Date of Filing:13.06.2008<br /> Date of Order:13.02.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> <br /> Dated: 13TH DAY OF FEBRUARY 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> COMPLAINT NO: 1318 OF 2008<br /> <br /> T.R. Deepak<br /> S/o. T.S. Rajashekar<br /> R/at No. 531, 5th Main Road<br /> Kengeri Satellite Town<br /> Bangalore 560 060 Complainant<br /> <br /> V/S<br /> <br /> The New India Assurance Co. Ltd.<br /> (D.O-V) No. 9, Infantry Road<br /> Bangalore 560 001 Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act 1986. <br /> The facts of the case are that complainant has taken mediclaim policy for himself and his family members. Complainant under went Cardiac checkup with Dr. Devi Shetty’s Narayana Hrudayalaya on 22.08.2007. They advised to undergo operation immediately. Complainant informed the expenses incurred to the Paramount Health Services Ltd. He got reply on 25.08.2007 denying cashless benefit. Complainant is working for Private Co. and he had continuity of mediclaim policy for 3 consecutive years and he paid premium. Complainant arranged loan for the operation and under went final diagnosis on 27.08.2007 and discharged from hospital on 29.08.2007 on medication advice and to get admit on 03.09.2007 to undergo surgery. Complainant under went surgery on 06.09.2007 and got discharged on 14.09.2007. Complainant submitted original papers on 04.10.2007 to the Paramount Health Service with claim form claiming Rs. 1,88,672/-. Paramount Health Services Pvt. Ltd. rejected his claim by letter dated 02.01.2008 stating that as per policy clause 4.1 preexisting disease are excluded. Complainant submitted that he came to know about the disease on 25.03.2007 when he went for treatment in Ragavs Diagnostic & Research Centre Pvt. Ltd., Bangalore. The disease suffered by the complainant was not pre-existing. Complainant paid the amount for 3 consecutive years and 4th renewal was done. On 15.12.2007 the bonus amount of Rs. 1,250/- was not paid to the complainant. Therefore, the complainant has prayed that opposite party may be directed to pay Rs. 1,88,672/- medical expenses and Rs. 11,250/- bonus amount.<br /> 2. Notice issued to opposite party. Opposite party put in appearance through advocate and defence version filed stating that complainant is the policy holder of opposite party company from 2004. Complainant has been renewing the same. Complainant submitted claim on 04.07.2007 for Rs. 1,88,672/-. Paramount Health Services repudiated the claim. On receiving repudiation letter the complainant approached the present opposite party vide letter dated 21.11.2007 and requested opposite party to reprocess the claim. On scrutinizing the papers by this opposite party’s expert it is opined that Aerotic Value disease and Mitral Value disease are not congenital in origin but acquired secondary to Rheumatic fever in childhood. Based on the above opinion the company consented for the repudiation decision taken by M/s. Paramount Health Services Pvt. Ltd. and expressed inability to consider the claim. Hence, opposite party prayed to dismiss the complaint.<br /> 3. Affidavit evidences are filed.<br /> 4. Arguments are heard.<br /> 5. The points for consideration are:<br /> “1. Whether the repudiation of the claim by the opposite party is justified?<br /> 2. Whether the complainant is entitled for the insurance amount?”<br /> 6. It is admitted case of the opposite party that complainant is a policy holder of opposite party company from 2004 and he has been continuously renewing the policy. The relevant policy No. is 670500/48/06/20/70000480. This policy covers a period from 15.12.2006 to 14.12.2007. The sum assured is Rs. 75,000/- for the complainant. The complainant submitted that he under went cardiac checkup at Narayan Hrudayalaya on 22.08.2007 and the doctors advised to go for operation immediately. The complainant informed the matter to the Paramount Health Services Pvt. Ltd. and sought for cashless benefit. The same was denied to him. He arranged through loan for the operation and underwent a final diagnosis on 27.08.2007 and he was admitted to the hospital on 03.09.2007 and he under went surgery on 06.09.2007 and discharged on 14.09.2007. The complainant submitted all the original papers connected to his hospitalization along with claim form claiming Rs. 1,88,672/- to the opposite party. The claim was rejected as per the policy clause 4.1 on the ground pre-existing diseases are excluded from the scope of the policy. Hence, the claim was treated as no claim. It is the case of the complainant that he has taken policy for continuous 