BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER
O.P. No: 354/2001
Dated : 15..04..2009
Complainant:
Sureshkumar.B., Cherukara Puthen Veedu, Chakkavarakkal- P.O., Kunnikode (via) Kollam.
(By Adv. N. Krishnankutty)
Opposite party:
The Branch Manager, The New India Assurance Co.Ltd., Kottarathil Buildings, Palayam, Thiruvananthapuram.
(By Adv. M. Nizamudeen)
This O.P having been heard on 16..03..2009, the Forum on 15..04..2009 delivered the following:
ORDER
SMT. BEENA KUMARI. A., MEMBER:
Brief facts of the case are as follows:
The complainant has taken an insurance policy under the Pravasi Suraksha Kudumba Arogya Scheme of the opposite party. The effective date of the policy as per the policy certificate is 12/5/2000. During July 2000 the complainant felt a pain on his left arm. Further the disease of the complainant was diagonised as “Cervical Disc Prolapse C6-C7”. Complainant was admitted in the Medical College Hospital and he had undergone “Anterior Cervical Discectomy C6-C7”. Complainant stated that he had spend more than Rs.50,000/- for his treatment. The complainant submitted that as per the terms and conditions of the policy he is entitled to get the whole expenses incurred for the treatment. Therefore the complainant had submitted the duly filled up Claim Form with the opposite party along with supporting documents required for processing the claim on 1/12/2000. But the opposite party rejected the claim without any basis and contrary to the records produced by the complainant along with the claim form. Complainant submitted that he had suffered much mental agony due to the rejection of his claim by the opposite party and has alleged that there is deficiency in service on the part of the opposite party. 2. The opposite party New India Assurance Co. Ltd filed their version. The main contention raised by the opposite party is that the symptoms of Cervical Disc Prolapse C6-C7 was existing prior to 1 ½ years from the date of consultation ie. 10/10/2000. The symptoms had thus existed prior to the date of proposing the insurance. As per the conditions of the policy issued to the complainant all pre-existing disease/conditions and complications arising there from are excluded from the scope of the policy cover. Exclusion No.VIII.I of the policy states as follows: "Such diseases which have been in existence at the time of proposing this insurance, pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition". For that reasons the opposite party repudiated the claim vide letter dated 5/1/2001. Hence opposite party prayed for the dismissal of the complaint.
3. In this case complainant and opposite party filed proof affidavit. Nobody has been cross examined. From the side of complainant 6 documents were marked and from the side of opposite party 5 documents were marked. 4. Points that would arise for consideration are:
Whether the complainant had the alleged disease before the commencement of the policy? Whether the repudiation of the claim by the opposite party is justifiable? Reliefs and costs?
5. Points (i) to (iii) : In this case the complainant's case is that he is entitled to get the expenses incurred by him for his treatment under the insurance policy issued by the opposite party. The opposite party argued that the complainant is not eligible to get the benefit under the policy because the complainant was having the disease at the time of issuing the policy. To prove his claim complainant has filed proof affidavit and produced 6 documents. The document marked as Ext.P1 is the copy of policy certificate No.2000/47/760702, Ext.P2 is the copy of claim form submitted before the opposite party, Ext. P3 is the treatment certificate of the complainant. Ext.P4 is the copy of letter dated 5/1/2001 of the opposite party. Ext.P5 is the copy of letter dated 6/7/2001 of the complainant with Acknowledgment card. Ext.P6 is the copy of referral O.P card and summary sheet of complainant's treatment at Medical College Hospital, Thiruvananthapuram. The opposite party also filed proof affidavit and produced 5 documents to prove their contentions. Ext.D1 is the copy of policy and its conditions, Ext.D2 are the answers to the questionnaire submitted by the opposite party to Dr. Marthanda Pillai, who treated the complainant. Ext.D3 is the claim repudiation letter dated 5/1/2001. Ext.D4 is the repudiation letter dated 3/9/2001, Ext. D5 is the treatment record of the complainant issued by Dr. Marthanda Pillai, who had treated the complainant.
