Decided on May 07,2009

V.G.Dhanapalan Respondents


M.V.VISWANATHAN,JUDICIAL MEMBER - (1.)THE above appeal is preferred from the order dated 11th March 2004 passed by CDRF, Alappuzha in OP No. A 256 of 2002. The complaint therein was filed by the respondent as complainant against the appellant/opposite party, claiming the insurance amount under A1 medi -claim policy. The complainant alleged deficiency in service on the part of the opposite party/insurance company in repudiating the claim made under the medi -claim policy. The opposite party/ insurance company entered appearance and contended that they repudiated the claim on valid grounds and that there was no deficiency in service in repudiating the medi -claim. The Forum below on an appreciation of the evidence upheld the case of the complainant that there was deficiency in service on the part of the opposite party in repudiating the claim. Thereby the impugned order was passed directing the opposite party to pay an amount of Rs.65,518.28 with interest at 10% per annum from the date of the complaint with cost of Rs. 400. Aggrieved by the said order the present appeal is preferred by the opposite party insurance company.
(2.)THE learned counsel for the appellant/ opposite party submitted his arguments based on the grounds urged in the memorandum of the present appeal. He much relied on Ex B4 discharge summary dated 15.10.2001 issued from Amritha Institute of Medical Science and Research Centre and argued for the position that the complainant insured suppressed material facts regarding pre -existing disease. Thus, the appellant justified its action in repudiating the insurance claim. On the other hand, the respondent/complainant supported the findings and conclusions of the Forum below. He canvassed for the position that there was no suppression of material facts and that there was no pre -excising disease as contended by the opposite party/insurance company. He also relied on Ex B3 medical certificate issued by the doctors attached to Amritha Institute of Medical Science and Research Centre and pointed out that the complainant as patient had no information about his illness of coronary artery disease and pheripheral vascular disease before his admission at Amritha Institute of Medical Science and Research Centre. Thus, the respondent/complainant prayed for dismissal of the present appeal.
(3.)THE points that arise for consideration are:
(1) Whether there was any deficiency in service on the part of the appellant/opposite party in repudiating the insurance claim made by the complainant based on A1 medi -claim policy?

(2) Is there are sustainable ground to interfere with the impugned order dated 11.3.2004 passed by CDRF, Alappuzha in OP No. A256 of 2002.

Points 1 and 2

There is no dispute that the complainant had taken medi -claim policy for the period from 29.3.2001 to 28.3.2002. During the pendency of the said A1 policy the complainant/ insured was hospitalized from 28.9.2001 to 30.9.2001 and from 14.10.2001 to 17.10.2001. The aforesaid hospitalization was for coronary artery disease and Pheripheral Vascular Disease. He was treated for the aforesaid disease at Amritha Institute of Medical Science and Research Centre. The complainant made the medi -claim for Rs. 65,518.28. But the same was repudiated by the opposite party/insurance company by issuing A9 (B5) repudiation letter dated 16.1.2002. It is because of the repudiation of the claim, the complainant preferred the complaint in OP No. A256 of 2002 before the CDRF, Alappuzha.

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