Date of Filing: 23/08/2011

        Date of Order:18/10/2011

BEFORE THE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE -  20

Dated:  18^th DAY OF OCTOBER 2011

PRESENT

SRI.H.V.RAMACHANDRA RAO,B.SC.,B.L., PRESIDENT

SRI.KESHAV RAO PATIL, B.COM., M.A., LL.B., PGDPR, MEMBER

SMT.NIVEDITHA .J, B.SC.,LLB., MEMBER

COMPLAINT NO.1562 OF 2011

K. Ramachandra Reddy,

S/o. Late Kondareddy,

Aged About 60 years,

R/at: No.1071, 24^th Main,

Sector-I, HSR Layout,

BANGALORE-560 102.

(Rep. by In.person)                                                                      ….  Complainant.

V/s

(1) Star Health & Allied Insurance

Company Limited, KRM Centre 6^th Floor,

No.2, Harrington Road, Chatpet,

Chennai-600031.

Rep. by Manager, Claims Department.

(Rep. by Advocate Sri.Y.P.Venkatapathi)

(2) Sagar Hospitals,

No.44/54, 30^th Cross, Tilaknagar,

Jayanagar Extn., Bannerughtta Road,

Bangalore-560041.

Rep. by Dr. M.Muni Reddy, General

Surgeon & Surgical Oncologist,

(Rep. by In person)                                                              …. Opposite Parties.

BY SRI. H.V.RAMACHANDRA RAO, PRESIDENT

-: ORDER:-

The brief antecedents that lead to the filing of the complainant U/s 12 of the Consumer Protection Act seeking direction to the Opposite Party No.1 to pay Rs.1,50,000/-, are necessary:-

          The complainant has obtained “Joint Family Health Optima Insurance Plan” policy from the opposite party No.1 under policy bearing No. P/141119/01/2010/001148 and it was valid, which covers the complainant and his wife Smt. R.T. Rama.  The wife of the complainant suffered from Rectal Prolapse and she was treated as inpatient in the hospital of the second opposite party between 02.11.2010 to 07.11.2010 and the complainant incurred an expenditure of Rs.90,260/-.  On 02.11.2010 itself the complainant submitted a claim, but the opposite party No.1 stated that it is not a cashless one and the complainant could claim reimbursement after the treatment.  Accordingly the complainant made claim before the opposite party No.1 who repudiated it on 30.01.2011 stating that the complainant’s wife was having vaginal hysterectomy previously and that is the cause of Rectal Prolapse.  The second opposite party has issued a certificate that is not a cause and that cannot be a cause.  Several correspondences were made even then the opposite party No.1 has not settled the claim.  Hence the complaint.

2.       In this case opposite party No.2 appeared inperson and stated that they have no objection to grant relief to the complainant as against the first opposite party.  In brief the version of the opposite party No.1 are:-

          The insurance by the complainant, its validity, its repudiation are all admitted.  The repudiation is in accordance with law.  There is no illegality or irregularity.  All the allegations to the contrary are denied.

3.       To substantiate their respective cases the complainant has submitted a “version of complainant” and stated that it may be read as his evidence.  The opposite party has filed their affidavit.  The arguments were heard.

4.       The points that arise for our consideration are:-

:- POINTS:-

1. Whether the repudiation of the claim by the opposite party No.1 is unfair trade practice/deficiency in service?
2. What Order?

5.       Our findings are:-

Point (A) & (B)         :           As per the final Order

                                       for the following:- 

-:REASONS:-

Point A & B:-

6.       Reading the pleadings in conjunction with the documents on record, it is an admitted fact that the complainant had obtained “Joint Family Health Optima Insurance Plan” from the first opposite party under policy bearing No. P/141119/01/2010/001148 and it was valid between 02.03.2010 and 01.03.2011.  It is also an admitted fact that between 02.11.2010 and 07.11.2010 regarding Rectal Prolapse the wife of the complainant has been treated as an inpatient in the second opposite party’s hospital.  Wherein the complainant has paid Rs.90,260/- for the said treatment.  When the complainant claimed this the opposite party No.1 repudiated the claim stating that the complainant’s wife was also treated for vaginal hysterectomy and that previous history is the cause of this sufferings it was not disclosed, hence they have repudiated which means it is a non-disclosure of the pre-existing disease.

7.       The relevant portion of the policy schedule issued by opposite party No.1 reads thus:-

That means the complainant had intimated to the opposite party about the hysterectomy of his wife and the treatment of hysterectomy and alleged applications.  That means well at the time of taking the policy the hysterectomy of his wife has been intimated to the opposite party.  Hence they cannot repudiate the claim on the ground of non-disclosure.

8.       Even the second opposite party has stated that hysterectomy is not the cause for Rectal Prolapse, rightly.  Even then the opposite party No.1 has declined to grant the relief to the complainant.  This reminds made me of Kannada proverb “ºÀArUÉ ºÉÆqÉzÀgÉ zÀªÀqÉAiÀÄÄ ªÀÄÄjzÀAvÉ”.  Hysterectomy is done at some other place and Rectal Prolapse will be done in a diagonally opposite place, both have no nexus to each other.  Hence repudiation of the claim by the opposite party No.1 is nothing but an unfair trade practice.

9.       There is no per contra material produced by the opposite party No.1 to show that hysterectomy is the cause for Rectal Prolapse.  When that is the case the question of repudiation is illegal and it is an unfair trade practice.  Even while taking the policy the complainant had informed the opposite party No.1 about hysterectomy of the wife hence it is not a case of non-disclosure.  Hence the complainant is entitled to the medical and hospital charges.  Hence we hold the above points accordingly and proceed to pass the following:-

ORDER

1.        The complaint is Allowed-in-part.

2.        The opposite party No.1 is directed to pay to the complainant the sum of Rs.90,260/- together with interest thereon at the rate of 12% per annum from 07.11.2010 until payment within 30 days from the date of this order.

3.        The opposite party No.1 is also directed to pay to the complainant a sum of Rs.2,000/- as costs of this litigation.

4.        The opposite party No.1 is directed to send the amounts as ordered at Serial Nos. 2 & 3 above to the complainant through DD by registered post acknowledgment due and submit the compliance report to this Forum with necessary documents within 45 days from the date of this order.

5.       Return the extra sets filed by the parties to the concerned as under Regulation 20(3) of the Consumer’s Protection Regulation 2005.

6.       Send a copy of this order to both the parties free of costs, immediately.

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this the 18^th  Day of October 2011)

MEMBER                                               MEMBER                                         PRESIDENT