Andhra Pradesh

Nellore

CC/17/2015

Darimadugu Adinarayana Son of D.Venkataswamy - Complainant(s)

Versus

Star Health And Alliend Insurance Co,Ltd Rep by its Branch Manager Authorized - Opp.Party(s)

S.V.V.S.S.Durga Prasad Rao

10 Mar 2016

ORDER

Date of Filing     :05-12-2014

                                                                                                Date of Disposal:10-03-2016

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE

Thursday,  this the 10^th  day of  March, 2015

 

PRESENT: Sri M. Subbarayudu Naidu, B.Com.,B.L.,LL.M.,President(FAC) & Member                             

                   Sri N.S. Kumara Swamy, B.Sc.,LL.B., Member.

 

C.C.No.17/2015

 

Darimadugu Adinarayana, S/o.D.Venkataswamy,

Hindu, Aged 72  years, Senior Citizen, R/o.D.No.26/103,

2^nd Cross Road, Z.P.Colony, Nellore.                                                      ..… Complainant  

                                                                           Vs.

Star Health & Allied Insurance Company Limited, Represented by it’s Branch Manager / Authorised Signatory, Holding Office at D.No.24/385, Rajagopalapuram, Dargamitta, Nellore.                                                                                  ..…Opposite party

                                                              .  

            This complaint coming on 12-02-2016 before us for hearing in the presence of                Sri S.V.V.S.S.Durga Prasad Rao, advocate for the complainant and Sri M. Leela Mohan, advocate for the opposite party  and having stood over for consideration till this day and this Forum made the following:

 

ORDER

(ORDER BY  Sri M. SUBBARAYAUDU NAIDU, PRESIDENT(F.A.C.)

 

This case is filed by  the complainant against the opposite party  to direct the opposite party to pay sum assured amount of Rs.3,00,000/- with subsequent interest thereon at 18% p.a. from the date of claim petition till the realization to the complainant; to grant damages of Rs.1,00,000/- towards  his mental agony and also to grant costs of the complaint and pass such other relief or reliefs as the Hon’ble Consumer Forum may please to deemed it fit and proper in the circumstances of the case in the interest of justice.

 

The Factual matrix leading to filing of this Consumer Case is as stated  as hereunder:

II.	(a)  It is a case of the complainant that  he is being a senior citizen  inspired by the opposite party’s agents  and thereby  obtained policy under product name senior citizens red carpet insurance policy  and so the opposite party  had issued policy bearing No.P/131125/01/2012/000535, dated 07-03-2012 in his favour  for the period of one year (07-03-2012 to 06-03-2013).
	(b)   It is also submitted by the complainant in para-2 at page No.1 of his complaint that the insured person / complainant was duly renewed the above said policy for another one year and the opposite party had  issued renewal policy bearing No.P/131125/ 01/2012/ 000535, dated 07-03-2013. Whileso, on receiving the policy premium amount of Rs.14,494/- only by the opposite party and issued policy in favour of complainant for the period again one year and the policy is in force from 07-03-2013 to 06-03-2014.  Thereafter,  the complainant had suffering with the neuro problem  and thereby got admitted in the Bollineni Ramanaiah Memorial Hospital, Nellore and undergone as                in-patient I.P.No.64082 by paying necessary fees to said hospital on 24-07-2013 and discharged on 04-08-2013 and had spent a sum of Rs.1,70,000/- towards medical expenses.  After discharging from the said hospital, the complainant approached the opposite party and filed claim application with all the documents pertaining to the treatment for claiming the insurance amount under the policy.
	(c)    It is also further submitted by the complainant in para -1 at page No.2 of his complaint that he had approached the opposite party at Nellore for medical expenses as per the policy  and opposite party is postponed matter  and the complainant had approached  and at last he had received one letter dated 31-03-2014 from the Star Health and Allied Insurance Company Limited, Chennai and repudiated his claim with false allegations.  Being a senior citizen, the complainant  had obtained the policy pertaining to the health purpose and non-disclosure of facts by him is meaningless and which amounts to deficiency of service on the part of opposite party in rendering service to him. The insurance companies are very interesting to develop their business under the same time, they are failed to render service   and assurances to the policy – holders, particularly the policy meant for  health purpose, “Senior Citizens Red Carpet Insurance” and complainant is aged about 69 years at the time of taking policy.  The policy holder had subjected to ill-health and because of the age.  So, it amounts to deficiency in service on the part of the opposite party towards him.
	(d)    It is also further submitted by the complainant in para-2 at page No.2 of his complaint that the opposite party had repudiated his claim and he got issued suitable reply dated 02-07-2014 to the opposite party and the opposite party Corporate Office  at Chennai had sent their reply notice dated 25-07-2014, the same allegations of  prior their  notice.  The opposite party had failed to pay the sum assured amount of Rs.3,00,000/- to the complainant  / insured  and committed deficiency in service has promised by them at the time of taking the policy and in particular, the policy meant for the health purpose.   So, the opposite party is liable to pay sum assured amount of Rs.3,00,000/- with accrued  interest thereon at 18% p.a. from the date of claim petition to the complainant till the date of realization.
	(e)       There are causes of action to file this complaint which are narrated in 3rd para of complaint. Hence, the complaint.

 

III.       DEFENCE:  The opposite party was resisted the complaint by filing written version / counter  filed by the opposite party on 29-06-2015 by denying the allegations of the complainant in his complaint.  The  complaint is not maintainable either in law or on facts.

(i)	It is submitted by the opposite party in paras 3 and 4 at page No.1 of its written version / counter  that it is true that complainant  took out the said policy and  admitted it and renewed the same as contended by him.  The opposite party has further states that the said policy taken under the scheme is subject to conditions, clauses, warranties, exclusions etc.,  attached to the said policy.  The  attached policy conditions in detail runs into                  8 pages and under heading 3 exclusions column in sub-section 23, sub-heading                         sub-clause 2.  “Any disease contacted by the insured person during the first 30 days from the commencement date of the policy is not entitled for the benefits”.  The opposite party / company shall not be liable to make any payments  under the said policy under  the exclusions.  The complainant had full knowledge of the attached terms and conditions suppressed the facts of his ailments for reasons best known to him.
(ii)	It is also further submitted by the opposite party that in para – 7 at page No.2  of it’s written version / counter that the company states that as per claim statement and the admission particulars into Bollineni Ramanaiah Memorial Hospital, Nellore is true.  As per the said hospital record evidenced by the treating doctor namely                                     Dr.A.V. Ramanamoorthy, the  complainant presented himself on 12-07-2013 as out patient and gave his history of parkinsonism and diabetes.  The complainant is suffering from GIAT  disturbances, History or giddiness  on walking since April, 2012.  On enquiry, it is revealed that the complainant earlier on 16-07-2012 met                                  Dr.Y. Vijayachandra Reddy, Department of Cardiology  at Heart Institute, Apollo, Chennai and reported that he is  suffering giddiness on walking since April, 2012 since 20 years.  GIAT disturbance is cordial symptom of parkinsonism.  He is  admittedly suffering from parkinsonism from April, 2012 onwards.
(iii)	It is also submitted by the opposite party that in paras 8 and 9 at page No.3 of it’s written version / counter that from April, 2012 as mentioned in doctor’s certificate of Apollo Hospital is not first consultation and it is the subsequent consultation.  A combined reading of the first report and second report alone decided the crucial attack of the disease.  In any event the  said disease appears to be present to the knowledge of the complainant earlier to March dated 06-03-2012 on which date he had applied for the  said policy.  The complainant has given incorrect  information with regard to blood pressure and  diabetic problem and parkinsonism also.  The complainant  had intentionally suppressed the facts  and knowing  gave incorrect information.  He is not eligible to claim the amount towards the treatment as alleged by him.  The opposite party had legally refused to  entertain the claim and the same be in accordance with Insurance Law and terms and conditions of the said policy.
(iv)	There is no cause of action to file this complaint by the complainant.  Hence, it is prayed that this Hon’ble District Consumer Forum may be pleased to dismiss the complaint with costs.

 

            IV)      Basing on the complaint , written version, affidavits and written arguments of the parties concerned,  the following  points are for consideration and they are as follows as:-

(a)	Is there any deficiency in service on the part of the opposite party towards the complainant?
(b)	Whether the complainant is entitled the reliefs as prayed for, if it is so,  to what extent?
(c)	To what relief?

