This C.C. came before us for final hearing on 18-8-2009; in the presence of Sri.P.Sanjay Kumar, Advocate for complainant and of Sri.K.Ravindranath, Advocate for opposite party No.1 and of Sri.G.Seetha Rama Rao, Advocate for opposite party No.2; upon hearing the arguments and upon perusing the material papers on record, and having stood over for consideration till this day, this Forum passed the following order:
O R D ER
(Per Sri.Vijay Kumar, President)
1. This complaint is filed u/s.12-A of Consumer Protection Act, 1986. The brief facts of the complaint are that, the deceased, complainant No.1 was an account holder with opposite party No.1, vide account No.1716 and he was practicing advocate. The deceased, complainant No.1 had taken a policy bearing No.050400/48/05/00551 and UHID No.FHAU 0000457002, covering the life of the complainant No.1 and his family members from 9-6-2004 to 8-6-2005. The opposite party No.2 with collaboration of opposite party No.1 undertakes to cover the risk under Group Medi Claim Policy.
2. Later, the complainant No.1 suffered illness on 3-6-2003. The complainant No.1 was treated as inpatient for HTN/Type 2 DM Cerebro Vascular accident and related illness and ultimately he was discharged on 25-6-2005. on 26-6-2005 he was joined in Vamshi hospital, Hyderabad and discharged on 7-9-2005, but did not attain the normalcy. He was discharged at the request of his family members. After the death of deceased, the complainant No.1, the complainants No.2 and 3 presented all the documents to the opposite party No.2 through the opposite party No.1, requesting them to pay the assured amount of Rs.1,00,000/-. Later the opposite party No.2, addressed a letter dt.26-12-2005 asking the deceased, complainant No.1 to submit certificate from the treating doctor regarding the past history. Accordingly, the certificate issued by Dr.G.Krishna Reddy of Sri Rama Clinic Bayyaram, dt.1-2-2006, was submitted to the opposite party No.2, but the opposite party No.2 repudiated the claim on the ground that the hospitalization of the complainant No.1 is for the management of an ailment, which is related to a pre existing condition clause 4.1, due to which his claim is repudiated.
3. During the pendency of the complaint, the deceased complainant No.1 died, and complainants No.2 and 3 were brought on record as legal heirs of complainant No.1. Thereafter the complainant No.2 also died. Now the complainant No.3 is only the complainant to prosecute the complaint. As per the order in I.A.61/2008, the complainant No.3 being a legal heir of deceased, complainant No.1, is the only complainant on record, to prosecute the complaint.
4. On receipt of the notice, the opposite party No.1 filed counter and denied all the averments made in the complaint and submitted that there is no cause of action arose against the opposite party No.1 and this opposite party No.1 is no way concerned with the complaint and prayed to dismiss the complaint.
5. The opposite party No.2 filed the counter, denied all the averments made in the complaint. In the counter, the opposite party No.2 admits that it has issued the policy, as afforded by the complainant. They further contended that in his proposal form, the complainant submitted that he never suffered with any disease prior or at the time of taking of policy, as per the contention of the complainant he joined in hospital on 3-6-2005 for treatment of Cerebro Vascular Accident and he has developed complications. About 15 days ago, a problem was started with the severity of pain increasing over the days resulting in hospitalization. The line of treatment indicates that the problem is serious, which could not have arisen after taking the policy and accordingly the opposite party No.2 has rejected the claim of the complainant. In the light of clause No.4.1 of the scheme/policy and as such the claim is not admissible and prayed to dismiss the complaint.
6. In support of the complaint a number of documents have been relied upon by the complainant, but these documents are not relevant to decide the case. However, the relevant documents are marked as Exs.A.1 to A.3. Ex.A.1 is the certificate from the treating doctor regarding the past history and duration of D.M., Ex.A.2 is the certificate issued by Dr.G.Krishna Reddy, dt.1-2-2006 showing that the deceased/complainant No.1 was in patient for the last 10 years and for the last one and half year, he is suffering with wild hypertention like 150/90 mm Hg. And without medicine he maintained normal value of hypertention, and on his investigation, the complainant No.1 got blood sugar and also normal value, Ex.A.3 is the repudiation letter issued by opposite party No.2.
