<br /> COMPLAINT FILED: 25.08.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 06th NOVEMBER 2008<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.1874/2008<br /> <br /> <br /> COMPLAINANTS 1. Sri.Narayan,S/o D.K.Abbaiah,Aged about 66 years.2. Smt.Lalitha,W/o A.Narayan,Age 53 years.Both are residing atNo.49, 5th Cross,Wilson Garden,Bangalore.Advocate – Sri.H.R.Anantha KrishnamurthyV/s.<br /> OPPOSITE PARTIES 1. The National Insurance Company (Ltd.,)Office: No.1, 3rd Floor,Unity Building,Mission Road,Bangalore.Represented by its Manager.2. VIPUL MEDCORP PVT. Ltd.No.154, 2nd Floor,Mallige Complex,K.H.B Colony,5th Block, Koramangala,Bangalore – 560 095.Represented by its Manager.Advocate – Sri.S.Srishail<br /> <br /> <br /> O R D E R<br /> <br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the claim towards medical expenses incurred by the complainant and pay a compensation of Rs.2,00,000/- towards mental agony on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> <br /> Complainants are covered under the Mediclaim Family Floater policy issued by the OP, which is valid from 28th June 2008 to 27th June 2009. Complainant No.2 is the wife of complainant No.1. OP.2 is authorized by OP.1 who act as a service provider. Complainant No.2 fell sick and approached Bangalore Institute of Oncology for treatment. On examination she was advised to under go UltraSonography and CT Scan. She underwent for the said test on 28.06.2008. The scan report is dated 08.07.2007 disclosed “metastatic adenocarcinoma”. She under went treatment for the same before that she requested OP.2 to provide cashless facility. Unfortunately it was rejected by the OP.2 on 12.07.2008. Then complainants were forced to pay the medical expenses of Rs.56,701/-. Thereafter made claim to the OP. Unfortunately OP repudiated the said claim on the ground that the treatment is taken for the pre existing disease. The said repudiation is unjust and improper. For no fault of the complainants they were made to suffer both mental agony and financial loss. When their repeated requests and demands went in futile they felt deficiency in service on the part of the OP. Under the circumstances they are advised to file this complaint and sought for the reliefs accordingly.<br /> <br /> 2. On appearance, OP.1 filed the version denying all the allegations made by the complainant in toto. Of course OP.2 remained ex-parte. It is contended by the OP.1 that the claim made by the complainant towards the medical expenses refers to the pre existing disease. Though complainant was aware of the said disease, it was not disclosed at the time of renewal of policy. So there is a suppression of material facts. Metastatic adenocarcinoma a liver disease cannot occur within a month or two. Complainant though knowing very well about the said disease did not narrate the same. Hence they have not approached the Forum with clean hands. The repudiation made by the OP is just and proper. The other allegations in the complaint are all baseless. There is no deficiency in service on the part of the OP. Among these grounds, OP.1 prayed for the dismissal of the complaint.<br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainants have Proved <br /> the deficiency in service on the part of <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainants are <br /> entitled for the relief’s now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainants are covered under the Mediclaim Family Floater policy issued by the OP.1 which is in force from 28.06.2008 to 27.06.2009. It is also not at dispute on the earlier occasion when complainant No.2 took the treatment and made claim of the medical expenses it was honored by the OP. Now as contended by the OP themselves that the present policy is only a renewal policy. Though complainants are aware of the fact that the treatment taken by the complainant No.2 is for the pre existing disease still suppressed it. The fact that complainants are regular in making payment of premium is not at dispute. Before issuance of policy she was subjected to medical examination is also not at dispute. When that is so, the defence of the OP appears to be defence for defence sake.<br /> <br /> 7. According to the complainant when she felt the abdominal pain she approached Bangalore Institute of Oncology she was referred to UltraSonography and CT Scan and it was diagnosed that she is suffering from “metastatic adenocarcinoma”. For that she has taken the treatment. If the OP is of the view that the said disease is a pre existing disease and complainant has taken treatment for the same on the earlier occasion then they would have produced certain records and documents to that effect. But no such documents or records are produced. Whether complainant No.2 was aware of the said disease prior to 28.06.2008 is not known. That fact of knowledge is not established by OP. Hence for this simple reason the contention of the OP that complainant has suppressed certain material facts which are well within her knowledge rather does not hold much force.<br /> <br /> 8. The fact that the complainant has spent Rs.56,701/- for the treatment is also not at dispute. Having considered all these facts and circumstances the repudiation made by the OP appears to be unjust and improper. Complainants for no fault of theirs were made to suffer both mental agony and financial loss. The defence of the OP that the claim of the complainant come under the exclusion clause.4 does not find the base. We are satisfied that complainant is able to prove the deficiency in service on the part of the OP. Hence they are entitled for the relief to some extent. With these reasons we answer point Nos.1 & 2 accordingly and proceed to pass the following:<br /> <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP is directed to settle the claim for Rs.56,701/- and pay the same along with a compensation of Rs.5,000/- within four weeks from the date of communication of this order and also pay a litigation cost of Rs.1,000/-.<br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 06th day of November 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />