<br /> This is a complaint filed by the complainant K.Amaresh Patil against the Divisional Manager United Indian Insurance Company Divisional Office Raichur. The brief facts of the complaint are as under:-<br /> <br /> The complainant had insured his life with Respondent Company in individual medi-claim policy by name “Hospitalization & Domiciliary Hospitalization Benefit for an assured sum of Rs. 1,00,000/- on 28-03-02 to mid night of 28-03-03 by paying premium of Rs. 1,298/- on 28-03-02. The complainant was healthy prior to and as on the date of submitting the proposal form with Respondent Company. Hence he answered duly and rightly to the details sought in proposal form. Further the concerned penal doctor of Respondent Dr. Basavaprabhu Patil Manvi has also certified the same to Respondent before issuing the above said policy by Respondent.<br /> <br /> About five months after the Issuance of policy the complainant felt some giddiness on and off, hence immediately approached Dr. Vedhamurthy.S. consulting physician and cardiologist at Bellarry, who after thorough examination on 24-25/9/02 diagnosed as the case of complete heart block and referred/advised the complainant for higher treatment to Sri. Jayadev Institute of Cardiology, Bangalore, for implantation of permanent pace maker at the earliest. The complainant got admitted in Sri. Jayadev Institute of cardiology Bangalore on 27-09-02 for implantation of said permanent pace maker and under went some tests as per advise of Dr. B.Ramesh and N.G. Shivaswamy Assistant Professor of Cardiology & which result papers of tests retained by Hospital authorities and the same results are noted in a note book issued to the complainant and the ECG paper only issued to the complainant. The pace maker was implanted in the heart of the complainant by Dr. B.Ramesh with the Assistant & Dr. N.G. Shivaswamy of Sri. Jayadev Institute of Cardiology, Bangalore on 28-09-02 and got discharged from the said hospital on 03-10-02. <br /> The complainant in all spent Rs. 1,27,505/- for the said treated as per bill dt. 04-10-02 issued by Jayadev Hospital. The illness of the complainant and admittance of same was intimated to the Respondent Company by its authorized agent by name K.Rudrappa through letter dt. 30-09-02. Further the claim form along with Xerox copy of the treatment and tests were furnished to the Respondent on 10-10-02. The Respondent in-turn wrote a letter dt. 09-01-03 for seeking further information without looking to all the papers provided earlier to that letter, through Xerox copy of note book along with Xerox copy of letter dt. 03-10-02 issued by Dr. N.G.Shiva Swamy of Jayadev Hospital. However the complainant again furnished the same vide letter dt. 12-01-03 to the Respondent for which the Respondent has not taken any steps for settlement of his claim in spite of continuous personal approach and by verbal clashing with concerned Officers of the Respondent, the complainant finally asked them to dispose of matter through letter dt 04-01-05 in any manner and for which the Respondent has repudiated the matter through RPAD letter dt. 05-01-05. The reasons for repudiation of claim by Respondent as shown in the said being unrealistic and improper and im-practical approach, is not sustainable in law and it amounts to deficiency in service by Respondents. Hence for all these reasons the complainant has sought for payment of assured sum of Rs. 1,00,000/- as per the policy along with 12% P.A. interest from 10-10-02 till realization and for payment of Rs. 20,000/- as compensation for mental harassment together with Rs. 50,000/- towards cost.<br /> <br /> 2. The Respondent Insurance Company has filed written statement contending that from the letter/correspondence it is evident that the Respondent though sought certain clarification and documents to show the deceased was treated within the frame work or terms and conditions of the policy. But the complainant failed to produce such documents or clarification. Therefore this Respondent forced to close the claim at their end. The contention of the complainant that he was healthy prior to and as on the date of submitting the proposal for medi-claim policy is false and the complainant is called upon to produce strict proof of the same. The allegation that after (5) months