Chandigarh

DF-II

CC/336/2016

Pushpa Gupta - Complainant(s)

Versus

Royal Sundaram General Insurance - Opp.Party(s)

Munish Goel Adv.

12 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	336 of 2016
Date  of  Institution	:	13.5.2016
Date   of   Decision	:	12.4.2017

 

 

 

 

 

Pushpa Gupta d/o Raj Kumar Gupta R/o H. No. 5234/1, Modern Housing Complex, Mani Majra, Chandigarh.

 

                …..Complainant

Versus

 

1.   Royal Sundram General Insurance Registered Office, 21 Patullos Road, Chennai-600002 through its Managing Director/Director/Authorized Signatory.

 

2.   Royal Sundram General Insurance SCO 82, 1^st and 2^nd floor, Sector 40C, Chandigarh through its Director/Manager/Authorized signatory.

 

3.   Balwinder (Authorized agent), SCO 82, 1^st and 2^nd floor, Sector 40C, Chandigarh.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

         SH. RAVINDER SINGH             MEMBER

 

 

For complainant(s)      :     Sh. Munish Goel, Adv.

 

For OP No.1&2           :     Sh. R.K. Bashmboo, Adv.

 

For OP No.3             :     Ex-parte.    

 

 

RAVINDER SINGH, MEMBER

 

 

     In nutshell the complainant took a medi-claim policy from OPs No.1&2 through its agent OP No.3 by paying premium amount of Rs.5,078/- having coverage of Rs.3 lakh valid from 26.12.2014 to 25.12.2015. Accordingly, the complainant was issued the policy in question though without any terms and conditions.  It is pleaded that at the time of taking the policy the complainant was in proper health and without any ailment. Subsequently, the complainant got the policy renewed  w.e.f. 26.12.2015 to 25.12.2016. In February, 2015 for the first time the complainant suffered from diabtetes and hypertension and got treatment from Forties Medical Centre. Thereafter on 8.12.2015 the complainant was admitted in Fortis Hospital for treatment of hypertension and diabetes mellitus and discharged on 15.12.2015. Afterward, the complainant submitted his claim with the OPs. But to the utter surprise of the complainant the OPs illegally vide letter dated 23.3.2016 denied to consider the claim of the complainant on the ground that the complainant is having history of diabetes mellitus for 3-4 years. Alleging the said act of OPs as deficiency in service, this complaint has been filed.

 

2.     Notice of the complaint sent to Opposite Parties seeking their version of the case. However, since nobody appeared on behalf of Opposite  Party No. 3 despite service, therefore, it was  proceeded ex-parte.
3.     OPs No.1&2 in their joint reply while admitting the factual matrix of the case stated that  on receiving claim of the complainant, the OPs, scrutinize the case of the complainant and it came to the notice that the complainant is a known case of diabetes mellitus for 3 to 4 years. The discharge summary of the complainant dated 15.12.2015 under the past history expressly stated that the patient is a known case of  hypertension since 5-6 months and diabetes mellitus diagnosed in Feb. 2015. In Triage History and physical sheet of the insured/complainant it is stated under past medical history that the complainant is diabetes  mellitus since 3 years.  It is pleaded that the insurance being a contract of utmost good-faith the complainant should have declared the pre-existing disease which is a material information while undertaking a risk related health insurance policy. Thus, since the complainant suppressed the material fact therefore, her claim was rightly repudiated by the answering OPs.  Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.
4.     The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party No.1&2 made in their reply.
5.     Contesting parties led evidence in support of their contentions.
6.     We have heard the ld. Counsel for the contesting parties and have also perused the record.
7.     Smt. Pushpa Gupta the complainant took family Health Protector Policy number HLAMFF0001  valid from 26.12.2014 to 25.12.2015 on payment of premium of Rs.5078/- (AnnexureC2) for insurance cover of Rs.3,00,000/- from Royal Sundram Alliance Insurance Company Limited . She renewed the Health Insurance policy for a further period w.e.f. 26.12.2015 to 25.12.2016 on payment of Rs.5175/- on 25.12.2015 (Annexure C-6). On renewal of policy the complainant was given cumulative bonus of Rs.15,000/- and floater sum insured of Rs.3,00,000/-.  The complainant suddenly fell sick and contacted Fortis Medcentre, Sector 11D, Chandigarh on 13.2.2015 for check up/treatment (Annexure C-7). She was diagnosed for PYOGNIC LIVER ABSCESS PNEUMONITIS URINARY TRACT INFECTION SEPSIS (ENTEROCOCCUS POSITIVE).  The complainant was reported case of hypertension since 5-6 months and diabetes mellitus since  Feb. 2015 (Annexure C-9). She was admitted  in Fortis Hospital, Mohali on 8.12.2015 and discharged on 15.12.2015 for treatment (Discharge Summary Annexure C-9).
8.     As per Discharge summary prepared by doctors on 15.12.2015, which is a replica of medical treatment record, of the complainant clearly observed to be a case of hypertension since 5-6 months only and diabetes since Feb. 2015 only.
9.     The OPs have repudiated the claim merely relying upon the entry in the TRIAGE HISTORY AND PHYSICAL SHEET dated 8.12.2015 (Annexure R-4/page 23) wherein the diabetes shown to be since 3-4 years. The OPs have not produced any record or evidence in proof that the complainant is patient of diabetes for the last 3-4 years.  This seems to a clerical mistake on the part of doctor who prepared the Triage History on the verbal observations of attendants of the patient without any cogent evidence on record.
10.     After thorough examination of entire evidence on record, we have observed no impediment in award of insurance claim of Rs.2,14,411/- to the complainant by the OPs.
11.     Keeping into consideration the facts as discussed/mentioned above, accordingly to meet the end of justice, the complaint is hereby  allowed with direction to the OPs NO.1&2 to reimburse the amount of Rs.2,14,411/-  to the complainant which she has spent on her treatment during the medical policy.
12.     OPs No.1&2 shall comply with the order within 30 days from the date of receipt of this order, failing which shall pay the awarded amount alongwith interest @12% p.a.

    The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

 

Announced

12.4.2017

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER