This case is filed by the complainant against opposite party Oriantal Insurance Company Limited under section 12 of Consumer Protection Act, 1986 for deficiency of service. The case of complainant in brief is that Sri Jugal Kishore Bargaria entered into a contract by opening a policy bearing number 321201/48/2010/604 for the period from 06/07/2009 to midnight of 05/07/2010 covering tisk amount of rupees 1 lakh for his family members. The policy was renewed for the period from 06/07/2011 to 05/07/2011 under policy number 321201/48/2011/635 from 06/07/2011 to 05/07/2012 to 05/07/201. It may be mentioned that during the subsistence of policy Sri Jugal Kishore Bargaria one of the beneficiary was attacked by Ischemic Heart disease, Triple vessel coronary artery disease and he was treated at Asian Heart Institute by paying more than 12,00,000.00 (Twelve lakhs) only and intimation was given to opposite party Insurance company. After treatment the complainant submitted all papers, vouchers, bills along with claim form, but the opposite party number 1 vide letter dated 09/2012 repudiated the claim of beneficiary on the ground that the ailment is related with pre-existing condition. The complainant wrote a letter on 12/12/2012 to opposite party which was received by opposite party on 13/12/2012 but opposite party failed to give any reply. As there is deficiency of service on the part of oppositr party failed to give any reply. As there is deficiency of service on the part of opposite party, complainant has filed this case in this Consumer Forum for realization of assured sum amount of one lakh only with comopensatory cost and cost of proceeding payable by opposie party.
Notice was issued to opposite party which was duly served and opposite party Insumrance Company failed to appear and contest the case. As such this case is heard exparte. Complainant examined himself and submitted his affidavit as examination in chief. We have heard learned counsel of complainant perused the exhibited documentand case record.
Complainant Sri Jugal Kishore Bargaria in his evidence has stated that he entered into a contract with opposite party by opening a policy bearing number 321201/48/2010/604 for the period from 06/07/2009 to midnight of 05/07/2010 covering risk amount of rupees 1 lakh for his family menbers. The policy was renewed for the period from 06/07/2010 to 05/07/2011 under policy number 321201/48/2013/553 and on 06/07/2013 to 05/07/2014. It may be mentioned that during the subsistence of policy Sri Jugal Kishore Bargaria one of the beneficiary wa attcaked by Ischemic Heart Institute disese, Triple vessel coronary artery disease amnd he was treated at Asian Heart Institute by paying more than 12,00,000.00 (Twelve lakhs) and intimation was given to opposite party Insurance Company. After treatment the complainant submitted all papers, vouchers, bills along with claim form, but the opposite party number 1 vide letter dated 09/2012 repodiated the claim form, but the opposite party number 1 vide letter dated 09/2012 repodiated the claim of beneficiary on the ground that the ailment is related with pre-existing condition. The complainant wrote a letter on 12/12/2012 to opposite party which was received by opposite party on 13/12/2012 but opposite party failed to give any reply.
Complainant exhibited the following documents.
Exhibit : 1. Family floater policy number 321201/48/2011/635
- Family floater policy number 321201/48/2011/591
- Family floater policy number 321201/48/2013/553
- Family floater policy number 321201/48/2014/775 4(1)
- Family floater policy number 321201/48/2010/604
- Letter to Admit J.K.Bagarria from the Div Manager Oriental Insurance Compeny
- Letter to Oriental Insurence by Jugal Kishore Bargaria.
- Letter to Oriental Insurance by Jugal Kishore Bargaria dated 25/01/2013
- Patient cash bill dated 16/03/2012
- Patient intimation slip dated 11/12/2014
- Patient deposit receipts dated 11/12/2014 112 11(a) to 11(c)
- Original discharge copy dated 16/03/2012
- Laboratory copy dated 07/03/2012 to 18/03/2012 13(1) to 13(36)
- Family floater policy prospectus Oriental Insurance Limited
- Happy Family floater policy.
We have gone through all the exhibited documents in connection with this case and the consitions laid in the insurance policy which is exhibit 14. It is not disputed that Heart disease/Diabetic mellitus(HD/DM) and all pre existing disease are excluded from the mediclaim policy. Exhibit 12, the discharge cerificate issued dated 15/03/2012 by Asian Heart Institute Mumbai discloses that Jugal Kishore Bargaria aged 62 years was diagnosed as Ischemic Heart Disease, Triple Vessel coronary artery disease moderate as hypertension, epilepsy, stress, hyperglycemia etc. It is also reported that complainant was suffering HTN since 5 years, epilpsy since 15 years. Opposite party/Divisional Manager of Oriental Insurance company vide exhibit 6, in the repudistion letter communicated to complainant specifically mentioned that after scrutiny of the claimed documentss it was found that the patient element is related with pre existing
condition and falls under 4 years of exclusion, but the policy is only a 3rd year one. In a reported case CPJ(2012) page number 322 Honourable National Commission in National Insurance Company Limited and others versus Girin R Shah held that insurance company failed to establish link between pre existing disease and the abscess for which insured was operated on.
Honourable High Court Delhi, in revision petition number 1503/2004 G. Kothaainchair versus the Branch Manager, United India Insurance Company Limited and others decided on 29/10/2007, it was held that an Insurance Compant can repudiate theclaim only when there is fundamental/material breach of terms and consition of policy.
In our present case Insurance Company vide repudiation letter exhibit 6 has clartely established linked between pre existing disease and abscess.
we are of condered view that insurance company has committed no error in repudiating the claim and decided the matter as per clause 4.1 policy condition. As such there is no diciciency of service on the part of opposite party Insurance Company. Hence prayer for complainant petition is rejected and this case is dismissed.
