0BEFORE THE DISTRICT CONSUMER’S FORUM: KURNOOL
Present: Sri. T.Sundara Ramaiah, B.Com B.L., President
And
Sri. M.Krishna Reddy, M.Sc., M.Phil., Male Member
And
Smt. S.Nazeerunnisa, B.A., B.L., Lady Member
Monday the 30th day of July, 2012
C.C.No.165/2011
Between:
P.Sunkanna, S/o P.Saravappa,
R/o Flat No.101, First Floor, V.C. Homes, N.R.Peta, Kurnool - 518 004.
…Complainant
-Vs-
1. The Branch Manager, Reliance Life Insurance Company Limited,
Shop No.39-42, R.M.K. Plaza,Opp.Zilla Parishad, KURNOOL-518 004.
2. The Registered Office, Reliance Life Insurance Company Limited,
H.Block, 1st Floor, Dheerubai Ambani, Knowledge City, Navi Mumbai,
MAHARASTRA - 400 710.
3. Youns Malik, Sales Manager - Cum - Agent,Reliance Life Insurance Company Limited,
Shop No.39-42, R.M.K. Plaza, Opp.Zilla Parishad, KURNOOL-518 004.
...Opposite ParTies
This complaint is coming on this day for orders in the presence of Sri.M.Sivaji Rao, Advocate for complainant and Sri.V.Chandra Prabhakar, Advocate for opposite parties 1 to 3 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri. T.Sundara Ramaiah, President) C.C. No.165/2011
1. This complaint is filed under section 11 and 12(A) of C.P. Act, 1986 praying:-
- To direct the opposite parties to pay medical expenses incurred by the complainant to a tune of Rs.49,174/- to the complainant with interest @ 18% per annum from 11-05-2011 the date of admission by the complainant in the Hospital;
- To award a sum of Rs.25,000/- towards the compensation for causing hardship, and mental agony to the complainant;
- To grant the costs of the complaint;
And
- To pass any other order or orders that Honourable Forum may deem fit and proper under the circumstances of the case.
2. The case of the complainant in brief is as under:- The complainant took “Reliance Care for Your Plan” policy bearing No.078149/18174190 from opposite party No.1 on 24-11-2010. The period of the policy is from 24-11-2010 to 23-11-2013. The said policy was issued covering the medical risk for the complainant and his wife. The complainant got nasal disease. He was admitted in Medi City Hospital, Hyderabad on 11-05-2011. He under went several tests and under gone surgery on 11-05-2011. The complainant was discharged from the Hospital after nasal surgery on 12-05-2011. The complainant incurred expenditure of Rs.54,174/- for Hospitalization and medicines. Subsequent to the discharge from hospital the complainant submitted the claim along with necessary documents to opposite party No.1. On 29-10-2011 the complainant received repudiation letter from opposite party No.2 stating that the complainant did not disclose preexisting disease in the proposal form. The complainant never had nasal disease prior to taking of the policy. Before submitting the proposal form the complainant has under gone medical tests on 17-11-2010 on the request of opposite party No.3 who is the agent. The complainant was put to mental agony because of repudiation of the claim by opposite party No.2. Hence the complaint.
3. Opposite parties 1 to 3 filed written version stating that the complaint is not maintainable. On the application submitted by the complainant a policy bearing No.18174190 was issued by opposite parties 1 and 2. The said policy was issued on the basis of the proposal form filed and submitted by the complainant. On investigation of the case it is found that the complainant was having said nasal problem since one year prior to the issuance of the policy. The complainant had concealed material facts regarding his health condition prior to the date of the application form. As per clause 6.1 of the policy no liability could be fastened on the opposite party. The contract of insurance is based on good faith. The claim of the complainant was repudiated as he suppressed material facts regarding his health condition prior to the date of the application form. Opposite party No.3 has nothing to do with admission or denial of liability under the policy. The complaint is not maintainable. It is liable to be dismissed.
4. On behalf of the complainant Ex.A1 to A11 are marked and sworn affidavits of the complainant and opposite party No.3 are filed. On behalf of the opposite parties 1 and 2 Ex.B1 to Ex.B6 are marked and sworn affidavit of opposite party No.2 is filed.
5. Both sides filed written arguments.
6. Now the points that arise for consideration are:
- Whether there is deficiency of service on the part of Opposite Parties?
- Whether the complainant is entitled for the reliefs as prayed for?
- To what relief?
7. POINTS i and ii:- Admittedly on the application made by the complainant opposite party No.2 issued policy bearing No.18174190 covering the medical risk. The period of the said policy is from 24-11-2011 to 23-11-2013. It is also admitted that the complainant paid first premium of Rs.10,889/-. Admittedly the claim made by the complainant was repudiated by opposite party No.2 under Ex.A10 dated 29-10-2011. Aggrieved by the said repudiation of the claim by opposite party No.2, the complainant preferred present complaint.