V.  POINTS 1  AND 2: 

The oral arguments of the learned counsel for complainant

            The learned  counsel for the complainant Sri  S.V.V.S.S.Durga Prasad Rao has vehemently argued that the complaint of the complainant, his  chief-affidavit  (P.W.1), documents are marked  in his favour and his written arguments of the case may be read as part and parcel of his oral arguments of the case.  He has also further contended that the  material facts of the case are not in dispute and repetition of them once again is hereby avoided.  He has also further argued that the complainant had received a letter  dated 31-03-2014 (Ex.A3) from the opposite party’s office at Chennai and it is for repudiation of his claim by giving reasons in it.  In fact, the complainant,  being  a senior citizen  and said policy is particularly pertaining to the health purpose and non-disclosure of the facts by him,  is meaningless and which amounts to deficiency  in service on the part   of opposite party in rendering service to him.  He has also further urged that the  complainant got issued a suitable notice  dated 02-07-2014 to the opposite party (Ex.A4) and the opposite party’s  corporate  office at Chennai, sent a reply notice  dated 25-07-2014 with the same allegations of repudiation of the claim to the complainant.  The material documents Exs.A1 to A5 on behalf of  the complainant  may be read as part and parcel of his oral arguments of the case.  Finally, he has also prayed that the Hon’ble Consumer Forum may be pleased to allow the complaint with costs as prayed for.

 

The oral arguments of the learned counsel for opposite party

            On the  other hand Sri M. Leela Mohan, the learned counsel for opposite party has also vehemently argued that the written  version / counter, chief-affidavit of opposite party, the documents are filed on his behalf and written arguments of the case may be read as part and parcel of his oral arguments of the case.  He has further argued that as per the main terms  of the insurance policy if it is an accident, it covers  from the date of policy and in cases of, if it is general disease the risk covers only after one month.  He has also further contended that the claim is made on the grounds of related to ‘Parkinson  Disease’ and on account of the same, complainant had fell down and  sustained some injuries.  The said policy is one based solely on the declaration of the person, who takes the said policy.  The complainant had gave an undertaking to the effect that  he  had not suffering with any disease and   the letter dated 25-07-2013 (Ex.B2).  The said learned counsel for the opposite party has further urged that the complainant was treated by one doctor by name Mr.Y. Vijaya Chandra Reddy, at Heart Institute at Apollo Hospital, Chennai and his out-patient consultation record dated 16-12-2012 which clearly  discloses coronary ariti  disease as giddiness onwards from April, 2012.  The statement  was made voluntarily  by the complainant to his daughter long prior to the  year 2012.  It is a clear admission.  The complainant had suppressed those facts and obtained the policy with ulterior motives to get wrongful gain.  There is no deficiency in service on the part of the opposite party towards the complainant.  The complainant is not entitled to reliefs as prayed for.  The claim of the complainant rightly rejected by the opposite party.   Finally, the said learned counsel for the opposite party has prayed that the Hon’ble Consumer Forum may be pleased to dismiss the complaint with costs.

 

Forum’s Findings and Observations

               Heard, the learned counsel for both parties and perused the record very carefully.  Parties led their evidence by way of affidavits.  Each case has to be judged on its own facts.  He, who seeks equity from the Consumer Forum must come with clean hands.  The Consumer Forum is primarily would function on the principles of natural justice.

 

                To appreciate the controversy between the parties in this Consumer Case, it would be appropriate if we narrate all the circumstances of the case both on question of facts as well as question of law in detail. 

 

Concept of Insurance:- 

            Insurance is an important service sector specifically covered under the definition of ‘service’  in Section-2 (1) (o) of Consumer Protection Act, 1986.  Because of uncertainty of  human life as well as perils / risks in trade or industry, insurance business  had developed and is developing.  The concept of insurance coverage springs from the principle of indemnity.    The Insurance Company accepts the liability to indemnity  the insured for the loss suffered by him due to peril against the consideration (premium) received by it.  But in actual practice, the insurer by showing mandatory provisions of rules and regulations  framed  by them in order to turn down the pleas of insured while disbursing the valid claims of the insured at their convenience.  Foundation of insurance contract is Uberrima fides  i.e., good faith and not fraud.  Insurer and insured must observe  utmost  good faith.  The duty of good faith is of a continuing nature.  In case of ambiguity or doubt in terms of the policy, it should be interpreted   in favour of the insured and against the company – LIC  Vs. Rajkumar (1999) 3 SCC 465.   Delay in making  payment  of  a claim has  been simply held as deficiency in service in the case of  New India Assurance Company Limited Vs. Ambalal Chandlal Shah  which reported in 2002  (3) CPJ  238 (NC). 

