BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 54 of 2018
Date of Institution : 05.02.2018
Date of Decision : 18.07.2019
Manjit Singh son of Shri Bhagirath, resident of C/o Jyoti Jewellers, Near B.D.O. Office,Rania District Sirsa.
……Complainant.
Versus
- ICICI Lombard General Insurance Company Limited, through its Manager having its office at ICICI Lombard House, 414 Veer Saverkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
- Krishan Kumar, c/o ICICI Lombrd Metropolis Mal, 5th Floor, Unit No.7-8 Opposite Vidyut Sadar Delhi Road, Hisar (Mob.No.70270-00519) (agent of the company).
- Ravi Kumar Mehta son of Shri Prem Chand Mehta, Mangalia Wali, Ward No.4, Near Primary School, Rania District Sirsa (Sub Agent).
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH.R.L.AHUJA………………. ……PRESIDENT.
SH.ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. L.S.Sarori, Advocate for the complainant.
Sh. H.S.Raghav, Advocate for opposite party No.1.
Ops No.2 & 3 exparte.
ORDER
The case of the complainant, in brief, is that the complainant purchased a medi-claim policy from Ops vide policy/cover note No.4128i/HPR/92584690/01/000 previous policy No.4128i/HP/92584690/ 00/000 for the period from 11.08.2016 to 10.08.2017 for sum assured of Rs.3 lac and he had paid Rs.9602/- as premium thereof. During the subsistence of the policy, the complainant felt pain in spine code with problem of flatulent swelling on Axilla, therefore, he remained admitted in Apex Hospital, Sirsa 04.07.2017 and remained on bed continuously for 15/20 days. The complainant submitted all the requisite bills and treatment record with the Ops but they have repudiated the claim vide letter dated 31.07.2017 on the ground that during the processing of pre-authorization request No.110100317990 for admission of Apex Hospital & Research Centre on 04.07.2017 we came to know that the insured Manjit Singh has diabetes from 10 years and on triglim as per calculation paper dated 30.06.2017 and as per Dr.R.K.Mehta statement attested with insured signatures, but the same was not disclosed during pendency inception i.e. 22.08.2014 despite the fact that he was suffering from diabetic for the last one year. The Ops have wrongly and illegally repudiated the claim of the complainant and it amounts to deficiency in service on their part. Hence, this complaint.
2. On notice Ops appeared and filed their joint reply wherein it has been submitted that the present complaint is not maintainable as there is no deficiency in service on the part of Ops in repudiating the claim which was duly intimated vide letter dated 31.07.2017. The present complaint has been filed after concealing the material facts from this Forum. The complainant had purchased the policy in question without disclosing the fact that he was suffering from diabetes, which is clear violation of the terms and conditions of the policy. There is no deficiency and unfair trade practice on the part of Ops. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The perusal of the case file reveals that in order to prove his case, the complainant has furnished his affidavit Ex.CW1/A wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record documents such as termination notice Ex.C1, thanks letter Ex.C2, certificate Ex.C3, policy schedule Ex.C4, Ex.C5, receipts for medical tests Ex.C6 to Ex.C11, treatment record and tests reports, bills Ex.C12 to Ex.C18. On the other hand, learned counsel for the Ops have tendered written statement in their evidence by separate statement of Sh.H.S.Raghav, Advocate for Op No.1.
6. The perusal of the record reveals that the complainant has purchased a medi-claim policy from Ops vide policy/cover note No.4128i/HPR/92584690/01/000 previous policy No.4128i/HP/92584690/ 00/000 for the period from 11.08.2016 to 10.08.2017 for sum assured of Rs.3 lac and he had paid Rs.9602/- as premium thereof. That the complainant suddenly fell ill and suffered from pain in spinal code in lower operation and on suffering from flutuent swelling on Axilla, therefore, he remained admitted in Apex Hospital, Sirsa from 04.07.2017 and took treatment. He has clearly mentioned in his complaint that he is suffering from diabetes from the last one year, but however, the Ops have repudiated the claim of the complainant on the ground that the complainant is suffering from diabetes for the last 10 years as per the report of Dr.R.K.Mehta, Apex Hospital Ex.R14.
7. Admittedly, the complainant has purchased medi claim policy from Op No.1 on making the payment of premium. It is also an admitted fact that the complainant suffered from spinal problem and he got admitted in Apex Hospital, Sirsa where he got treatment and paid the bill of the hospital. Due intimation was given to the Ops and claim was lodged but however, the claim was repudiated by the Ops on the basis of report of Dr.R.K.Mehta, Apex Hospital by which he has reported that the patient is diabetic for the last 10 years and this fact was intentionally concealed by the complainant at the time of getting the policy.
8. From the record, it is apparently clear that the complainant has been getting policies from Op No.1 from time to time and during the subsistence of the policies he was disclosed as patient of diabetes. The perusal of Ex.C14 reveals that in the upper part no doubt the doctor has reported according to patient past history as given by him he was diabetic for the last 10 years and for which he is taking tab triglin 1 BD. Patient has no previous consultation papers for the same but in the lower part of this document it has been reported by him on 11.07.2017 that it has been brought to our notice by patient that he is having diabetes for last 10 years, is incorrect statement, he is having same for last one year only. Though, this report of the doctor Ex.C14 is self contradictory on the basis of which the Ops have repudiated the claim of the complainant, but however, the Ops have not led any independent cogent and convincing evidence in order to prove their defence plea that the complainant was having the problem /disease of diabetes from the last 10 years i.e. pre existing disease before the inception of policy. Rather, the Ops only tendered their written statement in their evidence and even did not tender the affidavit of any authorized signatory in support of their pleas in the written statement. So, it appears that the Ops have repudiated the claim of the complainant arbitrarily and in a very casual manner and the same is liable to be set aside and the Op No.1 is under legal obligation to settle and pay the claim of the complainant.
8. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim of the complainant within a period of 30 days from the receipt of the copy of this order. The Ops are further directed to pay Rs.2,000/- to the complainant as composite compensation on account of harassment and litigation expenses. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:18.07.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
