This C.C coming on before us for final hearing, on 11-11-2008 in the presence of Sri.K.Koteswar Rao, Advocate for Complainant, and in the presence of Smt. P.Sandhya Rani, Advocate for the opposite party No-1 and opposite party No-2 served and called absent ; upon perusing the material papers on record; upon hearing arguments, and having stood over for consideration, this Forum passed the following:-
ORDER
(Per Smt.V.Vijaya Rekha, Member )
1. This complaint is filed under section 12(1) of the Consumer Protection Act, 1986 with the following averments;
2. The complainant obtained a Medi claim Insurance Policy from the opposite party No-1 vide policy No.610902/48/03/20/00000313 on 23-6-2003 for the period of one year and the same was renewed in the years 2004, 2005, 2006 and 2007 and at the time of obtaining the policy the complainant informed that he is diabetic. On 10-8-2006 the complainant admitted in Care Hospital, Hyderabad due to chest pain and after conducting the necessary tests the doctors advised to under go CABGs, accordingly the complainant under went Coronary Artery by-pass surgery on 15-8-2006 and discharged from the Hospital on 23-8-2006 and spent Rs.1,62,822/- towards medical expenses. The complainant further stated that he made claim form on 27-9-2006 by claiming an amount of Rs.1,62,822/- towards medical expenses but the opposite party No-2 addressed a letter on 6-11-2006 and repudiated the claim of the complainant by the reason of pre existing diseases are not covered under policy. The complainant also alleged that the attitude of the opposite parties amounts to deficiency of services and as such prayed to award an amount of Rs.1,62,822/- towards medical expenses along with interest @ 24% P.A. from the date of claim and costs.
3. Along with the complaint the complainant filed affidavit and also filed(i)Policy copy (ii)Premium receipt for Rs.5,906/-(iii)Receipt for Rs.7,500/-, dated 10-8-2006 issued by Care Hospital, Hyderabad (iv) Receipt for Rs.1,30,000/-, dated 11-8-2006 issued by Care Hospital, Hyderabad(v)Bill dated 11-8-2006 for Rs.12,049/-(vi) Bill dated 11-8-2006 for Rs.2,674/-(vii)Receipt dated 12-8-2006 for Rs.16,000/-(viii) Receipt dated 22-8-2006 for Rs.15,000/-(ix) Receipt dated 23-8-2006 for Rs.924/-(x) Receipt dated 23-8-2006 for Rs.1,61,000/-(xi) Angio-grem report (xii)Bio-chemistry test report, dated 11-8-2006(xiii)Ultrasound report , dated 11-8-2006(xiv) Bio-chemistry test report, dated 11-8-2006(xv) Bio-chemistry test report, dated 11-8-2006(xvi) Bio-chemistry test report, dated 11-8-2006(xvii)Blood grouping test report(xviii)Department of Serology report (xix)Haematology test report(xx) Ultrasound report , dated 12-8-2006(xxi)Pathology report(xxii)Report dated 12-8-2006(xxiii)Report of Ultrasonography(xxiv)Echo cardiographic report dated 12-8-2006(xxv)Serology report (xxvi) )Haematology test report(xxvii)Plasma Glucose test report (xxviii)Haemoglobin test report(xxix) Plasma Glucose test report(xxx)Serum creatinine report(xxxi)ECG report dated 21-8-2006(xxxii) Haemoglobin test report, dated 21-5-2006(xxxiii) Serum creatinine report, dated 21-8-2006(xxxiv) Echo cardiographic report dated 21-8-2006(xxxv) ECG report dated 26-8-2006(xxxvi)Xerox copy of policy for the year, 2006(xxxvii)Xerox copy of premium receipt, for Rs.6,015/-(xxxviii)Letter dated, 17-8-2006 addressed by the daughter-in-law of complainant to the opposite party No-2(xxxix)claim form(xxxx)letter dated 4-10-2006 addressed by the complainant to the opposite party No-2.
