DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the 21^st  day of March 2012

Present  : Smt.Seena H, President

             : Smt. Preetha.G. Nair, Member       

             : Smt. Bhanumathi.A.K, Member             Date of filing: 07/10/2011   

                                                (C.C.No.169/2011)                             

Mohammed,

S/o.Kunchan,

Pudoracha, Thachampara,

Mannarkkad, Palakkad                           -         Complainant

(By Adv.C.Ramadas)                                               

V/s

1. The Manager

    New India Assurance Co.Ltd.

    Kottarathil Building,

    Branch Palayam,

    Thiruvananthapuram

(By Adv.T.Giri)      

2.The Manager,

    New India Assurance Co.Ltd.

    Palakkad Branch, Palakkad                        -        Opposite parties   

(By Adv.T.Giri)                                         

O R D E R

            By  Smt.SEENA.H. PRESIDENT

Complainant availed a Pravasi Suraksha Kudumbarogya Health Policy from opposite party. The period of the coverage of the policy is 5years from 16/11/99 to 15/11/2004. At the time of taking policy complainant was not having any diseases. Complainant has undergone a master check up while going abroad as per the norms of  Saudi Gulf Country consultant.  After reaching Saudi Arabia also medical checkup was done.  No diseases were found.  Later complainant came to India and once again went abroad. He had a master check up at Kovai Medical Centre. From there it was found some irregularities in the heart beat. Subsequently angiogram was done on 2/7/2002 and it was found that there was a heart block. It was advised to have a CABG surgery and the same was done at Miot hospital, Madras. All the treatment records and medical bill were submitted to opposite party by post.  So far opposite party has neither honoured the claim nor repudiated it. Complainant has not received any intimation regarding repudiation. Complainant had spent an amount of Rs.1,30,239/- towards medical expenses and hospital charges.  The act of opposite parties amounts to deficiency in service on their part and hence the complaint. Complainant prays for an order directing the opposite parties to pay  Rs.1,30,239/- being the medical expense along with Rs.20,000/- as compensation for pain and sufferings.

Opposite parties has admitted the policy. According to opposite parties their liability is as per the terms and conditions of the policy. Pre-existing diseases are not covered as per the terms of the policy. Opposite party admits receipt of two claim forms from the complainant. As per the case sheet from Kovai Medical College, it is understood that the complainant was a known diabetic Mellitus patient for the past 12 years and known hypertensive patient for the last 2 years. Since complainant has not disclosed with respect to his previous ailments and treatment at various  hospitals, 1^st opposite party requested for all medical records prior to the hospitalization for cardiac surgery, treatment record at Abudhabi and treatment records under  Dr.Alavi  Thrissur  Medical College etc., Complainant has not furnished the said records. Only a letter without any documents was received by opposite party. Again a letter dated 14/10/2004 was sent to opposite party asking for records of full treatment in India and abroad before hospitalization. It is also stated in the letter that if the records are not received within 7 days of the receipt of the said letter the claim will stand closed. Complainant has not responded and hence claim stand closed in October 2004 itself. So the complaint is time barred also. According  to opposite parties since complainant has not produced the documents called for confirms that he has pre-existing disease. Further say of the complainant that claim was not repudiated is not correct. All the letters are usually sent by ordinary post. Further contention of opposite parties is that the Forum has no jurisdiction to entertain the complaint, since no cause of action arose within the territorial  limits of the Forum.

The evidence adduced consists of the respective chief affidavits of the parties. Ext.A1 to A6 and Ext.B1 to B5.

Issues for consideration are

1. Whether complaint is time barred and whether complaint is maintainable before the Forum ?
2. Whether there is any deficiency in service on the part of opposite parties?
3. If so, what is the cost and relief ?

