DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD Dated this the 17th day of July 2010.
Present : Smt. Seena.H, President : Smt. Preetha.G. Nair, Member : Smt. Bhanumathi.A.K, Member
C.C.No.131/2009 Hamsa S/o. Kunjumoideen Ottupara Veedu Thenkara (P.O) Mannarkkad Palakkad-678 761. - Complainant (Adv. Somy Xavier) Vs
The Branch Manager United india Insurance Company Ltd Mannarkkad Branch 1st Floor, Pazheri Plaza Kodathippadi Mannarkkad (P.O) Palakkad. - Opposite party (Adv.K. Lakshminarayanan)
O R D E R
By Smt. Preetha.G. Nair, Member The complainant has taken Medi claim Insurance Policy 101205/48/07/06/00001705 from the opposite party for the period 28/02/2008 to 27/02/2009. The policy covered the family members of the complainant. The policy was issued to the complainant after enquiry and scrutiny by the opposite party. During this period the complainant has no claim under the policy. The policy was renewed by the opposite party after receiving the necessary premium from the complainant for the period 28/02/2009 to 27/02/2010. The complainant has submitted claim application of an amount of Rs.17,373/- on 30/07/2009 for reimbursement of the medical expenses incurred to him. But the opposite party did not honour the claim or repudiate the same. The opposite party stated that the complainant has suppressed the material fact that the disease for which he has claimed insurance was pre existing disease. So the opposite party orally stated that the claim was repudiated and - 2 - returned the documents produced for the claim. Then the complainant send a lawyer notice to the opposite party. The complainant subsequently received a letter from the opposite party repudiating the claim with a reason for pre-existing disease dated 11/08/2009. The complainant stated that the policy certificate never contains the clause of the pre-existing disease. The acts of opposite party amounts to deficiency in service and unfair trade practice. Hence the complainant prays an order directing the opposite party to pay Rs.17,373/- for the claim amount with 12% interest and to pay the cost of the proceedings to the complainant.
Opposite party filed version stating the following contentions. The opposite party admitted that the complainant has taken a Universal Health Insurance policy. The allegation in the complaint that any type of disease and treatment will be covered under the policy is denied by the opposite party. The opposite party stated that at the time of issuing the policy the terms and conditions are stipulated. And one of the important condition is that if the insured suppress any material fact like any disease for which already he is undergoing treatment and the policy can be repudiated by the company. The contention of the complainant that the policy is issued without any condition is denied by the opposite party. On verification of the treatment records the opposite party has found that the complainant was under going treatment of Cardiac Angiography for two years before the issuance of policy and repudiated the claim. The company has no liability to pay any amount or interest as claimed by the complainant. So the opposite party prayed that the complaint may be dismissed with costs.
Complainant adduced the evidence by way of affidavit and documents. Exhibit A1 to A6 marked on the side of the complainant. Complainant filed questionnaire. But the opposite party not filed answers to the questionnaire. Later after the evidence was closed, opposite party filed IA to reopen evidence for filing answers, affidavit and documents and it was allowed. Then the complainant filed petition for cross examination of opposite party. But the opposite party failed to present before the forum for cross examination. In IA 100/10, the complainant has stated that the purpose of cross examination of the opposite party was to clarify the ambiguities in the proof affidavit, answer to the questionnaire and - 3 - documents. But the opposite party not present for the cross examination. No documents marked on the side of opposite party. Matter was heard. Issues to be considered are:
Whether there is any deficiency in service on the part of opposite party? What is the relief and cost?
Issues I & II We perused relevant documents on record. It is admitted that complainant had taken Universal Health Insurance Policy from the opposite party. The complainant has taken the policy for the period 28/02/2008 to 27/02/2009. Thereafter the policy was renewed by the opposite party for the period 28/02/2009 to 27/02/2010 marked as Exhibit A2. According to Exhibit A1 and Exhibit A2 the column of Pre-existing disease is seen to be left blank. The opposite party has not raised objection to marking of Exhibit A1 and A2. The opposite party stated that while issuing the policy the terms and conditions are stipulated. No evidence was produced by the opposite party for issuing the terms and conditions of policy to the complainant. In the answers filed by the opposite party stated that pre existing disease was not covered under the policy and this has been stated in the policy condition. But the opposite party has not produced the policy condition and not present for cross examination. Further the opposite party stated that on verification of treatment records they found that the disease was pre-existing. No evidence was produced by the opposite party for treatment of pre-existing disease. No evidence to prove that the complainant has taken medicines for the alleged disease before the issuance of policy.
The opposite party has not produced evidence for the suppression of material fact made by the complainant. Also no evidence was produced by the opposite party to prove the complainant must have known pre existing disease was stated at the time of taking the insurance policy . It is also the settled law that it is for the insurance companies to prove that material information has been concealed by the complainant. So far as the facts of present case are concerned the opposite party miserably failed to prove their case. - 4 - In view of the discussion held above we are of the view that there is deficiency in service on the part of opposite party. Hence the complaint allowed. We direct the opposite party to pay the insurance claim amount of Rs.17,373/- along with interest @ 12% per annum from the date of repudiation of insurance claim to the date of order and also pay Rs.2,000/- as cost of the proceedings to the complainant. Order shall be complied within one month from the date of receipt of order failing which the whole amount shall carry interest @ 9% per annum from the date of order till realization.
Pronounced in the open court on this the 17th day of July , 2010
PRESIDENT (SD) MEMBER (SD) MEMBER (SD) APPENDIX Date of filing: 25/09/2009 Witness examined on the side of Complainant Nil Witness examined on the side of Opposite party Nil Exhibits marked on the side of the complainant Ext. A1 – Copy of Insurance Policy schedule of United India Insurance Co Ltd Ext. A2 – Copy of Insurance Policy schedule of United India Insurance Co Ltd
3. Ext. A3 – Discharge summary of Al Shifa Cardiac Care 4. Ext. A4 - Copy of letter dated 11/08/2009 5. Ext. A5 series – Bills and receipts of Al Shifa Hospital 6. Ext. A6 - Legal notice dated 25/08/2009. Exhibits marked on the side of the Opposite Party Nil Forums Exhibits Nil
Costs - Allowed Rs.2,000/-
| | [HONORABLE Smt.Bhanumathi.A.K] Member[HONORABLE Smt.Seena.H] PRESIDENT[HONORABLE Smt.Preetha.G.Nair] Member | | 
