. IN THE CONSUMER DISPUTES REDRESSAL FORUM KASARAGOD consumer case(CC) No. C.C.34/2006
S.Karuppuswamy
...........Appellant(s)
Vs.
The Branch Manager
...........Respondent(s)
BEFORE:
1. K.T.Sidhiq 2. P.P.Shymaladevi 3. P.Ramadevi
Complainant(s)/Appellant(s):
1. S.Karuppuswamy
OppositeParty/Respondent(s):
1. The Branch Manager
OppositeParty/Respondent(s):
1. Subhramanya Bhat
OppositeParty/Respondent(s):
1. S.Mahalinga
ORDER
Date of filing : 17-03-2006 Date of Order : 13-06-2008 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD CC.No.34/2006 Dated this, the 13th day of June 2008 PRESENT SRI.K.T.SIDHIQ : PRESIDENT SMT.P.RAMADEVI : MEMBER SMT.P.P.SHYMALADEVI : MEMBNER S.Karuppuswamy, S/o.Suraji, Karim Quarters, Kudlu Temple Road, } Complainant Adkathbail, Kasaragod. The Branch Manager, The Oriental Insurance Co.Ltd, City Point Building, Press Club Junction, M.G.Road, } Opposite party. Kasaragod. O R D E R SRI.K.T.SIDHIQ, PRESIDENT In brief, the case of the complainant is that the Opposite party repudiated the medi-claim of the complainants son relying on the exclusion clause 4.1 and 4.3 contained in the policy. Hence the complaint claiming Rs.18,000/- the amount nearly spent by the complainant for the treatment of congenital hydrocele of his son Nattu Durai. 2. Complainant was examined as PW1, Exts A1 to A5 were marked. Opposite party produced Exts B1 and B2. i) As per Exclusion clause 4.1 of Universal health policy insurer shall not be liable to make any payment under this policy in respect of any expenses for all diseases/ injuries which are existing when the cover incepts for the first time. ii) As per Exclusion No.4.3 of the policy the expenses incurred during first year of operation of policy for the disease hydrocele is not payable. 3. We are unable to justify the stand taken by Opposite party in repudiating the claim, because 4. The Note to the exclusion clause 4.1 & 4.2 (a)(b) provides. a) In the opinion of Panel of Medical Practitioners constituted by the company for the purpose, the insured person could not have known of the existence of the disease or complaints there of at the time of making the proposal for insurance of the company. b) Insured had to taken any consultation, treatment or medication in respect of hospitalization for which claim has been lodged under the policy prior to taking the insurance. 5. The Opposite party has not produced any records to show that the complainant was known about the existence of the disease or complaints and his son Nattu Durai had undergone any consultation treatment or medication for congenital hydrocele prior to marking the proposal for insurance to the company. 6. Hence in the absence of any evidence to contrary, the case of the complainant clearly comes within the boundaries of this notes (a) &(b) to the exclusion clause 4.1 and 4.2. 7. Further the Honble National Consumer Disputes Redressal Commision held Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their clause 4.1 of the policy in a malafide manner to repudiate all the claim. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unkown to him which he is genuinely unaware of them. Hind sight every one realise much later that he should have known from some symptoms. If this so every person should do medical studies and further not take any insurance policy, 2008 CTJ 347(CP) (NCDRC) Ratio of this case is applicable to a great extent to this case. 8. According to OP as per clause 4.3 of the exclusion clause the expenses incurred during the first year of operation of policy for the disease hydrocele in not payable. As rightly pointed out by the counsel for complainant the policy itself is of one year duration. So if this clause is up held, Insurance company is not liable to pay any claim. This policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without bonafide intention of giving any benefit to the insured. 9. Hence the act of rejection of the claim of the complainant amounts to gross deficiency in service for which Opposite party is liable. Reliefs & Costs Ext.A4 is a bill but printed as receipt issued from Sanjay Hospital, Palani in the name of Nattudurai the son of the complainant. It shows that Rs.9400/- is the amount towards the treatment charges. Ext.A5 is a receipt dtd 9-4-05 iussued to Nattu Durai evidencing payment of Rs.9400/- as against the bill Ext.A4. Of course the complainant is entitled for the said amount. In the result complaint is partly allowed and the opposite party is directed to pay Rs.9400/- with interest @ 9% from the date of complaint. Opposite party shall also pay Rs.2000/- towards cost of these proceedings. Failing which on application by the complainant proceedings will be initiated U/s.25 & 27 of CP Act for the recovery of the said amount. Sd/- Sd/- Sd/- MEMBER MEMBER PRESIDENT A1. 7-2-06 Policy Schedule A2.9-2-04 Policy Schedule A3.11-4-05 Discharge Summary A4. 9-4-05 Receipt issued by Sanjay Hospital A5. ,, Receipt issued by Sanjay Surgical Hospital B1. Universal health Insurance Policy Proposal Form. B2. Photocopy of Discharge Summary PW1.S.Karuppuswami Sd/- Sd/- Sd/- MEMBER MEMBER PRESIDENT Forwarded by Order SENIOR SUPERINTENDENT Pj/
