BEFORE THE A.P.S TATE CONSUMER DISPUTES REDRESSAL COMMISSION:

HYDERABAD.

F.A.No.109/2007 against C.C.No.162/2006 Dist. Forum-II, Hyderabad .



Between:



1.M/s. Royal Sundaram Alliance Insurance Co.Ltd.,

Rep. by its Branch Manager,

A Block , V Floor, Jawel Pawani Towers,

Somajiguda, Hyderabad 500 082.



2. M/s. Royal Sundaram Alliance Insurance Co.Ltd.,

Rep. by its authorized signatory,

“Sundaram Towers”, 45 & 46, Whites Road,.

Chennai 600 014. … Appellants/

Opp.parties



And



A.Surender Rao, S/o.A.Kamalakar,

Age:37 years, Occ:Business,

R/o.Flat No.304, H.No.2-1-161/1/304,

Blossom Apts., Old Nallakunta,

Hyderabad -500 044. … Respondent/

Complainant



Counsel for the appellants : Sri Katta Laxmi Prasad



Counsel for the respondent : Sri. Mohd. Anwar Siddiqui



CORAM : THE HON’BLE JUSTICE SRI.D.APPA RAO , PRESIDENT,

SMT. M.SHREESHA, HON’BLE MEMBER

AND

SRI SYED ABDULLAH, HON’BLE MEMBER



TUESDAY, THE SEVENTEENTH DAY OF MARCH,

TWO THOUSAND NINE.



Oral Order : (Per Sri Syed Abdullah, Hon ‘ble Member. )

***



The appellants are the opposite parties in C.C.No.162/2006 ,Dist. Forum-II, Hyderabad. Order was passed against the opposite parties with a joint and several liability to pay the medical bill amount of Rs.39,162/- to the complainant along with compensation of Rs.5,000/- and costs of Rs.1000/- .



Aggrieved by the impugned order this appeal is preferred by the appellants/opp.parties contending that the District Forum failed to appreciate the implications of the case in proper perspective.





Briefly stated facts of the case in C.C.No.162/2006 are as under:

The complainant had taken UTI Credit Card and the agent of the opp.party approached the complainant for enrolling him in the health insurance scheme “Health Shield Plan” commenced by opposite party and he was enrolled in the said scheme on 15.7.2004. As per the terms and conditions the complainant had taken insurance coverage for Rs.1,50,000/- against any medical accident and treatment for other ailments in case of any hospitalisation and the opposite party should reimburse the medical expenditure. Necessary premium was paid and on that policy was issued commencing from 15.7.2004 upto 14.7.2005. While so in November 2005 the complainant was diagnosed for right renal stone in his bladder and he was admitted as an inpatient in the Apollo hospital on 11.11.2005 where he was operated for the removal of the said stone. He was discharged on 14.11.2005 . The complainant had incurred an expenditure of Rs.39,162/- for operation and medication etc. in the hospital. The complainant submitted a claim form to the opposite party on 24.11.2005 claiming reimbursement of Rs.39,000/- from the insurance coverage but the opposite party in its reply dt. 9.12.2005 turned out the claim on the ground that he had pre existing disease which is outside the scope of policy. The repudiation is unjust. Hence attributed as deficiency in service and filed complaint.



The opposite party no. 1 filed counter stating that the complainant had pre existing disease at the time of taking policy and on account of suppression of pre existing ailment before issuance of policy the complainant is not entitled for the claim and there by the opposite party is justified in repudiation of the claim.



During enquiry both the complainant and opp.parties have filed their affidavits in support of their version along with documents Exs.A1 to A7 and Exs.B1 to B7 . On the basis of the evidence on record the District Forum gave its finding that the complainant had at first taken insurance policy from the opposite parties in July 2004 which was in force upto 14.7.2005 and then got renewed the policy from 15.7.2005 to 14.7.2006 which shows that the complainant was hospitalized after one year of taking the policy but not immediately after taking of the policy and therefore it was not proper on the part of the opposite party to repudiate the claim stating that the complainant was having pre existing disease at the time of taking policy.



The opposite parties have very much relied upon Ex.B1 which is a copy of Admission Request Note. This document is completely illegible to read and understand . By seeing this document it cannot be said for whom it relates to . There is no dispute that the policy commenced in the Month of July, 2004 and after one year it was renewed from 15.7.2005 upto 14.7.2006 . While so the complainant was admitted in Apollo Hospital on 11.11.2005 long after renewal . Ex.B2 is the Ultra sound scan of abdomen report of the complainant dt. 11.7.2005. It does not show any abnormality at all . Even assuming that just before renewal on 15.5.2005 the complainant had undergone ultra sound test Ex.B3 which is the investigation report given by Globe Associates about the treatment taken by the complainant and it cannot be a basis to have adverse effect and to repudiate the claim . Having renewed the policy under Ex.A2 the opposite parties cannot refuse to extend the medical benefits under the policy . Ex.A1 has not excluded the pre existing disease of Kidney stones and there by the opposite parties are not justified in repudiating the claim made by the complainant. When the complainant had incurred a sum of Rs.39,162/- the opposite parties are bound to pay the same. The District Forum had rightly allowed the claim along with compensation. Appeal is devoid of merits.



In the result appeal is dismissed . Order of the District Forum is confirmed. No costs.





PRESIDENT LADY MEMBER MALE MEMBER

Dt.17.3.2009