Consumer Complaint No. : PDF/79/2008
Date of filing : 28/March/2008
Date of decision : 30/March/2009


Smt. Vidya Shrimal Khinvsara, )
R/at : 590, Rasta Peth, Trimurti Towers, )
Block No. B/2/12, )
PUNE – 411 002. )…COMPLAINANT

: Versus :

1. Medi Assist India Pvt.Ltd., (Head Office),)
Third Floor, No.49, First Main Road, )
Sarakki Industrial Layout, J.P. Nagar, )
Third Stage, Bangalore – 560 07. )
)
2. Medi Asst. India Pvt. Ltd. (Branch Office,)
Medi Assit, 301, Mantri Terrace, )
Thube Park, Behind Sancheti Hospital, )
Shivajinagar, )
PUNE – 411 005. )... OPPOSITE PARTIES

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Per :- Mr. Gaikwad, President Place : PUNE

// JUDGMENT //

This is a complaint alleging deficiency in service on the part of the Opposite Parties. The facts in brief are as under :-

[2] The Complainant is a house-wife. She had taken the insurance policy from the Opposite Party No.2, which is a Branch office of the Opposite Party No.1 Company situated at Bangalore. The policy was during the period 13/9/2007 to 12/9/2008. The Complainant was required to be hospitalized for the purpose of an operation. She had spent an amount of Rs. 13,460/- towards the medical bills and the operation charges. She had filed the claim before the Opposite Party No.2. The same was however repudiated by the Opposite Party No.2 on 12/11/2007. The Complainant therefore prays that the repudiation of the claim is illegal and therefore there is a deficiency in service. She has claimed an amount of Rs.13,460/- towards her hospitalization and medical charges. She has also claimed certain amount of compensation towards mental agony and torture and for litigating expenses.

[3] The postal acknowledgments bearing signatures of the employees of the Opposite Parties No. 1 and 2 have been duly received by this Forum. The Opposite Parties were called upon to appear before the Forum on 21/5/2008. On that day, the Opposite Parties failed to appear. The case was adjourned for passing the ex-parte orders, these orders came to be passed on 7/7/2008. The Complainant was directed to verify the documents and to file affidavit in support of the claim.

[4] The Complainant has filed written notes of arguments on her own. We have perused the same. We have also gone through the letter of repudiation dtd.12/11/2007. It inter-alia reads that the claim was repudiated because incisonal hernia is complication of LSCS, which is done previously before inception of policy, as per IPD papers. As such, the claim is repudiated under Clause 4.1 of the policy contending inter-alia that the said disease was pre-existing at the inception of the policy.

[5] This is a solitary ground on the basis of which the claim is repudiated by the Opposite Parties. It is clear that the Opposite Parties are duly served with the notice. They had allowed the complaint to proceed ex-parte against them. Alongwith written notes of arguments, the Complainant has filed certain documents in original. Amongst other, two original policy taken by the Complainant for the period 13/9/2006 to 12/9/2007 and for the period 13/9/2007 to 12/9/2008 are produced. The payments of the premium for these two policies had been made on 7/9/2006 and on 12/9/2007. The Complainant was complaining of certain pain in her abdomen. On the advice of her doctor, she underwent ultra-sonography test. The report of that test dtd. 4/8/2007 is produced. The impression mentioned in that report is small reducible incisional hernia. Prima-facie, the disease was disclosed to the Complainant, only on undergoing the sonography test. The same was done on 4/8/2007. This is a period when the Complainant was under the cover. Now on the advice of the medical practitioner, she has undergone the operation on 13/8/2007. The amount of Rs.13,460/- was spent by the Complainant at the time of this operation and during the post operation treatment. It may be mentioned that during all this relevant period, the cover was available.

[6] Unfortunately, the Complainant has relied upon the next policy commencing from 13/9/2007 to 12/9/2008. The operation was performed on 13/8/2007. It was prior to the inception of the policy. Consequently, therefore, in the previous policy, it was expected on the part of the Complainant to prefer the claim. In any case, we do not find that there is any legal impediment on account of the claim being made for the subsequent policy starting from 13/9/2007 to 12/9/2008. At the time of the operation dtd.13/8/2007, the cover was available during the previous policy from 13/9/2006 to 12/9/2007.

[7] The other significant circumstance is about the knowledge of alleged pre-existing disease by the Complainant. The repudiation is made solitary on the ground that when LSCS was performed and when the IPD papers were seen, it was disclosed by the Opposite Parties that the said disease was pre-existing. There is nothing adduced by the Opposite Parties to substantiate the same. On the other hand, they had allowed the complaint to proceed ex-parte. Secondly, the Complainant appears to have disclosed all the facts by producing on the record the original documents. If regard being had that sonography was done on 4/8/2007 and the operation was performed on 13/8/2007, it cannot be accepted that the Complainant knew or had reason to believe that she was suffering from incisional hernia. We are therefore inclined to hold that repudiation of the claim is bad in law. The Complainant therefore has satisfied the Forum that there is deficiency in service on the part of the Opposite Parties. She is entitled to recover an amount of Rs.13,460/- from the Opposite Parties. We therefore proceed to pass the following order :-

// ORDER //

The complaint is allowed in part.

The Complainant do recover an amount of Rs.13,460/- together with future interest @9% p.a. from 12/11/2007 till realization thereof by the Complainant from the Opposite Parties No.1 and 2. The aforesaid amount be paid to the Complainant within a period of two months from the date of receipt of this order by the Opposite Parties.

Other claims are rejected.

(Smt. S.G. Joshi) (P.K. Gaikwad)
Member President