Full Judgment
(The Appellant as the complainant filed a complaint before the District Forum against the opposite party praying for a direction to the opposite party to pay Rs.50,000/- towards medi claim policy with 24% interest per annum and to pay Rs.50,000/- towards compensation for mental agony and to pay costs. The District Forum dismissed the complaint. Against the said order, this appeal is preferred by the complainant praying to set aside the order of the District forum in CC.111/2005 dated 26.09.2007.)
A.K. Annamalai, Presiding Judicial Member
The unsuccessful complainant is the appellant.
The appellant availed a Mediclaim policy from the Respondent for the period from 30.8.2001 on payment of premium of Rs.914/- per annum and during the force of the policy he undergone treatment for heart ailment from 5.4.2002 to 16.4.2002 and claimed a sum of Rs.50,000/- for the expenses incurred by him from the opposite party on the basis of Mediclaim policy which was repudiated by the opposite party stating that the appellant had pre-existing disease which is excluded under the policy and thereby the complainant was forced to file a consumer complaint claiming the reliefs before the District Forum.
2. The District Forum after an enquiry dismissed the complaint by accepting the contention of the opposite party.
3. Against the impugned order the complainant come forward with this appeal by contending that there is no suppression of material facts relating to the pre-existing disease and the District Forum erroneously relied upon the exclusion clause dismissed the complaint. Whereas the Respondent / opposite party contended that as per the investigation report and the medical records revealed that the complainant was having pre-existing ailment even prior to the policy and thereby the claim was rejected on the basis of clause 4.1 of the terms and condition of the policy.
4. We have carefully gone through the materials placed before us and considered both sides contentions and averments. It is not in dispute that the complainant availed mediclaim policy from the opposite party and during the period on force of the policy, the complainant undergone treatment for the alleged Heart disease as per the document in Ex.A1, A2 to A8 which is also not in dispute that the claim was rejected by the opposite party on the basis of exclusion clause stating that the complainant was having pre-existing disease. The opposite party came to the conclusion regarding the pre-existing disease only on the basis of the letter under Ex.B1 and Ex.B2 progress card issued by the same Hospital. On perusal of Ex.B1 and B2 it is stated that the complainant was admitted the Hospital on 5.4.2002 for chest pain and as per the History recorded in the Case sheet he is known case of Hypertension and Ischemic Heart disease on irregular treatment and he was admitted for treatment and treated for heart attack and connected to the ventilator for respiratory system failure and he was discharged on 16.4.2002 and in Ex.B2 the progress of treatment given was recorded for the period of treatment given to the appellant but no where stated that he had any earlier treatment prior to 5.4.2002 and it was mentioned what treatment he has taking prior to the admission in the Hospital not known. In those circumstances the opposite party had not produced any other medical treatment records relating to the complainant prior to the policy under Ex.A1 which was taken on 30.8.2001 and only after 8 months during the month of April 2002 the complainant had the treatment from 5.4.2002 to 16.4.2002 in the Ramakrishna Hospital for which the hospital alone Ex.B1 and B2 letter and progress card were obtained by the opposite party. They have not even produced the proposal form to establish what nature of disease or health condition of the policy holder declared to show that the complainant had suppressed the pre existing disease. Even though it was stated that as per the investigation report they came to know under Ex.A10 about it no such investigation report was filed except the letter under Ex.B1 which was issued by the Hospital on the basis of requisition made by them by the letter dated 29.7.2002 which was also not produced. The complainant has produced the relevant details relating to the treatment and expenses incurred by him under Ex.A2 to A8 which were also not disputed by the opposite party. In those circumstances we are of the view that the opposite parties simply based on the letter under Ex.B1 which certified only with some previous treatment, without having any details of dates and the treatment relating to the period after taking of the policy wrongly and erroneously rejected the claim of the complainant and the District Forum also failed to consider those aspects deeply dismissed the complaint erroneously. Hence, this appeal is deserves to be allowed by setting aside the order of the District forum accordingly.
In the result, the appeal is allowed. The order of the District Forum in CC.No.111/2005, dated 26.09.2007 dismissing the complaint is hereby setaside. Complaint is allowed. The opposite party is directed to pay a sum of Rs.50,000/- claimed by the complainant as Mediclaim Policy for the treatment under gone by the complainant with 9% interest from the date of rejection of the claim i.e., on 16.8.2002. Further a sum of Rs.2,000/- towards costs is also ordered. Directions shall be complied within 6 weeks from the date of this order.
There is no separate order for costs in this appeal.