STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                    UNIONTERRITORY,CHANDIGARH

Sh. Mohinder Singh son of Late Sh. Bhutu Ram R/o H.No.1150, Sector 40-B, Chandigarh.

Versus

National Insurance Company Limited through its Senior Branch Manager, SCO-305-306, Sector 35-B, Chandigarh.

…..Respondent/Opposite Party.

BEFORE:

Argued by:Sh. Rohit Goswami, Advocate for the appellant.

PER DEV RAJ, MEMBER

2.           

3.          It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Party nor did it indulge into unfair trade practice. The remaining averments, were denied, being wrong.

4.          

5.          

6.          

7.           

8.          

9.          

10.       Issuance of

11.         

12.        

“5.3 All supporting documents relating to the claim must be filed with TPA within 30 (thirty) days from the date of discharge from the hospital.  In case of Post-hospitalization, treatment (Limited to 60 days).  All claim documents should be submitted within 30 (thirty) days after completion of such treatment.

Note:Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the physical circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.”

13.        

14.        , the principle of law, laid down, was to the effect, that it is the fundamental principle of Insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew. The insured has a duty to disclose all the facts, and similarly it was the duty of the Insurance Company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applies to both equally. It was, thus, the duty of the Insurance Company to disclose all the facts and circumstances, relating to the insurance cover, to the complainant. It was also required of it, to apprise the complainant of the benefits of insurance, exclusion clauses, contained therein, and the warranties referred to, in the same. It was, under these circumstances, the utmost duty of the insurer to supply the Insurance Policy and the terms and conditions thereof, to the insured, so as to enable him (complainant) to go through the same and understand the clauses contained therein. Not only this, it was also the duty of the Insurance Agent or Insurance Advisor to explain the terms and conditions of the Insurance Policy, including the exclusion clauses, contained therein. However, in the instant case, respondent/Opposite Party, as stated above, failed to prove that the terms and conditions of the Insurance Policy were supplied to the appellant/complainant. In, it was observed that being aware of the existence of the policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. The principle of law, laid down, in the aforesaid cases, is fully applicable to the facts of the instant case. Since the terms and conditions of the Insurance Policy were not supplied to the complainant, it was neither aware of the exclusions, nor was bound by the same.

15.         

16.        

17.        

(i)      to pay Rs.11,604/- to the appellant/complainant, which he had spent on the treatment/medication of his wife in the P.G.I on 9^thth

(ii)     to pay cost of litigation, to the tune of Rs.5,000/- to the appellant/ complainant;

18.        

19.        

20.        

Pronounced.

January 3, 2014.

Sd/-

Sd/-

                                                                  [DEV RAJ]

Ad/-

STATE COMMISSION

(First Appeal No.487 of 2013)

Argued by:Sh. Rohit Goswami, Advocate for the appellant.

Dated the 3^rd

ORDER

Ad