Delhi

New Delhi

CC/621/2014

Rajendra Kumar Goenka - Complainant(s)

Versus

M/s. Royal Sundaram Alliance Insurance Co. Ltd - Opp.Party(s)

02 Mar 2020

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

                                                 (DISTT. NEW DELHI),

                                               ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                                        NEW DELHI-110001

 

Case No.C.C.621/2014                                            Dated:

In the matter of:

Rajendra Kumar Goenka,

A2/142A, Keshav Puram,

Lawrance Road, Delhi-110035.

…..Complainant

Versus

 

The Manager,

Royal Sundram Alliance Insurance Co. Ltd.,

1505-1506, 15^th Floor,

Ambadeep Building Tower-II,

       14, K.G. Marg,  New Delhi-110001.

 

        Also at:

 

       The Managing Director,

Royal Sundram Alliance Insurance Co. Ltd.,

      Vishranthi Melaram Towers,

       No.2/319, Rajiv Gandhi Salai(OMR),

       KARAPAKKAM, Chennai-600097.

Opposite Party

 

NIPUR CHANDNA, MEMBER

 

                                           ORDER

 

The complainant has filed the present complaint against the O.P. u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant has taken an Family Health Protector  Insurance Policy bearing No.HMA002597000101.  On January, 2014, while the complainant was coming back from office, he started feeling  trouble in breathing.  A stranger in the way helped him and took him to the nearby hospital named Jain Muni Hospital, instead of treating him, the hospital referred him to Sunder Lal Jain hospital where certain tests were performed by the doctor.  After discharge, the complainant lodged the claim with OPs  for reimbursement the amount and submitted all the medical documents.  It is further alleged that despite receiving the entire documents, OP-2 failed to process the claim of the complainant.  The complainant sent a letter dt. 23.5.2014 to the OPs to process the claim and disburse the amount but no positive response was received from the OPs, hence this complaint.

2.     Complaint has been contested by OP.  O.P appeared and filed its written statement. In its written statement O.P has alleged that the complainant was the known case of hypertension and diabetes before the inception of the policy. And the complainant failed to declare this ailment in the proposal form while taking the policy in question. It is further alleged that the deceased was intimated about repudiation of claim vide letter dated 17.02.2014 on the ground of non-disclosure of the material facts in the proposal form.  Hence the complainant is not entitled to any relief against the O.P and the complaint is liable to be dismissed with heavy costs.

3. Complainant has filed his affidavit affirming the facts alleged in the complaint.  Complainant has also filed copy of policy referred above, copy of discharge summary, copy of bill, copy claim form and True copy of repudiation letter dated 17.2.2014. On the other hand Shri Aneesh Bhaskaran,  has filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.

4.     We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties.

5.     There is no dispute on the point that the complainant  had taken Family Health Protector  Insurance policy referred above.

6.     There is no dispute on the point that the complainant was got admitted in the Sunder Lal Jain Hospital,  discharged summary of the hospital reveals that the complainant was admitted in the hospital on 2.1.2013 and he was discharged from the hospital on 4.1.2013  There is no dispute on the point that the complainant had spent a sum of Rs.37,000/- in getting the treatment.

7.     The only question for consideration is whether repudiation of claim of the complainant by the OP  on ground of pre-existing disease was justified or not or whether the hypertension could be said to be pre-existing diseases or  whether the complainant was a patient of abovementioned diseases prior to taking the policy in question .

8.      In this case the claim of the complainant was repudiated on the ground that he had pre-existing disease at the time of inception of the policy.  It is a settled proposition of law that the burden to prove undeclared pre-existing disease is upon the OP and they are required to discharge this burden by producing any cogent evidence on record.  Learned Counsel for the OP has failed to point out any piece of evidence which could prove that the complainant was suffering with any pre-existing disease.  The contention of the OP is that the complainant was suffering from hypertension(which is pre-existing disease) causing the present illness, hence, rightly repudiated.  Our attention is not drawn to any document which could even suggest that the complainant had this existing illness prior to taking the policy.  It is also a settled proposition that the pre-existing disease means the disease for which the insured had been hospitalized or undergone operation in near proximity to the Policy.  This view has been taken by this Commission in the case of Pradeep Kumar Garg vs National Insurance Company Ltd. [III (2008) CPJ 423]. 

9.     Claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the ' discharge summary' of the insured by invoking the ' exclusion clause' or non-disclosure of ' pre-existing disease' unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above.

10.    It may be stated here that in the present case there is nothing on record to prove the fact that prior to the issuance of the policy the complainant had taken treatment from any doctor or any hospital for the diseases Hypertension and diabetes.   Moreover, the perusal in “discharge on request” the treating doctor has clearly mentioned that the complainant has no history of DM/HTN/CAD/TB.  In fact, the complainant was evaluated and was found to be newly diagnosed diabetic and hypertension.  The OP is relying upon the prescription of Jain Muni Roshan Lal Charitable hospital but the complainant had not taken any treatment from this hospital and was referred to Sunder Lal Jain hospital for the treatment, hence, the repudiation of the claim of the complainant by relying upon the prescription Jain Muni Roshan Lal Charitable hospital is unjustified. 

11.    The plea taken by O.P of suppression of material facts regarding hypertension for repudiating the claim of the complainant was not justified. OP had repudiated the claim of the complainant without any basis and on wrong assumption and in an arbitrary manner which amounts to deficiency in service on the part of the OP.   We therefore hold, OP guilty of deficiency in services and direct it as under:

i).     Pay to the complainant for a sum of Rs.37,000/- alongwith interest @ 9% from the date of filing of complaint i.e. 19.8.2014 till its realization.

ii)      Pay to the complainant a sum of Rs.10,000/- as compensation,  which will include the cost of litigation.

       

The order shall be complied within 30 days of the receipt of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post. File be consigned to Record Room.

    

Pronounced in open Forum on 02/03/2020

 

(ARUN KUMAR ARYA)

                                                                                                            PRESIDENT

                           (NIPUR CHANDNA)                                                        (H M VYAS)

                                        MEMBER                                                               MEMBER