Haryana

StateCommission

A/629/2015

NEW INDIA ASSURANCE CO. LTD. - Complainant(s)

Versus

RAVINDER GARG - Opp.Party(s)

B.S.TAUNQUE

11 Dec 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :     629 of 2015

Date of Institution:     28.07.2015

Date of Decision :     11.12.2015

 

1.     The New India Assurance Company Limited, Regional Office, SCO No.36-37, Sector 17-A, Chandigarh through its Manager (Legal).

2.     The New India Assurance Company Limited Opposite Madhu Palace, Jagadhri Road, Yamuna Nagar, through its Branch Manager.

3.     The New India Assurance Company Limited Divisional Office, 100 The Mall, Ambala Cantt, through its Divisional Manager.

                                      Appellants/Opposite Parties

Versus

 

Ravinder Garg s/o Sh. Rameshwar Dass of M/s Mahadeva Steel, Resident of VPO Balachaur, Chhachhroli, District Yamuna Nagar.

 

                                      Respondent/Complainant

 

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

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Present:               Shri B.S. Taunque, Advocate for appellants.

                             Shri Aftab Singh, 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 May, 2015, passed by District Consumer Disputes Redressal Forum, Yamuna Nagar (for short ‘the District Forum’) in Complaint No.1040 of 2010.

2.      Ravinder Garg-complainant (respondent herein), had been taking Hospitalization and Domiciliary Hospitalization Benefit Policy for him and his wife, since 21.07.2003. During its 8^th renewal from 13.08.2010 to 12.08.2011, vide cover note Annexure C-8 for Rs.2.00 lacs, the complainant fell ill. He was admitted in Medanta Hospital, Gurgaon on 12.07.2010. He was diagnosed a patient of Coronary Artery disease, triple vessel disease, angina, hypertension and Type II diabetes mellitus. Coronary angiography was done on 12.07.2010. OPCAB X4 – LIMA to LAD, RSVG to OMI, Distal XX and Distal RCA was done on 14.07.2010. He was discharged from the above said hospital on 20.07.2010. Discharge Summary is Annexure A-9. He filed claim with the Insurance Company with respect to the expenses incurred by him but the same was repudiated vide letter dated 09.09.2010 (Annexure C-10) stating as under:-

“1.     Patient suffered from DM, HTN, and CAD-TVD. The treatment of DM, HTN and its complications like CAD comes under Ist two years exclusion clause. The policy is in 2^nd year of inception, therefore the claim is non payable as per clause 4.3 of the policy.

2.      On going through the records it is found that patient is suffering from DM from last 15 years. Policy in 2^nd year of inception. Therefore claim is non payable as per clause 4.1 of the policy. DM, HTN, CAD-TVD”.

3.      The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986.

4.      The opposite parties/Insurance Company contested complaint by filing reply wherein it reiterated the facts stated in the repudiation letter and prayed for dismissal of the complaint.

5.      On appraisal of the pleadings of the parties and the evidence adduced on the record, the District Forum accepted directing the Insurance Company, as under:-

“(a)    To release the insurance claim amounting to Rs.2,00 lacs out of Rs.2,57,717/- (which has been spent by the complainant on his treatment) to the complainant as sum insured under the medi-claim policy alongwith simple interest @ 9% per annum from the date of institution of complaint to the date of decision including the benefit of bonus etc., if any, accrued upon the policy.

(b)     To pay Rs.15,00/- as compensation on account of harassment & mental agony etc cause to the complainant for a long period of about 5 years (i.e. from the date of treatment to till the date of decision) by the negligent act of the insurance company.

(c)     To pay Rs.10,000/- as costs for unwanted litigation including the advocate’s fee etc.

The aforesaid directions must be complied with by the Ops-Insurance Company within the stipulated period otherwise all the aforesaid awarded amounts shall fetch further simple interest 2 12% per annum for the period of default. The complaint is decided accordingly in the above terms.”

6.      The only plea raised by the appellants/Insurance Company is that there was a gap of 23 days in the renewal, as the policy was due for renewal w.e.f. 21.07.2008 and was got renewed on 13.08.2008, therefore, it would be treated as fresh policy and thus, the treatment received during the year July 2010 fell within the Exclusion Clause as the policy was in the second year treating its inception from 13.08.2008.

7.      The contention raised is unfounded, as even the policy which was taken from 13.08.2008 to 12.08.2009, it finds endorsement as “previous medi-claim policy renewal”. Had it been a fresh policy, the Insurance Company should have specifically mentioned it to be a fresh policy and not renewal policy. Therefore, the treatment undertaken by the complainant during the year 2010 could not be treated as a pre-existing disease to be falling within two years as the policy has been continuous since 2003. It is pertinent to mention here that even thereafter the policy is being continuously renewed from 13.08.2009 to 12.08.2010, 13.08.2010 to 12.08.2011 and so on without any break.

8.      Learned counsel for the appellants/Insurance Company has referred to repudiation letter Annexure A-10, wherein it has been mentioned that the complainant was suffering from DM, HTN, and CAD-TVD for the last 15 years. Even this contention is without force. In view of Clause 4.1 of the policy (Annexure A-4), the exclusion period is only four years for pre-existing disease. Since the policy was continuing since 2003, therefore, the complainant’s claim does not fall within Exclusion Clause.

9.      The judgment in United India Insurance Co. Ltd. versus Kanta Gupta, II(2012) CPJ 191 (NC), is not applicable because the claimant suffered from DM Triopathy CRF LVF (kidney problem) during the first year of the policy which fell under the Exclusion Clause. However, in the instant case the policy was continuous since 2003.

10.    In view of the above, it cannot be said that the complainant’s claim was not covered under the policy. The Insurance Company wrongly repudiated complainant’s claim. Thus, no case for interference in the impugned order is made out.

11.    Hence, the appeal stands dismissed being devoid of any merit.

12.    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 11.12.2015

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL