BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH ======== Consumer Complaint No | : | 169 of 2010 | Date of Institution | : | 12.03.2010 | Date of Decision | : | 04.04.2011 |
Tavlin Singh Rajput s/o Sh.Daljit Singh Rajput, Advocate, Punjab and Haryana High Court at Chandigarh r/o H.No.5506, Sector 38 West, Chandigarh. ….…Complainant V E R S U S 1] M/s Reliance General Insurance, Anil Dhirubhai Ambani Group, V. Nariman Point, Mumbai – 400 021. 2] The Regional Manager, Reliance General Insurance, Anil Dhirubhai Ambani Group, SCO No. 212-214, Sector 34, Chandigarh. ..…Opposite Parties CORAM: SH.RAJINDER SINGH GILL, PRESIDING MEMBER DR.(MRS) MADANJIT KAUR SAHOTA, MEMBER Argued by: Sh. Daljit Singh Rajput, Adv. Proxy for Sh.Amarjit Singh, Advocate for complainant. Sh. Yogesh Saini, Advocate proxy for Sh.Paras Ram Goyal, Advocate for OPs. --- PER RAJINDER SINGH GILL, PRESIDING MEMBER Concisely put, the father of the complainant being an Advocate and Member of Punjab & Haryana High Court Bar Association became Member of Group Mediclaim Insurance Policy issued by Ops, which was valid from 16.8.2007 to 15.8.2008. As per the said policy, the member of the High Court Lawyers Public Charitable Trust is entitled to have the facility of the mediclaim insurance for himself and his two family members for Rs.1,00,000/- (each family member with floater). Unfortunately, the complainant met with an accident on 12.08.2008 and admitted in Kapoor’s Kidney & Uro Stone Center Pvt. Ltd. and operated for total hip replacement system –Proxima-Mom (Depuy) and discharged on 18.08.2008. He incurred Rs.2,20,000/- on his treatment. The complainant submitted the claim along with requisite documents to the OPs through High Court Lawyers Public Charitable Trust on 16.10.2008 but till date, the claim was not released. It has further been averred by the complainant that his claim had been wrongly and illegally repudiated by OPs vide letter dated 31.12.2009 (Annexure C-4). Hence this complaint alleging that the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice. 2. In their written reply, the introductory facts with regard to the issuance of the insurance policy have been admitted. The main defence of the OPs is that the treatment taken by the insured pertained to disease which was pre-existing in nature as is evident from the documents submitted by him and therefore, the claim was rightly repudiated vide letter dated 31.12.2009 (Annexure R-2) as per the terms and conditions of the insurance policy. Denying all the material allegations of the complainant and pleading that there has been no deficiency in service or unfair trade practice on their part prayer for dismissal of the complaint has been made. 3. Parties led evidence in support of their contentions. 4. We have heard the learned counsel for the parties and have also perused the record. 5. On perusal of the record, it came to light that when the complainant was admitted in the hospital on 12.08.2008, it was reported that the complainant had history of juvenile rheumatoid arthritis on regular medication since last few years (5 years-progressive pain). As the coverage is since 16.8.2007, therefore, the ailment/complication is pre-existing prior to the policy inception and the same is violation of condition No.4.1 of the terms and conditions of the insurance policy and that was also confirmed from the documents which the complainant has submitted with the OPs. In the said documents, it has specifically mentioned that the insured was suffering from the said disease for the last few years (5 years). The OPs had repudiated the claim vide letter dated 31.12.2008 (AnnexureC-4) on the ground the disease suffered by the complainant was pre-existing. The medical record placed on record substantiates the disease to be pre-existing and the same was annexed as Annexure R-2. 6. In view of the above findings, we are of the considered opinion that the OPs had rightly repudiated the claim as it was violative of the terms and conditions of the insurance policy. Hence, there is no merit in the present complaint and the same is hereby dismissed leaving the parties to bear their own costs. 7. Certified copies of this order be sent to the parties free of charge. The file be consigned. Sd/- sd/- April 4, 2011 | [Dr. (Mrs) Madanjit Kaur Sahota] | | [Rajinder Singh Gill] | Cm | Member | | Presiding Member |
| | DR. MRS MADANJIT KAUR SAHOTA, MEMBER | MR. RAJINDER SINGH GILL, PRESIDING MEMBER | , | | 
