Tripura

StateCommission

A/39/2018

The ICICI Lombard General Insurance Company Ltd. - Complainant(s)

Versus

Sri. Satya Ranjan Pal - Opp.Party(s)

Mr. Rajib Saha, Mr. Utpal Das

08 Mar 2019

ORDER

Tripura State Consumer Disputes Redressal Commission, Agartala.

 

 

Case No.A.39.2018

 

 

1. The ICICI Lombard General Insurance Company Ltd.,

Represented by its General Manager,

Registered office at ICICI Lombard House, 

414, Veer Savarkar Marg, Near Siddhi Vinayak Temple,

Prabhadevi, Mumbai- 400 025.

 

2. The ICICI Lombard General Insurance Company Ltd.,

Represented by the Branch Manager, 

Having its Branch office at GRS Tower, 

2^nd Floor, RMS Chowmuhani, Agartala- 799001.

… … … … Appellant/Opposite party No.1 & 3.

Vs

1. Sri Satya Ranjan Pal,

S/o Late Mahendra Ch. Pal,

Kunjaban Colony,

P.O. Abhoynagar, Agartala,

West Tripura.

… … … … Respondent/Complainant.

2. Falck Global Assistance, Claims Department,

C/o Falck India Pvt. Ltd., Upper Floor, the Peach Tree,

Block-C, Sushant Lok-I, Sector 43,

Gurgaon, Haryana - 122 015.

… … … … Respondent/Opposite party No.2.

 

 

 

Present

Hon’ble Mr. Justice U.B. Saha

President,

State Commission

 

Mr. Narayan Ch. Sharma,

Member,

State Commission

 

Dr. Chhanda Bhattacharyya,

Member,

State Commission

 

 

For the Appellants:                                              Mr. Rajib Saha, Adv.

For the Respondent No.1:                                   Mr. Ratnadeep Paul, Adv.

For the Respondent No.2:                                   Absent.

Date of Hearing & Delivery of Judgment:          08.03.2019.

J U D G M E N T [O R A L]

 

U.B. Saha, J,

The instant appeal is directed against the judgment dated 14.06.2018 passed by the learned District Consumer Disputes Redressal Forum (hereinafter referred to as District Forum), West Tripura, Agartala in Case No.C.C.01 of 2018 along with an application for condoning the delay of 153 days in preferring the appeal.

2. Respondent has filed his objection to the prayer for condonation of delay.
3. Heard Mr. Rajib Saha, Ld. Counsel appearing on behalf of the appellants (hereinafter referred to as opposite parties/Insurance Company) as well as Mr. Ratnadeep Paul, Ld. Counsel appearing for the respondent (hereinafter referred to as complainant). None appears for the respondent no.2 (hereinafter referred to as opposite party no.2).
4. Today is fixed for hearing on condonation petition.
5. As the District Forum record has already been received and the parties are agreed to for final disposal of the appeal, the condonation petition is taken up first for hearing. Though according to us, the delay has not been properly explained, but then also, considering the interest of justice, the delay of 153 days in preferring the appeal is condoned. The condonation petition is accordingly, disposed of.
6. As agreed to by the Ld. Counsel appearing for the parties, the appeal is taken up for final disposal at this admission stage itself.
7. Brief facts of the case needed to be discussed are as follows:-  

Complainant, Sri Satya Ranjan Pal, had purchased one International Travel Insurance Policy, being Policy No.4129/130258963/00/000 on 28^th April, 2017 from the appellants, ICICI Lombard General Insurance Company Ltd. from its Branch Office at Agartala through its agent, namely, Munmun Saha. The aforesaid insurance policy was valid for a period from 12^th May 2017 to 25^th September 2017. Complainant went to Chicago, America on 12^th May, 2017. During his stay at Chicago, America, complainant suffered illness and he had to take treatment for Bronchitis with Bronchopasm, asthma from Lutheran Hospital, 7950 W. Jefferson Blvd, Fort Wayne, IN 46804, 260-435-7001 and paid $3,763/- as treatment cost. On return to India, he claimed the amount spent by him for his treatment at Chicago, America from the opposite parties-Insurance Company, but his claim was repudiated by the opposite parties-Insurance Company on the ground that he had suppressed his past medical history of cardiac ailment.

Being aggrieved by and dissatisfied with such decision of the opposite parties-Insurance Company, the complainant filed a complaint petition under Section 12 of the Consumer Protection Act, 1986 before the learned District Forum with a prayer for direction to the opposite parties-Insurance Company to pay $3,763.45 i.e. Rs.2,42,667/- as costs of the treatment and also Rs.60,000/- as compensation for harassment, inconvenience, frustration and mental agony and further Rs.20,000/- as cost of litigation along with interest @9%.

