Per : Mr. V. P. Utpat, President Place : PUNE
// J U D G M E N T //
(04/05/2013)
This complaint is filed by the aggrieved consumer against the Insurance Company and Standard Chartered Bank for deficiency in service. The brief facts of the complaint are as follows,
1] The complainant is the resident of Krutarth Socety, Pune – 37. He is a business man and having credit card of opponent no. 2. He had received call from the opponent no. 2 on 10/6/2008 and he was informed that he will get hospital cash insurance policy being valuable customer of the said bank. The complainant has informed that he is 71 years old and suffering from diabetes and other ailment, but still he was insisted for taking said policy. His son had also obtained Master policy. He had informed to opponent no. 1, .e. Insurance Company about his pre-existing disease.
On 6/4/2009, he was admitted in the hospital at Senapati Bapat Road, Pune for medical treatment and he was charged an amount of Rs. 2500/- per day for five days during the period of 6/4/2009 to 11/4/2009. He had applied for reimbursement of the said amount but his claim was repudiated by stating that his claim is excluded from the terms of the policy. He has claimed an amount of Rs. 25,000/- by way of deficiency in service, Rs. 1,00,000/- towards mental agony and cost of the proceeding.
2] The opponent no. 1 and 2 both have appeared and resisted the complaint by fling written statement separately. According to the opponent no. 2, the complainant had entered into contract with the opponent no. 1 as regards to the medical insurance and his claim is repudiated as per the terms and conditions of the policy. The opponent no. 2 has no concern with said claim. It has prayed for dismissal of the complaint.
According to the opponent no. 1, in view of terms and condition of the insurance policy, the complainant was aware that he is not entitled to claim reimbursement, as he was suffering from diabetes and hypertension prior to the alleged treatment. He had suppressed this material fact, hence his claim is repudiated by the Insurance Company. The opponent no. 1 has prayed for dismissal of the complaint.
3] After scrutinizing the documentary evidence on record and considering the pleadings as well as hearing the arguments of both the parties, the following points arise for my determination. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether the Insurance Company has rightly repudiated the mediclaim of the complainant? | In the affirmative |
2. | What order? | Complaint is dismissed |
REASONS :-
4] The learned Advocate for the complainant argued that even though the opponents were aware that the complainant is 71 years old and suffering from ailment, such as diabetes and hypertension, still he was invited for taking insurance policy. He has not suppressed any material fact and his claim is wrongly repudiated, hence he is entitled to compensation. Per contra, the learned Advocate of the opponent argued that the complainant is not a layman, he is a businessman. He had entered into contract with the open eyes. He was aware of the terms and conditions of the policy. It is crystal clear from the terms and conditions of the policy that the company shall not be liable under policy for claim in connection with or in respect pf pre-existing disease and any disease, illness, medical condition, injury which is complication of pre-existing disease. The opponent has produced the discharge card of the complainant, which is disclosing that the complainant is a chronic patient of diabetes and hypertension since 1990. He is taking regular treatment of injection of human Insulin as well as he is suffering from heart trouble. In such circumstances, in the light of terms and conditions of the policy, he is not entitled for any mediclaim from the opponent. I found much substance in the argument of learned Advocate for the opponent. The opponent has also relied upon the ruling of “Oriental Insurance Co. Ltd. V/S Sony Cherian”, reported in II 1999 CPJ 13 SC, in which Hon’ble Apex court has observed that,
“The insurance policy between the insurer and
the insured represents a contract between the
party. Since the insurer undertakes to compensate
the loss suffered by the insured on account of risks
covered by the insurance policy, the terms of the
agreement have to be strictly construed to determine
the extent of liability of the insurer. The insured
cannot claim anything more than what is covered
by the insurance policy.”
It is significant to note that in the present proceeding, the complainant was aware about the exclusion clause of the policy, still he has claimed for the mediclaim and that was rightly repudiated by the opponent. I do not find infirmity in the decision taken by the insurance company. I held that the complaint is deserves to be dismissed as there in no deficiency in service. In the result, I answer the points accordingly and pass the following order,
** ORDER **
1. Complaint is dismissed with no
order as to the costs.
2. Copies of this order be furnished to
the parties free of cost.