 

            Here in this case, the complainant is a senior citizen  at the age of 69 years at the time of obtaining the policy from the opposite party .  It is  a health  insurance policy  and it is meant for obtaining the expenses incurred towards medical bills of the complainant and nothing more.  The opposite party while assessing the claim amount of  the complainant  has raised so many objections and tried to repudiate  it.  It is not correct. The policy itself is a  health insurance  for the senior citizens.  The very true spirit of the insurance and its object  are not  properly understood  by the opposite party.  Now, the opposite party cannot turn down the rightful claim of the complainant.  The complainant has not obtained the policy to generate profit  and in view of his health condition at the old age, got the insurance policy by paying premium to insurance company.  There is a lot of deficiency in service on the part of the opposite party towards the complainant.  There is a force in the contentions of the  counsel for the complainant.  It is no longer good  to keep the matter pending and ultimately repudiated  the claim of the complainant by the opposite party.  Mental agony cannot be measured in terms of money.  The said learned counsel for the complainant has  convinced us by explaining the objects of  insurance.  We are of the view that the complainant is entitled to reliefs as mentioned in point No.3.  These two points 1 and 2 are held in favour of the complainant and against the opposite party, accordingly.

 

            IV   POINT No.3:In the result, the complaint is allowed-in-part ordering the opposite party to pay Rs.3,00,000/- (Rupees three lakhs only) to the complainant  with interest at 9% p.a. from the date of the complaint till the date of realization; and also to pay Rs.25,000/- (Twenty five thousand)  to him towards  damages as compensation and also to pay Rs.3,000/- (Rupees three thousand only)  to him towards  costs of the complaint  within one month from the date of receipt of the order, accordingly.

 

Typed to the dictation to the Stenographer, corrected  and pronounced by us in the open  Forum, this the  10^th   day of   March, 2016.

 

 

                 Sd/-                                                                                          Sd/-

           MEMBER                                                                               PRESIDENT(F.A.C.)

 

                                                APPENDIX OF EVIDENCE

 

Witnesses Examined for the complainant

 

P.W.1  -

10-08-2015

Sri Darimadugu Adinarayana, S/o.D. Venkataswamy, Nellore. (Chief  Affidavit filed)

 

Witnesses Examined for the opposite party

 

R.W.1  -

30-09-2015

Sri Ch. Veera Raghavaiah, S/o.Balaiah, Represented by it’s Branch Manger, ASSI AVP, Star Health & Allied Insurance Company Limited, Nellore  (Chief Affidavit filed)

 

                             EXHIBITS MARKED FOR THE COMPLAINANT

 

Ex.A1  -	-	Photostat copy of  Senior Citizens Red Carpet Insurance  Policy-Schedule  in policy No.P/131125/01/2012/000535 in favour of the complainant issued by the opposite party.
Ex.A2  -	-	Photostat copy of  Senior Citizens Red Carpet Insurance  Policy-Schedule  in policy No.P/131125/01/2013/000771 in favour of the complainant issued by the opposite party.
Ex.A3  -	31-03-2014	Photostat copy of  letter from  opposite party  branch at  Chennai-600031 to the  complainant.
Ex.A4  -	02-07-2014	Copy of legal notice from complainant’s advocate                    A. Ramachandra Raju to the  opposite party alongwith  two registered post acknowledgements.
Ex.A5  -	25-07-2014	Letter from opposite party to the  complainant’s advocate  A. Ramachandra Raju.

 

                         EXHIBITS MARKED FOR THE OPPOSITE PARTY

 

Ex.B1  -	-	Senior Citizens Red Carpet Insurance Policy  terms and conditions.
Ex.B2  -	-	Photostat copy of Bollineni Superspeciality Hospital, Nellore, record in material papers of   complainant, Senior Citizens Red Carpet Insurance Policy-Schedule in policy No.P/131125/01/2012/000535 and P/131125/01/2013/ 000771 in favour of complainant, letter relating to attached to and forming part of policy No.P/131125/01/2013/000771 and policy inspection date  as 07-03-2012.
Ex.B3  -	16-07-2012	Photostat copy of Department of Cardiology  reports in favour of complainant.
Ex.B4  -	06-03-2012	Photocopy of  Proposal No.614974 in favour of complainant issued by Star Senior Citizens’ Red  Carpet Insurance – Proposal.

 

                                                                                      

                                                                                                                     Id/-

                                                                                                         PRESIDENT(F.A.C.)

 

Copies to:

1.	Sri S.V.V.S.S.Durga Prasad, Advocate, H.No.27-2-956, A.C.Nagar, Nellore-2.
2.	Sri M. Leela Mohan, Advocate, 10/554, Kamakshi Nagar, Sri Gayathri Nilayam, Santhapet, Nellore-524 001.

 

Date when free copy was issued: