BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.
Complainant No. 463 of 2012
Date of instt.21.09.2012
Date of decision:4.02.2015
Rekha wife of Shri Subhash Chand resident of village Arainpura district Karnal.
Vs.
Life Insurance Corporation of India, Karnal through its Divisional Manager.
……… Opposite party
Complaint U/s 12 of the Consumer
Protection Act.
Before Sh.Subhash Goyal……. President.
Smt.Shashi Sharma……….Member.
Present Sh.Kavinder Tyagi Advocate for the complainant.
Sh.N.K.Zak Advocate for the OP.
ORDER:
The complainant has filed the present complaint against the OP u/s 12 of the Consumer Protection Act on the allegations that he had purchased one mediclaim policy bearing No. 177503173 on 15.1.2011 from the OP under the name of LIC’s Health Protection Plus Plan for the sum insured Rs.two lakh. That in the month of July, 2011 the complainant fell ill and was admitted in the North Delhi Nursing Home Pvt. Ltd. Delhi and remained admitted there from 19.7.2011 to 29.7.2011 and she was admitted in the hospital and remained there admitted from 2.8.2011 to 12.8.2011 and incurred the expenses of Rs.22000/-. The complainant informed the OP and lodged claim and submitted all the relevant documents but the claim of the complainant has been repudiated which amounts to deficiency in services on the part of the OP. Thus, the complainant has filed the present complaint alleging deficiency in services and has prayed that the OP be directed to make the payment of Rs.22000/- alongwith the compensation for the harassment caused to him and litigation expenses. She has also tendered her affidavit in support of the contents of the complaint.
2. On notice the OP appeared and filed its written statement raising the preliminary objections that the complaint was not maintainable; that the complainant has no loucs standi to file the present complaint; that the complainant has no cause of action to file the present complaint and that the complainant was estopped by her own act and conduct from filing the present complaint.
On merits, obtaining of the policy, illness of the complainant was not denied but it was contended that at the time of obtaining of the policy, the complainant had concealed the true and material facts relating to her health and as such the claim has been rightly repudiated and as such there was no deficiency in services on the part of the OP and dismissal of the complaint has been sought.
3. We have heard the learned counsel for the parties and have gone through the case file very carefully.
4. Therefore, after going through the facts and circumstances of the case, evidence on the file and the arguments advanced by the learned counsel for the parties, it emerges that the complainant has filed the present compliant against the OP on the allegations that she was holder of the policy namely Health Protection Plus Plan
Ex.C3 under which she was entitled to get compensation for medical expenses to the extent of Rs.two lakhs and the complainant fell ill in the month of July, 2011 and was admitted in the North Delhi Nursing Home Pvt. Ltd. Delhi from 7.2.2011 to 29.7.2011 and again remained admitted w.e.f. 2.8.2011 to 12.8.2011 and incurred expenses and thus she was entitled to be reimbursement to the expenses of Rs.22000/-. However, the claim of the complainant was repudiated vide letter dated 22..10.2011 Ex.C6.
However, as per the contention of the OP, the claim has rightly been repudiated because the patient was suffering from dextrocadia with situs invertus and as such the claim has been repudiated on account of suppression of true facts.
5. Therefore, as per the circumstances of the case , it is admitted fact that the complainant was policy holder and during the continuance of the said policy, she fell ill and paid the amount in the hospital and submitted the claim for reimbursement but the same has been repudiated on the ground that the complainant was suffering from Kartagenes Syndrome and as such the said disease was not covered under the policy and the same was suppression of true facts.
However, after going through the circumstances of the case , it emerges that dextrrocaida is not disease but the heart of the patient is on the right side instead of the left side of the body and the same cannot be said to be suppression of material fact in order to repudiate the claim. Therefore, we hold that repudiation of the claim by the OP was not sustainable in the eyes of law and as such there was deficiency in services on the part of the OP in not paying the claim of the complainant.
Therefore, as a sequel to our above discussion, we accept the present complaint and direct the OP to make the payment of Rs.22000/- to the complainant alongwith interest @ 9 % per annum from the date of filing of the present complaint i.e.21.09.2012 till its actual realization. The complainant shall also be entitled for a sum of Rs.5000/- for the harassment caused to him and a sum of Rs.2200/- towards legal fee and litigation expenses. The OP shall make the compliance of this order within a period of thirty days from the date
Announced
dated: 04.02.2015
(Subhash Goyal)
President,
District Consumer Disputes
Redressal Forum, Karnal.
(Smt.Shashi Sharma)
Member.
Present Sh.Kavinder Tyagi Advocate for the complainant.
Sh.N.K.Zak Advocate for the OP.
Arguments heard. Vide our separate order of the even date, the present complaint has been accepted. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.
Announced
dated: 04.02.2015
(Subhash Goyal)
President,
District Consumer Disputes
Redressal Forum, Karnal.
(Smt.Shashi Sharma)
Member.
