Haryana

StateCommission

A/378/2016

NEW INDIA ASSURANCE CO. - Complainant(s)

Versus

SHIV DAYAL - Opp.Party(s)

R.C.GUPTA

13 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

                                                                First Appeal No.378 of 2016

Date of Institution: 18.04.2016 & 02.05.2016

                                                               Date of Decision: 13.07.2016

 

The New India Assurance Company Limited, through its Branch Manager, Kurukshetra, now through its authorized signatory of Regional Office, SCO No.36-37, Sector 17-A, Chandigarh.

….. Appellant

Versus

 

Shiv Dayal S/o Gokul Ram, R/o H.No. 577/8, U.T.I. Bank Building, 1st floor, Railway Road, Kurukshetra.

                                      …..Respondent

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mrs. Urvashi Agnihotri, Member.                                                                                                                                        

Present:               Shri R.C. Gupta, Advocate for appellant.

 

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:-

It was alleged by complainant that he obtained medi-claim policy from opposite party (O.P.) which was valid from 14.09.2007 to 13.09.2008. Thereafter the said policy was renewed from 14.09.2008 to 13.09.2009.  On 20.05.2009 he went to Shri Balaji Action Medical Institute, Delhi for medical check-up where angiography was done and it was found that there was blockage in the heart arteries.  Doctor conducted bye- pass surgery on 21.05.2009 and he remained admitted in that hospital from 20.05.2009 to 26.05.2009.  He spent Rs.One lakh on the treatment and requested the O.P. to reimburse the claim, but, O.P. repudiated the same on the ground that his case was not covered by insurance policy.

2.      O.P. filed reply controverting his averments and alleged that he was a known case of hyper-tension which was confirmed and was responsible for coronary artery disease (In short “CAD”).  As per clause No.4.3 of insurance policy, hyper-tension and related diseases first two years came under for exclusion clause, so his claim was rightly repudiated.

3.      After hearing both the parties, learned District Consumer Disputes Redressal Forum, Kurukshetra (In short “District Forum”) allowed the complaint vide impugned order dated 25.02.2016 and directed O.P. to pay Rs. One lakh to complainant.

4.      Feeling aggrieved therefrom O.P./insurance company has preferred this appeal.

5.      Arguments heard. File perused.

6.      Learned counsel for the appellant vehemently argued that hyper tension is in exclusion clause for two years i.e. if any person is having hyper tension within two years of obtaining insurance policy, he is not entitled for compensation.  CAD is related to hyper-tension.  He obtained treatment within two years, so he is not entitled for compensation.

7.      This argument is of no avail. There is no evidence on the file showing that complainant was having problem of hyper-tension.  Just on the basis of presumption it cannot be opined that due to this problem he was having CAD.  CAD can be due to other circumstances also.  Insurance company was supposed to prove this fact with cogent evidence, which it has miserably failed to prove.

8.      More so, against clause No.4.3  only hyper-tension is mentioned and it’s co-related disease/problem is no-where mentioned. When specific problem is mentioned in the insurance policy, it cannot be stretched to snatch benefit from the aggrieved person.  Learned district Forum rightly came to conclusion that O.P. has miserably failed to connect CAD with hyper-tension or clause No.4.3.  The findings of learned District Forum are well reasoned based on law and facts and cannot be disturbed.  Resultantly, appeal fails and the same is hereby dismissed in limine.

9.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules.

 

July 13th, 2016                       Urvashi Agnihotri                                R.K.Bishnoi,                                                               Member                                              Judicial Member                                                         Addl. Bench                                        Addl.Bench                

S.K.