State Consumer Disputes Redressal Commission
The New India Assurance Co.,Ltd. ... vs Jangiti Venkataramana Raju Hyderabad on 24 April, 2009
BEFORE THE A BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD. F.A.No. 1541 OF 2006 AGAINST C.D.NO.1150 OF 1999 DISTRICT FORUM-II HYDERABAD Between: The New India Assurance Co.,Ltd. Rep. by its Divisional Manager, Divisional Manager, 2nd Floor, Santhoshima Complex, RTC X Road, P.B.No.1850, Hyderabad-20 Appellants/opposite party A N D Jangiti Venkataramana Raju S/o Venkateswarulu, Aged 42 y ears, Occ: Astro Palmist 2-1-567/9, Nallakunta, Hyderabad Respondent/complainant Counsel for the Appellant: Sri Katta Laxmi Prasad Counsel for the Respondent Smt K.Bharathi Devi QUORUM: SRI SYED ABDULLAH, PRESIDING MEMBER
& SRI R.LAXMINARSIMHA RAO, MEMBER FRIDAY THE TWENTY FOURTH DAY OF APRIL TWO THOUSAND NINE Oral Order ( As per Sri R.Laxminarsimha Rao, Member) *** This appeal is filed against the order of the District Forum-II, Hyderabad in C.D.No.1150 of 1999.
The brief facts of the complaint are that the respondent obtained mediclaim insurance policy from the appellant for the period from 28.6.1998 till 27.5.1999 and he had paid an amount of Rs.2,138/- towards the premium. The respondent was entitled to reimbursement to an extent of Rs.2 lakhs. On 15.3.1999 the respondent had vomited blood and he was admitted in CDR Hospital, Hyderguda, Hyderabad where he was diagnosed with Left Destroyed Lung with bronchiectasis. Pneumonectomy was done on 17.3.1999 and the respondent discharged on 27.3.1999 and he incurred an amount of Rs.70,072/- for the treatment. AS the claim lodged on 30.3.1999 was not settled by the appellant, the respondent addressed a letter dated 18.5.1999 requesting for settlement of the claim. On 21.7.1999 the appellant repudiated the claim of the respondent and the respondent on 24.8.1999 got issued legal notice demanding for payment of the amount under the claim for which the appellant had issued on 6.9.1999 a reply reiterating the grounds of repudiation and also justifying its action. The respondent had Pul Kochs in the year 1982 and after taking treatment the disease was cured in the year 1982 itself. Therefore alleging deficiency in service on the part of the appellant, the respondent had approached the District Forum.
At the instance of the appellant, the matter was remanded to the District Forum and the appellant herein had filed counter stating that the claim was outside the purview of the terms and conditions of the policy and the claim was repudiated after having considered all the aspects and also after obtaining the investigation report and also after taking the opinion of the expert. The policy was issued on the basis of declaration made by the respondent and believing it as true and with utmost good faith. The respondent had not given intimation about his treatment, till claim was submitted. The appellant had considered the claim on the basis of documents produced and expert opinion of Dr.G.Ramakrishna Reddy and Dr.Balasubrahmanyam who rendered their opinion on 25.5.1999 and 7.7.1999 respectively. The appellant got conducted a detailed enquiry by its Investigator who made enquiry with Srihari Kumar, RMO of CDR Hospital and submitted his report. The appellant acting on the basis of expert opinion and investigation report came to the conclusion that the ailment suffered by the respondent was pre-existing disease. The claim was repudiated after taking into consideration of the documents, expert opinion and investigation report. Therefore there was no deficiency in service on the part of the appellant.
The District Forum passed the impugned order holding that the appellant did not contest the case except filing the counter even after the matter was remanded by the State Commission.
