Delhi

New Delhi

OC/1086/2005

Raminder Parmar - Complainant(s)

Versus

M/S. Om Kotak Mahindra Life Insurance - Opp.Party(s)

20 Oct 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.OC/1086/05                            Dated:

In the matter of:

Raminder Parmar,

R/o 347-C, Sushant Lok-I, Gurgaon

……..COMPLAINANT

       

VERSUS

OM Kotak Mahindra Life Insurance,

6th Floor Peninsula Chamber,

Penisula Corporate Park,

Gangpatrao Kadam Marg, Lower Parel, Mumbai

Through Branch Office at:

Delhi C.P Office, Ambadeep Building, 7th Floor,

K.G Marg, Delhi

                                         ……. OPPOSITE PARTY

 

ORDER

President: C.K Chaturvedi

               

The Complaint pertains to deficiency on the part of OP in repudiating the death claim of nominee complainant after death of her mother Mrs. Harinderjit Kaur Parmar on 30.09.04.

The facts are that deceased mother of complainant was insured with OP, Kotak Life Insurance which is not in dispute. It is alleged that towards third week of April 2003, she complained of headache, giddiness, which was later diagnosed as Malignant Tumor. The immediate cause of death was described as Glioblastoma (glee-oh-blast-oh-ma) Multiforme GII Tumor of Brain and Aspiration, Pneumonia with candic arrest.

The nominee filed a claim with OP on 27.10.04, intimating all these facts in the claim form, with other relevant information of past medical attendants. The OP vide its letter Feb.14, 2005 rejected the claim, on the ground that the deceased has furnished negative information in clause 15(a), 15(c) and (i) of the proposal form. The OP informed that as per the report of Indraprastha Apollo Hospital dated 28.04.03, and Dr. Anoop Kholi, Sr. Consultant and Neurologist dated 26.04.03. She was operated for left frontal malignant melanoma about 3 years prior to policy issued. The OP in its reply has reiterated the position already described above.

We have considered the pleadings, evidence on record, the treatment records and medical documents and considered the submission made.

It is submitted by the Counsel for the Complainant that burden to prove the suppression of facts and any earlier pre-existing disease is on the insurance company. It is stated that the document Annexure R-3; at page 24 of the reply of Indraprastha Apollo Hospital is a Bone Scan report, by Sr. Consultant Dr. Uma Ravishankara, on a reference by physician Dr. Anoop Kohli. This scan report under the provisional diagnosis, stated right frontal malignant melanomas operated 3 years ago, and mentions current complaint of headache and gave a conclusion of essentially a normal bone scan for age. No evidence of skeletal Metastasis is seen. It is seen from the referral letter of Dr. Anoop Kohli at page 25 of Annexure R3, that he had mentioned operation 3 years ago of Rt. Frontal Malignant? On oral observation and she had given history of headache for 20 years.  On the basis of these observations of Dr. Kohli on 26.04.03, the scan report of Apollo hospital, mentioned operation of 3 years.

It is stated in evidence of complainant that her mother was not suffering from any ailment when she took policy, and there was no disease noted as her medical examination done before issuing policy. In the written arguments, it is stated that on 15.01.2000, insured attended the clinic of Dr. Ahmad Zaheer for removal of moles and warts on the left upper end of the forehead, the same were removed in OPD, without hospitalization and medical intervention. The certificate of Dr. Ahmad Zaheer dated 02.11.05, based on hospital record in annexed with evidence filed by complainant. In this certificate Dr. Zaheer has opined that carcinoma of skin has no relation to carcinoma of brain, which was a terminal disease.

We have considered the entire case and find that the proposal form was filed in 27.03.03, while the deceased insured has gone to OPD of Apollo Hospital on 15.02.2000, for a OPD procedure for removal of moles/warts on face, which by no stretch of meaning can be called as pre-existing disease, nor it can be called as suppression of any material fact by the insured, nor it can be said to be within a period of 3 years, when proposal is made on 27.03.03.. In the given circumstances, we do not find any breach of condition by insured nor suppression of fact. The OP only on the basis of referral paper of Dr. Kohli, cannot discharge the burden on it, to avoid the policy.

We accordingly hold OP liable to deficiency by arbitrary repudiation of claim and direct OP to pay the complainant the insured sum of Rs.3,50,000/-  with interest according to rules and pay Rs.50,000/- for harassment and litigation expenses in last 10 years of pending complaint.

The order shall be complied with within 30 days of the receipt of the copy of the order; otherwise action can be taken against OP under Section 25 / 27 of the Consumer Protection Act.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

        Pronounced in open Court on 20.10.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 (Ritu Garodia)

MEMBER

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