ORAL ORDER
Per – Hon’ble Mr. Justice R. C. Chavan, President
This appeal filed by the Appellant/original Opponent – The Oriental Insurance Company Ltd. (hereinafter referred to as ‘the Insurance Company’ for the sake of brevity) is directed against an order dated 10/09/2012 passed by the South Mumbai District Consumer Disputes Redressal Forum partly allowing the Consumer Complaint No.283 of 2010 and directing the Opponents therein to pay to the Respondent No.1/original Complainant – Mr. Prakash G. Karhade (hereinafter referred to as ‘the Complainant’ for the sake of brevity) an amount of `11,36,136/- towards reimbursement of medical expenses incurred by the Complainant besides an amount of `5,000/- by way of compensation towards mental agony and costs quantified at `3,000/-.
[2] Facts which are material for deciding this appeal are as under:-
On 02/10/2008, the Complainant had availed from the Insurance Company an Overseas Mediclaim Policy. There is no dispute that the Complainant was suffering from hypertension since the year 1995. The Complainant went to Thailand and underwent angioplasty at BangkokPattayaHospital during the period 06/11/2008 to 11/11/2008 and incurred expenditure to the tune of `11,36,136/- for this hospitalization. He preferred an insurance claim with the Insurance Company which was repudiated. Aggrieved thereby, the Complaint approached the District Forum and filed a consumer complaint.
[3] Insurance Company contested the claim contending that the Complainant was suffering from hypertension since the year 1995 and the ailment for which the treatment was given and reimbursement was sought was directly related to the pre-existing ailment/condition. On these main grounds, the Insurance Company justified repudiation of the Complainant’s claim.
[4] The Forum, upon considering rival contentions, came to pass the impugned order. Aggrieved thereby, the Insurance Company is before us.
[5] We have heard Adv. Smt. Sapna Bhuptany on behalf of the Appellant/Insurance Company and Adv. Smt. Nasim Jahangir Khan instructed by Thodur Law Associates on behalf of the Respondent No.1/original Complainant. We have also perused the record and also gone through the briefs of written arguments filed on behalf of the Respondent No.1.
[6] Arguments advances before us give rise to the only point as to whether the Forum was justified in allowing the consumer complaint? We hold that the Forum was not justified in doing so for the following reasons:-
[7] It is not in dispute that the Complainant was suffering from hypertension since the year 1995 as could be seen from the certificate dated 12/03/2009 issued by Complainant’s own physician, Dr. Vishwanath B. Amin. Apart from this the Complainant in his affidavit had categorically stated that had he known that there would be no reimbursement for pre-existing disease, he would not have taken out the mediclaim policy. It was in fact, the Complainant’s allegation that the Insurance Company suppressed from him the information that he would not get the insurance cover if he had pre-existing disease. It was alleged that the Insurance Company was at fault in not ascertaining whether the Complainant was having pre-existing disease or not and the Insurance Company was negligent in dealing with the matter. It was also alleged that while selling the insurance policy and collecting premium from the Complainant, the Insurance Company assured that the Complainant would get reimbursement and it was stated that had the Complainant been told that he shall not get reimbursement for pre-existing ailments, he would not have taken the mediclaim policy. This implies that the Complainant knew that he was suffering from hypertension. Whether in such condition the Complainant could be reimbursed or not depends upon the terms and conditions of the mediclaim policy, which clearly show that for pre-existing diseases, reimbursement would not be admissible. In this case, pre-existing disease viz. hypertension is the possibly direct cause of the purpose for which the Complainant was required to take treatment at BangkokPattayaHospital. Therefore, there was nothing amiss in the Insurance Company’s refusal to honour the claim. The Forum ought to have held accordingly and ought to have dismissed the complaint. Hence, the present appeal will have to be allowed. We hold accordingly and pass the following order:-
ORDER
Appeal is allowed.
Impugned order dated 10th September, 2012 passed by the South Mumbai District Consumer Disputes Redressal Forum in Consumer Complaint No.283 of 2010 is hereby set aside. Consequently, the consumer complaint stands dismissed.
Parties shall bear their own costs.
Pronounced and dictated on 10th December, 2013
