Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 21.
Instituted on : 10.01.2017.
Decided on : 23.07.2018.
Smt. Sangeeta w/o Ajay Pal Singh R/o H.No.58-B/1, Achrya Puri, Near Bus Stand, Gurgaon at present H.No.1500/3/30 Mahila Ashram, Near Gandhi Camp, Rohtak.
………..Complainant.
Vs.
M-Tech Developers Pvt. Ltd., ANS House 144/2 Ashram, Mathura Road, New Delhi through its Managing Director.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.RAJBIR SINGH DAHIYA, PRESIDENT.
SH. VED PAL, MEMBER.
Present: ……….Sh.Ankit Joon, Advocate for the complainant.
Sh.Sameer Gambhir, Advocate for opposite party.
ORDER
RAJBIR SINGH DAHIYA, PRESIDENT:
1. Brief facts of the case are that complainant purchased hospitalization policy bearing no.2013742828000230 for the period 16.11.2014 to 15.11.2015 from the opposite party. That as per policy complainant himself alongwith his wife and two children were covered in the policy. That on 05.05.2016 during the policy period, wife of the applicant namely Devisha suffered from the illness and was got admitted with RG Urology and Laproscopy Hospital. That complainant had spent an amount of Rs.98000/- on her treatment and deposited all the bills and medical documents in original with opposite party, well within time for settlement of claim but with no effect. That the opposite party, vide its letter dated 23.06.2016 had repudiated the claim on the ground that the life assured was suffering from diabetes since 2004. That the diabetes was initially deducted in the year 2014 after inception of the policy and moreover the treatment undergone has nothing to do with diabetes. That the act of opposite party of repudiating the genuine claim of the complainant is illegal and amounts to deficiency in service. Hence, this complaint and the complainant has prayed for directing the opposite party to pay Rs.98000/- alongwith interest, compensation and litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the Devisha wife of complainant was suffering from pre-existing disease of diabetes since 2004 but the same was never disclosed to Insurance company at the time of policy inception. Hence the claim is repudiated as per Health Gain Policy terms and conditions. That there is no deficiency in service on the part of opposite party and dismissal of complaint has been sought.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C24 and has closed his evidence. On the other hand ld. counsel for the OP has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R32 and closed his evidence.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. The main objection taken by the respondent that claimant had pre-existing diabetic disease at the time of issuance of the policy since 2004. They have placed on record Ex.R4 which is of 23.03.2016 well after the issuance of the policy and the document Ex.R5 purportedly to be the statement of the husband of the claimant Mr. Naveen Batra and the same is allegedly signed and thumb marked by Naveen Batra and the claimant. The date of statement is shown as 25.05.2016. The OPD slip Ex.R4 is of no help to the respondent as the same belongs to a day after the policy was taken. Ex.R5 has not been admitted by the claimant. The statement does not say a single word pertaining to the claimant. To controvert this Ex.R5, the complainant has placed on record Ex.C3 and Ex.C4 Discharge Card of the Gaur Nursing Home. Ex.C3 is pertaining to delivery of a female child on 04.011.2004. The investigation and summary shows the sugar as “NIL”. Same is the case of Ex.C4, the discharge summary of the same wherein another baby was born to the claimant on 14.08.2018. It also shows sugar as
“NIL”. So the documents Ex.R4 and Ex.R5 are of no help to the respondent.
6. We have observed in many cases that the employee Investigator of the insurance company create some evidence by manipulating from the citizens who are ignorant about technicalities of law. The insurance company take shelter of these hyper-technicalities to defeat the claim of the insured. This case is a glazing example of such manipulation. The respondent company has suppressed the fact, the reason best known to them that before issuance of a policy a medical check-up of insured is done by Doctor of the insurance company and blood sample and urine samples are taken. Had the claimant been suffering from diabetes at the relevant time, it could have surfaced in the lab report of samples. The respondent held back report of this medical check-up which presumably must have been against them. As such objections of opposite party are rejected. The citation referred by the OP has no bearing on the facts of this case.
7. In view of the above, complaint succeeds and we hereby award the amount spent by the complainant on treatment of his wife as shown in bills Ex.C20 to Ex.C23 i.e. to pay Rs.87606/-(Rupees eighty seven thousand six hundred and six only) alongwith interest @9% p.a. from the date of filing the present complaint i.e. 14.02.2017 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as litigation expenses and compensation to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
20.07.2018.
................................................
Rajbir Singh Dahiya, President
..........................................
Ved Pal Hooda, Member.
