Haryana

StateCommission

A/414/2016

LIFE INSURANCE CORP.OF INDIA - Complainant(s)

Versus

PREM KUMAR - Opp.Party(s)

ARNAV SOD

24 Oct 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      414 of 2016

Date of Institution:      12.05.2016

Date of Decision :       24.10.2016

 

1. Life Insurance Corporation of India, Divisional Office,        Chandigarh, through Manager (LH&PF).
2. Life Insurance Corporation of India, Branch Office Sirsa through its Branch Manager.
3. Life Insurance Corporation of India, Divisional Office,        Rohtak, SCO 3-4-5, Sector-1, Rohtak, District Rohtak.

                                                                            

Appellants-Opposite Parties

Versus

 

Prem Kumar s/o Shri Banarsi Dass, Resident of House No.2734, Mamera Road, Ward No.11, Ellanabad, District Sirsa.

                                      Respondent-Complainant

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                                                                                                         

Present:             Shri Arnav Sood, Advocate for appellants.

                           None for respondent.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          This Opposite Parties’ appeal is directed against the order dated March 1^st, 2016 passed by District Consumer Disputes Redressal Forum, Sirsa (for short ‘the District Forum’) in Consumer Complaint No.104 of 2013.

2.                Prem Kumar-complainant/respondent, was insured with Life Insurance Corporation of India (LIC) vide Insurance Policy Exhibit-C. The policy commenced from 27^th July, 2011.    The sum assured was Rs.4.00 lacs. On 31^st May, 2012 the complainant suffered heart problem. He was admitted in Heart and General Hospital, 7, Vivekanand Marg, C-Scheme, Jaipur on the same day, that is, 31^st May, 2012 and was operated upon. He was discharged on 3^rd June, 2016. The complainant stated to have spent Rs.2,21,850/- on his treatment. Claim being filed and not paid by the LIC, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Forum.

3.                The Opposite Parties-LIC, contested complaint by filing written version. It was stated that Major Surgical Benefit Sum Assured was Rs.4.00 lacs. The insured was required to disclose the past details of the hospitalization/treatment/illness in the proposal form but he did not disclose the true facts in the proposal form. It was prayed that the complaint be dismissed.

4.                On appraisal of the pleadings and evidence of the parties, the District Forum vide impugned order allowed complaint and directed the LIC-opposite parties to pay Rs.2,21,850/- to the complainant along with interest @ 9% per annum from the date of filing of the complaint, that is, 22.04.2013 till payment besides litigation expenses of Rs.3,000/-.

5.                The impugned order has been assailed by relying upon the repudiation letter Exhibit R-4 whereby complainant’s claim was denied on the following four grounds:-

1.      Pre-existing illness irrespective of prior medical treatment or advice.

2.      Pre-existing illness irrespective of prior medical treatment or advice.

3.      Surgeries not listed in the allowed surgeries (1-49).

4.      Pre-existing illness irrespective of prior medical treatment or advice.”

6.                The grounds taken in the repudiation letter (Exhibit R-4) are not supported by leading any cogent and convincing evidence. No evidence has been led by the appellants-LIC that the complainant at any point of time suffered any disease prior to the purchase of the policy which could be said to have been covered under the exclusion clause, to be termed as the pre-existing disease as per clause 3.

7.                Learned counsel for the appellants-LIC referred to Clause 2(ii) under heading “Major Surgical Benefit” reproduced as under:-

                   “(ii)    Major Surgical Benefit:

In the event of an Insured under the Policy undergoing any specified Surgery in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during the Cover Period then, subject to the terms and conditions of the Policy, the benefit amount reckoned as the percentage of the Sum Assured as mentioned in the Surgical Benefit Annexure against the specified Surgery performed, shall be payable by the Corporation.”

8.                Schedule of Surgeries was referred to and a perusal of which shows that the disease suffered by the insured was covered under the policy. The complainant had undergone angioplasty with stent implantation, which is certainly covered under the policy. The District Forum, thus, has rightly allowed the complaint and no case for interference is made out. Hence, the appeal is dismissed.

9.                The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced: 24.10.2016

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL