Haryana

StateCommission

A/1136/2015

National Insurance Company Limited - Complainant(s)

Versus

Shyam Sunder Dudeja - Opp.Party(s)

17 Oct 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No         1136 of 2015

Date of Institution:      31.12.2015

Date of Decision :       17.10.2016

 

National Insurance Company Limited, 5C/1&2, BP, Railway Road, NIT, Faridabad through its Divisional Manager.

Now through its Authorized Signatory, Puja Dhawan, Assistant Manager, Regional Office II, SCO No.337-340, Sector 35B, Chandigarh.

                                      Appellant-Opposite Party No.1

Versus

 

1.      Shyam Sunder Dudeja son of Shri Hira Nand Dudeja, resident of House No.1493, Sector 14, Faridabad.

Respondent-Complainant

 

2.      M/s Park Medi Claim TPA Private Limited (Third Party Administrator-Health Services), 702, Vikram Tower, Rajendra Place, New Delhi -110008.

                                      Respondent-Opposite Party No.2

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member.

 

                            

Present:               Shri J.P. Nahar, Advocate for appellant

                             Shri Manoj Kumar Sood, Advocate for the respondent-complainant.

                             (Service of respondent No.2 dispensed with vide order dated March 29^th, 2016)

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

National Insurance Company Limited-opposite party No.1 (for short ‘Insurance Company’) is in appeal against the order dated November 04^th, 2015 passed by District Consumer Disputes Redressal Forum, Faridabad (for short, ‘District Forum’) whereby complaint filed by Shyam Sunder Dudeja-complainant was allowed.  The Insurance Company was directed to pay Rs.2,00,000/- alongwith interest at the rate of 9% per annum from the date of filing the complaint, that is, February 06^th, 2013 till realization; Rs.2200/- as compensation and Rs.1100/- litigation expenses to the complainant.

2.      Complainant purchased Hospitalization Benefit Policy –Individual Mediclaim (Annexure A-3) for the period November 10^th, 2011 to November 09^th, 2012 from the Insurance Company.  He fell sick and was hospitalized in Metro Heart Institute, Faridabad from July 18^th, 2012 to July 12^th, 2012.  He spent Rs.3,00,000/- on his treatment.  He filed claim with the Insurance Company but the same was repudiated on the ground that he had pre-existing disease.  Hence, the complaint.

3.      Learned counsel for the Insurance Company has urged that complainant was a patient of Hypertension as find mentioned in medical record of Metro Heart Institute, Faridabad wherein it is stated that the complainant is a known case of Hypertension for the last 8 years.  So, the complainant was not entitled to the benefit of insurance. 

4.      The question for consideration before this Commission is as to whether the Insurance Company was justified in repudiating complainant’s claim or not?

5.      In Satish Chander Madan vs. M/s Bajaj Allianz
General Insurance Company Limited, Revision Petition No.3619 of 2013 decided on January 11^th, 2016, Hon’ble National Consumer Disputes Redressal Commission, New Delhi held as under:-

“10. Learned counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hyper tension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the heart problem suffered by the petitioner was caused by pre existing hypertension. There is no merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected.”

6.      In view of above, the claim of the complainant was wrongly repudiated by the Insurance Company. The order passed by the District Forum requires no interference. Hence, the appeal is dismissed.

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

 

 

 

Announced 17.10.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

UK