Haryana

StateCommission

A/173/2015

ROYAL SUNDARAM ALLIANCE INSURANCE CO. - Complainant(s)

Versus

POONAM DEVI AND ANOTHER - Opp.Party(s)

R.K.BASHAMBOO

27 Aug 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

         

                                                         First Appeal No.173 of 2015

Date of Institution: 20.02.2015

                                                               Date of Decision: 27.08.2015

 

Royal Sundaram Alliance Insurance Company Limited, through Shri G.Vinay Parkash, Legal Manager of Subramanian Building, IInd floor, No.1, Club House Road, Annasalai, Chennai-6000002.

…..Appellant

Versus

 

1. Poonam Devi W/o Shri Ajit Pal
2. Ajit Pal

Both the Respondents No.1 and 2 are the residents of C-450, Sector-10, Gautam Budh Nagar (U.P.).

                                      …..Respondents

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mr.Diwan Singh Chauhan, Member.                                                                                                                                            

Present:              Mr.Vikas Sharma, Advocate counsel for appellant.

                             Mr.Ajit Pal husband of Mrs. Poonam Devi complainant-respondents appeared in person.

 

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:

          It was alleged by the complainants that medi-claim policy Ex. P-2 was obtained from opposite party (O.P.)/appellant effective from 24.04.2012 to 23.04.2014.  On 26.02.2012 Poonam Devi was admitted at Brahm Shakti Sanjivani Super Speciality Hospital, Bahadurgarh (In short “Brahm Shakti Hospital”) due to acute abdomen pain. During diagnose it was found recurrent Appendicitis (PID) and was operated upon. She was discharged on 20.06.2012.  More than Rs.41614/- were spent on her treatment. Claim was submitted and all the formalities were completed but the same was repudiated on the ground of concealment of pre-existing disease. Doctor of Brahm Shakti Hospital opined that disease was not pre-existing.  O.P. be directed to pay Rs.35,000/- as cost of treatment, Rs.5000/- for mental harassment and Rs.5000/- as litigation expenses. 

2.      O.P. filed reply controverting their averments and alleged that as per terms and conditions of insurance policy insured was not entitled for any compensation for previous ailment.  It was confirmed by Poonam Devi through her written statement that she was having pain after every 3-4 months which used to subsides with tablets.  Poonam Devi was admitted at Brahm Shakti Hospital due to pain in abdomen, vomiting and nausea.  It was diagnosed as recurrent appendicitis with PID.  Poonam Devi concealed  this fact at the time of obtaining insurance policy, so her claim was rightly repudiated under the clause pertaining to conclusion and exclusions of insurance policy.  Other averments were also denied and requested to dismiss the complaint.

3.      After hearing both the parties, learned District Consumer Disputes Redressal Forum, Jhajjar (In short “District Forum”) allowed the complaint vide impugned order dated 15.01.2015 and directed as under:-

“Therefore, it is directed that the respondent shall make the payment of Rs.35,000/- to the complainants along with an interest @ 9% p.a. from the date of admission of complainant No.1 i.e. 20.06.2012 till realization of final payment.  The complainants are also entitled for a sum of Rs.2000/- on account of litigation expenses litigation expenses for the present unwanted and unwarranted litigation only due to the deficiency in service on the part of the respondent. The complaint stands disposed of accordingly.”

4.      Feeling aggrieved therefrom, O.P. has preferred this appeal.

5.      Arguments heard.  File perused.

6.      The only point raised and involved is that whether insured concealed any pre-existing disease or not.

7.      It is argued by learned counsel for the appellant that as per health claim form EX.P-4 it is clear that it was a case of  recurrent Appendicitis (PID).  Poonam Devi also admitted in his written statement that after 3-4 months she used to have abdomen pain which used to subsides with the tablets.  It shows that she was having this problem at the time of obtaining insurance policy on 24.04.2012, but, she concealed the fact, so the claim was rightly repudiated as per terms and conditions pertaining to pre-existing condition and exclusion clause.

8.      This argument is devoid of any force. As per statement of Poonam Devi Ex.R-6 it cannot be presumed that she was aware about the disease of Appendicitis.  If there was normal pain for which she use to take tablet it does not mean that she was having serious ailment.  Pain in abdomen can be due to any reason.  More so doctor of  Brahm Shakti Hospital clarified this fact as per his certificate Ex.P-8.  It is specifically mentioned therein that it was not 3-4 months, but, 3-4 days when she was having the pain of paincritics. As per his certificate it is not the case of recurrent paincritics since very long. So there is no question of any concealment. Pre-existing conditions is defined in insurance policy as under:-

                   “Pre Existing Condition

Pre-Existing Condition means any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed and/or received medical advice/treatment, within 48 months prior to your first Hospital cash plan policy with us.”

9.      There is no finding on the file to show that there was any sign or Symptom on the basis of which complainants could judge the previous ailment. An ordinary person cannot consider abdomen pain as appendicitis.   So these arguments are of no avail. Findings of learned District Forum are well reasoned based on law and facts and cannot be disturbed. Resultantly, appeal fails and the same is hereby dismissed.

10.    The statutory amount of Rs.22,636/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

August 27th, 2015       Diwan Singh Chauhan                                    R.K.Bishnoi,                                                   Member                                                          Judicial Member                                             Addl. Bench                                                    Addl.Bench