of the policy he felt some giddiness on and often and approached Dr. Vedamurthy who detected complete heart block and referred to Jayadev Hospital Bangalore, and that the complainant got admitted at Jaidev Institute of Cardiology at Bangalore and pace maker was implanted in the heart of the complainant by Dr. B.Ramesh and Dr. N.C. Shivaswamy and discharged from the said hospital on 03-10-02 are all false. Though the complainant submitted his claim form claiming Rs. 1,27,505/- but he has not produced any original bills or documents for the purpose of verification and scrutiny by this Respondent like Original Test Reports conducted at Jayadev Hospital before undergone for operation i.,e Cath Report, ECG or Blood Report, Second Echo Report and such other reports mentioned in the bill dt. 03-10-02 of Jayadev Institute of Cardiology Bangnalore. The non submission of records in spite of several oral and written requests goes to show that the claim of the complainant is not bonafide one. The heart disease is of pre-existing disease, which is excluded under the coverage of the policy by way of exclusion in clause No.-4 of the terms and conditions of the Medi-claim Insurance Policy. Therefore the claim of the complainant is not covered under the policy. <br /> It cannot be contended that letter dt. 05-01-05 of this Respondent is a letter of repudiation being unrealistic improper and with impractical approach to deny the liability. The claim was pending because of necessary requirement of documents, which have been called for from the complainant. Hence for all these reasons the Respondents has sought for dismissal of the complaint.<br /> <br /> 3. During the course of enquiry that the complainant has filed his sworn affidavit as his evidence and has got marked as many as [12] documents at Ex.P-1 to P-12. The Respondent in rebuttal has filed his sworn affidavit of its Divisional Manager as chief examination and has got marked [11] documents at Ex.R-1 to R-11<br /> <br /> 4. Heard the arguments of both sides and perused the records The following points arise for our consideration and determination:-<br /> <br /> 1. Whether the complainant proves deficiency in service by the Respondents in not settling his claim under his Medi claim policy, as alleged?<br /> <br /> 2. Whether the complainant is entitled for the reliefs sought for.<br /> <br /> 5. Our finding on the above points are as under:-<br /> <br /> 1. In the negative.<br /> <br /> 2. As per final order for the following.<br /> <br /> REASONS<br /> <br /> POINT NO.1:-<br /> <br /> 6. Bearing in mind the pleadings of both parties it is necessary to know as to how the Respondent Insurance Company has in fact repudiated the claim of the complainant as alleged by him and as disputed by the Respondent. In this regard it is further necessary to know the correspondence taken place between the complainant and Respondents which have been produced by the complainant at Ex.P.6, P-7, P-9 and P-10.<br /> Ex.P-6 is the letter of Respondent Company dt. 09-01-03 addressed to the complainant inviting its earlier letter dt. 19-12-02 wherein they had called for certain information which has not been furnished by the complainant and through this letter the Respondent has again called for required documents for producing the same namely:-<br /> 1. Claim form duly completed in all respect.<br /> 2. Name & address of Doctor treatment first given by him.<br /> 3. Since how long you are suffering with one disease.<br /> 4. As per report submitted by you are getting weakness on & off since six months. Do your face any other complaint than the weakness & from which date, submit one Test Report on receipt of the same as above, on merits of paper, we will process the claim.