7. Opposite party Nos.1 and 2 filed their chief-affidavit, reiterating the contents of the counter as chief-affidavit.
8. Both parties filed their written arguments. Heard both sides. Perused the oral and documentary evidence, upon which the point that arose for consideration are,
1. Whether the complainant is entitled to the assured amount
covered under the policy?
2. To what relief?
Points No.1 and 2:
9. It is an undisputed fact that the complainant No.1 has taken the medi claim policy under AB Arogyadhan through opposite party No.1, who insured the account holder and his family member by collecting premium of Rs.686/- covered the life of the complainant, his family members for a period from 9-6-2004 to 8-6-2005. Later the complainant No.1 suffered with illness and he was treated as inpatient for the ailment of cerebro vascular accident and again he was joined in Vamsi hospital, Hyderabad and taken treatment, but he did not recover, later he died. On his death, the complainants Nos.2 and 3 prosecuted the complainant. During the pendency of the complaint, the complainant No.2 also died. Now the complainant No.3 is alone prosecuting the complaint. After the death of the complainant No.1, the claim is made to the opposite party No.2 through the opposite party No.1 requesting them to pay the assured amount of Rs.1,00,000/-. The opposite party No.2 addressed a letter, dt.26-5-2005 asking the complainants to submit certificate from the treating doctor regarding the past history. Accordingly, the complainant has produced a certificate, dt.1-2-2006 and submitted the same to opposite party No.2. On this aspect of the case, he refers to Ex.A.2, which clearly discloses that he treated the deceased/complainant No.1 and did not find any serious complication in the health condition of the complainant No.1/deceased. Even after submitting Ex.A.2 to the opposite party No.1, it had repudiated the claim of the complainant stating that the present hospitalization is related to pre-existing condition Clause No.4.1 and the claim is repudiated under Ex.A.3. The opposite party No.2 did not give any reason as to why the complainant is not entitled to the assured amount. In fact the reason assigned by the Dr.G.Krishna Reddy is not so serious, which can be contributed to the pre-existing condition to violate the clause 4.1 of the policy. The repudiation of claim of complainant No.1 by the opposite party No.2 is on flimsy grounds, without assigning any reason. So far as the conditions in the policy are concerned, we had no difficulty in appreciating this condition. It was not the case of opposite party No.2 that the deceased/ complainant No.1 was a chronic patient of any ailment. It is not in dispute that the deceased/complainant No.1 was subsequently developed ailment after taking the policy. This ailment cannot be linked with the pre-existing illness. On this ground alone, the opposite party No.2 is not justified in repudiating the claim of the complainant. No satisfactory reasons are assigned in the repudiation letter. The alleged repudiation of the claim is only on flimsy ground. Therefore, it cannot be sustained. In view of the aforesaid facts and circumstances of the case, we are of the opinion that the complaint is fit to be allowed.
10. In the result, the complaint is allowed. Opposite party No.2 is directed to pay an amount of Rs.1,00,000/- (Rupees one lakh only) covered under the policy together with interest at 9% P.A. from the date of filing of complaint till the date of deposit. Further, the opposite party No.2 is directed to pay an amount of Rs.1,000/- towards costs of the litigation. There is no order as to the compensation. The claim against the opposite party No.1 is dismissed, as it is a proforma party and nothing to do with the complaint.
Dictated to the Steno, transcribed by her, corrected and pronounced by us in the open forum on this 24th day of September, 2009.
PRESIDENT MEMBER MEMBER
DISTRICT CONSUMERS FORUM
KHAMMAM
APPENDIX OF EVIDENCE
Exhibits marked for Complainant:
Ex.A.1 is the certificate from the treating doctor regarding the past
history and duration of D.M.,
Ex.A.2 is the certificate issued by Dr.G.Krishna Reddy, dt.1-2-2006 Ex.A.3 is the repudiation letter issued by opposite party No.2.
PRESIDENT MEMBER MEMBER
DISTRICT CONSUMERS FORUM KHAMMAM
