DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

Civil Station, Palakkad 678001, Kerala

Dated this the 27^th day of August, 2009

Present: Smt.Seena.H, President

Smt.Preetha.G.Nair, Member

Smt.Bhanumathi.A.K, Member

C.C.No.123/2008

Parvathy Amma,

67 years,

7/916, Vadukapalayam,

Kalpathy, Palakkad 678003. - Complainant

(By Adv.A.B.Prasad & K.V.Gopesh)

Vs

The National Insurance Company Ltd.,

East Fort Complex,

Fort Maidan,

3^rd Floor, Kunnathurmedu.P.O,

Palakkad. - Opposite party

(By Adv.A.Rajivijay Sankar)

O R D E R

By Smt.Preetha.G.Nair, Member

Complainant had taken the mediclaim policy with the opposite party in the year 2006 as per policy No.570705/48/06/8500000377 expiring on 14/07/07. The policy was renewed as per policy No. 570705/48/07/8500000454 for the period from 15/07/07 to 14/07/08. The complainant was admitted in the Kovai Medical Center and Hospital Ltd., Coimbatore on 09/07/08 due to coronary artery disease. The complainant had undergone heart surgery on 10/07/08. The complainant had spent more than Rs.1,25,000/- in the hospital. The complainant filed the claim petition for Rs.50,000/-. But the opposite party repudiated the claim stating that the complainant was diabetic and has got hypertension for the past 7 years. According to the complainant heart attack or unstable angina was not pre-existing before issuance of the policy. The complainant is an old lady and had incurred heavy loss due to the repudiation of the claim by the opposite party. The complainant is put to much hardship, difficulties, harassment due to the irresponsible and unfair

trade practice committed by the opposite party. Hence the complaint. The

complainant prays for an order directing the opposite party to pay an amount of Rs.1,25,000/- towards the medical expenses incurred and mental agony caused to the complainant.

2. The opposite party filed version stating the following contentions. The opposite party admitted that an Aroghya Bima policy was issued to the complainant on the basis of the individual declaration made by her for a sum of Rs.50,000/-. The complainant had undergone heart surgery on 10/07/08 and a claim form was submitted to the opposite party with her medical records. On going through the medical records it was found that the complainant was diabetic and was suffering from hypertension for the past 7 years. According to opposite party hypertension and diabetic were the main reasons for the illness and the policy was obtained without disclosing the existing illness. This amounts to fundamental breach and suppression of materials facts on the part of the insured. Hence the complaint is liable to be dismissed with cost.

3. Complainant was cross examined. Complainant filed affidavit along with documents. Ext.A1 to A4 marked on the side of complainant. Opposite party also filed affidavit with documents. Ext.B1 to B5 marked on the side of opposite party. Exts.B3 and B5 was marked subject to proof. Matter was heard.

4. Points to be considered are;

1. Whether there is any deficiency in service on the part of opposite party?

2. If so, what is the relief and cost?

5. Points 1 & 2:

The opposite party admitted that an Aroghya Bima policy was issued to the complainant for an insured sum of Rs.50,000/-. According to opposite party as per exclusion No.4.1 of the policy, all expenses incurred on disease/injuries which are preexisting when the cover incepts for the 1^st time are not payable. In Ext.B5,

the discharge summary issued from Kovai Medical Center & Hospital Ltd, under the head history it is stated that the complainant is a known diabetic/hypertensive

since 7 years. It is the settled position that a mere history given in the hospital ipso facto is of no consequence as history alone cannot be treated as valid grounds to repudiate a claim. Further as per Ext.A2, discharge summary, it is specifically stated that patient is suffering from effort angina and exertional dyspnea since February 2008. Complainant herein has renewed the policy in the year 2007. Hence it is clear that the said disease is not a preexisting one. Opposite party has not adduced any evidence to show that the insured was suffering from the said disease prior to the issuance of the policy, or having knowledge of the disease, has deliberately suppressed it prior to the issuance of the policy. Complainant while cross examined has also not deposed anything to show that she was diabetic and hypertensive for the past 7 years as alleged by the opposite party.

6. In the aforesaid facts and circumstances, we are of the view that opposite party failed to prove the preexisting disease of the complainant with cogent and convincing evidence and that the complainant has suppressed material facts in the proposal form.

7. In the result complaint allowed. We direct the opposite party to pay an amount of Rs.50,000/-(Rupees Fifty thousand only) being the claim amount and Rs.10,000/-(Rupees Ten thousand only) as compensation and Rs.1,000/-(Rupees One thousand only) cost to the complainant. The order shall be complied within one month from the date of receipt of this order failing the whole amount shall carry interest @ 9% p.a from the date of order till realisation.

8. Pronounced in the open court on this the 27^th day of August, 2009

Sd/-

Seena.H,

President

Sd/-

Preetha.G.Nair,

Member

Sd/-

Bhanumathi.A.K,

Member

Appendix

Witness examined on the side of complainant

PW1 – Mrs.Parvathi Amma

Witness examined on the side of opposite party

Nil

Exhibits marked on the side of complainant

Ext.A1 – Mediclaim policy

Ext.A2 (Series) – Discharge summary (7 in Nos)

Ext.A3 – Medical bill No.7615 dt.16/07/2008 issued by Kovai Medical Center and Hospital Ltd.

Ext.A4 – Letter dt.04/09/08 sent by opposite party to complainant

Exhibits marked on the side of opposite party

Ext.B1 – Copy of proposal form

Ext.B2 – Copy of policy

Ext.B3 – Medical certificate issued by Dr.V.Nandakumar

Ext.B4 – Letter dtd.31/07/2008 sent by complainant to TTK Health Care Services Pvt. Ltd.

Ext.B5 – Copy of Discharge summary

Costs (Allowed)

Rs.1,000/- (Rupees One thousand only) allowed as cost