IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA.

Dated this the 1^st day of February, 2010.

Present:- Sri. Jacob Stephen (President)

Smt. C. Lathika Bhai (Member)

Sri. N. Premkumar (Member)

C.C. No. 120/05

Between:

Rachel Alex,

Palliparampil House,

Thelliyoor P.O.,

Vennikulam, Pathanamthitta

(By Adv. Anzil Zachariah)                                                         ....             Complainant.

And:

1. The General Manager,

National Insurance Company Ltd.,

Branch Office, Post Box No.37,

Ennakattil Estate, M.C. Road,

Thiruvalla, Pathanamthitta.

2. Baby Tharayil,

Tharamel House, Puramattom P.O.,

Pathanamthitta.

Addl.3.The General Manager/Manager,

             National Insurance Co. Ltd.,

             Divisional Office, P.B. No.434,

             Vazhuthacaud,

             Thiruvananthapuram – 14.                                            ....            Opposite parties.

O R D E R

Sri. N. Premkumar (Member):

                        Complainant filed this complaint for getting a relief from the Forum.

                        2. Fact of the case in brief is as follows:-  The 1^st opposite party is the National Insurance Co. Ltd. and 2^nd opposite party is an agent of 1^st opposite party.  The 3^rd opposite party is the General Manager of National Insurance Co. Ltd.

                        3. The complainant is a policy holder of the 1^st opposite party and purchased a policy by paying Rs.1,751/- towards premium for hospitalization and domiciliary benefit insurance policy for the period from 8.10.2004 to 7.10.2005.  On 1.8.2005 the complainant was admitted at Muthoot Medical Centre, Kozhencherry for various treatment.  She submitted the claim before 1^st opposite party.  But 1^st opposite party repudiated the claim stating that the ailment seems to be complication of pre-existing disease.  The complainant is a policyholder of the 1^st opposite party from 2002 onwards.  The complainant is unaware of the remarks stated by the 2^nd opposite party.  The opposite parties failed to inform the norms of the said policy.  The complainant never underwent any surgery or any treatment so far for varicose or for any other related disease as stated by the 1^st opposite party.

                        4. The 2^nd opposite party while accepting and renewing of policy informed about medical checkup before LIC doctor It was not done though the complainant was ready for medical check up.  Now the 1^st opposite party is raising untenable contentions to repudiate the claim.  The repudiation is arbitrary and malafide.  The non-attention to claim by the opposite parties amounts to deficiency in service.  Hence this complaint for getting insurance claim with interest for opposite parties dereliction of duty and negligence which caused mental agony and inconvenience to complainant with compensation and cost.

                        5. Opposite parties entered appearance and filed version stating that complaint is not maintainable either in law or on facts.  They admit that complainant was covered a hospitalization and domiciliary hospitalization benefit policy bearing No.570202/48/04/8500000194 valid from 8.10.2004 to 7.10.2005.  They also admits that complainant had lodged a claim, claiming reimbursement of the medical expenses which is said to be incurred with her hospitalization treatment on 1.8.2005 at Muthoot Medical Centre.  As per exclusion clause 4.1 of the terms attached to the policy, all pre-existing ailments are excluded from the coverage under the policy.  Complainant’s claim was properly and closely scrutinized by the opposite party and found the ailment from commencement of the policy.  Therefore the claim of the complainant was rightly repudiated for cogent and sound reasons with due application of hind.  Hence opposite parties canvassed for the dismissal of the complaint with cost.

                        6. From the above pleadings, following points are raised for consideration:

(1)   Whether the complaint is maintainable before the Forum?

(2)   Whether the relief sought for in the complaint are allowable?

(3)   Relief & Cost?

            7. Evidence of the complainant’s consists of the proof affidavit filed by the complainant, who has been examined as PW1 and the documents produced were marked as Ext.A1 to A5.  On opposite parties side, 1^st opposite party filed proof affidavit.  He was examined as PW1.  After the closure of evidence, both parties were heard.

            8. Point Nos.1 to 3:- In order to prove the complainant’s case, complainant filed proof affidavit along with certain documents.  He was examined as PW1 and the documents produced were marked as Ext.A1 to A5.  Ext.A1 is the Mediclaim Policy Certificate issued by the opposite parties for the period from 8.10.2002 to 7.10.2003.  Ext.A2 is the receipt of premium amount of Rs.1,548/- of Ext.A1.  Ext.A3 is the policy certificate during the year 2003-2004.  Ext.A4 is the discharge summary issued by the Muthoot Medical Centre.  Ext.A5 is the bill issued by Muthoot Medical Centre for an amount of Rs.23,146/-.

