DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

CASE   NO:   CC- 67 of  2023

 

S/O- Late Jagadish Pal,

Kamalghat Bazar, P.O. Kamalghat,

P.S. Lefunga, West Tripura- 799210.

 

-VERSUS-

 

1. Cholamandalam MS General Insurance Company Ltd.,

2nd Floor, DARE House,

2 NSC Bose Road, Chennai- 600001.

 

2. Cholamandalam MS General Insurance Company Ltd.,

Agartala Branch, Mantribari Road, 

Agartala,West Tripura. 

P.O. Agartala, Pin- 799001,

Opposite to Titan Watch Showroom,

Represented by its 

Branch Manager. ….......Opposite Parties.

 

   ________PRESENT__________

 

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR(SMT) BINDU PAUL

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

SRI SAMIR GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

 

C O U N S E L

 

 

For  the  O.P. : Sri Subhajit Chakraborty,

 

 

 

F I N A L    O R D E R

1. This case is filed by Sri Gopal Pal of Kamalghat, West Tripura here-in-after called the 'Complainant' against (1) Cholamandalam MS General Insurance Co. Ltd., Chennai here-in-after called the 'O.P. No.1' and (2) The Branch Manager, Cholamandalam MS General Insurance Co. Ltd., Agartala Branch, Agartala, West Tripura here-in-after called the 'O.P. No.2' alleging deficiency in service on the part of the O.Ps.

1.1 The case in short is that the complainant is a businessman running hotel business at Kamalghat Bazar and had good health condition. In the month of July, 2020 the the agent of the O.P.  made approach to the complainant for purchasing Health Insurance Policy namely 'Arogya Sanjeevani Policy'.  After discussion the complainant agreed to purchase the said Policy from the O.P. 

1.2 Accordingly in the 2nd week of July, 2020 the medical examination of the complainant was done  by the O.P. in their authorized pathology and diagnostic centre and thereafter the complainant paid yearly premium amount of Rs.13,539/-.

1.3 Health Insurance Policy card was issued by the O.P. vide Policy No-2892/00011660/001/00, membership No- A6132566A and customer ID No- 101772530277,  which was renewed every yer and lastly premium was accepted on 12.07.2022  covering period  up to the midnight of 12.07.2023. Thereafter the complainant again paid premium  on 12.07.2023 but the O.P. by a letter dated 06.07.2023 cancelled the policy of the complainant.

1.4 On 22.04.2023 the complainant was admitted in the TMC & B.R. Ambedkar Teaching Hospital with pain in the left foot and lower fat of leg and treated there up to 26.04.2023. 

 

1.5 On 27.04.2023 the complainant went to Kolkata and was admitted in the Fortis Hospital, Kolkata for treatment/operation of left Ilio-femoral grafting as he was diagnosed peripheral vascular disease of left lower limb.

1.6 The complainant approached for availing benefits of Arogya Sanjeevani Policy but the representative of the O.Ps denied to provide any benefit and told to apply after completion of the treatment. 

1.7 As the O.Ps denied to provide cashless facility the complainant had to incurred the cost of operation and treatment amounting to Rs.2,69,000/- to the Fortis Hospital. 

1.8 Thereafter on 06.06.2023 after recovery from the illness the complainant approached to the O.P. No.2 but on 06.07.2023 the O.P. issued cancellation notice to the complainant on the ground of non disclosure of material facts that the complainant suffering from hypertension for last 7 years as per medical record submitted by the complainant and this was not disclosed by him  at the time of filling up of the proposal form of insurance policy. 

1.9 On various occasion the complainant requested to the O.Ps for payment of the treatment cost  but the O.Ps denied. All the medical documents- insurance Policy, Treatment sheets of Fortis Hospital as well as TMC Hospital etc. are kept with the O.P. 

1.10 Hence the complainant filed this case before this Commission for adequate relief and compensation. 

2. The O.Ps in their written objection denied and disputed the allegations made by the complainant in his complaint petition. It is stated that the complainant suppressed about his earlier ailments i.e., hypertension etc. which is directly connected with the diagnosed medical ailment as such the claim is not considerable by the O.P. as per terms of the Policy. The claim of the  complainant to the medical treatment is rightly repudiated for the grounds of non-disclosure of pre-existing disease which are directly related to the pre-existing condition of the insured. 

 

 

3. Hearing argument following points are taken up for discussion and decision: -

 

4. From the evidence and documents it is proved that the complainant obtained policy of Insurance from the O.P. in the year, 2020 and since then he has been renewing his policy year to year.

4.1 The complainant was admitted in TMC, Agartala on 24.04.2023 with pain in left foot and lower part of leg. Thereafter, the complainant was admitted in  Fortis Hospital, Kolkata on 28.04.2023. The ultimate diagnosis was peripheral Vascular Disease of left lower limb and he has history of hyper tension with further history of smoking and alcohol. 

 

4.2 According to the O.P. the complainant is guilty of suppressing material facts as the complainant was having hypertension for last 7 years which is one of the direct connection or cause of peripheral vascular disease. But the medical report of the Hospital nowhere mentioned that the hypertension when developed as the complainant obtained the policy of Insurance in the year, 2020 and since then he had been renewing the policy year to year. In the documents also nowhere mentioned that Peripheral Vascular disease of left lower  limb  had any connection with hypertension. 

4.3 Suppression of material fact at the time taking of Insurance shall be proved only if the fact is material and if the complainant having knowledge of such material fact of pre-existing disease obtained the policy of Insurance by suppressing such fact. Meaning thereby, even in case of pre-existing disease it can not be said to be the suppression of material fact until and unless the complainant had prior knowledge of such disease.

 

 

4.4 In the case at hand, there is no iota of evidence that at the time of taking the policy of insurance the patient had knowledge of hypertension; the fact of hypertension has any connectivity with Peripheral Vascular Disease of left  lower limb and finally that the complainant had knowledge of such Peripheral Vascular Disease of left lower limb at the time of taking the policy of Insurance. As such, all the points are decided against the O.P. and in favour of the complainant as the repudiation of claim by the O.P. Insurance Company is baseless, arbitrary.

 

5. In the result, it is ordered that the O.P. Insurance company shall pay the sum of Rs.2,69,000/- to the complainant with interest @ 7.5% P.A. from 22.08.2023 i.e., the date of admission of the case till the date of actual payment.  In addition to that the O.P. shall pay a further sum of Rs.20,000/- to the complainant as compensation which is inclusive of litigation cost. 

 

 

6. The case stands disposed of.

7. Supply copy of this Final Order free of cost to the parties.

 

Announced.

 

 

 

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

 

DR(SMT) BINDU PAUL

MEMBER,

DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.

 

 

SRI SAMIR  GUPTA

MEMBER,

DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.