8. After filing of the case, the learned District Forum issued notices to the opposite parties-Insurance Company. The Branch Office of opposite parties-Insurance Company at Agartala had received the notice on 24^th January, 2018. Notice to other opposite parties was also sent by speed-post. After receipt of the notice, the opposite party no.1 i.e. appellant no.1 herein, appeared before the learned District Forum and filed written statement denying the claim of the respondent-complainant. Thereafter, the said appellant did not appear and also not adduced any evidence to support the contention made in the written statement. So, evidence of the complainant side was recorded.
9. Complainant had produced the original policy, documents, papers related to treatment at America, bills, cash memos, letters and discharge summary. He also submitted his examination-in-chief and examined him as a witness. Delivery report of the consignment was also produced.
10. On the basis of the evidences available before the learned District Forum, the learned District Forum passed the impugned judgment.
11. Mr. Saha, Ld. Counsel appearing for the appellant-opposite parties while urging for setting aside the impugned judgment would contend that the respondent-complainant i.e. the insured while purchasing the International Travel Insurance Policy from the appellant-opposite parties, Insurance Company suppressed the fact of pre-existing disease and according to terms and conditions of the policy, if any person suppressed the fact of pre-existing disease then he will not be entitled to get the benefit of insurance policy.
12. On the other hand, Mr. Paul, Ld. Counsel appearing for the respondent-complainant submits that the complainant had specifically informed to the agent of the appellant-Insurance Company regarding his past medical history. He further submits that the learned District Forum did not commit any error while passing the impugned judgment, particularly, when before the learned District Forum there was no evidence contrary to the evidence adduced by the complainant.
13. We have gone through the evidence of the complainant particularly, examination-in-chief by way of affidavit wherein it is specifically stated that “I informed my past medical history regarding heart bypass surgery (Effective Coronary Artery Bypass Grafting) to the agent of O.P No.1 and also shown her Discharge Summary of the surgery and thereafter the agent forwarded certain policy documents which I accordingly signed and thereafter satisfying all conditions the Opposite Party No.1 issued the policy in my favor covering my medical benefit. The insurance was valid for a period of 137 days from 12^th May 2017 to 25^th September 2017.”  

Though the Insurance Company filed its written statement, but did not adduce any evidence including the evidence of the agent in support of its contention in the written statement. The opposite parties-Insurance Company is not a rustic litigant, rather it has the legal department and also empanelled lawyer. Therefore, it was very much within their knowledge that to disprove the contention of the complainant, the opposite parties-Insurance Company is required to adduce evidence.

When the Insurance Company did not adduce any evidence before the learned District Forum, there was no other option before the learned District Forum except to accept the contention of the complainant particularly when the written statement cannot be treated as evidence. More so, in the written statement, the Insurance Company neither denied the fact regarding purchase of the policy from the agent of the Insurance Company, namely, Munmun Saha nor the fact of the treatment of the complainant at Lutheran Hospital, Chicago, America. For the argument sake even if it is considered that the complainant had the heart ailment prior to purchase of International Travel Insurance Policy, but fact remains that he had no history of bronchopasm or bronchitis. Further bronchopasm or bronchitis has no relation with the heart disease, rather mere respiratory treatment related to lungs which are caused due to lung infection.

The learned District Forum in its findings specifically stated that “The documents required as per policy was submitted. But the claim was repudiated on the ground of preexisting disease. O.P. failed to produce any single evidence to support that petitioner suffered bronchitis due to his preexisting heart ailment. So, such plea taken by the O.P. Insurance company is baseless and is not supported by any evidence.

We have gone through the prescription and the cash memo along with medical report and examination report. It is written that petitioner suffered from acute bronchitis with bronchopasm on 14.07.17. From the cash memo it is found that he spent total $3,763 equal to Indian currency Rs.2,42,667/- for treatment purpose.”

According to us, the learned District Forum rightly held that the complainant is entitled to get the treatment cost as per the terms of the Insurance Policy and also compensation for harassment and towards cost of litigation. Therefore, according to us, the learned District Forum did not commit any error while passing the impugned judgment. Hence, no interference is called for. The appeal is dismissed being devoid of merit. No order as to costs.

Send down the records to the learned District Forum, West Tripura, Agartala.

 

 

MEMBER State Commission Tripura

MEMBER State Commission Tripura

PRESIDENT State Commission Tripura