STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                                    U.T., CHANDIGARH 

Star Health & Allied Insurance Company Limited, earlier at  SCO 257, 2nd Floor, Sector 44-C, Chandigarh, Now at SCO No.130-131-Top Floor, Sector 34-A, Chandigarh through its Manager, through its Authorized Signatory, M/s Star Health and Allied Insurance Company Limited, Ist Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi-110001 .

                                                                         ….Appellant

                                                   Versus

Pritpal Singh, House No.614, Sector-18-B, Chandigarh. 

                                                                                               ……Respondent

                 Appeal under Section 15 of the Consumer Protection Act,1986                           against  order dated 27.04.2018 passed by District Consumer                          Disputes Redressal Forum-II, U. T. Chandigarh in C.C.No.                      768/2017.

Argued by:     Mr. Satpal Dhamija, Advocate for the appellant.

BEFORE:       JUSTICE JASBIR SINGH (RETD.), PRESIDENT

                        MRS. PADMA PANDEY, MEMBER

PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT

                Appellant/Opposite Party has filed this appeal against order dated 27.04.2018, passed by the District Consumer Disputes Redressal Forum(II), U.T. Chandigarh (for short the Forum only),  allowing a consumer complaint filed by the respondent/ complainant.  

 2.        The appeal is barred by limitation of 6 days. An application has been moved seeking condonation of delay. After looking at the averments in the application which is supported by an affidavit, the application is allowed and the delay is condoned.

3.           As per  facts on record, the respondent/complainant purchased one mediclaim policy from the appellant/OP for himself and his wife on making premium amount of Rs.19,000/-. It was valid between 20.1.2015 to 19.1.2016.  Wife of the complainant suddenly fell ill on 29.9.2015 and she was taken to PGIMER, Chandigarh, where she was advised angioplasty. She was admitted on 7.10.2015 for the said procedure and thereafter an implant was put by the doctors against total cost of Rs.1,80,000/-. The matter was taken up with the OP for reimbursement of the expenses, referred to above. However, claim of the complainant was neither repudiated nor settled. 

4.            Upon notice, reply was filed by the appellant/OP. Factual matrix were not disputed. It was only said that when Policy was purchased by the respondent/complainant, his wife was suffering from a disease i.e. hypertensive ischemic coronary artery disease. On account of above, she had fallen ill which resulted into incurring of aforesaid expenditure. It was specifically stated that on account of further complication of hypertension, she suffered chest pain. By taking it as a pre-existing disease, it was stated that the respondent was not entitled to reimbursement of expenses  and his claim was rightly repudiated vide letter dated 29.12.2015. Pleading that there was no deficiency in providing service, a prayer was made for dismissal of the complaint.

5.              To the reply, rejoinder was filed by the complainant controverting all the pleas taken by the OP/appellant and reiterating the averments made in the complaint.

 6.            Both the parties led evidence.  The Forum, on analysis of pleadings of the parties, evidence on record, and the arguments addressed, allowed the complaint by ordering that the amount, referred to above, i.e. Rs.1,80,000/- be reimbursed to the respondent/complainant with interest @9% p.a. whereof 29.12.2015 till the time of making the payment. The Forum also granted compensation of Rs.10,000/- and litigation expenses to the tune of Rs.7000/-. The awarded amount was ordered to be paid  in a time bound manner, failing which, it was to entail penal consequences.

7.          Counsel for the appellant vehemently contended that on account of pre-existing disease suffered by wife of the respondent, claim raised for  reimbursement of expenses was rightly repudiated under the  terms and conditions of the Policy. The said contention was rejected by the Forum by observing as under ;

“In the present complaint, the repudiation of the claim raised by the complainant is taken as surprise that how the insurance companies are avoiding the genuine claims at the cost of their own enrichment. It is very well explained under the terms & conditions of the policy that in case treatment is availed for any pre-existing disease during the coverage period then fifty percent of the claim shall be payable. Acting contrary to its own terms & conditions, the Opposite Party wrongly repudiated the whole claim as raised by the complainant stating that the insured had taken the treatment for the complication of pre-existing disease and thus not covered for the reimbursement.  This outright rejection of the claim draws an adverse inference. Before finalizing the liability of the Opposite Party in the present complaint, we go a step further to mention that the complainant is not entitled for the amount so mentioned in the referred terms & conditions, but is entitled for the whole claim since the insured has not taken any treatment or incurred the expenses on the treatment of any pre-existing disease.

       Nowhere it has been opined by any expert of the Opposite Party nor proved that the ailment suffered by the insured was pre-existing or the ailment suffered by the insured was the complication of the pre-existing disease suffered by the insured.  Even if it is presumed that the present ailment suffered by the insured is complication of her pre-existing disease, even then there is no term & condition of the policy whereby the expenses incurred for the treatment of complication arising out of the pre-existing disease are not covered. There is no such whisper about the same in the terms & conditions as placed on record. Therefore, in view of the matter, we are of the opinion that the repudiation of the claim of the complainant done by the Opposite Party is totally unjustified, untenable and amounts to deficiency in service.”    

8.        On noticing terms and conditions of the Policy, it was rightly said that the claim was wrongly repudiated by the appellant.  It was further observed that there was no proof that wife of the respondent/complainant  suffered on account of a pre-existing disease. It was further rightly said that the respondent/complainant was entitled to reimbursement of the entire amount because the appellant/OP has failed to show that  wife of the respondent was suffering from any pre-existing disease. There is nothing on record to show that ailment suffered, qua which reimbursement was sought, was the result of any complication caused by a pre-existing disease. It was also said that such a reason was wrongly given to reject the claim contrary to the terms and conditions of the policy itself. We are of the opinion that the order passed by the Forum is quite justified.    No case is made out to interfere in the order, under challenge.

9.          For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.

10.            Certified copies of this order, be sent to the parties, free of charge.

11.         The file be consigned to Record Room, after completion.