BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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                                        Complaint Case No : 1216 of 2009

                                        Date of Institution   :    26.08.2009

                                        Date of Decision     :    10.12.2009

Ankur Bansal son of Sh.Arjun Bansal, Resident of H.No.576, Sector 7, Panchkula, Haryana.

….…Complainant

                                V E R S U S

1]     New India Assurance Co. Ltd., SCO No.36-37, Sector 17, Chandigarh through its Chief Regional Manager.

2]     New India Assurance Company Ltd., 100, The Mall, P.B.No.25, Ambala Cantt. Haryana through its Divisional Manager.

                                        ..…Opposite Parties

CORAM:    SH.JAGROOP SINGH MAHAL       PRESIDENT

                SH.SIDDHESHWAR SHARMA         MEMBER

DR.(MRS) MADHU BEHL              MEMBER

Argued by:        Sh.Saurabh Goel, Adv. for complainant.

Sh.Parvinder Singh Bedi, Adv. for OPs.

PER SHRI JAGROOP SINGH MAHAL, PRESIDENT

                Concisely put, the complainant, availed a mediclaim policy from OP vide Ann.C-1 and during the currency of said policy, he got his eyes checked at Grewal Eye Institute, Sector 9, Chandigarh where he had to undergo C3R surgery on 31.10.2008 and discharged on the same day.  Approximately Rs.16,200/- (Ann.C-2) were spent on the said surgery. Then a claim was lodged with OPs, but it was repudiated.  The repudiation was challenged before the Insurance Ombudsman but it too rejected the claim of the complainant on the ground that the disease was a pre-existing disease.  It is averred that the complainant was neither asked about the health conditions at the time of giving the cover note nor any such document was required to be signed by the complainant and no terms & condition of the policy were ever explained to him.  It is also averred that the OPs knowing that the complainant was suffering from the disease for which he has undergone a surgery during the last one year have again issued a policy for a period of one year and this time also no form was required to be signed and no undertaking was taken.  Hence, this complaint has been filed alleging the above repudiation as illegal, arbitrary and deficiency in service on the part of OPs due to which the complainant had to suffer a lot.

2]             OPs filed joint reply and admitted factual matrix of the case.  It is stated that the complainant was under regular treatment of Keratoconus in his right eye since 5^th May, 2004 from the Grewal Eye Institute, Sector 9, Chandigarh and this fact was never disclosed by him at the time of purchase of the policy on 14.5.2008.  It is also stated that the complainant in the proposal form itself declared that he is not suffering from any disease and thereby concealed the fact that he was suffering from Keratoconus and was under regular treatment with said Institute in order to extort the undue benefits from the OPs.  It is further stated that the claim of the complainant was rightly repudiated firstly by the OPs and then by Insurance Ombudsman on the ground of pre-existing disease.  Rest of the allegations have been denied and it is prayed that the complaint be dismissed.

3]             Parties led evidence in support of their contentions.

4]             We have heard the ld.Counsel for the parties and have perused the record.         

5]             The OP has mentioned in para 3 of the written reply that the complainant did not disclose at the time of the purchase of the Insurance Policy that he was getting regular treatment of Keratoconus in the right eye since 5.05.04. According to them the complainant had concealed this fact that he was suffering from the said disease and was getting regular treatment  from Grewal  Eye Institute, Sector 9-C, Chandigarh, as mentioned in para 3 of the reply.  On the other hand the contention of the complainant is that no document was got signed from him and no undertaking was given by him but the covering note was given to him and subsequently the policy dated 14.05.08 was sent to him through post.  It is denied if any terms and conditions of the policy were ever shown to him or he was ever asked about any such disease for which he may be getting treatment.  It was necessary for the OP to place on file the proposal form to prove that the complainant did not disclose the treatment he was taking from Grewal  Eye Institute, Sector 9-C, Chandigarh but the same has not been produced by the OP. An adverse inference is therefore to be drawn against the OP to the effect that the complainant never concealed any such information and the terms of the policy were never told to the complainant, that he would not be given reimbursement of expenses regarding pre-existing disease.  If the OP was informed of the treatment being taken by the complainant and knowing fully well, the policy was issued to him, then the reimbursement of claim cannot be denied because there is no concealment of the disease by the complainant. 

6]             It is a general tendency among the Insurance Companies that they are eager to issue the Insurance Policy without verifying and without bringing its terms and conditions to the notice to of the insured but they project all the terms and conditions against the insured, as and when the claim is submitted.  This is unfair trade policy being adopted by the OP.  The repudiation of the claim amounts to deficiency in service and therefore cannot be accepted.  We are of the opinion that the present complaint must succeed.  Accordingly the complaint is allowed.  The OP is directed to pay a sum of Rs.16,200/- alongwith costs of litigation of Rs.2,200/- with in 30 days of the receipt of the copy of this order, failing which they would be liable to pay the same alongwith penal interest @12% p.a. since the filing of the present complaint i.e. 26.08.09, till the amount is actually paid to the complainant.

                Certified copies of this order be sent to the parties free of charge.  The file be consigned.