The Manager,United Insurance Ltd V/S Abraham Neyyarappally
Abraham Neyyarappally filed a consumer case on 16 Apr 2008 against The Manager,United Insurance Ltd in the Alappuzha Consumer Court. The case no is CC/27/2006 and the judgment uploaded on 30 Nov -0001.
1. JIMMY KORAH 2. K.Anirudhan 3. Smt;Shajitha Beevi
Complainant(s)/Appellant(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
ORDER
SRI. JIMMY KORAH (PRESIDENT) The case of the complainants is that they are medi claim policy holders of the opposite party for the last 12 years without any brake. The family members of the petitioners were insured under hospitalization and domiciliary hospitalization and benefit policy. The period of policy of the policy subjected to this complaint is from 31.7.2004 to 30.7.2005. The case of the complainants is that the 2nd complainant admitted in hospital on two different occasions for the disease rheumatoid arthritis ie., from 10.2.2005 to 12.2.2005 and 28.9.2005 to 30.9.2005. The treatment was done by Dr.V.Venugopal in Krishna hospital, Cochin. And the 1st complainant involved in an accident on 20.12.2004 and in consequences of that he was treated at SV Hospital, Cherthala and he had taken bed rest for 8 weeks. Against these deceases and accident the complainants preferred a claim application before the opposite party. But the opposite party repudiated their claim. Against this repudiation complainants filed the present complaint. 2. Opposite appeared and filed version by taking following contentions. Complainants are medi claim policy holders from 11.7.1997 to 10.7.2003. Thereafter they taken the policy from 31.7.2003 and renewed the said policy up to 30.7.2005. The complainants have specifically stated in their proposal form that 2nd complainant is suffering from rheumatoid arthritis. The complainant is preferred the claim under this policy for the same decease ie. rheumatoid arthritis. Hence this is a pre-existing decease and it cannot be allowable as per the terms and conditions of the policy. With regard to the claim of the 1st complainant the counter of the opposite party is that he has not treated as inpatient and no evidence was produced for bed rest of 6 weeks. Hence this claim is also not allowable. Hence petition may be dismissed on the above said reasons. 3. Complainants given evidence and marked 27 documents. Opposite party adduced evidence and marked 27 documents. Documents are marked as Exts. A1 to A27 and Exts.B1 to B27 respectively. 4. Considering the contentions of the both parties this Forum framed following issues:- Whether any deficiency of service on the part of the opposite party, if so what is the relief to be allowed? 5. With regard to the claim of the 2nd complainant the reason for repudiation stated that, the 2nd complainant is suffering rheumatoid arthritis before taking the policy on 31.7.2003. It is true that complainant was a policy holder of the opposite party without any brake from 11.7.1997 to 10.7.2003. Thereafter the policy was renewed after a short brake ie. after 21 days. In the proposal form of the policy taken on 31.7.2003 it was specifically stated that she was under gone rheumatoid arthritis. The proposal form of the 2nd complainant was marked as Ext.B6. A similar nature of dispute was considered by the Honble National Consumer Disputes Redressal Commission in the decision of Oriented Insurance Co. Ltd. Vs. K. Anandam (III (2007) CPJ 450 (NC). In this decision policy was lapsed due to dishonouring of the cheque issued by the insured and there after the policy was renewed after a gap of 9 days. The Honble National Commission held that the new policy issued can be considered as only a fresh policy and the benefit under the existing policy will not get under the new policy. Hence the policy issued to the complainant cannot be considered as a continuing policy, but it is only a new policy. In the proposal form submitted by the applicant on 31.7.2003 it is specifically stated that she underwent treatment rheumatoid arthritis. As per the terms and conditions of the policy, clause 4.1 of the Ext.B4, it is specifically stated that All deceases/injuries which are pre-existing when the cover incepts for the 1st time are excluded. Hence the claim preferred for rheumatoid arthritis can be considered only as pre-existing disease and the repudiation of the opposite party on the claim of the 2nd complainant is justifiable. Counsel for the complainant submitted certain decisions. But these decisions are not applicable in this case. Hence there is no deficiency of services can be attributed to the opposite party for the said repudiation. With regard to the claim of the 1st complainant, the contention of the opposite party is that there is no evidence for his treatment as inpatient. As per the report of the private investigator of the company the accident claimed by the claimant is genuine and he sustained a fracture. But there is no evidence to substantiate that he was admitted as inpatient in SV Hospital on 28.12.2004. At the same time it can be seen that he was admitted at SV Hospital, Cherthala from 28.12.2004 to 2.1.2005. This fact can be revealed from Ext.A18 document ie. discharge summary card of 1st complainant. The opposite party has not taken any steps for impeaching the credibility of this document through summon the doctor who treated the patient. The proceedings in a CDRF is summary in nature and strict principle of Evidence Act is not applicable here. Hence there is a presumption in favour of the documents produced before the Forum. It is the duty of the party to disprove the document who challenges it. From the above discussion it can be seen that the 1st complainant sustained a fracture from an accident and he was treated at SV Hospital, Cherthala from 28.12.2004 to 2.1.2005. Apart from that clause 2.3 of Ext.B4 document shows that discharging a person on the same day can be considered under hospitalization benefit. The 1st complainant is a doctor working in ESI Hospital, Alappuzha. As per Section 53 of the ESI Act there is a specific bar for claiming, receive or recover compensation from any other person. The 1st complainant is an employee come within the purview of the ESI Act. Hence he can claim compensation only under ESI Act. Hence he is not entitled to get any benefit or compensation from the opposite party. The repudiation of the claim of the 1st complainant is also justifiable. We are appreciating the effort and pain taken by the counsel for the complainant for presenting the case. From the above discussion this Forum found that there is no merit in this complaint. Complaint dismissed. No order on cost. Pronounced in open Forum on this the 16th day of April, 2008. Sd/- SRI. JIMMY KORAH : Sd/- SRI. K. ANIRUDHAN : Sd/- SMT. N. SHAJITHA BEEVI : APPENDIX:- Evidence of the complainant:- PW1 - Dr.Abraham Neyyarappally (Witness) Ext.A1 - Photo copy of the family health plan card Ext.A2 - Photo copy of the policy schedule Ext.A3 - Letter dated 28.9.2005 (Photo copy) Ext.A4 - Letter dated 9.11.2005 (Photo copy) Ext.A5 - Letter dated 18.11.2005 (Photo copy) Ext.A6 - Application dated 22.10.2005 (Photo copy) Ext.A7 series - Cash bills (10 Nos.) (Photo copies) Ext.A8 - Revised medi-claim insurance policy (Photo copy) Ext.A9 - Annexure B (Photo copy) Ext.A10 - Medical Certificate Ext.A11 - Discharge treatment summary Ext.A12 - Letter dated 28.9.2005 Ext.A13 - Lab Report Ext.A14 - Prescription of Dr. Venugopal Ext.A15 series Cash bills (15 Nos,) (Photo copies) Ext.A16 - Personal Accident Insurance Medical report Ext.A17 - Medical Report Ext.A18 - Discharge Summary card Ext.A19 - Personal Accident Insurance Claim Form Ext.A20 - Application dated 17.8.2005 Ext.A21 - Casualty bill (Photo copy) Ext.A22 - Cash bill for Rs.1725/- (Photo copy) Ext.A23 - Statement of accounts (Photo copy) Ext.A24 - Application dated 3.7.2006 (Photo copy) Ext.A25 - Application dated 12.7.2006 (Photo copy) Ext.A26 - True copy of the letter 10.7.2006 Ext.A27 - Individual medi-claim policy (Photo copy) Evidence of the opposite party:- RW1 - Ashokan (Witness) Ext.B1 - Policy schedule Ext.B2 - Policy schedule Ext.B3 - Policy schedule Ext.B4 - Medi-claim Insurance Policy Ext.B5 - Medi-claim insurance proposal form Ext.B6 - Medi-claim insurance proposal form Ext.B7 - Medi-claim insurance proposal form Ext.B8 - Medi-claim insurance proposal form Ext.B9 - House holders insurance policy Ext.B10 - Medi-claim Insurance Policy claim form Ext.B11 - Photo copy of the Medical Report Ext.B12 - Certificate dated 12.2.2005 Ext.B13 - Certificate dated 14.10.2004 Ext.B14 - Certificate dated 11.5.2005 Ext.B15 - Letter dated 24.10.2005 Ext.B16 - Revised Medi-claim insurance policy Ext.B17 - Medical Certificate dated 30.9.2005 Ext.B18 - Personal accident insurance claim form Ext.B19 - Photo copy of the Medical Report Ext.B20 - Discharge summary card Ext.B21 - Cash bill for Rs.1725/- Ext.B22 - Casualty bill for Rs.110/- Ext.B23 - Hospital Card Ext.B24 - Letter dated 19.4.2005 Ext.B25 - Letter dated 18.10.2005 Ext.B26 - Letter dated January 13, 2006 Ext.B27 - Letter dated 20.2.2006 // True Copy // By Order Senior Superintendent To Complainant/Oppo. 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