KUNCHA RAMANA KUMAR Vs. BRANCH MANAGER NEW INDIA

JUDGEMENT

(1.) The appellant is the unsuccessful complainant in CD 148/2006 before the District Forum, Guntur where under the medi-claim policy sought to be recovered was dismissed.

(2.) Briefly stated the facts of the case are that the complainant had taken a medi claim policy from the OPs in the year 1977 bearing policy no. 621002/48/05/75025 and the policy being renewed every year. During the year 2005 while renewing the policy the assured amount was enhanced to Rs.two lakhs. During the period of the policy i.e. from 18.09.2005 to 17.09.2006, the complainant was affected with ailment, ie., Avascular Necrosis. So the complainant made a preauthorization request to the OPs through TPA TTK Health Care Services Pvt. Ltd requesting them to facilitate cashless settlement to the Apollo Specialty Hospital, Chennai. The complainant was admitted in Apollo hospital on 29.09.2005 at Chennai and undergone surgery on 01.10.2005 under cashless settlement as per the terms and conditions of medi-claim policy. But surprisingly on 6.10.2005 the hospital was informed by the OP 1 with the remark that the ailment is pre-existing and he is not eligible for insurance amount so the complaint was compelled to pay Rs.1,97,868/- to the Apollo hospital at the time of discharge. After payment of the amount the complainant made a request to OP 1 for indemnifying the insurance claim. On 2nd March,2006, the OPs sent a cheque for Rs. one lakh through TTK Health Care Service Pvt Ltd by RP which amount was received but not informed that it was received without prejudice to his rights. Instead of settling Rs.1,97,868/- only a sum of Rs.one lakhs was sent. Immediately the complainant got issued legal a notice dt.4.3.2006 demanding balance Rs.97,868/-. The complainant was subject to mental agony for non settling of the claim. So the act or omission would amounts to deficiency in service.

(3.) The OPs 1and 2 filed their version resisting the claim. It is stated that the complainant is guilty of suppresio vari and suggestio falsi in filing the false complaint to get unlawful gain. At the time of taking policy the complainant intentionally failed to disclose the pre-existing disease i.e Avascular Necrosis. As per the doctors report, the complainant was having pre exiting disease. Point 4.1 is very clear on this aspect. During the year 1999-2000 a sum of Rs.18,240/- was paid to the complainant for the same problem. After making enquiries it was clear that the complainant was not having pre-exiting disease at the time of taking policy, so the said payment was made. But in the year 2005 the complainant suppressing the said ailment and without mentioning the pre-exiting disease had renewed the policy and enhance it to Rs. Two lakhs so as to have unlawful gain. However, the claim was settled for Rs. one lakh by paying the said amount. Therefore there is no liability to pay any further amount as claimed for.