Issue No.1

Opposite party  raised a contention that complaint is barred by limitation. According to opposite parties they have issued a letter dated 14/10/2004 to the complainant requesting to produce treatment records both in India and abroad. It is also further stated in the said letter that if the records are not received within 7 days the file stands closed. So cause of action for filing the complaint is within 2 years from October 2004.  Complainant has denied receipt of any such letter. Opposite party has failed to prove that the complainant has received the said letter. It is the settled position of law that the cause of auction starts from the date of repudiation of insurance claim. Even if we assume  that the said letter is received by the complainant, it is not a letter of repudiation. Hence we find that complaint is not time barred.

With regard to the 2^nd contention that the complaint is not maintainable before the Forum as the whole transaction and cause of action was outside the limits of the jurisdiction of this Forum, we find that in Ext.A1, claim servicing office address is at Palakkad which is within the jurisdiction of the Forum. Hence we answer both issues in favour of the complainant.

Issue 2 & 3

Heard both parties and has gone through the entire evidence on record.  Policy stands admitted by opposite parties. The hospitalization and surgery done within the period of the policy is also admitted. Complainant has undergone angiogram and CABG surgery  is also born by Ext.A3. According  to the opposite parties, they could not process the claim since the complainant has not produced the requested  documents. It is further stated that as per their investigation complainant was having hypertension for the past 2 years and diabetic Mellitus for the past 12 years. In Ext.B5, the investigator has reported that the master health checkup records reveals that the insured is a known patient of Diabetic for the past 12 years and a known patient of hypertension for the past 2 years as per the recordings of ophthalmologist. No such report is placed before us by the opposite parties. Ophthalmology is a branch which  deals with the diseases of the eye. No credible piece of evidence before us to prove that the complainant had ever an eye disease. More over in the said report itself, the investigator has clearly stated that the insured had visited the above hospital for the first time on 25/6/2002. Nothing is on record to show that complainant had visited the same hospital prior to the said date. Further in Ext.B2 the letter  sent by the opposite party to the complainant it is stated instead of 12 years, known diabetes mellitus since 4 years. It is seen that opposite party’s documents itself is contradictory. Further in the case sheet issued from Kovai Hospital and certificates issued by the treated doctors, it is only recorded known case of hypertension and diabetes mellitus. Period  is not mentioned any where.  Complainant has taken the policy in the year 1999. It is only in the year 2002 complainant had undergone  the said surgery. Proof of pre-existing  disease heavily lies upon the insurer. We find that opposite party has failed to prove the said aspect with cogent and convincing evidence. Hence we find opposite parties deficient in service in not honouring the genuine claim of the complainant.

In the result complaint allowed. Opposite parties are directed to pay complainant an amount of Rs.1,30,300/- (Rupees One lakh  thirty thousand three hundred only) being the claim amount along with Rs.20,000/- (Rupees Twenty thousand only) as compensation. Order to be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for whole amount from the date of order, till realization.

Pronounced in the open court on this the 21^st day of March  2012.

  Sd/-

Seena.H

President

   Sd/-

Preetha G Nair

Member

     Sd/-

Bhanumathi A.K.

Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1 – Photocopy of Policy   

Ext.A2 –  Photocopy of Claim form

Ext.A3 –  Certificate issued by Miot Hospitals dtd.9/9/02

Ext.A4 – Photocopy of letter sent by the complainant to opposite party dated

            12/6/03  

Ext.A5 – Photocopy of letter sent by the complainant to opposite party dated

            13/12/02

Ext.A6 – Photocopy of letter sent by opposite party to complainant dated

             8/1/03

Exhibits marked on the side of the opposite parties

Ext.B1 – Letter sent by 2nd opposite party to complainant dtd.14/10/04

Ext.B2 – Letter sent by 2nd oppsoite party to complainant dated 19/5/03

Ext.B3 – Letter sent by 2nd oppsoite party to complainant dated 08/1/03

Ext.B4 – Letter sent by 2nd oppsoite party to complainant dated 28/11/02

Ext.B5 – Investigation report of Insurance Investigator R.  dated 31/3/03

Cost Allowed

No cost allowed.