State Consumer Disputes Redressal Commission
1. National Insurance Company Ltd, Rep ... vs 1. Mr.T.Sadagopan, 21St Street, Anna ... on 2 September, 2013
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE : THIRU.A.K.ANNAMALAI PRESIDING JUDICIAL MEMBER
THIRU.S.SAMBANDAM MEMBER F.A.NO.233/2010 (As against the order in CC.No.56/2006 on the file of DCDRF, Chennai (North)) DATED THIS THE 2nd DAY OF SEPTEMBER 2013
1. National Insurance Company Ltd, Rep by its Branch Manager, Vijaya Plaza, C-32, II Floor, M/s.Srinivasan Ramalingam II Avenue, Anna Nagar, Counsel for Appellants / Chennai 600 040.
Opp.parties
2. National Insurance Company Ltd, (Subsidiary of General Insurance Corporation Of India), Registered Office :
3, Middleton Street, Calcutta.
-vs-
1. Mr.T.Sadagopan, 1st Respondent /1st Complainant
2. Mrs.S.Saranayaki (expired) 2nd Respondent/2nd complainant
3. Mr.T.V.Devarajan M/s.K.Ganesan Counsel for Respondents 1,3to 5/
4. Mrs.T.V.Lakshmi Vijayaraghavan complainants /LRs of 2nd complainant
5. Mr.T.V.Srivatsan All are residing at Plot No.1462, H Block, 21st Street, Anna Nagar, Chennai 600 040.
The Respondents are the complainants filed a complaint before the District Forum against the opposite parties praying for the direction against the opposite parties to pay Rs.25,030/- towards medical and other expenses and to pay Rs.3,00,000/- as compensation for mental agony and deficiency in service and to pay Rs.2000/- as costs. The District Forum allowed the complaint. Against the said order this appeal preferred by the Appellants / opposite parties praying to setaside the order passed by the District Forum in CC.No.56/2006 dated 5.1.2010.
-2-This appeal coming before us for hearing finally on 01.8.2013, upon hearing the arguments on either side, perusing the documents, lower court records, and the order passed by the District Forum, this commission made the following order.
A.K.ANNAMALAI, PRESIDING JUDICIAL MEMBER
1. The appellants are the opposite parties.
2. The complainants filed a complaint against the opposite parties praying for payment of medical expenses spent by them towards treatment for the 1st complainants wife under the continued the earlier policy with the opposite party National Insurance Company limited for the period of treatment during the year 2004 between 29.4.2004 to 8.5.2004 and the claim was repudiated by the opposite parties on the ground that the earlier policy under the Mediclaim policy were with the New India Assurance company Limited till 1996 and subsequently renewed with the opposite parties and doing so there was a delay of 528 days after 27.6.95 and only on 10.12.1996 the policy was renewed and thereby subsequent policy to be treated as new one and as per the terms and conditions of the renewed policy for the pre-existing disease under exclusion clause the claim was repudiated.
3. The District Forum allowed the complaint by directing the opposite parties to pay a sum of Rs.25,000/- towards expenses incurred by the complainant and to pay Rs.50,000/- as compensation for mental agony and for deficiency in service and to pay Rs.2000/- as costs.
-3-4. Against this impugned order the opposite parties filed the appeal stating that the District Forum erroneously allowed the complaint without considering the question of renewal of policy and exclusion clause relating to pre-existing disease and reiterated the contention already raised before the District Forum in their version.
5. We have heard both sides rival contentions and perused the materials placed before us in this regard. It is not in dispute that the 1st complainant was having mediclaim policy from the year 1991 with New India Assurance company Limited till 1996 and thereafter continued the policy with the opposite party National Insurance Company Limited for himself and his wife and during the period in force for the period from 29.4.2004 to 8.5.2004 the 1st complainants wife undergone treatment for Heart ailment in which when the claim was made and the same was repudiated on the ground that there was a gap of 528 days in renewing the subsequent policy and because of the terms and conditions of the renewed policy in the pre-existing disease the claim cannot be entertained against which the 1st complainant also made an complaint before the Insurance Ombudsman and as per the award of Insurance Ombudsman under Ex.A2 the insurer was held liable and directed to settle the claim upto 60% of the claim made by taking into consideration of continuity of earlier policy and the claim with bonus paid earlier to the complainant and the insurer failed to mention in the exclusion clause relating to the -4- treatment Heart disease and instead of mentioned as none and thereby the policy holder is entitled for the claim made. Inspite of that the opposite party have not settled the claim, the 1st complainant has filed the consumer complaint and the District Forum on enquiry has taken into consideration of all the points raised by both sides and came to the conclusion that the claim was related to the period from 29.4.2004 to 8.4.2004 for which the policy was well in force, for which the claim for medical expenses was made and for the same. The opposite parties contention that there was a breaking policy for the period of 528 days and thereby the claim was rejected is not a proper one and Ex.A1 cannot be considered as a new policy as contended by the complainants, but it is only a renewal of the earlier policy from the year 1996 and the complainant has suppressed the facts of the case that the pre-existing disease for the complainants wife during the year 1995.
The District Forum also accepted the ruling relied upon by the opposite parties relating to the renewal of policy reported in III (2007) CPJ 450 NC and III (2001) CPJ 10 (SC) for the violation of the terms and conditions of the policy. Having known about the Heart ailment of the complainants wife and renewed the policy under Ex.A1 in which without mentioning any exclusion clause relating to the disease and instead of that mentioned as None by the insurer wrongly would estop the opposite parties from repudiating the claim. Hence, we are of the view that the District Forum has considered all the material facts in this case and came to the proper conclusion by allowing the complaint and directed the opposite parties to pay a sum of Rs.25,030/-
-5-towards medical expenses incurred by the 1st complainant.
As far as the compensation is concerned direction for to pay a sum of Rs.50,000/- as compensation for mental agony and for deficiency in service we are of the view that it is on the higher sides, it should be reduced reasonably by taking into consideration of the nature of the claim made in this regard and thereby to that extent alone the appeal is to be allowed.
In the result, the appeal is allowed in part by modifying the order of the District Forum by reducing the compensation to Rs.25,000/- instead of Rs.50,000/- awarded which is setaside. The opposite parties are directed to pay only a sum of Rs.25,000/- towards compensation for mental agony and for deficiency in service suffered by the 1st complainant.
In other respects the order of the District Forum is confirmed.
The award shall be complied within 6 weeks from the date of this order.
S.SAMBANDAM A.K.ANNAMALAI MEMBER PRESIDING JUDICIAL MEMBER INDEX; YES / NO VL/D;/PJM/ORDERS