Date of Filing : 03.06.2011
Date of Order : 21.01.2012
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 21st day of January 2012
PRESENT
Sri. S.S. NAGARALE, B.A., LL.B. (SPL) …. President
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 1021/ 2011
Sri.K.Ravi,
S/o.late.Kannan,
Aged about 53 years,
No.150, 5th Cross,
Vivekanagar,
Bangalore 560 047. ……. Complainant
V/s.
1. The Manager,
Reliance General Insurance Co. Ltd.,
No.28, East Wing, 5th Floor,
Centenary Building,
M.G.Road,
Bangalore 560 001.
2. The Manager,
Medi Assist India TPA Pvt LTd.,
No.797, Annapooma, 10th Main,
4th Block, Jayanagar,
Bangalore 560 011. …… Opposite Parties
ORDER
(By the President Sri. S.S. Nagarale)
This Complaint is filed by the Complainant u/s. 12 of the Consumer Protection Act, 1986 seeking the relief that OP be directed to pay Rs.42,644/- along with interest.
1. Brief facts of the Complainant is that, the complainant had obtained a medi-claim policy from the OP on 03.09.2007 and it was in force. On 11.02.2009 the complainant was admitted to St.Philomena Hospital and was diagnosed as Hypertrophied Inferior Turbinates and underwent bilateral partial inferior ternectomy and discharged on 14.02.2009 and paid Rs.22,644/- to the hospital authorities. In this regard the complainant made claim with the OPs. But the OPs on 03.03.2009 have repudiated the claim alleging that this is pre existing disease which is untenable one. Hence the claim.
2. OP2 though served notice remained absent. In brief the version of the OPs are the medi-claim policy, its validity, the complainants claim regarding treatment, his claim with the OP and repudiation are all admitted. There is no deficiency in service.
3. The complainant has filed a memo stating that the complaint and documents be read as its evidence and OP has filed its affidavit. Heard the arguments.
4. Points that arise for our consideration are:
A) Whether the repudiation of the claim by the OP is amounts to deficiency in service?
B) What order ?
5. Our answers to A & B are as per the order for the following
REASONS
6. Reading the pleadings in conjunction with the affidavits and documents on record, it is an admitted fact that the complainant is having a medi-claim policy obtained from the OP. It was valid during the period in question. This is also an admitted fact that the complainant on 11.02.2009 was admitted to St.Philomena Hospital, with the history of bilateral partial inferior ternectomy since six months and surgery was done on 12.02.2009 and he was discharged on 14.02.2009. The complainant had paid a sum of Rs.22,644/- in this regard. The complainant made claim with the OP in this regard who repudiated the claim on the ground that none disclosure of pre existing disease. This is challenged before this forum. The discharge summary issued by the St.Philomena Hospital simply states that the complainant was admitted on 11.02.2009. There was history of bilateral partial inferior ternectomy since six months, he underwent bilateral partial inferior ternectomy surgery and discharged on 14.02.2009 which does not say that the complainant had pre existing disease earlier to the date of policy. No doctor has examined by the OP to show that this problem was earlier to the date of policy was not disclosed.
7. Further in a case between National Insurance company Limited –vs- Rajan Kumar and another reported in IV (2011) CPJ 11 ruled thus:
Consumer Protection Act, 1986-Sections 2(1)(g), 2(1)®,14(1)(d),15-Medi-claim-Pre-existing disease-claim repudiated-Forum allowed complaint-Hence appeal-Contention, life assured concealed her disease in proposal form and also disease suffered by her was not covered under policy-Not accepted-Opinion of doctor is not sufficient that disease existed prior to date of obtaining policy but Insurance Company has to prove that life assured was in full knowledge of disease having been suffered by her-Not a case of suppression or any fraud-Insurance Company liable to pay expenses incurred by complainant on treatment.”
That means to say the OP must show that the complainant knows that he had disease earlier to the date of policy, even that he had not disclosed it. In this case there is no such plea, there is no such material, nor there is any evidence in this regard. The complainant never knows that he had this problem earlier to the date of the policy, hence how can he disclose. Repudiating is nothing but deficiency in service. Hence under these circumstances we hold the above points accordingly and pass the following
ORDER
Complaint is allowed in part.
OPs are directed to pay Rs.22,644/- together with interest at 12% per annum from 14.02.2009 until payment within 30 days from the date of this order.
The complainant is also entitled for Rs.2,000/- as cost of the present litigation from the OP.
OP is directed to send the above ordered amount by way of DD/cheque directly to the complainant with intimation to the forum.
Send copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 21st day of January 2012.
Order accordingly
PRESIDENT
I concur the above findings
MEMBER
