District Consumer Forum, Bokaro.
Complaint Case No. 72 of 2008

Krishna Prasad Singh

R/o 28 Lohanchal Biada Housing Colony, Sector-12, Bokaro Steel City. Dist.- Bokaro.

Versus

The Branch Manager,

United India Insurance Co. Ltd., A-17, Sector-4, Bokaro Steel City. Dist.- Bokaro.

Before-

S.M.Alam, President

Vijay Bahadur Singh, Member
Shabnam Praveen, Member



Date of Judgment-: 02 March, 2009

Date of case filing-: 15 September 2008

-: Judgment:

Complainant has filed this case against opposite party and sought direction against the opposite party to pay Rs. 26781.15 with interest @ 18% besides Rs. 20000/- for compensation to the complainant.

2 Brief facts of the case is that the complainant secured medical coverage through the opposite party United India Insurance Co. Ltd. vide individual health policy No. 210700/48/04/3048 coverage period from 18.07.2004 to 17.07.2005, subsequently the said medical insurance policy was renewed every year and still continue and therefore, it is clear that the complainant has remained under health insurance coverage without any break from 18.07.2000 to 17.07.2009. The details of which has been annexed with the complaint.

3 The further case of the complainant is that the complainant fall ill during the month of August, 2007 got himself admitted at M.V. Hospital for diabetes Pvt. Ltd, 4, west Mada Church Road, Royapurna, Chennai, on 08/08/2007 and was discharged from the said hospital on 10.08.2007. After returned from the hospital the complainant submitted claim of 17.08.2007 being the cost of his treatment amounting to Rs. 26781.15 to the opposite party under health insurance policy, No. 210700/48/07/20/0000085 effective from 18/07/2007 to 17/07/2008. The said claim of the complainant remained pending in the opposite party office, however after 8 month the opposite party learnt that the earlier submitted claim Form and documents has been missing hence the complainant sent another documents but the said claim of the complainant has not been settled even through the period of year has all ready passed since the date of submission of the claim. The complainant also sent a legal notice upon the opposite party on 12.08.2008 and requesting the opposite party to settle the claim as soon as possible but the opposite party did not heed the request of the complainant which is deficiency in service on the part of the opposite party for which the opposite party is liable to pay the said amount together with compensation to the complainant.

4 After issuance of notice the opposite party appeared and filed its written statement disputed the claim of the complainant on the ground that the complainant had suppressed the facts that he was suffering from Diabetes and other dieses at the time of filing of proposal for securing medical claim policy from the opposite party. The opposite party further submitted that the discharged summary dated 10.08.2007 by M/s Heritage Health Service Pvt. Ltd. mentioned that the complainant was suffering from type “2” Diabetes Mellitus (DM) since the last 5 year and was having other complication like Hypertension, coronary artery disease etc. Although in the proposal Form submitted by him at the time of taking the said policy for the first time in the year 2004 he had categorically stated that he was not suffering from any such disease and that is why the policy was issued with the clear outstanding that the complainant was not suffering from diabetes, Mellitus. As matter of fact condition No. 4(i) of the policy clear providing that insurer would not to be cover the risk if the dieses were pre-exiting. The Medical Officer of the TPA vide his review note dated 17.09.2007 opined that DM was pre-existing and all other dieses were complication of the said DM and therefore, the case was non admissible. The TPA also took opinion of another Doctor physician and health insurance consulted who in his written opinion dated 13.09.2008 corroborated the opinion of the earlier Doctor.

5 The opposite party has not repudiated the claim of the complainant as yet. As such there is no occasion for the complainant to file the present case. However from the above facts it would be clear that there is no deficiency on the part of the opposite party and hence the opposite party is not to be held liable for payment of any compensation or interest to the complainant as sought in the complaint petition and the case is fit to be dismissed.

6 Heard learned counsels for the complainant and opposite party, and perused the case records and paper filed on their behalf.

7 Admittedly the complainant is covered under individual health policy of United India Insurance Co. Ltd. vide Policy No. 210700/48/04/3048. This policy was taken by the complainant in the year of 2004 and the same policy was being continued up till 2009. In the month of August, 2007 the complainant fall ill and got himself admitted in M.V. Hospital for diabetes Pvt. Ltd, 4, west Mada Church Road, Royapurna, Chennai. The complainant after recovered discharged from the said hospital and submitted his claim against the bill incurred of his treatment at the said hospital to the opposite party for earlier settlement of claim worth Rs. 26781.15. The opposite party received the said papers sent by the complainant but the opposite party was not satisfied and with the claim of the complainant and he got the matter verified by 2 consultant Doctors of insurance co. and according to whom the complainant was suffering from type “2” Diabetes Mellitus since the last 5 years. Although at the time of taking the said policy in the year 2004, the complainant has stated that he was not suffering from any diabetes. So according to the opposite party the complainant having pre-existing dieses and as a result he is not entitled for any claim. However the opposite party has asserted that it has yet not repudiated the claim of the complainant and the same is under active consideration of the insurance co., meaning thereby that the complainant has filed the present case without valid cause of action against the opposite party.

8 We, therefore, observed that the amount incurred on account of treatment of the complainant is meager amount and the opposite party should pay the said amount to the complainant, as the period of his treatment was in validity period of insurance and the complainant is entitled for such amount. However at the same time we observed that the opposite party is not deficient in service since the matter is still under consideration of the opposite party; therefore, the complainant is not entitled for compensation or cost of litigation except the claim amount which is Rs. 26781.15.

9 Under the facts and circumstances of the case, the opposite party United India Insurance Co. Ltd. is directed to pay Rs. 26781.15 (Rupees twenty six thousand seven hundred eighty one and fifteen paisa) only to the complainant within 30 days from the date of this order.