COMPLAINT FILED: 28-08-2009 <br /> DISPOSED ON: 23-06-2010<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> DATED THIS THE 23RD JUNE 2010<br /> <br /> PRESENT :-SRI. B.S.REDDY PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> COMPLAINT NO.2095/2009<br /> <br /> <br /> COMPLAINANT <br /> <br /> Sri. Atul.K.Alur,<br /> S/o.Late KrishnaRao Alur,<br /> Age:45 Years, Occ:Advocate,<br /> R/o. No.146 F-6,<br /> 2nd Main, 2nd Stage,<br /> Gruhalaxmi HBCS Layout,<br /> Kamalanagar,<br /> Bangalore-79.<br /> <br /> Advocate Smt.J.Tejavathi, <br /> <br /> V/s.<br /> <br /> OPPOSITE PARTIES 1. United India Insurance <br /> Co., Ltd.,<br /> No.366/72, 19th Main, <br /> I Block,<br /> Rajajinagar, <br /> Bangalore-10.<br /> <br /> Advocate Sri.S.Maheswara<br /> <br /> 2. E-Meditek Solutions Ltd.,<br /> Dickenson Road,<br /> Bangalore-42. <br /> <br /> Ex-parte<br /> <br /> <br /> <br /> <br /> <br /> O R D E R<br /> <br /> <br /> SMT. M. YASHODHAMMA, MEMBER <br /> <br /> <br /> This is the complaint filed u/s.12 of the C.P. Act of 1986 by the complainant seeking direction against OP 1 & 2 to pay Rs.24,325/- with interest at 24% p.a. and compensation of Rs.25,000/- towards mental agony and harassment with costs on the allegation of deficiency in service. <br /> <br /> The brief averments made in the complaint are as follows:<br /> <br /> 2. Complainant has obtained Individual Mediclaim Insurance Policy for a total sum of Rs.3.5 lakhs from OP-1 for himself as well as his family members. The policy bearing No.071603/48/07/20/00000124, the same was got renewed up to midnight 16-06-2009. In the month of October’ 2007 complainant suffered from fever and throat infection. After diagnosing him doctor, informed that he is suffering from paraumblical Hernia. Doctor advised for the operation. Complainant informed doctor that he is not having any problem relating to hernia. Complainant was given medicine for fever and throat infection. Doctors thinking that it may create some problem at the later stage, advised for operation. Complainant preferred to get operated in Christmas vacation. As per doctor’s advise. Complainant got admitted to the city hospital on 23-12-2007. Operation was conducted on 25-12-2007 by Dr.Sheshgiri Rao. The chetiderial was fixed for discharge of urine. After 5 days complainant returned to hospital for removal of the chetiderial. Doctor advised 15 days bed rest. Complainant claimed medical reimbursement from the OP. On 15-11-2008 OP-2 acknowledged for having received the documents, sought for production of policy for past two years i.e., 2005 to 2007. Complainant furnished two years policy on 25-06-2009. OP-2 replied that it is not liable to pay the claim amount as per clause 4.3 of the policy on the ground paraumblical hernia is a pre-existing decease and repudiated the claim. Hence complainant felt deficiency in service. Under these circumstances he is advised to file this complaint for the necessary reliefs. <br /> <br /> 3. OP-1 on appearance filed its version admitting the issuance of the Individual Mediclaim Policy in favour of the complainant and its liability is limited as per the terms of the policy. Further OP-1 admits the facts that the complainant was admitted to the hospital on 24-12-2007 and he was suffering from paraumblical hernia; got operated on 25-12-2007 and incurred expenses to the extent of Rs.24,325/-. OP-1 repudiated the claim of the complainant on 17.11.2008 as per clause 4.3 of the policy. As per clause 4.3 of the policy during the Ist year of the operation of the policy, the expenses on treatment of disease such as cataract, benign, prostotic, Hyperthrophy, Hysterectomy, Herina, congenital internal diseases etc., are not payable and same will be treated as pre-existing. If these disease are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing. Among other grounds OP-1 prayed for dismissal of the complaint. <br /> <br /> 4. Inspite of service of notice OP-2 remained absent without any sufficient reason or cause hence OP-2 is placed ex-parte. <br /> <br /> 5. In order to substantiate the complaint averments complainant filed his affidavit evidence and produced mediclaim health policy, premium paid receipts, discharge summary, reply of OP-2, letter of repudiation. On behalf of OP-1 its Assistant Manager, divisional Office, Malleshwaram Branch, Bangalore filed his affidavit evidence and terms of the policy and policy schedule. Then heard the arguments of both the parties.