The Branch Manager, M/S Oriental Insurance Company Ltd. Vs. E.A. Rahim and Another - Court Judgment

SooperKanoon Citationsooperkanoon.com/1107840
CourtKerala State Consumer Disputes Redressal Commission SCDRC Thiruvananthapuram
Decided OnOct-31-2012
Case NumberFirst Appeal No.27 of 2012 (Arisen out of Order Dated 29/08/2011 in Case No. Complaint Case No. CC/11/21 of District Idukki)
JudgeTHE HONOURABLE SHRI. JUSTICE P.Q. BARKATH ALI PRESIDENT & THE HONOURABLE MR. M.K. ABDULLA SONA MEMBER
AppellantThe Branch Manager, M/S Oriental Insurance Company Ltd.
RespondentE.A. Rahim and Another
Excerpt:
justice shri. p.q. barkath ali, president this is an appeal filed by the 2nd opposite party in cc no.21/2011 on the file of consumer disputes redressal forum, idukki challenging the order of the forum dated: 29th august 2011. 2. the appellant/2nd opposite party is the oriental insurance company ltd. represented by its branch manager kothamangalam. the second respondent/1st opposite party is medi assist tpa rt limited, kochi. 3. the case of the 1st respondent/complainant as detailed in the complaint and as testified by him as pw1 before the forum in brief of this: the complainant-pw1 availed a medi-claim policy from the 2nd opposite party through the appellant in 2010. the coverage was for rs.50,000/-. it was enhanced rs. 2,00,000/- on 10th july 2009. on 18th may 2010, the pw1 suffered a severe heart attack and under went treatment at lissie hospital, ernakulam were he had undergone angioplasty for which had to spent rs.1,75,709/-. when he claimed the amount the appellant/insurance company gave a cheque for rs.45,000/- only, on the ground that in the medical report, there was 80% and 90% block in two vessels, which is a pre-existing disease and that he was a known case of hyper tension and that therefore he is entitled only rs.50,000/- and 10% of the amount was deducted as commission. the allegation that he was a known case of blood pressure and had a pre-existing disease is not true. pw1 has never undergone any treatment for the same. therefore the appellant is bound to pay the entire expenses incurred by him. rs.25,000/- is claimed as compensation. 4. the appellant and the first opposite party in their version before the forum contended thus. the complaint is barred under the arbitration and conciliation act. there is a special clause in the contract that any dispute between the parties has to be referred for arbitration. from the treatment records of the pw1 from the morning star medical centre, adimali where he was admitted initially it is seen that the pw1 was a known case of hypertension and there was also dyslipidema. therefore complainant is entitled only for an amount of rs.45,000/-. 5. pws1 and 2 were examined and exts.p1 to p8 were marked on the side of the complainant and on the side of appellant, the assistant manager of the insurance company was examined as dw1 and he produced exts. r1 (series) and r2 (series). on an appreciation of evidence the district forum found that at the time of issuance of insurance policy pw1 had no pre-existing disease and that therefore he is entitled to the entire amount spent by him for treatment and directed the opposite parties to pay rs.1,75,709/- with 12% interest from the date of petition and rs.2,000/- as costs. the 2nd opposite party/insurance company has come up in appeal challenging the said order of the district forum . 6. the counsel for the appellant/insurance company sri. varkala b. ravikumar submitted that the treatment records of the pw1 at morning stat medical centre, adimali marked as ext.r2 series shows that pw1 was a known patient of hypertension and that therefore the appellant is liable to pay only rs.45,000/- towards treatment expenses. the counsel for the 1st opposite party/complainant supported the order of the district forum. 7. the only point argued by the counsel for the appellant/insurance company is that ext.r2 series the photocopy of the medical records of the morning stat medical centre, adimali shows that pw1 was suffering from hypertension which he did not reveal at the time of issuance of the policy, that there was suppression of the material fact and that therefore the insurance company is bound to pay only rs.45,000/-. there is no substance in the above contention. ext.r2 series is only a photocopy of the treatment records. it does not show that pw1 was suffering from any hypertension. it is written therein ‘k/c htn with an irregular treatment and a question mark was put. dw1 the assistant manager of the insurance company was unable to explain the same. the doctor who treated pw1 at morning star hospital adimali was not examined by the appellant to prove that pw1 had hypertension. 8. on the other hand, pw2 the doctor who treated the complainant at lissiehospital, categorically stated that pw1 is non-hypertensive and non-diabetic patient. therefore we are in complete agreement with the finding of the forum that the appellant had failed to prove that the pw1 had a pre-existing disease at the time of issuance of the concerned insurance policy and that therefore he is entitled to the entire expenses incurred by him for treatment. we are of the view that the impugned order of the forum is a well reasoned one. we find no material irregularity much less any jurisdictional error to interfere with. the forum has ordered re-imbursement of rs.1,75,709/- which pw1 has spent for his treatment as proved by ext.p4 with 12% interest from the date of the petition and rs.2,000/- as costs. we find no ground to interfere with in the said finding of the forum below. in the result, we find no merit in this appeal and the same is here by dismissed with a cost of rs.5,000/-.
Judgment:

JUSTICE SHRI. P.Q. BARKATH ALI, PRESIDENT

This is an appeal filed by the 2nd opposite party in CC No.21/2011 on the file of Consumer Disputes Redressal Forum, Idukki challenging the order of the Forum dated: 29th August 2011.

