Haryana

StateCommission

A/229/2019

ORIENTAL INSURANCE COMPANY LTD. - Complainant(s)

Versus

RAM KARAN AND OTHERS - Opp.Party(s)

V.RAMSWAROOP

16 Aug 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

 

                                                      First Appeal No.229 of 2019

                                                 Date of Institution: 05.03.2019

                                                               Date of Decision: 16.08.2022

 

Oriental Insurance Company Limited, Regional office, LIC Building, Jagadhari Road, Ambala Cantt. through its Regional Manager.

…..Appellant

Versus

1.      Ram Karan Goyal son of Sh. Kashmiri Lal, House No. 26, Chaudhary House Colony, Railway Road, Karnal.

2.      The Manager, Raksha T.P.A. Private Ltd. SCO No. 359-360, First Floor, Sector-44D, Chandigarh-160047.

3.      The Manager, Raksha Health Insurance TPA Priavate Ltd. C/o Escort Corporate Central 15/5, Mathura Road, Faridabad (Haryana)-121003.

…..Respondents

CORAM:    S.P.Sood, Judicial  Member

                    Suresh Chander Kaushik, Member

 

Present:-    Mr. V.Ramswaroop, Advocate for the appellant.

                   Mr. R.K. Hooda, Advocate for respondent No.1.

                   Respondent No.2 dispensed with.

                   Respondent No. 3 exparte.

 

                                                 ORDER

S P SOOD, JUDICIAL MEMBER:

          The present appeal No.229 of 2019 has been filed against the order dated 28.01.2019 of the District Consumer Disputes Redressal Forum, Karnal (In short Now “District Commission”) in complaint case No.268 of 2017, which was allowed.

2.       The brief facts of the case are that complainant purchased medi claim insurance policy No. 261301/48/2017/1685 from OP No. 1. The policy was valid from 26.08.2016 to 25.08.2017. OP No. 2 & 3 were the settlers of mediclaim policy.  Unfortunately, on 17.01.2017 complainant felt acute retrostenal and abdomirnal pain and on the next day he was admitted in Kalyani Hospital CHD Sector-45, Karnal where he was operated upon for PTCA+ stent to LAD. He immediately informed the OPs about this development and submitted the mediclaim form along with hospital bills of Rs.1,28,000/-, but, claim was repudiated vide letter dated 29.06.2017 without any cogent reason. Thus there was deficiency in service on the part of the O.Ps.

3.      In its written version, OP No. 1 raised preliminary objections with regard to maintainability, locus standi, cause of action and concealment of true and material facts. On merits, OP No. 1 submitted that complainant was suffering from Hypertension & Diabetes and he did not disclose this fact to OP No. 1 before obtaining the insurance policy. OP No. 1 has rightly repudiated the claim of the complainant as per clause No. 4.2 of the terms and conditions of the policy and requested to dismiss the complaint.

4.      OP No. 2 in its statement dated 29.01.2018 stated that written statement filed by OP No. 1 be read as statement of OP No. 2.

5.      OP No. 3 was proceeded exparte vide order dated 30.10.2018.

6.      After hearing both the parties, the learned District Commission, Karnal has allowed the complaint vide order dated 28.01.2019, which is as under:-

“Thus, as a sequel of above discussion, we allow the present complaint and direct the OPs to pay mediclaim of Rs.1,28,000/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant for mental agony, harassment and towards litigation expenses.”

7.      Feeling aggrieved therefrom, O.P. No.1-appellant has preferred this appeal.

8.      This argument has been advanced by Sh. V. Ramswaroop, learned counsel for the appellant and Sh. R.K. Hooda, learned counsel for respondent No.1. With their kind assistance the entire record of appeal as well as the original record of the District Commission including whatever the evidence has been led on behalf of  both the parties had also been properly perused and examined.

9.      Learned counsel for the appellant vehemently argued that complainant was suffering from hypertension and diabetes, which was not disclosed by him at the time of obtaining the insurance policy. As per clause No. 4.2 of the insurance policy, if disease occurred within two years from the purchase of the policy then complainant was not entitled to get any charges of expenses. Thus, the complainant was not entitled for the claim amount as prayed for.

10.    Learned counsel for the respondent No. 1 vehemently argued that the claim of the complainant cannot be repudiated on account of non-disclosure  of the fact of pre-existing disease when policy was obtained.  The learned District Commission rightly allowed the claim of the complainant. The complainant was legally entitled for the claim amount as prayed for and appeal filed by the appellant be dismissed.

11.              It is admitted fact that during the subsistence of the insurance policy, complainant was operated upon by  PTCA and stent to LAD. It is also admitted that he spent Rs.1,28,000/- on his treatment.  It is not disputed that the life assured has obtained policy from OP No.1.  Perusal of Ex.C-1 i.e. Repudiation Letter dated 29.06.2017, shows that the claim was repudiated on the ground that complainant was suffering from hypertension and diabetes prior to purchase of medi claim policy which he did not disclose and the present ailments fall under first two years of the policy exclusion so this claim was not payable. Complainant was 57 years of age at the time of purchasing of policy. As per IRDAI instructions it is the duty of the insurer to put insured through medical examination if insured is more than 45 years of age and thereafter issue him medi-claim policy, but some how or the other, no medical examination was conducted by the appellant, therefore now OPs, cannot turn around and deny this claim.  The learned District Commission rightly allowed the claim of the complainant. The learned District Commission had committed no illegality while passing the order dated 28.01.2019.  The appeal is also devoid of merits and stands dismissed.

12.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant-respondent No.1 against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

13.              Applications pending, if any stand disposed of in terms of the aforesaid judgment.

14.              A copy of this judgement be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgement be uploaded forthwith on the website of the commission for the perusal of the parties.

15.              File be consigned to record room alongwith a copy of this judgement.

 

16th  August, 2022             Suresh Chander Kaushik            S. P. Sood                                                                Member                                             Judicial Member    

S.K

(Pvt. Secy.)