<br /> <br /> 6. 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 complainant has Proved <br /> the deficiency in service on the part of <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the relief’s now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 7. We have gone through the pleadings of the parties, both affidavit and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on the above points are:<br /> <br /> Point No.1:- Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> R E A S O N S<br /> <br /> 8. At the out set it is not in dispute that the complainant obtained Individual Medicalim Insurance policy from OP-1 for himself as well as for his family members. The said policy is bearing No.071603/38/07/20/00000124 and is in force up to midnight 16-06-2009. Further it is also not at dispute that in the month of October 2007 complainant suffered from fever and throat infection. After diagnosing doctor informed the complainant that he is suffering from paraumblical hernia and advised for the operation. Though complainant informed the doctor that he is not having any problem relating to hernia, doctor thinking that it may create some problem at the later stage, advised for operation. It is also not at dispute that on 23-12-2007 complainant got admitted to City Hospital and got operated for paraumblical hernia on 25.12.2007 by Dr.Sheshagiri Rao. Complainant was advised 15 days bed rest. Complainant claimed medical reimbursement of Rs.24,325/- from OP. OP-2 sought for production of policy for two years. Even after complainant sending policy for two years. OP-2 has not given any reply. Finally on 25-06-2009 OP-2 repudiated the claim as per clause 4.3 of the policy. <br /> <br /> 9. It is contended by the OP-1 that during the Ist year of the operation of the policy, the expenses on treatment on diseases such as cataract, benign, prostatic, Hernia etc are not payable. If these diseases are pre-existing at the time of proposal they will not be covered even after renewal if the insured is aware of the existence of the same before inception of policy; the same will be treated as pre-existing. This contention of the OP-1 cannot be accepted because policy inception date is 12-06-2006. The complainant has undergone operation on 25-12-2007. Complainant in his affidavit clearly denied the fact that he was having any knowledge or any problem relating to the hernia. Doctor in anticipation of any problem at the later stage has, advised for the operation. Burden of proving suppression of facts and pre-existing disease is on the OPs. The Op’s failed to discharge the burden. OPs have not produced any piece of evidence to show that complainant was suffering from hernia at the time of submitting the proposal or at the time of obtaining the policy. Repudiation of claim is unjust and improper.<br /> <br /> 10. When policy is in force, as per the terms of the policy complainant is entitled for reimbursement of medical expenses. Hence repudiation of claim by OP’s amounts to deficiency in service on the part of the OPs. We are satisfied that complainant has proved the deficiency in service against OPs. Under the circumstances complainant is entitled for reimbursement of medical expenses to the extent of Rs.24,325/- along with litigation cost of Rs.2,000/-. Accordingly we proceed to pass the following:<br /> <br /> O R D E R<br /> <br /> The complaint filed by the complainant is allowed in part. <br /> <br /> OPs are directed to settle the medical reimbursement claim for Rs.24,325/- to the complainant within 30 days from the date of communication of this order. Failing which complainant is entitled to claim interest at 12% P.A from the date of repudiation i.e., 17.11.2008 till the date of realization and pay litigation cost of Rs.2,000/-. <br /> <br /> Send copy of this order to both the parties free of costs. <br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by her verified and corrected, and then pronounced in the Open Court by us on this the 23rd day of June 2010.) <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> gm <br />