BEFORE THE DISTRICT FORUM: KURNOOL
Present: Sri. T.Sundara Ramaiah, B.Com B.L., President
And
Sri. M.Krishna Reddy, M.Sc., M.Phil., Male Member
And
Smt. S.Nazeerunnisa, B.A., B.L., Lady Member
Monday the 9th day of April, 2012
C.C.No.121/2011
Between:
Syed Meer Ismail, S/o S.Meer Sadiq,
Manager in Co-Operative Central Bank, H.No.14/98, Velugodu- 518 533, Kurnool District.
…Complainant
-Vs-
1. The Divisional Manager,Oriental Insurance Company Limited,
H.No.40/383, Bhupal Complex, Kurnool - 518 001.
2.The General Manager,District Co-Central Bank,
H.No. 46-1-C, Opp. Eye Hospital, Kurnool - 518 002.
...Opposite ParTies
This complaint is coming on this day for orders in the presence of Sri P.Siva Sudarshan, Advocate for complainants and Sri N.Isaiah, Advocate for opposite party No.1 and Sri K.Rama Krishna Rao, Advocate for opposite party No.2 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Smt. S.Nazeerunnisa, Lady Member)
C.C. No.121/2011
1. This complaint is filed under section 11 and 12 of C. P. Act, 1986 praying:-
- To direct the opposite party No.1 to pay the policy amount of Rs.30,000/- with interest @ 24% per annum from the date of payment i.e., 31-01-2011 to till the date of realization along with benefits;
- To grant a sum of Rs.20,000/- towards mental agony;
- To grant the cost of the complaint;
- To grant any other relief as the Honourable Forum deems fit and proper in the circumstance of the case.
2. The case of the complainant in brief is as under:- The complainant is working as manager in opposite party No.2 organization and he joined the universal Health insurance policy scheme of opposite party No.1 through opposite party No.2 for the period from 30-07-2010 to 29-07-2011. The opposite party No.1 issued policy bearing No.433100/47/2010/3510. As per the policy the opposite party shall pay the hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an inpatient. On 21-12-2010 while the complainant was on duty suddenly he fell down and admitted him in Surya Hospital, Kurnool for treatment and he was discharged on 28-12-2010. He incurred a sum of Rs.30,285/- towards medical expenses for his treatment. The complainant submitted claim form to opposite party No.1 through opposite party No.2 along with relevant documents. The opposite party No.1 repudiated the claim on the ground that the insured was suffering from pre-existing disease “EPILEPSY” and the hospitalization bill was given by doctor on his own letter head which is not valid to claim medi claim. Due to the negligent attitude of the Opposite Parties, the Complainant suffered mental agony. There is deficiency of service on the part of Opposite Parties. Hence the complaint.
3. Opposite Party No.1 filed written version stating that the complaint is not maintainable. It is admitted that the complainant took the medi claim policy from Opposite Party No.1 through Opposite Party No.2 bearing No.433100/47/2010/3510 covering the period from 30-07-2010 to 29-07-2011. It is also admitted that Opposite Party No.1 shall pay the hospitalization and medical expenses to the insured under the policy. The opposite party No.1 repudiated the claim on the grounds that the complainant had been suffering from pre-existing disease, ‘EPILEPSY’ and that the hospitalization bill was given by doctor on his own letter head which is not valid to claim medi claim. The complainant suppressed material fact regarding his health condition and obtained policy with false declaration. Hence the complaint is liable to be dismissed.
Opposite Party No.2 filed written version stating that opposite party No.2 is neither a necessary nor a proper party to the disputes. Opposite Party No.2 forwarded the claim form to opposite party No.1. Opposite Party No.2 has no liability under the policy. Hence the complaint is liable to be dismissed against the opposite party No.2.
4. On behalf of the complainant Ex.A1 to A7 are marked sworn affidavit of complainant is filed. On behalf of the opposite parties sworn affidavits of opposite parties are filed. No document is marked. PW1 is examined.
5. Both sides filed written arguments.
6. Now the points that arise for consideration are:
- Whether there is deficiency of service on the part of opposite parties?
- Whether the complainant is entitled for the reliefs as prayed for?
- To what relief?
7. POINTS i and ii:- Admittedly the complainant obtained medi claim insurance policy bearing No. 433100/47/2011/867 covering the period from 30-07-2010 to 29-07-2011 for a sum of Rs.30,000/- which is marked as Ex.A1. Ex.A2 is the photo copy of discharge card issued by Surya Hospital, Kurnool and Ex.A3 is the photo copy of Bill issued by Surya Hospital. Ex.A4 and Ex.A5 are the photo copies of C.T. Scan Brain Plain Report of Padma Chandra Centre, Kurnool along with bills. The bunch of medical bills is marked as Ex.A6. It is the case of the complainant that he took medi claim insurance policy from opposite party No.1, that after taking the policy he fell ill and took the treatment in Surya Hospital, and spent a sum of Rs.30,285/- towards medical expenses. He submitted claim form to opposite party No.1 through opposite party No.2 for reimbursement and opposite party No.1 repudiated the claim with unreasonable grounds under Ex.A7 dated 15-02-2011. It is the case of the opposite party that the complainant suppressed the material fact regarding his pre existing disease “EPILEPSY” at the time of taking policy and the hospital bill issued by the doctor on his letter head is not valid for medi claim. So the opposite party repudiated the claim under Ex.A7.
8. PW1 who is Nemro Surgeon and sole proprietor of Surya Hospital, Kurnool, who was examined on behalf of the complainant, in his evidence stated that he issued Ex.A2 discharge card and Ex.A3 hospital bill for Rs.20,000/- towards hospitalization expenses. From the evidence of PW1 and Ex.A1 to Ex.A6 it is very clear that the complainant had suffered from ill-health and he spent a sum of Rs.30,285/- for treatment. The onus is on the insurance company to establish that the complainant took treatment for preexisting disease before taking the policy from opposite party No.1. The learned counsel for the complainant contended that opposite party No.1 did not file any document that the complainant suppressed ill-health and obtained the policy.
9. The learned counsel appearing for the complainant cited a decision reported in I (2012) CPJ 84 (NC). Where in it was held that to prove pre-existing disease the respondent not produced any documentary evidence or expert medical opinion. In another decision I (2012) CPJ 204 (NC) it was observed that the respondent was unable to produced any documentary evidence or medical record to show that petitioner had been treated for any pre-existing disease.
10. In the present case the opposite party No.1 could not produce medical evidence to show that the complainant had been taken treatment for pre-existing disease before he obtained the policy from opposite party No.1. The opposite party No.1 did not produce the proposal from to show that the complainant suppressed the material fact regarding his health condition. It is the contention of the opposite party that the doctor gave the bill on his letter head and that it is not valid. PW1 the doctor who gave treatment to the complainant in his evidence admitted that he issued Ex.A3 bill for Rs.20,000/- nursing charges and including doctor fee. Merely because PW1 the doctor who gave treatment to the complainant issue Ex.A3 on his letter head the opposite party cannot escape from its liability. Opposite party No.1 without any justification repudiated the claim of the complainant. There is deficiency of service on the part of opposite party No.1. Opposite Party No.2 forwarded the claim to opposite party No.1, so opposite party No.2 is not liable.
11. In the result, the complaint is partly allowed directing the opposite party No.1 to pay the insured amount of Rs.30,000/- with interest of 9% from the date of complaint i.e., 15-09-2011 till the date of realization, Rs.1,000/- as compensation for mental agony and Rs.500/- as costs of the complaint within one month from the date of the order. The complaint against opposite party No.2 is dismissed.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 9th day of April, 2012.
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant: PW1 For the opposite parties : Nill
List of exhibits marked for the complainant:-
Ex.A1 Photo copy of Policy No.433100/47/2011/867.
Ex.A2 Photo copy of Discharge Card issued by Surya Hospital,
Kurnool dated 28-12-2010.
Ex.A3 Photo copy of Bill issued by Surya Hospital, Kurnool
dated 13-01-2011.
Ex.A4 Photo copy of CT Scan Brain Plain Report of Padma
Chandra Diagnostice Center, Kurnool dated 21-12-2010.
Ex.A5 Photo copy of CT Scan Brain Plan and Contrast Report
of Padma Chandra Diagnostice Center, Kurnool along with
bills dated 23-12-2010.
Ex.A6 Photo copy of A Bunch of Medical Bills (Nos.19).
Ex.A7 Photo copy of Repudiation Letter dated 15-02-2011.
PW1 Deposition of Dr.T.V.S. Reddy dated 04-01-2012.
List of exhibits marked for the opposite parties:- NILL
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