8. It is the case of the complainant that he got nasal disease subsequent to the issuance of the policy by opposite parties 1 and 2, that he was admitted in Medi City Hospital, Hyderabad on 11-05-2011 and discharged on 12-05-2011 after nasal surgery. The complainant to establish that he under went surgery in Medi City Hospital, Hyderabad relied on Ex.A6 Discharge Summary. As seen from Ex.A6 it is very clear that the complainant was admitted in Medi City Hospital, Hyderabad on 11-05-2011 and discharged on 12-05-2011 after nasal surgery. As seen from Ex.A3 to Ex.A6 it is very clear that the complainant got nasal problem and he under went surgery in Medi City Hospital, Hyderabad on 11-05-2011. The complainant filed present complaint claiming medical expenses of Rs.49,174/-. It is the case of the opposite parties 1 and 2 that the complainant was suffering from nasal disease since one year prior to the date of the application form for the policy and that he suppressed the said fact and obtained the policy fraudulently to gain wrongfully. The contract of insurance is based on good faith. The insured has to reveal material facts regarding his health condition in the proposal form. Admittedly there is no mention in the proposal form of the complainant that he was having nasal disease on that date. According to the complainant he got said disease after he received the policy issued by opposite party No.2. The burden is on the insurer to establish that the insured suppressed the material fact regarding his health condition in the proposal form. The opposite parties did not place satisfactory evidence to establish that the complainant was having nasal disease prior to the date of proposal form. The opposite parties filed Ex.B6 Xerox copy of letter said to have been issued by Dr.S.Srinivasa Kishore of the Medi City Hospital, Hyderabad. The said letter does not contain the date. It is also not stated in Ex.B6 that the complainant had nasal disease since one year prior to the date of commencement of the policy. There is no mention in Ex.B6 as to when the complainant got the said disease. It is submitted by the learned counsel appearing for the complainant that original of Ex.B6 is forged. There is no material on record to conclude that original Ex.B6 was forged. The opposite parties 1 and 2 have not chosen to file at least the affidavit of the Doctor of Medi City Hospital, Hyderabad who gave the original of Ex.B6. Except in the affidavit evidence of opposite parties 1 and 2 there is no independent evidence on record to show that the complainant was suffering from nasal disease since one year prior to the date of proposal form for policy. Therefore the contention of the opposite parties 1 and 2 that the complainant suppressed the material fact regarding his health condition in the proposal form cannot be accepted. Opposite parties 1 and 2 repudiated the claim of the complainant without valid reason.
9. According to the complainant he spent an amount of Rs.49,174/- towards medicines, treatment and operation. The complainant filed Ex.A7 medical bills issued by Medi City Health Care Hospital, Hyderabad. As seen from Ex.A7 it is very clear that the complainant incurred an amount of Rs.36,446/-. The complainant also filed Ex.A8 and Ex.A11 medical bills. He has not chosen to file the affidavit of the person who issued Ex.A8 and Ex.A11 bills. The complainant took treatment in Medi City Health Care Hospital, Hyderabad for nasal disease when the policy issued by opposite party No.2 was in force. Therefore the opposite parties 1 and 2 are liable to pay medical expenses of Rs.36,446/- to the complainant.
10. In the result, the complaint is partly allowed directing the opposite parties 1 and 2 jointly and severally to pay medical expenses of Rs.36,446/- to the complainant with interest at 9% from the date of repudiation of claim i.e., 29-10-2011 till the date of payment along with costs of Rs.500/-. The complaint against opposite party No.3 is dismissed.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 30th day of July, 2012.
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant : Nill For the opposite parties : Nill
List of exhibits marked for the complainant:-
Ex.A1 Premium Receipt for Rs.10,889/- dated 11-11-2010.
Ex.A2. Policy document contract No.18174190.
Ex.A3 Reports of health check up of the complainant
dated 17-11-2010.
Ex.A4 Photo copy of I.D. Card of the complainant.
Ex.A5 Photo copies of a bunch of Test Reports of the complainant
(Nos.5).
Ex.A6 Photo copy of Discharge Summary of the complainant
issued Medicity Hospial, Hyderabad dated 12-05-2011.
Ex.A7 Photo copy of a bunch of Medical bills.
Ex.A8 Bill for Purchasing Medicines by the complainant issued by
Sri Saideva Pharmacy, Kurnool dated 28-05-2011 and
Subrahmaneswara Medicals, Kurnool dated 03-06-2011.
Ex.A9 Letter from Medi Assist requesting the complainant to send
Discharge Summary dated 11-08-2011.
Ex.A10 Letter from Medi Assist requesting the claim of the
complainant dated 29-10-2011.
Ex.A11 Photo copy of Cash bill for Rs.654/- dated 16-05-2011.
List of exhibits marked for the opposite parties:-
Ex.B1 Photo copy of Letter of Authority dated 01-02-2012.
Ex.B2 Photo copy of Policy Application No.U0056977.
Ex.B3 Photo copy of policy document.
Ex.B4 Photo copy of Letter from Medi Assist requesting the claim
of the complainant dated 29-10-2011.
Ex.B5 Photo copy of A bunch of Medical Bills and
Medical Reports.
Ex.B6 Photo copy of Letter issued by Medi City Hospital.
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
// Certified free copy communicated under Rule 4 (10) of the A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