4. After receipt of notice the opposite party No-1 appeared through it’s counsel and field counter by denying the allegations made in the complaint. The opposite party No-2 was called absent.
5. In the counter the opposite party No-1 admitted the issuance of policy bearing No.610902/48/03/20/00000313 in the name of the complainant on 23-6-2003 and it was renewed till 23-6-2006 and denied the other allegations of the complainant. The opposite party No-1 also contended that as per the policy the complainant was a diabetic and as per the condition No.4.1 of the policy the diseases/injuries which are pre existing are not covered under the policy and more over the complainant is a diabetic since last 5 years and the same leads to present ailment and they repudiated the claim of the complainant as per the policy conditions. The opposite party No-1 further contended that the complainant made his claim form on 4-10-2006 to the opposite party No-2 and in turn the opposite party No-2 repudiated the same through a letter dated 3-11-2006 as such there is no deficiency on the part of them and prayed to dismiss the complaint.
6. In view of the above submissions made by both the parties now the point for consideration is whether the complainant is entitled to any relief as prayed or not?
7. As seen from the averments of the complaint and counter there is no dispute between the parties in issuance of Medi-claim Insurance policy for a sum of Rs.1,00,000/- and as per the allegations of the complainant the complainant joined in Care Hospital, Hyderabad on 10-8-2006 as in-patient with a complaint of chest pain, after conducting the necessary tests, the doctors advised the complainant, to under go Coronary Artery by-pass grafting surgery and on 15-8-2006 the complainant under went the said ailment and discharged on 23-8-2006 and on 27-9-2006 he made a claim for an amount of Rs.1,62,822/- towards medical expenses but the claim of the complainant was repudiated, as such he filed the present complaint for Redressal. On the other hand the opposite party made a contention that the complainant is not entitled to claim compensation under the policy, and the complainant was a diabetic since last 5 years and as per the exclusion class 4.1, the pre existing diseases are not covered under policy, but in support of their contentions the opposite party did not file any material for consideration and as seen from the policy copy,the policy is Hospitalization and Domiciliary Hospitalization benefit policy and in one of the columns of the policy, it was mentioned that the complainant was diabetic, it clearly shows, at the time of obtaining the policy the complainant informed his health condition and after considering the proposal of the proposed only the insurer had given the said policy, and more over as per the policy bearing No.610902/81/06/0000001840, dated 13-6-2006 the period of policy is from 23-6-2006 to 22-6-2007 and in the present case on hand the complainant under went heart ailment on 15-8-2006 and taken treatment as in patient for 13 days and as such as per the policy, the complainant is entitled for a sum of Rs.1,00,000/- and also entitled the other benefits if any.
In view of the above discussion we feel that the attitude of opposite parties amounts to deficiency of service in payment of policy amount to the complainant and the repudiation of whole claim of the complainant is unjust and against the rules of natural justice. As per the conditions of the policy the liability of the opposite parties shall not extend to pay any expenses incurred relating to the disease(s)/sickness/injury and for consequences attributable thereto or accelerated thereby or arising there from, as such the complainant is entitled to the amount as per the policy.
8. In the result, the complaint is allowed in part and the opposite parties are directed to pay an amount of Rs.1,00,000/- and also liable to pay the benefits if any together with interest @ 9% per annum from the date of repudiation i.e., 3-11-2006 under the Hospitalization and Domiciliary Hospitalization benefit policy bearing No. 610902/81/06/0000001840 and also directed to pay an amount of Rs. 2,000/- towards costs of the litigation.
Typed to dictation, Corrected and pronounced by us, in this Forum on this 28th day of November, 2008.
President Member Member
District Consumers Forum, Khammam
APPENDIX OF EVIDENCE
WITNESS EXAMINED FOR
Complainant Opposite parties
Nil Nil
DOCUMENTS MARKED FOR
Complainant Opposite parties
Nil Nil
President Member Member
District Consumers Forum, Khammam