6. We have carefully examined the documents produced by the complainant and opposite party. Dr. Marthanda Pillai is the doctor who had treated the complainant. Ext.D2 is the answers to the Questionnaire submitted by the opposite party to Dr. Marthanda Pillai. Ext.D2 clearly shows that the complainant was suffering from neck pain, shoulder pain, radicular pain in left arm and was undergoing treatment for the above said complaints for 1 ½ years prior to the date of consultation after arrival in India on 10/10/2000. The symptoms of said disease started prior to the date of proposing the insurance which was on 12/5/2000. As per the conditions of policy Ext.D1, all pre-existing disease, conditions and complications arising there from are excluded from the purview of the policy. Exclusion No.VIII.I of Ext.D1 policy states as follows:-
"Such diseases, which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury, which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness, complication arising from pre-existing disease will be considered part of that pre-existing condition". Opposite party argued that due to the abovesaid reasons the opposite party was not in a position to consider the claim of the complainant for payment and the opposite party repudiated the claim. Opposite party also submitted that the opposite party is bound to indemnify the complainant/insured only as per the conditions of policy which constitute the contract of insurance. As per the conditions of policy issued to the complainant, the complainant is not entitled to get any amount from the opposite party. We also agree with the argument of the opposite party on the basis of the evidence and documents submitted by the opposite party. From the materials on record we have concluded that the complainant had failed to establish his case. In this case, the contention raised by the opposite party that the disease Cervical Disc Prolapse C6-C7 was existing before 1 ½ years from the date of commencement of the insurance policy has not been proved otherwise by the complainant. But the opposite party has succeeded to prove their contentions. In this case the opposite party has not committed any deficiency in service or unfair trade practice to the complainant. The repudiation of the claim of the complainant by the opposite party is valid and justifiable.
In the result complaint is dismissed.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 15th day of April, 2009.
BEENA KUMARI.A MEMBER.
G.SIVAPRASAD, PRESIDENT. S.K. SREELA, MEMBER. ad.
O.P.No.354/2001 APPENDIX
I. Complainant's witness: NIL
Complainant's documents:
P1 : Copy of certificate of insurance No.2000/47/762/80186 (760505) dt. 12/5/2000 P2 : Copy of Claim Form (card No.5072) dt. 1/12/2000 P3 : Copy of treatment certificate of I.P.No.068447 P4 : Copy of letter No.505/5072 dt. 5/01/2001 P5 : Copy of letter dated 6/7/2001 issued to the complainant by opp. Party P6 : Copy of summary sheet and O.P card No.158636 dt. 31/10/2000 III. Opposite party's witness: NIL
IV. Opposite party's documents:
D1 : Copy of certificae of Insurance with certificate No.2000/47/760702/80186 (760505) dt. 12/05/2000 D2 : Copy of question and reply dt. 4/1/2001 produced by opp. Party. D3 : Copy of Regd. Letter dt. 5/01/2001 issued by opp. Party D4 : Copy of letter dt. 3/9/2001 issued to complainant by opp. Party. D5 : Prescription issued by Dr. A. Marthanda Pillai, Medical College Hospital, Tvpm dt. 10/10/2000 to the complainant.
PRESIDENT
ad.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT SMT. BEENA KUMARI. A : MEMBER SMT. S.K. SREELA : MEMBER
O.P. No: 354/2001
Dated : 15..04..2009
Complainant:
Sureshkumar.B., Cherukara Puthen Veedu, Chakkavarakkal- P.O., Kunnikode (via) Kollam.
(By Adv. N. Krishnankutty)
Opposite party:
The Branch Manager, The New India Assurance Co.Ltd., Kottarathil Buildings, Palayam, Thiruvananthapuram.
(By Adv. M. Nizamudeen)
This O.P having been heard on 16..03..2009, the Forum on 15..04..2009 delivered the following:
ORDER
SMT. BEENA KUMARI. A., MEMBER:
Brief facts of the case are as follows:
The complainant has taken an insurance policy under the Pravasi Suraksha Kudumba Arogya Scheme of the opposite party. The effective date of the policy as per the policy certificate is 12/5/2000. During July 2000 the complainant felt a pain on his left arm. Further the disease of the complainant was diagonised as “Cervical Disc Prolapse C6-C7”. Complainant was admitted in the Medical College Hospital and he had undergone “Anterior Cervical Discectomy C6-C7”. Complainant stated that he had spend more than Rs.50,000/- for his treatment. The complainant submitted that as per the terms and conditions of the policy he is entitled to get the whole expenses incurred for the treatment. Therefore the complainant had submitted the duly filled up Claim Form with the opposite party along with supporting documents required for processing the claim on 1/12/2000. But the opposite party rejected the claim without any basis and contrary to the records produced by the complainant along with the claim form. Complainant submitted that he had suffered much mental agony due to the rejection of his claim by the opposite party and has alleged that there is deficiency in service on the part of the opposite party. 2. The opposite party New India Assurance Co. Ltd filed their version. The main contention raised by the opposite party is that the symptoms of Cervical Disc Prolapse C6-C7 was existing prior to 1 ½ years from the date of consultation ie. 10/10/2000. The symptoms had thus existed prior to the date of proposing the insurance. As per the conditions of the policy issued to the complainant all pre-existing disease/conditions and complications arising there from are excluded from the scope of the policy cover. Exclusion No.VIII.I of the policy states as follows: "Such diseases which have been in existence at the time of proposing this insurance, pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition". For that reasons the opposite party repudiated the claim vide letter dated 5/1/2001. Hence opposite party prayed for the dismissal of the complaint.
