P T G MENON Vs. C V RAJAN

JUDGEMENT

(1.) THIS is a case wherein a senior citizen was denied the mediclaim benefits by the Insurance Company on the assumption that he had not disclosed relevant information to the Insurance Company about the pre-existing disease while obtaining the policy.

(2.) MR. O. P. Kingar, a retired employee of Hindustan Aeronautics Ltd. Bangalore, had obtained a family mediclaim policy No. 4867040000735 on 22. 2. 1993 for a period of one year from 22. 2. 1993 to 21. 2. 1994 from New India Assurance Company Ltd. , by paying an annual premium of Rs. 4,680. The complainant was admitted to Apollo Hospital, Madras on 2. 3. 1993 as he had suffered chest pain and was discharged on 10. 3. 1993 after he underwent certain procedures. Thereafter a claim form was submitted to the opposite party (the Insurance Company) claiming the actual expenses incurred i. e. , Rs. 78,157 on 12. 4. 1993. The Insurance Company repudiated the claim. Hence, the insured, Mr. Kingar filed the complaint before the District Forum claiming a sum of Rs. 1,20,157. Case of the complainant:

(3.) MR. Kingar had planned to visit his brother-in-law in UK in the month of April 1993. Accordingly, he went to HAL Hospital for medical check-up, Chest X-ray, ECG, etc. on 4. 2. 1993. The results were found within the normal limits. On 8. 2. 1993 the complainant went to the British High Commission at Madras for visa. The New India Assurance Company's agents approached the complainant's son Mr. Rakesh Kingar for group insurance to get Income-tax rebate for filing the return upto March, 1998. The proposal and the premium were accepted by the opposite party. At that time Mr. Kingar was in good health. On 25. 2. 1993 Mr. Kingar had little chest pain and went to HAL Hospital and the CMO of the HAL referred the petitioner to Apollo Hosital, Madras for check-up. The petitioner was admitted in Apollo Hospital on 2. 3. 1993 for investigation which revealed 'recent on set of angina' (it was recent angina not existing earlier) and angioplasty was performed on the petitioner. The opposite party was informed of the above development. The petitioner was discharged from the hospital on 10. 3. 1993. The petitioner submitted the claim papers for the treatment obtained at Apollo Hospital to the opposite party. No reply from the opposite party was received for about five months in spite of constant followup Mr. Kingar sent a letter dated 10. 9. 2003 under Registered Cover to the opposite party for immediate settlement of the claim. The petitioner received a letter dated 16. 9. 1993 from the opposite party asking the petitioner to submit an authority letter to the effect that the petitioner has no objection if any hospital, including HAL Hospital furnishes whatsoever details sought by the Insurance Company. The certificate has already been signed by the petitioner at the time of taking the policy and it was a part and parcel of the policy. This was done by the opposite party only to harass the petitioner. On 19. 1. 1994 a letter was received from the Insurance Company repudiating the claim under different clauses. The original letter on the basis of which the claim was repudiated has never been produced either at District Forum or at the State Commission in spite of giving sufficient opportunity to the opposite party. The opposite party was shown the original letter from HAL's Chief Medical Officer and copies of this letter and reports were sent to the opposite party, which shows that everthing was normal as on 4. 2. 1993. A letter was sent by the petitioner to the opposite party with the remarks of the Chief Medical Officer of the HAL stating that the X-ray and the ECG taken on 4. 2. 1993 were all within normal limits. The opposite party did not respond at all. Then the petitioner approached Jayamahal Consumer Protection (JCP) Society for help. A letter was sent by the JCP Society to the Divisional Manager of opposite party requesting him to settle the claim immediately as the matter has been delayed for one year. Since no reply was received from Divisional Manager, the JCP Society has written a letter to the Chairman of the opposite party requesting him to instruct the Divisional Manager to settle the claim at the earliest. The JCP Society sent a reminder to the Chairman of the opposite party. Another reminder was also sent to the Chairman of the opposite party requesting him to take action. Thereafter, on 5. 7. 1994, a case was filed in District Consumer Forum. Ultimately the judgment was delivered on 27. 3. 1998 by the District Forum, dismissing the complaint.