Haryana

StateCommission

A/668/2015

ORIENTAL INSURANCE CO. - Complainant(s)

Versus

RAVI SHANKAR GOYAL - Opp.Party(s)

ASHWANI TALWAR

06 Jan 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      668 of 2015

Date of Institution:      11.08.2015

Date of Decision :       06.01.2016

 

1.     The Oriental Insurance Company Limited, Oriental Insurance House, P.B. No.7073, A-25/27, Asaf Ali Road, New Delhi – 110002.

2.     The Oriental Insurance Company Limited, Branch Office above Axis Bank, G.T. Road, Panipat.

Both 1 and 2 through authorized signatory, Oriental Insurance Company Limited, Regional Office, L.I.C. Building, 2^nd Floor, Jagadhri Road, Ambala Cantt.

                                      Appellants/Opposite Party No1

Versus

 

1.      Ravi Shankar Goyal, Resident of Jamna Filling Station, G.T. Road, Samalkha, District Panipat.

Respondent/Complainant

2.      M/s Park Mediclaim Consultants Private Limited through its Senior Branch Manager, 702, Vikrant Tower, Rajindra Place, Delhi-110008.

                                      Respondent/Opposite Party No.2

 

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

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Present:              Shri Aditya Kochhar, Advocate proxy for Shri Ashwani Talwar, Advocate for appellants.

                             Shri Subhash, Advocate for respondent No.1.

                             Respondent No.2 – performa party.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

This appeal of opposite parties is directed against the order dated 19^th May, 2015 passed by District Consumer Disputes Redressal Forum, Panipat (for short ‘the District Forum’) in Complaint No.142 of 2014.

2.      Ravi Shanker Goyal-complainant/respondent No.1 and his family members, were insured with The Oriental Insurance Company Limited (for short ‘the Insurance Company’)-Opposite party No.1, for the period March 28^th, 2012 to March 27^th, 2013, vide Insurance Policy Annexure C-5, under ‘Happy Family Floater Policy Schedule’ for Rs.5.00 lacs. One of the insured namely Krishna Goyal got paralysis attack. She was admitted in Medanta Global Health Private Limited, Sector-38, Gurgaon, where she remained admitted for eight days. A bill of Rs.5,44,985.79 (Annexure C-10) was prepared by the hospital for the treatment expenses. Since, it was cashless policy, the claim was sent through Medanta Hospital to the Insurance Company but the same was denied on the ground that the disease suffered by the patient (Krishna Goyal) being a pre-existing disease, was not covered under the policy. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed.

3.      In its reply, the Insurance Company while denying claim of the complainant on the ground stated in the repudiation letter, prayed for dismissal of the complaint.

4.      On appraisal of the pleadings and evidence of the parties, the District Forum vide impugned order accepted complaint directing the Insurance Company to pay Rs.5.00 lacs to the complainant alongwith interest @ 9% per annum from the date of filing complaint till its realization and cost of litigation at Rs.3300/-.

5.      The impugned order has been assailed solely on the ground that the disease suffered by Krishna Goyal was not covered under the policy being a pre-existing. In support, reliance was placed upon the repudiation letter Annexure C-3.

6.      Indisputably, Krishna Goyal was insured with the Insurance Company for the period March 28^th, 2012 to March 27^th, 2013 vide Insurance Policy Annexure C-5. Except the repudiation letter (Annexure C-3), there is no evidence produced by the Insurance Company to indicate that any such disease existed at the time of purchasing the policy and it was pre-existing. It is settled law that the onus to prove that the insured Krishna Goyal had a pre-existing disease was on the Insurance Company which as stated above, has failed to do. Thus, in the absence of any credible evidence, the Insurance Company cannot escape its liability to pay the claim of the complainant. In view of these facts, this Commission is unable to conclude that the patient had any pre-existing disease which would justify repudiation of the claim. 

7.      As a sequel to the aforesaid discussion, the appeal fails and is hereby 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 06.01.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL