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ANDHRA PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION VIJAYAWADA
T. Sunil Chowdary, President, P. Mutyala Naidu, Member
STAR HEALTH AND ALLIED INSURANCE COMPANY LTD. - Appellant
Versus
DARIMADUGU ADINARAYANA & ORS. - Respondents
FA 471 of 2016
Decided On : 08-04-2019
For the Appellant :Mr. T.L.K. Sharma, Advocate.
For the Respondent:Mr. G. Malyadri, Mr. S.V.V.S.S. Durga Prasada Rao, Advocate.
The central legal point established in the judgment is the interpretation of insurance policy terms, the relevance of medical records in establishing pre-existing conditions, and the reasonableness of the awarded amounts.
Headnote:
Consumer Protection Act - Insurance Policy - Section 15 of the Consumer Protection Act, 1986 - [P/131125/01/2012/000535, Ex. A-3, Ex. B-4] - The court discussed the provisions of the insurance policy, including the coverage, claim settlement, and pre-existing disease disclosure requirements. The interpretation of the policy terms and the relevance of medical records in establishing pre-existing conditions influenced the court's decision to allow the complaint in part and modify the awarded amounts.
Fact of the Case:
The complainant obtained a senior citizens insurance policy and incurred medical expenses, which the insurance company repudiated. The District Forum allowed the complaint, directing the opposite party to pay the medical claim amount, damages, and costs.
Finding of the Court:
The court found that the insurance company repudiated the claim on erroneous grounds and awarded amounts not in line with the policy's scope. The court considered the complainant's medical records and the policy terms to determine the entitlement to the medical claim, damages, and costs.
Issues: The issues involved the repudiation of the medical claim, interpretation of policy terms, and the awarded amounts by the District Forum.
Ratio Decidendi: The court's decision was influenced by the interpretation of the insurance policy terms, the relevance of medical records in establishing pre-existing conditions, and the reasonableness of the awarded amounts.
Final Decision: The appeal was allowed in part, directing the opposite party to pay the medical claim amount, reduced damages, and costs to the respondents.
ORDER :
T. Sunil Chowdary, President (Oral)—This appeal is filed, under Section 15 of the Consumer Protection Act, 1986, assailing the order dated 10.3.2016 passed in CC No. 17 of 2015 on the file of the District Consumer Disputes Redressal Forum, Nellore (herein after referred as District Forum). The complaint filed by the complainant was allowed in part.
2. The parties hereinafter will be referred to as they were arrayed before the District Forum for the sake of convenience.
3. The facts which are relevant for disposal of this appeal are briefly as follows:
One Darimadugu Adinarayana had obtained “Senior Citizens Red Carpet Insurance Policy” bearing No. P/131125/01/2012/000535 dated 7.3.2012 from the opposite party by paying a premium of Rs. 14,494. The policy was in force with effect from 7.3.2012 to 6.3.2013. The complainant renewed the policy with effect from 7.3.2013 to 6.3.2014 by paying a premium of Rs. 14,494. Due to Neuro problem, the complainant was admitted in Bollineni Ramanaiah Memorial Hospital, Nellore on 24.7.2013 and discharged on 4.8.2013. The complainant spent an amount of Rs. 1,70,000 towards medicines and treatment. The complainant submitted medical bills and other relevant documents for settlement of medical claim. The opposite party repudiated the claim of the complainant on 31.3.2014. On 2.7.2014 the complainant got issued a notice directing the opposite party to pay the medical claim amount. On 25.7.2014 the opposite party issued a reply. Having no other alternative the complainant filed the complaint.
4. The opposite party filed written version admitting taking of the policy by the complainant, inter alia, contending that the complainant suppressed the pre-existing disease, therefore, the opposite party rightly repudiated the claim of the complainant. It is the further case of the opposite party that, any disease contacted by the insured person within 30 days from the date of commencement of the policy is not entitled for the benefits under the policy. Hence the complaint is liable to be dismissed.
5. Before the District Forum, both parties filed evidence affidavits. On behalf of the complainant, Exs. A-1 to A-5 were marked. On behalf of the opposite party, Exs. B-1 to B-4 were marked.
6. Basing on the material available on record, the District Consumer Forum arrived at a conclusion that the opposite party repudiated the claim of the complainant on erroneous grounds consequently allowed the complaint directing the opposite party to pay an amount of Rs. 3,00,000 with interest at the rate of 9% p.a. from the date of complaint till the date of realization; Rs. 25,000 towards damages and Rs. 3,000 towards costs to the complainant. Hence, the appeal.
7. The learned Counsel for the opposite party (appellant) attacked the impugned order on the following three grounds:
(i) The District Forum has not properly considered the recitals of Ex. B-1 policy and allowed the complaint on untenable grounds;
(ii) The District Forum, without considering scope of policy, awarded an amount of Rs. 3,00,000 even though the complainant spent an amount of Rs. 1,70,000 towards treatment and medicines; and
(iii) If the order of the District Forum is allowed to stand, certainly it would amount to mis-carriage of justice. It is a fit case to allow the appeal.
8. Per contra, the learned Counsel for the complainant (respondents) submitted that the District Forum considered various documents filed by both parties in right prospective and allowed the complaint. He further submitted that the findings recorded by the District Forum is supported by the material available on record, therefore, it is a fit case to dismiss the appeal.
9. The point that arises for consideration is:
Whether the impugned order is liable to be set aside?
10. During the pendency of the appeal, the complainant (Respondent No. 1) died and his L.Rs. were brought on record