<br /> <br /> Ex.P.7 is the reply letter of the complainant dt. 12-01-03 for reply to the letter dt. 09-01-03 furnishing some information as detailed therein. Ex.P-9 is another letter of the complainant dt. 04-01-05 addressed to the Respondent reminding the earlier correspondence for early treatment of the claim. Ex.P-10 is the letter of the Respondent dt. 05-01-05 in reply to the letter of the complainant dt. 04-01-05 vide at Ex.P-9. This letter of Respondent at Ex.P-10. according to the complainant is repudiation letter, so it is important to note the contents of this letter which reads as under:-<br /> “With reference to the above, while acknowledging your letter dt. 04-01-05. We invite your kind attention to our letter dt. 05-03-03. Wherein we had requested you to send us certain clarification/documents. Despite our request you have not produced as per our requirement. We had also explained to you that unless appropriate evidences to show the disease was treated within the frame work or our terms and conditions of our policy, we are not in a position to consider your claim. Hence, we treat you claim closed at our end.”<br /> <br /> From a close perusal of the same it shows that in-spite-of the earlier letter of the Respondent dt. 05-03-05 [a copy of which is produced at Ex.R-5] the complainant has not produced the required documents as called for. So unless appropriate evidence to show the disease was treated within the frame work or terms and conditions of the policy, they are not in a position to consider his claim. Hence they treat the complaint’s claim as closed at their end. The letter at Ex.R-5 being material reads thus:-<br /> With reference to the above, while acknowledging your letter dt. 24-01-03 in reply to our letter dt. 09-01-03, we wish to inform you as under:-<br /> 1. In your letter Para-3, you have mentioned that you are not suffering from any disease earlier than 25-09-02.<br /> <br /> 2. You have not produced any test reports conducted at Sri. Jayadeva Institute of Cardiology, Bangalore before you have under gone for an operation i.e, Cath Report ECG, All blood Reports 2d Echo Report and such other mentioned in the bill dt. 03-10-02 of Jayadeva Institute of Cardiology, Bangalore.<br /> <br /> 3. As per the Xerox copy of Note Book submitted by you that, you are suffering from giddiness on and often since six months once in 6 to 10 minutes.<br /> <br /> 4. As per Admission Sheet No. 120329 issued by Jayadev Institute of Cardiology, Bangalore it was diagnosed as Chronic Case of Heart Block and known case of Chronic Heart Block.<br /> <br /> 5. In spite of our oral request repeatedly you are not producing us the test Reports undergone by you prior to operation.<br /> <br /> 6. You have taken the policy with us on 29-03-02 commencing the risk from 29-03-02 to 28-03-03 as per policy condition No-4 Exclusion 4.1 reading as under:<br /> <br /> “Approved by Ministry vide letter Ref.No.64[48] Ins.1.96 dated at the March 1997. All disease/injuries which are pre-existing when the cover incepts for the first time”<br /> Therefore, you claim does not fall outside the scope of terms and conditions of the policy issued to you<br /> <br /> From a close perusal of the letter of the Respondent dt. 05-01-03 produced by the complainant at Ex.P-10 in the light of letter of the very Respondent dt. 05-03-05 at EX.R-5 seeking clarification from the complainant it shows that Respondent has sought certain clarification from the complainant vide letter Ex.R-5 and the complainant has not furnished the same as stated in letter at Ex.P-10. So it cannot be said that the Respondent has repudiated the claim of the complainant in its totality. Under all these circumstances it amply shows that the complaint of the complainant is pre-mature one without exhausting remedy with the Respondent as per the letter at Ex.P-10 and Respondent-5 as referred to above. Hence it cannot be said that the Respondent has repudiated the claim of the complainant therefore Point No-1 it is answered in the negative.<br /> <br /> POINT NO.2:-<br /> <br /> 7. In view of our finding on point No-1 holding that the complaint is pre-mature and no deficiency in service by the Respondent so the complainant is not entitled for reliefs sought for. In the result we pas the following order:<br /> <br /> ORDER<br /> <br /> The complaint of the complainant being pre-mature and devoid of merits with regard to alleged repudiation so the complaint is hereby dismissed. No order as to cost.<br /> <br /> (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum On 30-11-05.)<br /> <br /> <br /> Sd/-<br /> Sri. N.H. Savalagi,<br /> President,<br /> District Forum-Raichur.<br /> <br /> Sd/-<br /> Sri. Pampannagouda, <br /> Member<br /> District Forum-Raichur.<br /> <br /> <br /> Sd/- <br /> Smt.Kavita Patil, <br /> Member. <br /> District Forum-Raichur<br /> <br />