State Consumer Disputes Redressal Commission
United India Insurance Co. Ltd vs Safiya, W/O. Moidhukutty on 18 April, 2013
Daily Order
Kerala State Consumer Disputes Redressal Commission Vazhuthacaud,Thiruvananthapuram First Appeal No. A/12/335 (Arisen out of Order Dated 20/01/2012 in Case No. Complaint Case No. CC/11/17 of District Wayanad) 1. UNITED INDIA INSURANCE COMPANY DIVISIONAL OFFICE,LMS COMPOUND TRIVANDRUM KERALA ...........Appellant(s) Versus 1. SAFIYA KATTURKKAL HOUSE,PAZHAMBALAKODE PALAKKAD KERALA ...........Respondent(s) BEFORE: SMT.A.RADHA PRESIDING MEMBER PRESENT: ORDER KERALA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL NO.335/2012
JUDGMENT DATED 18/04/2013
PRESENT:
SMT. A. RADHA : MEMBER
SHRI. K. CHANDRADAS NADAR : JUDICIAL MEMBER
APPELLANTS:
1. United India Insurance Co. Ltd.,
Divisional Office, Park House Building,
Round North, Thrissur-680 001.
2. United India Insurance Co. Ltd.,
Ottapalam, Ottapalam P.O.,
Pin-679 101,
Both Rep. by Asst. Manager T. Reshmi,
United India Insurance Co. Ltd.,
Divisional Office-1, L.M.S. Compound,
Thiruvananthapuram.
(By Adv: Sri. R. Jagadhish Kumar)
Vs
RESPONDENT
Safiya, W/o. Moidhukutty,
Katturkkal House, Pazhambalakode,
Palakkad.
(By Adv: Sri. Samchandrabose)
APPEAL NO.335/2012
JUDGMENT DATED 18/04/2013
SMT. A. RADHA : MEMBER
This appeal is preferred by the opposite parties against the order passed in C.C.No.17 of 2011 on the file of CDRF, Palakkad. The Forum below directed the opposite parties to pay Rs.32,160/- and Rs.5,000/- as compensation and Rs.1,000/- as cost of proceedings.
2. The complainant and her family members were having individual Health Insurance Policy with the opposite parties from 2004 and the same was renewed in 2010. During the policy period the complainant experienced pain upper side of her right hand and undergone treatment and had to spend an amount of Rs.32,160/- for the treatment. The claim submitted to the opposite parties was repudiated on the ground that the complainant suppressed the material facts that she had pre-existing disease and the same was not revealed in the policy records. The complaint is filed for the expenses incurred by her for her treatment along with compensation and cost.
3. It is admitted in the version that the complainant had a valid policy from 09/07/2010 to 08/07/2011 with opposite parties. It is contented that the ailments suffered by the complainant was congenital in nature. The doctors of the opposite parties diagnosed the ailment as Subcutaneous Hemangioma based on the MRI report. The MRI report revealed that the ailment had 10 years history and hence the disease was existing prior to the inception of the insurance coverage. It is the primary duty of the insured to declare the ailment details in the proposal form. The complainant suppressed this material facts and the claim made by the complainant is inadmissible. The claim is not entertainable under clause 4.8 of the policy and the matter was communicated to the complainant and there is no deficiency in service on the part of the opposite parties. It is also contented that the policy produced is not the continuation of the policy taken in the year of 2004.
4. No oral evidence adduced by the complainant, the documents Exbts. A1 to A11 were marked on the side of complainant. On the side of the opposite parties DW1 and DW2 were examined and documents were marked as Exbts.B1 to B8. Based on the evidence and records, the Forum below allowed the complaint in favour of the complainant.
