Haryana

StateCommission

A/642/2015

NATIONAL INSURANCE CO.LTD. - Complainant(s)

Versus

RAM CHANDER DAHIYA - Opp.Party(s)

SANDEEP PURI

18 Dec 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal    No  :    642 of  2015

Date of Institution  :      30.07.2015 

Date of Decision    :      18.12.2015

  

1.      National Insurance Company Limited 3, Middleton Street, Post Box No.9229, Kolkata -71, through its Chief Officer.

 

2.      National Insurance Company Limited through its Branch Manager, Sonipat Branch Geeta Bhawan, Road, Sonipat now at Ist Floor Opposite Gurdwara Sahib, Old D.C. Road, Sonipat.

 

                                      Appellants/Opposite Paries

Versus

Ram Chander Dahiya s/o Sh. Deep Chand, Resident of Shashtri Colony, Gohana Road, Sonipat at present House No.1402, Sector-23, Sonipat.

                                      Respondent/Complainant

CORAM:

                             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                             Mr. Diwan Singh Chauhan, Member.                        

 

Present:               Shri Sandeep Suri, Advocate for appellants.

                             Shri A.K. Goyal, Advocate for respondent.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

This appeal of opposite parties is directed against the order dated 8^th June, 2015, passed by District Consumer Disputes Redressal Forum, Sonipat (for short ‘the District Forum’), in Complaint No.317 of 2014.

2.      Ram Chander-Complainant/respondent, purchased a medi-claim insurance policy Annexure R-2 for Rs.4.00 lacs from National Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties/appellants, for the period 28.05.2014 to 27.05.2015. On 12.08.2014, he fell ill. He was hospitalized in Medanta the Medicity Global Health Private Limited, Gurgaon from 12.08.2014 to 08.09.2014. He spent Rs.10,40,302/- on his treatment. He filed claim with the Insurance Company but the same was repudiated on the ground that the disease suffered by him was pre-existing and his claim was not covered under the policy. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed.

3.      The Insurance Company in its reply stated that as per report (Annexure R-3) of Medanta Hospital, Gurgaon, the insured had history of diabetes mellitus for 7-8 years, CAD for three years and had underwent PTCA. So his claim was not covered under the policy.

4.      On appraisal of the pleadings and evidence of the parties, the District Forum allowed complaint and directed the Insurance Company to pay Rs.4.00 lacs to the complainant alongwith interest at the rate of 9% per annum from the date of filing of the complaint till its realization. Hence, appeal.

5.      Learned counsel for the Insurance Company has urged that vide Annexure R-3, the patient had a history of diabetes mellitus for 7-8 years, CAD for three years and had underwent PTCA.

6.      A perusal of document Annexure R-3 purported to have been issued by Medanta Hospital, Gurgaon, shows that it does not contain the name of patient. In the absence of name of patient, it cannot be connected to the complainant. Rather, during the course of hearing, the complainant has placed on the file the certificate issued by Medanta Hospital certifying that Ram Chander Dahiya-complainant, never underwent PTCA, neither suffered CAD nor diabetes. In the face of said certificate and Exhibit R-3 being relied upon by the Insurance Company, not bearing the name of patient, the Insurance Company has not been able to establish that the disease for which the complainant has sought reimbursement was a pre-existing disease. In this view of the matter, the Insurance Company cannot disown its liability to pay the benefits of insurance to the complainant.

7.      For the reasons recorded above, the appeal is devoid of merits. It is dismissed.

8.      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 18.12.2015

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL