BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.259 of 2015
Date of Instt. 12.06.2015
Date of Decision :06.11.2015
Jaswinder Singh son of Gurcharan Singh, R/o H.No.173, G.T.B. Avenue, Jalandhar.
..........Complainant Versus
Oriental Insurance Co.Ltd., Opp.Circuit House, Near Hotel Skylark, Jalandhar City.
.........Opposite party.
Complaint Under the Consumer Protection Act.
Before: S. Jaspal Singh Bhatia (President)
Ms. Jyotsna Thatai (Member)
Sh.Parminder Sharma (Member)
Present: Sh.Anuj Mehta Adv., counsel for complainant.
Sh.AK Arora Adv., counsel for opposite party.
Order
J.S.Bhatia (President)
1. The complainant has filed the present complaint under the Consumer Protection Act, against the opposite parties on the averments that the complainant hired the services of the opposite party for getting medi-claim policy of his own as well as of his family. The complainant earlier in the year 2012 obtained the said policy from the opposite party and paid a premium of Rs.4947/- against the said policy. As per the condition of the said policy, the opposite party assured the complainant to give all the medical benefits to the complainant and his family members upto Rs.2,00,000/-. Thereafter, complainant renewed his policy for the next year i.e in the year 2013 and again paid an amount of Rs.6158/- to the opposite party for the similar amount of sum assured Rs.2,00,000/-. During the period of said policy, the complainant all of a sudden got infection in his liver and due to the said reason, he went to the Mannat Super Specialty Hospital, Jalandhar and he was admitted in the said hospital on 1.1.2014 and discharged on 3.1.2014. During that period, he was diagnosed by the doctors of the said hospital and his other tests as well as scan were also conducted in by the said hospital as well as other scanning centres. In total an amount of Rs.25,723/- was spent by the complainant during the said treatment period before the above said hospital. Thereafter, the complainant approached the office of the opposite party and filed a claim as per the terms and conditions of the above said policy. It is alleged that ultimately opposite party sent a letter of rejection of the claim by stating that the claim is not covered under 4.1 condition without any justification. On such like averments, the complainant has prayed for directing the opposite party to pay him Rs.25,723/- alongwith interest. He has also claimed damages.
2. Upon notice, opposite party appeared and filed a written reply, inter-alia, pleading that the claim of the complainant has rightly been repudiated by the opposite party and that being so the present complaint is not maintainable. The complainant in the present case was admitted for treatment of Liver Cirrhosis, Gastric Ulcer, Oesophageal Varics and Diabetes. The complainant was called upon to provide the previous history and duration of the ailment and in response o the query, the complainant has produced a certificate issued by Mannat Advanced Gastroenterology, Gynaecology & IVF Centre, which is reproduced as under;-
'Mr.Jaswinder Singh was admitted in our hospital on 1.1.2014 and discharged on 3.1.2014.
He has history of Diabetes; however, its duration history is not in record.
He has history of liver cirrhosis; there is no mention in our records regarding the exact cause of his liver disease'.
3. The complainant has maneuvered the certificate from Mannat Advanced Gastroenterology, Gynaecology & IVF Centre and has not disclosed the history of his earlier disease of diabetes and liver cirrhosis. Since, the complainant has a history of diabetes and liver cirrhosis and taking into consideration that the policy of insurance is in the 2nd year, the claim of the complainant was denied under Exclusion Clause 4.1 of the policy of insurance.
4. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C16 and closed evidence.
5. On the other hand, learned counsel for the opposite party has tendered affidavit Ex.OPA alongwith documents Ex.OP/1 to Ex.OP/5 and closed evidence.
6. We have carefully gone through the record and also heard the learned counsels for the parties.
7. The facts involved in the present case are not much disputed. Ex.C1 is Happy Family Floater Policy Schedule for the period from 16.2.2013 to 15.2.2014. Earlier to this policy, the complainant has also obtained policy from the opposite party for the previous year. However, during the validity of the present policy Ex.C1, the complainant was admitted in Mannat Super Specialty Hospital, Jalandhar on 1.1.2014 and discharged on 3.1.2014. After discharge from the hospital, he filed a claim with opposite party insurance company but the opposite party insurance company repudiated his claim on the ground of pre-existing condition as per clause 4.1 of the terms and conditions of the policy vide letter Ex.C15 on the ground that he was suffering from pre-existing disease and was having a history of diabetes and liver cirrhosis. Counsel for the complainant contended that complainant was not having any diabetes or liver cirrhosis prior to his admission in the hospital and even under the previous year policy, the complainant did not obtain any claim on the ground of any illness and opposite party insurance company has wrongly repudiated his claim. On the other hand, it has been contended by learned counsel for the opposite party insurance company that the complainant has submitted certificate Ex.C1 wherein it is mentioned that he has history of diabetes, however, its duration history is not in record and further he has history of liver cirrhosis, there is no mention in their records regarding the exact cause of his liver disease. He further contended that the complainant has intentionally suppressed the duration of history and opposite party has rightly rejected the claim. The opposite party insurance company has repudiated the claim of the complainant on the ground that complainant was having a history of diabetes and liver cirrhosis, as such the onus was on the insurance company to prove the same. In the certificate Ex.C14 issued by the Mannat Hospital, although it is mentioned that complainant has a history of diabetes, however, its duration is not on record. So it can not be said that the complainant was suffering from diabetes before taking the policy from the opposite party for the first time. The opposite party insurance company has not produced any record to show that complainant ever obtained any treatment for diabetes or liver cirrhosis before the inception of the policy in question. So in the circumstances, we hold that the opposite party insurance company has failed to prove that the complainant was suffering from any pre-existing disease as alleged by it, so it was not justified in repudiating the claim of the complainant.
8. In the above circumstance, the present complaint is accepted and opposite party insurance company is directed to pay Rs.25,723/- to the complainant alongwith interest @9% per annum from the date of repudiating of his claim till the date of payment. It is clarified that interest amount is being granted by way of compensation. The complainant is also awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.
Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia
6.11.2015 Member Member President
