Complainant through Lrd. Adv. Pingale
Opponent through Lrd. Adv. Jogwadikar
Per : Mr. V. P. Utpat, President Place : PUNE
J U D G M E N T
15/07/2014
This complaint is filed by the consumer against the Insurance Company for deficiency in service under section 12 of the Consumer Protection Act, 1986. The brief facts are as follows,
1] The complainant is a resident of Kalyani Nagar, Pune - 6. The opponent is a Divisional Office of National Insurance Co. Ltd., which is situated at Deccan Gymkhana, Pune – 4. It is the case of the complainant that he had obtained insurance policy for Rs. 2,00,000/- for the period of 19/05/1999 to 18/05/2000. The complainant himself, his wife and son Ashish were covered under the said policy. He had paid an amount of Rs. 2,448/- as a premium for the said policy. Then, the said policy was renewed for the period of 19/05/2000 to 18/05/2001. Again it was renewed for the period of 19/05/2001 to 18/05/2002. Thereafter it was renewed for the period of 19/05/2002 to 18/05/2003. There is break of some days from 18/05/2003 onwards. However, the complainant had taken mediclaim policy for the period of 22/09/2003 to 21/09/2004 by paying premium of Rs. 6,711/-. Coverage of Rs. 3,50,000/- was given to the complainant and his family under that policy. The said policy was continued further for the period of 22/09/2004 to 21/09/2005 and 22/09/2005 to 21/09/2006, 22/09/2006 to 21/09/2007. The complainant had paid premium for these policies from time to time. The wife of the complainant was suffering from small fibroid since June 2001. From June 2005 there was growth in the size of the fibroid with presence of Ovarian Cyst in the right ovary. The complainant had consulted Dr. Gandikota. Doctor advised the wife of the complainant for operation and she was admitted in Jehangir Hospital on 06/10/2006 and operated on 07/10/2006. She was admitted in the hospital till 11/10/2006. After taking discharge from the hospital, the complainant had submitted mediclaim for the expenses, which were made by the complainant for the operation of his wife i.e. Rs. 58,237/- along with all the medical papers. The mediclaim submitted by the complainant was repudiated by the opponent on 11/12/2006 on the ground that the claim was as regards pre-existing disease. No opportunity was given to the complainant while rejecting the said claim. According to the complainant, the mediclaim is wrongly repudiated by the Insurance Company and he is entitled to Rs. 58,237/- along with interest @ 18% p.a., compensation of Rs. 25,000/- for mental and physical torture, Rs. 5,000/- towards miscellaneous expenses and an amount of Rs. 2,000/- as a notice charges. The total claim of the complainant is for Rs. 1,11,202/-. The complainant has asked interest @ 18% p.a. on the said amount.
2] The opponent has resisted the complaint by fling written version, in which it has denied the contents of the complaint. The opponent has not seriously disputed about the insurance policy taken by the complainant from time to time as well as payment of the premium for the said policies. It is also not in dispute that the policy was existing at the time of treatment taken by the wife of the complainant. According to the opponent, the claim was rightly repudiated by them, as there was break in the policy for the period of four months. The disease, which is referred in the mediclaim, was in existence in the year 2001. The policy was not continuous, hence it should be treated that the policy was taken for the first time in the year 2003. In that circumstances, disease was in existence before taking policy and as per the terms and conditions of the policy, the complainant is not entitled for mediclaim for the treatment of pre-existing disease. The opponent has prayed for the dismissal of the complaint with costs.
4] After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the counsels and considering pleadings, the following points arise for the determination for the Forum. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether complainant has established that there is deficiency in service on the part of the opponent? | In the affirmative |
2. | What order? | Complaint is partly allowed. |
REASONS :-
4] The undisputed facts in the present proceeding are that the complainant has obtained mediclaim policy from the opponent since 1999 onwards. It is also not disputed by either party that there was break in the policy in the year 2003 for the period of four months i.e. from 19/05/2003 to 21/09/2003. According to the opponent, as there was break in the policy and it was not continuous, the complainant is not entitled for the benefit of medical expenses for the treatment taken by the wife of the complainant for the disease, which was developed after obtaining policy i.e. from 2001.
5] The learned Advocate for the complainant argued before this Forum that the alleged disease was developed in the year 2006 and at that time the complainant had required to perform operation. Hence, it should be treated that the mediclaim submitted by the complainant was within the four corners of the terms and conditions of the policy. It is also argued by the learned Advocate for the complainant that, at the time of obtaining policy every time the health condition of the wife of the complainant was disclosed and there is no suppression of material fact on the part of the complainant and after knowing this fact, the opponent had issued insurance policy. The burden lies upon the Insurance Company to prove that the complainant has committed breach of terms and conditions of the policy. In the present proceeding, the opponent has not produced any independent evidenced to show that there is breach of conditions of the policy. The Insurance Company has not produced the proposal form in the present proceeding to show that the complainant has suppressed the material fact and the disease was in existence before obtaining the policy. According to the Insurance Company, it reveals from the medical record filed by the complainant that the complainant was suffering from certain disease since 2001. It is on the record that the complainant had obtained the policy initially in the year 1999. It is not the case of the opponent that the said disease was developed during the period of break up of the policy i.e. from 19/05/2003 to 21/09/2003. On the contrary, it has come on record that this so called disease was in existence in the year 2001 i.e. after obtaining policy from the opponent. In these circumstances, it is the considered opinion of the Forum that there is no breach of conditions of the policy, as the disease was developed when the wife of the complainant was covered by the policy from 19/05/1999 to 18/05/2003. In these circumstances, this Forum held that the opponent has wrongly repudiated the mediclaim of the complainant without sufficient reason. Hence, the complainant is entitled for the refund of medical expenses incurred by him for the treatment of his wife to the tune of Rs. 58,237/-. The complainant is also entitled to receive compensation for mental and physical torture to the tune of Rs.20,000/- and costs of the proceeding to the tune of Rs. 5,000/-. In all the complainant is entitled to receive an amount Rs. 83,237/- from the opponent. In the result this Forum answer the points accordingly and pass the following order.
O R D E R
- The complaint is partly allowed.
- The opponent is directed to pay in all an amount of Rs. 83,237/- (Rs. Eighty Three Thousand Two Hundred and Thirty Seven only) to the complainant within six weeks from the date of receipt of copy of this order.
- On failure to pay abovementioned amount within stipulated period of six weeks, it shall carry interest @ 9% p.a. from the date of filing of the complaint till its realization.
4. Copies of this order be furnished to
the parties free of cost.
5. Parties are directed to collect the sets, which were provided for Members within one month from the date of order, otherwise those will be destroyed.
