NEELAPALLI NOOKARAJU Vs. UNITED INDIA INSURANCE COMPANY LTD

JUDGEMENT

(1.) The unsuccessful complainant is the appellant. The appeal is challenge to the order passed by the District forum, Kakinada in C.D.No.164 of 2005.

(2.) The factual matrix of the case is that the appellant joined in A.B.Arogyadan Scheme on 27.8.2004 under which the respondent no.2 issued certificate of insurance on 27.11.2004 for the period from 27.8.2004 to 8.6.2005 covering the risk on the life of the appellant, his wife and two sons. The appellant fell sick and the doctors in Government General Hospital referred him to NIMS. The appellant before admitting to the NIMS wrote a letter to the opposite party no.1 seeking direction to NIMS as it was not one of the network hospitals. The appellant was advised to take treatment immediately as he was suffering with coronary artery disease. As per the medical advice, he was admitted as inpatient on 21.12.2004 and discharged on 25.12.2004 after the operation was performed upon him. The appellant incurred expenditure of Rs.1,24,574/- towards the operation charges and medical expenses. Thereafter on 13.1.2005, the appellant made representation to the opposite parties for reimbursement of the medical expenditure as per the terms of the policy. The claim was repudiated stating that it did not fall under the purview of the policy. Hence, the appellant filed the complaint before the District Forum sought directions to the respondents to pay the assured amount of Rs.50,000/- with interest, damages and costs.

(3.) The respondents resisted the case by admitting that the appellant joined in the scheme on 27.8.2004 and the respondent no.2 issued medi-claim policy valid from 27.8.2004 to 8.6.2005 but denied that it was within the knowledge of the respondent no.1 that due to ill health he was referred to NIMS from Government General Hospital and in NIMS he was operated for coronary artery disease. The respondents admitted that the appellant made representation after the discharge from the hospital for medical reimbursement and contended that after receipt of claim form by the respondent no.1 it was referred to the Third Party Administrator, i.e., M/s Family Health Plan Limited for processing the claim who after going through the documents opined that the claim did not fall under the coverage of policy as the appellant was hypertensive and diabetic since one year and there was history of symptoms of double vessel disease since five months and underwent PTCA with two stunts to CAD and that the hospitalization of the appellant was found to be for management of an ailment which was related to a pre-existing condition and the same was excluded as per clause 4.1 of the policy. Hence, prayed for dismissal of the complaint.