DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM

WEST TRIPURA : AGARTALA

 

 

CASE NO:  CC – 108  of   2017

 

 

Sri Tinku Nath Sharma,

C/O- Subhash Nath Sharma,

Durganagar, Khowai,

P.O. Khowai, Khowai Tripura. ........…...Complainant.

 

 

             -VERSUS-

 

      1. Life Insurance Corporation of India (LICI),

Silchar Branch, Cacher, Assam.

 

 

        2. The Branch Manager,

Teliamura, S.O. A.A. Road,

Teliamura, Tripura-799201. ......... Opposite Parties.

 

 

 

__________PRESENT__________

 

 

 SRI A. PAL,

PRESIDENT,

  DISTRICT CONSUMER 

 DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. DR. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

 

C  O  U  N  S  E  L

 

For the Complainant : Sri Koushik Roy,

  Sri Udai Sankar Singha,

  Smt. Riya Majumder,

  Sri Koomar Chakraborty,

  Advocates.   

 

For the O.P. : Sri Prahlad Kr. Debnath,

  Advocate.

 

 

JUDGMENT  DELIVERED  ON:  03.04.2018.

 

J U D G M E N T

This case arises on the petition filed by one Tinku Nath Sharma U/S 12 of the Consumer Protection Act. Petitioner's case in short is that he purchased LIC's Jeevan Arogya Policy from the O.P. After purchase of the policy he underwent angioplasty operation on 27.04.16. After recovery he submitted claim for Rs.1,66,702/- as cost of treatment with supportive documents. But claim was not satisfied. He then sent reminder. Ultimately his claim was rejected by O.P. It was rejected on the ground that he has been suffering from hypertension and he suppressed the material fact. He then approached the Ombudsmen but did not get any relief. Thereafter he approached this District Forum for redress.

 

2. The O.P. Insurance company appeared, filed written statement denying the claim. It is stated that the petitioner suppressed the material fact at the time of purchasing the policy. He committed fraud and his claim was rightly repudiated by the Insurance company. There was deficiency of service by Insurance Company.

 

3. On the basis of assertion made by both the parties following points cropped up for determination;

(I) Whether the petitioner's claim for reimbursement for the cost of treatment was repudiated without reasonable cause?

(II) Whether the petitioner is entitled to get cost of treatment and compensation as claimed? 

 

4. Petitioner produced the Policy Certificate, Rejection letter, Discharge Summary, Claim Form, Bills of the Apollo Hospital, Reports, Deposit receipt of Apollo Hospital, C.T. Scan Report, Boarding Pass, Appeal to ombudsman and Award, Receipt of complain, Award of Insurance Ombudsman. Petitioner also produced the Statement on affidavit of one witness i.e., the petitioner himself.

 

5. O.P. on the other hand produced the Proposal Form of Insurance Policy, Copy of Insurance Policy, Discharge Summary and also statement on affidavit of one witness, Md. Ali Chowdhury.

 

6. On the basis of all these evidence on record we shall now determine the above points.

 

Findings and decisions:

 

7. Learned advocate for O.P. in this case produced the decision of State Consumer Disputes Redressal Commission in case no- 35 of 2016. 

 

8. Learned advocate for petitioner also argued that his claim was justified and his claim over reimbursement was repudiated for nothing.

 

9. We have to scrutinized the evidence as produced by both the parties. Firstly we have to go through the Insurance Policy Certificate and found that 'Jeevan Arogya' Policy was purchased and it commenced from 28.04.2015 which will expire on 28.04.2050. Admittedly premium was paid and petitioner suffered ailment when the policy was alive. He was admitted on 26th April 2016 and discharged on 29th April 2016. 

 

10. Petitioner in his statement on affidavit stated that he had undergone treatment in the Apollo Hospital, Chennai. He also stated that he never underwent any treatment for hypertension. 

 

11. P.W.2, Bijoy Choudhury stated that he was in the Apollo Hospital with the complainant at the time of his treatment.

 

12. Md. Ali Chowdhury, O.P.W.1, on the other hand, Manager(Admin) of the LICI stated that pre-existing ailment was suppressed by the petitioner. He was totally careless of his health &  about his disease of hypertension and at the time of purchasing policy he was suffering from hypertension.

