Haryana

StateCommission

A/199/2015

ORIENTAL INSURANCE CO. - Complainant(s)

Versus

DR.PURSHOTTAM SINGLA - Opp.Party(s)

J.P.NAHAR

16 Sep 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal    No  :    199 of 2015

Date of Institution  :      02.03.2015  

Date of Decision    :      16.09.2015

 

The Oriental Insurance Company Limited, Sirsa, through its Branch Manager, now through its authorized signatory S.P. Singh, Regional Manager, LIC Building, Jagadhri Road, Ambala Cantt.

                                      Appellant-Opposite Party

Versus

Dr. Purshottam Singla s/o Sh. Diwan Chand, Daya Hospital, Old Court Road, Mandi Dabwali, District Sirsa.

                                      Respondent-Opposite Party

CORAM:

                             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                             Mr. Diwan Singh Chauhan, Member.                                                                                          

For the Parties:  Shri J.P. Nahar, Advocate for appellant.

                             Shri Gitish Bhardwaj, Advocate for respondent.  

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

 

The Oriental Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party, is in appeal against the order dated November 12^th, 2014, passed by District Consumer Disputes Redressal Forum (for short District Forum), Sirsa.

2.      Dr. Purshotam Singla-complainant-respondent, purchased Medi-claim Insurance Policy (Exhibit C-2) from the Insurance Company for the period from March 26^th, 2007 to March 25^th, 2008.  The policy was in continuation of earlier policies which commenced about 5/6 years back. The Insurance Company appointed Paramount Health Services Private Limited-opposite party No.2, as Third Party Administrator for settlement of claims.

3.      The complainant suffered stomach pain. He was admitted in Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. He was diagnosed as Thrombus in vein in the abdomen and remained admitted in PGIMER, Chandigarh from September 14^th, 2007 to September 28^th, 2007. He filed claim of Rs.83,000/- with the Insurance Company but his claim was repudiated vide letter dated January 8^th, 2009 (Annexure A-5) stating therein as under:-

“Dr. Purostoam Singla was hospitalized from 14/9/08 to 28/9/08 as a case of superior mesenteric vein thrombosis.

As per our data and policy copy sent, date of inception of policy is 26/3/07. As per discharge summary patient has history of deep vein thrombosis 11 years back. Therefore the ailment is pre-existing and claim stand repudiated as per clause 4.1.”

4.      Aggrieved of the repudiation of his claim, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Forum.

5.      The opposite party-Insurance Company in its reply admitted that the complainant and his family were insured with it for Rs.1.00 lac. It was stated that the complainant had not furnished all the required documents to the T.P.A. As per the Discharge Summary issued from PGIMER, Chandigarh, the complainant had suffered from the disease 11 years back as having history of APD-Duodenal ulcer for the last 22 years but this fact was not disclosed by the insured in the proposal form. It was prayed that the complaint merited dismissal.

6.      On appraisal of the pleadings of the parties and the evidence adduced on the record, the District Forum allowed complaint directing the Insurance Company as under:-

“………this complaint is hereby allowed, with a direction to the opposite party to pay medical expenses of Rs.83,000/- to the complainant, with interest @ 9% per annum, from the date of discharge from the hospital i.e. 28.9.2007, till payment. Complainant is also hereby awarded compensation of Rs.10,000/- for his harassment, mental agony etc and litigation expenses of Rs.2200/- against the opposite parties.”

7.      Learned counsel for the appellant-Insurance Company contended that nothing was payable to the complainant in view of Clause 4.1 of the Insurance Policy and therefore the order of the District Forum deserves to be set aside.

8.      Though the Insurance Company has relied upon Clause 4.1 of the policy but the same has not been produced by it either before the District Forum or before this Commission. Oral version without any documentary evidence cannot take the shape of proof. Even otherwise, the plea with respect to the pre-existing disease could be taken if the insured had regular/continuous problem. Some casual problem 11 years back could not be a ground to reject the claim. There is no clause on the file to show that complainant’s claim was not covered under the policy. Thus, no ground to interfere with the order of the District Forum is made out.

9.      Hence, the appeal fails and is hereby dismissed.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 16.09.2015

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL