Complainant through Lrd. Adv. Likhit Gandhi
Opponent through Lrd. Adv. Dharmapal
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Per : Mr. V. P. Utpat, President Place : PUNE
// J U D G M E N T //
(06/05/2014)
This complaint is filed by the consumer against the insurance company for deficiency in service under section 12 of the Consumer Protection Act, 1986. The brief facts are as follows.
1] The complainant is resident of Mitramandal Colony, Parvati, Pune – 9. The opponent is the office of insurance company, which is situated at Tadiwala Road, Pune – 1. Since 2006, the complainant and his wife are regularly and continuously drawn mediclaim policy from the opponent without any break. The sum insured for the said policy was Rs. 1,00,000/-. The last policy was valid for the period of 14/12/2010 to 13/12/2011 and the first policy was for the period of 14/12/2006 to 13/12/2007. The complainant had not suffered from any health problem from 14/12/2006 to Jan. 2011. She had not made any claim during that period. In the moth of Jan. 2011, she was suffering from chest pain, hence she was admitted in Poona Hospital and she was operated for Angioplasty. The cost of the operation was Rs. 1,75,000/-. As per the terms and the conditions, the said mediclaim policy has cashless provision i.e. during the hospitalization, she does not require to pay any cash in the hospital. However, the opponent has denied the said facility by letter dtd. 2/2/2011. After taking discharge, she had submitted all the documents along with proposal for reimbursement of the charges. But her claim was repudiated unilaterally on 11/2/2011. Again on 15/2/2011 and on 3/2/2011, the opponent has demanded documents regarding hospitalization of the complainant. However on 20/6/2011 again the opponent has repudiated the claim of the complainant under clause no. 4.1 i.e. on the ground of pre-existing disease. The complainant has further submitted that she had disclosed about the bypass surgery, which was performed on her in the year 1998. It is the case of the complainant that she never suppressed any material fact; still the complainant’s claim was rejected. She had asked principal sum assured of Rs. 1,00,000/-, domiciliary hospitalization limit of Rs. 20,000/-, cumulative bonus of Rs.35,000/-. She has also asked compensation for inconvenience to the tune of Rs. 50,000/-. She has further claimed interest @ 12 p.a. on the said amount.
2] The opponent has resisted the complaint by filing written version. The facts as regards deficiency in service are denied by the opponent. It is the case of the opponent that, it has rightly repudiated the mediclaim of the complainant, as the complainant had suppressed material fact i.e. pre-existing disease. The opponent has also contended that the complainant’s claim as regards compensation and bonus are also not genuine. The opponent has prayed for the dismissal of the complaint.
3] After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the counsels and considering pleadings, the following points arise for the determination of the Forum. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether complainant has established that the opponent has caused deficiency in service by wrongly repudiating the insurance claim? | In the affirmative. |
2. | What order? | Complaint is partly allowed. |
REASONS :-
4] The admitted facts in the present proceeding are that the complainant had obtained mediclaim policy from the opponent from 14/12/2006 to 13/12/2007. It further reveals from the policy document that the complainant has paid total premium of Rs.4,700/- and the sum assured was Rs. 1,00,000/-. The complainant has produced the bills and vouchers from Poona hospital, showing that she had spent an amount of Rs. 1,53,579/- on 2/2/2011 for her illness. It reveals from the letter which was issued by the opponent that her claim was repudiated on the ground that she was suffering from Hypertension since 13 years and she is known case of heart disease since 12 years. It is the case of the complainant that at the time of submission of proposal, she has informed that she is suffering from heart disease and she was operated for bypass surgery and after knowing these facts, her proposal was accepted and the policy was issued. The complainant has called the original proposal, which was submitted by her but the opponent failed to produce the said document. It is pertinent to note that the document is in the custody of the opponent and the same is denying to bring it on record. In such circumstances, an adverse inference can be drawn against the opponent.
5] The learned Advocate for the complainant argued before this Forum that the heavy burden lies upon the insurance company to establish that the complainant had suppressed pre-existing disease. In order to discharge this burden, the insurance company has not produced any authenticate record. In such circumstances, it is very difficult to digest that the complainant had suppressed material facts and her claim was rightly repudiated by the opponent on the ground of pre-existing disease. In absence of original proposal, which was submitted by the complainant, this Forum is of the opinion that the opponent has wrongly repudiated the insurance claim of the complainant.
6] The complainant ahs asked the policy amount of Rs.1,00,000/-. The complainant has also asked amount of cumulative bonus. It reveals from the policy that there is no such term and condition. The complainant has also asked domiciliary hospitalization limit of Rs.20,000/-. It is the opinion of the Forum that the entire claim as regards insurance is restricted to Rs. 1,00,000/-. The complainant has further asked an amount of Rs. 50,000/- by way of compensation for inconvenience and mental agony. That claim is also exaggerated. It is the opinion of the Forum that the complainant is entitled for Rs.10,000/- as compensation for inconvenience and mental agony, cost of the litigation and compensation for deficiency in service. In all the complainant is entitled to Rs. 1,10,000/-. In the result the Forum answers the points accordingly and pass the following order.
** O R D E R **
1. The complaint is partly allowed.
2. It is hereby declared that the opponent
has caused deficiency in service by
wrongly repudiating the claim of the
complainant.
3. The opponent is directed to pay an
amount of Rs. 1,10,000/- (Rs. One Lac
Ten Thousand only), to the complainant
within six weeks from the date of receipt
of copy of this order.
4. On failure to pay the abovementioned
amount within six weeks, it shall carry
interest @ of 9% p.a. from the date of
filing of the complaint till its realization.
5. Copies of this order be furnished to
the parties free of cost.
6. Parties are directed to collect the sets,
which were provided for Members within
one month from the date of order, otherwise
those will be destroyed.
Place – Pune
Date- 06/05/2014
