Tripura

StateCommission

A/15/2023

SBI General Insurance Company Ltd - Complainant(s)

Versus

Sri Dhiraj Dhar - Opp.Party(s)

Mr. Prabal Kumar Ghosh

30 Jun 2023

ORDER

J U D G M E N T [ORAL]

Today, the case has been fixed for order.

Heard Mr. P.K. Ghosh, learned counsel appearing for the appellant-opposite party (Insurance Company) and Mr. H. Datta, learned counsel appearing on behalf of the respondent-complainant (here-in-after referred to as complainant).

1. This is an appeal preferred by the appellant-Insurance Company against the judgment and order dated 31.10.2022, passed by the learned District Consumer Disputes Redressal Commission, West Tripura, Agartala in connection with Case No.C.C.42 of 2021.
2. The fact of the case is that, the complainant had purchased a policy under the name and style ‘Arogya Plus’ of SBI General Insurance on 20.02.2019 for himself and for his wife from appellant-Insurance Company on being paid the due premium against the said policy. The complainant subsequently fell ill and he was admitted to R.N. Tagore International Institute of Cardiac Science in Kolkata for abdominal discomfort on 21.12.2020. He has incurred expenditure for his medical treatment amounting to Rs.95,036/- only. After discharged from the hospital, the complainant submitted the medical bills along with necessary documents to the appellant-Insurance Company for reimbursement of the medical bills, but the appellant-Insurance Company repudiated the claim of the complainant on the ground that the complainant had suppressed the fact that he had a pre-history diseases of Percutaneous Transluminal Coronary Angioplasty in 2019 and hence, considering the past-medical history of the complainant the said claim was ruled out by the appellant-Insurance Company and they further stated that the insured-complainant is not entitled to get any cashless benefit from the opposite party-insurer, the appellant herein. Though, according to the complainant, he was having a valid health insurance policy of the SBI General Insurance Co. Ltd.
3. Being aggrieved by the denial of the appellant-Insurance Company, the complainant filed a complaint before the learned District Commission claiming the claim amount of Rs.95,036/- along with compensation for mental agony and harassment for an amount of Rs.85,000/- as well as Rs.20,000/- for cost of litigation.
4. After adjudication of the case on merit, the learned District Commission passed the impugned judgment in favour of the respondent-complainant which is as follows:-

     “On overall appreciation of the Complainant's evidence we find that the Complainant has been able to prove his claim and we also found that there are deficiency in service on the part of the O.P. No.1. Hence, it is ordered that O.P. No.1 will pay the medical bill amount of Rs.95,036/-/- as Complainant claimed the amount in the complaint petition and also Rs.20,000/- for causing harassment and mental agony and also litigation costs of Rs.5,000/- i.e. in total of Rs.1,20,036/-(Rs.95,036/- + Rs.20,000/- + Rs.5,000/-). The O.P. No.1 is directed to make the whole payment within 2 month from the date of this judgment and if the payment is not made within 2 month then it will carry interest @7% per annum till the payment is made in full. Accordingly, the complaint is partly allowed……….”

5. On being aggrieved by the decision of the learned District Commission, the appellant-Insurance Company has preferred the instant appeal.
6. Mr. Ghosh, learned counsel appearing for the appellant-Insurance Company has strongly denied that there was no negligence and deficiency in service on the part of the appellant-Insurance Company in dealing with the claim of the complainant. He has also contended that after going through all the claim documents, it was found that the insured had a history of Percutaneous Transluminal Coronary Angioplasty in 2019 which was not disclosed by the respondent-complainant at the time of making out the insurance policy. Hence, this is a wilful suppression of fact and on this ground the complainant-respondent is not eligible to get the benefit of reimbursement of medical cost under the said insurance policy. He has further submitted that the learned District Commission has failed to appreciate the aforesaid facts and wrongly passed the judgment in favour of the complainant which needs to be set aside to restore the rule of law.
7. Mr. Datta, learned counsel appearing for the respondent-complainant has submitted that the learned District Commission has rightly allowed compensation in favour of the respondent-complainant as the deficiency of service on the part of the appellant-Insurance Company has been evidentially proved. He has further submitted that there was no wilful suppression of facts on the part of the respondent-complainant and the appellant-Insurance Company could not adduce any evidence to justify their denial of the claim. He has also contended that before issuing the insurance policy, the appellant-Insurance Company maintained all the necessary formalities as well as medical fitness test in the approved diagnostic clinic of appellant-Insurance Company and on being satisfied with the medical report, the appellant-Insurance Company had issued the aforesaid policy in favour of the complainant. According to Mr. Datta, learned counsel for the complainant, the judgment passed by the learned District Commission is just and proper and no intervention is required for the ends of justice.
8. We have examined the pleadings of the learned counsel appearing for the parties and also gone through the evidences adduced for adjudication of the case as well as the impugned judgment. According to us, it has been put beyond any doubt that the complainant, the respondent herein, had duly purchased the insurance policy from the appellant-opposite party-Insurance Company and the respondent-complainant had adduced due evidences in support of his claim for reimbursement of medical cost from the appellant-Insurance Company. It is admitted position that before issuance of insurance policy in favour of the complainant he was subjected to full-body medical tests as per rule by the Corporation’s empanelled agency and after examining all health related documents, the appellant-Corporation insured the complainant. Having satisfied with the reports of their own agency, according to this Commission, now they cannot take the plea of suppression of any health related issues of the complainant.
9. In the light of above, we are in conformity with the decision of the learned District Commission that the respondent-complainant would be able to establish his claim by submitting evidences.
10. On examination of the whole gamut of the case, we feel it proper to reduce the compensation as awarded by the learned District Commission to the extent that the opposite party no.1, i.e. the appellant herein, will pay Rs.95,036/- (Rupees ninety five thousand and thirty six) only along with Rs.5,000/- (Rupees five thousand) only as cost of litigation, in total Rs.1,05,036/- (Rupees One lakh five thousand and thirty six) only to the complainant within a period of 2 (two) months from today, failing which, it will carry interest @6% per annum till the payment is made in full.

            In the result, the appeal is partly allowed and thereby disposed of with the modifications of the impugned judgment as indicated above.