            9. In order to prove the opposite parties contention, 1^st opposite party filed proof affidavit.  He was examined as DW1.  Apart from oral evidence, opposite parties had not produced any materials to prove their contention.

            10. On the basis of the averments and contention of the parties, we have perused the entire materials on record and revealed that there is no dispute regarding the validity of the policy and coverage.  The only contention raised by opposite parties is that complainant has pre-existing disease.

            11. On a perusal of Ext.A1 to A3, it is evident that complainant was a policy holder of opposite parties from 2002 onwards.  Ext.A4 shows that complainant has undergone treatment for varicose veins with venous ulcer left leg during the Ext.A3 policy period.  Ext.A5 shows the complainant had paid Rs.23,146/- for hospital treatment.  It is pertinent to note that Ext.A4 does not show that complainant had pre-existing disease.

            12. As per Ext.A3 policy, a contractual obligation reposed upon the opposite parties to pay valid claim.  The non-payment of claim amount by opposite parties is not only a breach of contract but also a clear deficiency of service.  Opposite parties failed to adduce any evidence to prove that complainant had pre-existing disease.  Available evidence on record shows that complainant’s claim is valid and just.  Therefore, complainant’s case proved beyond any doubt.  It is the boundan duty of opposite parties to pay the claim amount.  Hence we are of the view that this complaint is allowable in respect of A5 treatment expenses with interest and cost.  The other reliefs such as cost of calls, notice, etc. cannot be allowed in the absence any evidence to that effect.  Since interest is allowed from the date of filing of the complaint separate compensation is not allowable.

            13. In the result, complaint is allowed thereby the complainant is allowed to realise an amount of Rs.23,146/- (Rupees Twenty three thousand one hundred and forty six only)with interest at the rate of 9% per annum from the date of filing of this complaint till this date, along with the cost of Rs.1,000/- (Rupees One thousand only) from the opposite parties.  The opposite parties are directed to pay the aforesaid amount to the complainant within 30 days from the date of receipt of this order failing which interest will follow at the rate of 12% per annum till the realisation of the whole payment.

            Declared in the Open Forum on this the 1^st day of February, 2010.

                                                                                                                    (Sd/-)

                                                                                                            N. Premkumar,

                                                                                                                  (Member)

Sri. Jacob Stephen (President)                    :           (Sd/-)

Smt. C. Lathika Bhai (Member)                  :           (Sd/-)

Appendix:

Witness examined on the side of the complainant:

PW1    :  Rachel Alex

Exhibits marked on the side of the complainant:

A1       :  Mediclaim Policy Certificate issued by the opposite parties for the period from              

                8.10.2002 to 7.10.2003 to the complainant. 

A2       :  Receipt of premium amount dated 8.10.2002 for Rs.1,548/- issued by the opposite 

               parties to the complainant.

A3       :  Policy certificate during the year 2003-2004 issued by the opposite parties

               to the complainant. 

A4       :  Photocopy of the discharge summary issued by Muthoot Medical Centre to 

               the complainant. 

A5       : Photocopy of bill dated 17.8.2005 for Rs.23,146/-issued by Muthoot Medical 

              Centre, Kozhencherry to the complainant.

Witness examined on the side of the opposite parties: 

DW1   :  Jacob Varghese

Exhibits marked on the side of the opposite parties:  Nil.

                                                                                                            (By Order)

                                                                                                  Senior Superintendent.

Copy to:-  (1) Rachel Alex, Palliparampil House, Thelliyoor P.O.,

                        Vennikulam, Pathanamthitta

(2)   The General Manager, National Insurance Company Ltd.,

            Branch Office, Post Box No.37, Ennakattil Estate, M.C. Road,

            Thiruvalla, Pathanamthitta.

(3)   Baby Tharayil, Tharamel House, Puramattom P.O., Pathanamthitta.

(4) The General Manager/Manager, National Insurance Co. Ltd.,

                       Divisional Office, P.B. No.434, Vazhuthacaud, Thiruvananthapuram – 14.

                  (5) The Stock File.