Delhi

New Delhi

CC/1215/2010

Kapoti Chakraborty - Complainant(s)

Versus

M/S. United India Insuracne Company Ltd. - Opp.Party(s)

11 Jan 2023

ORDER

 

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.CC.1215/2010

IN THE MATTER OF:

 

Mrs. Kapoti Chakraborty

D-46, Retreat Apartments

20, I.P. Extension, Delhi-110092.                            .....COMPLAINANT

 

VERSUS

 

1. United India Insurance Company Ltd.

       D)-04010054, Janpath, Connaught Place

          New Delhi-110001.

2. Medsave Health Care Limited

        F-701 A, Lado Sarai, Mehrauli,

           New Delhi-110030... OPPOSITE PARTIES

 

          Hon’ble   Ms. Poonam Chaudhry, President

            Hoon’ble Mr. Bariq Ahmad, Member

             Hon’ble   Mr. Shekhar Chandra, Member

 

                                                                 Date of Institution:-  14.10.2010                                                                                    Date of Order   : -      11.01.2023

Mr. Shekhar Chandra, Member:

 

          The complainant bought a medical policy in the in the sum of Rs. two lakhs from opposite party No. 1 for the period from 06.08.2006 to 05.08.2007. In the month of July, 2007 the complaint had some health problems; she got herself examined and advised of operation for diagnosis of postmenopausal bleeding with multiple uterine fibroid. She was hospitalized on 15^th July, 2007 and operated on the next day at Sir Gangaram Hospital, New Delhi. Complainant was informed that opposite party No. 1 does not have credit facility with Sir Gangaram Hospital. However, the complainant informed the opposite parties about the scheduled operation on 12^th July. 2007. On 26^th July, 2007, after treatment, the complainant filed a claim of Rs. 73,896.85 before the opposite parties with supporting documents.

          The opposite parties raised certain queries with regard to investigation report during hospitalization as also prior to hospitalization and the treatment taken by the complainant in the year 1998, when the complainant allegedly was diagnosed for fibroid uterus for the first time. The complainant provided relevant information and submitted that no diagnosis had taken place in the year 1998 of the fibroid uterus and the same seemed to b an error on the part of the complainant or the hospital. The complainant continued to follow her case before the opposite parties for reimbursement of the medical expenses. Lastly on 23^rd March, 2010 complainant sent a letter to the opposite parties to which opposite party No. 2 responded and asked the complainant to follow her case with opposite party No. 1. As per version of the complainant, nothing has been heard from the opposite party

 

No. 1 so far, thus this complainant case seeking reimbursement of claim and compensation etc.

          In the written statement, the opposite party No. 1 has strongly opposed the prayer of the complainant and submitted that claim of the complainant is covered under the policy since 06.08.2007 and as per claim form the claimant/complainant was diagnosed first time of the said disease on 27.01.2006 as mentioned by the complainant herself in the claim form. The complainant states that she does not have any past history of any disease, whereas as per discharge summary the complainant was diagnosed to have fibroid utgerus since 1998 and as per her declaration in the claim form said disease first diagnosed before she bought the policy. Thus, the claim merits repudiation as per Exclusion Clause 4.2 and 4.3 of the Mediclaim Policy.

          In her rejoinder affidavit, the complainant has not specifically denied the allegations made in the reply by opposite party No. 1 but asserted that the said statement is not supported by any document or evidence.    

Learned counsel for the opposite party/Insurance Company has drawn our attention to a decision rendered by the Hon’ble Supreme Court of India in ‘Life Insurance Corporation of India Vs. Manish Gupta’, Civil Appeal No. 3944 of 2019’. The facts of said case are almost identical to the present one.  In this case the District Consumer Forum granted the relief to the claimant which was affirmed by the State Consumer Forum as also the National Consumer Forum.  However, in Civil Appeal, the Hon’ble Supreme Court set aside the judgment with the following observations:-

“The consumer fora have made a fundamental error in allowing the claim for reimbursement of medical expenses in the face of the uncontroverted material on record. The documentary material indicates that there was a clear failure on the part of the respondent to disclose that he had suffered from rheumatic heart disease since childhood. The ground for repudiation was in terms of the exclusions contained in the policy. The failure of the insured to disclose the past history of cardiovascular disease was a valid ground for repudiation.

        We accordingly allow the appeal and set aside the impugned judgment and order dated 10^th December, 2018 fo the NCDRC. The complaint filed by the respondent shall stand dismissed. There shall be no order as to costs.”

 

We have perused the record and heard the parties at length. It is to be noted that an officer of an Insurance Company which is a public sector undertaking has made a statement that there cannot be any bias or arbitrariness as the stand taken by the opposite party is solely on the basis of the declaration made by the complainant in her claim form and the medical

 

history of the complainant or the observations of the medical doctors of the complainant.

We, therefore, dismiss the complaint leaving the parties to bear their own costs.

A copy of order be sent to both parties free of cost.

File be consigned to record room alongwith a copy of the order.

 

                                                                  

 

Poonam Chaudhry

(President)

 

Bariq Ahmad                                                                                                            Shekhar Chandra

    (Member)                                                                                                                  (Member)

 

 

11^th January, 2023