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ANDHRA PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HYDERABAD
MR. R. LAKSHMINARASIMHA RAO & MR. THOTA ASHOK KUMAR, MEMBERS
UNITED INDIA INSURANCE CO. LTD. - Appellant
Versus
GATTU VENKANNA & ANR - Respondents
F.A. No. 673 of 2012
Decided On : 19-06-2013
Advocate Appeared:
For the Appellant :Mr. Ravishankar Jandhyala, Advocate.
For the Respondent:Mr. V. Nasimha Rao, Advocate.
The central legal point established in the judgment is the requirement for producing evidence to support a claim and the necessity for both parties to adhere to the terms and conditions of the insurance policy.
Headnote:
Insurance Policy - Coverage of Chronic Rinal Sinusitis with Adenoiditis - 2007/2008/484100660/127 - The court considered the coverage of chronic Rinal Sinusitis with Adenoiditis under the insurance policy 2007/2008/484100660/127. The court analyzed the renewal status of the policy and the terms and conditions of coverage. The decision highlighted the importance of producing evidence to establish a claim and the need for both parties to adhere to the terms of the insurance policy.
Fact of the Case:
The respondent obtained an insurance policy for his family, and his son underwent surgery for sinusitis. The insurance company repudiated the claim, citing pre-existing conditions and non-renewal of the policy.
Finding of the Court:
The court allowed the appeal, setting aside the District Forum's order, and remitted the matter back for both parties to adduce evidence.
Issues: 1. Coverage of chronic Rinal Sinusitis with Adenoiditis under the insurance policy. 2. Deficiency in service by the insurance company. 3. Relief sought by the parties.
Ratio Decidendi: The court emphasized the need for evidence to establish a claim and the importance of adhering to the terms and conditions of the insurance policy.
Final Decision: The appeal was allowed, and the matter was remitted back to the District Forum for both parties to adduce evidence.
JUDGMENT :
1. The opposite party no.2 is the appellant.
2. The brief facts of the complaint are that the respondent no.1 obtained IOB Health Care Plus Policy through IOB, Nalgonda in the year 2007 and it was valid till 15.8.2008 and during the coverage period he got renewed the next policy vide Policy No. 01111000/2008/484100660/127 for his entire family, i.e. himself, wife, son and daughter. On 4.9.2008 Keerthi Manu, the son of the respondent no.1 got suffered from sinusitis and approached Medi Centre Hospital, which entrusted the matter to the agents of the respondent no.2 and instructed the respondent no.1 to admit his son in the hospital and accordingly the first respondent admitted his son in the hospital on 6.9.2008. The doctor operated upon the son of the respondent no.1. As the appellant could not be contacted in time the respondent No. 1 paid the hospital bill of `55,334-91 Ps. and he also incurred a sum of `10,000/-. The respondent No. 1 preferred the claim with the appellant which required him to submit split bills and accordingly the respondent No. 1 submitted the bills for a sum of `49,000/- towards surgery and bilateral fees for the remaining amount. Again the appellant required the respondent No. 1 to submit the same bills which the respondent No. 1 had complied with. However, the claim remained unsettled.
3. The respondent No. 2 remained ex parte.
4. The appellant resisted the case contending that the respondent No. 1 having account with Indian Overseas Bank, had purchased IOB Health Care Policy for the period commencing from 4.9.2008 and it is the first policy. During the first year, the Rihnal Sinusitis disease from which the son of the respondent No. 1 was suffering was excluded according to condition 8.3. Such disease is covered only during the subsistence of the extended policy. The son of the respondent No. 1 was having pre-existing disease of Sinusitis and he did not disclose the same and it amounts to suppression of the disease and as such OP-2 had rightly not settled the claim.
5. The respondent No. 1 and the appellant filed their respective affidavits. The respondent No. 1 filed Exs.A-1 to A-7, and the appellant did not mark any documents.
6. Feeling aggrieved by the order of the District Forum, the appellant-insurance company has filed appeal contending that the first respondent obtained the medi-claim insurance policy in the year 2007 which was valid till 15.8.2008 and he had taken the second insurance policy for the period from 4.9.2008 till 3.9.2009 and as such it cannot be considered as continuation of the earlier policy. The diseases such as cataract, hernia, fistula etc., are not covered by during the first year of the insurance policy and if the diseases other than congenital internal disease are pre-existing they are not covered even during the subsequent period of renewal. The disease is covered after three consecutive continuous policy years provided there was no hospitalization and the renewal has been continuous and without any break.
7. The learned counsel for the first respondent has filed written arguments.
8. The points for consideration are:
1. Whether the chronic Rinal Sinusitis with Adenoiditis are covered by the terms of the insurance policy?
2. Whether there was any deficiency in service on the part of the opposite parties?
3. To what relief?
9. POINT NO.1: The first respondent, an account holder of Indian Overseas Bank, Nalgonda obtained IOB Health Care Plus Policy in the year, 2007 valid for the period till 15.8.2008 covering the risk of the first respondent, his wife, son and daughter. The son of the first respondent was operated upon for sinusitis on 6.9.2008 and the first respondent incurred an amount of `55,334/- for treatment of his son. The appellant repudiated the claim of the first respondent on the premise that his son was suffering from Chronic Rihnal Sinusitis is with Adenoiditis prior to the first respondent issuing insurance policy and Clause 8.3 excludes coverage of any such
