IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Monday the 16th day of March, 2020
Filed on 21.07.2015
Present
1. Sri.S.Santhosh kumar(President)
2. Smt. Sholly.P.R ,LLB (Member)
3. Smt. C.K.Lekhamma.LLB(Member)
In
CC/No.226/2015
Between
Complainant:- Opposite parties:-
Sri.Baiju.K.V 1. Bharathi AXA Life Insurance
S/o Sathy Company Ltd.
Harithachandanam Registered Office, Unit 601 &602,
Chungam, Alappuzha 6th Floor, Raheja Titanium
Off Western Express Highway
Gargoan(East) Mumbai-400006
Represented by its Managing Director.
2. Bharathi AXA Life Insurance
Company Ltd.
Branch Office, Sarada complex
Mullackal, Alappuzha
Rep. by its Manager
O R D E R
SMT. SHOLLY.P.R (MEMBER)
This is a case based on a consumer complaint filed u/s 12 of the Consumer Protection Act. 1986.
1. The averments in the complaint in short are as follows:-
The complainant had taken a policy by name Bharti AXA Health Tripple Health Insurance Plan for a sum assured value of Rs. 3,70,000/- during the year 2014 vide policy no. 501-1955704. He had made a medical checkup in the month of October 2014. After a thorough medical examination and study by the medical team have diagnosed on 7-11-2014 that the complainant is having soft tissue swelling on his right upper thigh. Accordingly he was admitted in Medical College Hospital on 7-11-2014 and underwent a surgery for removing lipoma on the right thigh of the complainant. He was discharged on 8-12-2014 and submitted a claim to the opposite party as per the terms and conditions of the policy of insurance for realizing the benefits under the said policy being the beneficiary of the policy. The opposite party repudiated the claim of the complainant vide letter dtd. 6/1/2015 stating that the policy holder had withheld material information regarding his health at the time of affecting the assurance. The complainant had never suppressed any material facts of the opposite party and all the relevant facts regarding the health conditions was disclosed by the complainant to the opposite party at the time of availing the policy. And medical examination of the complainant in depth was done by the approved medical examiner of the opposite party prior to the subscribing of the policy and that policy was issued by the opposite party only upon satisfying the health condition from the certificate issued by the approved medical examiner. Therefore it is submitted that explanation put forth by the opposite party that the complainant was suffering from pre-existing disease is utter falsehood and baseless. Being aggrieved by the illegal repudiation the complainant again approached the opposite party and thereafter he approached the zonal manager of the opposite party. But not settled the claim of the complainant and thus he filed the complaint alleging deficiency in service on the part of the opposite party.
2. Notice issued to the opposite parties were served, but due to the non appearance of the opposite parties they were set ex-parte and on the basis of the proof affidavit and documents filed by the complainant on 3/8/2017 an exparte order was pronounced by this Forum earlier.
Aggrieved by the above order the opposite parties filed an appeal before the Hon’ble State Commission where the appeal allowed on 21-12-2018 by setting aside the order passed by the District Forum on certain conditions for fresh disposal of the matter after giving reasonable opportunity to the appellants/opposite parties to file written version and to adduce evidence, if any and also to dispose of as early as possible.
As per the direction in the order of the Hon’ble State Commission notices issued to both the parties and those were served, but the opposite parties did not turned up and no version filed. In the circumstances we are of the view that inspite of the direction of the Appellate Forum the opposite parties are not interested in contesting the matter hence they were set ex-parte again and the earlier proof affidavit filed by the complainant has taken as the chief Examination and the documents got marked as Ext.A1 to A4.
3. The points for consideration are:-
1. Whether there is any deficiency in service on the part of the opposite
parties?
2. If so, the relief and costs?
4. The complainant had taken a policy from the opposite parties during march 2014 for a sum assured value of Rs. 3,70,000/-. The policy produced and got marked as Ext.A1. According to the complainant he was admitted as an inpatient in the Medical College Hospital on 7-11-2014 and underwent surgery for removing Lipoma on his right thigh and was discharged on 8-12-2014. Ext.A3 is the case records of the policy holder. Even though he submitted a claim to the opposite party for releasing the benefits under the policy it was repudiated on the ground that the policy holder has withheld material information regarding health at the time of affecting the assurance. Ext.A4 is the copy of the letter sent by the complainant to the opposite party along with the certificate dtd. 27-1-2014 issued by Dr. R.V.Ramlal. The said letter shows that the soft tissue swelling which appeared on the right thigh of the complainant is dinovo and it is not related to any pre existing condition like diabetics or whatsoever. The affidavit filed by the complainant is not challenged by the opposite parties even after taking the matter for considering the written version of them as per the order of the Appellate Forum. The action of the opposite parties in repudiating the claim of the complainant amounts to deficiency in service.
5. In the result opposite parties are directed to work out the claim of the complainant treating him eligible for the claim as per the terms of the policy and to pay the sum so arrived with 9% interest per annum from the date of complaint till realization and to pay an amount of Rs. 10,000/(Ten thousand only) towards compensation and also directed to pay Rs.5000/-(Five thousand only) towards costs of the proceedings to the complainant. This order shall be complied within one month from the date of the receipt of this order.
Dictated to the Confidential Assistant, transcribed by him corrected by me and pronounced in open Forum on this the 16th day of March, 2020.
Sd/-Smt. P.R.Sholly (Member)
Sd/-Sri. S.Santhosh Kumar(President)
Sd/-Smt. C.K.Lekhamma (Member)
Appendix:-Evidence of the complainant:-
Ext.A1 - Policy Schedule
Ext.A2 - Copy of the health claim intimation form
Ext.A3 - Copy of the case records of the policy holder
Ext.A4 - Copy of the letter sent by the complainant to the OP along with the
certificate dtd. 27/1/2014 issued by the Dr. R.V.Ramlal.
Evidence of the opposite parties:-Nil
// True Copy //
To
Complainant/Oppo. party/S.F.
By Order
Senior Superintendent
Typed by:- Br/-
Compared by:-
