State Consumer Disputes Redressal Commission
K.Narasimha Raju,Vizianagaram-535 ... vs National Insurance Company Limited, ... on 21 July, 2011
BEFORE THE A
BEFORE THE CIRCUIT BENCH OF A.P STATE CONSUMER
DISPUTES REDRESSAL COMMISSION AT VISAKHAPATNAM.
F.A.No.362/2010 against C.C.No.73/2009, DISTRICT FORUM,
VIZIANAGARAM
Between:
K.Narasimha Raju
D.No.20-18/1-8,
Krishnarajapuram,
(P.O)
Vizianagaram-535 002 Appellant/
Complainant
And
National Insurance
Company Limited,
Rep. by its Branch
Manager,
Sai Durga Complex,
Station Road, Up
stairs of Sweet India,
(P.O) Vizianagaram,
A.P. ..Respondent
Opp.party.
Counsel for the
Appellant : Mr.K.V.S.Raju
Counsel for the Respondent : M/s.Manne Hari Babu
QUORUM:THE HONBLE JUSTICE
SRI D.APPA RAO, PRESIDENT
AND
SRI R.LAKSHMINARASIMHA
RAO, MEMBER
THURSDAY, THE TWENTY FIRST DAY OF JULY, TWO THOUSAND ELEVEN.
Oral Order (Per Honble Justice Sri D.Appa Rao, President ) ***** The appellant is the unsuccessful complainant.
The case of the complainant in brief is that his employer has taken a Group Health Insurance policy covering the period from 12-5-2008 to 11-5-2009. While so on 29-10-2008 when he attended the office and returned and went to his sisters house at 8.00 p.m. he was suddenly stuck with paralysis. He was conscious though he could not get up, immediately he was hospitalized where he spent Rs.41,543/- and Rs.21,113/- in two spells. Therefore, he claimed these amounts together with interest, compensation of Rs.10,000/- and costs of Rs.2,000/-.
The insurance company resisted the matter. While admitting the issuance of policy, it alleged that the complainant was not entitled to these amounts as he suppressed the pre-existing disease. One of the terms and conditions of the policy is that during the first two years of coverage, the expenses incurred for Hypertension and other ailments are not covered. The doctor who treated the complainant has mentioned that he was treated for Hypertension. Therefore, it has rightly repudiated the claim the ailment being pre-existing and prayed for dismissal of the complaint.
The complainant in proof of his case filed his affidavit evidence while the insurance company filed the affidavit evidence of its Assistant Manager and no documents were marked by both the parties.
The District Forum after considering the evidence placed opined that as per condition 4(3) of the policy, the complainant having suffered with Hypertension within six months from the date of taking the policy and hence was not entitled for any relief and accordingly dismissed the complaint.
Aggrieved by the said order, the complainant preferred this appeal contending that the District Forum did not appreciate the facts in correct perspective. It ought to have seen that disease Paralysis was not mentioned in the policy exclusion clause 4.3 and therefore prayed to allow the appeal.
The point that arises for consideration is whether the order of the District Forum is vitiated by any mis-appreciation of fact or law in that regard?
It is an undisputed fact that the complainant suffered from paralysis while the Group Health insurance policy was in force. The policy was repudiated by the insurance company as the complainant suffered from Hypertension and paralysis even before issuance of policy. The very doctor, K.Satya Rao by his certificate dated 8-3-2009 mentioned that he had treated the complainant for Hypertension with Left Hemeplegia Ischemia stroke was detected to be having hypertension at the time of stroke. No previous history or any medical record showed existence of hypertension earlier. The certificate categorically says that he had hypertension for the first time.
Clause 4.3 reads as follows:
4.3 During the first one year of the operation of the policy the expenses for treatment of Benign ENT disorders & surgeries like Tonsillectomy/Adenoidectomy/Mastoidectomy/Tympanoplasty.
Treatment of diseases such as Cataract, Benign Prostatic Hperthropathy, Hysterectomy, Hernia, Hydrocele, Congenital Internal Diseases, Fissures/Fistula in anus Piles, sinusitis and related disorders, polycystic ovarian diseases, Non infective arthritis, Undiscended testis, Surgery of gall bladder & bile duct excluding malignancy, Surgery of Genito urinary system excluding malignancy, Pilonidal sinus, Gout & Rheumatism Hypertension, Diabetes, Calculus diseases, Surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy.
.
From this it is beyond doubt that if the assured had hypertension within two years from the operation of the policy, he would not be entitled to be compensated. Since the policy commenced on 12-5-2008 and he had Hypertension on 29-10-2008 within two years, he would not be entitled to policy amount.
The learned counsel for the complainant contended that Paralysis (Hemiplegia ischemia) has nothing to do with Hypertension. Since he had hypertension for the first time, he was entitled to reimbursement. The fact remains that he had Hypertension followed by some other ailment. It does not anywhere over rule the fact of Hypertension suffered by him during the first two years of operation of the policy. Therefore, his case comes under clause 4.3 which we have mentioned earlier.
We do not see any mis-appreciation of fact or law in this regard.
In the result this appeal fails and is accordingly dismissed.
There shall be no order as to costs.
Sd/-PRESIDENT.
Sd/-MEMBER.
JM Dt.21-07-2011