Heard counsel for the parties.

The above appeal has been filed against the order of the State Consumer Disputes Redressal Commission Maharashtra, Mumbai dated 05.04.2023 passed in CC/20/150 whereby the complaint was allowed ex-parte and the following directions have been passed:-

          “(i) Complaint is hereby allowed.

          (ii) The opponent is hereby held as guilty for deficiency in service.

          (iii) The Opponent is hereby directed to pay sum of Rs.50,91,080/- along with interest @9% per annum from the date of repudiation of the claim i.e. from 29/11/2019 till realisation of the entire amount.

          (iv) The Opponent is also directed to pay compensation of Rs.1,00,000/- for mental agony and Rs.25,000/- towards costs of litigation.

          (v) Copies of the order be furnished to the parties.”

Mr. Sarbendu Bagchi, Respondent has filed CC/20/150 for directing the appellant to pay Rs.5091080/- under Home Suraksha Plus policy and Rs.500000/- as compensation for mental agony and harassment and Rs.50000/- as litigation cost. It has been stated by the complainant that the complainant obtained Home Suraksha Plus policy from the opposite party for the period of 15.01.2015 to 14.01.2020 in the process of taking home loan. In May, 2018 problem of elevated creatinine was detected in the body of the complainant. The complainant underwent treatment with a nephrologist but in the month of August, 2019, the complainant’s creatinine level suddenly shot up and admitted in hospital for check up on 14.08.2019 where he was diagnosed with acute and chronic renal failure and presently the complainant is undergoing dialysis twice in a week. The complainant submitted his insurance claim under two policies i.e. Sarva Suraksha Claim No.RRCI19-10733667 for Rs.100000/- and Home Suraksha Plus Policy No.RR-CI19-10731309 for Rs.5091080/-. The claim under Sarva Suraksha Policy was settled for Rs.100000/- by the opposite party on 09.09.2019 while claim of Rs.5091080/- under Home Suraksha Plus Policy has been repudiated by letter dated 29.11.2019.

It appears that in spite of service of notice, the opposite party could not appear before the State Commission and the State Commission has proceeded ex-parte and by the impugned order the State Commission has awarded a sum of Rs. 5091080/- towards the insurance claim with the interest @ 9% per annum and Rs.100000/- for mental agony and Rs.25000/- towards litigation cost.

The counsel for the appellant has raised very short issue during the arguments before this Commission that in the Home Suraksha Plus policy one of the coverage under Section III was for “Major Medical Illness and Procedures” and sum insured was Rs.5091080/-. But in the paragraph after this table it has been mentioned ‘in case of co-applicant, benefits under section III & IV (Major Medical Illness and Procedure & personal accident) was limited to 50% of sum insured for each insured. He submits that admittedly there were two insured as such 50% of sum insured of Rs.5091080/- was payable. The award of Rs.5091080/- was not proper. The award of the State Commission is liable to modified this extend. He further submits that there is no reason to award compensation for mental agony by State Commission in as much as the claim was repudiated by the appellant on the ground of the concealment of previous ailment at the time of taking policy.

I have considered the arguments of the counsel for the parties. A perusal of the insurance policy clearly shows that sum insured for Major Medical Illness and Procedure was of Rs.5091080/- and its 50% has to be awarded as per the terms and conditions of the policy as there were two insured. But the State Commission has overlooked the terms and conditions of the policy. Therefore, the order of the State Commission is liable to be modified. The State Commission has not recorded any findings for awarding the compensation for mental agony in as much as the compensation could not be claimed in multiple head.

So far as interest is concerned, the claim was set up on 14.08.2019. Therefore, interest is liable to be given from March, 2020 till the date of payment. So far as payment is concerned admittedly there is a bank clause and payment has to be made to the bankers and it shall be open to the appellant to make payment to the banker.  

ORDER

The appeal is partly allowed. The order of the State Commission dated 05.04.2023 passed in CC/20/150 is modified and it is held that the complainant/respondent is entitled to 50% of Rs.5091080/- and the order relating to compensation of Rs.100000/- for mental agony is set aside. The respondent is entitled for interest on above amount @ 9% per annum from March, 2020 till the date of payment.