Haryana

StateCommission

A/663/2013

United India Insurance Company Ltd - Complainant(s)

Versus

Rajinder Singh - Opp.Party(s)

Mr.R.C. Gupta, Advocate counsel for the appellant

02 Feb 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

HARYANA PANCHKULA

 

 

First Appeal No.633 of 2013

Date of the Institution:13.09.2013

Date of Decision:02.02.2017

 

United India Insurance Company Ltd., Divisional Office No.XXI, SCO 106, 2^nd floor, Commercial Complex, Sector-16, Faridabad through its Manager/Divisional Manager now, through authorized signatory of Regional Office, SCO No.123-124, Sector-17 B, Chandigarh.

                                                                             .….Appellant

Versus

1.      Rajinder Singh aged 58 years son of Sh. Mehma Singh, Resident of House No.184, Chopra Garden, Yamuna Nagar.

2.      M/s Medsave Health Care Ltd., F-701, Behind Gold Course, Lado Sarai, New Delhi-110036 through its Director/manager/ Principal Officer.

                                                                             .….Respondents

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

                    Mrs. Urvashi Agnihotri, Member

 

Present:-    Mr.R.C. Gupta, Advocate counsel for the appellant.

                    None for the respondents.

 

O R D E R

URVASHI AGNIHOTRI, MEMBER:

 

1. United India Insurance co. Ltd. -OP is in appeal against the Order dated 08.07.2013 passed by the learned District Consumer Disputes Redressal Forum, Faridabad (for short ‘District Forum’), whereby the complaint of Ms. Rajni Sharma has been allowed by directing the OPs to pay an amount of Rs.52,100/- to her for her treatment with interest @9% p.a. from the date of complaint i.e.13.05.2011 till the date of actual payment and also to pay Rs.2200/- towards litigation expenses.
2. Briefly stated, the complainant obtained a Family Medicare Policy for a total insured value of Rs.2,00,000/- from OP No.1 for the period 16.11.2009 to 15.11.2010. During the validity of the policy, the complainant became seriously ill as she was having complaints of pain, tingling, numbness over left side of face, vomiting on and off and severe headache. She was admitted in Fortis Hospital, Vasant Kunj, New Delhi where she remained under treatment from 11.06.2010 to 18.06.2010. She spent Rs.52,100/- on her treatment for which she lodged a claim with the OP, but the same was rejected vide letter dated 08.02.2011. Aggrieved against this, the complainant approached the District Forum for the redressal of her grievance.
3. Pursuant to notice, the opposite party No.1 appeared and filed the written reply pleading that the complainant obtained the Medicare Policy for the first time commencing from 16.11.2009 to 15.11.2010. As per summary of the hospital, the disease was pre-existing, the complainant was not entitled to reimbursement of the expenses of treatment and so the claim was repudiated.
4. OP No.2 was proceeded against exparte as none appeared on its behalf inspite service.

The learned District Forum thoroughly went in to the prescriptions and other treatment record of the complainant including the expenses vouchers of the treatment. On that basis, the learned District Forum came to the conclusion that the complainant was right in claiming the insurance amount as the same has actually been spent on her treatment. Regarding plea raised by the OP-1 about the pre existing disease suffered by the complainant, the learned District Forum did not find any substance therein and rejected the same. Accordingly, the complaint was  allowed rejecting the pleas raised by the OP-1 and by awarding Rs.52,100/- alongwith 9@ as claimed by the complainant. 

5. Against the impugned order, the OP-1/appellant has filed appeal before us reiterating their pleas as raised before the District Forum. We have heard the learned counsel for the appellant and have gone through the record. A perusal of the record shows that the  OP-1 has miserably failed to produce on record any material showing the previous illness suffered by the complainant or the details of any treatment taken by her. Mere verbal statement regarding such allegations does not justify the repudiation of the insurance claim. In the present case, no proposal form on behalf of the complainant has been produced by the OP- insurance company and the in the absence of the proposal form, it can not be presumed that the complainant had made any false declaration. Similarly, in the discharge summary of the complainant, there is no mention whatsoever regarding the treatment given to the complainant. Therefore, it can not be presumed that the complainant was having any previous or pre existing ailment for which the alleged treatment was taken by her.
6. Consequently, we do not find any merit in the appeal of OP-1 and uphold the well reasoned and detailed order passed by the learned District Forum, whereby the complainant of the complaint has been allowed by granting the aforesaid relief.

7.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules.

February 02nd, 2017

Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench