Tamil Nadu

South Chennai

243/2005

K.Sivasankara Rao - Complainant(s)

Versus

The New India Assurance Co. Ltd - Opp.Party(s)

D.Subbaroyan

04 Dec 2017

ORDER

                                                                        Date of Filing :   12.11.2004

                                                                        Date of Order :   04.12.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

PRESENT: THIRU. M.MONY, B.Sc., L.L.B. M.L.,                     : PRESIDENT            

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

             DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

 

C.C.NO.243/2005

MONDAY THIS 4^TH DAY OF DECEMBER 2017

K. Sivasankara Rao,

F-1, B-Block, 2^nd Floor,

No.109, G.N. Chetty Road,

T.Nagar, Chennai 600 017.                        Complainant

 

                                        ..Vs..

 

The Branch Manager,

The New India Assurance Company

Limited, 58, Panthenon Road,

Egmore, Chennai 600 008.                         Opposite party.

 

Counsel for Complainant           :    M/s. D.Subbaroyan & others          

Counsel for opposite party        :    M/s. Elveera Ravindran & others    

ORDER

THIRU. M. MONY, PRESIDENT

This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act 1986 seeking direction to pay  a sum of Rs.42,371/- being the excess incurred in the hospital for the surgery and also to pay a sum of Rs.1,00,000/- towards compensation for mental agony and to pay cost of the complaint.

1. The averment of the complaint in brief are as follows:

         The complainant submit that  he has availed  medi claim policy for the period from 28.9.2001 to 27.9.2002.   On 3.1.2002 the complainant was admitted in Appollo Specialty Hospital, Chennai for a bilateral Hydrocele with banalities disease.  A  surgery was performed on 4.1.2002 by a team of Doctors in the said Hospital.   On 6.1.2002 the complainant was discharged from the hospital.   The policy duly covering the period of medical treatment namely 28.9.2001 to 27.9.2002 vide Policy No.712701/48/01/00814.   The complainant expended a sum of Rs.42,371/- towards such medical treatment.  On 18.1.2002 the complainant submitted the claim form with relevant document  as required by the opposite party claiming the said amount of Rs.42,371/-.  On 22.3.2002 the opposite party repudiated the claim stating the condition clause 4.1.    Hence the complainant is constrained to issue legal notice. But the opposite party has not sent any reply.     As such the act of  the opposite party amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.

2.    The brief averments in the Written Version filed by the  opposite party is  as follows:

 

      The  opposite party deny each and every allegations except those that are specifically admitted herein.   The opposite party submit that the said ailment does not appear overnight but is a gradual process.  Hence the complainant knowing that he had the said complaint had suppressed the said information which is a material fact in order to clandestinely cover his misfortune.    According to the investigation report it could be seen that the insured had obtained the above medical cover, by suppressing his medical condition, inspite of his knowledge for the same and which he ought to have disclosed to the opposite party at the time of proposal of the policy.    The reason for such disclosure is mandatory to afford the opposite party an opportunity to either reject the entire proposal or to accept the proposal with rejection of any claims connected with the said factors.   Hence it is clearly seen that the complainant knowing  his health condition willfully suppressed the said facts to illegally cover his treatment.    On the basis of the records available and on the application of mind to the facts and circumstances of the case this opposite party had chose to repudiate the claim vide letter dated 22.3.2002 clearly explaining the reason for the repudiation being that as per clause 4 (1) of the  policy the opposite party is not liable to pay any claim for the diseases that are pre existent.    Hence there is no deficiency in service on the part of the opposite party and the complaint is liable to be dismissed.

3.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A7 marked.  Proof affidavit of opposite party filed and Ex.B1 to Ex.B4 marked on the side of the  opposite party.

4.   The points for the consideration is: 

1. Whether the complainant is entitled a sum of Rs.42,371/- being the expenses incurred in the hospital for the surgery with interest  as prayed for?

 

2. Whether the complainant is entitled to a sum of Rs.10,00,000/- towards compensation for mental agony with cost as prayed for?

 

 

5.  POINTS 1 & 2 :   

        Oral arguments of opposite party heard.   The complainant after filing written arguments has not turned up to advance any oral arguments.   Perused the records (viz.) complaint, written version, proof affidavit and documents etc.    The complainant pleaded in the complaint and contended that he has availed a medi claim policy for the period from 28.9.2001 to 27.9.2002 is admitted.   On 3.1.2002 the complainant was admitted in Appollo Specialty Hospital, Chennai for a bilateral Hydrocele with banalities disease.  Due  surgery was performed on 4.1.2002 by a team of Doctors in the said Hospital.   On 18.1.2002 the complainant was discharged from the hospital.   Ex.A1 is the discharge summary.   The policy duly covering the period of medical treatment namely 28.9.2001 to 27.9.2002 vide Policy No.712701/48/01/00814 as per Ex.B2.   The complainant expended a sum of Rs.42,371/- towards such medical treatment on 18.1.2002 the complainant submitted the claim form with relevant documents as regard by the opposite party claiming the said amount of Rs.42,371/- as per Ex.A3.  Ex.A2 is the inpatient final bill.  On 22.3.2002 the opposite party repudiated the claim stating the policy condition in clause 4.1. as per Ex.A4.    Hence the complainant is constrained to issue legal notice Ex.A5.  The opposite party has not sent any reply.  Thereafter the complainant filed this complaint claiming a sum of Rs.42,371/- being the expenses incurred for treatment with interest  and also to pay a sum of Rs.1,00,000/- as compensation for mental agony with cost for the deficiency in service of the opposite party.

6.     The learned counsel for the opposite party contended that admittedly the complainant availed the medi claim policy and the policy is covered on the date of treatment.   The policy is only for Rs.3,00,000/-.  After receipt of the claim form with the relevant  documents the opposite party appointed an investigator; who has investigated the case and reported that “ the complainant  has suppressed the ailment of Diabetes Mellitus (NIDDM) for 15 years, a known smoker of 30 cigarettes per day for last 30 years, with occasional consumption of Alcohol.   It was also observed that the patient is a known Hypercholesterolemia with family history of Hypertension  as per Ex.B3.  The learned counsel for the opposite party further contended that as per the discharge summary Ex.A1 it is very clear that the complainant  was aged 45 years old,  Vital stable Bilateral Hyorocele present left bigger than right proves that the complainant is a known Diabetic patient who suppressed the fact is not denied by the complainant in this case.  As per Medical Insurance policy condition in Clause 4.1. is as follows:

“All injuries / diseases which are pre existing when the cover inspects for the first time.”

Hence the  opposite party rightly repudiated the claim as per Ex.A4.  Considering the facts and circumstances of the case this forum is of the considered view that the  complainant is not entitled for any relief as prayed for in the complaint and the point is answered accordingly.         

In the result the complaint is dismissed.  No cost.

Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the  4^th     day  of  December  2017. 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents

Ex.A1  6.1.2002   - Copy of discharge summary.

Ex.A2  6.1.2002    - Copy of inpatient final bill.

Ex.A3  18.1.2002  - Copy of attending doctors report.

Ex.A4  22.3.2002  - Copy of letter of repudiation.

Ex.A5  29.12.2003         - Copy of legal notice.

Ex.A6  12.8.2004  - Copy of legal notice.

Ex.A7  17.8.2004  - Copy of Ack.

Opposite parties’ side document: -     

Ex.B1 28.9.1999  -  Copy of Proposal form signed by the complainant.

Ex.B2-              -  Copy of policy of insurance along with terms and

                               conditions.

Ex.B3  26.11.2002         -  Copy of investigation report

Ex.B4  31.3.2002  -  Copy of medical opinion.

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.