DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD
Dated this the 31st day of December 2008.
Present : Smt. H. Seena, President : Smt. Preetha.G. Nair (Member) Smt. Bhanumathi.A.K. (Member) C.C.No.17/2007
M. Sundaran S/o. Muthu Puthanpura, Kazhani Kallepully Kavassery, Alathur Palakkad. - Complainant (Advocates Rajeshkutty & M.K. Ganesh) V/s 1. The Manager The New India Assurance Company Ltd., P B No.43, N S Towers Near Stadium Bus Stand Coimbatore Road Palakkad 2. Jayaprakash Development Officer The New India Assurance Company Ltd Anamary, Alathur (P.O) Palakkad 3. Vijayamohan Agent (No.35471) The New India Assurance Company Ltd Kazhani, Chungam, Kavassery (P.O) Palakkad. - Opposite parties. (Advocate A.R.V Sankar) O R D E R By Smt. H. Seena, President Complainant availed an insurance policy called Universal Health Insurance with the first Opposite party at the instance of Opposite parties 2 & 3 by paying a premium of Rs.548/-. Policy period commence from 25/05/2006 to 24/05/2007. Policy was issued after a thorough medical checkup. On 07/07/2006, complainant was admitted in Amritha Institute of Medical Science and Research Centre, Cochin, where the disease was diagnosed as Coronary artery disease and therefore underwent a bypass surgery. An expenditure of about Rs.1,25,956.94 was incurred. As per the policy, Opposite party has to reimburse - 2 - medical expenses to the tune of of Rs.15,000/-. Complainant submitted the claim form complying all formalities on 17.08.2006. Opposite party No.1 did not honour the claim. The claim was rejected on the ground that the disease suffered by the complainant was preexisting one. Complainant submits that he did not have any pre-existing disease or any other such illness at any point of time prior to the taking of the policy. Lawyer notices were issued to the Opposite parties for which 1st Opposite party replied stating untrue contentions. According to the complainant, the act of the Opposite parties amounts to clear deficiency of service on their part.
Opposite parties filed version with the following contentions.
Opposite parties admits that the petitioner has availed policy for the period 25/05/2006 to 24/05/2007. Petitioner submitted a claim form for Rs.1,25,956/-. As per the policy, the sum assured for one illness is Rs.15,000/-. Further it has been revealed from the discharge summary submitted by the petitioner along with the claim form that the petitioner had contracted with the coronary artery disease inferior wall MI on 10/03/2006. The petitioner has suppressed material facts and obtained the policy. As per clause 4.1 appended to the policy “All disease/injuries which are pre-existing when the cover incepts for the first time” is excluded from the scope of the policy. According to the Opposite parties no medical checkup was done prior to the issuance of the policy as stated by the Complainant. The claim was rejected after application of mind and hence there is no deficiency of service on their part.
The evidence adduced consists of affidavit and Exhibit A1 to Exhibit A3 marked on the side of the complainant and affidavit and Exhibit B1 to B5 marked on the side of the Opposite parties.
Matter was heard. Now the issues for consideration are Whether there is any deficiency of service on the part of the Opposite parties? If so, what is the relief and cost?
- 3 - Point 1 & 2
Opposite parties heavily relies on Ext B3 document, claim form and discharge summary issued by the concerned doctor where in it is specifically stated under the head diagnosis that Inferior wall (MI 10/03/2006). According to the complaint, he did not have any pre-existing disease at any point of time prior to the taking of the policy. Other than a mere note in the discharge certificate no other evidence has been adduced by the Opposite parties. It is a settled position that burden to prove that the insured suppressed material facts heavily lies on the insurer. Insurance Company has failed to bring on record any documentary evidence to indicate that the insured had been treated for the same disease either as inpatient or outpatient. National Commission has held in Aviva LIC Pvt Ltd V T. Umavathi III (2007) CPJ 336 (NC) that alleged concealment of material facts not acceptable in absence of any cogent and convincing evidence. We are of the view that the Opposite parties has failed to substantiate their contentions by cogent and convincing evidence. We therefore answer the issues in favour of the complainant.
Hence complaint is allowed. We direct the Opposite parties to pay a sum of Rs.15,000/- being claim amount and Rs.2,000/- as compensation and Rs.1,000/- as cost of the proceeding within one month of receipt of this order failing which the complainant is entitled to get the aforesaid amount with interest at the rate of 9% interest from the date of order till realization.
Pronounced in the open court on this the 31st day of December, 2008.
President (SD)
Member (SD)
Member (SD) - 4 -
APPENDIX Exhibits marked on the side of the complainant Ext. A1 – Universal Life Insurance Policy Ext A2 series – Copy of Lawyer notice acknowledgment and postal receipts. Ext A3 – Reply notice
Exhibits marked on the side of Opposite parties Ext B1. - Proposal form submitted by the complainant Ext B2 – Policy with terms and conditions Ext B3 – Claim form submitted by complainant Ext B4 – Letter of repudiation Ext B5 – Acknowledgment of repudiation letter.
Costs Allowed Forwarded/By Order
Senior Superintendent
......................Smt.Bhanumathi.A.K
......................Smt.Preetha.G.Nair
......................Smt.Seena.H | | 
