Haryana

StateCommission

A/646/2015

UNITED INDIA INSURANCE CO. - Complainant(s)

Versus

ARVIND KUMAR SINGH - Opp.Party(s)

P.S.SAINI

08 Nov 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

         

                                                         First Appeal No.646 of 2015  

Date of Institution: 20.07.2015

                                                               Date of Decision: 08.11.2016

 

United India Insurance Company Limited, Regional Office, SCO No.123-124,  Sector 17-B, Chandigarh through its duly constituted attorney Smt. Sunita Sharma, Dy. Manager.

…..Appellant

Versus

 

1.      Arvinder Kumar Singh S/o of Sh. Jagdish Kumar, R/o H.No.1748, Sector 23-A, Faridabad.

2.      Smt. Pushplata Singh w/o Sh. Arvind Kumar Singh, R/o H.No.1748, Sector 23-A, Faridabad.

3.      M/s Raksha TPA Pvt. Ltd., 15/5, Mathura Road, Faridabad-121003.

                                      …..Respondents

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mrs. Urvashi Agnihotri, Member.                                                                                                                                        

Present:              Shri P.S.Saini, Advocate counsel for the appellant.

Shri Kamal Grover, Advocate counsel for the respondent Nos.1 and 2.

None for the respondent No.3.

 

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:

It was  alleged that complainant NO.1 was insured by M/s Chola Mandlam Insurance Company Barakhamba Road, New Delhi in group insurance which was got  done by his employer.  His medi claim policy was valid from 13.04.2010 to 12.04.2011 for Rs.One lac which was got renewed from 13.04.2011 to 12.04.2011 for Rs.Three lacs. On 15.01.2012 complainant No.2  i.e., Pushpalata Singh w/o complainant No.1 fell ill and was taken to Fortis Hospital, Faridabad. She remained admitted there up-to 19.01.2012 and Rs.52060/- were paid to that hospital. As they were no satisfied with their treatment, she was taken to Asian Hospital,  Faridabad where she remained admitted from 28.01.2012 to 07.02.2012 and spent Rs.1,75,600/- on treatment. The claim was furnished with the O.Ps., but, the same was repudiated on the ground of concealment of pre-existing disease, whereas there was no concealment. The O.ps directed to pay Rs.Four lacs including cost of treatment, mental harassment agony etc.

2.      O.Ps. filed reply controverting their averments and alleged as per record submitted by the complainants it was found that she was a case of diabetic mellitus (D.M.) and hypothyroidism since two years. It shows that she was having this problem in the year 2010 i.e. before obtaining insurance policy. As per exclusion clause No.4.1 of policy complainants were not entitled for compensation qua pre-existing disease unless the policy continued for 48 months and their claim was rightly repudiated.

3.      After hearing both the parties, learned District Consumer Disputes Redressal Forum, Faridabad (In short “District Forum”) allowed the complaint vide impugned order dated 26.05.2015 and ordered as under:-

“Opposite party No.1 is directed to pay Rs.2,27,600/- with interest @ 9% p.a. from the date of filing of this complaint till realization of amount within 30 (thirty) days from the date of receipt of this order to the complainant.  Opposite party is also directed to pay Rs.5500/- as compensation towards mental agony, harassment alongwith Rs.2200/- as litigation expenses to the complainant.”

4.      Feeling aggrieved therefrom, opposite party No.1 has preferred this appeal.

5.      Arguments heard. File perused.

6.      Learned counsel for the appellant vehemently argued that from the perusal of  discharge summary of Fortis Hospital Annexure A-6 it is clear that the complainant was a case of diabetes and hypertension.  It is also mentioned in discharge summary  Ex.C-5 that she was suffering from diabetes and hypertension.  As per discharge summary of Asian Hospital Ex.C-8 she was suffering from diabetic mellitus and hypertension since two years i.e. since the year 2010, but, when the policies Ex.C-1 and C-2 were obtained this fact was concealed.  When policy Ex.C-1 was obtained on 13.04.2010 sum assured was Rs.One lac and lateron on when policy Ex.C-2 was obtained on 13.04.2011 that was increased to Rs.three lacs.  It shows that fact of illness was to their notice and they concealed the same. As per clause 4.1 of insurance policy insured is not entitled for compensation. In support of his arguments he placed reliance upon opinion of Hon’ble National Commission expressed in  Ram Swaroop Aggarwal & Anr. Vs. New India Assurance Co. Ltd., 1 (2014) CPJ 615 (NC) and Paramjit Kaur Vs. LIC of India & Anr. IV (2014) CPJ 132 (NC).

7.      However there is no dispute as far as opinion expressed by Hon’ble National Commission in aforesaid case law is concerned but the appellant cannot derive any benefit from the same because it has miserably failed to show that insured concealed the fact of illness. At the time of obtaining insurance policy proposal form must have obtained by insurance company, but, that is not produced in the evidence. At that time insured must have been asked about previous illness.  In the absence of proposal form it cannot be seen whether insured answer in affirmative or negative. If insured answered in affirmative then how insurance company can reject the claim. That was best piece of evidence which is with-held by the appellant. It is well settled proposition of law that if best piece of evidence is with-held by any party then it is to be presumed that the same was going against the same. In such like matter the benefit of doubt is to be given to the consumer and not to the service provider as opined by Hon’ble National Commission in Revision petition No.4544 of 2012 decided on 27.11.2013 titled as National Insurance Company Ltd. Vs. Gopanaboina Sathyam and revision petition No.3236 of 2013 decided on 07.08.2014 titled as Sh. Abhishek Jain Vs. HDFC Standard Life Insurance Co. Ltd. So it cannot be opined that complainants concealed the fact of previous illness when obtained the insurance policy and are not entitled for compensation. Impugned order dated 26.05.2015 passed by the District forum is well reasoned and cannot be set aside. Resultantly appeal fails and the same is hereby dismissed.

8.      The statutory amount of Rs.25000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and verification.

November 08th, 2016

Mrs.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

S.K.