State Consumer Disputes Redressal Commission
M/S. Icici Lombard General Insurance ... vs D.J. Gunasekaran Jeyakumar, 30 G, ... on 12 June, 2014
IN THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, MADURAI BENCH.
Present: THIRU.J. JAYARAM, PRESIDING JUDICIAL MEMBER
THIRU.S. SAMBANDAM, MEMBER
F.A.No.486/2012
(F.A.No.455/2012 on the file of State Consumer Disputes Redressal
Commission, Chennai.)
(Against the order in C.C.No.191/2010, dated 09.08.2011 on the file of DCDRF,
Tirunelveli)
THIS THURSDEAY, THE 12th DAY OF JUNE 2014.
1. M/s. ICICI Lombard General Insurance Co., Ltd.,
Through its Authorized Signatory,
Zenith House, Keshav Rao Khade Marg,
Mumbai - 400 034. Apellant/1st Opposite Party
2. M/s.ICICI Lombard General Insurance Co.,Ltd.,
Through its Branch Manager,
IA, Lion Arcade,
Sindhupoondurai West Street,
Tirunelveli - 627 001. Appellant/2nd Opposite Party
Vs
1. D.J. Gunasekaran Jeyakumar,
30 G, Jebamani Building,
Eruvadi Road,
Tirunelveli District.
2. Stella Guna Seelan,
W/o. D.J. Gunaseelan Jeyakumar,
30 G, Jebamani Building,
Eruvadi Road,
Tirunelveli District. Respondents/Complainants
Counsel for Appellants/opposite parties: Mr.S. Suresh, Advocate.
Counsel for Respondents/Complainants: M/s. S. Haja Mohideen Gisthi, Advocate.
2
This appeal coming before us for final hearing on 03.06.2014 and on
hearing the arguments of both sides and upon perusing the material records this
Commission made the following:
ORDER
THIRU. J. JAYARAM, PRESIDING JUDICIAL MEMBER.
1. This appeal is filed by the opposite parties against the order of the District Forum, Tirunelveli, in C.C.No.191/2010, dated 09.08.2011, allowing the complaint.
2. The case of the complainants is that the 1st complainant who is the husband of the 2nd complainant had taken a health insurance policy with the opposite parties covering himself, his wife and two children and that when the policy was in force his wife suddenly took ill and was taken to Meenakshi Mission Hospital, Madurai on 04.11.2009 where it was diagnosed that she was suffering from Hernia and as she was health card holder of the opposite party, she sent a claim for Rs.93,000/- to the 1st opposite party on 04.11.2009 towards treatment expenses and the 1st opposite party called for additional information from the Hospital and after verification the opposite party insurance company at Hyderabad issued a letter of authorization to the hospital on 05.11.2009 for treatment to the 2nd complainant and after receipt of letter of guarantee for payment of Rs.63,000/- the hospital commenced treatment and operation was performed on 06.11.2009 and she was discharged on 09.11.2009. But, the 1st opposite party repudiated the claim on 09.11.2009 stating that there was 3 possibility of the disease being pre-existing one cannot be ruled out. The 2nd complainant underwent surgery for incisional Hernia operation which was not a recurrence of a particular disease. The repudiation of her legitimate claim amounts to deficiency in service on the part of the opposite parties. Hence, the complaint.
3. According to the opposite parties, the 2nd complainant took treatment at Meenakshi Mission Hospital, Madurai for Hernia operation but she had already undergone Umbilical Hernia Operation previously on 14.08.2007 at Jeyasekaran Hospital, Nagercoil and thereafter she has taken treatment in Madurai Meenakshi Mission Hospital for her pre-existing disease which is excluded from the policy and also these material facts were suppressed by the complainant in the proposal form and the claim was repudiated for valid reasons and there is no deficiency in service on their part.
4. The District Forum considered rival contentions and allowed the complaint holding that there is deficiency in service on the part of the opposite parties. Aggrieved by the impugned order, the opposite parties have preferred this appeal.
5. It is contended by the appellants/opposite parties that the 2 nd complainant had pre-existing disease and the material facts were suppressed and so the complainant is not entitled to claim under the policy. The point to be considered is whether the 2nd complainant was suffering from pre-existing disease and whether there is suppression of material facts. The contention of 4 the respondent/complainant is that Hernia is not a recurring one and that she had no pre-existing disease. It is contended by the complainants that unlike other diseases once a person is operated for Hernia the above disease could not be considered as subsisting one and once Hernia operation is completed one cannot expect the recurrence of the same problem. There is no evidence on record to prove that after Umbilical Hernia Operation, the 2nd complainant was suffering from the same disease continuously and had taken treatment for the above disease. There are no materials to hold that she was suffering from recurrence of the disease and took treatment and therefore Hernia could not be considered as pre-existing disease. So, also there are no materials to come to the conclusion that the consequent surgery could be due to the complications arising out of the earlier operation and that there was pre-existing disease. No documentary evidence is adduced to establish that there is suppression of material facts and that the complainant had prior knowledge of the disease/ medical problem. Therefore, we hold that the contention of the appellants/opposite parties that the 2nd complainant was suffering from pre- existing disease and that there is suppression of material facts by the complainant having prior knowledge of the disease is untenable.
6. The District Forum has allowed the complaint holding that there is deficiency in service on the part of the opposite parties directing the opposite parties jointly and severally to pay Rs.63,000/-being the amount guaranteed for the treatment and to pay a sum of Rs.10,000/- towards taxi fare and to pay 5 Rs.25,000/- as compensation for mental agony and to pay costs of Rs.5000/-. For the mental agony, we feel that compensation of Rs.25,000/- awarded by the District Forum is on the higher side and so we are inclined to reduce the compensation from Rs.25,000/- to Rs.10,000/-.
7. In the result, the appeal is partly allowed modifying the order of the District Forum by reducing the compensation for mental agony to Rs.10,000/- (Rupees Ten Thousand only) instead of Rs.25,000/- as ordered by the District Forum and confirming the rest of the order. No order as to costs in this appeal.
S.SAMBANDAM, J.JAYARAM, MEMBER. PRESIDING JUDICAIL MEMBER. INDEX: YES / NO TCM/Mdu Bench/Orders- 2014/June