BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD, THIRUVANANTHAPURAM. PRESENT SRI. G. SIVAPRASAD : PRESIDENT SMT. BEENAKUMARI. A : MEMBER SMT. S.K.SREELA : MEMBER O.P. No. 126/2002 Filed on 26.03.2002 Dated : 30.06.2009 Complainant:
Therassamma, residing at Kaliyal Kottiya, Thanponnankala, Kanjiramkulam, Kanjiramkulam P.O.
(By adv. S.R. Thankaraj)
Opposite party:
The Divisional Manager, United India Insurance Company Ltd., Branch Office, Hospital Junction, Neyyattinkara.
(By adv. Sreevaraham G. Satheesh)
This O.P having been heard on 30.05.2009, the Forum on 30.06.2009 delivered the following:
ORDER SMT. S.K.SREELA : MEMBER The brief facts of the case are the following: The complainant had taken a policy under Kamadhenu Insurance Scheme and the complainant was regularly paying the premium without any default. That due to pain and swelling on the breast of the complainant, she was admitted as an inpatient in Directorate of Medical Education, Medical College Hospital, Thiruvananthapuram and was discharged on 03.07.2001 and she is still continuing the treatment. The complainant had incurred more than ten thousand rupees for her treatment. As per the said insurance scheme, the opposite party is liable to pay the entire medical expense for a period from 29.04.1999 to 28.04.2002. But wilfully the opposite party has cheated the complainant and as per the scheme the complainant has the absolute right to realise the amount from the opposite party. Hence this complaint for payment of the amount as per the insurance premium along with other reliefs. The insurance company, the opposite party, has filed their version contending as follows: Admittedly the complainant is a beneficiary of the Kamadhenu Insurance taken by the husband of the complainant. The complainant submitted a claim for the medical expenses for the treatment for pain and swelling on her breast. Along with the claim form, she submitted the medical records and the essentiality certificate from the doctor of Medical College Hospital, Thiruvananthapuram showing a medical expense of Rs. 6386/-. The referral O.P card from the Medical College hospital shows that she was under treatment from 22.06.2001 to 03.07.2001. In that record the doctor has noted against the column complaints and finding that “Patient came with history of swelling left breast – 2½ years. History of sudden increase in size 20 days”. The policy commences only on 29.04.1999 and this alleged complications/ailment was pre-existing even at the time of inception of the policy. As per the condition III(1) of the policy, pre-existing disease are excluded and hence the claim of complainant was not payable. There is no irresponsible attitude from the side of the opposite party. There is no deficiency of service in terms of the policy conditions. Hence prays for dismissal of the complaint. The complainant and opposite party have filed their affidavits. Exts. P1 to P16 were marked on the part of the complainant and Exts. D1 to D3 were marked on behalf of the opposite party. From the contentions raised the following issues arise for consideration. Whether the act of the opposite party in repudiating the claim is justifiable? Whether there is any deficiency in service on the part of the opposite party? Reliefs and costs.
Points (i) to (iii):- There is no dispute with regard to the policy. The complainant alleges that for the treatment for pain and swelling on her breast she was admitted in the Directorate of Medical Education, Medical College Hospital, Thiruvananthapuram wherein she was treated and discharged on 03.07.2001 and that she had incurred more than ten thousand rupees for her treatment, but the opposite party has not yet refunded the amount. The opposite party has contended that since the disease of the complainant was existing prior to the taking of the policy, the claim is not payable as per the policy conditions. We have perused all the records on file. Exts. P6 and D1 are one and the same. As per Exts. P6 and D1 which is the copy of the referral O.P, Directorate of Medical Education, Medical College Hospital, pertaining to the complainant, it is evident that, under the head complaints and findings, it has been noted that patient came with history of swelling left breast- 2½ years. As per Ext. P6 date of admission is 22.06.2001 and that of discharge is 03.07.2001. As per Ext. P1, period of insurance is 3 years from 29.04.1999 to 28.04.2002. Exts. P6 and D1, wherein the history of the patient is recorded on the basis of the information given by the complainant also, would prove that the disease of the complainant is in existence for the last 2½ years which means that at the time of taking of the policy, the complainant has been suffering from the disease mentioned in the complaint. The learned counsel for the opposite party has produced the decision of the Hon'ble National Commission reported in I (2007) CPJ 202(NC), wherein it has been held that the repudiation of the claim by the petitioner who suffered heart problem since 1994 itself is justifiable as the same being pre-existing not covered under policy. From the records on file, it is evident that at the time of purchase of the policy, the complainant has not disclosed that she was suffering from the ailment prior to the taking of the policy itself and therefore it amounted to mis-statement in the proposal form. The learned counsel for the opposite party had argued that pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of the insurance whether or not the insured person had knowledge that the symptoms were relating to the sickness complications arising from pre-existing disease will be considered part of that pre-existing conditions. In support of the said contentions of the opposite party, the decision of the Union Territory Consumer Disputes Redressal Commission Chandigarh reported in III(2003) CPJ 608 was also produced. The opposite party has succeeded to establish and prove what has been alleged in the letter of repudiation. We find that the communication by the Insurance Company to the complainant as per Ext. D2 has been taken in good faith after due application of mind and there has been no deficiency in service on the part of the opposite party. Hence the complaint is liable to be dismissed. In the result, the complaint is dismissed. No order as to costs. 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 30th day of June 2009. S.K. SREELA : MEMBER
G. SIVAPRASAD : PRESIDENT
BEENAKUMARI. A : MEMBER
O.P. No. 126/2002 APPENDIX I COMPLAINANT'S WITNESS : NIL II COMPLAINANT'S DOCUMENTS :
P1 - Copy of certificate of insurance dated 29.04.1999. P2 - Copy of form of essentiality certificate dated 22.06.2001 P3 - Copy of form of essentiality certificate dated 13.12.2001 P4 - Copy of Mediclaim Insurance policy claim form with date of admission 22.06.2001. P5 - Copy of schedule of expenses incurred by the claimant. P6 - Copy of referral O.P care dated 22.06.2001 P7 - Copy of clinical biochemistry investigation request report dated 26/6. P8 - Copy of clinical biochemistry investigation request report P9 - Copy of clinical biochemistry investigation request report P10 - Copy of clinical biochemistry investigation request report P11 - Copy of clinical biochemistry investigation report dated 25.06.2001. P12 - Copy of cash bill No. 22320 dated 31.12.2001. P13 - Copy of cash bill No.81326 dated 10.03.2002. P14 - Copy of cash bill No. 23280 dated 14.02.2002. P15 - Copy of cash bill No. 28150 dated 17.02.2002. P16 - Copy of cash bill No. 254945 dated 15.01.2002. III OPPOSITE PARTY'S WITNESS : NIL IV OPPOSITE PARTY'S DOCUMENTS :
D1 - Copy of O.P Ticket with DOA 22.06.2001 D2 - Copy of letter dated 20.02.2002. D3 - Copy of front page of letter. PRESIDENT
......................Smt. Beena Kumari. A
......................Smt. S.K.Sreela
......................Sri G. Sivaprasad | | 
