 that apart the other amounts were not covered as there was suppression of ailment for which she had taken treatment and therefore it prayed for dismissal of the complaint.

The point that arises for consideration is whether the order of the District Forum is vitiated by mis-appreciation of fact or law in that regard?

It is not in dispute that a medi-claim policy was issued in favour of the assured for Rs.3,00,000/-.  It is also not in dispute that she died on 12-11-2003. Her husband, the complainant, got treated her and claimed Rs.1,75,009/- by producing the bills for Rs.38,031/- dated 06-6-2003, Rs.60,325/- dated 19-7-2003, Rs.23,470/- dated 20-8-2003 and Rs.53,183/- dated 14-11-2003.  The insurance company admittedly did not rebut the evidence before the District Forum and belatedly in the appeal it filed Exs.B1 to B3 to show that the complainant agreed to receive Rs.50,000/- towards full and final satisfaction and hence Rs.50,000/- was paid on 15-11-2006 which was encashed by the complainant and therefore  he  was not entitled to the rest of the amount,.  They did not disclose as to why only the claim for Rs.50,000/- was only admitted.  Equally it is not known as to why the other claims were dis-allowed.  They had not chosen to file any evidence in this regard. They disallowed the rest of the claim without any justification.  Therefore, the insurance company was unjust in rejecting the claim in the light of the fact that an amount of Rs.50,000/- was paid.  What all the complainant will be entitled to is the balance amount after deduction of Rs.50,000/- from out of Rs.1,75,009/-.  Equally the complainant has withdrawn an amount of  Rs.1,12,462/- deposited by the insurance company at the time when the amount was directed to be deposited as per orders in I.A.No.2014/2009 dated 17/12/2009.  Therefore, the insurance company is liable to pay the remaining balance of Rs.12,547/- together with interest at 9% p.a. from 15-11-2006  together with costs of Rs.5,000/- awarded by the District Forum and another costs of Rs.2,000/- in this appeal.

In the result the appeal is allowed in part directing the appellants, insurance company to pay the balance sum of Rs.12,547/- together with interest at 9% p.a. from 15-11-2006 together with costs of Rs.5,000/- awarded by the District Forum and another costs of Rs.2,000/- in this appeal.  Time for compliance four weeks.

Sd/-PRESIDENT.

Sd/-MEMBER.

JM                                                                                                             Dt.28-10-2010