DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD<br /> <br /> Dated this the 16th day of July 2007.<br /> <br /> Present : Prof.O.Unnikrishnan, Member<br /> Smt.K.P.Suma, Member<br /> <br /> <br /> C.C.No.91/2006,<br /> <br /> <br /> Rajan.K.<br /> ' Lakshmi '<br /> Kuthanoor (P.O)<br /> Palakkad. - Complainant<br /> <br /> V/s<br /> 1. The Senior Branch Manager<br /> National Insurance Co., Ltd<br /> City Branch, Ambika Arcade<br /> M.G. Road<br /> Thrissur – 1.<br /> 2. The Branch Manager<br /> National Insurance Co. Ltd<br /> East Fort Complex<br /> Palakkad. - Opposite party <br /> <br /> ORDER<br /> <br /> By Prof. O. Unnikrishnan, Member<br /> <br /> <br /> The complainant in this complaint states that he took a Jana Seva Insurance Mediclaim policy for an amount of Rs.20,000/- from an authorized lady agent on 19.02.2002. The complainant says that he was 63 years then. The policy period was from 19.02.2002 to 18.02.2007.<br /> <br /> The complainant submits that he had ensured by the opposite parties that he had no pre-existing health problems at the time of issuing the policy. <br /> - 2 -<br /> <br /> But unfortunately, during the month of Oct-Nov 2005, the complainant suffered from Hernia and was admitted in West Fort Hospital, Thrissur and did a surgery, was discharged on 09.12.05 . After discharge and getting back to normal health condition the complainant made a claim with the opposite party on 29.12.2005 by enclosing all the documents including Bills, discharge certificate, medical report, claim form and intimation.<br /> <br /> The complainant with much feelings express in his allegation that on 15.03.2006, he received a letter form the opposite party rejecting the claim and stating that the investigation report shows that the complainant had ailment even before taking the insurance and was shocked to receive this communication. The complainant denies the fact that he had health problems at the time of taking the insurance. The complainant says that the problems of hernia developed during 2005 and no basis for the opposite party to reject his claim. The opposite party are only trying to misuse the fund taken from the complainant for the insurance and evading from making payment on baseless grounds.<br /> <br /> The complainant further submits that the medical report and discharge records issued by Dr. Varghese C.J shows that he had hernia only during October 2005 and not before that. So there is absolutely no basis for the opposite party to reject the claim of him. The denial of the claim amount of him by the opposite party amounts to unfair trade practice and deficiency in service.<br /> <br /> Hence the complainant prays before this forum for the realization of an amount of Rs.54,825.59 & a sum of Rs.25,000/- for unfair trade practice and <br /> - 3 -<br /> Rs,2,500/- towards the cost of this petition.<br /> <br /> After admitting the complaint, notice was served to the opposite party for their appearance before the Forum. Opposite party appeared and filed the version.<br /> <br /> The opposite party in his version denies all allegations submitted in the complaint and states that the group personal accident policy No.570704/2001/8204521 were issued to M/s. Janaseva Foundations, Thrissur as per this policy 16 persons were covered under mediclaim and not issued any policy to the complainant in the above case. The opposite party express that the complaint is bad for non-joinder.<br /> <br /> The opposite party states that they have not engaged any lady agent as stated by the complainant. While issuing the policy of Janaseva Foundations <br /> there is no such practice to find out the pre-illness of the proposed. It is purely based on the declaration given by the individual.<br /> <br /> The opposite party in his allegation submits that on receipt of the claim petition from the complainant they deputed an investigator to investigate the genuiness of the claim. The complainant had deposed before the investigator on 15.02.06 that he had the hernia more than five years. Hence the claim of the complainant has been repudiated only after verification, investigation and application of mind, since the complainant had hernia five years ago and he has suppressed the material facts during the time of getting insured. <br /> <br /> <br /> - 4 -<br /> The opposite party states that the complainant is not entitled to get any relief as prayed since he has made deliberate attempt to defraud the insurance company by suppressing the material facts that he had contracted the decease much before submitting the proposal form for mediclaim insurance.<br /> <br /> The opposite party prays before this forum that the forum may be please to pass an order to dismiss this case as there was no deficiency in service from the opposite party and this complaint is false and frivolous.<br /> <br /> Complainant and opposite party filed proof affidavits. Complainant filed no answers to the questionaire of opposite party. Exhibits B1 to B4 was marked from the part of opposite party. Evidence closed.<br /> <br /> Heard both the parties <br /> <br /> We have perused the relevant documents produced before the forum. The contention of the opposite party is that the claim of the complainant was repudiated based up on the investigation report of the investigation officer. The existing illness had admitted by the petitioner and deposed before the investigator. <br /> <br /> The investigation report along with the deposition of the complainant is also produced before the forum in which it is evident that the complainant was suffering from the said disease for the last five years and is undergoing treatment by one Dr. Rajagopal at Palakkad. Hence we are of the view that the repudiation of opposite party as per Clause 4.1 of the policy is genuine and cannot be attributed as deficiency of service on their part.<br /> - 5 -<br /> In the above circumstances, the complaint is dismissed with no order as to costs.<br /> <br /> Pronounced in the open court on this the 16th day of July, 2007<br /> Member (SD)<br /> <br /> Member (SD)<br /> <br /> APPENDIX<br /> Exhibits marked on the side of the complainant<br /> Nil<br /> <br /> Exhibits marked on the side of the Opposite Party<br /> Ext.B1 – Claim processing form <br /> Ext.B2 – Policy with terms and conditions <br /> Ext.B3 – Discharge certificate from West Fort Hospital<br /> Ext. B4- Medical Certificate<br /> <br /> <br /> Forwarded/By Order,<br /> Sd/-<br /> Senior Superintendent<br /> <br /> <br /> <br /> <br />