3. In this case complainant and opposite party filed proof affidavit. Nobody has been cross examined. From the side of complainant 6 documents were marked and from the side of opposite party 5 documents were marked. 4. Points that would arise for consideration are:
Whether the complainant had the alleged disease before the commencement of the policy? Whether the repudiation of the claim by the opposite party is justifiable? Reliefs and costs?
5. Points (i) to (iii) : In this case the complainant's case is that he is entitled to get the expenses incurred by him for his treatment under the insurance policy issued by the opposite party. The opposite party argued that the complainant is not eligible to get the benefit under the policy because the complainant was having the disease at the time of issuing the policy. To prove his claim complainant has filed proof affidavit and produced 6 documents. The document marked as Ext.P1 is the copy of policy certificate No.2000/47/760702, Ext.P2 is the copy of claim form submitted before the opposite party, Ext. P3 is the treatment certificate of the complainant. Ext.P4 is the copy of letter dated 5/1/2001 of the opposite party. Ext.P5 is the copy of letter dated 6/7/2001 of the complainant with Acknowledgment card. Ext.P6 is the copy of referral O.P card and summary sheet of complainant's treatment at Medical College Hospital, Thiruvananthapuram. The opposite party also filed proof affidavit and produced 5 documents to prove their contentions. Ext.D1 is the copy of policy and its conditions, Ext.D2 are the answers to the questionnaire submitted by the opposite party to Dr. Marthanda Pillai, who treated the complainant. Ext.D3 is the claim repudiation letter dated 5/1/2001. Ext.D4 is the repudiation letter dated 3/9/2001, Ext. D5 is the treatment record of the complainant issued by Dr. Marthanda Pillai, who had treated the complainant.
6. We have carefully examined the documents produced by the complainant and opposite party. Dr. Marthanda Pillai is the doctor who had treated the complainant. Ext.D2 is the answers to the Questionnaire submitted by the opposite party to Dr. Marthanda Pillai. Ext.D2 clearly shows that the complainant was suffering from neck pain, shoulder pain, radicular pain in left arm and was undergoing treatment for the above said complaints for 1 ½ years prior to the date of consultation after arrival in India on 10/10/2000. The symptoms of said disease started prior to the date of proposing the insurance which was on 12/5/2000. As per the conditions of policy Ext.D1, all pre-existing disease, conditions and complications arising there from are excluded from the purview of the policy. Exclusion No.VIII.I of Ext.D1 policy states as follows:-
"Such diseases, which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury, which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness, complication arising from pre-existing disease will be considered part of that pre-existing condition". Opposite party argued that due to the abovesaid reasons the opposite party was not in a position to consider the claim of the complainant for payment and the opposite party repudiated the claim. Opposite party also submitted that the opposite party is bound to indemnify the complainant/insured only as per the conditions of policy which constitute the contract of insurance. As per the conditions of policy issued to the complainant, the complainant is not entitled to get any amount from the opposite party. We also agree with the argument of the opposite party on the basis of the evidence and documents submitted by the opposite party. From the materials on record we have concluded that the complainant had failed to establish his case. In this case, the contention raised by the opposite party that the disease Cervical Disc Prolapse C6-C7 was existing before 1 ½ years from the date of commencement of the insurance policy has not been proved otherwise by the complainant. But the opposite party has succeeded to prove their contentions. In this case the opposite party has not committed any deficiency in service or unfair trade practice to the complainant. The repudiation of the claim of the complainant by the opposite party is valid and justifiable.
In the result complaint is dismissed.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 15th day of April, 2009.
BEENA KUMARI.A MEMBER.
G.SIVAPRASAD, PRESIDENT. S.K. SREELA, MEMBER. ad.
O.P.No.354/2001 APPENDIX
I. Complainant's witness: NIL
Complainant's documents:
P1 : Copy of certificate of insurance No.2000/47/762/80186 (760505) dt. 12/5/2000 P2 : Copy of Claim Form (card No.5072) dt. 1/12/2000 P3 : Copy of treatment certificate of I.P.No.068447 P4 : Copy of letter No.505/5072 dt. 5/01/2001 P5 : Copy of letter dated 6/7/2001 issued to the complainant by opp. Party P6 : Copy of summary sheet and O.P card No.158636 dt. 31/10/2000 III. Opposite party's witness: NIL
IV. Opposite party's documents:
D1 : Copy of certificae of Insurance with certificate No.2000/47/760702/80186 (760505) dt. 12/05/2000 D2 : Copy of question and reply dt. 4/1/2001 produced by opp. Party. D3 : Copy of Regd. Letter dt. 5/01/2001 issued by opp. Party D4 : Copy of letter dt. 3/9/2001 issued to complainant by opp. Party. D5 : Prescription issued by Dr. A. Marthanda Pillai, Medical College Hospital, Tvpm dt. 10/10/2000 to the complainant.
PRESIDENT
......................Smt. Beena Kumari. A
......................Smt. S.K.Sreela
......................Sri G. Sivaprasad | | 
