State Consumer Disputes Redressal Commission
National Insurance Company Ltd. ... vs P.Govindarajulu Reddy And Another ... on 27 May, 2009
BEFORE THE A BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION : AT HYDERABAD. FA No.169/2006 against CD.No.43/2005 District Consumer Forum-I, Hyderabad. Between: National Insurance Company Ltd. 1st Floor, Jhaveri Mansion, Bank Street, Opp.Central Bank of India, Koti, Hyderabad. Appellant/Opp.Party. And 1.P.Govindarajulu Reddy, S/o.Perumallu Reddy, Aged about : 65 years, Occ: Sale Tax Practitioner, 2.Smt.P.Bharathi, W/o.P.Govindarajulu Reddy, Aged about 52 years, Occ: Housewife, R/o.Plot No.99, Navanirman Nagar, Road No.71, Jubilee Hills, Hyderabad 33. Respondents/Complainants 1 and 2. Counsel for the Appellant : Mr.P.Bhanu Prakash. Counsel for the Respondents : Mr.K.Yadagiri Reddy. QUORUM: THE HONBLE SRI JUSTICE D.APPA RAO, PRESIDENT, SMT.M.SHREESHA, MEMBER, AND SRI K.SATYANAND, MEMBER.
WEDNESDAY, THE TWENTY SEVENTH DAY OF MAY, TWO THOUSAND NINE.
Oral Order (Per Sri K.Satyanand, Honble Member) *******
1. This is an appeal filed by the opposite party Insurance Company assailing the order of the District Forum which directed the said company to pay to the complainants Rs.2,00,000/- with interest at the rate of 12% per annum from the date of repudiation till the date of filing of the complaint and thereafter at the rate of 9% per annum from the date of filing of the complaint till the date of realization along with costs of Rs.2,000/-.
The facts that led to filing this appeal are as follows:
2. The complainants are man and wife, who took a medi-claim policy from the opposite party to a maximum of Rs.2,00,000/- valid from 13.11.2000 to 12.11.2001 covering the medi claims in respect of both of the complainants. The complainants took a renewal policy for the subsequent year also valid from 13.11.2001 to 12.11.2002. In the last week of August, 2002, while the renewed policy was in vogue, the complainant No.2 fell down and developed severe pain in both her knees. She, therefore, consulted the doctors at Apollo Hospital. They advised her to join in the hospital as she had to undergo an operation.
Accordingly, the 2nd complainant took admission into the Apollo Hospital on 11.09.2002, where she underwent surgery for both the knees successively on 12.09.202 and 16.09.2002. She was finally discharged on 21.09.2002. For this treatment, complainant No.2 incurred a total expenditure of Rs.3,47,274/- Complainant No.1, therefore, addressed letter to the opposite party on 30.09.2002 intimating about the treatment and the proposed claim.
The opposite parties sent the forms and asked the complainant No.1 to file the claim along with the documents indicated. Accordingly, the complainants submitted the claim along with the documents. For some time the opposite parties remained silent without giving any response. The complainants, therefore, addressed a letter on 20.02.2003 with a request to settle the claim as early as possible. Ultimately, the opposite parties without considering the real facts addressed a letter dt.21.02.2003 stating that the claim had been repudiated on the ground of concealment. Aggrieved by the said repudiation, the complainants issued a legal notice. As the opposite party allegedly gave reply with untenable pleas saying that complainant No.2 was suffering with a pre-existing disease for the last five or ten years prior to the prayer thereof, as such the complainants filed the complaint.
3. The Insurance Company resisted the claim through a counter reiterating the grounds in the repudiation letter and reply to the legal notice and asserting that the complainants were guilty of concealment and that they had documents to that effect. As the rival pleadings disclosed a consumer dispute, the District Forum embarked upon an enquiry.
4. The complainants filed affidavit of complainant No1 and relied upon documents, marked as Exs.A.1 to A.35. The opposite party also filed an affidavit and relied upon documents, marked as Exs.B.1 to B.10.
5. On a consideration of the material brought on record, the District Forum gave a finding rejecting the plea of the opposite party that there was a pre-existing disease and the complainants were guilty of suppressing the information for obtaining an insurance policy.
Accordingly, the District Forum allowed the complaint and granted the relief.