A perusal of the insurance policy shows that the sum assured was for Rs.2 lakhs and the period of insurance was from 28.5.1998 till 27.5.1999. The respondent was admitted in CDR Hospital Hyderabad and as per the bill issued by the hospital, an amount of Rs.2,23,500/- was incurred by the respondent towards room, nursing charges, surgeon fees and operation theatre charges and the bill was issued for the period from 15.3.1999 to 27.3.1999 on 30.3.1999. The respondent lodged claim with the appellant stating that on 15.3.1999 he vomited blood and was admitted to CDR Hospital and it was requested to condone the delay in giving the intimation and consider the claim by releasing the amount in terms of the necessity of the amount for post-operative care and other family commitments. On 21.7.1999 the claim repudiation letter was issued by the appellant stating that the insured was suffering from the disease which had been in existence at the time of proposing insurance.
The District forum had not referred the contents of the counter though it held that a counter filed by the appellant was placed on record. The respondent got issued a legal notice dated 24.8.1999 demanding the amount and that the respondent was not suffering from any disease as on the date of policy nor he was treated for any disease earlier. The appellant got issued reply to the notice on 6.9.1999 denying the allegations made in the notice and the reply and it was stated that the appellant considered the claim on the basis of the documents, expert opinion of Dr.G.Ramakrishna Reddy and Dr.Balasubramanyam dated 25.5.1999 and 7.7.1999 respectively and also on the basis of the investigation report. The expert opinion and investigation form the basis for arriving at the conclusion that the ailments suffered by the respondent was a pre-existing disease and the respondent deliberately suppressed the fact in the declaration form and as such it was stated that the claim was frivolous and vexatious resulted in its repudiation. This reply notice had put an end to the correspondence in regard to the settlement of the claim lodged by the respondent.
There is no denying the fact that the respondent treated for Left Destroyed Lung with bronchiectasis in CDR Hospital from 15.3.1999 to 27.3.1999 and he had incurred an amount of rs.2,33,500/- as shown in Ex.A10.
We will come to the amount whether the respondent is entitled to, a little later and the main controversy between the parties is in regard to the disease bronchiectasis suffered by the respondent. The appellants claims that it had been pre-existing disease or pre-existing condition whereas the respondent denied stating that he suffered from Pul Kochs 1982 as he was completely cured of the disease in the year 1982 itself. The insurance policy was issued in favour of the respondent on 28.5.1998. Therefore the policy was issued after a gap of six years from the year in which the respondent said to have suffered from Pul Kochs.
Though the appellant had contended that the claim was repudiated on the basis of documents produced by the appellant, opinion of experts dated 25.5.1999, 7.7.1999 and also the investigation report submitted to it no evidence was placed before the District Forum even after the appellant had filed revision petition and obtained order for remand of the mater to the District Forum. An iota of contention putforth by the appellant in the absence of any supporting document thereof can be looked into and more, particularly so when at the instance of the appellant the case was remanded and the appellant had chosen to file only its counter but no documents at all. In the backdrop, we have no other alternative except to disbelieve the version of the appellant that the respondents claim was repudiated without application of mind and having not considered the relevant documents and in absence of any investigation report. In the circumstances, we hold that the District forum rightly held that there was deficiency in service on the part of the appellant in regard to the repudiation of the claim of the respondent.
The respondent had not challenged the order of the District Forum in regard to the quantum of amount awarded towards reimbursement of his medical expenses. The District forum had given a clear finding that the respondent had sought relief with a claim for Rs.2,35,008 after the matter was remanded by the State Commission and at no point of time the respondent had come with the plea that he had incurred the amount of Rs.2,35,008 and all the time the respondent was consistent in submitting that he had incurred an amount of Rs.70,071/-. The respondent also has not challenged the quantum of amount awarded by the District forum. In the circumstances, we are of the considered opinion that the amount of Rs.70,071/- as awarded by the District Forum holds good and the appellant is liable to pay the same to the respondent. In the light of the discussion we hold that the appeal is devoid of any merits and liable to be dismissed.
In the result, this appeal is dismissed. In the circumstances, there is no order as to costs.
PRESIDING MEMBER MEMBER Dt. 24.04.2009