Lagisetty Pandiah Vs. Bajaj Allianz General Insurance Co. Ltd. - Court Judgment

(Sri K. Satyanand,Honble Member)

Not satisfied with the quantum of relief granted by the District Forum, the complainant preferred this appeal obviously to get complete relief as prayed for.

The facts that led to filing this appeal are briefly as follows:

The complainant while proceeding on a foreign tour obtained an insurance policy coverage from the opposite party obviously in order to cover any unforeseen ailment that might set in the far off lands. He obtained the policy valid from 13-5-2005 to 10-8-2005 for various packages including the one for medical expenses for a coverage upto 50,000 US dollars. It seems after going to US, he fell ill due to some Hepatitis ‘C for which he claimed to have taken treatment from the medical attendants there. He claimed to have spent an amount of Rs.99,600/- towards the medical expenses. After getting back to India, he filed a claim for reimbursement of the medical expenses that he incurred in U.S. by way of a claim form received by the opposite party insurance company on 22-9-2005. Though in the pleadings, he claimed to have enclosed all the bills besides other medical transcripts, claim form did not indicate any fact of such enclosure. Likewise the claim form marked as Ex.A1 and A2 did not also quantify the claim amount. The insurance company ultimately repudiated the claim on the ground that he was suffering from a pre-existing condition which he concealed without disclosing it in the proposal form. Aggrieved by the said repudiation, the complainant filed the C.C. claiming an amount of Rs.99.600/- as representing the amount he spent towards medical expenses and also other amounts by way of compensation and costs.

The opposite party did not file any counter and in fact was not represented by any counsel as observed by the District Forum.

In support of his case, the complainant filed his own affidavit and relied upon documents marked as Exs.A1 to A11.

On a consideration of the evidence adduced by the complainant, the District Forum came to the conclusion that there was no nexus between the so called hypertension which according to the insurance company was proved to be his pre-existing condition on his own showing and the disease for which he had taken treatment in the U.S. Accordingly the District Forum held that the repudiation was not justified and such unjust repudiation marked the deficiency in service, as a consequence, the District Forum granted relief to a tune of Rs.50,000/- as against the opposite party and expressed an opinion that more than could not be awarded as the complainant himself failed to prove the actual medical bills.

Aggrieved by this partial relief, the complainant filed the present appeal with the usual grounds. Along with the appeal, he also filed a petition to receive additional evidence obviously comprising the bills about which the District Forum commented even while saying that they were enclosed with the claim form and in any view of the matter, the repudiation was on that ground.

Heard both sides.

In as much as the insurance company did not file any appeal and the complainant filed the appeal only for the limited purpose of getting the balance of relief, the scope of the appeal remains very narrow as the basic findings of the District Forum would be no more under issue. In other words, the finding of the District Forum as to deficiency in service actuated by the unjust repudiation cannot be called in question in this appeal of limited scope. Therefore, the only point that arises for consideration is whether the appellant is entitled to any enhancement of the relief granted by the District Forum?

Obviously realizing the lacunae in his evidence, the appellant came forth with a petition to adduce additional evidence. In order to induct additional evidence, he averred that those documents were already enclosed with his claim form and in any view of the matter, that was not a ground of repudiation and therefore, the furnishing of those bills would cure the inadequacy in the evidence pointed out by the District Forum thereby strengthening his case for enhancement. But additional evidence cannot be readily received for mere asking. There should be proper foundation and also a very profound cause shown by such petitioner as to why he could not adduce such evidence. A close look at the claim form amply indicates that the petitioner had neither quantified the expenses of which the reimbursement was claimed nor did he mention the factum having enclosed the supportive documents, especially the bills. No doubt, the opposite party entered appearance and contested the matter. Yet the complainant had filed several documents before the District Forum but he withheld the most important bills, the copies of which now he is seeking to file for reasons best known to him. In the absence of any foundation that he ever submitted those bills to the insurance company by explicit evidence which could have been found no where else except in the claim form, the belated filing of the copies of the bills cannot be readily accepted for mere asking. The fact that the repudiation did not bank upon the non filing of the bills is all the more untenable for the simple reason that they repudiated the claim on more fundamental ground namely the concealed pre-existing condition which of-course, the District Forum brushed aside. So the absence of the opposite party bestowing attention upon the inadequacy of the supportive documents does not give any additional advantage to the appellant to fill up the lacuna at a belated stage. So we do not think that this is a fit case where the additional evidence could be allowed to be adduced. This discussion takes us to the truism that there are no merits in the appeal.

Accordingly the appeal is dismissed but without costs in the circumstances of the case.