6. Aggrieved by the said order, the opposite party preferred this appeal finding fault with the appreciation of evidence by the District Forum and its conclusions. It is first submitted that the District Forum did not apply its mind in passing the order when Ex.B.5 revealed that complainant No.2 was having pre-existing disease since five to ten years before taking medi-claim policy. It failed to see that as per Ex.A.7, a discharge summary of Apollo Hospital, it was clearly mentioned that the patient had been suffering from severe pain, swelling and stiffness of both joints prior to taking medi-claim policy. It failed to examine the documents filed by the appellant which would establish the fact that there was no deficiency. It failed to consider Clause No.4.5 of the medi-claim policy and finally it erred in granting interest, when the policy was silent regarding payment of interest.
7. Heard both sides. The point that arises for consideration is whether there are any good grounds to interfere with the finding and the order of the District Forum?
8. Obviously, the ailment in respect of which the complainants preferred the claim happened during the period when the medi-claim policy in question was valid. It is also clear from the record that the ailment/treatment and other facts are beyond controversy, but the repudiation was on the foot of a lone fact that the complainants suppressed the pre-existing disease of complainant No.2 which according to them was very much in existence even by the date of the policy.
This is an allegation made by the opposite party to substantiate the repudiation. It is therefore, apt to point out that the repudiation would stand or fall if only the opposite party is able to establish that there was such a pre-existing disease and the complainants deliberately suppressed it.
We have two confronting versions in the documentary evidence adduced by both sides. Dr.Jairamchander Pingles observation in Ex.A.7 indicated one version, while Dr.B.S.Reddys remark in Ex.B.5 indicated yet another version. In Ex,A.7 the following chief complaints were recorded:
Pain, swelling, stiffness of both knee joints since 1 year. Worsened since 6 months. Gradual onset pain both knee joints. Morning stiffness both hands and knees since 1 year.
Symptoms more for past 6 months.
Aggravated with left knee more painful than right knee, following a fall at home on 25.08.2002.
Ex.A.7 was issued on 21.09.2002 by way of discharge summary. The chief complaints set out supra would take us back only to 20th September, 2001 or 20th March, 2002 depending upon the complaint being prevalent since one year or six months as the narrated chief complaints in Ex.A.7 itself is equivocal as to the period of prevalence of the complaint.
It is pertinent to point out that even if there was any complaint since one year it was not prominent and it became prominent only six months before the date of discharge. By the date of discharge i.e. 21.09.2002 surely more than six months elapsed after the date of procurement of the insurance policy i.e 09.11.2001. It is not sufficient to simply rely upon a probable fact of the disease being in existence prior to the taking of the policy. It is also to be shown that the complainants deliberately and knowingly suppressed it. There is no material to impute any knowledge of those chief complaints to the complainant No.2 at the stage of securing policy, as after all even according to doctors observations those symptoms were in a low key a year ago while they became worsened only six months prior to Ex.A.7. This is some where in March, 2002. So the endeavor of the Insurance Company to take advantage of Ex.A.7 itself is found futile and on the other hand Ex.A.7 observations ruled out not only confirmed existence of any disease by the date of taking the policy but also the theory of deliberate suppression.
9. The next piece of evidence they attempted to rely upon is Ex.B.5 which makes a reference to the probable existing of the disease attributed to the complainant No.2 as being in vogue for five to ten years by then. Ex.B.5 is a medical opinion issued by Dr. B.S.Reddy, who gave an opinion basing on records. He did not claim to have treated complainant No.2 any time like 5 or 10 years prior to his issue of medical opinion which remained undated. In other words, Dr.B.S.Reddys medical opinion did not reflect his personal knowledge of the patients complaint. Added to this infirmity the appellant failed to file any affidavit of Dr.B.S.Reddy whose medical opinion is highly devoid of any probative value. It is patently clear from the record that the appellant tried to justify the repudiation on the basis of a very feeble piece of evidence as Ex.B.5. We are not impressed by the quality of evidence adduced by the Insurance Company to justify the repudiation. In other words, we do not find any reasons to set aside the order of the District Forum.
10. Accordingly, the appeal is dismissed with costs in a sum of Rs.2,000/-. Time for compliance six weeks from the date of receipt of the order.
PRESIDENT MEMBER MEMBER Dt:27.05.2009.