ACHANTA RAMAKRISHNA RAO vs NEW INDIA ASSURANCE CO. LTD.

THE unsuccessful complainant filed this appeal questioning the order made in C.D. No. 19/1997. Since he died pending the appeal, his L.Rs. were brought on record as appellants 2 to 7.

THE case of the first complainant is that he is a holder of Cancard issued by the second opposite party Bank. THE first opposite party, Insurance Company, jointly with the second opposite party launched a scheme, Cancomfort, to provide insurance coverage to Cancard holders and members of their families against personal accident and unanticipated medical expenses. THE complainant subscribed to the said scheme and obtained Cancomfort Medi Claim Insurance Policy for himself, his wife and daughter. THE period of the policy was from 1.12.1995 to 21.10.1996. THE complainant stated that he is a known diabetic and hypertensive patient suffering from unstable Angina. He got admitted in Mullapudi Venkata Ramanamma Memorial Hospital, Tanuku on 4.4.1996 with chest pain and he was discharged on 10.4.1996. He proceeded to Madras and admitted himself in the Institute of Cardio Vascular Diseases run by Madras Medical Mission on 12.4.1996. He underwent Angiogram on 15.4.1996 and also By-pass surgery on 17.4.1996. He was discharged from the hospital on 30.4.1996. He incurred an expenditure of Rs. 1,88,562.60 ps. As the claim submitted by him was rejected, he filed the complaint. The first opposite party, Insurance Company, in its written version stated that the liability of the insurer is excluded for diseases which were pre-existing and as the insurer was suffering from Angina prior to the coverage, he is not entitled to claim any compensation.

The second opposite party merely stated in its written version that contract of insurance is between the complainant and the first opposite party and as such no deficiency can be attributed to the second opposite party.

THE first complainant marked Exs. A1 to A14 besides filing his affidavit while the first opposite party marked Exs. B1 to B4. THE District Forum found that there is no deficiency in service on the part of the opposite parties and accordingly dismissed the complaint. Hence the appeal. The first complainant is a Cancard holder. He joined Cancomfort Scheme under which there is insurance coverage not only for the holders but also their family members against personal accident and unanticipated medical expenses. There is also no dispute that the complainant paid the premium under Cancomfort Scheme through the second opposite party for insurance coverage to himself, his wife and daughter. The policy was from 1.12.1995 to 21.10.1996. Ex. A6 is the insurance coverage certificate dated 1.12.1995. Ex. A14 is the receipt evidencing payment of premium by the complainant.

THE complainant was admitted in Sri Mullapudi Venkata Ramanamma Memorial Hospital, Tanuku on 4.4.1996 on complaint of chest pain and he was discharged on 10.4.1996. Later he got himself admitted in the Institute of Cardio Vascular Diseases run by Madras Medical Mission at Madras. He underwent Angiogram on 15.4.1996 and By-pass surgery on 17.4.1996. He filed Ex. A7 copies of bills relating to his medical expenditure at Tanuku, so also Ex. A8 copies of bills relating to the medical expenditure incurred at Madras. He claims to have incurred in all Rs. 1,88,562.60 ps. and Rs. 378/- Ex. A5 is the claim filed by the complainant. Exs. A1 to A4 and Exs. A9 to A12 are the correspondence between the complainant and the Insurance Company. THE main contention of the first opposite party is that under Clause 14 of the policy, the corporation is not liable. Clause 14 reads as follows : "All diseases/injuries which are pre-existing when the cover incepts for the first time." Admittedly the complainant had earlier taken similar policy covering the period from 1.1.1994 to 31.10.1994 hence Ex. B3 is not first coverage certificate. The first appellant stated that he is a known diabetic and hypertensive patient suffering from unstable Angina and the said fact was disclosed by him in a separate sheet appended to the application for insurance. In the written version filed by the first opposite party, it is merely stated that it is admitted by the first appellant that he is a known diabetic and hypertensive patient suffering from unstable Angina prior to the coverage and, therefore, he is not entitled to claim any compensation. Hence it is clear that the allegation of the complainant that he has attached a sheet to his proposal/application disclosing his previous diseases that he is a known diabetic and hypertensive patient suffering from unstable Angina is not denied. When this is disclosed, we do not think that there is any suppression of material information. Further Clause 14 of the policy does not apply to this case as "All diseases/injuries which are pre-existing when the cover incepts for the first time" and in this case the cover does not incept now for the first time, there was an earlier policy. As such the contention of the first opposite party does not merit any acceptance. The first opposite party cannot go on accepting policies and finally when a claim is presented repudiate the same on the ground that there was pre-existing disease in respect of the latest policy. This cannot be the purport or effect of Clause 14. For the above reasons, we are of the view that the repudiation of the claim of the first appellant when he has honestly disclosed the pre-existing disease and when there is no material suppression, is unjust and arbitrary, there is, therefore, deficiency on the part of the first opposite party. Accordingly the appeal is allowed and the order of the District Forum is set aside and the complaint is allowed. In view of the bills produced, Ex. A7 and Ex. A8, the complainant has incurred an expenditure of Rs. 1,88,562.60 ps. and Rs. 378/-. Accordingly, the complaint and appeal are allowed directing the first opposite party to pay the said sum with interest at 9 per cent per annum from the date of filing the complaint till realisation. Time for payment six weeks. Appeal allowed.