3 consecutive years without any break and 4th renewal was also done. The policy being continued till 14.12.2008. The only defence taken by the opposite party is that the disease Aortic Stenosis Severe was a pre-existing disease which the complainant would have been suffering from prior to taking the first policy from the opposite party. The Paramount Health Services repudiated the claim. The complainant approached the present opposite party and requested the opposite party to reprocess the claim. Opposite party submitted that on scrutinizing papers by the opposite party’s experts it is opined that Aerotic Value Disease and Mitral Value Disease are secondary to Rheumatic Fever in child hood. Based on the above opinion company consented for repudiation decision taken by Paramount Health Services. It is not the case of the opposite party that complainant had known the existence of disease or any symptoms of disease thereof at the time of making claim in insurance company. The complainant has admittedly taken insurance policy right from 2004 and he was continuously renewing policy without any break. The discharge summary of Narayana Hrudayalaya stated the disease suffered by the complainant was pre-existing. In the history of present illness it is stated presented with h/o breathlessness since 1 year. No palpitation/giddiness/ syncope. In the previous history the discharge summary mentions as under:<br /> “CAG done here on 27/08/2007 revealed RHD-severe AS, mild MR, severe AR, normal coronaries. Normal LV systolic function.”<br /> 7. In the family history “nothing Significant” is mentioned. The complainant was operated on 06.09.2007. Diagnosis reveals moderate aortic stenosis, severe aortic regurgitation, sinus rhythm. By looking into the medical papers and discharge summary of Narayana Hrudayalaya there is nothing to suggest that complainant’s disease was a pre-existing one. The opposite party has submitted in the defence version that on scrutinizing the papers by the opposite party’s experts the claim has been repudiated. But the opposite party has not produced the expert opinion before this forum. The opposite party has not even given the name of experts who had scrutinized the medical papers. The opposite party has not even produced affidavit of the doctors or experts in support of their defence. Therefore, the defence of the opposite party that claim is not admissible under clause 4.1 of the policy condition cannot be accepted at all. The opposite party has completely failed to establish that the disease which the complainant had undergone for operation and treatment was pre-existing disease. The complainant has admittedly taken treatment and undergone operation in the Narayana Hrudayalaya and he has put up his claim since he had availed mediclaim insurance policy. It is for the opposite party to establish by producing proper legal and acceptable evidence as to how the claim is not admissible. In this case the opposite party has failed to establish its defence. Therefore, the complainant is entitled for insured amount. As per the relevant policy it is for the period from 15.12.2006 to 14.12.2007. The sum assured for the complainant is for Rs. 75,000/-. Therefore, the opposite party shall have to be directed to pay sum assured to the complainant though the complainant has submitted claim for Rs. 1,88,672/-. Taking into consideration of all the documents and papers in the defence version and arguments I am of the opinion that it is just, fair, proper and reasonable to direct the opposite party to pay Rs. 75,000/- sum assured to the complainant. Consumer Protection Act is a social and benevolent legislation intended to protect better interests of the consumers. The opposite party is an insurance company cannot repudiate the valid claim of the complainant by taking technical defence. The opposite party having failed to establish the defence is bound to pay the insured sum to the complainant. In the result I proceed to pass the following:<br /> ORDER<br /> <br /> 8. The Complaint is partly allowed. The opposite party is directed to pay Rs. 75,000/- to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within 30 days the above amount carries interest at 12% p.a. from the date of this order till payment / realization.<br /> 9. The complainant is entitled for Rs. 2,000/- towards costs of the present proceedings from the opposite party.<br /> 10. Send the copy of this Order to both the parties free of costs immediately. <br /> 11. Pronounced in the Open Forum on this 13TH DAY OF FEBRUARY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br />