2. The appellant/2nd opposite party is the Oriental Insurance Company Ltd. represented by its Branch Manager Kothamangalam. The second respondent/1st opposite party is Medi Assist TPA Rt Limited, Kochi.

3. The case of the 1st respondent/complainant as detailed in the complaint and as testified by him as PW1 before the Forum in brief of this: The complainant-PW1 availed a medi-claim policy from the 2nd opposite party through the appellant in 2010. The coverage was for Rs.50,000/-. It was enhanced Rs. 2,00,000/- on 10th July 2009. On 18th May 2010, the PW1 suffered a severe heart attack and under went treatment at Lissie Hospital, Ernakulam were he had undergone angioplasty for which had to spent Rs.1,75,709/-. When he claimed the amount the appellant/insurance company gave a cheque for Rs.45,000/- only, on the ground that in the medical report, there was 80% and 90% block in two vessels, which is a pre-existing disease and that he was a known case of hyper tension and that therefore he is entitled only Rs.50,000/- and 10% of the amount was deducted as commission. The allegation that he was a known case of blood pressure and had a pre-existing disease is not true. PW1 has never undergone any treatment for the same. Therefore the appellant is bound to pay the entire expenses incurred by him. Rs.25,000/- is claimed as compensation.

4. The appellant and the first opposite party in their version before the Forum contended thus. The complaint is barred under the Arbitration and Conciliation Act. There is a special clause in the contract that any dispute between the parties has to be referred for arbitration. From the treatment records of the PW1 from the Morning Star Medical Centre, Adimali where he was admitted initially it is seen that the PW1 was a known case of Hypertension and there was also Dyslipidema. Therefore complainant is entitled only for an amount of Rs.45,000/-.

5. PWs1 and 2 were examined and Exts.P1 to P8 were marked on the side of the complainant and on the side of appellant, the Assistant Manager of the Insurance Company was examined as DW1 and he produced Exts. R1 (series) and R2 (series). On an appreciation of evidence the District Forum found that at the time of issuance of insurance policy PW1 had no pre-existing disease and that therefore he is entitled to the entire amount spent by him for treatment and directed the opposite parties to pay Rs.1,75,709/- with 12% interest from the date of petition and Rs.2,000/- as costs. The 2nd opposite party/Insurance company has come up in appeal challenging the said order of the District Forum .

6. The counsel for the appellant/Insurance company Sri. Varkala B. Ravikumar submitted that the treatment records of the PW1 at Morning Stat Medical Centre, Adimali marked as Ext.R2 series shows that PW1 was a known patient of hypertension and that therefore the appellant is liable to pay only Rs.45,000/- towards treatment expenses. The counsel for the 1st opposite party/complainant supported the order of the District Forum.

7. The only point argued by the counsel for the appellant/insurance company is that Ext.R2 series the photocopy of the medical records of the Morning Stat Medical Centre, Adimali shows that PW1 was suffering from hypertension which he did not reveal at the time of issuance of the policy, that there was suppression of the material fact and that therefore the Insurance company is bound to pay only Rs.45,000/-. There is no substance in the above contention. Ext.R2 series is only a photocopy of the treatment records. It does not show that PW1 was suffering from any hypertension. It is written therein ‘K/C HTN with an irregular treatment and a question mark was put. DW1 the Assistant Manager of the Insurance Company was unable to explain the same. The doctor who treated PW1 at Morning Star Hospital Adimali was not examined by the appellant to prove that PW1 had hypertension.

8. On the other hand, PW2 the doctor who treated the complainant at LissieHospital, categorically stated that PW1 is non-hypertensive and non-diabetic patient. Therefore we are in complete agreement with the finding of the Forum that the appellant had failed to prove that the PW1 had a Pre-existing disease at the time of issuance of the concerned insurance policy and that therefore he is entitled to the entire expenses incurred by him for treatment. We are of the view that the impugned order of the Forum is a well reasoned one. We find no material irregularity much less any jurisdictional error to interfere with.

The Forum has ordered re-imbursement of Rs.1,75,709/- which PW1 has spent for his treatment as proved by Ext.P4 with 12% interest from the date of the petition and Rs.2,000/- as costs. We find no ground to interfere with in the said finding of the Forum below.

In the result, we find no merit in this appeal and the same is here by dismissed with a cost of Rs.5,000/-.