 

13. We have gone through the discharge summary issued by the Apollo Hospital on 29.04.16. There it was written that history of hypertension was 2 years without any medication. From this it is clear that he was not aware about any hypertension which was found by the doctors in the year 2016 at the time of his treatment. Range of the blood pressure is given in the discharge summary. It is written 130/80. So it can not be assumed that he was a patient of high blood pressure at the time of purchasing the policy in the year 2015. As such hypertension was found without medication in the year 2016. 

 

14. Learned advocate for the O.P. preferred the decision of the National Consumer Disputes Redresssal Commission in case of Phoola Devi Vs. LICI, in Revision Petition No. 2271 of 2011. In that case the petitioner did not disclose the disease suffering for last 22 years. Our Supreme Court  in (2009)8 SCC 316 viewed that it is the obligation of policy holder to make a true and full disclosure about health condition. 

 

15. In Revision Petition No. 65 - 66 of 2011 our National Commission also held that in the case of suppression of existing disease claim is not justified. In case No. A.35 of 2016 our Hon'ble State Commission also viewed that in case of suppression of material facts contract is violated and petitioner is not entitled to get claim. 

 

16. The evidence as produced before us do not support  the facts that the petitioner was patient of hypertension in the year 2016. He was not taking any medicine for hypertension. At the time of his treatment after more than one year in the Apollo Hospital his systemic hypertension was detected by the doctors. It was assumed that he was suffering from that disease at the time of purchasing policy. It is clear that petitioner was not aware about such hypertension at the time of purchasing policy. O.P. Insurance company also did not arrange for his examination by any doctor and relied on the statement that he was hypertensive at the time of purchasing policy. Accordingly direction given by them which was accepted.

 

17. Some question were put to the petitioner to describe the health details and petitioner replied that he had no blood pressure, hypertension or high blood pressure as he was not aware about it on 29th April 2015 when he signed in the declaration. He was also not under medication. In such a position we can not say that petitioner suppressed the material fact knowing fully that he was a patient of hypertension. It is true that in case of suppression of material fact he is not entitled to get the cost of treatment. But in this case on scrutiny of the evidence it is found that petitioner was not aware about his hypertension and there is no specific evidence to support that on 29.04.2015 he had been suffering from high blood pressure. He did not make any false statement as such.

 

18. Petitioner produced all bills, vouchers, claim form, confirmation report in support of the claim. O.P. Insurance company also did not deny all these claim papers. 

 

19. The appeal before the ombudsman failed on the same ground that petitioner was suffering from hypertension for the last  2 years prior to the purchase of policy. But such conclusion can not be withdrawn without any definite proof. This is only assumed and presumed as he suffered an accident on 2003 and underwent surgery. In absence of any medical evidence we can not say that he  is a patient of hypertension at the time of purchasing the policy. As such his claim was rejected without any proper justification on assumption and presumption by Insurance company. Such rejection is considered as deficiency of service by Insurance company. Therefore, the complainant is entitled to get the cost of treatment and also compensation as claimed. Both the points are decided accordingly.

 

20. In view of our above findings over the points we consider that the petitioner is entitled to get the claim amount of Rs.1,66,702/-(Rupees One Lac Sixty Six Thousand Seven Hundred Two) as it is supported by sufficient documents and covered the policy. Petitioner is also entitled to get Rs.25,000/-(Rupees Twenty Five Thousand) compensation for deficiency of service of O.P. Insurance Company and Rs.5,000/-(Rupees Five Thousand) for litigation cost. In total petitioner is entitled to get Rs.1,96,702/-(Rupees One Lac Ninety Six Thousand Seven Hundred Two). O.P. is to pay the amount within 2(two) months. If not paid will carry interest @ 9% P.A. Case disposed. 

 

 

   Announced.

 

 

 

SRI A. PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA.

 

 

 

 

SMT. DR. G. DEBNATH,

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA SRI  U. DAS

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA