COMMON JUDGMENT
JUSTICE SHRI. K.R. UDAYABHANU : PRESIDENT
The appellants in Appeal-531/10 are the complainants and the appellants in Appeal-620/10 are the opposite parties/United India Insurance Company Ltd. in CC.161/01 in the file of CDRF, Thiruvananthapuram. The opposite parties/appellants are under orders to pay a sum of Rs.1,24,901/- along with compensation of Rs.5000/- and cost of Rs.1000/- to the complainants. The complainants/appellants in A-531/10 have sought for interest at the rate of 12% per annum on the amounts allowed.
2. The complainants are the insured and the consumer organization that has filed the complaint along with the insured. The 2nd complainant who is an official of the VSSC has claimed the amount incurred for the treatment expenses of his father the 3rd opposite party who is also covered by the group medical insurance policy. The policy coverage is Rs.1,50,000/-. The 2nd complainant had availed the policy on 16.3.99 for Rs.15,000/- as the sum insured himself and the members of the family consisting of 5 members including his father the 3rd complainant. The period of coverage was from 26.3.99 to 15.3.2000. In May 1999 itself he made a claim for a sum of Rs.11,535/- which was paid. Thereafter the 2nd complainant enhanced the coverage to Rs.1,50,000/- on 22.6.99 as his father the 3rd complainant underwent a bye-pass surgery and has incurred an expenditure of Rs.1,25,184/- towards hospital expenses. The claim preferred has not been honoured so far it is alleged. Hence the complainants claimed the above amount and compensation of Rs.10,000/- with interest at 12%.
3. On the other hand, the opposite parties/insurance company have contended that the complainant misused the facility for enrolment to the group insurance policy to those persons who had not availed the policy earlier. Further it is contended that the enhancement of the sum insured by taking a 2nd policy was made concealing the illness of the 3rd complainant and that it was deliberately done with an eye to get the expenses of the bye-pass surgery. It is contended that the father of the complainant was ailing and the above illness was suppressed. The premium amount has been returned but the voucher dated:27.4.2001 has not been returned.
4. Evidence adduced consisted of the proof affidavit of the complainant and Exts.P1 to P8 and D1 to D4.
5. It is the case of the complainant that the group insurance policy with respect to the VSSC employees covered pre-existing diseases also and hence the opposite parties are liable to reimburse the expenses incurred with respect to the bye-pass surgery although the illness in this regard was existing on the date of availing the policy. We find that Ext.D1 the discharge summary from Malar Heart Foundation wherein the bye-pass surgery was conducted itself mentions that he had earlier undergone CAG (Coronary Angiogram) on 4.5.99 and was advised CABG in view of triple vessel disease and that the patient did not undergo the surgery then and hence thereafter he underwent the surgery at the Malar Hospitals. There is no dispute with respect to the above fact stated in Ext.D1 discharge summary. As noted above the present policy commenced on 22.6.99. The angiogram done at SreeChithra Hospitalon 4.5.99 as noted in Ext.D1. Hence evidently it is on the next month that he has availed the policy for Rs.1,50,000/- and got the bye-pass surgery done on 23.9.99. Evidently the father of the complainant was aged 64 years and was also having diabetes mellitus and hyper tension as mentioned in Ext.D1 and also was found to be having triple vessel disease and was advised to undergo CABG. Hence the only question that remains is whether pre-existing illness under the particular group insurance policy is covered. The counsel for the opposite parties/appellants has placed reliance on Ext.D13 the copy of the file note kept in the office of the opposite parties with respect to the present claim. In the file note put up to the Divisional Manager it is noted that since VSSC group mediclaim policy covers existing diseases and also as the sum insured is adequate the claim may be allowed. The Divisional Manager has negatived the suggestion and observed there was a wilful intention to lodge a huge claim and that is why the insured has taken the cover for a higher sum insured. As per Ext.D14 it has been ordered to settle the claim by paying the balance amount available to the credit of the insured as per his 1st enrolment and to cancel the 2nd enrolment by refunding the premium collected for the same. It is contended that the recommendation seen in the file note to honour the claim is made by the Assistant Divisional Manager. We find that the above suggestion has been negatived by the Divisional Manager and hence the opposite parties cannot be pinned down to the suggestion put up by a subordinate officer.
6. As to the contention that the recommendation of the Assistant Divisional Manager indicated that the coverage with respect to the particular group insurance policy included pre-existing diseases also. We find that there is no supporting evidence as such. It is the case of the complainants that clause 4.2 of the exclusion clause in Ext.P1 policy covered only certain diseases mentioned therein with respect to the 1st year of the operation of the insurance cover. The above diseases mentioned are cataract, hysterectomy etc. According to him in view of section 4.2 the rest of the illness are covered. We find that clause 4.2 is not with respect to the pre-existing illness.
7. On the other hand, counsel for the appellant/opposite parties has stressed on clause 4.9 of the exclusion clause wherein it is mentioned as excluded-charge incurred at hospital or nursing home primarily for diagnostic X-rays or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital. It is contended by the counsel for the complainants that clause 4.9 referred to only lab examinations etc. With respect to the diseases we find that clause 4.9 also covers charges incurred for treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital. The above part of clause 4.9 clearly indicates that pre-existing illness is excluded. Further there is no case for the complainants that the complainants had disclosed the pre-existing cardiac illness and the suggestion from the SreeChithra Hospitalthat the complainant has to go bye-pass surgery is mentioned in the proposal form.
8. In the circumstances we find that the bye-pass surgery underwent at the Malar Hospitals for which the amount has been claimed is excluded by clause 4.9 of the exclusion clause in Ext.P1 Mediclaim insurance policy. Hence we find that the order of the Forum cannot be sustained. The same is set aside. Hence Appeal-531/10 is dismissed and Appeal-620/10 is allowed.
Office will forward the LCR along with a copy of this order to the Forum.