UNITED INDIA INSURANCE COMPANY Vs. ANUMOLU RAMA KRISHNA
ANDHRA PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION
UNITED INDIA INSURANCE COMPANY
ANUMOLU RAMA KRISHNA
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(1.) AGGRIEVED by the order in CC
134/2003 on the file of District Forum, West Godavari at Eluru, the opposite parties preferred this appeal under Section 15 of the Consumer
Protection Act, 1986.
(2.) THE brief facts as set out in the case are that the complainant has taken Medi -claim Insurance Policy on 24.9.2001 from opposite parties
for himself and his wife for the period from 24.9.2001 to 23.9.2002. As
the complainant felt burning sensation and difficulty in breathing on
medical advice, he got himself admitted in Mullapudi Hospital on
30.10.2001 wherein they conducted various tests and decided to conduct CABG operation on 8.11.2001. The complainant submits that the said fact
was informed to opposite party No. 2 vide letter dated 8.11.2001. The
complainant submits that in spite of furnishing all the necessary
documents to opposite party No. 2 the claim lodged by the complainant for
an amount of Rs. 2,20,076 has not been settled by the opposite parties.
After a long lapse of 12 months the opposite party No. 2 repudiated the
claim on the ground that CABG existed prior to taking the policy.
Complainant submits that he was hale and healthy at the time of taking
the policy and that though he was subjected to medical examination on
23.9.2002 and submitted all the case records relating to the operation issued by Mullapudi Hospital the opposite parties repudiated the claim
nearly after one year on the ground of suppression of pre -existing
disease at the time of taking the policy. The action of the opposite
parties in repudiating the medi -claim of the complainant amounts to
deficiency of service. Hence this complaint praying to direct the
opposite parties to pay Rs. 2,90,000 with interest @ 12% p.a., from
February, 2002 till the date of payment and compensation of Rs. 25,000
towards mental agony.
(3.) OPPOSITE party No. 2 filed counter admitting the existence of policy in question and contends that the complainant suppressed the
material facts relating to his health at the time of taking the
medi -claim policy. Opposite party submits that the policy was issued
based on the declaration made by the complainant and the medical
certificate issued by Dr. K. Viswaswara Rao in good faith. Opposite party
submits that they received a letter dated 8.11.2001 from the wife of the
complainant stating that her husband was admitted to Usha Mullapudi
Cardiac Centre, Hyderabad for Coronary Bypass Surgery on 8.11.2001.
Immediately the Divisional Office deputed Mr. L. Siva Shanker an
investigator to investigate the claim. On receipt of investigation report
the opposite party asked the complainant to meet their Panel Doctor, Dr.
Kodali Rama Krishna along with ECGs and TMT reports taken prior to
operation but the complainant though appeared before the Panel Doctor did
not produce the said reports. On receipt of report from the Panel Doctor
the opposite parties had reasonable doubts about the pre -existing nature
of the disease of the complainant, therefore, appointed another
investigator Mr. G. Prabhakara Rao, who is an advocate along with Dr.
Vinjamuri Bhaskara Rao. In his report he observed that as per the case
sheet the patient/claimant is a highly diabetic hypertensive, which might
be existed with the patient since seven years as they are chronic
diseases. Dr. Vinjamuri Bhaskara Rao in his reort dated 28.1.2003 oberved
that the claimant has three diseases, Diabetics, Hypertensive and
Dyslipedemia which are chronic in nature, much before taking of
Medi -claim policy. The opposite parties submit that the claim preferred
by the complainant is not admissible in terms of the policy condition
Exclusion No. 4.1 as the disease CABG existed prior to taking of policy,
therefore, they repudiated the claim on 13.2.2003. There is no deficiency
of service on their behalf and seek dismissal of the complaint.
Learned counsel for the appellant/opposite parties submitted that the life assured suppressed Coronary Artery Disease (CAD) and
because of suppression of material facts relating to his health their
repudiation is justified. He further contended that the policy was
obtained on 24.9.2001 and the operation was conducted on 8.11.2001 and
that the CAD cannot be developed within a period of 45 days.;
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