5. The appellant's counsel argued that the claim submitted by the complainant was repudiated on the ground that she had congenital disease. The respondent had not given the details of existing disease at the time of taking the policy. It is a clear suppression of material facts concealing the details of ailment while taking the policy. The MRI scan report produced as Exbt: A4 reveals that the complainant had 10 years history of the ailment. It is also stated that the features are of Subcutaneous Hemangioma. She took the policy on 09/07/2004 to cover up the expenses for her treatment. In the instant case, there is both suppression of material facts and the presence of pre-existing disease was hidden by the complainant while taking the policy. When the claim was submitted it was scrutinized by a panel of Doctors of the opposite parties for obtaining their opinion. The doctors' diagnosed the ailment and certified that the complainant is having congenital disease. He also pointed out that the policy does not reveal that the policy had continuation in its coverage. The appellant adduced evidence by one of the panel Doctors who verified the records. The appellant repudiated the claim as per the exclusion clause. The Doctor who was examined clearly stated that Hemangioma can be caused due to fall. A Hemangioma is a vein growth congenital in nature. No contra medical evidence was adduced by the respondent to rebut the contentions of the opposite party. There is valid reason to repudiate the claim putforth by the respondent.
6. Submission made by the counsel for respondent is that the individual Health Insurance Policy was taken from 2004 for her family members and it was renewing annually and the present policy was valid from 09/07/2010 to 08/07/2011 with the appellant. During the policy period the complainant underwent a surgery and she had to spend an amount of Rs.32,160/-. The respondent submitted the claim form with all necessary documents for re-imbursement which was repudiated by the appellant on the ground that the disease suffered by the respondent was congenital in nature. It is asserted that the respondent was not having any ailment earlier. She had no pre-existing disease nor she had undergone any treatment for the said disease. The respondent submitted the bills wherein the MRI Scan (Exbt. B3) report stated 10 years history and it is subcutaneous Hemangioma. The respondent had no knowledge about such a disease until she was admitted in the hospital. As per the hospital records, the history given as pain right FA one year. When the documents submitted before the appellant, it was repudiated since the MRI Scan Report showed as history of 10 years, the appellant declared the disease as pre-existing. The ailment was not within the knowledge of the respondent while taking the policy. It is to be pointed out that the Doctor who was examined on the side of the opposite party was only having BHMS Degree. The Doctor also revealed that he had no personal know nor she was examined before a Medical Board. He came to knowledge that it is congenital disease as per Exbt.B4. The counsel also argued that the Medical Officer who issued the MRI Scan Report was not examined by the appellant. It is submitted that the respondent undergone for the surgery having swelling in the right arm and it was during the valid period of the policy and the respondent is entitled for the claim amount. No pre-existing disease was proved by the appellant except based on scan report which was not proved in evidence properly. The respondent is entitled for the claim amount and it is to be re-imbursed in toto.
7. Heard both the counsels in detail and had gone through the records. It is an admitted fact that respondent was having a valid policy during the period of treatment. From the document submitted by the respondent the history given in the MRI scan was taken as a ground for repudiation of the claim by the appellant. According to the complainant she had the pain for one year and she consulted the Doctor and on diagnosis by the Doctor the patient had the history of pain right FA one year. It shows that there had no pre-existing disease to the respondent. The appellant had not proved the MRI scan report by examining the concerned Doctor nor produced any documents against the complainant that ever before she had undergone any treatment for the said disease. As there is no proof against the complainant having suffered the said disease earlier, we have to consider that the appellant failed to prove that the congenital disease was within the knowledge of the complainant. In the absence of any proof regarding any treatment undergone by the complainant prior to the inception of the Insurance Policy, the claim of the complainant is to be allowed in toto. We find no suppression of material facts on the part of the complainant and the pre-existing disease was not proved by the appellant also.
In the result, appeal is dismissed and this Commission has no hesitation to uphold the order passed by the Forum below. The order is to comply within 30 days on receipt of the copy of the order.
The office is directed to send a copy of this order to the Forum below along with LCR.
A. RADHA : MEMBER
K. CHANDRADAS NADAR : JUDICIAL MEMBER
Sa.
KERALA STATE CONSUMER
DISPUTES REDRESSAL
COMMISSION
THIRUVANANTHAPURAM
APPEAL NO.335/2012
JUDGMENT DATED 18/04/2013
sa
[ SMT.A.RADHA] PRESIDING MEMBER