Rajasthan

StateCommission

A/982/2015

Cholamandalam Ms Gen. Ins. Co. Ltd. - Complainant(s)

Versus

Sanjeev Kumar Dubey s/o Ratnesh Dubey - Opp.Party(s)

Man Singh Chundawat

19 Jul 2016

ORDER

BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,RAJASTHAN,JAIPUR BENCH NO.1

 

FIRST APPEAL NO: 982 /2015

 

Cholamandlam MS General Insurance Co. Ltd. regd.office 'Dare House' 2^nd floor, 234 NSC Bose Road, Chennai & ors.

 

Vs.

 

Sanjeev Kumar Dubey s/o Ratnesh Dubey r/o Plot No. 9-A, Krishnapuri Rankari, Ajmer Road, Jaipur.

 

Date of Order 19.7.2016

Before:

 

Hon'ble Mr.Vinay Kumar Chawla-Presiding Member

Mr. Kailash Soyal - Member

 

Mrs. Jaya Pathak counsel for the appellant

 

BY THE STATE COMMISSION

 

This appeal has been filed against the judgment of

2

 

learned DCF Jaipur 4^th dated 1.6.2015 by which the complaint was allowed.

 

Brief facts are that the complainant had taken a medical health policy for himself and his wife on 9.11.2009. The complainant's wife was operated upon for Fibroid Uterus on 27.12.2009 and the complainant filed reimbursement bills for Rs. 31,642/- with the company but the company repudiated the claim on the ground “ As this is a fresh policy posibility of present ailment being a long standing pathology cannot be ruled out and treatments/ diagnostics related to primary/secondary infertility are not payable hence the claim is rejected”.

 

The company submitted before the learned DCF that it was a pre-existing disease at the time of taking the insurance cover which was concealed by the complainant and his wife. The learned DCF allowed the complaint on the ground that concealment of preexisting disease has not been proved.

 

We have heard the learned counsel for the insurance company who has relied upon I (2016) CPJ 57 (NC) Life

3

 

Insurance Corporation of India Vs. Bimla Devi, III (2011) CPJ 43 (NC) Maya Devi Vs. LIC of India, II (2011) CPJ 44 (NC) Pushpa Chauhan Vs. LIC of India and judgment of the Hon'ble Supreme Court in Civil Appeal No. 2776/2002 Saatwant Kaur Sandhu Vs. New India Assurance Co.

 

The learned counsel has submitted that no indemnity is available for claim directly or indirectly caused by or is connected with infertility. The counsel also submitted that she had concealed the fact that she had been prescribed or taken any medicine for the last 12 months. Thus, the claim was rightly rejected.

 

We have considered the arguments of the counsel and have perused the judgment of the learned DCF.

 

It is true that complainant was suffering from Dysmenorohoea which is a condition of painful menstruation for the last two years. Though the prescription dated 18.12.2009 of Sevayatan Hospital mentions that she was suffering from Dysmenorohoea . Whether she had taken any

 

4

 

treatment for this is not on record and the company has also not led any evidence to prove that she was on medication for Dysmenorohoea. The prescription shows that she was diagnosed of Fibroid Uterus only on 23.11.2009 in ultrasound conducted at Jain Fertility Centre. The prescription also states that complainant's wife had also taken medication for Ovulation induction a year before. The complainant has not lodged any claim for medicines for Ovulation induction which is directly connected with the infertility.

 

The complainant's wife was operated upon on 27.12.2009 i.e.after commencement of the insurance cover for Fibroid Uterus – it is a non-cancerous growth of muscle tissues of the uterus. The company has not led any evidence to prove that this operation was connected with the treatment of infertility. In their repudiation the company has expressed possibility of ailment being a long standing pathology. Thus possibility was expressed only and there is no evidence to prove this.We are in agreement with the findings of the learned DCF that concealment of any pre-existing disease has not been proved. There is no evidence whether she was on

 

5

 

medication for Dysmenorohoea and medication for Ovulation induction cannot be treated as pre-existing disease. The appeal does not deserves to be admitted and is dismissed.

 

 

(Kailash Soyal) (Vinay Kumar Chawla)

Member Presiding Member

 

nm