Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 190.
Instituted on : 04.04.2016.
Decided on : 06.03.2018.
Jagbir Singh s/o Randhir Singh R/o H.No.1816, Sector-2, Rohtak.
………..Complainant.
Vs.
- Bharti Axa General Insurance Company Limited, 418/29, 1st Floor, Chhotu Ram Nagar, Opp. University Shops, Main Delhi Road, Rothak through its Manager.
- Vidit Sharma, Specialist, Commercial Claims, North Bharti Axa General Insurance Company Limited, Peral Plaza, K-24, 3rd Floor, Plot –A, B, C, D, E, Sector-18, Noida-201301.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.RAJBIR SINGH DAHIYA, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh.Pawan Balhara, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for the opposite party No.2.
Opposite party No.1 given up.
ORDER
KOMAL KHANNA, MEMBER:
1. Brief facts of the complaint are that complainant had purchased online accidental policy from the opposite party company on 16.04.2014 and make the online payment of Rs.3499/- vide application No.41000946 for a sum assured of Rs.30 lacs. That complainant got mentioned about his all previous illness/disease on 21.04.2014 by giving the details that he is suffering from sugar, liver disease and suffering from liver arosis and left by poler and operation of right leg has been done and has send the details online to company and after receiving all the information the company and after proper verification issued the final policy No.SAP/S9900348/2C/04/B71011 and issued the accidental policy on dated 31.05.2014. That on 17.07.2014 complainant met with an accident and due to emergency circumstances the complainant was operated and an amount of Rs.150000/- was spent on operation and treatment. That the complainant duly informed the insurance company about the accident and filed the insurance claim. That the complainant was got medically examined by Civil Surgeon and his disability was assessed as 85%. That despite repeated requests of the complainant; the claim amount has not been paid to the complainant. The complainant served a legal notice dated 03.02.2016 but the opposite party vide its letter dated 04.02.2016 has repudiated the claim of the complainant illegally on false grounds. Hence this complaint with prayer to direct the opposite parties to pay an amount of Rs.850000/- as claim amount alongwith interest and a sum of Rs.150000/- as compensation on account of harassment as well as physical agony alongwith interest @ 18% p.a. from the date of its due till realization and Rs.11000/- as litigation expenses to the complainant.
2. After notice, opposite parties filed their written statement and submitted that it is affirmed to the extent that the complainant had obtained from this respondent a Smart Personal Accident Insurance policy for the period 16.04.2014 to 15.04.2015. That the complainant had wrongly described that he had operation of right leg. It has been ascertained that the complainant had in the past sustained injuries to his left hip/thigh for which he had undergone surgical treatment, left Bipolaar Hip Replace Implant. That the complainant was a previously operated case of Bipolar Prosthesis Lt. hip and the present diagnosis was Prosthesis Dislocation lt. hip for which prosthesis removal was done. It is wrong and denied that the complainant has spent the alleged sum of Rs.150000/- on operation and treatment. That the claim of the complainant is not admissible and this was clearly communicated to the complainant by letter dated 04.02.2016. It is prayed that the present complaint may kindly be dismissed with costs.
3. Complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C23 and closed his evidence. On the other hand, ld. counsel for the opposite party No.2 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R6 and closed his evidence.
4. Arguments heard and file perused.
5. After going through the file and hearing the parties it is observed that as per discharge card Ex.C7, the disability occurred to the complainant due to the accident on dated 17.07.2014 which clearly shows that due to this accident the dislocation of prosthesis of the left hip resulting in the complete removal of the same. Due to which the working ability has been effected. Investigation report Ex.R3 also confirms the surgery and as per disability certificate Ex.C18 there is 85% disability to the complainant and it is opined by the S.M.O. that the condition is progressive/not likely to improve and it may deteriorate”.
6. Regarding the repudiation of claim on account of policy exclusion clause 7.6- “Any pre-existing disability/accidental injury”, Insurance companies should not be having so much of inhuman view towards the plight of the insurer & just repudiate the claim without looking into the seriousness of the medical condition of the claimant. Accordingly we allow the complaint and direct the opposite party No.2 to pay the claim amount of Rs.850000/-(Rupees eight lac fifty thousand only) as claimed by the complainant alongwith interest @ 9% p.a. from the date of filing of present complaint i.e.04.04.2016 till its realization and shall also pay a sum of Rs.10000/- as litigation expenses and compensation. Rs.1000/-(Rupees one thousand only) per day is also awarded to the complainant w.e.f. 17.07.2014 to 03.08.2014 on account of hospitalization during his stay in the hospital.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
06.03.2018.
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Rajbir Singh Dahiya, President
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Komal Khanna, Member.
…………………………
Ved Pal, Member.
