State Consumer Disputes Redressal Commission
The New India Assurance Company Ltd And ... vs Smt.D.Usha Rani (Expired Hyderabad on 22 July, 2008
BEFORE THE A BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION - AT HYDERABAD. FAIA.No.1329/2008 and FASR.No.2797/2008 against CC.No.145/2006 District Consumer Forum-I, Hyderabad .. Between- 1.Divisional Manager, The New India Assurance Company Ltd. 4th Floor, Kautilya, Amrutha Estate, Somajiguda, Hyderabad 500 082. 2.The Authorised Signatory, M/s.Paramount Health Services Pvt. Ltd. 503, 5th Floor, M.G.R.Estates, Dwarakapuri Colony, Panjagutta, Hyderabad 500 082. Rep. by competent Authority to prefer appeal. The Authorized Signatory, The New India Assurance Company Ltd. Regional Office - 5th Floor, Surya Towers, S.D.Road, Secunderabad. Petitioners/Appellants/Opposite Parties. And Smt.D.Usha Rani (expired) Rep. by her husband Sri D.Venkateswara Rao, Age - 65 years, R/o. Plot No.30, Vasantha Valley, Whitefields, Kondapur, Hyderabad 500 032. Respondent/Complainant. Counsel for the Petitioner/appellant - Mr.K.N.V.Radha Krishna. Counsel for the Respondent - Admn.Stage. QUORUM- THE HONBLE MR.JUSTICE D.APPA RAO, PRESIDENT, SMT.M.SHREESHA,HONBLE LADY MEMBER, AND SRI G. BHOOPATHI REDDY, HONBLE MALE MEMBER.
TUESDAY, THE TWENTY SECOND DAY OF JULY, TWO THOUSAND EIGHT.
Oral Order (Per Honble Mr.Justice D.Appa Rao, President)
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Heard the learned counsel for the appellants on the delay excuse petition as well as on the appeal. Having heard the learned counsel and on perusing the record, we are of the opinion that this matter can be disposed of at the stage of admission.
1. This is an appeal preferred by the opposite parties against the order of the District Consumer Forum-I, Hyderabad, dated 02.11.2007 in CC.No.145/2006 in directing them to pay Rs.49,804/- together with interest at 12 percent per annum from 01.04.2005 till the date of realization and costs of Rs.2,000/-.
2. The case of the complainant in brief is that his wife, D.Usha Rani had taken a mediclaim policy for the year 2000-2001 mentioning that she had a pre existing disease of diabetes. Despite the fact that she mentioned that she was suffering from diabetes, the Insurance Company had issued the said policy for Rs.1,00,000/-.
While so, when she was unwell she approached Global Hospital at Hyderabad, where the consultant opined that her kidneys were not functioning properly and diagnosed the disease as NIDDM, diabetic retinopathy, diabetic nephrology, which is end stage of renal disease. He suggested for continuous ambulatory peritoneal dialysis (CAPD). Accordingly, she underwent treatment and discharged on 16.09.2005. She spent Rs.49,804/- in this regard. Therefore, she claimed Rs.49,804/- towards reimbursement of medical expenses, Rs.1,00,000/- towards compensation and Rs.10,000/- towards costs.
3. The Insurance Company resisted the complaint.
However it admitted that she was covered by a mediclaim policy. The exclusion clause in column No.4.1 of the agreement clearly states that -all diseases/injuries which are pre-existing when the covers incepts for the first time are excluded-. By virtue of this, the complainant was ineligible for the claim amount. She was suffering from Type II diabetes which she did not mention at the time of obtaining the policy. Since the disease was in an advance stage, damage to several organs had taken place. They are complications of advanced diabetes. Therefore, she was not entitled to the amount claimed.
4. The complainant filed Exs.A.1 to A.9. The opposite parties did not file any document.
5. The District Forum after considering the fact that she had disclosed that she was suffering from diabetes and later she underwent treatment at Global hospital due to renal failure, etc. opined that the repudiation of her claim was unjust. Therefore, the amount that was claimed by the complainant was ordered to be paid with interest at 12 percent per annum and costs of Rs.2,000/-.
6. Aggrieved by the said order, the Insurance Company preferred this appeal contending that the complainant did not mention that she was suffering from Type II diabetes while obtaining the insurance policy.
The fact that she was in advance stage of diabetes is evident from the prescription chit issued by the Global hospital. She was suffering from Nephrology and other complications. Therefore, she was not entitled to any amount.
7. It is not in dispute that the complainants wife D.Usha Rani had taken a mediclaim policy from the appellants Insurance Company mentioning that she was suffering from diabetes. She had taken the policy originally in the year 2000-2001 and later renewed by the appellant from time to time. While so on 20.12.2004 she was admitted in Global Hospital where it was diagnosed that she was suffering from continuous ambulatory peritoneal dialysis (CAPD).
She was discharged on 16.09.2005.
An amount of Rs.49,804/- was spent towards medical expenses which she claimed in the complaint.
8. The Insurance Company contends that though she revealed that she was suffering from diabetes, she did not state that she was suffering from Type II diabetes. She did not mention about the complications namely renal failure, etc.,and therefore, she was not entitled to any amount.
9. We may mention here that when the mediclaim policy was issued, the Insurance Company knew fully well that she was suffering from diabetes. She has frankly disclosed the disease from which she was ailing. It was in the year 2001 when the policy was issued. Later it was renewing the policy. She was admitted in the hospital in the year 2005 for diabetic complications. Undoubtedly when the Insurance Company was renewing it, it must have reasonably presumed that complications would set in and the complainant had renal failure for which CAPD was directed to be administered. The appellant ought not to have renewed the policy having known that the complainants wife was suffering from diabetes right from 2001.
Undoubtedly, these complications would arise particularly for a diabetic patient. It is not an unknown complication. Had the Insurance Company referred the matter to a doctor, he would have undoubtedly mentioned that this complication is natural in cases where patients suffer from diabetes. The complainant is entitled for reimbursement, which the District Forum rightly granted. It did not award any compensation towards mental agony. It has awarded interest at 12 percent per annum to be paid. We do not see any irregularity in appreciation of the fact in this regard.
10. In fact, this appeal was preferred with an application to condone delay of 147 days on the ground that there were some administrative latches. It was not elaborated. Day to day delay was not explained. The appellants (Insurance Company) have admittedly contested the matter before the District Forum. The Insurance Company must have known the order that was passed by the District Forum. The learned counsel for the appellant relying on a decision of Dr.S.Bandyopadhyay Vs.Kamal Kumar Mitra and Ors. Reported in II (2004) CPJ 51 contended that -refusing to condone delay can cause result in a meritorious matter being thrown out and cause of justice being defeated-. That was the reason why we have considered the main case in detail and we find no merits. We do not see any valid ground, whatsoever, to condone the abnormal delay of 147 days.
11. In the result, the delay condone petition as well as the appeal are dismissed at the stage of admission. Time for compliance four weeks.
PRESIDENT LADY MEMBER MALE MEMBER Dt-22.07.2008.